Every finding on record at Peak Resources- Shelby

Based on record review, and staff and Physician Assistant interviews, the facility failed to notify the Physician/Physician Assistant when a resident did not receive a prescribed medication for 1 of 1 resident reviewed for notification (Resident #75).The findings included:Resident #75 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes.Resident #75's physician orders and medication administration record (MAR) revealed the following: On 11/25/25 a physician order was written for semaglutide (0.25 mg or 0.50 mg) to be administered subcutaneously once a week on Mondays.The MAR indicated it was administered on 12/01/25 at 8:00 AM (Nurse #2), was not administered on 12/08/25 due to the resident refused (Nurse #2) and was not administered on 12/15/25 due to awaiting delivery from the pharmacy (Nurse #2). On 12/22/25 semaglutide (0.25 mg or 0.50 mg) was discontinued. A review of Resident #75's medical record revealed there was no documentation indicating the Physician/Physician Assistant had been notified that semaglutide was not administered as ordered.An interview conducted with Nurse #2 on 2/09/26 at 2:04 PM revealed she was assigned to Resident #75 on first shift (7:00 AM to 7:00 PM). Nurse #2 indicated Resident #75 had an order for semaglutide, but it was not available in the medication room on 12/01/25 or 12/08/25 or 12/15/25 and she did not administer the medication. Nurse #2 stated she documented on the MAR in error that she administered the semaglutide on 12/01/25 and that Resident #75 refused the medication on 12/08/25 and she should have documented the medication was not administered because it was unavailable. Nurse #2 indicated she notified the provider when a resident did not receive a prescribed medication, however she did not recall if she notified the Physician Assistant that Resident #75 had not received the semaglutide. An interview conducted with the Physician Assistant on 2/11/26 at 1:25 PM revealed she gave a new order on 11/25/25 for Resident #75 to start semaglutide 0.25 mg to help regulate her blood sugars and assist with weight loss. The Physician Assistant stated she entered the order in the electronic medical record (EMR) and notified Nurse #1 the order was ready to be sent to the pharmacy. The Physician Assistant stated she was not notified that the order sent to the pharmacy did not have the dose of the medication or that the medication was not delivered until 12/29/25. The Physician Assistant revealed there were no adverse outcomes from Resident #75 not receiving the semaglutide starting in November however the facility should have notified her that Resident #75 was not receiving the medication. An interview conducted with the Administrator on 2/11/26 at 3:42 PM revealed the Physician/Physician Assistant should be notified when a resident was not receiving a prescribed medication whether the medication was unavailable or the resident refused to take the medication.

Based on record review and Pharmacist, Physician Assistant, Medical Director, resident and staff interviews, the facility failed to respond to the pharmacy's request for a corrected physician order with the dosage information of a medication to ensure a resident's medication was obtained and administered as ordered for 1 of 3 residents reviewed for professional standards (Resident #75). The findings included:Resident #75 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes.The Physician Assistant note dated 11/25/25 revealed Resident #75 was evaluated due to a weight gain of approximately 15 pounds in 3 months. Resident #75 had a diagnosis of type 2 diabetes and was receiving scheduled insulin but was not complying with a diabetic diet which likely contributed to the weight gain. Resident #75 was agreeable to starting semaglutide to help with regulating her blood sugars and to assist with weight loss. A new order was given to start semaglutide 0.25 mg once a week on Mondays.Resident #75's physician orders and Medication Administration Record (MAR) revealed the following: On 11/25/25 a physician order was written for semaglutide (0.25 mg or 0.50 mg) to be administered subcutaneously once a week on Mondays.The MAR indicated semaglutide (0.25 mg or 0.50 mg) was administered on 12/01/25 at 8:00 AM by (Nurse #2), was not administered on 12/08/25 with a note the resident refused (Nurse #2) and was not administered on 12/15/25 due to awaiting delivery from the pharmacy (Nurse #2). On 12/22/25 semaglutide (0.25 mg or 0.50 mg) was discontinued per physician's order. On 12/29/25 semaglutide 0.25 mg was ordered to be administered subcutaneously once a week on Mondays.The MAR indicated semaglutide 0.25 mg was not administered on 1/05/26 or 1/12/26 due to resident refusal (Nurse #2), was administered on 1/19/26 at 8:00 AM (Staff Development Coordinator) and was administered on 1/26/25 at 8:00 AM (Nurse #3).The quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #75 was cognitively intact, had an active diagnosis of diabetes mellitus, and received insulin injections 7 out of 7 days during the assessment period. The care plan dated 1/30/26 revealed Resident #75 was at risk for hypoglycemic (low blood sugar) and hyperglycemic (high blood sugar) episodes due to a diagnosis of diabetes. The interventions included providing a diabetic snack at bedtime, monitoring for signs of hyperglycemia and hypoglycemia and notifying the physician if blood sugar readings were below 60 or above 450. An interview was conducted with Resident #75 on 2/09/26 at 3:09 PM. Resident #75 revealed on 11/25/25 the Physician Assistant ordered semaglutide to help regulate her blood sugars and assist with weight loss. Resident #75 indicated the medication was not administered until January 2026, but she did not question anyone about the delay because it usually took a while for the facility to get new medications from the pharmacy. Resident #75 stated she did refuse the first two doses of the semaglutide in January because she had a few questions for the Physician Assistant concerning possible reactions. Resident #75 stated the semaglutide was administered as ordered on 1/19/26 and 1/26/26. An interview conducted with Nurse #2 on 2/09/26 at 2:04 PM revealed she was assigned to Resident #75 on first shift (7:00 AM to 7:00 PM). Nurse #2 indicated Resident #75 had an order for semaglutide, but it was not available on 12/01/25 or 12/08/25 or 12/15/25 and was not administered. Nurse #2 stated when a resident's medication was not administered because it was unavailable she notified Nurse #1 and the provider, but she did not recall if she notified them concerning Resident #75 not receiving the semaglutide. Nurse #2 revealed the semaglutide was available on 1/05/25 and 1/12/25 but Resident #75 refused it because she had a few questions for the Physician Assistant concerning possible reactions. Nurse #2 stated she documented on the MAR in error that she administered semaglutide to Resident #75 on 12/01/25 and that it was refused on 12/08/25 and she should have documented on the MAR that the medication was unavailable.An interview conducted with Nurse #1 on 2/11/26 at 8:56 AM revealed she was the first shift (7:00 AM to 3:00 PM) unit manager. Nurse #1 stated when a resident had a new medication order it was entered into the electronic medical record (EMR), verified and then sent electronically to the pharmacy. Nurse #1 revealed the Physician Assistant entered an order in the EMR on 11/25/25 for Resident #75 to start semaglutide. Nurse #1 indicated she verified the order in the EMR and sent it to the pharmacy on 11/28/25. Nurse #1 stated she was not aware the dose of semaglutide was not on order or that the pharmacy needed the order to be clarified. During a phone interview with the Pharmacist on 2/11/26 at 1:48 PM he revealed the facility sent an order on 11/25/25 for Resident #75 to start semaglutide but the order did not include the dosage information. He stated the Former Director of Nursing (DON) was notified on 11/25/25, 12/03/25, 12/17/25 and 12/22/25 that the order needed to be resent with the dosage information so the pharmacy could dispense and deliver the medication. The Pharmacist revealed the facility sent a new order on 12/29/25 for semaglutide 0.25 mg to be administered subcutaneously once a week and the medication was delivered to the facility on [DATE].Several attempts made to contact the Former DON were unsuccessful.An interview conducted with the Physician Assistant on 2/11/26 at 1:25 PM revealed she evaluated Resident #75 on 11/25/25 due to a weight gain of approximately 15 pounds in three months. The Physician Assistant revealed she consulted with the Medical Director, and he agreed with starting semaglutide, so she entered the order in the EMR on 11/25/25. The Physician Assistant stated she was not notified the pharmacy needed the order for semaglutide to be clarified, or that Resident #75 was not administered the medication until 1/19/26. The Physician Assistant stated there were no adverse outcomes from Resident #75 not starting semaglutide however resident medications should be administered as ordered. During a phone interview with the Medical Director on 2/11/26 at 1:14 PM he revealed the Physician Assistant did consult him regarding Resident #75's weight gain and varying blood sugars and he agreed with starting semaglutide. The Medical Director stated Resident #75 not receiving the semaglutide would not have caused an adverse outcome however resident medications should be administered as ordered.An interview conducted with the Administrator on 2/11/26 at 3:42 PM when the pharmacy notified the Former DON the order sent for Resident #75 to start semaglutide did not include the dosage information, she should have clarified the order with the Physician Assistant and sent the updated order to the pharmacy. The Administrator indicated medications should be obtained from the pharmacy and administered to the residents as ordered by the physician.

Based on record review, and resident and staff interviews, the facility failed to ensure a resident's toenails were trimmed and podiatry services were arranged for 1 of 3 residents reviewed for foot care (Resident #63). Finding included: Resident #63 was admitted on [DATE] with diagnoses that included coronary artery disease (CAD), hypertension, diabetes mellitus and cerebrovascular accident (CVA). Resident #63's care plan revised on 12/07/25 revealed Resident #63 was care planned for activities of daily living (ADL) care. The goals included extensive and total staff assistance in all aspects of daily care to ensure all needs were met. Interventions included staff assistance with grooming and personal hygiene. Resident #63 was noted to walk independently with a cane. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #63's cognition was assessed as moderately impaired and he was independent with upper and lower body dressing, putting on/taking off footwear and personal hygiene. Resident #63 was coded as independent for ambulation with use of a walker as a mobility device. He was not coded for rejection of care during the assessment period. Resident #63's most recent weekly skin assessment completed by Nurse #1 dated 02/05/26 revealed no notation that the resident's toenails were long, thick and needed trimming or a referral for podiatrist's care. Review of the facility's podiatry clinic schedule for February 2026 revealed Resident #63 was not scheduled to be seen by the podiatrist. Resident #63's medical record from admission through 02/11/26 revealed no consultation reports or notations in Resident #63's medical record that he had been seen by a podiatrist. An observation and interview were conducted with Resident #63 on 02/08/26 at 11:37 AM. During the interview he removed his socks and showed the surveyor his toenails on the left foot. The toenails were observed to be thick and long extending past his toenail bed. Resident #63 stated, When I put my shoes on it hurts, I need them cut. When the surveyor asked Resident #63 if he had told a staff member he stated, Oh, I don't want to bother them, but they've seen. On 02/10/26 at 2:45 PM an observation of Resident #63's left foot toenails was conducted with Nurse #1. Resident #63's toenails were observed to be thick and long. The left hallux (innermost digit of the foot) toenail was curved to the side. Resident #63 stated to Nurse #1 that he was having some discomfort when he walked and while putting his shoes on. An interview was conducted with Nurse #1 on 02/10/26 at 2:50 PM. During the interview she stated she had conducted the resident's weekly skin assessment on 2/05/26. She stated she noticed his toenails were long at that time but didn't document it because the resident didn't have any complaints about them. Nurse #1 stated she felt like Resident #63 needed a podiatry consult after observing his toenails with the surveyor. An interview was conducted with Nurse Aide (NA) #1 on 02/10/26 at 2:52 PM. She stated she was responsible for Resident #63 during the 7:00 AM to 7:00 PM shift. NA #1 stated she had not seen the residents' toenails because he was always wearing his socks, which he applied independently. The interview revealed Resident #63 wanted to take his own baths in his room. Staff would provide set-up assistance only. She explained Resident #63 would also dress himself, so she had not seen his toenails, nor had he mentioned he was experiencing discomfort with the length of his toenails. An interview was conducted with NA #2 on 02/11/26 at 12:05 PM. During the interview she stated she had provided Resident #63 with set-up assistance for a bath on 2/08/26. She stated she did not observe Resident #63's toenails while caring for him because he dressed himself. An observation was conducted on 02/11/26 at 4:39 PM with the Wound Care Nurse. The Wound Care Nurse was observed measuring Resident #63's toenails on the left foot. The length of the toenail measurements were as follows: hallux 3 centimeters (cm), index (second) 1.9 cm, middle 1.6 cm, ring (fourth) 1.4 cm, and pinky (fifth) 1.1 cm. The Wound Nurse stated, his toenails are long and need to be trimmed by the podiatrist. An interview was conducted with the Director of Nursing (DON) on 02/11/26 at 2:46 PM. The DON stated the NAs should have been alerting the nurses and the nurses should have assessed Resident #63's toenails during weekly skin assessments. She stated if the nursing staff thought Resident #63's toenails were too long, they could have placed him on the podiatry list and obtained consent from the Responsible Party. The DON indicated she expected all residents to receive podiatry services when needed. An interview was conducted with the Administrator on 02/11/26 at 10:24 AM. The Administrator stated nobody had mentioned to her that Resident #63's toenails were long nor had he come to her and voiced concerns regarding his toenails hurting or difficulty ambulating. The Administrator stated normally the nurses were very good about following through if a resident needed to be seen by the podiatrist. The Administrator indicated she expected all residents to receive podiatry services when needed and Resident #63 would be receiving services moving forward.

Based on record review, staff and Pharmacist interviews, the facility failed to ensure a prescription that was sent to the pharmacy to be filled contained complete prescribing information for a diabetic medication so that the prescription could be filled and further failed to respond to attempts by the pharmacy to reach the facility to get a corrected physician order for 1 of 5 residents (Resident #75) reviewed for pharmacy services. The findings included:Resident #75 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes.The Physician Assistant note dated 11/25/25 revealed Resident #75 was evaluated due to a weight gain of approximately 15 pounds in 3 months. Resident #75 had a diagnosis of type 2 diabetes and was receiving scheduled insulin but was not complying with a diabetic diet which likely contributed to the weight gain. Resident #75 was agreeable to starting semaglutide (medication used to control diabetes and to lose weight) to help with regulating her blood sugars and to assist with weight loss. A new order was given to start semaglutide 0.25 mg once a week on Mondays.Review of a physician order dated 11/25/25 read; semaglutide (0.25 mg or 0.50 mg) to be administered subcutaneously once a week on Mondays and the order was discontinued on 12/22/25. The MAR indicated the medication was administered on 12/01/25 at 8:00 AM (documented it was given in error by Nurse #2), was not administered on 12/08/25 due to resident refusal (Nurse #2) and was not administered on 12/15/25 due to awaiting delivery from the pharmacy (Nurse #2).An interview conducted with Nurse #2 on 2/09/26 at 2:04 PM revealed she was assigned to Resident #75 from 7:00 AM to 7:00 PM as needed to assist with medication administration. Nurse #2 indicated on 12/01/25 or 12/08/25 or 12/15/25 she did not administer the semaglutide to Resident #75 because it was not available in the medication room. Nurse #2 revealed when a medication was unavailable for a resident, she sent a refill request to the pharmacy in the electronic medical record (EMR) and notified Nurse #1 and the provider if the resident missed a dose of the medication. Nurse #2 stated because the semaglutide was a new medication order she just thought it had not been delivered yet and she did not call the pharmacy to check on the status. Nurse #2 revealed she did not recall if she notified the Physician Assistant that Resident #75 had not received the semaglutide, but Nurse #1 was aware.An interview conducted with Nurse #1 on 2/11/26 at 8:56 AM revealed she was the unit manager from 7:00 AM to 3:00 PM. Nurse #1 stated when a resident had a new medication order it was entered, verified and sent to the pharmacy in the EMR. Nurse #1 revealed the Physician Assistant entered the order for Resident #75 to start semaglutide in the EMR on 11/25/25. Nurse #1 indicated she verified the order in the EMR and sent it to the pharmacy on 11/28/25. Nurse #1 stated she was not aware the order for semaglutide did not have the complete dosage information or that the pharmacy requested a new order. Nurse #1 revealed she thought Resident #75's semaglutide was not delivered because it was unavailable, but she did not follow up with the pharmacy to check on the status of the medication.During a phone interview with the Pharmacist on 2/11/26 at 1:48 PM he revealed the facility sent an order on 11/25/25 for Resident #75 to start semaglutide but the order did not include the complete dosage information. He stated the pharmacy attempted to call the facility, sent a fax notification and emailed the Former Director of Nursing (DON) and the Administrator on 11/25/25, 12/03/25, 12/17/25 and 12/22/25 that the semaglutide order for Resident #75 needed to be clarified so the medication could be dispensed and delivered to the facility. The Pharmacist revealed the facility responded to the pharmacy's requests and sent a new order for the semaglutide with the dosage information on 12/29/25 and the medication was delivered to the facility the same day.An attempt made to contact the Former DON on 2/11/26 at 1:55 PM was unsuccessful.An interview was conducted with the Administrator on 2/11/26 at 3:42 PM. She revealed the Former DON's last day working at the facility was on 1/23/26. The Administrator stated she had not received an email from the pharmacy in November 2025 or December 2025 that a medication order for Resident #75 needed to be clarified and she could not say if the Former DON received the email or if she was aware. The Administrator indicated when a medication was not available the assigned nurse, Nurse#1 and/or the DON should contact the pharmacy to check on the status of the medication or send a refill request in the EMR to ensure medications were available and administered to the residents as ordered by the physician.

Based on observation, staff interviews and Pharmacist interviews, the facility failed to remove an expired medication stored in 1 of 1 medication room refrigerator reviewed for medication storage (Medication room [ROOM NUMBER])The findings included:An observation of Medication room [ROOM NUMBER] was conducted on 2/9/2026 at 11:52 AM in the presence of Medication Aide (MA) #1. The following medication was found in the medication room refrigerator in a locked bin: one vial of Lorazepam 2 mg/ml (milligrams/ milliliter). The expiration date on the vial was August 2025 and was not opened. MA #1 confirmed the expiration date by reading aloud the date printed on the vial.An interview with the MA #1 was completed on 2/9/2026 at 11:53 AM. MA #1 stated that she was not sure who would check the medication room for expired medications and thought it was a night shift staff member that checked the temperature for the refrigerator. MA #1 reported that the Pharmacist would check the medication room monthly but would need to confirm with the Director of Nursing (DON).The interview conducted with the DON on 2/11/2026 at 2:50 PM revealed that the Pharmacist visits the facility once per month to check for expired medications. The DON reported once a medication was discontinued the nurse should have removed the medication from the cart or refrigerator and placed the medication in pharmacy container for medications to be returned to the pharmacy.An interview was completed with the Administrator on 2/11/2026 at 3:30 PM. The Administrator stated that expired medication should be sent back to pharmacy. The Administrator reported that each nurse should check medication orders each shift and send back discontinued medication to the pharmacy. The Administrator stated that she expected staff to check carts for expired and discontinued medications prior to dispensing medications to residents.A phone interview was completed with the Pharmacist on 02/11/2026 at 4:47 PM. The Pharmacist stated that he visits the facility once a month to complete medication administration observations with medication aides and nurses. The Pharmacist also reported that he had a team member that would visit the facility every other month to check the medication room for expiredmedications and medications that required more stock. The Pharmacist stated that he would check the medication in the medication carts during the medication administration observations for expired medications. The Pharmacist stated that the facility should not rely on pharmacy visits to review medication stock for expired medication because his team may not check the medication stock every month.

Based on record review and staff, resident and pharmacist interviews, the facility failed to maintain accurate records related to medication administration for 1 of 1 resident reviewed for accurate medical records (Resident #75).The findings included: Resident #75 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes. Resident #75's physician orders and Medication Administration Record (MAR) revealed the following: 11/25/25 semaglutide (0.25 mg or 0.50 mg) to be administered subcutaneously once a week on Mondays. The MAR indicated semaglutide was administered on 12/01/25 at 8:00 AM (Nurse #2), was not administered on 12/08/25 with a note the resident refused (Nurse #2) and was not administered on 12/15/25 due to awaiting delivery from the pharmacy (Nurse #2). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #75 was cognitively intact. An interview was conducted with Resident #75 on 2/09/26 at 3:09 PM. Resident #75 revealed on 11/25/25 the Physician Assistant ordered semaglutide to help regulate her blood sugars and assist with weight loss. Resident #75 indicated the medication was not administered until January 2026. An interview conducted with Nurse #2 on 2/09/26 at 2:04 PM revealed she was assigned to Resident #75 on first shift (7:00 AM to 7:00 PM). Nurse #2 indicated Resident #75 had an order for semaglutide, but it was not available on 12/01/25 or 12/08/25 or 12/15/25 and was not administeredNurse #2 stated she documented on the MAR in error that she administered semaglutide to Resident #75 on 12/01/25 and that it was refused on 12/08/25 and she should have documented on the MAR that the medication was unavailable. During a phone interview with the Pharmacist on 2/11/26 at 1:48 PM he revealed the facility sent an order on 11/25/25 for Resident #75 to start semaglutide but the order did not include the dosage information. The Pharmacist revealed the facility sent a new order on for semaglutide 0.25 mg and the medication was delivered to the facility on [DATE]. Several attempts made to contact the Former DON were unsuccessful. An interview conducted with the Administrator on 2/11/26 at 3:42 PM revealed she was not aware that Resident #75 was not administered semaglutide as ordered because it was not delivered by the pharmacy and unavailable. The Administrator stated when a medication was not administered it should be documented accurately in the resident record and on the MAR.

Based on record review, observations and staff interviews, the facility failed to follow their infection control policy for three residents (Resident #4, Resident #62 and Resident #103) when the Treatment Nurse failed to change her gloves and perform hand hygiene during wound care. This deficiency occurred for 1 of 3 staff members reviewed for infection control practices (Treatment Nurse). The findings included: A review of the facility's policy titled Infection Prevention and Control Program, reviewed and revised on 10/28/24, indicated: Gloves must be worn when handling blood and/or other potentially infectious material and if the employee has non-intact skin. Touch clean body sites or surfaces before you touch dirty or heavily contaminated areas. If gloves become torn or heavily soiled and additional resident care tasks must be performed, then change the gloves before starting the next task. Always change gloves after use on each resident and discard them in the nearest appropriate receptacle. Perform hand hygiene before and after donning gloves. 1. An observation of wound care for Resident #4 by the Treatment Nurse was made on 2/10/26 at 9:30 AM. The Treatment Nurse was already in the resident's room when the surveyor entered the room and was observed with a gown already on. The Treatment nurse sanitized her hands and donned clean gloves. The dressing was already removed from Resident #4's wound. The Treatment Nurse stated the dressing had come off during incontinence care earlier that morning. She proceeded to clean the pressure ulcer to Resident #4's coccyx with gauze soaked with wound cleaner. While wearing the same gloves the Treatment Nurse then applied Santyl (ointment used to remove dead tissue) ointment, wet to moist Dakin's (antiseptic wound cleaning solution) solution and packed the wound bed. She then applied a super absorbent pad over it. The Treatment Nurse then collected all of her supplies and threw them into the trash can. The Treatment Nurse doffed her gown, gloves and washed her hands with soap and water. An interview with the Treatment Nurse on 2/11/26 at 1:03 PM revealed she knew she was supposed to change her gloves and sanitize her hands after cleaning Resident #4's wound and before applying the new clean dressing, but she got nervous about being observed during the wound care and forgot this step. The Treatment Nurse stated, I had some training on infection control, but it obviously wasn't enough. An interview with the Infection Preventionist (IP) on 2/11/26 at 1:50 PM revealed the Treatment Nurse should have changed her gloves and washed her hands after cleaning Resident #4's wound and before applying the clean dressing. An interview with the Director of Nursing (DON) on 2/11/26 at 2:47 PM revealed the Treatment Nurse should have changed her gloves and performed hand hygiene before putting a new dressing on Resident #4's wound. The DON stated that the Treatment Nurse needed re-education on infection control and hand hygiene. 2. An observation of wound care for Resident #62 by the Treatment Nurse was made on 2/10/26 at 12:47 PM. The Treatment Nurse donned a clean gown and clean gloves. She then removed the old dressing from Resident #62's right ankle. She proceeded to clean the wound to Resident #62's right ankle with gauze soaked with wound cleaner. While wearing the same gloves the Treatment Nurse then applied a xeroform petrolatum dressing (mesh dressing impregnated with petrolatum). She then collected all of her supplies and threw them into the trash can. The Treatment Nurse doffed her gown, gloves and washed her hands with soap and water. An interview with the Treatment Nurse on 2/11/26 at 1:03 PM revealed she knew she was supposed to change her gloves and sanitize her hands after cleaning Resident #62's wound and before applying the new dressing, but she got nervous about being observed during the wound care and forgot this step. The Treatment Nurse stated, I had some training on infection control, but it obviously wasn't enough. An interview with the Infection Preventionist (IP) on 2/11/26 at 1:50 PM revealed the Treatment Nurse should have changed her gloves and washed her hands after cleaning Residents #62's wounds and before applying the clean dressing. An interview with the Director of Nursing (DON) on 2/11/26 at 2:47 PM revealed the Treatment Nurse should have changed her gloves and performed hand hygiene before putting a new dressing on Resident #62's wound. The DON stated that the Treatment Nurse needed re-education on infection control and hand hygiene. 3. An observation of wound care for Resident #103 by the Treatment Nurse was made on 2/10/26 at 10:30 AM. The Treatment Nurse entered the room after putting a gown on. She washed her hands and put gloves on. She removed the dressing from Resident #103's right heel pressure ulcer. The Treatment Nurse took her gloves off and rubbed hand sanitizer to both hands. She then applied another set of gloves and proceeded to clean the ulcer with gauze soaked with wound cleaner. Without removing gloves and performing hand hygiene, the Treatment Nurse patted the ulcer with a dry gauze and applied collagenase ointment using a cotton swab to the wound bed. She then covered the wound with calcium alginate, applied an abdominal pad over it and wrapped the right foot with a woven gauze bandage. She removed both gloves and applied hand sanitizer to both hands. She donned a new set of gloves and removed the dressing from Resident #103's left foot. Resident #103 had a surgical wound on his left foot which had staples from where his toes were amputated. The Treatment Nurse removed her gloves and rubbed hand sanitizer to both hands before applying another set of gloves. She then cleaned the wound with gauze moistened with wound cleaner. Without removing gloves and performing hand hygiene, the Treatment Nurse covered the wound with an abdominal pad and wrapped Resident #103's left foot with a woven gauze bandage. She then removed her gloves and washed her hands with soap and water at the sink inside the room. An interview with the Treatment Nurse on 2/11/26 at 1:03 PM revealed she knew she was supposed to change her gloves and sanitize her hands after cleaning Resident #103's wounds and before applying the dressing, but she got nervous about being observed during the wound care and forgot this step. The Treatment Nurse stated that she had some training on infection control, but it obviously wasn't enough. An interview with the Infection Preventionist (IP) on 2/11/26 at 1:50 PM revealed the Treatment Nurse should have changed her gloves and washed her hands after cleaning Resident #103's wounds and before applying the dressing. An interview with the Director of Nursing (DON) on 2/11/26 at 2:47 PM revealed the Treatment Nurse should have changed her gloves and done hand hygiene before putting new dressings on Resident #103's wounds. The DON stated that the Treatment Nurse needed re-education on infection control and hand hygiene.

