Every finding on record at Premier Nursing and Rehabilitation Center

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of Alarms (Resident #13). This was for 1 of 23 residents whose MDS assessments were reviewed for accuracy.The findings includedResident #13 was admitted to the facility on [DATE].Review of Resident #13's medical record revealed a physician's order dated 3/11/26 to check placement of the electronic monitor that was placed on Resident #13's left lower extremity on every shift.Review of the Medication Administration Record (MAR) dated April 2026 revealed the electronic monitor was verified as in place on Resident #13's left lower extremity every day of the month.Review of the MAR dated May 2026 revealed the electronic monitor was verified as in place on Resident #13's left lower extremity every day of the month.Review of the MAR dated June 2026 revealed the electronic monitor was verified as in place on Resident #13's left lower extremity every day of the month.Resident #13's quarterly MDS assessment dated [DATE] was not coded for Restraint and Alarms.An interview was conducted with MDS Nurse #1 on 8/12/26 at 8:40 AM. She explained the electronic monitor should have been included in the MDS assessment. MDS Nurse #1 added she would have been responsible for that task, it was an error and it would be corrected today.On 8/12/26 at 8:50 AM an interview was held with the Director of Nursing, she confirmed the electronic monitor should have been indicated on the MDS and MDS Nurse #1 was responsible for ensuring the MDS assessments were accurate.An interview with the Administrator was conducted on 8/12/26 at 9:00 AM, she reported she did not know if the electronic monitor should have been included in the assessment and she would have to defer to the MDS Nurses.

Based on record review, observation and staff interviews, the facility failed to provide medication administration according to professional standards of care for 1 of 7 residents (Resident #100).The findings include:Resident #100 was admitted on [DATE] with diagnosis that included cerebral infarction (disrupted blood flow to the brain), anxiety disorder, gastro-esophageal reflux (stomach acid goes up into the esophagus), hyperlipidemia (high blood fat), hypertension (elevated blood pressure), depression, and major depression.Resident #100's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had severe cognitive impairment and received an antidepressant, diuretic and antiplatelet.Review of the Resident #100's Medication Administration Record (MAR) for 7/2/2026 revealed medications to be administered at 8:00 am included: amlodipine besylate tablet 5milligrams (mg) one tablet daily for hypertension, aspirin chewable tablet 81mg daily for trans ischial attack (blockage of blood flow in the brain), magnesium oxide tablet 400 mg one tablet daily for hypomagnesemia (low magnesium level), famotidine 20 mg one tablet daily for esophageal reflux disease, potassium chloride packet 20 milliequivalents one packet daily for supplement, sertraline hydrochloride 25 mg one tablet daily for depression, carvedilol tablet 3.125 mg 1 tablet twice daily for hypertension, sennosides-docusate sodium tablet 8.6-50 mg 1 tablet twice daily for constipation, acetaminophen extra strength tablet 500 mg one tablet twice daily for chronic pain.Review of Resident #100's occurrence report dated 7/2/2026 documented the medications administered to Resident #100 included: magnesium oxide 400 mg, sodium 1 gram (salt), vitamin B12 1000 micrograms (promotion of healthy red blood cells, apixaban 5mg (prevention of blood clots), and flintstone vitamins.In an interview conducted on 8/12/2026 at 2:40 pm with Nurse #2, she stated Nurse #7 came to her and reported that Nurse #7 had administered Resident #100 Resident #14's medications. Nurse #2 stated she and Nurse #7 obtained Resident #100's vital signs and contacted the NP and family members. Nurse #2 also stated Resident #100 did not demonstrate dizziness, lethargy or symptoms of bleeding (bruising). Resident #100 attended fine dining and went to activities and visited with family members as she usually does.In an interview conducted on 08/13/2026 8:17 AM, Nurse #7 stated she was preparing medications for a resident and had to stop and change the Nurse Aide (NA) assignment multiple times. Nurse #7 stated when she walked away from the medication cart, she placed the package of medication into a medication cup, placed the cup into the medication cart and locked the cart. When she returned to the medication cart, two residents were at the medication cart asking for their medications. Nurse #7 took the medications in the medication cup out of the medication cart, crushed the medications and administered them to Resident #100. Nurse #7 stated after Resident #100 swallowed the medication she realized they were not Resident #100 medication.Nurse #7 confirmed she had not labeled the cup of medications with a resident identifier. Nurse #7 stated she notified Nurse #2 and the DON immediately and took Resident #100's vital signs, then notified the NP who was in the facility. Nurse #7 stated the NP assessed Resident #100. Nurse #7 stated Resident #100 was her normal self all day, with no complaints of dizziness, lightheaded or tiredness. Nurse #7 stated Resident #100 was in her wheelchair rolling around the facility and going to activities. Her family was in the facility and even went to an outside cookout the facility had that day. Nurse #7 stated Resident #100 did not act any differently than her normal self. Nurse #7 stated after the medication error, she completed education on medication pass, requesting residents not to be at the medication cart during medication pass time and was observed passing medication by nurse management (DON, Quality Improvement nurse, or nurse supervisors). In an interview conducted on 8/12/2026 at 2:48 pm with the Director of Nursing (DON), she stated she was notified of the medication error the morning of 7/2/2026. The DON stated she observed Resident #100 on 7/2/2026 sitting in her wheelchair laughing and talking. Resident #100 had rolled herself up the hallway and went to the activities and went to the outside cookout with her family members. The DON stated Resident #100 did not exhibit or complain of dizziness or lethargy, Resident #100 was not drooling or leaning to one side. The DON stated Resident #100's demeaner had not changed. In an interview conducted on 8/12/2026 at 3:15 pm with the Administrator, she stated she observed Resident #100 rolling around in her wheelchair, sitting straight and smiling as was Resident #100's usual self. The Administrator stated that an investigation was completed and identified distractions at the medication cart was the reason for the medication being administered to the wrong resident. The Administrator stated the Nurse Managers completed education with the nurses and medication aide's and followed up with audits and presentation to QAPI for review of sustainability. In an interview conducted on 8/13/2026 at 3:30 PM the Administrator stated she did not have a fully implemented plan of correction for the medication error. She stated 100% of all nurses and medication aides had not completed the medication administration training and training on distractions at the medication cart.

Based on record review and interviews with the resident, staff, and the contracted transportation company, the facility failed to make an audiologist appointment after a physician's order for a consultation. The facility also failed to arrange for transportation to the audiologist appointment for 1 of 1 resident reviewed for hearing difficulties (Resident #123).Resident #123 was admitted to the facility on [DATE] with diagnoses which included spinal stenosis in the lumbar region, chronic pulmonary embolism, generalized anxiety disorder, and major depressive disorder. A physician's order written on 12/4/2025 revealed Resident #123 was to have a consultation with an audiologist.The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #123 was cognitively intact. Resident #123 was coded for minimal hearing difficulty and no hearing aid.Record review revealed the previous Nurse Practioner (NP) wrote progress notes on 3/26/2026 and 4/1/2026 that stated waiting for audiologist appointment.An interview with the current NP was conducted on 8/13/2026 at 11:21 AM. The NP was new to the facility, only had been working there for 1 week. The NP explained that when she wrote an order, she would put it into the computer and let the nurse know about the consultation. Since working at the facility, she had been going straight to the [NAME] Clerk with the consultation orders, so the appointments wouldn't be missed. The NP anticipated the appointment order to be scheduled within the month or the next month of the consultation order. An interview on 8/13/2026 at 10:03 AM with Resident #123 revealed that she made an appointment with an external audiology clinic at the end of April, herself. When the contracted transportation company came to pick her up, the van could not accommodate her bariatric wheelchair. Resident #123 missed her appointment that day and another appointment was not rescheduled for her. Resident #123 stated she was hard of hearing, and she felt guilty and like a burden when she asked people to speak up during conversations. Resident #123 stated that a week ago she just ordered some hearing aids online to help her hear better. On 8/13/2026 at 10:26 AM, the [NAME] Clerk was interviewed and stated she was not aware Resident #123 had an audiologist appointment until the week of 4/30/2026. Resident #123 informed the [NAME] Clerk of the appointment and requested transportation. The [NAME] Clerk stated she did not have a physician's order for a consultation written in her logbook for Resident #123 to be scheduled for an audiologist appointment. The [NAME] Clerk knew that the facility's own transportation van would not be able to accommodate Resident #123, so she called the contracted transportation company to take Resident #123 to her appointment. On the day of the appointment (4/30/2026), it was revealed the wheelchair lift on the contracted transportation company van was not wide enough for Resident #123 to be able to wheel in; the van had a standard wheelchair lift. Therefore, because the transportation van could not accommodate her bariatric wheelchair, Resident #123 missed her audiologist appointment. During a telephone interview on 8/13/2026 at 10:51 AM with a representative from the contracted transportation company, it was revealed that the company does have bariatric transportation via wheelchair or stretcher. The company would need to know a week or a few days ahead. When the facility sent a request, they needed to give the weight of the resident and any special instructions. The contracted transportation company reported that when the facility sent the request for transportation on 4/22/2026 for Resident #123's 4/30/2026 appointment, Resident's #123 weight was included in the information but did not include Resident #123's was in a bariatric wheelchair and needed accommodations for transportation.An interview on 8/13/2026 at 10:19 AM took place with the Director of Nursing (DON). The procedure for appointments made for residents was that the physician would order the consultation, the nurse would see the order and place the order in the logbook for the [NAME] Clerk to collect. The [NAME] Clerk would check the logbook daily for any orders and then make appointments and arrange transportation as soon as possible or according to the order. The DON stated that if the order was written in December, she anticipated that the appointment would be made as soon as possible. The DON stated that the Administrator had been working on trying to get outside specialists to come into the facility, so residents did not have to leave the facility for appointments, thus avoiding any transportation issues like what happened to Resident #123.