Based on record reviews, and Nurse Practitioner (NP), Consulting Pharmacist and staff interviews, the facility failed to check finger-stick blood sugar (FSBS) for a resident that received insulin injections twice daily for 1 of 3 residents reviewed for unnecessary medications (Resident #40). The findings included: Resident #40 was admitted to the facility on [DATE] with multiple diagnoses which included, a right side below the knee amputation, type 2 diabetes mellitus and end stage renal disease. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #40 was cognitively intact and required substantial to max assist for most Activities of Daily Living (ADLs). The MDS also revealed Resident #40 was coded that she received insulin injections. Documentation on the care plan last reviewed on 11/8/2024 revealed Resident #40 had type 2 diabetes mellitus with interventions that included: to assess for hyperglycemic episodes such as acetone breath, polyuria and flushed skin, during rounds and prn. Treat as per physician orders. Assess for hypoglycemic episodes such as sweating, chills, rapid weak pulse, tachycardia and tremors, during rounds and prn. Follow facility protocol for any acute signs and symptoms of hyper/hypoglycemic episodes. During an interview with Resident #40 on 11/28/2024 at 11:28am, Resident #40 voiced she was a diabetic and was concerned that her blood sugar was no longer being checked. Resident #40 stated that she received 14 units of insulin in the morning and 16 units in the evening, but the staff was no longer checking her blood sugar. Resident #40 stated she did not know why they were stopped. Resident #40 stated she had episodes of increased sleepiness since her blood sugars had stopped being checked. A review of Resident #40's Physicians' orders revealed Resident #40 had active orders for Levemir Insulin 100unit/ml Administer 16 units daily at 8pm with a start date of 6/3/2022, and Levemir Insulin 100unit/ml Administer 14 units daily at 8am with a start date of 4/8/2024. Review of the Nurse Practitioner (NP) note dated 9/25/2024 revealed Resident #40's lispro (short acting insulin) sliding scale order would be discontinued. Note also revealed that the NP educated Resident #40 on the importance of maintaining a balanced diet and monitoring blood sugar levels. Further review of Resident #40's Physicians orders revealed an order for insulin lispro (short acting insulin) with a sliding scale was discontinued on 9/25/2024. Review of the Point-of-Care Blood Sugar Summary report for Resident #40 revealed no FSBS had been recorded since the morning of 9/25/2024. Record review revealed Resident #40 had an order for HbA1c every 3 months. HbA1c completed on 4/16/2024 with results of 6.7, on 7/15/2024 with results of 6.6, and on 10/15/2024 with results of 6.5. (HbA1c Range 5.0-6.1) During an interview on 11/19/2024 at 12:52pm Nurse #2 stated the Nurse Practitioner (NP) wrote the order for Resident #40's lispro insulin sliding scale to be discontinued and that she (Nurse #2) verified the order. Nurse #2 stated that orders were verified by reviewing the order from the NP, and making sure the order in the computer electronic Medication Administration Record (eMAR) was entered into the system correctly. Nurse #2 stated that orders were normally verified by the charge nurse, but orders could also be verified by the hall nurse. Nurse #2 stated that FSBS are dependent on what is ordered by the provider. Nurse #2 stated that most of the time when a resident received insulin injections, the resident also has FSBS completed. Nurse #2 was not aware of any instances of Resident #40 having increased sleepiness reported, but stated Resident #40 did stay up late into the evening on her phone. During an interview on 11/19/2024 at 1:29pm the Nurse Practitioner (NP) verified she had entered the order to discontinue the lispro insulin sliding scale for Resident #40 into the computer. The NP stated she did not intend for the FSBS to be discontinued, only the sliding scale insulin and that she would fix it. The NP stated that FSBS can be tied into the order for a medication when entered into the system and that is probably why the FSBS was stopped when the sliding scale was discontinued. During an interview on 11/20/2024 at 8:56am Nurse #3, stated the Med Aide (MA) checked the FSBS and Nurse #3 saw the results on the computer and then administered insulin injections. Nurse #3 stated as far as she knew every resident that received insulin also had FSBS completed. Nurse #3 came back later that day at 2:18 pm and stated she was incorrect earlier and stated FSBS for residents are based on the order from the provider. During an interview on 11/20/2024 at 2:16pm Nurse #1 stated she checked her own FSBS on her hall because she did not normally have an MA assigned. Nurse #1 stated the residents who receive insulin also have FSBS completed. During an interview on 11/20/2024 at 2:20pm. Nursing Assistant (NA) #1 stated she checked the computer and completed the FSBS that were ordered, then documented them on the eMAR. NA #1 was not aware of all the residents that received insulin. During an interview on 11/19/2024 at 1:51pm the Consulting Pharmacist stated he was unaware that Resident #40 did not have a current order for FSBS. The Consulting Pharmacist stated anyone receiving insulin should have some FSBS completed. The Consulting Pharmacist would recommend at least once daily but knew some providers ordered FSBS for every other or every third day. The Consulting Pharmacist stated when he completed his review in October the September FSBS were reviewed. He stated the October MAR would be reviewed on his next visit in November 2024. The Consulting Pharmacist stated if he had seen during his review there were no FSBS, he would have questioned why they were stopped. A joint interview was conducted with the Administrator and the Director of Nursing (DON) on 11/20/2024 at 3:23pm. The DON and Administrator were unaware that Resident # 40 had not had FSBS from 9/25/2024, but the Administrator asked if Resident #40 had a HbA1c. The DON verified Resident #40 had a HbA1c of 6.5 on 10/15/2024. The DON verified that after orders are entered by the NP a nurse would verify the order before it was changed on the eMAR. The DON also verified that insulin and FSBS orders can be connected on the eMAR. The DON stated that it is up to the provider if a resident received FSBS while on insulin. The Administrator stated FSBS are looked at on a case-by-case basis determined by the provider. The Administrator stated the Medical Director had mentioned there were papers that suggested the use of HbA1c to monitor instead of FSBS would be considered. The DON stated they did not have a policy regarding FSBS use for diabetics. During a telephone interview on 11/21/23 at 8:10am the Medical Director stated residents were looked at on a case-by-case basis regarding orders for FSBS. The Medical Director stated there is talk starting, regarding using the HGBA1C for monitoring but did not mention any study or papers supporting this.

Based on observations, staff interviews, and record review the facility failed to record an open date on multi-dose insulin pens, failed to discard expired insulin pens, and failed to store an unopened insulin pen in the refrigerator for 1 of 2 medication carts reviewed for medication storage (Hall A medication cart). The findings included: Review of the manufacturer's package insert for Levemir (Insulin detemir) flexpen stated to store unopened Insulin detemir insulin pens in a refrigerator and in-use (opened) Insulin detemir pens at room temperature for 42 days and then discard. Review of the manufacturers' instructions for Glargine insulin pen, Novolog insulin pen, and Lispro insulin pen, stated the insulin pens may be used for 28 days after opening, then discard. An observation of the medication cart on Hall A was conducted on 11/20/2024 at 11:05 AM with Nurse #1. The observation revealed an opened Glargine insulin pen and an opened Novolog insulin pen that were not dated. The medication cart observation also revealed an opened insulin detemir flexpen with an open date of 08/23/2024 and an opened Lispro insulin pen with an open date of 09/24/2024. The observation further revealed an unopened insulin pen was stored in the right top drawer of the medication cart and was labeled as refrigerate until opened. An interview was conducted with Nurse #1 on 11/20/2024 at 11:11 AM who stated insulin should be stored in the refrigerator until ready to use and all insulin pens should have an open date with a 28-day expiration date. Nurse #1 further stated that she did not realize the insulin pens were not dated and that two insulin pens were expired. An interview was conducted with the Director of Nursing (DON) on 11/20/2024 at 11:50 AM. The DON revealed all insulin pens should have been labeled when opened for use with a 28-day expiration date sticker. The DON indicated that all nurses were responsible for checking medications in the medication carts for expired medications. She also stated that all unopened insulin pens should be stored in the refrigerator until ready for use and that no expired medications should be available for use in the medication carts.

Based on observations, record review, resident interview, and staff interviews the facility failed to maintain a filled oxygen humidifier for 2 of 2 resident reviewed for oxygen therapy (Resident #14 and Resident #25). The findings included: 1. Resident #14 was admitted to the facility on [DATE] with diagnoses that included asthma and heart failure. Resident #14 ' s admission Minimum Data Set (MDS) dated [DATE] revealed Resident #14 was cognitively intact and received oxygen. Resident #14 ' s care plan revealed Resident #14 had impaired gas exchange due to chronic obstructive pulmonary disease (COPD). The goal for resident #14 was to have an effective gas exchange as evidenced by clear breath sounds, mental status within normal limits, and skin color within normal limits. Interventions included oxygen as ordered, administrator medications as ordered, encourage activities and self-care as tolerated, and assess and record signs of impaired gas exchange. A physician order dated 09/11/23 revealed Resident #14 received 2 liters (L) per minute of oxygen through the nasal cannula continuously. A physician order dated 09/30/23 revealed Resident #14 ' s oxygen concentrator filter to be cleaned with warm water, air dry, and replaced weekly. Observation conducted on 10/09/23 at 11:00 AM revealed Resident #14 ' s oxygen humidifier dated 10/05/23 was running low with little water in it. Observation and interview conducted with Resident #14 on 10/09/23 at 1:05 PM revealed Resident #14 ' s oxygen humidifier dated 10/05/23 had no water in it. Resident #14 further revealed staff was aware that it was low and should be back in the room later to change it out. Observation and interview conducted with Resident #14 on 10/10/23 at 11:05 AM revealed Resident #14 ' s oxygen humidifier dated 10/05/23 had no water in it. Resident #14 further revealed staff had not changed the humidifier and her oxygen felt dry in her nose. Observation and interview conducted with Nurse #1 on 10/10/23 at 11:15 AM revealed Resident #14 ' s oxygen humidifier was empty and needed to be changed. Nurse #1 further revealed all staff were responsible for checking humidifiers and reporting to the assigned Nurse if it is empty. Nurse #1 indicated she was not aware that it was empty. Interview conducted with Nurse Aide (NA) #1 on 10/11/23 at 10:00 AM revealed she observed Resident #14 ' s oxygen humidifier was empty after breakfast on 10/10/23 and notified Nurse #1 it needed to be changed. NA #1 further revealed NAs are unable to change residents ' oxygen humidifier and educated to notify assigned Nurse. Interview conducted with the Director of Nursing (DON) on 10/11/23 at 1:50 PM revealed she was not aware Resident #14 ' s oxygen humidifier was empty. The DON further revealed nursing staff has been educated to check oxygen humidifiers every shift and change if low. The DON stated Resident #14 ' s humidifier should have been changed. Interview conducted with the Administrator on 10/11/23 at 2:55 PM revealed she expected nursing staff to check residents ' oxygen humidifier daily and to be changed if low or empty. The Administrator indicated Resident #14 ' w oxygen humidifier should have been changed. 40476 2. Resident #25 was admitted to the facility on [DATE] with diagnoses that included asthma and congestive heart failure. Resident #25's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and received oxygen. A review of Resident #25's physician orders revealed: *An active order dated 07/16/21 to change oxygen tubing and set up weekly on Wednesday. *An active order dated 06/19/23 for oxygen at 3 liters per minute via nasal cannula as needed. A review Resident #25's Medication Administration Record (MAR) for 10/2023 revealed the oxygen tubing and set up was changed on Wednesday 10/04/23. A review of Resident #25's vital signs revealed the following: *10/09/23 at 5:10 PM submitted by Nurse #2 read, oxygen saturation level 95% on 3 liters per minute via nasal cannula. *10/11/23 at 9:49 AM submitted by Nurse #1 read, oxygen saturation level 95% on 3 liters per minute via nasal cannula. On 10/09/23 at 11:22 AM an observation and interview were made of Resident #25 who was lying in bed with oxygen being delivered via nasal cannula by the bedside concentrator at a setting of 3 liters per minute. The oxygen tubing was dated 10/04/23 with no water observed in the humidification container located on the oxygen concentrator. Resident #25 explained she preferred humidified oxygen, so her nose did not become dry and itchy. She stated at the time of the interview she was not experiencing any dryness or itching but staff were not good about changing her water container. The interview revealed in the past she had gone days without the water container being changed. She stated she felt more comfortable wearing oxygen because she sometimes became short of breath. The interview revealed she had told staff she wanted humidified oxygen but it had been a few months prior and she could not remember who she told. On 10/10/23 at 11:13 AM an observation was made of Resident #25's oxygen concentrator revealed the humidification container remained in the same condition with no water. Resident #25 was lying in bed with oxygen being delivered via nasal cannula by the bedside concentrator at a setting of 3 liters per minute. Resident #25 stated her nose was becoming dry and itching. She stated she did not know the humidification container was empty because it was located at the foot of her bed, and she couldn't see it. An interview was conducted with Nurse #1 on 10/10/23 at 11:19 AM. Nurse #1 stated she was responsible for Resident #25. She stated Resident #25 had an order to change the oxygen tubing and equipment weekly on Wednesdays. She stated the humidification containers were supposed to be checked each shift and changed when empty. The interview revealed Resident #25 did not have orders for the humidified oxygen because it was based on resident preference. She stated Resident #25 had complained of dryness in the past and humidification was added to her concentrator. Nurse #1 stated she had been in Resident #25's room but had not looked at her concentrator. She stated any staff member could look at the oxygen concentrator and notify her if it was empty. An interview was conducted with Nurse Aide (NA) #1 on 10/11/23 at 9:06 AM. NA #1 stated she had worked with Resident #25 on 10/10/23 and 10/11/23 and did not see the humidification container on the resident's oxygen was empty. She stated normally if she saw a container empty, she would let a nurse know. An interview was conducted with Nurse Aide (NA) #2 on 10/11/23 at 11:32 AM. NA #2 stated she had worked with Resident #25 on 10/10/23 with NA #1. She stated she had been working in the facility for one month and was told she wasn't allowed to change the humidification containers, so she did not look at the oxygen concentrator when she was in the room. An interview was conducted with Director of Nursing (DON) on 10/11/23 at 1:48 PM who stated it should be the responsibility of the nurse on the hall to ensure the oxygen humidification container was not empty. She stated the container should have been replaced. On 10/11/23 at 2:52 PM an interview was conducted with the Administrator. During the interview she stated Resident #25 wore her supplemental oxygen on an as needed basis and it was her preference to have humidified oxygen. She stated she did not think the oxygen had to be humidified as the facility had no physician order for it or standing physician order. The Administrator stated she did want staff to follow the physician order to change the equipment weekly or if the humidification container became empty.

Based on observations, record review and staff interviews, the facility failed to ensure a resident had been assessed to self-administer medications when the Nurse #1 gave the resident his medications to self-administer (Resident #63). This occurred for 1 out of 3 residents reviewed for medication administration. The findings included: Resident #63 was admitted to the facility on [DATE] with diagnoses which included hypertension and Parkinson's disease. Resident #63's quarterly Minimum Data Set (MDS) dated [DATE] revealed he was alert and oriented requiring was he cognitively intact extensive assistance of one staff member for most activities of daily living (ADL). On 04/04/23 at 4:32 PM an observation was conducted of Nurse #1 removing Resident #63's medication from the medication cart and placing the pills into a cup. Nurse #1 then obtained Resident #63's roommate's medication located in a clear cup and Resident #63's medication and entered the resident's room. Nurse #1 handed the cup of pills to Resident #63 and proceeded to turn her back to him while she sat his roommate up and administered his medication. Resident #63 was then observed picking through the cup of pills and swallowing each one, while Nurse #1 remained with her back to the resident. Nurse #1 then walked by Resident #63 and obtained the empty pill cup and exited the room. Resident #63's physician orders since his admission on 11/28/22 were reviewed and did not reveal an order to self-administer medication. An interview was conducted on 4/4/23 at 5:15 PM with Nurse #1. During the interview she stated she thought Resident #63 could self-administer his medication. Nurse #1 stated she did not feel like it was an issue to turn her back to Resident #63 or to take two residents' medications into the room at the same time. An interview was conducted on 4/5/23 at 10:23 AM with Resident #63. During the interview he stated Nurse #1 was the only nurse that handed him a cup of medication and left him to take it alone. He stated most nurses would stand with him while he swallowed the medication. Resident #63 stated he did not want to self-administer his medication further stating, there is no way I could keep up with my medication. An interview conducted on 04/05/23 at 12:42 PM with the Director of Nursing (DON) revealed no residents in the facility had orders to self-administer their medication. She stated she expected nurses to administer the resident's medication and remain in the room with the resident until they took all of the medication that was ordered. The DON stated if a resident were to request to self-administer their medication, they would need to sign a form prior to doing so and be assessed as safe to self-administer their medication.

Based on record review, resident, staff and family interviews the facility failed to allow unrestricted visitation by limiting visitation for 1 of 1 resident (Resident #51) reviewed for visitation. The findings included: Resident #51 was admitted to the facility on [DATE]. Review of Resident #51's admission Minimum Data Set (MDS) dated [DATE] revealed Resident #51 was cognitively intact and able to make her needs known. An interview conducted with Resident #51 and a family member on 04/03/23 at 11:55 AM revealed on Saturday 04/01/23 Resident #51's family member was asked to leave the facility. Resident #51 further revealed she had called her family member late that evening due to not feeling well and wanted company. Resident #51 stated her family member visited around 11:30 PM and was there for an hour in a private room and was asked to leave by Nurse #1 around 12:30 AM. Resident #51's family member stated Nurse #1 was rude and stated it was facility policy that the family member had to leave the facility. An interview conducted with Nurse #1 on 04/05/23 at 10:15 AM revealed she was an agency staff and had been working in the facility for a short period of time. Nurse #1 further revealed Resident #51's family member had visited late on 04/01/23. Nurse #1 stated Resident #51 was in a private room and Resident #51's family member had not caused any issues. Nurse #1 indicated Nurse #2 expressed concerns to her that Resident #51's family members were not supposed to visit late at night. Nurse #1 revealed she was unsure how long Resident #51's family member was going to visit but stated to the family member that she had been told by other nursing staff that they were not allowed to stay. Nurse #1 indicated Resident #51's family member got up and left the facility. An interview conducted with Nurse #2 on 04/05/23 at 2:05 PM revealed Nurse #1 had come to her and told her Resident #51's family member was there late visiting. Nurse #2 further revealed she had advised Nurse #1 that family members were not allowed to visit late in the facility unless the resident was on hospice. An interview conducted with the Director of Nursing and Administrator on 04/05/23 at 3:40 PM revealed they were not made aware that Resident #51's family member had visited late on 04/01/23. The Administrator further revealed the facility had no policy or rules that family members could not visit late at night. The DON and Administrator both stated Resident #51's family member should have not been asked to leave and all resident families were welcome at anytime as long as they do not disrupt nursing staff or other residents.