Based on observations, record review, and resident, staff, and resident representative interviews the facility failed to document bed rail entrapment risk assessments for the use of bilateral bed rails (Resident #103, Resident #125 and Resident #15) and failed to review the risks and benefits and obtain informed consent prior to installing and utilizing bilateral bed rails (Resident #15). The deficient practice was for 3 of 3 residents reviewed for accidents. The findings included: 1. Resident #103 was admitted to the facility on [DATE] with diagnosis that included trochanteric bursitis (inflammation of the fluid filled shock-absorbing sac at the outer bony point of the hip), spinal stenosis (narrowing of spaces inside your backbone), and osteoarthritis left hip. A review of Resident #103's electronic medical record (EMR) revealed an initial Physical Device Use Evaluation dated 3/3/2025 completed by the Director of Nursing revealed Resident #103 used top bed rails to promote independence in mobility. The evaluation indicated the discussion of risk, benefits, alternatives of the device and informed consent were explained to Resident # 103 on 3/3/2025. A review of Resident #103's physician order initiated on 3/3/2025 documented bilateral quarter length bed rails for bed mobility. Resident #103's medical record revealed subsequent Physical Device Use Evaluations were completed by the DON on 11/26/2025, 3/12/2026 and 6/17/2026 and did not include documentation of an entrapment risk assessment being completed for the use of the bilateral quarter length bed rails. A separate entrapment assessment was not identified in the medical record Resident #103's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and had functional limitation in range of motion of both lower extremities (hip, knee, ankle, foot). The MDS further revealed she needed substantial to maximum assistance to roll left and right in bed. Bed rails were not used as a restraint. Review of Resident #103's care plan with a review date of 8/4/2026 documented use of bed rails with interventions including, evaluating use of device periodically for continued effectiveness and appropriateness and bedrails to assist in turning and repositioning. Review of the Maintenance Department work history reports dated May 2026, June 2026, July 2026 and August 2026, revealed bed rails were documented as inspected monthly with no identified concerns. On 8/10/2026 at 11:00 AM Resident #103 was observed lying in her bed with bilateral quarter length bed rails in the raised position, no gaps were identified between the raised bed rails and the mattress. An observation and interview were conducted on 8/12/206 at 1:40 PM with Resident #103. Resident #103 was observed lying in her bed with bilateral quarter length bed rails in the raised position, no gaps were identified between the raised bed rails and the mattress. Resident #103 stated she needed the bed rails for bed mobility and positioning and demonstrated holding the bed rail and repositioning her weight from right to left side of bed. In an interview with the Director of Nursing (DON) on 8/13/2026 at 9:13 AM she stated she completed Resident #103's Physical Device Use Evaluation on 3/3/2025 and quarterly thereafter with the MDS Nurse. The DON stated that when she completed Resident #103's Physical Device Use Evaluation, she observed Resident 103's ability to grasp the bed rails, utilize the bed rails to reposition her weight in the bed and looked at the bed rails and mattress fit for gaps posing an entrapment risk. The DON stated she reviewed the bedrails and mattress for entrapment risk during the Physical Device Use Evaluation but there was not a separate entrapment risk assessment. The DON stated she had not identified an entrapment risk for Resident #103 when the evaluations were completed. She stated if she had identified an entrapment risk during Resident #103's Physical Device Use assessment, she would have notified the Maintenance Director to fix the gaps between the bed rails and mattress. 2. Resident #125 was readmitted to the facility on [DATE] with diagnosis that included chronic obstructive pulmonary disease and osteoarthritis of left hip. A review of Resident #125's EMR revealed Physical Device Use Evaluation dated 8/5/2025 completed by the Director of Nursing revealed Resident #125 used top bed rails to promote bed mobility. Resident #125's Physical Device Use Evaluation did not include documentation of an entrapment risk assessment being completed for the use of the bilateral quarter length bed rails. A separate entrapment assessment was not identified in the medical record. The evaluation indicated the discussion of risk, benefits, alternatives of the device and informed consent were explained to Resident #125 on 8/5/2025. A review of Resident #125's physician order dated 8/5/2025 revealed bilateral quarter length bed rails for bed mobility. Resident #125's medical record revealed subsequent Physical Device Use Evaluations were completed by the DON on 10/29/2025, 2/1/2026 and 5/7/2026 for Resident #125. The Physical Device Use Evaluation did not include documentation of an entrapment risk assessment being completed for the use of the bilateral quarter length bed rails. A separate entrapment assessment was not identified in the medical record Resident #125's annual MDS assessment dated [DATE] revealed he was moderately cognitively impaired. He had functional limitation in range of motion of both lower extremities (hip, knee, ankle, foot). The MDS further revealed Resident #125 was dependent to roll left and right in bed. Bed rails were not used as a restraint. Resident #125's care plan with review date of 5/19/2026, documented the use of bed rails with interventions including: assess resident for risk of entrapment from bed rails periodically and as necessary, check bed rails for proper functioning and used to turn, reposition and assist him to increase ability to enter and exit the bed. Review of the Maintenance Department work history reports dated May 2026, June 2026, July 2026 and August 2026, revealed bed rails were documented as inspected monthly with no identified concerns. On 8/12/2026 at 1:45 PM an observation and interview were conducted with Resident #125. Resident #125 was observed lying in his bed with bilateral quarter length bed rails in the raised position, no gaps were identified between the raised bed rails and the mattress. Resident #125 stated he utilized his bed rails for turning and repositioning himself during hygiene care. Resident #125 demonstrated repositioning his weight in bed utilizing the bed rails. In an interview with the Director of Nursing (DON) on 8/13/2026 at 9:13 AM she stated she completed Resident #125's Physical Device Use Evaluation on 8/5/2025 and quarterly with the MDS Nurse. The DON stated that when she completed Resident #125's Physical Device Use Evaluation, she observed Resident 125's ability to grasp the bed rails, utilize the bed rails to reposition his weight in the bed and looked at the bed rails and mattress fit for gaps posing an entrapment risk. The DON stated she reviewed the bedrails and mattress for entrapment risk during the Physical Device Use Evaluation as there was not a separate entrapment risk assessment. The DON stated she had not identified an entrapment risk for Resident #125, but she stated if an entrapment risk had been identified during Resident #125's Physical Device Use assessment, she would have notified the Maintenance Director to fix the gaps between the bed rails and mattress. In an interview with the Maintenance Director on 08/13/2026 9:45 AM it was revealed that there was a standing work order for the Maintenance Department to inspect each bed in the facility with sbed rails monthly. He stated the maintenance team checked bed rail fit that included inspecting for proper functioning and hazards. The Maintenance Director provided the steps for inspection of bedrails that included: inspect connectors on rails and tighten as necessary, remove any bent metal or rough edges to prevent injury, verify the function of the spring latch-knob assembly, ensure the rails engage and lock as specified and tighten, adjust or replace any parts such as end caps, knobs, bolts, screws that are loose, show signs of wear or are missing. The Maintenance Director stated when the bed rail does not fit properly with the mattress, we either replace the bed rail or place a wedge in between the mattress and the bed rail. 3. Resident #15 was admitted to the facility on [DATE] with a diagnosis of heart failure. Resident #15's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was moderately cognitively impaired. He had no functional limitation in range of motion of his upper extremities. He had functional limitation in range of motion of both lower extremities. He required substantial assistance to roll left and right in bed. He was dependent for transfers. Bed rails were not used as a restraint. Resident #15's medical record listed him as his own Resident Representative. His family member was also listed as Resident #15's Representative. Resident #15's comprehensive care plan revealed a focus area dated as initiated on 4/20/26 for use of bed rails. The goal dated as last revised on 6/8/26 was for Resident #15 to continue to use bed rails safely for facilitating bed mobility and/or transfers through the next review. An intervention was to use bedrails to assist resident to turn and reposition when in bed. A Physical Device Use Evaluation for Resident #15 dated 7/28/26 completed by the Director of Nursing (DON) revealed Resident #15 used top bed rails to reposition himself in bed and assist with care daily. These bed rails enhanced Resident #15's independence. There was no risk assessment included in this evaluation. The evaluation indicated the discussion of risk versus benefits of the device with Resident #15 and informed consent were not applicable. The discussion of risks versus benefits of the device and informed consent with Resident #15's Representative were not applicable. No entrapment risk evaluation, discussion of the risks versus the benefits of bed rails, or informed consent for bed rail use was found in Resident #15's medical record. On 8/10/2026 at 3:21 PM bilateral quarter length metal bed rails were observed at the head of Resident #15's bed in the raised position. In an interview with Resident #15 at that time, he stated these bed rails did not restrain him. He reported he used them to turn and reposition in his bed. He went on to say sometimes, the bed rails were in the way of him reaching his bedside table, but he asked staff to put his bedside table over his bed. On 8/11/2026 at a12:39 PM an observation of Resident #15 revealed bilateral quarter length metal bed rails at the head of Resident #15's bed in the raised position. In an interview with Resident #15 at that time he stated he didn't recall anyone ever explaining the risks versus the benefits of the bed rails to him or asking him for his consent for them. He reported the bed rails were already in place on his bed when he came to the facility. On 8/11/26 at 1:47 PM a telephone interview with Resident #15's family member indicated he did not recall anyone from the facility ever explaining the risks versus the benefits of the use of bed rails for Resident #15 with him or asking him for his consent. On 8/13/2026 at 8:18 AM in an interview the DON stated Resident #15 had bilateral quarter length metal bed rails in place at the head of his bed. She reported he used these to turn and reposition himself in his bed. She went on to say she had completed most of the Physical Device Use Evaluations for residents in the facility and had completed Resident #15's Physical Device Use Evaluation dated 7/28/26. The DON stated when she completed Physical Device Use Evaluations, she looked at the resident, watched the resident move around in the bed, looked at the mattress to ensure there were no gaps or anything that could pose an entrapment risk, and if she had any concerns about the bed rails she would ask the Maintenance Director to look at them. She reported that the Maintenance Department did not do bed rail entrapment risk assessments. The DON stated she did not review the risks versus the benefits of bed rails with residents or their representatives if the bed rails were not used as a restraint. She further indicated she did not obtain informed consent for the use of bed rails if the bed rails were not used as a restraint. On 8/13/2026 at 10:03 AM an interview with the Maintenance Director indicated that there was a standing work order in place for the Maintenance Department to inspect every bed in the building for bed rails monthly. He stated bed rails were inspected for proper installation and functioning and inspected for any hazards such as bent metal or loose or missing pieces. He reported he also verified with the DON that any resident who had bed rails in place had these bed rails on their care plan. The Maintenance Director indicated that the Maintenance Department did not install or remove bed rails without a request from the Nursing Department. He stated the Maintenance Department did not do bed rail entrapment risk assessments. On 8/13/2026 at 4:06 PM an interview with the Administrator indicated that Physical Device Use Evaluations should be completed in their entirety including a discussion of the risks versus the benefits of bed rails, obtaining informed consent from the resident or their Representative, and the assessment of the risk for entrapment from the bed rails before bed rails were implemented.

Based on record review, observation, staff and Nurse Practitioner interviews, the facility failed to ensure the right medication was administered to the right resident to prevent a significant medication error for 1 of 7 residents (Resident #100). The findings included:Resident #100 was admitted on [DATE] with diagnosis that included cerebral infarction (disrupted blood flow to the brain), anxiety disorder, gastro-esophageal reflux (stomach acid goes up into the esophagus), hyperlipidemia (high blood fat), dementia, hypertension (elevated blood pressure), depression and major depression disorder.Resident #100's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she had severe cognitive impairment and received an antidepressant, diuretic and antiplatelet.Review of the Resident #100's Medication Administration Record (MAR) for 7/2/2026 revealed medications to be administered at 8:00 am included: amlodipine besylate tablet 5milligrams (mg) one tablet daily for hypertension (high blood pressure), aspirin chewable tablet 81mg daily for trans ischial attack (blockage of blood flow in the brain), magnesium oxide tablet 400 mg one tablet daily for hypomagnesemia (low magnesium level), famotidine 20 mg one tablet daily for esophageal reflux disease, potassium chloride packet 20 milliequivalents one packet daily for supplement, sertraline hydrochloride 25 mg one tablet daily for depression, carvedilol tablet 3.125 mg 1 tablet twice daily for hypertension, sennosides-docusate sodium tablet 8.6-50 mg 1 tablet twice daily for constipation, acetaminophen extra strength tablet 500 mg one tablet twice daily for chronic pain.Review of Resident #100's occurrence report dated 7/2/2026 documented the medications administered to Resident #100 included: escitalopram 10 mg (used to treat anxiety), methylprednisolone 4 mg (slows down the immune system), dextromethorphan HBr and quinidine sulfate 20-10 mg (used to treat neurological conditions), risperidone 0.25 mg (antipsychotic), trazodone 50 mg (used to treat irritability, anxiety, and restlessness), metformin 500 mg (lowers blood sugar), metoprolol 25 mg (lowers blood pressure and heart rate).In an interview conducted on 8/12/2026 at 2:40 pm with Nurse #2, she stated Nurse #7 came to her and reported that Nurse #7 had administered Resident #100 Resident #14's medications. Nurse #2 stated she and Nurse #7 obtained Resident #100's vital signs and contacted the NP and family members. Nurse #2 also stated Resident #100 did not demonstrate dizziness, lethargy or symptoms of bleeding (bruising). Resident #100 attended fine dining and went to activities and visited with family members as she usually does.In an interview conducted on 08/13/2026 8:17 AM, Nurse #7 stated she was preparing medications for a resident and had to stop and change the Nurse Aide (NA) assignment multiple times. Nurse #7 stated when she walked away from the medication cart, she placed the package of medication into a medication cup, placed the cup into the medication cart and locked the cart. When she returned to the medication cart, two residents were at the medication cart asking for their medications. Nurse #7 took the medications in the medication cup out of the medication cart, crushed the medications and administered them to Resident #100. Nurse #7 stated after Resident #100 swallowed the medication she realized they were not Resident #100 medication.Nurse #7 confirmed she had not labeled the cup of medications with a resident identifier. Nurse #7 stated she notified Nurse #2 and the DON immediately and took Resident #100's vital signs, then notified the NP who was in the facility. Nurse #7 stated the NP assessed Resident #100 and ordered laboratory test and vital signs to monitor Resident #100 for adverse reactions. Nurse #7 stated Resident #100 was her normal self all day, with no complaints of dizziness, lightheaded or tiredness. Nurse #7 stated Resident #100 was in her wheelchair rolling around the facility and going to activities. Her family was in the facility and even went to an outside cookout the facility had that day. Nurse #7 stated Resident #100 did not act any differently than her normal self. Nurse #7 stated after the medication error, she completed education on medication pass, requesting residents not to be at the medication cart during medication pass time and was observed passing medication by nurse management (DON, Quality Improvement nurse, or nurse supervisors). Review of Resident #100's Nurse Practitioner (NP) progress note dated 7/2/2026 at 8:00 AM, revealed Resident #100 was administered Resident #14 8:00 AM medications. The NP documented; follow up medication error, resident without signs or symptoms of acute side effects; vital signs (blood pressure, pulse, respiration) and mentation at baseline. The NP ordered blood work of complete blood count (CBC), comprehensive medical panel (CMP) and magnesium levels.Review of Resident #100's NP progress note dated 7/4/2026 at 8:00 AM, revealed the NP conducted a follow up visit to review recent CBC, CMP and magnesium levels. The NP documented laboratory values were at Resident #100's baseline and no additional concerns from Resident #100 or nursing staff were verbalized. The NP documented under other relevant intervention that the risk assessment regarding the medication error as resolved, Resident #11 is at no increased for morbidity/mortality related to medication administration.In an interview conducted 8/12/2026 2:05 PM with the Nurse Practitioner, she stated she assessed Resident #100 the morning of the medication error and 2 days after the error. She stated Resident #100 did not have any adverse effects. Resident #100's vital signs (blood pressure, pulse, respirations, blood sugars) were at baseline, laboratory results were at baseline and mentation (mental activity) was normal for Resident #100. The NP had no concerns regarding adverse effects hours after the medication as Resident #100 was up in activities and her normal self. The NP stated she had ordered and reviewed the results of Resident #100's vital signs, complete blood count, comprehensive metabolic panel and magnesium levels and these had unremarkable results. She held Resident #100's normal 8:00 am medications on 7/2/2026 as some of the medications administered had the same indications as Resident #100's. The NP also stated the medication risk included tachycardia (fast heart rate), hypotension, and sedation (sluggishness or sleepiness). The NP stated Resident # 100 had not demonstrated any signs or symptoms of these medication potential adverse reactions, and she had observed Resident #100 up in her wheelchair throughout the facility and participating in a facility cook out on 7/2/2026. In an interview conducted on 08/13/2026 8:33 AM, NA # 7 stated Resident #100 was up as usual and went to the 100 hall to have coffee with another resident as usual. NA #7 showered Resident #100 the morning of 7/2/2026 and Resident #100 stood up and helped with the transferring from wheelchair to shower chair and back to wheelchair as normal. NA #7 stated Resident #100 went to the facilities Barbeque event on 7/2/2026 with her family. NA #7 stated Resident #100 did not complain of lightheadedness or dizziness during her shift, was laughing and wheeling herself throughout the facility as usual that day. In an interview conducted on 8/12/2026 at 2:48 pm with the Director of Nursing (DON), she stated she was notified of the medication error the morning of 7/2/2026. The DON stated she observed Resident #100 on 7/2/2026 sitting in her wheelchair laughing and talking. Resident #100 had rolled herself up the hallway and went to the activities and went to the outside cookout with her family members. The DON stated Resident #100 did not exhibit or complain of dizziness or lethargy, Resident #100 was not drooling or leaning to one side. The DON stated Resident #100's demeaner had not changed. In an interview conducted on 8/12/2026 at 3:15 pm with the Administrator, she stated she observed Resident #100 rolling around in her wheelchair, sitting straight and smiling as was Resident #100's usual self. The Administrator stated that an investigation was completed and identified distractions at the medication cart was the reason for the medication being administered to the wrong resident. The Administrator stated the Nurse Managers completed education with the nurses and medication aide's and followed up with audits and presentation to QAPI for review of sustainability. In an interview conducted on 8/13/2026 at 3:30 PM the Administrator stated she did not have a fully implemented plan of correction for the medication error. She stated 100% of all nurses and medication aides had not completed the medication administration training and training on distractions at the medication cart.

Based on observation, record review and staff interviews the facility failed to ensure that expired drugs were removed from 2 of 2 medication rooms (medication room [ROOM NUMBER] and medication room [ROOM NUMBER]) reviewed for medication storage. The findings include:a. Record Review of Resident #172's Electronic Medical Record (EMR) documented Resident #172 was discharged from the facility on 10/3/2025.On 8/11/2026 at 4:51 PM, an observation of medication room [ROOM NUMBER]'s refrigerator with the Director of Nursing (DON) revealed an unopened box labeled alirocumab injection 75 milligrams (mg) (used to lower LDL [low-density lipo-protein], known as bad cholesterol, and reduce the risk of heart attack) with the manufacturer's expiration date of 4/30/2026 and Resident #172's name. An observation on 8/11/2026 at 4:52 PM revealed the DON removed the alirocumab injection from medication room [ROOM NUMBER]'s refrigerator.On 8/11/2026 at 4:53 PM in an interview the DON stated the alirocumab injection expiration date printed on the medication box for Resident #172 was 4/30/2026. The DON also stated she removed the alirocumab injection from the refrigerator for destruction.b. On 8/11/2026 at 4:55 PM, an observation of a cabinet in medication room [ROOM NUMBER] with the DON revealed twelve individual sodium chloride injections (a mixture of salt and purified water) with an expiration date of 7/1/2026. The sodium chloride injections did not have a resident name printed on the label. The DON removed the sodium chloride injections and placed them into a clear bag.In an interview with the DON on 8/11/2026 at 4:46 PM she stated she had removed the sodium chloride from the cabinet for destruction.An interview conducted on 8/12/2026 at 8:30 AM with Nurse #5 revealed that expired medication should be removed from the medication carts and the medication rooms upon expiration of the medication. Nurse #5 stated medication carts were checked weekly by the nurses, and the medication rooms were checked monthly by the nurses or nurse management for expired medications. She was unable to state how the expired alirocumab injection and sodium chloride injections were overlooked.An interview conducted on 8/12/2026 at 9:00 AM with Nurse #1 revealed that medications were to be removed from the medication carts and medication rooms upon discharge of the resident or expiration of the medications. Nurse #1 stated the medication carts were checked weekly by the nurses, and the nurses and nurse managers checked the medication rooms monthly for expired medications. She was unable to state how the expired alirocumab injection and sodium chloride injections were overlooked.An interview conducted on 8/12/2026 at 10:32 AM with the DON revealed the nurses should have removed Resident #172's alirocumab injection from the medication room refrigerator upon discharge (10/3/2025). The DON stated the nurse discharging a resident should remove all medication from the medication cart and medication room for the discharging resident. The DON stated expired medications should be removed from the medication carts and medication rooms by the nurses. The DON stated the nurses checked the medication carts weekly for expired medications. She also stated the medication rooms were checked by the nurses and nurse management a minimum of monthly for expired medications. She stated the nurses and nurse managers must have overlooked the unopen box of alirocumab injection and the sodium chloride injections.

Based on record review, staff interviews, and resident interview, the facility failed to offer influenza and pneumococcal immunizations as required. In addition, there was no documentation the resident was provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunizations. This occurred for 1 of 5 residents reviewed for immunizations (Resident #53).A review of the facility's policy entitled Immunizations last revised 10/2/2020 read in part residents will be offered the pneumococcal immunization upon admission, unless it was medically contraindicated or the resident had already been immunized or the resident refused after receiving appropriate education and consultation regarding the benefits of the pneumococcal immunization. Residents will be offered the influenza vaccination annually from early October to March. Residents will be informed on admission of the requirements of the immunization program. Before offering the influenza and pneumococcal immunizations, residents will be provided education on the risks and benefits of the influenza and pneumococcal immunizations.Resident #53 was admitted to the facility on [DATE] with diagnoses which included peripheral vascular disease, hypothyroidism, and chronic kidney disease, stage 3 unspecified.Review of Resident #53's electronic medical record revealed no documentation of the influenza and pneumococcal immunizations being offered, if the immunizations were received or refused, or if education was provided about the risks and benefits of the influenza and pneumococcal immunizations.An interview on 08/13/2026 at 2:45 PM with the Director of Nursing (DON) revealed that the nurse on the floor who was doing resident's admission paperwork should have offered Resident #53 the influenza and pneumococcal immunizations when Resident #53 was admitted on [DATE].An interview with Nurse #6, who completed Resident #53's admission, took place over the phone on 08/13/2026 at 3:44 PM. Nurse #6 stated that during the admission process she was supposed to ask about flu, pneumonia, and covid vaccines. Nurse #6 stated that she did not remember if she asked the resident or not. In her interview, the nurse stated she probably did not ask about the flu vaccine because if Resident #53 was admitted to the facility in February, the flu season was almost over. An interview with Resident #53 on 08/13/2026 at 3:49 PM revealed that she wanted to receive the influenza and pneumococcal immunizations. Resident #53 stated the immunizations were not given to her. An interview on 8/13/2026 at 4:00 PM with the Administrator stated vaccinations for newly admitted residents were for the nurse to ask the resident if they had the flu and pneumonia vaccinations yet and if not, offer them to the resident.

Based on observation, record review, and staff interviews, the facility failed to treat a resident with dignity when a nurse aide did not sit while feeding a resident who needed assistance with meals for 1 of 2 dining observations (Resident #51). The reasonable person concept was applied as individuals have the expectation of being treated with dignity and would not want staff to stand over them while assisting with meals. Findings included: Resident #51 was admitted to the facility on [DATE]. Her active diagnoses included dysphagia. Review of Resident #51's Minimum Data Set assessment dated [DATE] revealed she was assessed as severely cognitively impaired and totally dependent on staff for eating. Review of Resident #51's care plan dated 4/21/25 revealed she was dependent on staff for eating. During observation on 4/23/25 at 1:06 PM Nurse Aide #4 was observed assisting Resident #51 with lunch. The nurse aide was standing next to Resident #51 who was seated in her specialized wheelchair with her bedside table in front of her with her meal tray. Nurse Aide #4 was not at eye level with the resident. A chair was available in the room and the nurse aide did not use it. During an interview on 4/23/25 at 1:12 PM Nurse Aide #4 stated they could sit or stand when providing assistance with meals. The nurse aide stated she felt like standing today but they could sit when assisting as well. During an interview on 4/23/25 at 1:19 PM the Director of Nursing stated staff were to sit when assisting residents with meals for dignity reasons. She stated some residents may not care but you never know what standing next to the resident while feeding them might imply to the resident, especially a person with dementia. Sitting puts staff at the resident's eye level and is more personable.

Based on observations, record review, and resident and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of swallowing/nutritional status (Resident #39) and hospitalization (Resident #138). This was for 2 of 24 residents reviewed for accuracy of assessments. Findings included: 1. Resident #39 was admitted to the facility on [DATE]. A review of an admission nursing progress note for Resident #39 dated 10/2/24 at 6:45 PM revealed in part he had a percutaneous endoscopic gastrostomy feeding tube (a PEG tube is a feeding tube placed into the stomach through the abdominal wall). A review of a physician's order for Resident #39 dated 10/2/24 revealed to flush his tube every 4 hours with 100 cubic centimeters (cc) of water (H2O). A review of Resident #39's March 2025 Medication Administration Record (MAR) revealed documentation indicating 100 cc of H2O was administered via Resident #39's PEG tube every 4 hours at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM, and 6:00 PM on 3/6/25 through 3/14/25 except on 3/9/25 at 2:00 PM when it was held. A review of Resident #39's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was not coded for having a feeding tube on admission or while a resident. He was not coded for receiving fluid intake via feeding tube. On 4/23/25 at 2:01 PM an interview with the Dietary Manager (DM) indicated she would have been responsible for coding the Swallowing/Nutrition section of Resident #39's quarterly MDS assessment dated [DATE]. She stated she was not aware that Resident #39 still had a PEG tube. On 4/23/25 at 3:39 PM an interview with the Director of Nursing (DON) indicated Resident #39's quarterly MDS assessment dated [DATE] should have accurately reflected the presence and use of his PEG tube. On 4/24/25 at 10:12 AM an interview with the Administrator indicated Resident #39's quarterly MDS assessment dated [DATE] should have been coded accurately at the time of the assessment. 48230 2. Resident #138 was admitted to the facility on [DATE]. A review of Resident #138's Discharge MDS assessment dated [DATE] revealed his discharge location to be a short term general hospital. A review of the discharge Nurse's note written by the Unit Manager dated 2/10/25 indicated Resident #138 was discharged with his belongings, medications, discharge paperwork and medication list. The Unit Manager was not available for interview. In an interview with the Director of Nursing (DON) on 4/23/25 at 8:55 AM she stated Resident #138 was discharged home on 2/10/25. MDS Nurse #1 was interviewed on 4/23/25 at 9:08 AM. MDS Nurse #1 stated she had miscoded Resident #138's Discharge MDS assessment as going to a short stay general hospital when he actually went home on 2/10/25. She stated the error was made unintentionally. An interview with the Administrator was conducted on 4/23/25 at 10:41 AM. She stated she expected Resident #138's Discharge MDS assessment to be coded that he went home from the facility on 2/10/25.