Based on observations, record reviews and resident, staff, Physician Assistant (PA), and Medical Doctor (MD) interviews, while under their care, the facility failed to implement an effective plan to protect the residents from accidents and injuries when smoking. Resident #34 and Resident #48 both utilized wheelchairs for mobility and had to navigate uneven pavement, with holes and cracks, to get to the side of the two-lane road which had a posted speed limit of 35 miles per hour and heavy local traffic. There were frequently cars parked across the street and during one observation a car had to go around Resident #48 as they smoked at the side of the road. The facility failed to ensure Resident #34 had a means to call for help. Both residents smoked during the day and night. Staff were not always aware of when the residents were at this location smoking. Sometimes when the residents returned to the building, the entrance door would be locked. There was no protection from the elements or interventions in place to warn drivers of the residents by the side of the road. There was no receptacle provided for the residents to extinguish their cigarettes or to leave their cigarette butts. This deficient practice occurred for 2 of 2 sampled residents (Resident # 34 and Resident #38). Immediate Jeopardy began on 08/15/22 when Resident #48 was provided an unsafe area to smoke. The Immediate Jeopardy was removed on 10/01/22 when the facility implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) to ensure safety measures, education, and monitoring systems put into place are effective. The findings included: 1. Review of the facility policy Smoking/Tobacco Use/ Electronic Cigarette Policy revised 07/07/2022 revealed for residents and families a.) Smoking/tobacco products are strictly prohibited, except in designated smoking areas and only for residents who are grandfathered tobacco product users. b) The use of tobacco products in any form is allowed off campus. Resident #48 was admitted to the facility on [DATE] with diagnoses which included hypertension, heart failure, renal failure, and age-related physical debility. Review of Resident #48 ' s admission Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact and required limited assistance for majority of activities of daily living (ADL). The MDS further revealed Resident #48 was coded for using a wheelchair and not coded for behaviors. The MDS also indicated Resident #48 was coded for tobacco use. Review of Resident #48 ' s care plan dated 08/15/22 revealed he currently used tobacco. The care plan ' s goal was Resident #48 would safely smoke cigarettes. Interventions included educate resident on potential risks of continuing tobacco use and offer tobacco cessation interventions, explain facility's smoking policy to resident and remind as needed, and explain to resident where the designated smoking areas are located. Review of the smoking assessment dated [DATE] revealed Resident #48 was a safe smoker. The assessment further revealed Resident #48 frequency use was hourly and was moderately mobile. The assessment stated Resident #48 had some difficulty maneuvering through the gate due to the latch and must take frequent rest breaks when self-propelling to the street. Review of Resident #48 ' s sign-out sheet revealed Resident #48 signed out to smoke on 08/15/22. The sign-out sheet further revealed Resident #48 had not signed out to smoke since 09/01/22. The sign out sheet indicated from 08/15/22 to 09/01/22 Resident #48 was not signed back in by facility representative. An observation conducted on 09/26/22 at 2:50 PM revealed Resident #48 was an estimated of 3 ft from the curb in the road smoking in a wheelchair with no staff present. It was observed to be no sidewalk out to the road where Resident #48 was sitting to smoke and no receptable for extinguished cigarette butts. The only way to the road was the driveway that visitors and transportation use. The observations further revealed cars parked on the other side of the road and traffic coming both ways. Observation revealed vehicles had go around Resident #48 due to where he was in the road. Observations of the smoking area revealed no cover area for different elements of weather, no fire extinguisher, or safety interventions in case of an emergency. Observations revealed an outside streetlight near the curb where Resident #48 had stationed to smoke. Resident #48 had a cell phone in his lap listening to music. An interview and observation conducted with Resident #48 on 09/26/22 at 3:15 PM revealed he had to go out to the road to smoke because the facility was a nonsmoking facility. Resident #48 further revealed he went out several times a day to smoke and sometimes at night and was not supervised because he was considered a safe smoker. Resident #48 had a cell phone in his hoodie pocket listening to music. Resident #48 was observed in his wheelchair and had to roll over multiple holes and cracks in the road. Resident #48 appeared to be tired and had to stop three times to catch his breath and strength to continue towards the facility door. Resident #48 was observed to also take two times to get up the small ramp to the facility door. Resident #48 was breathing hard and requested water from the Administrator once to the facility door. An interview conducted with the facility Physician Assistant (PA) on 09/28/22 at 10:45 AM revealed she was aware Resident #48 consistently smoked throughout the day. The PA further revealed she did not feel like it was safe for residents to be in the road smoking. The PA indicated Resident #48 was not able to move quick enough in his wheelchair due to being weak sometimes from [CONDITION(S)] treatments. An interview with the Administrator 09/28/22 at 3:35 PM revealed Resident #48 had not had an incident while smoking and felt that he was safe because he had completed a smoking assessment and was alert and oriented. The Administrator further revealed the facility was a nonsmoking facility before Resident #48 was admitted but felt like it was the residents right if he wanted to smoke. The Administrator stated there was no area other than the road for residents to smoke, but Resident #48 had been educated verbally on smoking rules and signing out. The Administrator revealed there was not a set time that doors were locked in the evening, but usually did when it started to get dark outside. The Administrator indicated she did not recall smoking residents had gone out in harsh weather elements, but indicated she had no plans or provisions for upcoming weather elements. An observation conducted on 09/28/22 at 4:30 PM revealed from the facility door to the road was an estimation of 132 feet. From the road to the road that intersected was 69 feet. It was further observed cars to be lined up parked on the right side of the road and made it impossible for two vehicles to pass one another other where Resident #48 had sat to smoke during observations. The road observed to have broken and uneven. An interview and observation was conducted on 09/29/22 revealed Resident #48 had exited the facility at 8:32 AM and was positioned to smoke at 8:37 PM. It was further observed Resident #48 was able to light his own cigarette and extinguished it by throwing it down on the road. Resident #48 had flickered the ashes in front of him and ashes were observed on his clothing and the seat of his wheelchair. Resident #48 revealed he sometimes got weak from [CONDITION(S)], and it was harder for him to get back to the facility when he felt weak and tired. Resident #48 indicated he smoked during the day and night and would have to ring the bell to get back in. Resident #48 stated he usually didn ' t tell staff he as smoking and just went because he felt he didn ' t have too. An interview conducted with a Nurse Aide (NA) #3 on 09/29/22 at 10:55 AM revealed Resident #48 went out to smoke several times a day and sometimes at night. NA #3 further revealed Resident #48 would rarely sign out and staff would not know when he was outside smoking. NA #3 stated nursing staff had not been educated on assisting or knowing when residents went out to smoke. NA #3 indicated at night there was an outside light that was on at some hours of the night. The NA revealed when the light was not on it was pitch dark and residents did not have a flashlight. NA #3 indicated residents that smoked would have to ring the bell to get back in because doors locked every evening around dark. The NA stated she did not feel that it was safe for residents to be in the road smoking and staff not being aware when they were outside. An interview conducted with the Medical Director (MD) on 09/29/22 at 2:55 PM revealed Resident #48 was a fall risk and was weak sometimes due to renal failure. The MD further revealed he believed Resident #48 was not completely safe in the road smoking and could be potential for an incident to occur. An interview conducted with the Director of Nursing (DON) on 09/29/22 at 4:50 PM revealed she was not aware Resident #48 was not consistently signing out. The DON further revealed Resident #48 should have been encouraged and educated on the importance of signing out each time he had smoked. The DON stated she did not know the smoking rules, interventions, or if residents were smoking at night. 2. Resident #34 was admitted to the facility on [DATE] with diagnoses which included fracture of lumbar vertebrae with routine healing, [CONDITION(S)], and peripheral [CONDITION(S)]. Review of Resident #34's quarterly Minimum Data Set, dated dated dated [DATE] revealed she was cognitively intact, required extensive assistance of 2 staff with transfers and utilized a wheelchair for mobility. The MDS assessment indicated Resident #34 required supervision with locomotion on and off the unit with set up help only. Review of a Smoke Risk Assessment performed on 08/20/22 revealed Resident #34 was assessed as a safe smoker by Nurse #1. The Smoking Risk Assessment revealed the resident was assessed with a score of 0 with 0-9 being documented as a safe smoker according to the scale on the assessment form. A telephone interview was attempted with Nurse #1 on several occasions without success. Resident #34 was documented starting on 08/21/22 as going out to smoke as indicated by her sign out/sign in sheet located in the resident's smoking notebook at the nurse's station. On 08/22/22 Resident #34 was assessed again as a safe smoker by Nurse #2. The Smoking Risk Assessment revealed the resident was assessed with a score of 3 with 0-9 being documented as a safe smoker according to the scale on the assessment form. The assessment indicated Resident #34 had a moderate problem with being careless with smoking materials (2) and a minimal problem with mobility (1) but was still documented as being a safe smoker. Under the smoking risk it was documented a smoking apron was needed. An interview on 09/28/22 at 3:03 PM with Nurse #2 revealed she had completed Resident #34's Smoking Risk Assessment on 08/22/22. She stated the resident had seen another resident smoking and had requested to be assessed for smoking safely on her own. Nurse #2 further stated it had been explained to the resident she would have to be able to sign out, accept responsibility for herself while out smoking as though she had signed out as leaving the facility. She indicated the resident was willing to sign in and out of the facility to accept responsibility for herself and wished to move forward with the assessment to be able to smoke off the facility premises. Nurse #2 further indicated during the assessment Resident #34 had minimal trouble maneuvering her wheelchair out to the road due to uneven pavement and had issues with lighting her cigarette and slight difficulty with not getting ashes on her pants when flicking them from her cigarettes. According to the assessment, Nurse #2 recommended a smoking apron due to her hand tremors but said she was not sure if one had been provided for the resident or where it was located. Nurse #2 stated she had not provided the apron nor evaluated whether the resident was able to put the apron on by herself and said she had not seen the resident wearing an apron when leaving the unit to go out to smoke. A review of Resident #34's care plan dated 08/24/22 revealed a focus area for resident currently using tobacco. The interventions included educate resident on potential risks of continuing tobacco use and offer tobacco cessation interventions, evaluate continued safety with smoking/tobacco product use quarterly, explain facility's smoking policy to resident and remind as needed, explain to resident where designated smoking areas are located and remind as needed, observe clothing/skin for any [CONDITION(S)], holes, etc., and report to physician as appropriate and provide supervision when smoking as needed. An observation on 09/27/22 at 2:11 PM revealed Resident #34 sitting in her wheelchair up against the curb on the side of the road in front of the facility smoking. The resident was not wearing a smoking apron. An observation on 09/28/22 at 2:13 PM revealed Resident #34 sitting in her wheelchair up against the curb on the side of the road in front of the facility smoking. The resident was not wearing a smoking apron. An interview on 09/28/22 at 10:36 AM with the Physician Assistant (PA) for the facility revealed she didn't think it was a good idea for residents to be on the road smoking; however, she stated she understood they had to be off the property to smoke. The PA stated she didn't think it was safe for the residents to be on the road smoking. An interview on 09/28/22 at 11:18 AM with the Unit Manager (UM) revealed she was aware Resident #34 went out to smoke off the property. The UM stated Resident #34 signed herself out to smoke and while off the property smoking, she was responsible for herself just like residents who left the building on a leave of absence. The UM further stated she was not aware the resident had been assessed as needing a smoking apron and said she had not seen the resident wearing an apron and was not sure if an apron had been provided to Resident #34. She indicated staff including herself were out during their breaks smoking off the premises as well and saw the residents out on the road smoking. The UM further indicated she was not aware if Resident #34 had a smoking apron in her room but said if she had been assessed to wear one it should be kept in her room. An interview on 09/28/22 at 3:03 PM with Nurse #2 revealed Resident #34 went out to smoke a lot during the day but said she had to sign out and sign back in when she returned. Nurse #2 stated the resident usually didn't tell them when she went out or came back in but was supposed to sign out and back in. She further stated any staff member could sign her back in. After seeing the sign in and out book, Nurse #2 indicated she was not sure why Resident #34 was not being signed back in by the staff. An interview on 09/28/22 at 3:35 PM with the Administrator revealed Resident #34 was allowed to smoke but had to do so off the property since their facility was non-smoking. She indicated during inclement weather she assumed Resident #34 would not go out to smoke and when it was hot, they could come to the front porch and the staff would get them some water or give them some water before they went out to smoke. The Administrator further indicated Resident #34 had been assessed as a safe smoker and was able to sign out as though she was leaving the building on a leave of absence and go out by herself to smoke. She stated Resident #34 was intact and able to get off the property to smoke so they had decided to let her smoke. The Administrator further stated Resident #34 was able to hold her cigarette, light it and extinguish it so she was able to smoke without assistance. The Administrator said she was not aware it had been recommended for the resident to wear a smoking apron and said to her knowledge she was not wearing one. She indicated the facility did have a smoking policy although they were a non-smoking facility and provided a copy of the policy. An interview on 09/28/22 at 4:00 PM with the Admissions Director revealed she was not aware Resident #34 wanted to smoke prior to her admission. She stated Resident #34 was admitted from home and in the admissions process she was informed the facility was smoke free and signed the admission paperwork. The Admissions Director further stated she was not aware why the resident was allowed to smoke after being non-smoking at the facility for 3 months but said she was aware when she admitted to the facility smoking was not allowed on the premises. An interview on 09/28/22 at 4:29 PM with NA #2 revealed Resident #34 was in and out of the facility pretty much all-day smoking. She stated she was out before daylight at 6:00 AM some mornings and had been out late at night when it was dark. NA #2 further stated when the door was locked the resident rang the bell for staff to let her back in at night. She indicated when Resident #34 had been out to smoke she had not noticed the resident wearing a smoking apron and was not aware she had been assessed as needing to wear an apron. An interview on 09/28/22 at 4:55 PM with NA #3 revealed Resident #34 smoked a lot and was out smoking late at night. She stated the staff was not always aware that she was out smoking until they looked for her and couldn't find her. NA #3 indicated the resident did not have a cell phone to call if she had a problem while out smoking but said employees were out smoking and would probably see and assist her if she had any problems. She further indicated Resident #34 was able to maneuver her wheelchair pretty well out to the road where she smoked and back into the facility. NA #3 said she was able to hold her cigarette, light it, flick her ashes and extinguish it without any problems. NA #3 indicated she was aware the resident had to be off the property to smoke but stated it was not safe because she was not fast enough in her wheelchair to get out of the way of a car and there was a lot of traffic on the road where the residents and the staff smoked. A continuous observation and interview on 09/29/22 from 8:23 AM to 8:53 AM revealed Resident #34 out in the road smoking. The resident was in her wheelchair dressed in sweatpants, sweatshirt, tee shirt under the sweatshirt, socks, and tennis shoes. The weather was 54 degrees, and the wind was moving at 13 miles per hour making it feel like 51 degrees according to the Weather.com app. The resident was actively smoking and there were ashes noted on her pants and wheelchair. There were no burn holes noted in her pants or shirt. The resident was able to hold her cigarette, get it to her mouth and with both hands light it due to her tremors. She was able to hold the cigarette with one hand and flick the ashes off her wheelchair, but some blew back on her clothing with the wind. Resident #34 extinguished her cigarette by throwing it on the road and putting it out with her shoe. An interview with the resident revealed she had been educated to sign out when going out to smoke, so she accepted responsibility for herself as though she had signed out and left the building. She further revealed she had not been told to wear a smoking apron and had not been provided a smoking apron by the facility. Resident #34 stated her sweatshirt was the only warm clothing she had and said she didn't have a coat for the colder weather. Resident #34 further stated she didn't have a cell phone or any means to communicate with the staff while out smoking. Resident #34 explained she was out one day when it was raining and by the time, she got back into the building from outside she was soaked from head to toe and had to have a complete clothing change. She stated no one had offered her an umbrella or raincoat on days she was out smoking when it was raining. Resident #34 further stated on days it was cooler she crossed the road in her wheelchair so she could sit in the sun where it was warmer. There were cigarette butts noted all along the side of the road and Resident #34 stated it was from the residents and staff smoking because there was no where to extinguish their cigarettes except on the pavement of the road. An observation on 09/29/22 at 10:00 AM revealed Resident #34 across the road in her wheelchair sitting in the sun. The back of her wheelchair was facing the road and she was sitting in her wheelchair in front of a parked car. An interview on 09/29/22 at 2:47 PM with the attending physician revealed from a professional opinion he would recommend all patients go on a patch and not smoke; however, if they are alert and oriented you really can't tell them they can't go off the property to smoke. The physician stated he would prefer for them to be able to smoke in a safer place that was not on the road but said they had to be off the property. The physician indicated it was not ideal for them to smoke in the road but said it was off the property as the facility required. He further indicated it might be advantageous to check into the city easement of the property to see if they could smoke within the easement that was not actually the property but not the road. An interview on 09/29/22 at 4:48 PM with the Director of Nursing (DON) revealed they were a non-smoking facility and if the residents were alert and oriented and signed themselves out what they did while signed out was their right. The DON reviewed the sign out books and said the residents should have consistently signed out and the staff should have consistently signed them back in to the facility. A follow up interview on 09/29/22 at 5:48 PM revealed the Administrator was not aware the residents were not consistently signing themselves out to smoke and staff was not consistently signing them back into the facility after smoking. She stated she expected them to sign out accepting responsibility for themselves while out smoking and expected the staff to sign them back in consistently to account for their whereabouts. The Administrator was notified of Immediate Jeopardy on 09/29/22 at 12:45 PM. The facility provided the following IJ Removal Plan with the correction date of 10/01/22. #1 Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Peak Resources [NAME] failed to ensure the safety of Resident #48 and Resident #34 while they were smoking off facility property. The Administrator and Director of Nursing determined that there were no additional residents who were smoking off facility property. #2 Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. Peak Resources [NAME] is a smoke-free facility. All residents/representatives are advised of this prior to or during the admission process by facility staff. Residents of Peak Resources [NAME] are not allowed to smoke on facility property and must exit facility property to do so. If a resident notifies facility staff that they wish to smoke after being admitted to the facility, facility staff offer resident smoking cessation options, including patches, gum, or medication, if approved by resident's physician. If they still choose to smoke off facility property, licensed nursing staff will complete a Peak Smoking Risk Observation to determine if the resident is safe to smoke independently off property. Residents who are able to smoke off property independently, will be educated by licensed nursing staff where to smoke, required safety equipment, including reflective vest, reflective strips if using a wheelchair, flashlights if smoking after dark, appropriate attire for inclement weather and the procedure to notify facility staff upon exiting and returning to the facility after smoking and the requirement to sign in and out at the nurse's station. Any resident who is unable to smoke off property independently will be offered smoking cessation options and will be issued a Nursing Home Notice of Transfer/Discharge. If resident chooses to smoke supervised, staff supervision will be provided at designated times. The Administrator purchased reflective vests, reflective strips, and flashlights on 9/29/2022 and provided them to Resident #48 and Resident #34. The reflective strips were put on Resident #48 and Resident #34 wheelchair on 9/29/2022 by the Maintenance Department. Resident #34 was provided a smoking apron on 08/22/2022 to prevent ashes from dropping on her clothes. The smoking apron is kept in the resident's room. Resident #34 was educated on the use of the smoking apron on 09/29/2022 by the Director of Nursing. The Administrator purchased a pair of Walkie-Talkie's on 09/30/2022 for Resident #34. One was provided to Resident #34 on 09/30/2022 and one was provided to the nurse assigned to Resident #34 by the Administrator on 09/30/2022. One walkie-talkie will be kept in Resident #34 room, and one will be kept with the nurse who is assigned to provide care to the resident. Resident #48 and Resident #34 were educated by the Director of Nursing on 9/29/2022 on the following: Smoking must occur off property in front of the curb in front of the facility and Resident #48 and Resident #34 were shown the location. Must wear a reflective vest when outside smoking. Resident #48 was able to don the reflective vest independently. Facility staff will assist Resident #34 with donning her reflective vest upon request if needed. Resident has been educated to ask for assistance if having difficulty with donning or doffing reflective vest. The reflective vests will be kept in the resident's rooms. Must have reflective strips on wheelchair while outside smoking Must use a flashlight after dark while outside smoking. The flashlights will be kept in the resident's rooms. Must notify facility staff when exiting the facility to smoke and upon returning to the facility after smoking. Smoking materials must be locked in a locked box in the resident room. Must sign in/out at the nurse's station upon exiting the facility to smoke and upon returning to the facility after smoking. To wear appropriate weather attire if choosing to smoke off property during inclement weather. To wear appropriate weather attire if choosing to smoke off property during extreme heat or cold weather. Risk of smoking during inclement and/or extreme weather conditions (potential for injury, dehydration, frost bite, heat exhaustion, sunburn) Resident number #34 was also educated to use the smoking apron and Walkie Talkie when outside smoking. Resident was informed that the apron is used to prevent ashes from being dropped onto her clothing and the Walkie Talkie is to be used to call for assistance. Resident was educated on the use of the Walkie-Talkie by the Administrator on 09/30/2022 and was able to use the Walkie-Talkie independently. The Walkie-Talkie was tested from the area where Resident #34 smokes off property to ensure that it worked properly, and communication was successful with the nurse inside the facility. All licensed nurses, medication aides, CNAs, and agency staff who may provide care to Resident #48 and Resident #34 will be in-serviced on the following: Smoking must occur off property in front of the curb in front of the facility and any resident who chooses to smoke off property must be shown the location. Residents who smoke off property must be provided a reflective vest when outside smoking. Facility staff must observe the resident donning the vest independently. If the resident cannot don the vest independently, facility staff will assist the resident to don the vest. The resident's reflective vests will be kept in the resident's room. Residents smoking off property in wheelchair must have reflective strips on the wheelchair. Residents must be provided a flashlight and be instructed to use the flashlight after dark. The flashlights will be kept in the resident's rooms. Residents will be instructed that they must notify facility staff when exiting the facility to smoke and upon returning to the facility after smoking. Resident rounds are completed at a minimum of every two hours. Residents must be provided a locked box and smoking materials must be locked in a locked box in the resident room. Residents must sign in/out at the nurse's station upon exiting the facility to smoke and upon returning to the facility after smoking. Resident rounds are complete at a minimum of every two hours. Residents must be instructed to wear appropriate weather attire if choosing to smoke off property during inclement weather. Residents must be instructed to wear appropriate weather attire if choosing to smoke off property during extreme heat or cold weather. Resident must be instructed about the risk of smoking during inclement and/or extreme weather conditions (potential for injury, dehydration, frost bite, heat exhaustion, sunburn) If the resident does not have a cellphone to notify facility of assistance, a Walkie Talkie is provided by facility staff. The nurse that is assigned to any resident who requires a Walkie Talkie for communication will keep one Walkie Talkie on during their shift. Staff supervision will be provided to any resident identified as unsafe to smoke independently at times designated by facility. This education will be completed by the Administrator, Corporate Management Nurse, DON, or SDC and will be completed by 09/30/2022. Any facility staff out on leave or on PRN status will be educated prior to returning to duty by the Administrator, Director of Nursing, or Staff Development Coordinator. Any newly hired licensed nurse, medication aide, CNA or agency nurse will be educated during orientation by the Director of Nursing, Staff Development Coordinator, or designee. The Director of Nursing will be responsible for tracking staff that have not received the education. The Director of Nursing, Corporate Management Nurse and Staff Development Coordinator were advised of their responsibilities on 09/29/2022 by the Administrator. TITLE OF THE PERSON RESPONSIBLE FOR IMPLEMENTING THE CREDIBLE ALLEGATION FOR IMMEDIATE JEOPARDY REMOVAL. The Administrator and the Director of Nursing will be ultimately responsible to ensure the implementation of credible allegation to remove this alleged immediate jeopardy. Immediate Jeopardy Removal Date: 10-1-2022 The credible allegation for the immediate jeopardy removal was validated on 10/5/22 with a removal date of 10/1/22. On 10/5/22, the facility's credible allegation was validated through observations, staff interviews, and record reviews. The facility provided education documentation for all staff on safe smoking practices for the smokers at the facility which included use of reflective vest, reflective strips on the wheelchairs, use of flashlight after dark, signing in and out when going outside for smoking, resident rounds at a minimum of every two hours, use of cellphone or walkie-talkie, provision of a locked box for the smoking materials and encouragement to dress appropriately for the weather. Interviews with licensed nurses, medications aides, nurse aides and agency staff revealed they received education on safe smoking practices for the smokers at the facility. Observations were made of both Resident #48 and Resident #34. Both wheelchairs were lined with reflective strips at the back and on the wheels. An observation of Resident #48 while smoking outside the facility revealed him wearing a bright orange toboggan to help with increased visibility. Interviews with Resident #48 and Resident #34 revealed they received education on use of reflective vest, flashlight after dark, use of cellphone or walkie-[NAME] [TRUNCATED]

Based on observations, record reviews, staff, Physician Assistant, and physician interviews, the facility failed to ensure skin assessments were completed as ordered and new skin breakdown was reported for 1 of 1 resident reviewed for wound care (Resident #21). Findings included: Resident #21 was admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #21 was coded as having skin issues upon admission and required ointment or medications to feet. Review of Resident #21's revised care plan dated 08/09/22 revealed Resident #21 was at risk for skin breakdown related to incontinence, assistance needed with daily living, and poor distribution of adipose tissue. Care plan goal stated Resident #21 would remain intact and free from any signs or symptoms of additional skin breakdown. Interventions included conducting skin inspection twice a week and paying particular attention to the bony prominences. Review of Resident #21's skin assessments revealed assessments had been completed only once a week from 05/09/22-08/03/22, and on 09/21/22, and 09/28/22. No skin assessments had been completed from 08/03/22 through 09/21/22. Skin assessments included checking yes or no for preexisting skin impairments and any new skin impairments observed and documenting the type of skin impairment and where it was located. Review of admission skin assessment dated [DATE] revealed Resident #21 was admitted with preexisting skin impairments of sacrum and groin area to include scabbed areas on the sacrum and rash like bumps on groin area. Review of weekly skin assessment dated [DATE] revealed yes for preexisting skin impairments with no description of skin impairments and checked no for any new skin impairments. Review of weekly skin assessment dated [DATE] revealed no was checked for preexisting skin impairments and any new skin impairments. Review of weekly skin assessment dated [DATE] revealed no was checked for preexisting skin impairments and any new skin impairments. Review of weekly skin assessment dated [DATE] revealed no was checked for preexisting skin impairments and any new skin impairments. Review of weekly skin assessment dated [DATE] revealed yes was checked for preexisting skin impairments with no description of skin impairment and checked no for any new skin impairments. Review of nursing note dated 06/20/22 revealed Resident #21 had raw/ pink area underneath left scrotum. Nursing staff had cleansed area with soap and water and notified Nurse Practitioner in-person. Review of skin tear assessment form dated 06/20/22 revealed Resident #21 was observed having skin tear underneath left scrotum. Nursing staff cleansed area with soap and water. Treatment was somewhat effective, and Nurse Practitioner was notified in-person with no further orders or recommendations for treatment. Review of skin assessment dated [DATE] revealed no was checked for preexisting skin impairments and any new skin impairments. Review of nursing note written by the Unit Manager dated 07/01/22 revealed she was informed by nursing staff of Resident #21 worsening rash to buttocks and groin. Order was received for [MEDICATION(S)] twice daily for 14 days. Review of physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of skin assessment dated [DATE] revealed no was checked for preexisting skin impairments and any new skin impairments. Review of nursing note written by Nurse #4 dated 08/01/22 revealed Resident #21 verbalized complaints of pain and redness to his penile tip. Resident #21 was in no acute distress. Resident #21 placed on doctor's board for evaluation as requested. Review of nursing note written by Nurse #6 dated 08/02/22 revealed Resident #21 called 911 twice. Resident #21 stated his rectum was burning and on fire internally. No abnormality was noted to rectal area upon examination. Nursing Assistant to clean area with soap and water and apply clean brief. No note of physician or nurse practitioner being notified. An interview conducted with Nurse #6 on 09/29/22 at 2:44 PM revealed she worked second shift at the facility and was familiar with Resident #21 and his on-going skin issues. She stated Resident #21 was admitted with skin issues and had continued to have skin issues on his bottom, groin, and genital area. She revealed she had been working with Resident #21 in August 2022 when he called 911 twice complaining of burning and pain inside and around his rectum. Nurse #6 stated she had completed an evaluation on Resident #21 and was not able to observe any issues. She revealed she had asked the nursing assistant to clean Resident #21 with soap and water and apply a new brief. Nurse #6 stated she did not recall notifying the physician of the 911 call or the concerns from Resident #21 but should have and did not recall if she had informed the on-coming nurse of the incident. Review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . No notes were made during routine visit addressing incidents from 08/01/22 or 08/02/22 where Resident #21 had complaints of pain, redness, and burning of genital area. Review of skin assessment dated [DATE] revealed no was checked for preexisting skin impairments and no for any new skin impairments. Review of nurses note written by the Unit Manager dated 09/06/22 revealed nursing staff was called to Resident #21's room. Resident #21 had blood in his brief and no blood was noted coming from his penis. Resident #21 had a pinkish red excoriation under the head of penis. Telephone order received from Physician Assistant (PA) for [MEDICATION(S)] to be applied twice daily for 14 days. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview conducted with the Unit Manager on 09/28/22 at 11:35 AM revealed she was familiar with Resident #21 and his on-going skin issues. She stated Resident #21 was admitted to the facility with skin issues on his bottom and groin area, and those had continued along with new skin issues on his genital area. The Unit Manager revealed early in September 2022 she had to notify the PA of a new skin issue on Resident #21's genital area and [MEDICATION(S)] was prescribed. She stated nursing staff was responsible for completing weekly skin audits on every resident as a standing order and nursing assistant staff was responsible for notifying nursing staff of any changes or new skin issues and the treatment nurse was responsible for reviewing weekly skin audits. The Unit Manager revealed she was not aware Resident #21's care plan interventions included skin audits twice weekly nor was she aware he had not received any skin audits from 08/03/22 through 09/21/22. She stated nursing staff should have followed Resident #21's care plan and completed twice weekly skin audits since admission. An interview was conducted with Nurse Aide (NA) # 4 on 09/28/22 at 9:41 AM revealed she was familiar with Resident #21 and was responsible for providing his personal care. She stated Resident #21 was admitted to the facility with skin issues on his bottom and groin area. She also stated Resident #21 continued to have on-going skin issues on his bottom, groin, and genital area and described them to be scabbed over sores on some areas of bottom, rash like bumps in his groin area, and raw red areas in his genital area. NA #4 revealed she had not been in-serviced on providing personal care to residents with skin issues but attempted to be gentler when providing personal care to Resident #21 and when he was showing signs of pain during personal care would ask what was causing pain and notified nurse. She also revealed Resident #21 did not vocalize being in pain when she was performing personal care but would grimace or wince when being cleaned. She stated nursing staff had been responsible for completing weekly skin checks for Resident #21, but she would notify nurse if any new skin issues had been observed during personal care. An interview conducted with NA #9 on 09/28/22 at 10:19 AM revealed she was familiar with Resident #21 and had been responsible for providing his personal care. She stated Resident #21 was admitted to the facility with skin issues on his bottom and genital area and continued to have skin issues on his bottom and genital area. NA #9 described Resident #21's skin issues as being scabbed, open, and raw areas from his bottom to his genital area. She revealed on occasions when she had assisted Resident #21 with personal care, he had made comments of it hurting or being tender and would show signs of it hurting by making a face and she notified the nurse. She stated she believed the Treatment Nurse had been visiting Resident #21 daily for his skin issues but was not aware of any new treatments or referrals made to the physician or the wound doctor. NA #9 revealed she notified nursing staff of any changes with Resident #21's skin issues observed during personal care and nursing staff was responsible for completing weekly skin checks. An interview was conducted with the Physician Assistant (PA) on 09/28/22 at 10:42 AM revealed she was familiar with Resident #21 and his on-going skin issues. She stated to her knowledge Resident #21 was admitted to the facility with skin issues that had continued and on a couple of occasions required an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The PA revealed she had not been made aware of continued red and raw areas on the genital area since ordering [MEDICATION(S)] on 09/06/22. She stated nursing staff should have been completing weekly skin checks and following up with any treatments needed or notifying physician of any changes. The PA revealed she believed Resident #21 was being followed by the wound doctor that comes every Monday but when checked the electronic record she found Resident #21 had not been referred to the wound doctor and she would discuss with the team if a referral needed to be made. An interview conducted with the Treatment Nurse on 09/29/22 at 2:33 PM revealed she had been the Treatment Nurse since 09/06/22 and prior to that had been the interim Director of Nursing and Staff Development Coordinator. She stated she was familiar with Resident #21 and his on-going skin issues. The Treatment Nurse revealed Resident #21 was admitted to the facility with skin issues on his bottom and groin area and those have continued along with skin issues on genital area. She stated since becoming the Treatment Nurse, she had been assessing Resident #21's skin weekly not due to receiving a referral but because of Resident #21's on-going skin issues. The Treatment Nurse revealed Resident #21 had not been referred or evaluated by the facility wound doctor and to her knowledge had only received [MEDICATION(S)] treatment on a couple of occasions. She stated nursing staff had completed at least weekly skin audits on Resident #21 as a standing order, but if the care plan required twice weekly skin audits nursing staff should have completed skin audits according to care plan. The Treatment Nurse had no knowledge as to why twice weekly skin audits were not completed or why no one completed skin audits from 08/03/22 through 09/21/22. She stated the facility physician should have been contacted anytime there had been skin changes with Resident #21 to evaluate for a change in treatment or when 911 was called. An interview conducted with the facility Attending Physician on 09/29/22 at 2:49 PM revealed he had begun working at facility as the Attending Physician the end of July 2022 and was at the facility every Thursday. He stated he was not as familiar with Resident #21 and was only notified around two weeks ago that Resident #21 had on-going skin issues being treated with barrier cream. The Attending Physician revealed he was not made aware Resident #21 had been admitted with skin issues that had continued and traveled to new areas or that he had been ordered [MEDICATION(S)] on different occasions with continued skin issues. He stated the facility physician should be notified when there had been skin changes with a resident or when skin issues were not improving so the resident could be assessed for a different treatment or if a referral needed to be completed to the wound doctor or another specialty. The Attending Physician revealed no knowledge of Resident #21 complaining of pain and redness in his genital area or calling 911 with concerns of pain and burning around his rectum which should have been reported to physician immediately and followed up to make sure was he evaluated properly. He stated nursing staff should have been completing at least weekly skin audits on Resident #21 to document and notify physician of any changes so treatment could be assessed. An interview was conducted with the Director of Nursing (DON) on 09/29/22 at 4:50 PM revealed no knowledge of the physician not being notified of Resident #21's skin changes or calling 911 with care concerns and that nursing staff should have notified facility physician immediately of any skin changes or Resident #21 calling 911 with care concerns. An interview with the Administrator on 09/29/22 at 6:02 PM revealed nursing staff should have also notified the PA or the physician of pain and changes in skin issues with Resident #21.