Based on observation, record review, and resident, Responsible Party (RP) and staff interviews, the facility failed to implement the comprehensive care plan in the area of activities of daily living (Resident #27), and failed to develop an individualized, person-centered comprehensive care plan to include the use of a percutaneous endoscopic gastrostomy feeding tube (a PEG tube is a feeding tube placed into the stomach through the abdominal wall) (Resident #39), and the use of a noninvasive mechanical ventilator (a device to help with nighttime breathing for people with respiratory issues) (Resident #290 and Resident #71). This was for 1 of 5 residents reviewed for activities of daily living, 1 of 2 residents reviewed for tube feeding, and 2 of 4 residents reviewed for respiratory services. Findings included: 1. Resident #27 was admitted to the facility on [DATE] with a diagnosis of intracerebral hemorrhage (bleeding in the brain). A review of Resident #27's annual Minimum Data Set (MDS) assessment dated [DATE] revealed he did not speak. Resident #27 was severely cognitively impaired. It was very important to have his family member involved in discussions about his care. His family member was the daily and activity preferences primary respondent. He had functional limitation of range of motion on both sides of his upper and lower extremities. He was dependent on staff for all transfers and mobility. His family member participated in his assessment and goal setting. A review of Resident #27's comprehensive care plan dated last revised on 9/13/24 revealed a focus area for activities of daily living. The goal was for Resident #27's activities of daily living to be completed with staff support to maintain his highest level of functioning. An intervention was mobility dependent in Geri chair. The associated care guide revealed Resident #27 was to be up in his Geri chair by 10:00 AM and back to bed by 2:00 PM daily Monday through Friday. On 4/21/25 at 1:21 PM Resident #27 was observed in bed. No Geri chair was observed in his room. On 4/21/25 at 3:19 PM a telephone interview with Resident #27's RP indicated she participated in all his care plan discussions. She stated she had expressed her desire to have Resident #27 assisted up into his Geri chair daily. She went on to say she although she visited often, she had not really seen him up in his Geri chair regularly since Christmas. On 4/22/25 at 11:48 AM Resident #27 was observed in bed. No Geri chair was observed in his room. On 4/22/25 at 2:11 PM Resident #27 was observed in bed. No Geri chair was observed in his room. On 4/23/25 at 10:59 AM Resident #27 was observed in bed. No Geri chair was observed in his room. On 4/23/25 at 12:55 PM Resident #27 was observed in bed. No Geri chair was observed in his room. On 4/23/25 at 3:07 PM an interview with Nurse Aide (NA) #1 indicated she was assigned to care for Resident #27 on the 7:00 AM to 3:00 PM shift on 4/21/25. She reported she was familiar with Resident #27 and had cared for him previously. She stated she had not gotten Resident #27 up into a Geri chair on 4/21/24 because when she went to get him up, there had not been a Geri chair in his room. NA #1 stated that while she could have gone to the storage area to get one, she had not. On 4/23/25 at 1:05 PM an interview with NA #2 indicated he was assigned to care for Resident #27 on 4/22/25 on the 7:00 AM to 3:00 PM shift. He stated he had not gotten Resident #27 up into a Geri chair on 4/22/25. He reported he was familiar with Resident #27 and had cared for him previously. He reported that if Resident #27's family member came to visit and asked for Resident #27 to be up in a chair he would assist Resident #27. NA #2 stated while he did have access to Resident #27's care plan and care guide, he had not seen that it indicated Resident #27 should be up in his Geri chair daily. On 4/23/25 at 1:14 PM an interview with NA #3 indicated she was assigned to care for Resident #27 on the 7:00 AM to 3:00 PM shift on 4/23/25. She stated she was familiar with Resident #27 and had cared for him previously. She reported she had not gotten Resident #27 up into a Geri chair today. NA #2 indicated while she did have access to Resident #27's care plan and care guide that indicated he was to be assisted up into his Geri chair daily, she had not gotten him up yet because she had gotten busy with other things. On 4/23/25 at 3:39 PM an interview with the Director of Nursing (DON) indicated the NAs should be assisting Resident #27 up into a Geri chair in accordance with expressed preferences and his care plan. On 4/24/25 at 10:12 AM an interview with the Administrator indicated the NAs should be following resident's care plan and care guide when caring for resident's. 2. Resident #39 was admitted to the facility on [DATE] with a diagnosis of gastrostomy status. A review of an admission nursing progress note for Resident #39 dated 10/2/24 at 6:45 PM revealed in part he had a percutaneous endoscopic gastrostomy feeding tube (a PEG tube is a feeding tube placed into the stomach through the abdominal wall). A review of a physician's order for Resident #39 dated 10/2/24 revealed to flush his tube every 4 hours with 100 cubic centimeters (cc) of water (H2O). The resident had an oral diet ordered and did not receive routine nutrition via the PEG tube. A review of Resident #39's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he had a feeding tube on admission, and while a resident. He received 501 cc per day or more of his average fluid intake per day via feeding tube. A review of the Care Area Assessment (CAA) on Resident #39's admission MDS assessment dated [DATE] revealed documentation indicating the CAA for feeding tube was triggered but not addressed in Resident #39's care plan. A review of Resident #39's comprehensive care plan, dated last revised on 2/7/25, did not reveal a focus area for the use of a feeding tube nor mention of his use of a feeding tube to receive nutrition or hydration. On 4/24/25 at 9:57 AM an observation of H2O flush via Resident #39's PEG tube by Nurse #2 was conducted. On 4/23/25 at 2:01 PM an interview with the Dietary Manager (DM) indicated she was responsible for addressing Resident #39's use of a PEG tube on his admission MDS assessment dated [DATE]. She reported that if the CAA for a feeding tube was triggered on the admission assessment, Resident #39's use of a feeding tube should have been reflected on his comprehensive his care plan. She stated she could not explain why it was not. On 4/23/25 at 3:39 PM an interview with the Director of Nursing (DON) indicated Resident #39 had a PEG tube since his admission to the facility on [DATE]. She stated if Resident #39's admission MDS assessment dated [DATE] reflected his use of a feeding tube and the CAA for this was triggered the DM should have included Resident #39's use of a feeding tube on his comprehensive care plan. On 4/24/25 at 10:12 AM an interview with the Administrator indicated if Resident #39's admission MDS assessment dated [DATE] reflected his use of a feeding tube and the CAA for this was triggered, his use of a feeding tube should have been included on his comprehensive care plan. 48230 3. Resident #290 was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure. The hospital discharge summary for Resident #290 dated 4/3/25 stated she needed to wear BiPAP machine (a device that delivers two levels of air pressure during inhalation and exhalation to help people with breathing difficulties) at night and with naps for obesity hypoventilation syndrome (a condition where a person breathes too shallowly, or their breathing is interrupted while sleeping due to obesity). In an interview with Resident #290 on 4/21/25 at 2:56 PM she stated she needed the BiPAP machine at night to help her breathe while she was sleeping. Resident #290 further stated staff helped her put the mask on at night and she can remove it herself in the morning. Resident #290 indicated the BiPAP machine was delivered to her room on 4/4/25 and she had been using it nightly since then. An interview with the Central Supply clerk was conducted on 4/23/25 at 8:38 AM. She stated Resident #290's BiPAP machine arrived on 4/4/25 and she delivered it to the resident's room herself. A review of the delivery order for Resident #290's BiPAP was reviewed. The delivery order was dated 4/4/25. Resident #290's Physician orders for the month of April 2025 revealed there was no order for BiPAP machine usage. Resident #290's comprehensive care plan dated 4/8/25 revealed no care plan that referenced BiPAP machine usage. Resident #290's admission Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact and had active diagnoses of respiratory failure and pneumonia. The MDS did not code Resident #290 as using a BiPAP machine. In an interview with the Minimum Data Set (MDS) Coordinator and MDS Nurse #2 on 4/22/25 at 2:27 PM they stated that comprehensive care plans were made by the MDS office based on the residents' MDS information. They further stated Resident #290 was not coded as using a BiPAP machine on her 5-day MDS assessment. MDS Nurse #2 indicated that when they go to make the care plan, a respiratory care section does not automatically populate. In this case, the MDS Nurse needed to either look back at the MDS assessment or rely on memory. MDS Nurse #2 revealed she was responsible for making the comprehensive care plan for Resident #290 and must have relied on memory as she missed adding the BiPAP machine usage. An interview was conducted with the Administrator and Director of Nursing on 4/22/25 at 2:52 PM. They stated that Resident #290 should have had a care plan for use of the BiPAP machine. They indicated Resident #290's BiPAP machine was delivered on 4/4/25 and that nursing could have added to the care plan at any time. 4. Resident #71 was admitted to the facility on [DATE] with diagnoses that included sleep apnea (sleep disorder characterized by repetitive pauses in breathing or reduced airflow during sleep). Resident #71's Physician orders for the month of April 2025 revealed there was no order for use of the CPAP machine. In an interview with Resident #71 on 4/22/25 at 11:38 AM she stated she wore the CPAP machine at night due to a diagnosis of sleep apnea and that she brought it from home when she was admitted . A nursing progress note dated 3/24/25 at 12:48 AM written by Nurse #3 stated Resident #71 was wearing her CPAP machine (CPAP- a machine that used mild air pressure to keep breathing airways open while sleeping). Nurse #3 was not able to be reached for interview. Resident #71 was observed using the CPAP machine while asleep on 4/22/25 at 8:45 AM. Resident #71's comprehensive care plan dated 3/24/25 revealed no reference to CPAP machine usage. Resident #71's 5-day Minimum Data Set (MDS) dated [DATE] revealed she was coded as needing a noninvasive mechanical ventilator (CPAP- a machine that used mild air pressure to keep breathing airways open while sleeping). In an interview with the Minimum Data Set (MDS) Coordinator and MDS Nurse #1 on 4/22/25 at 2:48 PM they stated that comprehensive care plans were made by the MDS office based on the residents' MDS information. They further stated Resident #71 was coded as using a CPAP machine on her 5-day MDS assessment. MDS Nurse #1 indicated that when they go to make the care plan, a respiratory care section does not automatically populate. In this case, the MDS Nurse needed to either look back at the MDS assessment or rely on memory. MDS Nurse #1 revealed she was responsible for making the comprehensive care plan for Resident #71 and must have relied on memory as she missed adding the CPAP machine usage. An interview was conducted with the Administrator and Director of Nursing on 4/22/25 at 2:52 PM. They stated that Resident #71 should have had a care plan for use of the CPAP machine. They indicated Resident #71 brought her CPAP from home when she was admitted to the facility and that nursing could have added to the care plan at any time.

Based on observations, record review, and resident, staff and Medical Director interviews the facility failed to obtain a physician's order for the use of a BiPAP machine (a device that delivers two levels of air pressure during inhalation and exhalation to help people with breathing difficulties) (Resident #290) and a physician's order for use of a CPAP machine (a machine that used mild air pressure to keep breathing airways open while sleeping) (Resident #71). The facility also failed to administer oxygen by tracheostomy (a surgical opening in the neck for breathing) in accordance with the Physicians order (Resident #39). This was for 3 of 4 residents reviewed for respiratory care (Resident #290, Resident #71 and Resident #39). Findings included: 1. Resident #290 was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure. The hospital discharge summary for Resident #290 dated 4/3/25 stated she needed to wear a BiPAP machine (a device that delivers two levels of air pressure during inhalation and exhalation to help people with breathing difficulties) at night and with naps for obesity hypoventilation syndrome (a condition where a person breathes too shallowly, or their breathing is interrupted while sleeping due to obesity). A review of Resident #290's Physician orders for the month of April 2025 revealed there was no order for BiPAP machine usage. Review of Resident #290's Admission Minimum Data Set (MDS) dated [DATE] revealed she was cognitively intact and had active diagnoses of respiratory failure and pneumonia. The MDS did not code Resident #290 as using a BiPAP machine. The BiPAP machine was observed at Resident #290's bedside on 4/21/25 at 2:56 PM. In an interview with Resident #290 on 4/21/25 at 2:56 PM she stated she needed the BiPAP machine at night to help her breathe while she was sleeping. Resident #290 further stated staff helped her put the mask on at night and she can remove it herself in the morning. Resident #290 indicated the BiPAP machine was delivered to her room on 4/4/25 and she had been using it nightly since then. In an interview with the Administrator and Director of Nursing on 4/22/25 at 2:53 PM they stated they did not know why Resident #290 did not have a Physician's order for use of the BiPAP machine, but that one should have been requested from the Medical Director or Nurse Practitioner on call when she was admitted . The Medical Director was interviewed on 4/23/25 at 11:43 AM. The Medical Director indicated he often does not see new admissions for a day or two after they arrive. He further indicated any orders needed would have been requested before he saw the resident. He stated he was unaware Resident #290 was using a BiPAP machine as those orders were not requested by nursing. 2. Resident #71 was admitted to the facility on [DATE] with diagnoses that included sleep apnea (sleep disorder characterized by repetitive pauses in breathing or reduced airflow during sleep). Resident #71's Physician orders for the month of April 2025 revealed there was no order for use of the CPAP machine. Review of a Nursing progress note dated 3/24/25 at 12:48 AM written by Nurse #3 stated Resident #71 was wearing her CPAP machine (CPAP- a machine that used mild air pressure to keep breathing airways open while sleeping). Nurse #3 was not able to be reached for interview. Review of Resident #71's 5-day Minimum Data Set (MDS) dated [DATE] revealed she was coded as using a noninvasive mechanical ventilator in the form of a CPAP machine. Resident #71 was observed using the CPAP machine while asleep on 4/22/25 at 8:45 AM. In an interview with Resident #71 on 4/22/25 at 11:38 AM she stated she wore the CPAP machine at night due to a diagnosis of sleep apnea and that she brought it from home when she was admitted . An interview was conducted with the Administrator and Director of Nursing on 4/22/25 at 2:52 PM. They stated that nursing should have requested an order for CPAP machine usage from the Medical Director or on-call Nurse Practitioner when Resident #71 was admitted . The Medical Director was interviewed on 4/23/25 at 11:43 AM. The Medical Director indicated he often does not see new admissions for a day or two after they arrive. He further indicated any orders needed would have been requested before he saw the resident. He stated he was unaware Resident #71 was using a CPAP machine as those orders were not requested by nursing. 41009 3. Resident #39 was admitted to the facility on [DATE] with a diagnosis of tracheostomy status. A review of a current physician's order for Resident #39 dated as initiated on 12/12/24 revealed to administer 4 liters (L) of oxygen (O2) per minute via tracheostomy to maintain Resident #39's O2 saturations above 90 percent (%). A review of Resident #39's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was moderately cognitively impaired. His vision was adequate. He had no functional limitation in range of motion of his upper extremities. Resident #39 had functional limitation in range of motion of his lower extremities on both sides. He received oxygen therapy and tracheostomy care. A review of Resident #39's comprehensive care plan dated last reviewed on 4/11/25 revealed a focus area dated last revised on 10/15 24 for ineffective breathing pattern related to tracheostomy with O2 at 3L per minute via nasal cannula (NC). The goal was for Resident #39 to verbalize understanding of his disease process, treatments and the importance of compliance through the next review. An intervention was oxygen therapy at 3L via NC as ordered. On 4/21/25 at 2:44 PM an observation of Resident #39 in his room revealed he was receiving O2 via NC at 3L per minute. He was not in any respiratory distress. On 4/22/25 at 2:12 PM an observation of Resident #39 in his room revealed he was receiving O2 via NC at 3L per minute. He was not in any respiratory distress. On 4/23/24 at 11:02 AM an observation of Resident #39 in his room revealed he was receiving O2 via NC at 3L per minute. He was not in any respiratory distress. In an interview with Resident #39 at that time he stated the correct rate for his O2 was 4L. A review of Resident #39's Medication Administration Record (MAR) for April 2025 revealed documentation by Nurse #2 indicating Resident #39 was receiving O2 at 4L via his tracheostomy on the 7:00 AM to 3:00 PM shift on 4/21/25, 4/22/25, and 4/23/25 and his O2 saturations were 95%. On 4/23/25 at 12:56 PM an interview with Nurse #2 revealed she was assigned to care for Resident #39 on 4/21/25, 4/22/25, and 4/23/25 on the 7:00 AM to 3:00 PM shift. She stated she was very familiar with Resident #39 and had been his regular day shift nurse since November 2024. She reported Resident #39 was receiving O2 at 3L per minute via a NC. When asked to look at the current physician's order for Resident #39, she stated the current physician's order was for O2 at 4L per minute via his tracheostomy. She reported her documentation on his MAR for 4/21/25, 4/22/25, and 4/23/25 indicated she had verified he was receiving 4L per minute via tracheostomy when she checked his O2 saturation on her shift. Nurse #2 went on to say at one time Resident #39 had been receiving O2 via his tracheostomy, but he wouldn't keep it on. She stated she should have called Resident #39's medical provider to get his O2 order changed, but she just hadn't thought about it. She reported Resident #39 had not experienced any respiratory distress and his O2 saturations had remained above 90 %. On 4/23/25 at 1:20 PM an interview with the Medical Director indicated he was familiar with Resident #39 and was his facility physician. He stated Resident #39 liked to do things his way, and he didn't have any problem with that. He reported he would have gladly changed Resident #39's O2 order to 3L per minute via NC if someone had let him know this was Resident #39's preference, although he did not recall anyone asking for this. The Medical Director stated Resident #39's O2 saturation had been stable, and he did not feel Resident #39 had experienced any harm from wearing his O2 at 3L per minute via NC rather than 4L per minute via his tracheostomy. On 4/23/25 at 1:46 PM an interview with the MDS Coordinator indicated he was involved in the revision of Resident #39's care plan focus area for ineffective breathing on 10/15/24. He stated he recalled a discussion about Resident #39's preference for his O2 being 3L per minute via NC. He went on to say he had not been involved in the review of Resident #39's care plan focus area for ineffective breathing on 4/11/25. On 4/23/25 at 1:48 PM an interview with MDS Nurse #1 indicated she had participated in the review of Resident #39's care plan focus area for ineffective breathing on 4/11/25. She stated she should have updated this area to reflect that Resident #39's preference for O2 was 3L per minute via NC as that was not actually what the physician's order was. On 4/23/25 at 3:39 PM an interview with the Director of Nursing (DON) indicated Resident #39 did not like to wear his O2 via his tracheostomy collar and preferred to wear it via NC. She stated Nurse #1 should have called a medical provider and gotten Resident #39's O2 order changed. She reported his care plan focus area for ineffective breathing should have reflected wearing O2 at 3L per minute via NC was Resident #39's preference rather than as ordered. On 4/24/25 at 10:12 AM an interview with the Administrator indicated with regards to medical issues like O2 rates and routes she would have to defer to her nursing staff. She stated she did feel Nurse #1 should have called a medical provider and gotten the O2 order changed rather than just documenting on Resident #39's MAR verifying he was receiving his O2 at 4L per minute via his tracheostomy if he was not.