Based on record reviews, observations and resident and staff interviews, the facility failed to treat residents in a dignified manner when staff did not provide incontinence care when requested and left a clean brief in the resident's visitor chair. The resident expressed feelings of being upset and mad. This affected 1 of 3 residents reviewed for dignity and respect (Resident #58). The findings included: Resident #58 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the admission Minimum Data Set (MDS) dated [DATE] indicated Resident #58 was cognitively intact and required extensive assistance with activities of daily living (ADL). The MDS further revealed Resident #58 was always incontinent of urine and frequently incontinent with bowels. a. An interview conducted with Resident #58 on 09/26/22 at 12:20 PM stated she was upset and mad as fire because staff had not answered her call light timely yesterday on 09/25/22 and she had wet all the way through her brief to the sheets. Resident #50 indicated she activated her call light at 4:15 AM through 5:00 AM no staff had come to assist her yet. Resident #8 stated she watched the clock on the wall next to her. Resident #58 further revealed she had to call and wake up a family member to contact the nursing station to send someone down to change her. Resident #58 stated once the family member called the nurses station that nursing staff had come to her room and she received assistance at about 5:10 AM. An interview conducted with a family member on 09/27/22 at 10:40 AM revealed Resident #58 had called her about 5:00 AM furious and mad that nursing staff had not answered her call light and she had gone through her brief and sheets. The family member further revealed she immediately called the nurses station and requested that nursing staff check on Resident #58. The family member stated the nurse refused to give her name and denied Resident #58's call light being on. An interview conducted with Nurse Aide (NA) #6 on 9/29/22 at 10:45 AM confirmed she was assigned to Resident #58 on 9/25/22 from 11:00 PM to 7:00 AM. NA #6 revealed she had assisted Resident #58 on 09/25/22 around 5:00 AM. NA #6 further revealed she was assisting another resident across the hall and does not recall Resident #58's call light being on. NA #6 stated when she returned to the nursing station a family member had contacted the front desk and NA #6 went immediately to assist Resident #58. NA #6 could not recall if Resident #58 had soaked her brief and sheets. NA #6 indicated she had changed Resident #58 earlier in the shift but could not recall what time. An interview conducted with Nurse #5 on 09/29/22 at 12:05 PM revealed she was on another hall giving medicine and Resident #58's family member called the nurses desk early in the morning. Nurse #5 stated the family member was upset and stated Resident #58 had been waiting a while to receive care. Nurse #5 indicated NA #6 was assisting another resident and Nurse #5 could not recall how long Resident #58's call light had been on. Nurse #5 stated weekends sometimes were short staffed, and care was not given as quickly as it should. Nurse #5 indicated she recalled enough staff working this past weekend. b. An interview and observation conducted on 09/27/22 at 10:50 AM revealed Resident #58 pointed to a chair with a clean brief laying in it. Resident #58 stated she was embarrassed and frustrated because therapy and her daughter had visited her room today and Resident #58 was not aware a brief was laying in the chair visitors would usually sit. Resident #58 stated she felt it was not acceptable and that she did not want her visitors knowing she had to wear a brief and felt like it was a breach of privacy. An interview and observation conducted with Nurse #4 on 09/27/22 at 10:55 AM revealed she was not aware a brief had been left in Resident #58's bedside chair. Nurse #4 stated it was not professional and was also a breach of privacy for Resident #58. Nurse #4 indicated briefs should be kept in Resident #58's closet. An interview conducted with NA #5 on 09/27/22 at 11:00 AM revealed she had observed the brief in the chair this morning before breakfast. NA #5 indicated Resident #58 did not complain about the brief NA #5 did not think about removing it. NA #5 stated Resident #58's gown and brief should have not been left in the chair for others to see. An interview conducted with the Director of Nursing (DON) on 09/29/22 at 4:35 PM revealed she had not been advised Resident #58 had complained of waiting for her call light to be answered on 09/25/22, and a brief had been left out for other residents and visitors to see. The DON indicated she expected for staff to answer call lights in a timely manner, and to keep private items such as briefs in Resident #58's closet until use. An interview conducted with the Administrator on 09/29/22 at 6:05 PM revealed she had not been advised Resident #58 had complained of waiting for her call light to be answered on 09/25/22, and a brief had been left out for other residents and visitors to see. The Administrator stated she expected call lights to be answered in a timely manner, and 45 minutes was too long. The Administrator indicated she expected NA #5 to remove the brief when she observed it and briefs were expected to stay out of sight until use.

Based on record reviews, staff and responsible person interviews, the facility failed to report to the state survey agency within the required timeframe and notify the responsible person for 1 of 1 resident reviewed for resident abuse (Resident # 21). The findings included: Review of facility policy and procedure titled Abuse, Neglect, Misappropriation of Resident Property, and Exploitation Policy with a revised date of November 28, 2016, read in part under the reporting section: if the events that caused the allegation involve abuse or result in serious bodily injury the notification must be made by phone or fax within 2 hours after the allegation is made. The administrator or designee would inform the resident representative within two hours of initial abuse investigation and once 5-working day report was completed notify resident representative of the results of the investigation, the corrective action taken, if any, upon completion of investigation. Resident #21 was admitted to the facility on [DATE]. Review of facility face sheet dated 05/06/22 revealed Resident #21's mother was listed as responsible person and was to receive financial, medical, and personal information. The admission minimum data set (MDS) dated [DATE] revealed Resident #21 was severely cognitively impaired. Review of initial facility reported incident (FRI) report dated 06/29/22 revealed allegations of resident abuse towards Resident #21 by staff when performing incontinence care. The initial report also revealed the facility had been made aware of the incident at 11:30 AM and the report was faxed to the state agency at 4:30 PM. Telephone interview with Resident #21's resident representative dated 09/26/22 at 1:08 PM revealed she was the responsible person for her son Resident #21. She stated she had no knowledge of the facility investigation for the allegation of abuse towards Resident #21 by staff during incontinence care. Resident #21's resident representative revealed no one from the facility had contacted her about an abuse investigation or of the outcome of the investigation. She revealed no one ever informed her of any concerns with abuse and she would have liked to have been notified. An interview was conducted with the previous Director of Nursing (DON) on 09/27/22 at 9:52 AM revealed she had completed an investigation of an allegation of abuse towards Resident #21 by staff during incontinence care. The previous DON revealed she was not familiar with the time frames of reporting and was not aware the initial report with allegations of resident abuse should have been faxed in within two hours or that Resident #21's responsible person should have been notified of the allegations of abuse and the outcome of the investigation. She stated she had not been trained on how to conduct a resident abuse investigation and had to rely on instructions from corporate on how to complete the initial report form and the 5-working day report. Administrator interview was conducted on 09/29/22 at 6:02 PM and revealed she had been aware of investigation of alleged abuse towards Resident #21 by staff during incontinence care, but the investigation was completed by previous DON. She stated she was not aware the initial facility report alleging resident abuse had to be reported to the state agency within two hours and it had been her understanding that if the initial allegations of abuse had not alleged harm or bodily harm the initial report had to be reported within 24 hours. She also stated she had not been made aware Resident #21's responsible representative had to be notified of the investigation or of the outcome of the investigation. The Administrator reviewed the facility abuse policy and revealed she would have expected the previous DON to have faxed the initial report form to the state agency within the correct time frame and to notify Resident #21 responsible representative during the initial investigation and once the investigations had been completed.

Based on record review and staff interviews, the facility failed to develop a care plan for activities of daily living (ADL) 1 of 7 residents reviewed showers and skin integrity (Resident #43). Findings included: 1. Resident #43 was admitted to the facility 08/15/22 with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The admission Minimum Data Set (MDS) dated [DATE] reveled Resident #43 was severely cognitively impaired. The MDS reflected Resident #43 required extensive assistance with bed mobility, transfers, and personal hygiene; limited assistance with dressing; supervision assistance with eating and toilet use; and was totally dependent for bathing assistance. Review of Resident #43's care plan last updated 09/07/22 revealed there was no care plan for ADL. During an interview with the MDS Coordinator on 09/29/22 at 09:14 AM she confirmed Resident #43 did not have a care plan for ADL. The MDS Coordinator stated Resident #43 should have had a care plan for ADL in place so nursing staff would know how much assistance the resident needed with each activity of daily living. She stated the ADL care plan should have been developed within 21 days of Resident #43's admission and was not developed due to an oversight. An interview with the Regional MDS Consultant on 09/29/22 at 04:24 PM revealed Resident #43 should have had an ADL care plan in place since she needed assistance with her activities of daily living. An interview with the Director of Nursing (DON) on 09/29/22 at 04:35 PM revealed Resident #43 should have had an ADL care plan in place that reflected how much assistance she required with each activity of daily living, and it should have been developed within the Resident Assessment Instrument (RAI) guidelines. An interview with the Administrator on 09/29/22 at 05:35 PM revealed Resident #43 should have had an ADL care plan in place that reflected how much assistance she required with each activity of daily living.

Based on observations, record reviews, staff and resident interviews, the facility failed to provide showers for 1 of 3 dependent residents (resident #58) reviewed for Activities of Daily Living (ADL). Findings included: 1. Resident #58 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission Minimum Data Set (MDS) dated [DATE] indicated Resident #58 was cognitively intact. The MDS further revealed Resident #58 was total dependent and required one staff assist for bathing. The MDS also indicated it was very important for Resident #58 to choose between a tub bath, shower, or bed bath. Review of Residents shower log documented Resident #58 was scheduled to receive showers on Monday and Friday during second shift. The shower log further documented Resident #58 had only received a shower on 09/10/22, 09/18/22, and 09/21/22. An interview and observation with Resident #58 on 09/26/22 at 12:20 PM revealed she had not received consistent showers as scheduled since admission. Resident #58 further revealed she preferred a shower and had to ask nursing staff on weekends to receive one. Resident #58 stated nursing staff would offer bed baths, but Resident #58 preferred a shower because her hair was not washed during bed baths. Resident #58 stated her hair felt dirty and oily. Observation revealed Resident #58 to have greasy and tangled hair. An interview conducted with NA #7 on 09/27/22 at 3:25 PM revealed she had worked weekends and had given showers to Resident #58 on 09/10/22 and 09/18/22. NA #7 further revealed Resident #58 had expressed that she had not received showers on her scheduled days during the week and needed a shower. NA #7 indicated multiple residents had complained showers were not being given as scheduled and preferred. An interview conducted with NA #2 on 09/28/22 at 4:25 PM revealed she was not aware Resident #58 had not received scheduled shower days. NA #2 further revealed Resident #58 had not refused showers and was expected to receive showers every Monday and Fridays during 2nd shift but could not recall why she had not. An interview with NA #3 on 09/28/22 at 5:00 PM revealed she had assisted Resident #58 with showers, and she had never refused. NA #3 further revealed there had been days that Resident #58 had not received a shower, but a bed bath instead because NAs had run out of time to give showers. NA #3 indicated Resident #58 did not always get her hair washed during a bed bath if nursing staff did not have time. NA #3 stated Resident #58 did prefer showers. An interview with the Director of Nursing (DON) 09/29/22 at 4:35 PM revealed she did not recall Resident #58 had not refused showers but was aware recently Resident #58 did not receive a shower on her scheduled day and it was pushed to the next day. The DON stated it was expected for residents to receive their scheduled days and preference. An interview with the Administrator 09/29/22 at 6:05 PM revealed she was aware Resident #58 had sometimes not received a shower on scheduled days but could not recall why. The Administrator stated Resident #58 should receive showers as preferred and on scheduled days.

Based on observations, record review, and staff interviews the facility failed to implement infection control for hand hygiene when 1 of 1 facility staff (Nurse Aide #1) did not remove his gloves and perform hand hygiene after providing incontinence care for 2 of 3 residents observed for incontinence care (Resident #55 and Resident #38). Findings included: Review of the facility's policy titled Handwashing/Hand Hygiene revised June 2019 read in part as follows: The facility considers hand hygiene to be the primary means to prevent the spread of infections. All personnel should follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based-hand rub containing 60-95% [MEDICATION(S)] or isopropanol and rub for the following situations: after contact with bodily fluids or excretions, before moving from a contaminated body site to a clean body site during resident care, and after removing gloves. 1. A continuous observation of Nurse Aide (NA) #1 on 09/27/22 from 03:15 PM to 03:20 PM revealed NA #1 provided incontinence care for Resident #55. With gloved hands, NA #1 cleaned stool with a washcloth and placed it in a trash bag, removed the soiled brief and placed it in a trash bag, applied a clean brief, applied barrier cream to Resident #55's inner thighs, fastened the brief, pulled Resident #55's gown down, and removed his gloves. NA #1 adjusted Resident #55's overbed table, applied a clean pair of gloves, adjusted Resident #55's bed cover, picked up the trash bags containing the dirty washcloth and soiled brief, pulled both gloves down over the top of the trash bags, opened Resident #55's door, walked down the hall, opened the soiled utility door and placed the trash bags in the soiled utility room, walked back down the hall, and used hand sanitizer. NA #1 did not remove his gloves and perform hand hygiene after removing stool and before applying barrier cream to Resident #55's inner thighs or before fastening Resident #55's brief and pulling down her gown. NA #1 did not perform hand hygiene after removing gloves and before touching Resident #55's overbed table, the doorknob of Resident #55's door, or the doorknob to the soiled utility room. During an interview with NA #1 on 09/27/22 at 03:45 PM he confirmed he did not remove his gloves and perform hand hygiene after removing stool and before applying barrier cream to Resident #55's inner thighs. NA #1 stated he usually cleaned stool first because he often contaminated the washcloth with stool if he cleaned urine away first, and he was not trained to wipe from front to back for female residents. He stated he had not been trained to remove gloves and perform hand hygiene when moving from a dirty task to a clean task, such as removing stool and then applying barrier cream to a resident's inner thighs. NA #1 stated not performing hand hygiene after removing his gloves and before touching other items was an oversight. An interview with the Infection Preventionist on 09/29/2022 at 02:12 PM revealed staff were trained to wipe from front to back during incontinence care for female residents. The Infection Preventionist stated NA #1 should have removed his soiled gloves after cleaning stool, performed hand hygiene, donned a clean pair of gloves, applied barrier cream to Resident #55's inner thighs, removed those gloves, and performed hand hygiene. She also stated staff were trained to perform hand hygiene after removing gloves and before touching other items. An interview with the Director of Nursing (DON) on 09/29/22 at 04:35 PM revealed NA #1 should have removed his gloves and performed hand hygiene after cleaning stool. She stated NA #1 should have donned a clean pair of gloves to apply barrier cream to Resident #55's inner thighs, removed those gloves, and performed hand hygiene before touching other items in the resident's environment. An interview with the Administrator on 09/29/22 at 05:35 PM revealed staff should wipe from front to back during incontinence care for female residents. She stated gloves should be removed and hand hygiene should be performed after providing incontinence care and before touching other items in the resident's environment. 2. A continuous observation of Nurse Aide (NA) #1 on 09/27/22 from 03:32 PM to 03:42 PM revealed NA #1 provided incontinence care to Resident #38. With gloved hands NA #1 cleaned stool with a washcloth and placed the washcloth in a trash bag, removed the soiled brief and placed it in a trash bag, applied a clean brief, applied barrier cream to Resident #38's bottom, asked Resident #38 to roll onto her back, cleaned urine with a wash cloth, applied barrier cream, fastened the brief, pulled Resident #38's gown down, removed his gloves, picked up the trash bags containing the dirty wash cloths and soiled brief, pulled back the privacy curtain, and used hand sanitizer. During an interview with NA #1 on 09/27/22 at 03:45 PM he confirmed he cleaned stool first for Resident #38, applied barrier cream, removed urine, and applied barrier cream while using the same pair of gloves. NA #1 stated he usually cleaned stool first and then urine because he usually contaminated the washcloth with stool if he cleaned urine away first, and he was not trained to wipe from front to back for female residents. He stated he had not been trained to remove gloves and perform hand hygiene after removing stool and before cleaning away urine. NA #1 stated not performing hand hygiene after removing his gloves and before touching other items was an oversight. An interview with the Infection Preventionist on 09/29/2022 at 02:12 PM revealed staff were trained to wipe from front to back during incontinence care for females. The Infection Preventionist stated NA #1 should have cleaned urine first and then cleaned stool for Resident #38, removed his soiled gloves, performed hand hygiene, donned a clean pair of gloves, applied barrier cream to the front of Resident #38's bottom, applied barrier cream to the rear of Resident #38's bottom, removed those gloves, and performed hand hygiene. She also stated staff were trained to perform hand hygiene after removing gloves and before touching other items. An interview with the Director of Nursing (DON) on 09/29/22 at 04:35 PM revealed NA #1 should have cleaned urine first and then cleaned stool during incontinence care for Resident #38. She stated after the incontinence care was provided NA #1 should have removed his soiled gloves, performed hand hygiene, donned a clean pair of gloves, applied barrier cream to the front and then rear of Resident #38's bottom, removed his dirty gloves, and performed hand hygiene before touching other items in the resident's environment. An interview with the Administrator on 09/29/22 at 05:35 PM revealed staff should wipe from front to back during incontinence care for female residents. She stated gloves should be removed and hand hygiene should be performed after providing incontinence care and before touching other items in the resident's environment.

Based on interview and record review, the facility failed to complete baseline care plans within 48 hours of admission for 4 of 5 residents reviewed (Resident #309, # 52, # 57, # 53). The findings included: 1. Resident #309 was admitted to the facility on [DATE]. Admission diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the electronic medical record revealed the base line care plan was initiated on 3/7/2022 and completed on 3/15/22. The admission Minimum Data Set, dated dated dated [DATE] revealed Resident #309 was severely cognitively impaired and totally dependent on one person for bathing and required supervision of one person for transfers. Interview with the Regional Nurse Manager on 3/16/22 at 11:16 AM revealed she completed the baseline care plan on 3/15/2022. The Regional Nurse Manager stated that she was unsure why the care plan was not completed on time, therefore she completed it. She further expected the care plans to be completed within 48 hours. Interview with the interim Director of Nursing (DON) on 3/16/2022 at 4:02 PM revealed she had been at the facility for two weeks as the new DON. The DON stated she expected the admitting nurse to complete a 48-hour care plan. She stated that if the resident is admitted on a Friday, then the facility had a Registered Nurse (RN) in the building that would complete the care plan within the 48-hour time frame. The DON further expected the care plan to be reviewed and discussed at the next morning's clinical meeting. Interview with the facility Administrator on 3/16/2022 at 4:11 PM revealed she expected baseline care plans to be completed within 48 hours. 2. Resident #57 was admitted to the facility on [DATE] diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the electronic medical record revealed the baseline care plan was initiated on 2/25/2022 and completed on 2/28/2022. The quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #57 was severely cognitively impaired and totally dependent on one person for bathing and substantial assistance of one person for transfers. Interview with the MDS nurse on 3/16/22 at 3:28 PM revealed she was unsure why the base-line care plan was not completed within the 48-hour time frame. She stated that she only worked at the facility but two days a week. She further stated that when a resident is admitted on a Friday the RN working on the weekend should complete the care plans. Interview with the interim Director of Nursing (DON) on 3/16/2022 at 4:02 PM revealed she had been at the facility for two weeks as the new DON. The DON stated she expected the admitting nurse to complete a 48-hour care plan. She stated that if the resident is admitted on a Friday, then the facility had a Registered Nurse (RN) in the building that would complete the care plan within the 48-hour time frame. The DON further expected the care plan to be reviewed and discussed at the next morning's clinical meeting. Interview with the facility Administrator on 3/16/2022 at 4:11 PM revealed she expected baseline care plans to be completed within 48 hours. 3. Resident #52 was admitted to facility on 2/25/2022. The admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the electronic medical record revealed the baseline care plan was initiated on 2/25/2022 and completed on 2/28/2022. The quarterly MDS dated [DATE] revealed resident was cognitively intact and dependent with dressing and bathing. The resident required extensive assistance with mobility and transfers. Interview with the MDS nurse on 3/16/22 at 3:28 PM revealed she was unsure why the base-line care plan was not completed within the 48-hour time frame. She stated that she only worked at the facility but two days a week. She further stated that when a resident is admitted on a Friday the RN working on the weekend should complete the care plans. Interview with the interim Director of Nursing (DON) on 3/16/2022 at 4:02 PM revealed she had been at the facility for two weeks as the new DON. The DON stated she expected the admitting nurse to complete a 48-hour care plan. She stated that if the resident is admitted on a Friday, then the facility had a Registered Nurse (RN) in the building that would complete the care plan within the 48-hour time frame. The DON further expected the care plan to be reviewed and discussed at the next morning's clinical meeting. The DON stated that her expectations were all care conference and baseline care plan were to be completed within 48 hours. Interview with the facility Administrator on 3/16/2022 at 4:11 PM revealed she expected baseline care plans, and care conference's to be completed within 48 hours. 4. Resident #53 was admitted to the facility on [DATE]. The admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the electronic medical record revealed the baseline care plan was initiated on 2/25/2022 and completed on 2/28/2022. The quarterly MDS dated [DATE] revealed resident was cognitively intact and required assistance with bathing, dressing and transfers. Interview with the MDS nurse on 3/16/22 at 3:28 PM revealed she was unsure why the base-line care plan was not completed within the 48-hour time frame. She stated that she only worked at the facility but two days a week. She further stated that when a resident is admitted on a Friday the RN working on the weekend should complete the care plans. Interview with the interim Director of Nursing (DON) on 3/16/2022 at 4:02 PM revealed she had been at the facility for two weeks as the new DON. The DON stated she expected the admitting nurse to complete a 48-hour care plan. She stated that if the resident is admitted on a Friday, then the facility had a Registered Nurse (RN) in the building that would complete the care plan within the 48-hour time frame. The DON further expected the care plan to be reviewed and discussed at the next morning's clinical meeting. The DON stated that her expectations were all care conference and baseline care plan were to be completed within 48 hours. Interview with the facility Administrator on 3/16/2022 at 4:11 PM revealed she expected baseline care plans, and care conference's to be completed within 48 hours.