Based on observations, record review, and resident and staff interviews the facility failed to attempt alternatives, assess entrapment risk, review risks and benefits and obtain informed consent prior to installing and utilizing bilateral quarter length side rails for 1 of 1 resident reviewed for side rails (Resident #290). Findings included: Resident #290 was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure. Resident #290's 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact and had impairment to bilateral upper and lower extremities. The MDS further revealed she needed substantial to maximum assistance with bed mobility. Resident #290 was observed lying in her bed with bilateral quarter length side rails in the raised position on 4/21/25 at 11:15 AM. In an interview with Resident #290 on 4/21/25 at 11:15 AM she stated she needed the side rails for bed mobility and positioning. A review of Resident #290's electronic medical record (EMR) revealed she was her own Responsible Party (RP). The EMR further revealed no evidence that the following was completed prior to the installation and usage of bilateral quarter length side rails: attempt alternatives, assess entrapment risk, review risks and benefits and obtain informed consent. An observation was conducted on 4/22/25 at 1:45 PM. Resident #290 was observed lying in her bed with bilateral quarter length side rails in the raised position. Resident #290 was observed lying in bed with bilateral quarter length side rails in the raised position on 4/23/25 at 2:50 PM. An interview with Nurse #1 on 4/23/25 at 11:28 AM she stated she was the admitting nurse for Resident #290 on 4/3/25. Nurse #1 indicated she did not do side rail assessments as they were completed by the Unit Manager. The Unit Manager could not be reached for interview. In an interview with the Director of Nursing (DON) on 4/23/25 at 12:34 PM she stated Nurse #1 should have completed the side rail assessment for Resident #290 upon admission. She further stated all Nurses were expected to complete all forms in the admissions packet when admitting a new resident to their hall. An interview was conducted with the Administrator on 4/23/25 at 2:49 PM. The Administrator stated that Resident #290 should have had a side rail assessment completed upon admission. She was unsure who was responsible for this task.

Based on observations, record review, and staff interviews, the facility failed to maintain an accurate medical record with regards to documentation of actual oxygen (O2) administration rate and route. This was for 1 of 4 residents (Resident #39) reviewed for the accuracy of medical records related to respiratory care. Findings included: Resident #39 was admitted to the facility on [DATE] with a diagnosis of tracheostomy status. A review of a current physician's order for Resident #39 dated as initiated on 12/12/24 revealed to administer 4 liters (L) of oxygen (O2) per minute via tracheostomy to maintain Resident #39's O2 saturations above 90 percent (%). On 4/21/25 at 2:44 PM an observation of Resident #39 in his room revealed he was receiving O2 via NC at 3L per minute. He was not in any respiratory distress. On 4/22/25 at 2:12 PM an observation of Resident #39 in his room revealed he was receiving O2 via NC at 3L per minute. He was not in any respiratory distress. On 4/23/24 at 11:02 AM an observation of Resident #39 in his room revealed he was receiving O2 via NC at 3L per minute. He was not in any respiratory distress. In an interview with Resident #39 at that time he stated the correct rate for his O2 was 4L. A review of Resident #39's Medication Administration Record (MAR) for April 2025 revealed documentation by Nurse #2 indicating Resident #39 was receiving O2 at 4L via his tracheostomy on the 7:00 AM to 3:00 PM shift on 4/21/25, 4/22/25, and 4/23/25 and his O2 saturations were 95%. On 4/23/25 at 12:56 PM an interview with Nurse #2 indicated she was assigned to care for Resident #39 on 4/21/25, 4/22/25, and 4/23/25 on the 7:00 AM to 3:00 PM shift. She stated she was very familiar with Resident #39 and had been his regular day shift nurse since November 2024. She reported Resident #39 was receiving O2 at 3L per minute via a NC. When asked to look at the current physician's order for Resident #39, Nurse #1 stated the current physician's order was for O2 at 4L per minute via his tracheostomy. She reported her documentation on his MAR for 4/21/25, 4/22/25, and 4/23/25 7:00 AM to 3:00 PM shift indicated she had verified he was receiving 4L per minute via tracheostomy when she checked his O2 saturation on her shift. Nurse #2 went on to say at one time Resident #39 had been receiving O2 via his tracheostomy, but he wouldn't keep it on. She stated she should not have documented on Resident #39's MAR verifying he was receiving his O2 at 4L per minute via his tracheostomy if he was not. On 4/23/25 at 3:39 PM an interview with the Director of Nursing (DON) indicated Resident #39 did not like to wear his O2 via his tracheostomy collar and preferred to wear it via NC. She stated Nurse #1 should have called a medical provider and gotten the O2 order changed and not documented on Resident #39's MAR verifying he was receiving his O2 at 4L per minute via his tracheostomy if he was not. On 4/24/25 at 10:12 AM an interview with the Administrator indicated Nurse #1 should have called a medical provider and got the order changed rather than just documenting on Resident #39's MAR verifying he was receiving his O2 at 4L per minute via his tracheostomy if he was not.

Based on observations, record review, and staff interviews, the facility failed to implement their policy for enhanced barrier precautions (EPB) when Nurse #4 failed to wear a gown when providing tracheostomy (a surgical opening in the neck for breathing) care for Resident #27 and when Nurse #5 and Nurse #6 failed to wear a gown during a high contact care activity that included transfer and the provision skin care and hygiene for Resident #39 who had a tracheostomy. This was for 3 of 8 staff members observed for infection control practices. This had the potential to result in the risk of multidrug-resistant organism (MDRO) transmission. Findings included: A review of the facility's policy titled Enhanced Barrier Precautions dated last revised on 6/13/24 revealed in part the following: Enhanced Barrier Precautions are used in conjunction with standard precautions to reduce the risk of MDRO transmission during high-contact resident care activities. It includes the use of both gown and gloves. Enhanced Barrier Precautions apply to residents with any of the following: Presence of an indwelling medical device with or without the presence of an MDRO infection or colonization. Examples of indwelling medical devices: Tracheostomies. Resident care activities that are considered high contact include but are not limited to: Transferring. EBP should be utilized for transfers under the following circumstances: Providing hygiene. 1. On 4/22/25 at 4:05 PM a continuous observation of tracheostomy care was conducted for Resident #27 with Nurse #4. Personal Protective Equipment (PPE) supplies including gowns were observed outside Resident #27's room. An EBP sign was observed over the head of Resident #27's bed. Nurse #4 was observed to perform hand hygiene and don (apply) clean gloves prior to the start of the procedure. She was not wearing a gown. At 4:17 PM Nurse #4 was observed to remove Resident #27's tracheostomy collar, and as she attempted to remove Resident #27's tracheostomy inner cannula she was stopped and asked to step outside Resident #27's room. Nurse #4 replaced Resident #27's tracheostomy collar at 4:17 PM, remove her soiled gloves and performed hand hygiene at which time the continuous observation ended. On 4/22/25 at 4:18 PM an interview with Nurse #4 was conducted in the hall outside Resident #27's room. Nurse #4 indicated she had not been wearing a gown when she was performing tracheostomy care for Resident #27. She stated she had received education on the use of EBP for residents who had tracheostomies, and there were PPE supplies including gowns outside Resident #27's room. She reported EBP precautions were designed to prevent the spread of germs to Resident #27 during his tracheostomy care. Nurse #4 stated she did usually wear a gown during this care but had been nervous and had forgotten. On 4/23/25 at 3:39 PM an interview with the Director of Nursing (DON) indicated she had been made aware of the concern that Nurse #4 had not adhered to EBP precautions when providing tracheostomy care to Resident #27 on 4/22/25. She stated while Nurse #4 had previously received education on the use of EPB precautions, she had been reeducated immediately after the incident. The DON stated Nurse #4 should have been wearing a gown during Resident #27's tracheostomy care to prevent the spread of microorganisms to Resident #27. On 4/24/25 at 10:12 AM an interview with the Administrator indicated Nurse #4 should have followed EPB which included wearing a gown while performing tracheostomy care to Resident #27 to prevent the potential spread of microorganisms. 2. On 4/23/25 at 11:02 AM a continuous observation of skin care for a rash and abrasion was conducted for Resident #39 with Nurse #5 and Nurse #6. An EBP sign was observed at the entry of Resident #39's room. PPE including gowns were observed on the treatment cart. Nurse #5 and Nurse #6 were observed to perform hand hygiene and apply clean gloves prior to entering Resident #39's room. Resident #39 was observed to have a tracheostomy. Nurse #5 was observed to assist Resident #39 to transfer to a standing position and use a washcloth with soap and water to wash Resident #39's inner thighs and buttocks, rinse and dry the area. Nurse #6 was then observed to apply a barrier cream to the same area. While applying the cream to Resident #39's inner thigh and buttocks area, the right arm sleeve of Nurse #6's shirt was observed to contact the skin of Resident #39's back. Neither Nurse #5 nor Nurse #6 were observed to be wearing a gown during the activity. At 11:10 AM Nurse #5 and Nurse #6 were observed to remove their soiled gloves, perform hand hygiene, and exit Resident #39's room at which time the continuous observation ended. At 11:10 AM, in the hall outside of Resident #39's room, an interview was conducted with Nurse #5 and Nurse #6. Nurse #5 stated she had previously received education of the importance of EBP for residents who had an indwelling device such as a tracheostomy like Resident #39 did to prevent the potential spread of microorganisms, and she usually did wear a gown, but she had just not been thinking about it this time. She stated there were gowns available in the treatment cart outside Resident #39's room. Nurse #6 stated she did not usually wear a gown when providing skin treatments to Resident #39, because sometimes it made him nervous. On 4/23/25 at 3:39 PM an interview with the Director of Nursing (DON) indicated she was not aware of any issues with Resident #39 being nervous about staff wearing gowns when performing activities that required the use of EBP, and this was not currently reflected on his care plan. The DON stated if that were the case, she would expect the nurse to provide education to Resident #39 regarding the reason and importance of EBP, and if he was still resistant, the nurse should report this to her so she could speak with Resident #39. The DON indicated all nursing staff had been educated on the facility's EBP policy and should be adhering to this when providing care to residents such as Resident #39 who had a tracheostomy. On 4/24/25 at 10:12 AM an interview with the Administrator indicated nurses should be adhering to the facility's EBP policy when providing care to residents.

Based on record review, staff, and Psychiatric Nurse Practitioner interviews, the facility failed to protect 2 of 5 residents' rights to be free from physical abuse (Residents #114 and #29). All residents involved resided in the memory care unit. Resident #99 struck the back of Resident #114's head on 9/8/23 and hit Resident #114's left jaw twice on 10/11/23. Both incidents occurred after Resident #114 wandered into Resident #99's room. Resident #114 had redness and a small amount of swelling to the left side of face after the second incident. Resident #99 slapped Resident #29 on the cheek after Resident #29 touched Resident #99's pants in the activity room. Resident #29 sustained no injuries. A reasonable person would not expect to be physically abused in their home and would experience feelings such as intimidation, fear, humiliation, embarrassment, and anxiety. This was for 2 of 5 residents reviewed for abuse. 1. Resident #99 was admitted to the facility on [DATE]. Resident #99's diagnoses included nontraumatic brain dysfunction, dementia, paranoid schizophrenia, anxiety disorder, hypertension, hallucinations, and major depressive disorder. Resident #99's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was moderately cognitive impaired. Resident #99 was coded as exhibiting disorganized thinking and inattention. Resident #99's annual Minimum Data Set, dated dated dated [DATE] revealed he was cognitively intact, and he was coded for supervision or independence for most activities of daily living. Resident #99's care plan initiated on 2/22/2022 had a focus on resident's ineffective coping characterized by ineffective coping, verbal/physical aggression or agitation, or combativeness related to cognitive impairment/dementia or aggressive to other residents who wander into his room. This focus had an intervention that included the resident was placed on 1:1 continuous observation on 10/11/2023. Resident #99's care plan last revised on 2/16/24 had a focus on resident's ineffective coping characterized by verbal/physical aggression agitation, or combativeness related to cognitive impairment/dementia or aggressive to other residents who wander into his room. This focus had an intervention that included the resident was placed on 1:1 continuous observation on 10/11/2023. Review of physician's orders revealed no orders for Resident #99 to have a 1:1 sitter. a. Resident #114 was admitted to the facility on [DATE]. Resident #114's diagnoses included dementia, anxiety, irritability, and anger. Resident #114's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he had severe cognitive impairment. The care plan created on 3/22/2023 indicated Resident #114 was allowed to wander on the unit and be redirected as needed from other residents' rooms. The Facility Reported Incident (FRI) dated 9/8/2023 revealed Resident #114 wandered into the room of Resident #99 leading to an altercation and Resident #99 reported to have struck Resident #114 at the back of the head. The report indicated Resident #114 was upset regarding the altercation but remained calm. The report revealed Resident #99 was placed om 1:1 monitoring, and Resident #114 placed on every 15 minutes check. The report further revealed a STOP sign was placed on Resident #99's door and that both resident's care plans were updated to reflect the additions. Resident #114's progress note completed by the Assistant Director of Nursing (ADON) on 9/8/2023 at 4:15 p.m. revealed she interviewed Resident #114 who disclosed being hit by Resident #99 and denied pain. The note further revealed the ADON completed a skin assessment and Resident #114 was noted with skin tear to right wrist and left base of head/neck. The note reveals she initiated a Neuro check and skin check placed. She further revealed she contacted the medical provider and responsible party for the resident. A review of the Facility Reported Incident (FRI) dated 10/11/2023 revealed Resident #114 wandered into the room of Resident #99 resulting in an altercation. Resident #99 hit Resident #114 twice on the left jaw to get him out of his room. Resident #114 was noted with redness and small amount of swelling to left side of face. Again, the report stated that Resident #99 was placed on 1:1 monitoring immediately, and Resident #114 placed on a 15-minute checks. The nursing progress incident note dated 10/11/2023 at 18:10 p.m. by the ADON revealed she assessed Resident #114 who had his left side of face red and slightly swollen. She further documented that Resident #114 was placed on observation every 15 minutes and the medical provider was notified of the incident and no new orders were given at that time. In an interview with Resident #114 on 3/19/2024 at 1:34 p.m. he stated he was fine and could not recall altercations he has been involved with Resident #99. During an interview with Resident #99 on 3/19/2024 at 2:21 p.m. he revealed he did not remember hitting Resident #114, but revealed he yells at anyone invading his space and property. He stated he has hit some residents to make them leave his room. In an interview with the Nurse Aide #8 (NA#8) on 3/21/2024 at 11:40 a.m. she revealed that on 10/11/2023 she was coming out of the shower room with another resident and saw Resident #114 stumble out of Resident #99's room backward. She revealed she caught the resident and sat him in the TV room. She stated Resident #99 reported Resident #114 wandered to his room and he had struck him twice on the side of the jaw to make him leave the room. NA#8 reported Resident #99 had removed the stop sign from his door. She revealed that during incidents of 9/8/2023 and 10/11/2023 no on 1:1 monitoring. During an interview with NA#8 on 3/21/2024 at 10:45 a.m. she stated Resident #114 and Resident #99 were not on 1:1 monitoring on 9/8/2023 and 10/11/2023, but they monitored the resident s as they went about. She revealed she was the medication technician during the incident of 9/8/2023 when a NA told her Resident #99 had hit Resident #114. She revealed she called a Nurse who attended to Resident #114. She further revealed there were no injuries during the two incidents and that Resident #99 had a psychiatric appointment on 10/23/2023 due to hitting resident #114 on 10/11/2023. Resident #114's Psychiatric Nurse Practitioner (NP) note dated 10/12/2023 at 8:00 a.m. revealed Resident #114 did not have any injuries noted to his face, but had his left cheek was red with no bruising or swelling. The NP noted that Resident #114 denied pain and staff reported Resident #114 to be at baseline and stable. An interview on 3/21/24 at 1:42 PM with the Psychiatric Nurse Practitioner (NP) revealed she had been notified of the incident between Resident #99 and Resident #29. She stated she had a meeting with the facility Administrator to discuss potential changes in Resident #99's care which included a move to a different facility. She stated that she was not aware he had a 1:1 sitter. An interview was conducted with the Director of Nursing (DON) on 3/22/2024 at 12:19 p.m. She revealed that Resident #99 had been placed on a 1:1 supervision on 9/8/2023 and 10/11/2023 to ensure safety of other residents in the unit. She revealed the changes for Resident #99 were care planned. She revealed the facility in coordination with the psychiatrist were working on moving Resident #99 to a larger area within the facility away from other residents on the dementia unit and possibly transfer to an inpatient psychiatric facility. The DON stated she was not sure when the 1:1 supervision for resident #99 stopped on both incidents. She revealed the 1:1 monitoring of Resident #99 at arm's length did not stop after the incident of 10/11/2023. An interview was conducted with the Administrator on 3/22/2024 at 12:29 p.m. who stated she had been at the facility for 3 weeks. She revealed Resident #99 will remain on 1:1 supervision, keep the stop sign posted on his door, and in the interim move Resident #99 to a safer area in the facility where no resident is wandering. She revealed Resident #99 was supposed to have remained on 1:1 monitoring due to his behavior. She revealed she was not sure why 1:1 monitoring for Resident #99 was stopped and when. Telephone calls to the prior Administrator on 3/20/2024 at 12:00 p.m. and 3:27 p.m., and on 3/21/2024 at 11:10 a.m. went unanswered. 40200 b. Resident #29 was admitted to the facility on [DATE] with diagnoses that included traumatic brain injury and non-Alzheimer's dementia. Resident #29's significant change Minimum Data Set, dated dated dated [DATE] revealed he was severely cognitively impaired, and he was coded for assistance or independence for most activities of daily living. A review of the Facility Reported Incident (FRI) dated 2/26/24 read in part Resident #29 was touching Resident #99 on the pant leg. Resident #99 stated Do not touch me and then slapped Resident #29 on the cheek. Staff separated both residents. The FRI continued that Resident #99 had a Brief Interview for Mental Status (BIMS is an assessment tool used to screen and identify cognitive condition) score of 13 in December. A St. Louis University Mental Status (SLUMS) was completed on 2/26/24 with a score of 10. (SLUMS is an assessment tool used to detect cognitive impairment. A score of 1-19 is defined as cognitive impairment and is indicative of dementia). A subsequent BIMS was also completed on 2/26/24 with a score of 6. (A score of 13-15 is cognitively intact and a score of 0-7 is severely impaired cognition.) The FRI continued that Resident #29 was monitored throughout the day and did not have any change in his daily routine to indicate mental anguish. An interview on 3/22/24 at 10:20 AM with Nursing Assistant (NA) #1 revealed she was the only facility staff person in the activities room during this incident. She stated she had not witnessed the incident as she was passing out the breakfast trays. She stated she heard the slap and turned to see what was going on. She then separated the residents and notified the nurse. NA #1 stated she thought that Resident #99's 1:1 sitter was out of the room in the hall. An interview was attempted with NA #3 who was assigned as a 1:1 sitter for Resident #99 on 2/26/24 but was unsuccessful. Nurse's progress note completed by Nurse #1 dated 2/26/24 at 10:53 AM for Resident #29 revealed no pain or skin concerns noted. Nurse's progress note completed by Nurse #1 dated 2/26/24 at 12:32 PM revealed Resident #99 reported Resident #29 was touching his pants leg. Resident #99 stated he told Resident #29 not to touch him and then slapped him on the face. The Nursing Assistant was across the room passing breakfast trays and was unable to intervene quick enough to prevent the physical altercation. The residents were moved to separate tables. An interview on 3/21/24 at 2:03 PM with Nurse #1 revealed she was the nurse on duty in the memory care unit on the day shift on 2/26/24. She stated she had not witnessed the incident between Resident #99 and Resident #29. She stated that Resident #99 had a 1:1 sitter due to a previous resident to resident incident and she did not know where Resident #99's 1:1 sitter was during the incident. Nurse #1 stated that Resident #29 quickly forgot what happened and had no injuries as a result of the slap. An interview on 3/21/24 at 1:42 PM with the Psychiatric Nurse Practitioner (NP) revealed she had been notified of the incident between Resident #99 and Resident #29. She stated she had a meeting with the facility Administrator to discuss potential changes in Resident #99's care which included a move to a different facility. She stated that she was not aware he had a 1:1 sitter. An interview on 3/22/24 at 8:10 AM with the Director of Nursing (DON) revealed that they were exploring options for Resident #99 to be relocated to a private room or to another facility, and his family had also discussed taking him home. She stated due to Resident #99's history of physical abuse the facility had continued the 1:1 sitter for Resident #99, and she felt they should continue the 1:1 sitter until they found another option for him. She stated that prior to the 2/26/24 incident Resident #99 had been in line-of-sight monitoring, but all staff had been educated to remain within arms' reach after the incident on 2/26/24. She clarified that staff were verbally educated that line-of-sight just meant to keep the resident within sight and arms reach meant to stay within physical reach of the resident. She stated this was just verbal instruction and the facility had no policy about 1:1 sitters. An interview on 3/22/24 at 8:33 AM with the Administrator revealed she believed that Resident #99 did not mean any harm, he just wanted Resident #29 to stop touching his pants leg. She stated that Resident #99's 1:1 sitter had been in line-of-sight and that was changed to within arms' reach after the incident on 2/26/24.

Based on record review and staff interviews, the facility failed to complete and submit an initial report for an abuse allegation within 2 hours of discovery to the state regulatory agency. The facility also failed to notify the police department, or Adult Protective Services (APS) for staff to resident abuse (resident #350) for 1 of 3 residents investigated for facility reported incidents. Findings included: A facility grievance form dated 10/10/23 was filed by SW#1 on behalf of resident #350. A review of the form revealed the resident stated her hair was pulled and that a bruise on her right hand was caused by NA #5 because the resident did not want to go to bed. Resident #350 further stated that her parents were outside the locked door, and no one would let them in. The form further revealed SW #1 reported the incident to the Assistant Director of Nursing (ADON) and Administrator #2 immediately after taking the report from the resident. An interview with SW #1 on 3/20/24 at 11:10 AM revealed she visited Resident #350 on 10/10/23 and noticed a bruise on her right hand. SW #1 asked the resident how it happened, and the resident stated there was a fire drill in the night and NA#5 pulled her hand because she wanted the resident to go to bed but she didn't want to. SW #1 further stated she reported the concern for staff to resident abuse to the ADON and Administrator #3 on 10/10/23. The incident was reported to the state regulatory agency by Administrator #2 on 12/14/23. In an interview with the DON on 03/22/24 08:27 AM she stated she interviewed Resident #350 on 10/10/23 who stated there was a fire drill and NA #5 was trying to help her go to bed but she didn't want to go so the resident pulled her hand away. The DON asked Resident #350 if she thought NA #5 hurt her on purpose and she stated no. The DON indicated that the incident was not reported to the state regulatory agency, the police department or APS because Resident #350 was prone to delirium and the fire drill agitated her to the point she received an as needed medication to help calm her at 1:36 AM on 10/10/23. The DON further stated they did not think the bruise came from NA #5, but from banging on the doors during the fire drill. Administrators #2 and #3 were not available for interview. Administrator #1 stated in an interview on 03/22/24 at 9:00 AM that although she was not employed at the time of the incident, she would report any accusation of employee to resident abuse within 2 hours to the state regulatory agency as that is the policy for this company. She further stated she would report any allegations of abuse to the local police department and APS. The facility provided and implemented the following corrective action plan with a completion date of 1/2/24. 1. A police report was filed regarding abuse investigation for Resident #350 on 12/14/23 with no charges filed. APS was also notified on 12/14/23. 2. On 12/13/23, Quality Assurance (QA) nurse and Unit Manager initiated an audit of progress notes for the past 30 days to ensure all reportable events to include allegations of abuse and/or injuries of unknown origin were addressed and reported in a timely manner to the appropriate agencies. Any concerns identified during the audit would be immediately addressed by the Administrator and/or the Director of Nursing (DON) to include reporting appropriately to required agencies and providing retraining. 3. On 12/13/23, the Assistant Director of Nursing (ADON) and Unit Manager reviewed all risk management reports for the past 30 days to ensure all incidents meeting the criteria of reportable events were reported timely to the required agencies. Any concerns identified during the audit would be immediately addressed by the administrator and/or DON to include reporting appropriately and providing retraining. 4. On 12/13/13, the Administrator initiated an audit of all reportable investigative folders for the past 30 days. This audit is to ensure all required reportable events were reported timely and per guidelines. The Administrator would address all areas of concern identified during the audit to include reporting events per guidelines. 5. On 12/13/23, the facility nurse consultant completed an in-service with the Director of Nursing (DON) regarding facility policy on reportable events to include but not limited to abuse allegations that require immediate reporting to state, police, and APS even if allegations are not substantiated during the initial investigation. 6. The Interdisciplinary Team (IDT) would review Nurse progress notes 5x weekly x 4 weeks for any allegations of abuse to include allegations of abuse and/or injuries of unknown origin. This audit is to ensure the event is investigated and reported in a timely manner per guidelines. The Administrator will address all areas of concern identified during the monitoring process. 7. Quality Assurance tasks: Facility Administrator to monitor concern forms weekly x4 weeks to ensure any potential abuse, neglect, or misappropriation are reported timely. Nursing administrative team to review weekly skin sheets during IDT for injuries of unknown origin x 4 weeks. Social services to perform safe surveys with A&O residents weekly x 4 weeks. Social services to ensure psychosocial needs of the identified resident are met. Facility to place staff at each exit door during fire drills or times of operation. The corrective action plan was reviewed on 3/22/24. Interviews confirmed all staff responsible for reporting initial allegations of abuse were educated to notify the police and the state regulatory agency of allegations of abuse. Administrator #1 stated there was always a member of management on call to ensure reports are made in a timely manner. Review of the monitoring tools, staff education, and Performance Improvement Plan were reviewed. The corrective action was verified as completed on 1/2/24.