Based on observation, record review, resident, and staff interviews the facility failed to provide incontinence care for 1 of 3 residents sampled for incontinence (Resident #2). The resident expressed feelings of being upset. The findings included: 1. Resident #2 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact and required extensive assistance of two staff members for bed mobility and transfers. She was coded as being dependent on one staff member for assistance with toileting. Resident #2 was coded as being always incontinent of bladder and frequently incontinent of bowel. Review of Resident #2's care plan dated 12/12/19 and updated on 02/12/21 revealed a focus area for urinary incontinence. The care plan stated Resident #2 was incontinent of bowel and bladder and required fluid restrictions due to [CONDITION(S)] and was at risk for urinary tract infections. Interventions included providing assistance to the bathroom, monitoring of fluid intake and frequent incontinence rounding. On 06/22/21 at 1:45 PM an interview was conducted with Resident #2. During the interview she stated she had been waiting 30-45 minutes for incontinence care because she had urinated and had a bowel movement on herself. She stated the incontinence had soaked through her brief onto her denim pants and she was upset. The interview revealed she had turned on her call light and Nurse #3 came into the room to answer her call light. She stated she told Nurse #3 that she needed to be changed but the nurse did not give her time to explain the severity of her incontinence before leaving the room. The interview revealed Nurse #3 stated to her, I'll let them know. During the interview with Resident #2, Patient Care Aide (PCA) #1 entered the room and asked the resident if she still needed to use the restroom because NA #2 was giving another resident a shower. Resident #2 told the PCA that she had a soiled brief and needed to be changed. On 06/22/21 at 1:58 PM an observation was conducted of Nurse Aide #2 providing incontinence care for Resident #2. He stated he was working on another hall however NA #3 who was responsible for the hall was giving a resident a shower and had asked him to keep an eye on her hall. When NA #2 assisted Resident #2 to stand from her wheelchair her incontinence had soaked through her brief onto her pants requiring a complete change of her undergarments. NA #2 stated to Resident #2, you had a mess. NA #2 cleaned the resident, providing a new brief and new pair of pants prior to assisting her back in her wheelchair and taking her to a facility activity. On 06/22/21 at 2:18 PM an interview was conducted with Nurse #3. She stated she was responsible for Resident #2's hall along with the isolation hall. The interview revealed NA #3 was assigned to the resident however was giving another resident a shower. She stated NA #4 was the second NA on the hall and she hadn't told her that she went on break. The interview revealed she saw Resident #2's call light on and went into the room to see what she needed. Resident #2 stated to her that she needed incontinence care and she told her she would tell the NAs. Nurse #3 stated she never had the chance to tell the NAs on the hall because she was called to another resident's room for a crisis situation requiring her attention. She stated when she came out of the other residents room Resident #2's light was off, and she thought the resident had already been assisted with incontinence care. On 06/22/21 at 2:28 PM an interview was conducted with PCA #1. She stated she was the only PCA hired in the building and was responsible for changing beds, passing meal trays and assisting residents with activities. The interview revealed she could not assist residents to the restroom. She stated she had answered Resident #2's light when it was originally on but knew NA #3 was giving another resident a shower and forgot to tell her Resident #2 needed assistance with incontinence care. On 06/22/21 at 2:42 PM an interview was conducted with NA #3. She stated she was assigned to Resident #2 on 06/22/21. The interview revealed nobody had told her Resident #2 needed to go to the restroom or incontinence care. She stated the last time she had provided incontinence care to Resident #2 was prior to the lunch meal at 12:00 PM. On 06/22/21 at 2:54 PM an interview was conducted with NA #4. During the interview she stated she was working on the hall with NA #3. She stated she was on break while NA #3 was in the shower room with another resident and was off of the hall for approximately 12 minutes. The interview revealed she thought she had told Nurse #3 she was going on her break however couldn't remember for sure. On 06/22/21 at 3:07 PM an interview was conducted with the Director of Nursing (DON). During the interview she stated the NAs working on the hall were supposed to tell the Nurse if they go on break and report to the other NA on the hall to ensure someone is covering the hall. She stated she expected for someone to be on the hall at all times tending to the resident's care needs. On 06/22/21 at 3:25 PM an interview was conducted with the Administrator. During the interview she stated someone should be on the hall at all times monitoring and attending to the resident care needs. She stated she was going to write a concern form regarding the incident and investigate it.

Based on resident interview, staff interview and record review the facility neglected to provide incontinent care for 1 of 3 sampled residents (Resident #1) who required extensive assistance and who had requested incontinent care because he had soiled himself. Resident #1 stated he was embarrassed and angry after he had asked to be changed and was told the staff member did not have time resulting in him attempting to clean himself and experiencing a fall. The findings included: Resident #1 was admitted into the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's admission Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact and required extensive assistance of two staff members for transfers. Resident #1 required extensive assistance of one staff member for dressing, toilet use and personal hygiene. The assessment revealed he was incontinent of bowel and bladder. Resident #1's care plan dated 5/28/21 revealed a focus area for Activities of daily living (ADL). The focus area revealed the resident required assistance with ADL care due to limited mobility and incontinence. The goal was for the residents needs to be anticipated and met by staff as evidenced by a clean, neat appearance with no odors. Interventions included assist with transfers, provide assistance with toileting and incontinence care. Review of an incident report dated 06/04/21 at 6:20 AM written by Nurse #2 revealed Resident #1 was observed on the floor. The resident stated he lost his balance leaning forward and slid onto the floor. No apparent injury was reported. The causative factor was described as being generalized weakness; poor core strength related to overall resident decline. The incident report revealed Resident #1 lacked the ability to sustain anatomical alignment Review of Resident #1's medical record revealed neurological check was initiated on 06/04/21 at 6:47 AM. The note revealed Resident #1 was observed on the floor with no complaints voiced from the resident. Resident #1 was released to the transportation company in stable condition for transport to [CONDITION(S)] following his fall. Review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The results from Resident #1's stool specimen revealed he had [CONDITION(S)] organisms present in his bowel, but the toxin was not detected. The results stated it could be due to colonization, the resident may be a carrier, or the level of toxin was below the level of detection. An interview conducted with Resident #1 on 06/22/21 at 9:26 AM revealed on 06/04/21 Nurse Aide (NA) #1 was assisting him to get ready for [CONDITION(S)] when he began to experience diarrhea. He stated NA#1 assisted him to put his clothing on when he had a bowel movement on himself. He asked NA#1 to change his brief and clothing however she stated to him that she didn't have time to change him. He then told her he could't go to [CONDITION(S)] with feces on himself and to bring him supplies and he would try to clean himself up. The NA left the room to go get two wash cloths- one wet and one dry which she handed to the resident, shut the door and left the room. He stated he was attempting to get the wash cloths from the bedside table when he leaned forward and fell on to his right side hitting his hip onto the floor and the right side of his head. The interview revealed he was sore and experienced pain but had no broken bones. He immediately began to yell for help from the staff and stated it was approximately 5 minutes before NA#1 and Nurse #1 entered the room. The interview revealed his call light was on the floor behind him and he couldn't reach it. He stated at [AGE] years old he felt embarrassed laying in bowel movement on the floor and being unable to care for himself. He also said he was angry at NA#1 for making him feel as if she didn't have time to help him or that the other residents were more important. On 06/22/21 at 9:56 AM an interview was conducted with Resident #1's Power of Attorney (POA). She stated the facility had contacted her on 06/04/21 regarding Resident #1's fall around 6:25 AM. The interview revealed she was confused because she knew the resident could not ambulate independently nor provide activities of daily living (ADL) care independently. The nurse on duty told her he was being prepared for [CONDITION(S)] when he had a bowel movement on himself and the NA told him she didn't have time to change him. When the resident attempted to clean himself, he experienced the fall due to loss of balance. She stated she immediately hung up with the nurse who notified her and called Resident #1 who stated he was still sitting in bowel movement and needed to be changed. She then stated she called the nurse back and asked her to go to his room and change him before he went to [CONDITION(S)]. She stated she could not remember the name of the nurse whom she had spoken with. An interview conducted with NA #1 on 06/22/21 at 11:33 PM revealed she was working with Resident #1 during the third shift assignment on 06/04/21. She stated that morning she was getting the resident ready for [CONDITION(S)] and he was experiencing loose stools. She stated, he was on his call light and I had to change him almost 8 times that night. The interview revealed she felt Resident #1 was constantly hitting his call light in need of assistance that morning. She stated, I got frustrated with him when he said he was having another bowel movement. The interview revealed Resident #1 was dressed in his wheelchair for [CONDITION(S)] when he told NA #1, he had experienced a bowel movement and needed to be changed. She stated she told him that she didn ' t have time to change him again because he had to go to [CONDITION(S)]. The interview revealed NA #1 asked Resident #1 if he could clean himself if she set him up with a washcloth. She stated she gave Resident #1 a washcloth to clean himself with, left the room and shut the door behind her returning to her other assigned hall (Hall A) to assist other residents getting up. She stated when she was finished and returned to the hall around ten minutes later, she noticed his call light was not on and she heard Resident #1 yelling for help. When NA #1 entered Resident #1's room she observed him laying on his side in the floor in the middle of his room. She stated he was complaining of pain on his bottom and was laying in stool. NA #1 then left the room to get Nurse #1 to come assist her in getting him back to bed and cleaned up. She stated Nurse #1 no longer worked in the facility. On 06/22/21 and 06/23/21 interviews were attempted with Nurse #1. Voicemails were left for Nurse #1 with no return phone call. An interview conducted with Nurse #2 on 06/22/21 at 11:56 PM revealed she was working during third shift on 06/04/21 as the supervising nurse. She stated Nurse #1 had came up the hall and told her Resident #1 experienced a fall and asked for help completing an incident report. Nurse #2 stated she asked Nurse #1 how Resident #1 a fall and she had stated that the resident was cleaning himself up when he fell forward. Nurse #2 stated she knew Resident #1 was unable to complete ADL care independently, so she went immediately to his room to ask him why he was cleaning himself up. Resident #1 told Nurse #2 that he was sitting in his wheelchair when he had a bowel movement on himself and asked NA #1 to change him. He stated NA #1 told him she didn't have time to change him and he was trying to clean himself up before he went to [CONDITION(S)] because he didn't want to sit in feces. Nurse#2 stated she went out of his room and found NA #1 and to ask her to check him again to ensure he was clean prior to leaving and told her [CONDITION(S)] would not change him or clean him up. The interview revealed the [CONDITION(S)] transporter was in the facility at that time and she told him to wait 10 minutes so NA #1 could clean the resident prior to leaving the facility. Nurse #2 stated she told the Director of Nursing about the incident and he told her he didn't need her statement and if he did, he would call her. The interview revealed the DON had never contacted Nurse #2 regarding the incident. She stated Resident #1 seemed very upset and embarrassed over the situation. On 06/22/21 at 11:18 AM an interview was conducted with the former Director of Nursing (DON). During the interview he stated he came into the facility on [DATE] to find the incident report in his box for Resident #1's fall. He stated he didn't recall talking to NA #1 that morning despite being in the building at 6:00 AM. The DON stated he went into the room to speak with Resident #1 and called his Responsible Party to inform her of the fall that had occurred. He stated he reviewed Resident #1's chart and saw how the nurses and NAs were transferring the resident to see if he was capable of being set up on his own to clean himself. The interview revealed Resident #1 was always laying flat in the bed and had lost his core strength and did not have the ability to sit up on his own. He stated Resident #1 was not appropriate to be alone by himself and required a one-person assistance with ADL. The DON stated he verbally spoke to the staff working with Resident #1 on 06/04/21 and informed them to not leave the resident alone and that he needed a one staff member assistance. He stated, the resident looked young, so it made staff feel like he was able to complete task on his own. The interview revealed he had verbally conducted an in-service on the incident and didn't remember having written documentation of an in-service.

Based on record review, staff and physician interviews, the facility neglected to provide necessary care and services to a surgical wound. The resident was admitted into the hospital on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This was for 1 of 3 sampled resident's reviewed for providing care according to professional standards (Resident #166). Immediate Jeopardy began on [DATE] when Nurse #1 failed to identify the need for and provide nursing and medical interventions when Resident #166 was noted to have a foul odor with a large amount of yellow drainage coming from her surgical wound. The immediate jeopardy was removed on [DATE] when the facility provided and implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of an 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. The findings included: Review of Resident #166's hospital discharge summary dated [DATE] revealed she would need her wound vac to her midline abdominal surgical incision changed three times a week on Monday, Wednesdays and Fridays. Vacuum-assisted (wound vac) closure of a wound is a type of therapy to help wounds heal. During the treatment, a device decreases air pressure on the wound. This can help the wound heal more quickly. The gases in the air around us put pressure on the surface of our bodies. A wound vacuum device removes this pressure over the area of the wound. This can help a wound heal in several ways. It can gently pull fluid from the wound over time. This can reduce swelling and may help clean the wound and remove bacteria. A wound VAC also helps pull the edges of the wound together. And it may stimulate the growth of new tissue that helps the wound close. A wound vacuum system has several parts. A foam or gauze dressing is put directly on the wound. An adhesive film covers and seals the dressing and wound. A drainage tube leads from under the adhesive film and connects to a portable vacuum pump. This pump removes air pressure over the wound. It may do this either constantly or it may do it in cycles. The dressing is changed every 24 to 72 hours. A wound vacuum system may help your wound heal more quickly by: · Draining excess fluid from the wound · Reducing swelling · Reducing bacteria in the wound · Keeping your wound moist and warm · Helping draw together wound edges · Increasing blood flow to your wound · Decreasing redness and swelling Resident #166 was admitted into the facility on [DATE] following a hospital admission where she underwent an exploratory laparotomy and right colectomy for an incarcerated incisional hernia with perforated cecum. admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #166's Skin Integrity Review dated [DATE] revealed she had a 6-inch surgical site to her midline abdomen which was packed with gauze. Review of Resident #166's [DATE] Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The review revealed the order was signed off by Nurse #1. The order did not include how often to change the wound vac. Review of Resident #166's Treatment Administration Record (TAR) for [DATE] revealed a wound vac was initialed by Nurse #14 as being applied on [DATE]. The review revealed no orders to change the residents wound vac for [DATE]. On [DATE] at 9:15 AM and 11:35 AM voicemails were left for Nurse #14 with no return phone call. On [DATE] at 5:40 PM a third voicemail was left for Nurse #14 with no return phone call. Review of Resident #166's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was initialed as completed by the nurses for each shift from [DATE] through [DATE]. The admission Minimum Data Set (MDS) dated [DATE] assessed Resident #166 as moderately intact cognition for daily decision making. She required extensive two-person assistance with bed mobility, transfers, dressing and toilet use. Resident #166 was coded for having a surgical wound. Review of a Medical Director's (MD) note dated [DATE] revealed Resident #166 was seen on this date for a new admission evaluation. The note revealed her wound vac was in place and her current level of care was stable. The note revealed Resident #166 was frail, and geriatric syndromes included functional decline. The MD stated her functional strength and assessment were good and the resident was a full code. Resident #166 was walking with full assist on admission and was a good candidate for Physical Therapy, Occupational Therapy and Speech Therapy. The plan for Resident #166's wound care was to follow up with the surgeon as directed. Review of Resident #166's TAR and nursing progress notes revealed no evidence of the wound vac being changed or any wound care or treatments to her abdominal surgical wound completed on [DATE] and [DATE]. Review of a nursing progress note dated [DATE] revealed the Physician was made aware that Resident #166 had experienced an 8.3-pound weight loss and swelling in her lower extremities. Resident #166 had refused to get up with Physical Therapy on this date. Review of a Surgeon's office note dated [DATE] revealed Resident #166 was seen on this date in their office for a post-op follow up after an exploratory laparotomy and right colectomy for an incarcerated incisional hernia with perforated cecum. The note revealed her wound vac was in place at the time of the evaluation along with two drains in her old right abdominal wall hernia. The note revealed Resident #166 was doing well and her drains were removed during the visit. A follow up appointment was scheduled for 4 weeks and no concerns were noted during the visit. Review of Resident #166's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #166's [DATE] TAR revealed the order to cleanse Resident #166's right lower abdominal drain sites with wound cleanser and apply a dry dressing were initialed as being changed by Nurse #1 on [DATE], and [DATE]. There was no documentation on the date of [DATE] that the dressing was changed, and it was documented on [DATE] Resident #166 had refused. Review of Resident #166's TAR revealed no evidence of the wound vac being changed or any wound care or treatments to her abdominal surgical wound completed on [DATE]. Review of a nursing progress note dated [DATE] revealed the nurse had went in to talk with Resident #166 regarding nutrition and the importance of eating to aide in recovery. Resident #166 denied any pain at that time. The note revealed Resident #166 did take several sips of the fluids that were offered. Review of Resident #166's TAR revealed no evidence of the wound vac being changed or any wound care or treatments to her abdominal surgical wound completed on [DATE]. Review of a nursing progress note dated [DATE] written by Nurse #1 (Treatment Nurse) at 11:29 AM revealed a foul odor was noted to Resident #166's wound with a large amount of yellow drainage. The note revealed she left a voicemail for Resident #166's Surgeon's office to contact the facility regarding any new orders or updates. Review of Resident #166's medical record revealed no documentation of Physician notification on [DATE] regarding the residents wound vac not being changed as ordered since her admission on [DATE] or the large amount of drainage coming from the wound. Review of Resident # 166's TAR for [DATE] revealed an order to change the residents wound vac twice weekly on Mondays and Thursdays initiated on [DATE] (Tuesday) by Nurse #1. The wound vac was scheduled to be changed was on Thursday [DATE]. Nurse #1 initialed the TAR on [DATE] and indicated Resident #166 refused as indicated by parenthesis around her Nurse #1's initials. On [DATE] at 8:58 AM an interview was conducted with Nurse Aide (NA) #4. During the interview she stated she did not recall Resident #166. When reminded by the surveyor that she took care of the resident a year ago on [DATE] and throughout her stay she stated she still did not recall Resident #166. On [DATE] at 8:59 AM an interview was conducted with Nurse #13. During the interview she stated she did not recall Resident #166. When reminded by the surveyor that she took care of the resident a year ago on [DATE] and during her stay in the facility she still stated she did not recall Resident #166. Review of a nursing progress note dated [DATE] written by Nurse #1 at 11:02 AM revealed she had gone into Resident #166's room to assess her wound vac functioning. A 5 centimeter (cm) by 5 cm discolored area was noted to her right abdomen. The Nurse Practitioner was noted to be in the building and made aware. On [DATE] at 9:32 AM an interview was conducted with Nurse #10. During the interview she stated she did not recall Resident #166. When reminded by the surveyor she was the resident's nurse on the date of [DATE] she stated she did not recall the situation or the resident. Review of a nursing progress note dated [DATE] written by Nurse #1 at 11:30 AM revealed the Nurse Practitioner was made aware of the wound changes and was in the room assessing Resident #166. Orders were received to send Resident #166 to the hospital related to an abdominal wound infection. Review of a Nurse Practitioner (NP) note dated [DATE] at 12:29 PM revealed he was notified by Nurse #1 who was concerned Resident #166's wound was getting worse. Resident #166 was experiencing altered mental status, a decline in appetite, decline in her wound and overall abdominal pain. The note stated the NP was sending the resident to the hospital, given the progression, or worsening of her abdominal incision with slough he felt the wound needed to be debrided (procedure to clean the wound a remove any necrotic or dead tissue) by a surgeon. Review of Resident #166's [DATE] TAR revealed an order dated [DATE] which read, Abdomen surgical site: Cleanse with normal saline, apply wet to dry dressing using normal saline one time prior to sending the resident to the Emergency Department. The order was initialed as being completed by Nurse #1. Review of Resident #166's hospital records dated [DATE] revealed Resident #166 presented to the Emergency Department with fever, malaise, foul smelling drainage from her right flank and complaints of pain. She had an opened midline abdominal surgical incision with purulent (thick, milky) drainage. In addition, there was a large area of fluctuance (tense area of skin with a wave-like or boggy feeling) and [CONDITION(S)] (redness) on the right flank with suspected skin necrosis. Resident #166 was diagnosed with [CONDITION(S)] (a serious bacterial infection that destroys tissue under the skin) after undergoing an emergent debridement of an abscess and necrotic tissue. Resident #166's hospital diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospital records revealed Resident #166 had been in the state of persistent shock since arrival to the Emergency Department continuing to require high doses of vasopressors (medication given to increase blood pressure) even with aggressive resuscitation. The note stated, it would be difficult for a young healthy person to survive a necrotizing infection this extensive and that involved this much of her abdominal wall. Orders were placed to proceed with terminal extubation (removal of an artificial ventilation tube) and comfort care. Review of Resident #166's death certificate revealed she expired on [DATE] due to [CONDITION(S)], [CONDITION(S)], perforated intestines and an incarcerated hernia. On [DATE] at 9:12 AM an interview was conducted with the Clinical Coordinator. She stated she remembered when Resident #166 came into the facility she had a poor appetite. The interview revealed she did not recall anything else about Resident #166 even though she was the charge nurse during her stay in the facility. She stated any nurse in the building could change a wound vac and if Nurse #1 was scheduled to work on a resident hall it was the nurse on the halls responsibility to change the resident's dressings. On [DATE] at 3:33PM an interview was conducted with Nurse #1. She stated on [DATE] Resident #166 was admitted into the facility in need of a wound vac placement so she put in an order to initiate the wound vac as soon as the resident arrived into the facility. She stated based on her hospital discharge summary the facility was supposed to change her wound vac three times weekly. She stated the charge nurse would have been the one putting that order in however it had been missed. The interview revealed the time frame was during the COVID-19 pandemic and Nurse #1 was the treatment nurse and was being pulled to a hall to work so she wasn't doing all of the treatments or handling wound care. Nurse #1 explained she didn't realize Resident #166's wound vac hadn't been changed since her admission until on [DATE] (Tuesday) when the resident was noted to have foul smelling drainage at her abdominal incision site. She stated she notified the surgeons office and placed an order to change the residents wound vac twice a week because she never heard back from the surgeon's office. She indicated she did not go ahead and change the wound vac on [DATE] but scheduled the order for Mondays and Thursdays. The interview revealed when she went into the room on [DATE] to change the wound vac Resident #166 stated she felt bad and did not want it changed. Nurse #1 stated she was informed on [DATE] Resident #166 was acting differently so she notified the in-house Nurse Practitioner to come and look at her incision site. Once he saw the site, he gave orders to send the resident to the hospital for an evaluation. The interview revealed that normally wound vacs would be changed either twice weekly or three times a week based on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] at 2:06 PM an interview was conducted with the Surgeon's Nurse Practitioner (NP). She stated upon Resident #166's hospital discharge she had put in orders for the residents wound vac to be changed on Mondays, Wednesday and Fridays while at the facility. The NP stated she couldn't speak to anything else regarding the resident's care that the Surgeons office always ordered the wound vacs to be changed two to three times weekly following surgery. On [DATE] at 2:32 PM an interview was conducted with Resident #166's Surgeon. He stated his office always ordered for wound vacs to be changed twice weekly or three times weekly. He stated he couldn't speak to the situation because he did not see Resident #166 on [DATE] before she went to the hospital. The interview revealed slough would be normal to see in a wound that a wound vac was applied even if the wound vac wasn't change as ordered. He stated if the wound vac was working accordingly it would not have caused an infection even if the nurses were not changing it as he ordered. His expectation was for the facility to follow wound care orders provided on a resident's discharge summary. On [DATE] at 4:52 PM an interview was conducted with the Director of Nursing (DON). During the interview he stated Resident #166's wound vac should have been changed per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The interview revealed any of the nurses in the facility could change a wound vac. On [DATE] at 9:35 AM an interview was conducted with the facility Medical Director (MD). During the interview he stated he did not recall the resident and could not believe the surveyor was asking him to recall from one year prior. He stated he would have to review his notes and call the surveyor back at the end of the day. On [DATE] at 3:45 PM an second interview was conducted with the MD. During the interview he stated he was driving and hadn't had time to review the resident's chart. On [DATE] at 11:32 AM a voicemail was left for the MD by the surveyor asking for a return phone call. On [DATE] at 8:58 AM an interview was conducted with the MD. During the interview he stated the Surgeon's orders were not adhered to regarding wound care and he thought it was a facility process issue. The interview revealed based on hospital records he felt the resident was still high risk regardless of wound care issues. He stated he couldn't speak to if having her wound vac changed per the Surgeon's orders would have changed the resident's outcome. The MD stated there was an issue with lack of follow through by the facility which needed to be addressed in the Quality Assurance meetings. The facility Administrator was notified of the immediate jeopardy on [DATE] at 3:35 PM. #1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident #166 was admitted into the facility on [DATE] following a hospital admission where she underwent an exploratory laparotomy and right colectomy for an incarcerated incisional hernia with perforated cecum. admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #166 ' s hospital discharge summary dated [DATE] revealed she would need her wound vac to her midline abdominal surgical incision changed three times a week on Monday, Wednesdays and Fridays. Facility failed to change Resident #166's wound vac from [DATE] to [DATE]. The nurse failed to enter the orders for the dressing change into the electronic health record. The Treatment Nurse noted a foul odor was noted to Resident #166's abdominal wound with a large amount of yellow drainage on [DATE]. She didn't realize Resident #166's wound vac hadn't been changed since her admission until [DATE] and stated she notified the surgeons office but never heard back from the surgeon's office. She stated she did not go ahead and change the wound vac on [DATE] but scheduled the order for Mondays and Thursdays because she was scheduled to work on another hall that day and wasn't doing treatments. On [DATE] the Treatment Nurse failed to notify the Physician that Resident #166 had refused the dressing change and was still experiencing a foul odor and drainage from her abdominal wound. On [DATE] a nursing assistant (NA) notified the treatment nurse that the resident was acting differently than usual. The treatment nurse came into the room to assess Resident 166 and continued to note a foul odor coming from her wound. She notified the Nurse Practitioner who was in the building. Resident #166 was seen by the Nurse Practitioner (NP) on [DATE] who noted the resident had altered mental status with an overall decline in appetite and was experiencing abdominal pain. The NP note stated given the progression or worsening of the abdominal incision even with wound vac Resident #166 was noted to have slough and sutures present. The NP felt the wound needed to be debrided by a surgeon at the hospital. Orders were given to send Resident #166 for an evaluation. Resident #166 presented to the Emergency Department with fever, malaise, foul smelling drainage from her right flank and complaints of pain. She had an opened midline abdominal surgical incision with purulent drainage. In addition, there was a large area of fluctuance and [CONDITION(S)] on the right flank with suspected skin necrosis. Resident #166 was diagnosed with [CONDITION(S)] after undergoing an emergent debridement of an abscess and necrotic tissue. Resident #166 expired on [DATE] due to [CONDITION(S)], [CONDITION(S)], perforated intestines, and an incarcerated hernia. An audit was completed by the Administrator, Staff Development Coordinator (SDC), Treatment Nurse and Director of Nursing on [DATE] of all residents to check for the following items: Does the resident have a wound? Are appropriate treatment orders in place? Have the treatments been completed as ordered? Are there signs and symptoms of infection or worsening condition? Has the physician been notified of worsening condition? There were no additional residents identified as having been affected by the alleged deficient practice. #2. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On [DATE], The treatment nurse was educated by the Administrator on responsibilities to ensure that all wounds are assessed upon admission and that appropriate physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Treatment Nurse will review all new admissions daily to ensure that any resident wounds have appropriate physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, treatment nurse is responsible to ensure that treatments are completed as ordered. If the treatment nurse is unavailable, the Director of Nursing (DON) will complete these tasks and/or assign them to another nurse to complete. The DON was notified of this responsibility on [DATE] by the Administrator. All licensed nursing staff will be educated by the Administrator, Corporate Nurse Manager, and/or the Staff Development Coordinator on the following: Implementation of treatment orders, management and care of wounds, signs and symptoms of wound complications, regular wound assessment, to report signs and symptoms of infection, including redness, increased drainage, foul smelling drainage, elevated temperatures, change in mental status, decline in status and resident refusals of care to the MD/NP and resident representative immediately. This will be completed by [DATE]. All CNAs will be educated by the Administrator, Staff Development Coordinator, Treatment Nurse and/or DON on monitoring residents for declines and changes in conditions and how to respond to resident refusals and to report signs and symptoms of infection, including redness, increased drainage, foul smelling drainage, elevated temperatures, change in mental status and decline in status and to report these findings to the nurse immediately. This will be completed by [DATE]. Any licensed nurse or Certified Nursing Assistant out on leave or on PRN status will be educated prior to returning to duty by the Director of Nursing, Staff Development Coordinator, and/or the Treatment Nurse. The Director of Nursing, Staff Development Coordinator and the Treatment Nurse were advised of this responsibility on [DATE]. The SDC will be responsible for tracking staff that have not received the education. Any newly hired licensed nurse will be educated during orientation by the Staff Development Coordinator. The DON will ensure that this process is followed. The Administrator and Director of Nursing will be responsible for oversight of this plan and ensure compliance with training. TITLE OF THE PERSON RESPONSIBLE FOR IMPLEMENTING THE CREDIBLE ALLEGATION FOR IMMEDIATE JEOPARDY REMOVAL. The Administrator and the Director of Nursing will be ultimately responsible to ensure the implementation of credible allegation to remove this alleged immediate jeopardy. Immediate Jeopardy Removal Date: [DATE] On [DATE], the facility's credible allegation of immediate jeopardy removal was validated by review of documentation regarding staff training of the importance of implementing Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's date of IJ removal of [DATE] was validated.