Based on staff interviews and record review the facility failed to accurately code the Preadmission Screening Resident Review (PASRR) status, falls, and hospice status the Minimum Data Set assessment for 3 of 29 minimum data set assessments reviewed. (Resident #110, Resident #348, and Resident #68) Findings included: 1. Resident #110 was admitted to the facility on [DATE]. Resident # 110's active diagnoses included psychophysiologic insomnia and bipolar disorder. Review of a PASRR Level II Determination Notification letter for Resident #110 dated 1/20/23 revealed Resident #110 was assessed to be a level II PASRR and Resident # 110's PASRR number ended in the letter B which meant Resident #110's Level II PASRR had no end date. Resident #110's most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed she was coded to not be a level II PASRR. During an interview on 3/20/24 at 1:48 PM with the MDS Coordinator stated Resident #110 was a level II PASRR and the MDS dated [DATE] was coded in error. He concluded Resident #110 should have been coded as having a level II PASRR. During an interview on 3/20/24 at 1:57 PM Administrator #1 stated the PASRR should be coded accurately on the MDS assessment. 35930 2. Resident #68 was admitted to the facility on [DATE] with diagnoses which included, in part, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. A review of Resident #68's significant change Minimum Data Set (MDS), dated [DATE], indicated that Resident #68 was severely cognitively impaired. Hospice Care was not indicated. A review of Resident #68's Care Plan, last revised 12/13/23, revealed a problem of has advanced directives with an intervention of resident/responsible party elected hospice. This intervention was initiated on 09/28/23. A review of Resident #68's Physician orders revealed an order, dated 12/22/23, which read, admit to hospice services effective 09/21/23. An interview was conducted with the MDS Coordinator nurse on 03/21/24 at 1:37 p.m. The nurse stated he completed the significant change MDS, dated [DATE], because Resident #68 was placed on hospice services. The nurse explained that he missed marking Hospice Care due to human error. A telephone interview was conducted with the Administrator on 03/27/24 at 8:38 a.m. The Administrator explained it was her expectation that a resident's MDS assessment accurately reflect a resident's current status. 48230 3.a. Resident #348 was admitted to the facility on [DATE] with diagnoses that included abnormality of gait and mobility. A Nursing fall risk assessment dated [DATE] indicated Resident #348 was not at risk for falls. A review of Resident #348's Admission Minimum Data Set (MDS) dated [DATE] indicated antidepressant medication had been received. The Care Area Assessment (CAA) for falls was triggered by specific answers in the MDS, which required further assessment and decision as to whether or not to address in the care plan. The CAA revealed Resident #348 was at risk for falls due to having received antidepressant medication and indicated falls were not addressed for the Care Plan. Interview with Nurse #6 (MDS nurse) on 3/21/24 at 9:05 AM revealed falls were triggered in the CAA dated 6/27/23 but the box to check for care planning was not filled in. She was unable to explain why the falls had not been care planned based on the CAA. 3.b. Resident #348 was admitted to the facility on [DATE] with diagnoses that included abnormality of gait and mobility. Facility documentation dated 7/20/23 indicated Resident #348 had sustained a fall without injury. A review of Resident #348's Quarterly Minimum Data Set (MDS) dated [DATE] did not indicate any falls since the prior assessment. During an interview with Nurse #6 (MDS nurse) on 3/21/24 at 9:05 AM she stated a fall that Resident #348 had on 7/20/23 should have been captured by the quarterly MDS on 8/9/23 which would have triggered it to be added to the care plan. She further stated she did not know how she missed the fall on 7/20/23, and it was her responsibility to complete the quarterly MDS for Resident #348 and update the care plan with changes.

Based on record review and staff interviews the facility failed to develop a person-centered care plan for 1 of 1 resident reviewed for respiratory services (Resident #37). The findings included: Resident #37 was admitted to the facility on [DATE] with diagnoses that included heart failure and shortness of breath. A review of Resident #37's physician orders revealed an order dated 2/16/24 for supplemental oxygen at 2 liters per minute by nasal cannula to keep the oxygen saturation above 90%. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #37 received continuous supplemental oxygen. A review of Resident #37's comprehensive care plan revealed no care plan was developed related to oxygen use from admission through 3/21/24. Interview with Nurse #6 (MDS nurse) on 3/21/24 at 9:05 AM revealed supplemental oxygen use was triggered on the admission MDS and should have been part of the care plan. She stated the mistake was made by human error. An interview with Director of Nursing (DON) on 3/21/24 at 11:59 AM revealed supplemental oxygen should have been part of the initial care plan as the admission MDS indicated Resident #37 was admitted with oxygen. In an interview with the Administrator on 3/22/24 at 10:00 AM, she stated supplemental oxygen use would be care planned.

Based on observations, record review, and staff interviews the facility failed to keep a dependent resident's fingernails trimmed for 1 of 6 residents reviewed for activities of daily living care (Resident #69). Findings included: Resident #69 was admitted to the facility on [DATE]. Her active diagnoses included contracture of left wrist, reduced mobility, lack of coordination, and diabetes mellitus. Review of Resident #69's Minimum Data Set assessment dated [DATE] revealed she was assessed as cognitively intact. She had no rejection of care documented in the assessment. She required maximal assistance with bathing, and moderate assistance with personal hygiene. Review of Resident #69's care plan dated 2/22/24 revealed she was care planned for activities of daily living care. The interventions included providing extensive physical assistance with personal hygiene and grooming. During observation on 3/19/23 at 3:54 PM Resident #69's left hand fingernails were observed to be long. During an interview on 3/20/24 at 8:20 AM Resident #69 stated she had asked for her nails to be cut on her left hand at some point recently, but it had not been done and she did not remember who she asked. She stated the nails on her left hand grew faster and needed to be trimmed more often but she was unable to trim her own nails due to her weakness, coordination, and inability to use her left hand. During observation on 3/20/24 at 8:20 AM Resident #69's left hand fingernails were observed to be long. During an interview on 3/20/24 at 11:04 AM Nurse Aide #10 stated Resident #69 was a diabetic so nurse aides could only file her nails down. She further stated nursing could clip diabetic resident's fingernails. She stated Resident #69 did not refuse to let her file her nails down in the past. Nurse aides should ask if residents want their nails done if they see residents' nails are long during morning care. The nurse aide stated she worked with Resident #69 on 3/16/24, 3/17/24, and 3/19/24 as well as today (3/20/24). She stated she did note that Resident #69's fingernails on her left hand were long on those days. She further stated she did not offer nail care or report the long nails to the nurse on those days. She stated she did not have a reason she did not offer nail care to Resident #69 or report to anyone that Resident #69 needed her nails done. During an interview on 3/20/24 at 11:13 AM the Director of Nursing stated even if an alert and oriented had long nails noted, she would want the aide to offer nail care. Upon observing Resident #69's nails she stated the left-hand fingernails were long especially compared to the resident's right hand and she or another nurse would trim them. She concluded nail care should have been offered to Resident #69 prior to now.

Based on record review and staff interview, the facility failed to investigate and analyze falls to determine causative factors and implement targeted interventions to reduce risk of further falls for 1 of 3 residents (Resident #348) reviewed for accidents. The findings included: Resident #348 was admitted to the facility on [DATE] with diagnoses that included abnormality of gait and mobility. A fall risk assessment dated [DATE] indicated Resident #348 was not at risk for falls. A review of Resident #348's Admission Minimum Data Set (MDS) dated [DATE] indicated the resident was moderately cognitively impaired and had no fall history. He required extensive assistance with bed mobility and transfers, total assist with toileting, used a wheelchair for mobility and had no impairment in range of motion. The Care Area Assessment (CAA) dated 7/3/23 for the 6/20/23 MDS revealed Resident #348 was coded as at risk for falls due to having received antidepressant medication one or more of the last 7 days since admission. The CAA showed falls were not addressed in the Care Plan. Resident #348's comprehensive care plan that was developed based on the 6/20/23 admission MDS that triggered a CAA for fall risk, did not include any reference to fall risk. An interview with Quality Improvement (QI) Nurse on 3/22/24 at 9:14 AM revealed she was responsible for investigating fall incident risk management reports each day. These were sent to her when filled out by the Nursing staff and should be filled out after every fall. She stated that she finished the fall investigation if not complete. The QI nurse then took the incident report with investigation to the IDT meeting each morning where they discussed interventions and completed a root cause analysis. The interventions were then added to the care plan by MDS staff. Resident #348's Nurse progress note dated 7/20/23 at 4:32 PM revealed the resident had an unwitnessed fall and was found lying on the floor next to her bed by Nurse #4. The resident was assessed and was found to have no injury, but she did complain of right leg pain. The note then stated Resident #348 was sent to the hospital for evaluation. The resident's Responsible Party (RP) and Nurse Practitioner (NP) were notified. A review of a Nurse progress note dated 7/20/23 at 8:00 PM revealed Resident #348 returned from the hospital where they had found no fractures or other problems. There was no evidence an investigation into the cause of the fall had been completed for Resident #348's 7/20/23 fall. Nurse #5 was working with Resident #348 at the time of the fall on 7/20/23. In an interview with Nurse #5 on 3/22/24 at 10:05 AM, she stated she did not recall the resident. incident report with investigation to the IDT meeting each morning where they discussed interventions and completed a root cause analysis. The interventions were then added to the care plan by MDS staff. An interview with Director of Nursing (DON) on 3/21/24 at 11:59 AM revealed the system for fall reporting. The Nurse that was responsible for the resident filled out a risk management incident report after every fall, this report went to the QI Nurse, herself (the DON) and the Administrator. The risk management incident report was discussed in IDT each morning where interventions were discussed. QI Nurse completed any parts of the investigation that weren't completed such as interviews with witnesses. The risk management incident report was used to assess the reason a fall happened and to develop interventions to prevent future falls. The DON further stated Nursing was alerted on a quarterly basis for each resident to complete a fall assessment. The DON added that fall assessments were supposed to be completed after every fall. She explained that she did not know why Resident #348 only had one assessment done when a fall assessment should have been completed after each fall. The DON stated she did not know why no risk management incident reports were completed and that no one would know a fall needed to be investigated without the report. In an interview with the Administrator on 3/22/24 at 10:00 AM, she stated all falls were documented by the Nurse on a risk management incident report and this was forwarded to the QI nurse, the DON, and herself. She further stated the incident reports were then taken to IDT meeting each morning to be evaluated for the reason for the fall and interventions to prevent further falls were discussed. Afterwards, the care plan was updated. The Administrator further stated she did not know why a risk management incident report was not completed and that this report is what triggered the fall to be investigated for causative factors including witness interviews.