Based on observation, record review, resident, staff, and corporate nurse interviews, the facility failed to prevent a cognitively impaired resident who wandered and was assessed for being at risk for elopement from exiting the facility unsupervised. This affected 1 of 2 residents (Resident #167) reviewed for supervision to prevent accidents. Resident #167 was located 2 hours and 35 minutes later in the emergency room (ER) of the local hospital where he was treated for a laceration of his left lower infraorbital (the area located below the eye and lateral to the nose) area and an abrasion to his left forehead. He was treated in the ER and transferred back to the facility the same day. Immediate Jeopardy began on 03/13/2021 when the facility failed to prevent a cognitively impaired resident with known wandering and exit seeking behaviors from exiting the A hall through an alarmed exit door and eloping from the facility unsupervised. The Immediate Jeopardy was removed on 05/07/2021 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to complete education and ensure monitoring systems put into place are effective related to supervision to prevent accidents. The findings included: Resident #167 was admitted to the facility on [DATE] to the quarantine hall (A hall) with diagnoses which included history of falling, difficulty walking and [CONDITION(S)]. Review of Resident #167's physician orders revealed an order for [MEDICATION(S)] (which is a drug used to treat and prevent blood clots) tablet 5 milligrams (mg) orally twice a day at 8:00AM and 8:00PM effective 03/11/2021. There was no Minimum Data Set (MDS) on file but his admission nursing assessment completed on 03/11/2021 revealed he was alert to person and situation but not time and was moderately cognitively impaired. The admission assessment also revealed he was independent with ambulation but required assistance of 1 staff member with dressing, toileting, personal and oral hygiene, and bathing. Review of a Psychosocial well-being elopement risk assessment completed on 03/12/2021 by the Corporate Nurse Consultant revealed the resident was a short-term rehab resident requiring [CONDITION(S)] three times weekly, moderately cognitively impaired, independent for walking in room and corridor, and independent for walking on and off the unit. Contributing factors for being at risk of elopement were recorded as verbalizing statements about leaving and wandering in and out of other resident rooms, recent move to the facility, diagnoses of dementia and reported from hospital that he had increased confusion at night. Interventions were recorded as pharmacist drug review, physical therapy, physician/Nurse Practitioner (NP)/Physician Assistant (PA) update, reality orientation, redirection, and social services. Outcome was recorded as interventions being somewhat effective. The evaluation was recorded as based on the risk assessment the resident presented an elopement risk and preventive actions to be taken were clothing labeled with identification, and door on A hall alarmed and functioning. Referrals that may be appropriate were recorded as psychotherapy. Plan of care was initiated on 03/12/2021. An interview on 05/17/2021 at 8:30AM with the Corporate Nurse Consultant (CNC) revealed she had been at the facility on 03/12/2021 and completed the elopement risk assessment. She stated the interventions put into place were the interventions included in his care plan. The CNC further stated she could not recall if she had discussed the resident's wandering behaviors and risk for elopement with the nurses but said he had the wanderer banner on his face sheet which the nurse's could see when they pulled up his profile in the computer system. She indicated his picture was not in the elopement book at the nurse's station until after his elopement and stated she was not sure why that had not been placed in the book. According to the CNC the resident was on a hall where the door alarm was working on the day of her assessment and the staff was monitoring him every 15 minutes to determine his whereabouts. She explained the interventions in place should have prevented the resident's elopement; however, given the issue with the door not being alarmed correctly, the resident was able to get out of the building. Review of Resident #167's care plan dated 03/12/2021 revealed the resident was at risk for elopement from the facility related to cognitive impairment, poor decision making, new admission as evidenced by aimless wandering/exit seeking and statements suggesting he was going home. The goal was for the risk of elopement to be minimized over the next review date of 06/13/2021. The interventions included alert staff of resident's risk for elopement, involve resident in activities of resident's choice/liking by offering diversions such as food, TV, conversation, puzzles, magazines, etc., notify Medical Doctor (MD) and Responsible Party (RP) if agitation, wandering behaviors increase, redirect as necessary, approach resident from the front and speak in calm reassuring tone, staff to monitor resident on a regular basis and know resident's whereabouts. Review of Resident #167's nursing progress notes revealed the following: Note written by Nurse #12 stated: 03/11/2021 at 7:29PM Behavior: Resident exit seeking stated he needed to go home resident redirected to his room explained to him why he is here. Additional note written by Nurse #12 stated: 03/11/2021 at 10:00PM Behavior: Resident walking in other residents' rooms resident taken back to his room. An interview on 05/03/2021 at 4:16PM with Nurse #12 revealed she had taken care of the resident on the evening of his admission on 03/11/2021 and stated he was confused and was able to ambulate on his own without assistance from staff or equipment. She informed the resident was wandering in and out of other resident rooms and was requiring redirection and assistance back to his room. Nurse #12 said she had reported the resident's wandering to the nurse on night shift. A note written by Nurse #13 stated: 03/12/2021 at 11:00AM Nursing: alert to name, confused wandering in and out of other resident rooms. Requires constant cues and reminding from staff to stop roaming and tearing up other resident's beds. Resident has been requesting to go home. Assisted by staff for redirection. An interview on 05/04/2021 at 11:22AM with Nurse #13 revealed Resident #167 was a wanderer but if she sat the resident in the hall with staff he would calm down and sit and talk. Nurse #13 stated he would also calm if he could talk with his wife on the telephone. She explained there were indications in his record that he could get out of the facility if he really wanted to get out. According to Nurse #13 the indications were his exit seeking behaviors, his ability to ambulate independently in the hallway and his comments he wanted to go home. Nurse #13 indicated he was able to ambulate independently but probably should have used a walker for stability when ambulating. She disclosed she was not sure why he had not had a wander guard placed on him but stated he probably should have had one placed before he eloped. Nurse #13 reported there were always wander guards available for use in the medication carts. A note written by Nurse #8 stated: 03/14/2021 at 12:25PM Behavior note recorded as late entry on 03/14/21 12:30PM Behavior: On 03/13/2021 the resident had attempted to exit from A hall door x 1 at approximately 8:15AM. Resident redirected, resident had breakfast and lunch, continued to make attempts to leave through the A hall door. Resident last observed at 2:45PM by Nurse Aide (NA) #6 in his room. At 3:15PM during rounds, resident was not in his room or on the hall. Staff initiated search, resident was not in the building, supervisor contacted 911 for assistance in searching. An interview on 05/02/2021 at 3:55PM with Nurse #8 revealed she had been assigned to Resident #167 on 03/13/2021 for the 7:00AM to 7:00PM on the day of his elopement. Nurse #8 stated she was assigned to the A hall and the C hall and had 29 residents for which she provided medications and treatments. She reported Resident #167 had tried to get out the A hall door at 8:15AM and had set off the alarm. Nurse #8 indicated she had reset the alarm that morning. She disclosed Resident #167 tried several times that morning to get out and she had reset the alarm and redirected him back to his room. Nurse #8 mentioned they were doing frequent checks on him (looking in on him every 15 minutes to make sure they knew where he was) because they did not have enough staff to sit with him 1 on 1 and said she had gone to the C hall to complete her treatments. She stated NA #6 was on the A hall providing care to residents while she went to the C hall. Nurse #8 said NA #6 last saw the resident around 2:45PM and went to provide care to 2 other residents. She indicated when NA #6 went to check on Resident #167 at 3:15PM he was not in his room. Nurse #8 further indicated NA #6 notified her Resident #167 was not in the room and told her she had not heard the alarm go off, so they began searching for the resident and notified the supervisor the resident was not in his room. She stated they searched the building and could not find the resident so the supervisor called the police, notified the resident's responsible party (RP), notified the Medical Director and called in ancillary staff to aid in the search for the resident. Nurse #8 further stated the supervisor also called the Director of Nursing (DON) at the time who also came in to aid in the search for the resident. According to Nurse #8 she must not have reset the alarm correctly since NA #6 had not heard the alarm go off. She reported Resident #167 had tried a couple of times that day to get out the A hall entrance door and stated she had reset the alarm after his last attempt while he was standing next to her still trying to get out and said she apparently had reset it incorrectly and had actually turned the alarm off or either it malfunctioned. Nurse #8 indicated the alarm had gone off a couple of times that day from the resident trying to get out the door but stated they had not heard the alarm when he got out of the building. She further indicated they had tried to look in on him frequently and stated she probably should have put a wander guard on him after his first attempt to get out the door and stated she did not know why she had not put one on him. Nurse #8 advised the supervisor was aware Resident #167 had tried multiple times to get out but stated he was working on a cart that day and was busy caring for his own residents. She disclosed staff on A hall had used that entrance when going out and each time she had to turn the alarm off with her key. According to Nurse #8 each nurse on each hall had the key to the door at the end of their hallway on their set of keys and if their door alarms, they must turn the alarm off with their key. She stated she had turned the alarm off several times that day because of the resident and staff utilizing the door and must not have alarmed it correctly the last time she turned the alarm off. Nurse #8 reported she knew the alarm was working earlier in the day because it had gone off a couple of times. She indicated she could not remember if she checked the alarm or not after Resident #167 was missing because she was searching for the resident and trying to take care of her other assigned residents. A follow up telephone interview on 05/04/2021 at 3:44PM with Nurse #8 revealed she still was not sure what happened with the exit door alarm on 03/13/21 but stated she nor NA #6 had heard the alarm go off when Resident #167 left the building unattended. She explained the only thing she could think was she had incorrectly reset the alarm after his first attempt to get out that day. Nurse #8 disclosed she had not thought about putting a wander guard on him that day but stated she probably should have done that after his first attempt to get out. She indicated if she had put the wander guard on maybe NA #6 would have heard the alarm go off and redirected the resident back to his room before he was able to get out the door. Nurse #8 stated the wander guards were available and kept on the medication carts and reported there were wander guards available for use that morning. Nurse #8 advised she was not sure she could have heard the door alarm on the C hall when she was down there doing treatments but stated NA #6 would have been able to hear the alarm. An interview on 05/02/2021 at 3:40PM with NA #6 revealed she had been assigned to Resident #167 on 03/13/2021. She stated he was agitated that day and wanted to go home and made a couple of attempts to get out of the A hall door and had set the alarm off a couple of times that morning. NA#6 indicated she had last laid eyes on the resident around 2:45PM and he was laying in his bed resting. She mentioned she went to provide incontinence care to 2 other residents on the floor and by the time she finished and checked on Resident #167 he was not in his room. She explained she looked in all the rooms on the A hall for him and when she couldn't find him, notified Nurse #8 (who was on the C hall) she couldn't find Resident #167. According to NA #6 everyone stopped what they were doing and searched the building for the resident but stated they had not found him in the building. NA #6 stated they began searching the premises outside for him when they couldn't locate him in the building. She further stated she had not heard the alarm go off on the A hall while she was providing care to other residents. An interview on 05/05/2021 at 11:37AM with the Rescue Squad representative revealed he had received a call on 03/13/2021 from a passerby that a gentleman, later found to be Resident #167, had fallen and was leaned up against a box at a local bakery (which was approximately a mile from the facility). The representative stated they had picked up Resident #167 at the local bakery and transported him to the local hospital ER since he had fallen and hit his head and had bruising and abrasions to his head and hand. He disclosed the resident was dressed in long sleeve shirt, pants, ball cap and shoes and was alert and able to identify himself to the rescue squad personnel and the hospital personnel. Review of an incident/investigation report # 2021- 1 filed by the local police department and dated 03/13/2021 revealed the police department had been called and responded to a missing person alert on 03/13/2021 at 3:45PM. A policeman and detective responded, and their report read in part: responded to facility in reference to a missing adult male (Resident #167). Spoke with the DON who stated the resident was last in his room at approximately 2:30PM and when the nurse (NA #6) checked on him at 3:15PM the resident was missing. The DON stated no alarm had sounded on any of the doors that alerts to anyone leaving the building. The facility does have surveillance cameras but at the time of this report there was no one that could view the camera footage to see when Resident #167 left the building. The staff stated they had checked the inside of the building to locate the resident; however, the resident was not located inside the building. Resident #167 will be entered NCIC (National Crime Information Center). Review of a case supplement report dated 03/13/2021 at 5:36PM revealed the following: Resident #167 was located at the local hospital emergency department (ED). The resident was not injured but had fallen and brought to the ED to get help. He is going to be discharged within an hour or so of me talking to him. Case closed and resident will be removed from NCIC. The route Resident #167 took to the bakery required him to cross an intersection with a 4-lane road and then cross another intersection with a 2-lane road. According to Weather.com the weather conditions in [NAME], North [NAME] on 03/13/2021 from 2:40PM to 4:15PM was sunny and 78 degrees Fahrenheit (F). Review of a hospital ER report revealed Resident #167 arrived at the local hospital ER at 4:16PM via rescue squad. He presented to the ER as status post fall. The note by the ER physician read: Patient was walking when he tripped on a hole in the sidewalk and fell striking his head. Sustained an abrasion to left forehead. No loss of consciousness but does take [MEDICATION(S)]. Moderate intensity sudden onset mild left frontal headache. Non-radiating. No vomiting. No numbness tingling. No other modifying factors or associated symptoms, no other provocative or palliative factors. CT (computerized tomography) of head impression: no acute [CONDITION(S)] is identified. CT scan of Cervical spine impression: No acute displaced fracture is identified. If clinical concern and/or patient's symptoms persist, also consider correlation with MRI. Additional findings described above also present on prior exam. The resident was discharged from the hospital ER at 7:27PM and returned via EMS to the facility. A note written by Nurse #2 stated: 03/13/2021 at 7:53PM Nursing: resident arrived back at facility via EMS, no acute distress noted. Wander guard applied to right ankle, call bell in reach. An additional note written by Nurse #2 stated: 03/13/2021 at 9:35PM Nursing: Return to facility/post elopement: Resident returned to facility via stretcher at 7:45PM. Wander guard applied to right ankle. Alert and confused but responsive to verbal and tactile stimuli. Vitals: Blood pressure of 118/74, Pulse of 78, Respirations of 18 and temperature of 97.2. Assisted to bed with 2-person assist. Neuro checks initiated. Currently lying in bed with head of bed (HOB) slightly elevated, call light intact. Refuses full body assessment x 2 attempts (agitated and stated he would leave if keep messing with him). Every 15 minutes visual checks initiated. Discolored bruising noted to left eyebrow. Area measures 2 centimeters (cm) by 2 cm with skin intact. Discolored bruising noted on left had. Area measures approximately 2 cm by 4 cm, skin intact. Discolored bruising noted to right hand, skin intact and measures 1 cm by 3 cm. Respirations are even and unlabored. No complaints of pain or discomfort voiced at this time. Tolerated by mouth medications without difficulty. Will continue to monitor. MD/family member notified. No attempts made to exit room/facility at this time. An interview on 05/02/2021 at 11:04PM with Nurse #2 revealed she was working and assigned to Resident #167 when he returned from the emergency room (ER) on 03/13/2021 sometime around 7:45PM. Nurse #2 reported she had placed a wander guard on the resident upon his return to the facility. Nurse #2 stated she had gotten report from Nurse #8 at change of shift and had been told Resident #167 had exited the building earlier in the day through the A hall door. She explained once the wander guard was placed the resident received every 15-minute checks to ensure his whereabouts and the wander guard was on. Review of a Post Elopement Report completed by Nurse #8 on 03/14/2021 for an elopement on 03/13/2021 revealed the following: Resident #167 attempted to exit A hall door at 8:15AM on 03/13/2021 and was redirected, observed throughout the morning. At 2:00PM resident was seen in the hall in his wheelchair, at approximately 3:15PM, resident could not be located in the facility. Event details: When and where was resident found? In ER at 4:15PM. Did resident sustain any injury during elopement period? If so, describe: Resident had 2 abrasions on face. Did resident exhibit any of the following behaviors prior to elopement? Anger regarding facility placement, combativeness, elopement attempts in past - unsuccessful, repeatedly opening door/setting off alarms of secured doors, resisting redirection from staff, verbalizing statements about leaving, and wandering with no rational purpose and attempting to open doors. Mental status: Does resident exhibit any of the following as a change in mental status of new onset? Agitation, anxiety, confusion, and restlessness. Possible contributing factors: Are any of the following factors present? Dementia, and [CONDITION(S)] (end stage renal disease). Interventions - Immediate measures taken: Personal alarm - i.e., motion detector, photograph posted, and hall door alarm functioning. Outcome of interventions: Interventions effective - resident on 15-minute monitoring. Notification guidelines: Notify MD/NP/PA immediately for appropriate interventions. Notifications: Supervisor contacted physician on 03/13/2021 at 9:17PM, Supervisor notified family member on 03/13/2021 at 3:50PM and wander guard placed 03/13/2021 upon return to facility. The report remains open. An interview on 05/03/2021 at 9:40AM with the Director of Nursing (DON) who was the weekend supervisor on 03/13/21, revealed he was not assigned to the resident, but the resident was assigned to Nurse #8. He said he had heard the alarm go off on the A hall a couple of times and was aware Resident #167 had attempted to leave the building but said he had not turned the alarm off because Nurse #8 had the keys to the A hall door. The DON disclosed Nurse #8 had notified him that she could not find the resident on rounds at 3:15PM. He stated Nurse Aide (NA) #6 had last seen Resident #167 at 2:45PM and then provided care to 2 other residents before getting back to check on him at 3:15PM. The DON advised he had notified the MD, the resident's RP, and the police when they could not locate Resident #167 in the facility. He indicated he had additionally contacted the former DON to let her know the resident had eloped. The DON explained he called in ancillary staff including the Regional Maintenance Director and Housekeeping Supervisor to assist in locating the resident. According to the DON when the police arrived, he gave a description of the resident but did not have a photo of the resident to share with the police. The DON stated once the former DON arrived, she took over the investigation and he went back to resident care on his hall. An interview on 05/03/2021 at 2:22PM with the former Director of Nursing (DON) revealed she was at home when she got a call from the weekend supervisor on 03/13/2021 that Resident #167 had eloped from the building. She stated she went to the facility and notified the Administrator and the regional nurse consultant of the elopement. The former DON explained she had instructed the weekend supervisor to get statements from the staff and start a timeline of the elopement. She indicated when she got there the police were already there and there was no picture in the resident's medical record to give to the police to aid in the search of the resident. The former DON advised she was unable to view the security footage and was waiting on the Regional Maintenance Director to arrive to assist with the footage. She stated the police left with a description and began a search for the resident. The former DON disclosed when the Regional Maintenance Director arrived at the facility, he tested the A hall door and it was alarmed and functioning. She explained the Regional Maintenance Director was able to review the footage with her from the security camera and they saw Resident #167 exit the building at 2:40PM through the A hall door and leave the premises at 2:50PM walking up the street in front of the facility. The former DON indicated staff had searched the premises and woods and creek around the facility and were unable to find the resident. She advised the family members of Resident #167 arrived at the facility around 4:15PM and stated sometime around 5:15PM she called the hospital and asked if they had a John Doe and they said no and then she asked if they had Resident #167 and they replied they did and he had been there approximately an hour. She indicated Resident #167 should have had a wander guard placed after his first attempt to get out of the building through the A hall door that morning. The former DON advised their 1 to 1 was not truly a 1 to 1 but was just frequent checks on the resident (every 15 minutes to determine whereabouts). According to the former DON, Resident #167 did not have a staff member or family member sitting with him while in his room except right after the elopement. An interview on 05/04/2021 at 2:56PM with the Regional Maintenance Director revealed he was called on 03/13/2021 and told Resident #167 had eloped from the facility and was missing. He stated when he came into the facility around 3:00 or 3:30PM he immediately went to the A hall entrance door and checked the door and when he pushed it open the alarm sounded and was loud and piercing. The Regional Maintenance Director further said once he checked the alarm, he went out to aid in the search for the resident. He indicated the door alarm and the wander guard alarm were separate alarms. The Regional Maintenance Director further indicated the alarms are tested every week by the Maintenance Director at the facility. He mentioned he was not sure what had happened that day but said the alarm was working on Thursday 03/11/2021 during the weekly testing when the Maintenance Director tested it and it was working on Saturday 03/13/2021 when he arrived at the facility after the elopement. The Regional Maintenance Director explained if the nurse did not properly turn the key to the on position when resetting the alarm then it would not alarm when someone went out the door. He indicated at the time of the elopement the alarm on the door required you turn it off if alarming, close the door and then turn the key to the on position to reset the alarm. According to the Regional Maintenance Director, if you did not do all the steps the door would not be alarmed. He reported after the elopement he changed the lock on the door such that the door automatically reset to on once you put in the key to turn off the alarm. The Regional Maintenance Director was not sure what happened to the alarm the day of the elopement but stated it was alarmed and functioning when he got to the facility. He indicated when he reviewed the security footage there was no sound so he could not determine if the alarm sounded or not. The Regional Maintenance Director advised when he reviewed the footage, Resident #167 was dressed in pants, long sleeve shirt, and a baseball cap but stated he could not see if he had on shoes. An interview on 05/04/2021 at 5:19PM with the Administrator revealed she remembered Resident #167 and his elopement from the facility. She stated she had been called that Saturday and came to the facility and she and the former DON were coordinating the investigation. The Administrator further disclosed if the staff knew prior to 03/13/2021, Resident #167 was an elopement risk they should have put a wander guard on him as their policy and procedure suggested. She indicated they had also discovered his picture had not been taken on his admitted [DATE] and stated it would have helped the police in their search for Resident #167 if his picture had been on file. The Administrator explained there had been some confusion on the part of the staff regarding who was supposed to take the picture and neither staff member had photographed the resident for his medical record. According to the Administrator they should have had his picture on file, and he should have had a wander guard placed prior to his elopement. The Administrator was informed of Immediate Jeopardy on 05/06/2021 at 11:25AM. The facility provided the following Credible Allegation of Compliance: #1 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 supervise a cognitively impaired resident with wandering behaviors who exited from the facility unsupervised. Resident #167 was admitted to the facility on [DATE] with diagnoses which included history of falling, difficulty walking and [CONDITION(S)]. The elopement assessment completed on 3/12/2021 identified Resident #167 at risk for elopement. Facility failed to follow policy and procedure by not placing wander guard on resident. Per nursing documentation resident displayed exit seeking behaviors. On 03/11/2021 at 7:29 PM, nursing progress note stated that resident was exit seeking and stated he needed to go home. The resident was redirected to his room. The nurse explained to him why he was at the facility. On 03/12/2021 at 11:00 AM, nursing progress note stated that the resident was wandering in and out of other resident rooms, requires constant cues and reminding from staff to stop roaming and tearing up other resident's beds. Resident has been requesting to go home. Assisted by staff for redirection. 03/13/2021, nursing progress note stated that the resident had attempted to exit from A hall door x l. Resident redirected, resident had breakfast and lunch, continued to make attempts to leave through A hall door. Staff had been trained to advance interventions to prevent elopement, such as wander guard, 15- minute monitoring checks, and one to one monitoring. Resident was last observed at 2:45 PM on 3/13/2021 by the nursing assistant in his room. At 3:15 PM, during rounds resident was not in his room or on the hall. Staff initiated search and could not locate the resident. The nurse supervisor contacted 911 for assistance in searching for Resident #167. The Director of Nursing (DON) called the local hospital emergency room around 5:15 PM and located Resident #167, two (2) hours and 35 minutes after he exited the facility. Per facility video surveillance, Resident #167 exited the facility through the A hall exit door on 3/13/21 at 2:40 PM and was off the premises of the facility by 2:50 PM. The Director of Nursing (DON) called the local hospital emergency room around 5:15 PM and located Resident #167, two (2) hours and 35 minutes after he exited the facility. Hospital records dated 3/13/21 noted the resident sustained a small laceration in his lower left infraorbital region that was shallow and non-gaping. The resident also sustained an abrasion to the left forehead but had no loss of consciousness. Resident #167 complained of a moderate intensity of mild left frontal headache that did not radiate and had not resulted in any vomiting or other associated symptoms. The resident had a computerized tomography (CT) scan which was negative. Resident #167 returned to the facility from the ER at the local hospital at approximately 7:53 PM and a wander guard was applied to his ankle by Nurse #2. Other interventions put into place were every 15 minute checks on the resident for 48 hours, alerted staff of resident's risk for elopement, involve resident in activities of resident's choice/interest, notify MD and RP if agitated or wandering behaviors increase, redirect as necessary, approach resident from front and speak in calm reassuring tone, and staff to monitor resident on a regular basis to determine whereabouts of resident. #2 Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. All residents were reviewed by the Director of Nursing to include interviews with nurses and CNA regarding exit seeking behaviors, both verbal and physically attempting to exit the facility. The DON reviewed all progress notes for documentation of these exit seeking behaviors. No additional residents were identified as exhibiting exit seeking behaviors on 3/13/2021. All facility staff were in-serviced regarding elopement procedures by utilizing Peak Resources - Elopement Procedures Lesson plan dated 3/13/2021. This plan was initiated on 3/13/2021 and education was completed by 3/16/2021 by the Administrator, Corporate Nurse Manager and/or the Staff Development Coordinator. The education included: All residents will be ass [TRUNCATED]

Based on record review, resident, and staff interview's the facility failed to provide incontinence care for 3 of 3 residents sampled for incontinence (Resident #42, Resident #16 and Resident # 17). The residents expressed feelings of being upset, angry, embarrassed, unclean and uncomfortable. The findings included: 1. Resident #42 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #42's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact for decision making. Resident #42 required extensive assistance of two staff members for bed mobility and transfers. She was coded as being dependent on one staff member for assistance with toileting. Resident #42 was coded as being always incontinent of bladder and frequently incontinent of bowel. Review of Resident #42's care plan dated 12/12/19 and updated on 02/12/21 revealed a focus area for urinary incontinence. The care plan stated Resident #42 was incontinent of bowel and bladder and required fluid restrictions due to [CONDITION(S)] and was at risk for urinary tract infections. Interventions included providing assistance to the bathroom, monitoring of fluid intake and frequent incontinence rounding. On 05/02/21 at 10:45 AM an interview was conducted with Resident #42. During the interview she stated on 04/25/21 she was provided incontinence care at 3:00 PM by the Nurse Aide. She stated the facility did not have a Nurse Aide (NA) on the hall from 7:00 PM to 11:00 PM on 04/25/21. The interview revealed she was not provided incontinence care again until 3:00 AM when a NA had come on duty and was completing her third shift incontinence rounding. Resident #42 stated she was upset feeling sad and embarrassed because she had to wait along with her roommate in a soiled brief to be changed. She stated when she was finally changed the NA had to change her brief along with her bed sheets because the urine had soaked through. The interview revealed she had filed a grievance with the facility regarding the issue. Review of a grievance dated 04/26/21 revealed on 04/25/21 Resident #16 stated the NA rounds were not performed as much as needed. Steps taken to investigate the incident included interviewing the resident, interviewing staff, review of the assignment schedule and interview with additional residents. The grievance stated the facility may need to improve time management versus caseload difficulty. Corrective action taken included an apology given to the resident. On 05/03/21 at 3:05 PM an interview was conducted with NA #1. She stated she was working on 04/25/21 during the 7:00 PM to 7:00 AM shift. The interview revealed the facility only had two NAs for a total of 73 residents during the shift. NA #1 stated she had frequently come into work and residents hadn't been provided incontinence care. NA #1 stated she remembered having to do a complete bed change for Resident #42 and her roommate. She stated Resident #42 was soaked with urine through her brief onto her bed pad and bed sheets when she finally got into the room to change her. NA #1 stated she was unable to complete every 2-hour incontinence rounding due to staffing in the building. She stated she may have been able to complete two incontinence rounds during her 12-hour shift for 73 residents. The interview revealed Resident #42 was not upset with her when she went in to change her bed but acted thankful that she was finally getting out of the wet brief and sheets. She stated once she came on shift she was assisting residents on another hall to bed and completing rounding prior to going to the hall Resident #42 resided. On 05/04/21 at 2:59 PM an interview was conducted with Nurse #2. She stated she was working on 04/25/21 on the 7:00 PM to 7:00 AM shift. The interview revealed she had received several complaints from residents regarding incontinence care and had changed residents herself during the shift. Nurse #2 stated the problem was the facility only had two NAs from 7:00 PM to 11:00 PM then an additional NA came in at 11:00 PM. She stated there were two nurses in the building for the 7:00 PM to 7:00 AM shift that were assigned to two halls themselves. The interview revealed usually from 7:00 PM to 12:00 AM the nurses were on a medication cart and unable to assist the NAs provide incontinent rounding to the residents. The interview revealed Resident #42 had complained to her regarding not receiving timely incontinence care. She stated the NAs were unable to complete every 2-hour rounding because of staffing and the facility not having enough help. On 05/04/21 at 3:44 PM an interview was conducted with NA #2. During the interview she stated she was working on 04/25/21 during the 7:00 PM to 7:00 AM shift along with NA #1. She stated they were responsible for 73 residents and were unable to complete every 2-hour incontinence rounding. The interview revealed she tried to provide incontinence care twice during her shift, once when she came on shift and the second time being at the end of her 12-hour shift. The interview revealed residents had complained to her about having to wait on incontinence care. On 05/05/21 at 10:34 AM an interview was conducted with the Director of Nursing (DON). The DON stated Resident #42 had filed a grievance regarding incontinence care on 04/25/21. He stated he had interviewed staff involved and gave an apology to the residents for having to wait on incontinence care. The interview revealed he told the NAs they needed to be more attentive to the residents needs and reviewed the schedule to see where the NAs were overloaded. The DON stated he hadn't completed any audits to ensure staff were completing incontinence rounding on a every 2-hour basis for residents. The interview revealed he was trying to staff with agency staffing to assist with the problem. On 05/06/21 at 6:00 PM an interview was conducted with the Administrator. During the interview she stated incontinence rounding should be completed on a every two-hour basis for residents. She stated she had brought in two agency companies providing staff to assist with the issue however agency staff were calling out when they were scheduled to work which made it difficult. 2. Resident #16 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #16's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact for decision making. Resident #16 required extensive assistance of one staff member for transfers and toileting. Resident #16 was coded as being always incontinent of bladder and bowel. Review of Resident #16's care plan dated 12/18/19 and updated on 03/12/21 revealed a focus area for urinary incontinence and assistance with activities of daily living (ADL). Interventions included providing assistance to the bathroom and frequent incontinence rounding. On 05/02/21 at 10:49 AM an interview was conducted with Resident #16. During the interview she stated on 04/25/21 she was provided incontinence care at 3:00 PM by the Nurse Aide along with her roommate Resident #42. She stated the facility did not have a Nurse Aide (NA) on the hall from 7:00 PM to 11:00 PM on 04/25/21. The interview revealed she was not provided incontinence care until 3:00 AM when a NA had come on duty and was completing her third shift incontinence rounding. Resident #16 stated she was angry, feeling upset and depressed because she had to wait along with her roommate in a soiled brief to be changed. She stated when she was finally changed the NA had to change her brief along with her bed sheets because the urine had soaked through. On 05/03/21 at 3:05 PM an interview was conducted with NA #1. She stated she was working on 04/25/21 during the 7:00 PM to 7:00 AM shift. The interview revealed the facility only had two NAs for a total of 73 residents during the shift. NA #1 stated she had frequently come into work and residents hadn't been provided incontinence care. NA #1 stated she remembered having to do a complete bed change for Resident #16 and her roommate. She stated Resident #16 was soaked with urine through her brief onto her bed pad and bed sheets when she finally got into the room to change her. NA #1 stated she was unable to complete every 2-hour incontinence rounding due to staffing in the building. She stated she may have been able to complete two incontinence rounds during her 12-hour shift for 73 residents. She stated once she came on shift she was assisting residents on another hall to bed and completing rounding prior to going to the hall Resident #16 resided. On 05/04/21 at 2:59 PM an interview was conducted with Nurse #2. She stated she was working on 04/25/21 on the 7:00 PM to 7:00 AM shift. The interview revealed she had received several complaints from residents regarding incontinence care and had changed residents herself during the shift. Nurse #2 stated the problem was the facility only had two NAs from 7:00 PM to 11:00 PM then an additional NA came in at 11:00 PM. She stated there were two nurses in the building for the 7:00 PM to 7:00 AM shift that were assigned to two halls themselves. The interview revealed usually from 7:00 PM to 12:00 AM the nurses were on a medication cart and unable to assist the NAs provide incontinent rounding to the residents. The interview revealed Resident #16 had complained to her along with her roommate Resident #42 regarding not receiving timely incontinence care. She stated the NAs were unable to complete every 2-hour rounding because of staffing and the facility not having enough help. On 05/04/21 at 3:44 PM an interview was conducted with NA #2. During the interview she stated she was working on 04/25/21 during the 7:00 PM to 7:00 AM shift along with NA #1. She stated they were responsible for 73 residents and were unable to complete every 2-hour incontinence rounding. The interview revealed she tried to provide incontinence care twice during her shift, once when she came on shift and the second time being at the end of her 12-hour shift. The interview revealed residents had complained to her about having to wait extended periods of time on incontinence care. On 05/05/21 at 10:34 AM an interview was conducted with the Director of Nursing (DON). The DON stated Resident #42 had filed a grievance regarding incontinence care for her and Resident #16 on 04/25/21. He stated he had interviewed staff involved and gave an apology to the residents for having to wait on incontinence care. The interview revealed he told the NAs they needed to be more attentive to the residents needs and reviewed the schedule to see where the NAs were overloaded. The DON stated he hadn't completed any audits to ensure staff were completing incontinence rounding on a every 2-hour basis for residents. The interview revealed he was trying to staff with agency staffing to assist with the problem. On 05/06/21 at 6:00 PM an interview was conducted with the Administrator. During the interview she stated incontinence rounding should be completed on a every two-hour basis for residents. She stated she had brought in two agency companies providing staff to assist with the issue however agency staff were calling out when they were scheduled to work which made it difficult. 3. Resident #17 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #17's quarterly Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact for decision making. Resident #17 required extensive assistance of one staff member for dressing and toileting. Resident #17 was coded as being always incontinent of bowel and frequently incontinent or urine. Review of Resident #17's care plan dated 10/02/20 and updated on 03/17/21 revealed a focus area for urinary incontinence and assistance with activities of daily living (ADL). Interventions included providing assistance to the bathroom and frequent incontinence rounding. On 05/02/21 at 10:05 AM an interview was conducted with Resident #17. He stated on 04/25/21 he rang his call bell at 7:15 PM and told a nurse who's name he could not remember that he needed to be changed because he had a bowel movement in his brief. The nurse stated to him she would get a NA to assist him. The interview revealed he didn't get his brief changed until 11:10 PM when NA #1 and Nurse #2 came into the room to assist him. Resident #17 stated he had sat in feces for 4 hours at that point and the NA had to change his bed pad along with his brief. He stated NA #1 told him she hadn't gotten to him because she was on another hall and the facility was short staffed. Resident #17 said Nurse #2 stated to him that he wasn't the only resident who had complained that day about not receiving incontinence care. Resident #17 stated it made him feel embarrassed, uncomfortable, and unclean having to sit in feces. On 05/03/21 at 3:05 PM an interview was conducted with NA #1. She stated she was working on 04/25/21 during the 7:00 PM to 7:00 AM shift. The interview revealed the facility only had two NAs for a total of 73 residents during the shift. NA #1 stated she had frequently come into work and residents hadn't been provided incontinence care. NA #1 stated she remembered Resident #17 complaining that he had to sit in feces. NA #1 stated she was unable to complete every 2-hour incontinence rounding due to staffing in the building. She stated she may have been able to complete two incontinence rounds during her 12-hour shift for 73 residents. She stated once she came on shift, she was assisting residents on another hall to bed and completing rounding prior to going to the hall Resident #17 resided. On 05/04/21 at 2:59 PM an interview was conducted with Nurse #2. She stated she was working on 04/25/21 on the 7:00 PM to 7:00 AM shift. The interview revealed she had received several complaints from residents regarding incontinence care and had changed residents herself during the shift. Nurse #2 stated the problem was the facility only had two NAs from 7:00 PM to 11:00 PM then an additional NA came in at 11:00 PM. She stated there were two nurses in the building for the 7:00 PM to 7:00 AM shift that were assigned to two halls themselves. The interview revealed usually from 7:00 PM to 12:00 AM the nurses were on a medication cart and unable to assist the NAs provide incontinent rounding to the residents. The interview revealed Resident #17 had complained to her about having to sit in feces. The interview revealed she finished her medication pass and provided incontinence care to Resident #17. She stated when she changed his brief he was sitting in feces and had to change his bed pad because it was soaking through his brief. She stated the NAs were unable to complete every 2-hour rounding because of staffing and the facility not having enough help. On 05/05/21 at 10:34 AM an interview was conducted with the Director of Nursing (DON). The DON stated he had a grievance regarding incontinence care on 04/25/21. He stated he had interviewed staff involved and gave an apology to the residents for having to wait on incontinence care. The interview revealed he told the NA's they needed to be more attentive to the residents needs and reviewed the schedule to see where the NAs were overloaded. The DON stated he hadn't completed any audits to ensure staff were completing incontinence rounding on a every 2-hour basis for residents. The interview revealed he was trying to staff with agency staffing to assist with the problem. On 05/06/21 at 6:00 PM an interview was conducted with the Administrator. During the interview she stated incontinence rounding should be completed on a every two-hour basis for residents. She stated she had brought in two agency companies providing staff to assist with the issue however agency staff were calling out when they were scheduled to work which made it difficult.

Based on observations, record reviews, resident and staff interviews, the facility failed to provide sufficient nursing staff, resulting in missed showers for dependent residents, partial baths or bed baths being provided instead of preferred showers, and incontinence care not being provided for 9 of 15 residents reviewed for staffing. The findings included: This tag is cross referred to: 1. F550: Resident Rights: Based on record review, resident, and staff interview's the facility failed to provide incontinence care for 3 of 3 residents sampled for incontinence (Resident #42, Resident #16 and Resident # 17). The residents expressed feelings of being upset, angry, embarrassed, unclean and uncomfortable. 2. F561: Self Determination: Based on observations, record reviews, staff and resident interviews, the facility failed to honor resident's preference and number of showers per week for 4 of 6 residents reviewed for choices. 3. F677: Activities of Daily Living for Dependent Residents: Based on observations, record review, resident and staff interviews, the facility failed to provide showers scheduled for dependent residents for 2 of 6 residents sampled for activities of daily living. On 05/02/2021 at 3:00PM an interview was conducted with Nurse #8. She stated she worked 7:00AM to 7:00PM on weekends and there was never enough help. Nurse #8 further stated they were dependent on Agency staff to fill the holes on weekends and they frequently called out and the staff was left with not enough help to take care of the residents. She indicated all the weekend staff was tired and were frequently asked to stay over to cover holes in the schedule. Nurse #8 further indicated the Nurse Aides (NAs) did not have time to complete all the showers and frequently had to give bird baths or bed baths instead of taking residents to the shower. According to Nurse #8, the NAs had not reported noted being able to complete incontinence care every 2 hours but said when they were short staffed there was no way they could do incontinence checks and care for every resident every 2 hours. On 05/02/2021 at 11:04PM an interview was conducted with Nurse #2. She stated she worked 7:00PM to 7:00AM on the weekends and stated she was about dead from work. Nurse #2 further stated they commonly worked on the weekends with 2 nurses and 3 NAs in the whole building at night and stated it was just too much for the staff. She indicated there was one NA that was slow that worked 2nd shift and she often did not complete incontinence rounds and when the 3rd shift NAs came in they would have to change 4-5 residents including their pads and bed sheets because they were so wet. On 05/04/2021 at 8:24AM an interview was conducted with NA #8. She stated staffing had been rough at times. She indicated they frequently used Agency staff to fill in the open positions on the schedule but unfortunately, they called in and left staff short. NA #8 explained they frequently pulled her or the Restorative Aide to cover holes in the schedule on 1st shift. She indicated she and the Restorative Aide worked together to get the residents on Restorative seen and sometimes had to work over shift to get everything done. NA #8 reported they currently had 2 NAs on medical leave, and it would be helpful when they were able to return to work full time. On 05/05/2021 at 2:09PM an interview was conducted with the Scheduling Assistant (SA). She stated she was currently doing the schedule utilizing Agency staff and the facility staff. The SA further stated she used two different Agencies they were contracted with to fill the holes in the schedule. She indicated staff are frequently asked to stay over due to call ins with Agency staff. The SA explained she had Monday through Friday staff that worked 8 hours shifts and weekend staff that worked 12-hour shifts. She disclosed Monday through Friday on 1st shift she had 4 nurses, a treatment nurse and a charge nurse with no open nurse positions. She said if a nurse called in on 1st shift, she pulled the treatment nurse or the charge nurse to replace the call in. The SA indicated Monday through Friday she had 1 nurse on 2nd shift and relied on Agency staff to fill the holes or asked the facility staff to work over if Agency staff was not available. She reported there were currently 4 open Nurse positions on 2nd shift Monday through Friday. The SA stated Monday through Friday on 3rd shift she had 1 nurse and relied on Agency staff to fill the holes or asked facility staff to work over their shift. She advised there were 2 open nurse positions on 3rd shift. On weekends they work 12 hour shifts and she indicated they had 2 nurses that worked 7:00AM to 7:00PM and there were 3 open nurse positions on the weekend. She indicated they had 3 nurses that worked 7:00PM to 7:00AM and they had no 7:00PM to 7:00AM nurse positions. The SA stated they were staffed for NAs on Monday through Friday 1st shift and had 5 full time NAs. She revealed on Monday through Friday 2nd shift she had 3 NAs and there were 4 open positions. On 3rd shift the SA explained there were 4 NAs but 1 was on medical leave and they had 1 float NA position open on 3rd shift. She reported on weekends there were 3 NAs on the 7:00AM to 7:00PM shift and 3 open NA positions. The SA stated on weekends there were 3 NAs on the 7:00PM to 7:00AM shift but one was on medical leave and there were 2 open positions for NAs on the 7:00PM to 7:00AM shift. According to the SA staffing the facility had been very challenging given the staff she currently had and all the open positions. She advised she currently had 9 open nurse positions and 11 open NA positions, and it had been difficult to recruit staff due to the area hospital and other nursing homes in the area. On 05/06/2021 at 4:52PM an interview was conducted with the Director of Nursing (DON). He revealed the facility had a challenged demographic and it had been difficult to recruit the caliber of nurse and NA he desired for the residents to have optimum health and care. The DON stated they were recruiting through agencies online and were offering sign on bonuses as well as bonuses to current staff working and filling the holes on the schedule. He explained he was working to develop a more professional environment and encouraging the staff to be more focused and work together professionally and move the facility in a more positive direction. The DON indicated their challenges with staffing were not insurmountable, but it had to be a collaborative effort among the staff. He further indicated they needed to admit appropriate residents to the facility based on the current skill set of the staff and said it was not logical to keep bringing difficult residents in the facility without the staff to care for them. According to the DON, he expected the residents to receive their showers as preferred, showers including getting their hair washed and incontinence care as needed. On 05/06/2021 at 6:00PM an interview was conducted with the Administrator. During the interview she admitted they had some challenges with staffing and were working with corporate to recruit staff for the open positions for nurses and NAs. The Administrator stated she expected the NAs to ask for assistance when they were not able to complete showers and provide incontinence care and stated there were ancillary staff working other positions who were NAs that could assist as needed with resident care. She disclosed she was not aware showers were not being provided based on resident preference and that incontinence rounds were not being provided every 2 hours and as needed. According to the Administrator, she expected the residents to receive their showers as preferred, including getting their hair washed and expected them to be provided incontinence care every 2 hours and as needed. She stated they had tried to relieve some of the work for their staff by using Agency staff but said it had been difficult when the Agency staff had called in or not shown up for their shift. The Administrator advised they were offering bonuses to their staff and were offering sign on bonuses for new hires.

Based on record review, staff and physician interviews, the facility failed to identify the seriousness of low oxygen saturation levels, assess the residents, provide nursing and medical interventions, identify the urgent need for medical attention or notify the physician for residents who experienced a low oxygen saturation levels. As a result, Resident #2 maintained a low oxygen saturation level ranging from 66% to 76% (normal range greater than 92%) for a 9-hour period resulting in a hospitalization . Resident #2 was confirmed to be hypoxic (deprivation of adequate oxygen supply at the tissue level) and was diagnosed with [REDACTED]. Resident #1 had a sudden onset of low oxygen saturation of 72% and oxygen therapy was initiated without ongoing assessments. A family member contacted Emergency Medical Services and had Resident #1 transferred to the hospital where the resident was diagnosed with [REDACTED]. This was for 2 of 3 sampled residents reviewed for respiratory care (Resident #1 and Resident #2). Immediate Jeopardy began on 11/07/20 when Resident #1 and #2 both had acute changes of condition with the high likelihood for serious outcomes, and the facility failed to respond with medical services. The immediate jeopardy was removed on 03/06/21 when the facility provided and implemented an acceptable credible allegation for 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. The findings included: 1. Resident #2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of Resident #2's most recent annual Minimum Data Set ((MDS) dated [DATE] revealed she was cognitively intact. Resident #2 required extensive assistance of one staff member for most activities of daily living (ADL). Resident #2 was coded as not receiving oxygen therapy during the assessment period. Review of Resident #2's November 2020 Physician orders [REDACTED]. Review of Resident #2's active care plan initiated on 02/25/20 revealed a focus area for respiratory care. An intervention included oxygen therapy as ordered. Review of a Physician order [REDACTED]. Review of Resident #2's November 2020 Physician orders [REDACTED]. Review of a nursing progress note dated 11/04/20 revealed Resident #2 was tested in the facility for COVID-19 with a positive result via a medical lab. Review of Resident #2's vital signs on 11/07/20 revealed the following: - 11/07/20 at 3:09 AM: Oxygen saturation level of 76% on 2 liters of supplemental oxygen. - 11/07/20 at 3:20 AM: Oxygen saturation level of 75% on 2 liters of supplemental oxygen. - 11/07/20 at 6:55 AM: Oxygen saturation level of 75% on 2 liters of supplemental oxygen. - 11/07/20 at 12:01 PM: Oxygen saturation level of 66% on 4 liters of supplemental oxygen. Review of nursing progress notes and nursing assessments dated 11/07/20 revealed no documented assessments by Nurse #3. On 02/25/20 at 8:55 AM an interview was conducted with Nurse #3. She stated she was responsible for Resident #2 during third shift on 11/06/20-11/7/20 from 11:00 PM to 7:00 AM. Nurse #3 stated she remembered Resident #2 experiencing a low oxygen saturation level but did not remember if she had notified the Physician or oncoming first shift nurse. She stated if she did notify the Physician it would have been listed under the facility's notification system called Urgent and could be pulled up. Nurse #3 stated during that time she was new to the facility and was still learning as a new nurse. The interview revealed she did not recall turning Resident #2's supplemental oxygen up from 2 liters during the night but remembered her being on oxygen due to a [DIAGNOSES REDACTED]. The interview revealed she had obtained Resident #2's vital signs on the morning of 11/07/20 at 3:09 AM, 3:20 AM, and 6:55 AM. Review of the facility's notification system revealed no record of Nurse #3 notifying the Physician of Resident #2's low oxygen saturation levels. A follow-up interview was conducted with Nurse #3 on 03/12/21 at 12:10 PM. She stated she knew Resident #2 was using supplemental oxygen when she came onto her shift and knew she had an order to maintain her oxygen level greater than 90%. She stated nobody had reported to her that Resident #2 was short of breath when she came on shift. The interview revealed she did not notice that Resident #2 was experiencing shortness of breath or showing signs of respiratory distress and indicated the resident was resting, and her color was pink. Review of the Event report dated 11/07/20 at 4:00 PM written by Nurse #1 revealed Resident #2 was sent to the hospital due to an onset of respiratory distress. The nurse had increased her oxygen and notified the Physician. Resident #2's vital signs upon transfer were: Oxygen saturation level of 66% on 4 liters of supplemental oxygen, temperature 100.8, blood pressure 127/63 and respirations 18 beats per minute. On 02/25/21 at 9:05 AM an interview was conducted with Nurse #1. She stated on 11/07/20 she was responsible for Resident #2 during the 7:00 AM to 7:00 PM shift. The interview revealed she did not receive anything in report from Nurse #3 regarding Resident #2's low oxygen saturation levels. She stated she was not aware of Resident #2's low oxygen saturation levels until she went into Resident #2's room at 11:30 AM to obtain vital signs and received an oxygen saturation level of 62% on 2 liters of supplemental oxygen via nasal cannula. She stated Resident #2 was alert but lethargic due to a [DIAGNOSES REDACTED].#1 stated Resident #2's color was good and she didn't appear short of breath. She stated you could not tell her oxygen saturation level was low. The interview revealed she increased Resident #2's oxygen to 4 liters around 11:30 AM and notified the Physician who gave orders to send the resident to the hospital for an evaluation. Review of Resident #2's hospital records dated 11/07/20 revealed she was admitted from the facility to the hospital with [MEDICAL CONDITION] (deprivation of adequate oxygen supply at the tissue level) consistent with COVID-19 pneumonia and oxygen saturation levels ranging in the 70%. Resident #2 was placed on 15 liters via a non-rebreather mask once at the hospital and was confirmed COVID-19 positive. Resident #2's oxygen saturation level would not maintain above 90% on the 15 liters with a non-rebreather mask and she was placed on a [MEDICAL CONDITION] (machine that pushes air into the lungs). Resident #2's respiratory status was documented as diminished air entry bilateral with bilateral rhonchi. Resident #2's hospital [DIAGNOSES REDACTED]. Resident #2 was hospitalized for [REDACTED]. She was discharged on [DATE] on 1-2 liters of supplemental oxygen and noted to be in a stable condition. On 02/24/21 at 12:39 PM an interview was conducted with the Director of Nursing (DON). She stated Resident #2 was sent to the hospital on [DATE] and had a status of full code. The interview revealed she was unaware of Resident #2 experiencing an oxygen saturation level in the 70% range throughout the early morning on 11/07/20 and stated those numbers should have been reported to the Physician via the communication board immediately. Upon review she stated she could not find where Nurse #3 had notified the Physician regarding Resident #2's oxygen level. The interview revealed Nurse #3 was new to the facility and may have just been placed off orientation. She stated her expectation was for the nurses on the hall to be aware if a resident was experiencing a change of condition and immediately notify the Physician on call and this information was incorporated into the facility's orientation for new nurses. On 02/25/21 at 8:30 AM an interview was conducted with the facility Nurse Practitioner (NP). She stated she would expect the nursing staff to notify her if they had a resident who had a low oxygen saturation level of 76% to 66% for a period of almost 9 hours. The NP stated that would be considered a change in condition and would need to be addressed immediately. On 02/26/21 at 8:40 AM an interview was conducted with the Medical Director (MD). He stated he was not familiar with Resident #2 however on 11/07/20 her vital signs should have been reported to the on-call Physician. The MD stated they should be notified immediately of a change in condition where a resident has an oxygen level in the 70% range, and it should not have gone on for an extended period of time. The interview revealed his expectation was for the responsible nurse to notice the abnormal vital sign, keep the resident comfortable and call the on-call Physician so orders could be obtained, and the situation be resolved. 2. Resident #1 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's most recent quarterly Minimum Data Set ((MDS) dated [DATE] revealed she was alert and oriented. Resident #1 required extensive assistance of one staff member for most activities of daily living (ADL). Resident #1 was coded as not receiving oxygen therapy during the assessment period. Review of Resident #1's care plan dated 06/16/17 and revised on 11/09/20 revealed a focus area for respiratory care due to Resident #1 being at risk for shortness of breath related to a history of asthma. An intervention included notifying the Physician if shortness of breath occurred. Review of a Physician order [REDACTED]. Review of Resident #1's nursing progress note dated 11/04/20 revealed she was diagnosed with [REDACTED]. Review of Resident #1's November 2020 Physician standard orders for oxygen/ respiratory therapy revealed the nurses could place residents on supplemental oxygen as needed for a low oxygen saturation level. The order did not specify how many liters of oxygen to apply. Review of a nursing progress note dated 11/07/20 at 3:54 PM written by Nurse #1 revealed Resident #1's Responsible Party (RP) had called and stated Resident #1 sounded short of breath. Nurse #1 checked on Resident #1 to find she had an oxygen saturation level of 72% (normal range 92-100%). The note revealed Nurse #1 initiated oxygen at 4 liters per minute (lpm) and Resident #1's oxygen level began to rise to 89%, 90% to 92%. Review of a nursing progress note dated 11/07/20 at 4:41 PM written by Nurse #1 revealed she had gone into Resident #1's room to find the nasal cannula tubing on the resident's forehead instead of in her nose. Resident #1's oxygen saturation level was at 70%. Nurse #1 replaced the nasal cannula into Resident #1's nose correctly and her oxygen saturation level increased to 90% on 4 liters of oxygen. On 02/24/21 at 11:13 AM an interview was conducted with Nurse Aide (NA) #1. She stated on 11/07/20 she was taking care of Resident #1. NA #1 stated Resident #1 was acting strange and confused during the morning, so she notified Nurse #1. NA #1 stated around 11:00 AM she told Nurse #1 the resident was breathing heavy and had not eaten her breakfast meal which was noticed when she picked up the trays. NA #1 stated she did not know if Nurse #1 went into Resident #1's room to check on her. She stated around 2:00 PM she went back into Resident #1's room to find her in the same condition continuing to experience heavy breathing so she notified Nurse #1 again. The interview revealed Resident #1's responsible party had called Nurse #1 as well and notified her of Resident #1's shortness of breath. When Nurse #1 entered the room to obtain an oxygen saturation level NA #1 stated it was in the 70% range (normal 92-100%). She stated Nurse #1 then ran down the hall to obtain an oxygen concentrator and applied oxygen to Resident #1 via a nasal cannula. The interview revealed after Nurse #1 applied oxygen to Resident #1 she still seemed confused removing the oxygen tubing causing her oxygen level to drop. On 02/24/21 at 10:07 AM an interview was conducted with Nurse #1. She stated on 11/07/20 she was responsible for Resident #1 during the 7:00 AM to 7:00 PM shift. Nurse #1 stated she had received a phone call from Resident #1's responsible party around 3:30 PM who said she was experiencing shortness of breath and needed oxygen. She stated she did not recall NA #1 coming to her and saying anything was wrong with Resident #1 however it had been a while and she may have forgotten. Nurse #1 stated she went into the resident's room with the RP still on the phone and checked her oxygen level to find a low reading. The interview revealed she ran from the resident's room to get an oxygen concentrator and initiated oxygen via nasal cannula at 4 liters and Resident #1's oxygen saturation level improved. Nurse #1 stated she received a second call from Resident #1's RP around 4:30 PM stating the resident was still experiencing shortness of breath and to go and check on her. When she entered the room Resident #1 did not have her oxygen on and her oxygen saturation level was low again. She stated she placed the nasal cannula back into Resident #1's nose and her oxygen level increased to 90%. The interview revealed she passed the information along to the second shift nurse during shift change however did not notify a Physician of Resident #1's change of condition requiring supplemental oxygen. She stated she did not feel like she needed to since the resident's oxygen level had increased on 4 liters. On 02/24/21 at 10:20 AM an interview was conducted with Nurse #2. She stated she was responsible for Resident #1 on 11/07/20 during the 7:00 PM to 7:00 AM shift. Nurse #2 stated she had received report from Nurse #1. During the interview she stated she was not informed during shift change that Resident #1 had experienced a change requiring the need for supplemental oxygen. She stated Resident #1 had not worn oxygen prior to that day. The interview revealed Resident #1's RP had called her around 8:30 PM during the middle of her medication pass stating he wanted Resident #1 sent to the hospital for an evaluation. The interview revealed she had received report and started her medication pass not making it to Resident #1's room yet. Nurse #2 stated she went into Resident #1's room to find her in no respiratory distress. She stated she obtained vital signs and they were within normal limits however did not chart them and could not remember what they were. She notified the Director of Nursing (DON) who was in the building and the Nurse Practitioner on call. The Nurse Practitioner ordered a nebulizer treatment every 4 hours as needed and a chest x-ray. Nurse #2 stated the NP told her if the family wanted to call Emergency Medical Services they could however if the resident was in no respiratory distress, she didn't see the need to send them out. She stated the RP contacted Emergency Medical Services (EMS) and Resident #1 was transported to the hospital at 9:30 PM. Review of the Nurse Practitioner (NP) computerized communication board revealed on 11/7/21 at 8:41 PM Nurse #2 notified the on-call NP that Resident #1's son was requesting she go to the hospital for an evaluation. Nurse #2 wrote to the NP that Resident #1 was in no distress but the residents Responsible Party (RP) would feel better if she went out. The note revealed Resident #1 kept taking her nasal cannula out of her nose which caused her oxygen level to drop and Nurse #2 had taped the cannula in place on the resident's nose. The NP gave orders to obtain a 2-view chest x-ray and nebulizer treatments as needed for shortness of breath and wheezing but stated she did not agree hospitalization was necessary. She stated if the family wanted the resident sent to the hospital, they could call emergency medical services (EMS). On 02/24/20 at 9:25 AM an interview was conducted with Resident #1's Responsible Party (RP). During the interview he stated he had spoken to Resident #1 on the afternoon of 11/07/20 in which she sounded out of breath and stated to him she felt short of breath. The RP stated he hung up the phone with Resident #1 and called Nurse #1. Nurse #1 then went into the room and checked her oxygen saturation level which was low. He stated he was told Nurse #1 initiated supplemental oxygen at that time. The RP stated he called Resident #1 back two hours later to ask how she was doing, and she was still short of breath. When he asked her if she was wearing oxygen, she stated no. The RP then called the nurses station and spoke with Nurse #1 to tell her what Resident #1 had said. He stated when the nurse went into the room the resident was in fact not wearing her oxygen, she placed the oxygen back into Resident #1's nose and her oxygen level increased. The RP stated when he called back, he spoke with Nurse #2 and asked how Resident #1 was doing. She stated to him she hadn't been into the room yet, but she would check on her. The RP stated he told Nurse #2 he wanted Resident #1 sent to the hospital for an evaluation. The interview revealed Nurse #2 called him back and stated she had spoken with the Director of Nursing and Nurse Practitioner who both recommended the resident not be sent to the hospital because she appeared to be in no respiratory distress at that time. He was told if he wanted her sent to the hospital, he could call Emergency Medical Services (EMS) himself in which he did. On 02/24/21 at 12:39 PM an interview was conducted with the Director of Nursing (DON). During the interview she stated Resident #1 was a full code and if there was a change of condition the nurse was responsible for notifying the Physician immediately. She stated she was in the facility on 11/07/20 working on another hall during night shift. The DON stated Nurse #2 had come to her stating the RP wanted Resident #1 sent to the hospital but that her assessment was the resident was in no respiratory distress. The DON stated she did not go assess the resident herself but told Nurse #2 to just let the Physician know the resident was in no respiratory distress. Review of the hospital records dated 11/07/20 at 10:00 PM revealed Resident #1 had a [DIAGNOSES REDACTED]. The report revealed Resident #1 was too lethargic to give any additional history when seen in the emergency room and her responsible party had given the information. Resident #1's vital signs at the hospital were temperature 102, heart rate 95, blood pressure 127/52 and oxygen saturation level of 92% on 4 liters of oxygen. The treatment plan for Resident #1 included low dose [MEDICATION NAME] (blood thinner) for treatment of [REDACTED]. On 11/10/21 Resident #1 was seen emergently at the bedside for acute [MEDICAL CONDITION], overnight she had experienced an increased reaction to Covid-19 Pneumonia with spiking fevers and more shortness of breath. Resident #1 was intubated and placed in the Intensive Care Unit (ICU). Resident #1's oxygen saturation levels were in the 70% ' s. A discussion was had with Resident #1's RP to transition the resident into comfort care. On 02/25/21 at 8:30 AM an interview was conducted with the facility Nurse Practitioner (NP). She stated she would expect the nursing staff to notify her if they had a resident who previously did not require oxygen therapy, placed on supplemental oxygen due to a low oxygen saturation level in the 70 % range. The NP stated that would be considered a change in condition and would need to be addressed immediately. On 02/24/21 at 10:21 AM an interview was conducted with the Medical Director (MD). He stated when he reviewed the NP notes from 11/07/21 he saw the responsible party had requested Resident #1 be sent to the hospital for an evaluation despite the nurse's assessment that the resident was experiencing no respiratory distress. The MD stated [MEDICAL CONDITION] (the absence of enough oxygen in the tissue to sustain bodily function) did not equal respiratory distress. The interview revealed he did not send residents out for respiratory distress unless they were in active accessory muscle distress which it did not seem like Resident #1 was in as evidenced by her oxygen saturation level increasing with supplemental oxygen use. He stated she was noted to be confused which meant she probably did not have the mentation at that time for supplemental oxygen to be useful which is why she was removing it. The MD stated the NP had ordered a nebulizer treatment and chest x-ray when Nurse #2 notified her. He stated looking at the summary of the notes from 11/07/20 since he wasn ' t in the building the situation was a clinical decision and if a responsible party was insistent the resident go to the hospital then they would be told it was their right to call emergency medical services. The interview revealed it was the facility protocol to place residents on [MEDICATION NAME] blood thinner when diagnosed with [REDACTED]. The interview revealed Resident #1 was hypoxic was placed on supplemental oxygen with her oxygen saturation improving yet still threw a clot and ended up with a [MEDICAL CONDITION] embolism. He stated there was no way the facility could have known that was occurring. The facility Administrator was notified of the immediate jeopardy on 03/05/21 at 9:06 AM. The facilty Administrator was notified of an additional example of immediate jeopardy on 3/23/21 at 11:40 AM. The facility provided the following credible allegation of Immediate Jeopardy removal: #1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: 1. Resident #2 tested positive for Covid-19 on 11/04/2020. Resident #2 had been ordered supplemental oxygen at 2-3 liters per minute to maintain oxygen saturations above 90% written on 08/13/2020. On 11/07/20 at 3:09 AM, Resident #2 oxygen saturation was documented to be 76% on 2 liters of supplemental oxygen. On 11/07/20 at 3:20 AM Resident #2 oxygen saturation was documented to be 75% on 2 liters of supplemental oxygen. On 11/07/20 at 6:55 AM Resident #2 oxygen saturation was documented to be 75% on 2 liters of supplemental oxygen. Nurse #3 did not notify Resident #2 physician/nurse practitioner or physician assistant (MD/NP/PA) of the low oxygen saturation levels nor did Nurse #3 increase Resident #2 oxygen as was ordered by the MD. There is no documentation that the resident was assessed by Nurse #3. On 11/07/20 at 11:30 AM, Nurse #1 noted that Resident #2 oxygen saturation was 62%. Oxygen was being administered at 2 liters per minute. Nurse #1 increased the resident's oxygen to 4 liters per minute and notified the resident's physician. Resident #2 was transferred to the emergency room for evaluation and treatment. The alleged non-compliance resulted from the failure of Nurse #3 to identify that the oxygen desaturations were life threatening, to assess the Resident #2, to increase Resident #2's oxygen per MD order, and by not notifying the MD/NP/PA of the life-threatening situation. These failures delayed Resident #2 from getting medical attention. Nurse #3 could not recall if she reported the desaturations to the MD/NP/PA or the oncoming nurse on 11/07/2020. Resident #2 was admitted to the hospital on [DATE] with [MEDICAL CONDITION]. Resident was treated at the hospital and subsequently returned to the facility on [DATE] for care post hospitalization for Bilateral Pneumonia secondary to Covid-19 virus. While hospitalized , she required high-flow nasal cannula and received Remdesivir (broad-spectrum [MEDICAL CONDITION] medication) and [MEDICATION NAME] (corticosteroid). She steadily improved and upon return required oxygen at 1-2 liters per minute via nasal cannula. 2. Resident #1 was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. On 11/07/20 at 3:54 PM, Nurse #1 documented in the resident progress notes that Resident #1 's Responsible Party (RP) had called and stated Resident #1 sounded short of breath. Nurse #1 checked on Resident #1 to find she had an oxygen saturation level of 72%. The note revealed Nurse #1 initiated oxygen at 4 liters per minute (1pm) and Resident #1's oxygen level began to rise to 89%, 90% to 92%. The nursing progress note, dated 11/07/20 at 4:41 PM written by Nurse #1, revealed she had gone into Resident #1's room to find the nasal cannula tubing on the resident's forehead instead of in her nose. Resident #1's oxygen saturation level was at 70%. Nurse #1 replaced the nasal cannula into Resident #1's nose correctly and her oxygen saturation level increased to 90% on 4 liters of oxygen. Nurse #1 did not notify Resident #2 physician/nurse practitioner or physician assistant (MD/NP/PA) of the sudden onset of low oxygen saturation levels nor did Nurse #1 notify the physician/nurse practitioner of Resident #1's change of condition requiring supplemental oxygen. On 11/07/2020 at 8:30 PM, Nurse #2 revealed that Resident #1's RP had called her around 8:30 PM during the middle of her medication pass stating he wanted Resident #1 sent to the hospital for an evaluation. Nurse #2 stated she was not informed during shift change that Resident #1 had experienced a change requiring the need for supplemental oxygen. Nurse #2 stated she went into Resident #1's room to find her in no respiratory distress. She stated she obtained vital signs and they were within normal limits however, she did not chart them and couldn't not remember what they were. She notified the Director of Nursing (DON) who was in the building and the Nurse Practitioner on call. The Nurse Practitioner ordered a nebulizer treatment every 4 hours as needed and a chest x-ray. Nurse #2 stated the NP told her if the family wanted to call Emergency Medical Services they could however if the resident was in no respiratory distress, she didn't see the need to send them out. She stated the RP contacted Emergency Medical Services (EMS) and Resident #1 was transported to the hospital at 9:30 PM. Review of the hospital records dated 11/07/20 at 10:00 PM revealed that Resident #1 had a [DIAGNOSES REDACTED]. Resident #1 did not return to the facility. The alleged non-compliance resulted from the failure of Nurse #1 to identify that the oxygen desaturations were life threatening, to assess the Resident #1, and by not notifying the MD/NP/PA of the life-threatening situation. These failures delayed Resident #1 from getting medical attention. An audit was completed by the Administrator on 03/05/2021. The Administrator reviewed all residents who are currently on oxygen therapy or have received oxygen therapy in the last 72 hours to determine if any other resident had episodes of oxygen desaturation and if so, was the MD/NP/PA notified and appropriate interventions applied. In addition, all physician orders [REDACTED]. All physician orders [REDACTED].<90% and to maintain oxygen saturations >90%. There were 17 additional potentially affected residents, however, no additional residents were identified as having been affected by the alleged deficient practice. All 17 residents had orders for parameters of notification. No resident had oxygen saturations <90%. #2. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. Nurse #3 was educated by the Director of Nursing on 02/28/2021 regarding the importance of oxygen saturation readings; to notify MD/NP/PA of any oxygen saturation level <90% and to increase the oxygen administration to maintain the oxygen saturation level >90% or per instruction on physician order. Oxygen-Nebulizer Administration Guideline was reviewed by the Regional Clinical Manager on 03/05/2021. Parameters were added to the guideline on 03/05/2021 to notify MD/NP/PA of any oxygen saturation level <90% and to increase the oxygen administration to maintain the oxygen saturation level >90% or per instruction on physician order. All licensed nursing staff will be educated by the Administrator, the Director of Nursing, and/or the Staff Development Coordinator regarding the following: 1. Oxygen saturation refers to the amount of oxygen that's in the bloodstream. The body requires a specific amount of oxygen in the blood to function properly. 2. The normal range of oxygen saturation for adults is 94 to 99 percent. 3. Oxygen saturations must be maintained >90%. If blood oxygen levels are too low, the body may not work properly. Hypoxemia can cause mild problems such as headaches and shortness of breath. In severe cases, it can interfere with heart and brain function. 4. Oxygen administration will be increased to maintain oxygen level >90% or as instructed by physician order. 5. The MD/NP/PA must be notified when oxygen saturation levels are below 90%. 6. If oxygen saturations are below 90% and the resident presents with other clinical signs of respiratory distress, including shortness of breath, cyanosis, elevated heart rate, and/or mental status changes, MD/NP/PA and EMS must be notified immediately. 7. Comprehensive assessments are important for all residents on oxygen therapy to assess for any signs and symptoms of respiratory distress. 8. All residents receiving oxygen therapy will be assessed for signs and symptoms of respiratory distress every shift or as ordered by the MD/NP/PA. 9. All residents receiving oxygen therapy will have oxygen saturations monitored every shift or as ordered by the MD/NP/PA. 10. All physician orders [REDACTED]. The Staff Development Coordinator and Administrator initiated the education for all licensed nursing staff on 03/05/2021. The Director of Nursing, Staff Development Coordinator, Nursing Supervisors and/or Administrator will provide the education to all licensed nurses prior to the start of their next shift. Any licensed nurse out on leave or on PRN status will be educated prior to returning to duty. The Director of Nursing will be responsible for tracking staff that have not received the education. The Staff Development Coordinator, Nursing Supervisors and the Director of Nursing were notified of this responsibility on 03/05/2021 by the Administrator. Any newly hired licensed nurse will be educated during orientation. All Certified Nursing Assistants will be educated by the Administrator, the Director of Nursing and/or the Staff Development Coordinator on signs and symptoms of respiratory distress, including shortness of breath, difficulty breathing, cyanosis, elevated heart rate, and/or mental status changes a (TRUNCATED)