Based on record review and interviews with staff, Speech Therapist, Nurse Practitioner and Physician the facility failed to review a history and physical from the hospital for a newly admitted resident, administer diabetes medications as listed on the hospital discharge summary, clarify medication orders with the physician, and monitor blood sugars for a resident with diabetes. Resident #3 was unresponsive to verbal stimuli on 5/25/22 and required hospitalization in the intensive care unit with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This was for 1 of 2 residents (Resident #3) reviewed for diabetes care. Immediate Jeopardy began on 5/19/22 when the facility failed to review a history and physical from the hospital resulting in the omission of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Immediate Jeopardy was removed on 6/30/22 when the facility provided and implemented an acceptable plan for Immediate Jeopardy removal. The facility remains out of compliance at the lower level of scope and severity of E to ensure education is completed and monitoring systems in place are effective. The findings included: Review of Resident #3's discharge summary dated 5/19/22 from the hospital revealed a discharge medication list which included the following medications used to treat diabetes: [MEDICATION(S)] 1000 milligrams twice per day and [MEDICATION(S)] (a medication used to treat diabetes) 0.75 milligrams inject under the skin one time weekly. Recommendation was listed to follow up with primary care physician for optimal control of diabetes. Blood sugar monitoring was not ordered. Resident #3 was admitted to the facility on [DATE] with medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the Unit Manager on 6/16/22 at 1:02 PM revealed the orders were entered from the medication list in the discharge summary. The Unit Manager reported she called the doctor for clarification of orders as needed. The Unit Manager did not recall requesting clarification of Resident #3's orders. She indicated there was not a protocol for blood sugars on admission for residents with diabetes. The Unit Manager further stated she just entered the medications and did not read the discharge summary or history and physical. She was unable to explain why [MEDICATION(S)] 1000 mg twice daily was not entered into the facility's orders as indicated in the medication list on the discharge summary. Review of Resident #3's care plan dated 5/23/22 revealed a problem of diabetes with goal of will adhere to treatment regimen through next review. Interventions included fingerstick blood sugar as ordered or per protocol, observe for signs and symptoms of [CONDITION(S)] or [CONDITION(S)] (low or high blood sugar), and administer medication as ordered by the physician. Review of Resident #3's Medication Administration Record (MAR) for May 2022 revealed the medication [MEDICATION(S)] was not listed. In addition, [MEDICATION(S)] 0.75 milligrams, a once weekly injection to control blood sugar, was on the MAR and documented on 5/24/22 as not given due to not available. Review of Registered Dietician progress note dated 5/24/22 indicated Resident #3's intake was variable, and he consumed 0-100% of meals. Review of a physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's 5-day Minimum Data Set assessment dated [DATE] revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 had moderate cognitive impairment and received speech therapy services. Review of Resident #3's nursing progress note written by Nurse #1 dated 5/25/22 at 9:30 AM revealed the following: resident was unresponsive to verbal stimuli, cool and clammy to touch with blood sugar of HI., indicating a blood sugar level of greater than 400 milligrams per deciliter. The nurse practitioner (NP) was notified and gave order to send Resident #3 to the hospital. Review of the emergency department note dated 5/25/22 for Resident #3 revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Lab report dated 5/25/22 at 10:56 AM indicated Resident #3's blood glucose level was 711milligrams per deciliter. Resident #3 required admission to the hospital intensive care unit, required intravenous insulin to lower his blood sugar and received treatment for [CONDITION(S)], a widespread infection, due to pneumonia. Interview with the Speech Therapist on 6/16/22 at 10:16 AM revealed she treated Resident #3 from 5/20/22 to 5/25/22 due to dysphagia (difficulty swallowing foods and liquids) and cognitive and communication deficits. The Speech Therapist revealed that she observed Resident #3 on the morning of 5/25/22 and noted he had no gag or swallow response. The Speech Therapist indicated she alerted the Nurse Practitioner of Resident #3's change in condition which resulted in transfer to the hospital for evaluation. Interview with the physician on 6/16/22 at 2:58 PM revealed he did not recall being asked to order blood sugar monitoring for Resident #3. The physician further stated he became aware on 5/24/22 that [MEDICATION(S)] was on the discharge summary list of medications but was not transcribed to the facility orders. He indicated he intended to discuss this with staff however Resident #3 was discharged to the hospital on 5/25/22. The physician stated that [MEDICATION(S)] would not have prevented Resident #3's elevated blood sugar reading on 5/25/22 which resulted in hospitalization . [CONDITION(S)], or widespread infection, could account for a highly elevated blood sugar reading. The physician stated he was not informed of the pharmacy recommendation for Resident #3 dated 5/20/22 regarding [MEDICATION(S)]. Interview with the Nurse Practitioner (NP) on 6/15/22 at 4:16 PM revealed that on the morning of 5/25/22 Resident #3 was clammy and diaphoretic, his blood sugar registered HI which indicated elevated blood sugar and he was sent to the hospital for evaluation. NP did not recall being informed that Resident #3 had been on insulin prior to hospitalization or a request for an order to check blood sugars. NP was unaware that [MEDICATION(S)] was listed on the hospital discharge medication list and was not listed on the facility medication administration record. Interview with the Director of Nursing (DON) on 6/16/22 at 12:51 PM revealed the discharge summary was used for orders for new admissions from the hospital. The facility received the discharge summary by fax prior to admission or a paper copy on admission. The unit manager entered the orders from the discharge summary including the discharge medication list. The DON stated that the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator was notified of Immediate Jeopardy on 6/28/22 at 2:12 PM On 6/29/22 the facility provided the following credible allegation of Immediate Jeopardy removal: Recipients who have suffered or are likely to suffer a serious adverse outcome as a result of the non-compliance: Resident #3 was alert and oriented on admission with slurred speech. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/19/22, Resident #3 was admitted to the facility with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The admitting nurse did not transcribe the order to the medication administration record per the hospital discharge summary. There was no order on the discharge summary for blood sugar monitoring, blood sugar was checked on admission and noted to be 177. On 5/20/22, the pharmacist consultant conducted an admission drug regimen review and identified the medication [MEDICATION(S)] was not listed on physician admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician determined the medication would remain on hold until further clarity was received on swallowing function and nutritional intake. On 5/24/2022, the [MEDICATION(S)] was not administered due to medication not being available. The nurse did contact the pharmacy to have it sent that evening, however, she did not notify the physician to obtain an order to give when the dose came in. Resident did not exhibit signs nor symptoms of [CONDITION(S)] at that time. The resident was sent to the hospital on the morning of 05/25/2022 prior to the physician obtaining clarification on swallowing function and nutritional intake, and before the medication was received. On the morning of 5/25/22, Resident #3 was unresponsive to verbal stimuli, cool and clammy to touch and blood sugar listed as high. The nurse practitioner was on site and aware of the resident's condition. The nurse practitioner examined the resident and gave new order to send Resident #3 to the emergency room for further evaluation. 911 was called, and the resident was transferred to the emergency room per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident representative was notified of transfer to the emergency room for evaluation. All newly admitted residents from the hospital and all residents with diabetes have the potential to be affected by the deficient practice. On 6/29/22, the Pharmacist reviewed all current residents admitted between 5/19/22 to 6/28/22 medications, including diabetic medications. The Pharmacist checked the resident discharge summary and compared it to the facility medication orders to ensure medications were transcribed accurately to the medication administration record upon admission. The Pharmacist contacted the Director of Nursing (DON) with all findings, and the DON contacted the physician for any necessary clarifications. The clarification orders were obtained, and the physician completed documentation for any errors identified. The audit was completed by 6/29/22. On 6/29/22, the Quality Assurance Nurse, Nurse Supervisor, Nurse Facilitator, Director of Nursing, and Pharmacist reviewed all diabetic residents to ensure orders for finger sticks are in place as ordered by the physician. The Quality Assurance Nurse, Nurse Supervisor, Nurse Facilitator, and Director of Nursing contacted the physician for any residents on diabetic medications identified without a fingerstick order to validate need for monitoring. A justification note was documented in the clinical record by the Quality Assurance Nurse, Nurse Supervisor, Nurse Facilitator, and Director of Nursing for any diabetic resident whose physician did not want a blood sugar obtained. Orders were written for all other diabetic residents that require blood sugars. The audit was completed by 6/29/22. On 6/29/22, the Quality Assurance Nurse, Nurse Supervisor, Nurse Facilitator, and Director of Nursing reviewed medication administration records from 6/1/22 to 6/28/22 for all current diabetic residents to ensure diabetic medications were administered per physician orders. The physician was contacted, and an incident report was initiated by the Quality Assurance Nurse, Nurse Supervisor, Nurse Facilitator, and Director of Nursing for any identified areas of concern. Actions taken by the facility to alter the process or system failure to prevent a serious adverse outcome for occurring or recurring: On 6/29/22, the Staff Development Coordinator initiated an in-service with all nursing assistants, nurses, dietary, housekeeping, medical records, accounts receivable, accounts payable, maintenance, social work, receptionists, admissions, Administrator and therapy regarding: 1. Signs and symptoms of [CONDITION(S)] per the Mayo Clinic guideline include but are not limited to elevated blood sugar, nausea, vomiting, shortness of breath, dry mouth, weakness, frequent urination, increased thirst, blurred vision, fatigue, headache, and confusion. On 6/29/22, the Staff Development Coordinator initiated an in-service with all nurses regarding: 1. Clarify the need for blood sugar monitoring orders when a resident receiving diabetic medication is admitted to the facility without orders in place for glucose monitoring. 2. Clarify orders for medications and blood sugar monitoring to include admission medication orders from the discharge summary with a physician if they are not clear and precise before transcribing to the MAR. 3. Obtain blood sugars when an acute change in condition is observed on a diabetic resident. 4. If a medication is unavailable, and not in the emergency medication kit, notify the pharmacy to obtain medication. If unable to obtain medication from pharmacy and administer during the scheduled time, notify the physician for alternative orders. On 06/29/2022 the administrator initiated an in-service with the Director of Nursing, Quality Assurance Nurse, Nurse Supervisor, Staff Development Coordinator and Nurse Facilitator on the process for completion of the admission checklist to include medication reconciliation for new admissions and notify the physician of any discrepancies in the clinical meeting. The Director of Nursing, Quality Assurance Nurse, Nurse Supervisor, Staff Development Coordinator and Nurse Facilitator to review all new admissions utilizing the admission check list during the next scheduled clinical meeting held Monday through Friday to ensure the admission process was completed. In-services will be completed by 6/29/22. After 6/29/22, the Administrator will ensure the remaining in-services for staff who have not worked or have not received the in-services are mailed certified mail with instructions to review, sign the in-service, and return to the Staff Development Coordinator or Director of Nursing before the next scheduled work shift. Alleged Immediate Jeopardy Removal date: 6/30/22 On 6/30/22 the credible allegation of Immediate Jeopardy was validated by onsite verification including record review and interviews which verified that the audits were completed. Interview with the Regional Clinical Pharmacy Manager revealed that the audit of all current resident medication records including diabetic medications were checked to ensure that the medications were transcribed correctly. The Director of Nursing (DON) was interviewed and verified that all audits were completed. Record review revealed that the audits were completed as indicated. Review of inservice records revealed that all staff received training regarding signs and symptoms of [CONDITION(S)]. Staff received training either in person or via certified mail. A review of inservices and inservice sign in sheets as well as staff interviews verified that education was provided to all nurses regarding blood sugar monitoring orders, clarification of medication orders to ensure that medications orders from the discharge summary are accurately and precisely transcribed to the medication administration record, and steps to take when a medication was not available. Inservice records indicated that the administrator provided education to the administrative nurses regarding the process of the admission checklist to address medication reconciliation for new admissions and notification of the physician of any discrepancies. Record review revealed that inservices were completed by 6/29/22. Interviews with staff revealed that education was provided. The facility's Immediate Jeopardy removal date of 6/30/22 was validated.

Based on record review and interviews with the Physician, Nurse Practitioner, Speech Therapist, and staff, the facility Administration failed to provide leadership and oversight to ensure effective systems were in place for reviewing history and physicals from the hospital for newly admitted residents, administering diabetes medications as listed on the hospital discharge summary, clarifying medication orders with the physician, monitoring blood sugars for a resident with diabetes, and acting upon recommendations contained in the Consultant Pharmacist ' s new admission Medication Regimen Review (MRR) for 1 of 2 residents (Resident #3) reviewed for diabetes care. Immediate Jeopardy began on 5/19/22 when the facility failed to have an effective system in place to ensure a history and physical from the hospital was reviewed resulting in the omission of the physician's order [MEDICAL RECORD OR PHYSICIAN ORDER] . Immediate Jeopardy was removed on 6/30/22 when the facility provided and implemented an acceptable plan for Immediate Jeopardy removal. The facility remains out of compliance at the lower level of scope and severity of E to ensure education is completed and monitoring systems in place are effective. The findings included: This tag is cross referenced to: F684 Based on record review and interviews with staff, Speech Therapist, Nurse Practitioner and Physician the facility failed to review a history and physical from the hospital for a newly admitted resident, administer diabetes medications as listed on the hospital discharge summary, clarify medication orders with the physician, and monitor blood sugars for a resident with diabetes. Resident #3 was unresponsive to verbal stimuli on 5/25/22 and required hospitalization in the intensive care unit with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This was for 1 of 2 residents (Resident #3) reviewed for diabetes care. F756 Based on record review and interviews with staff and the Physician, the facility failed to act upon the Consultant Pharmacist's new admission Medication Regimen Review (MRR) that identified [MEDICATION(S)] (a medication used in the treatment of diabetes) 1000 milligrams twice daily listed on the hospital discharge summary was omitted from the facility's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 was unresponsive to verbal stimuli on 5/25/22 at 09:30 AM. Resident #3 was cool and clammy to touch with a blood sugar of Hi, indicating an abnormal reading with a level greater than 400 milligrams per deciliter. Resident #3 required hospitalization in the intensive care unit with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator was notified of Immediate Jeopardy on 6/28/22 at 2:12 PM. The facility provided a credible allegation of Immediate Jeopardy on 6/29/22. The allegation of Immediate Jeopardy removal indicated: Resident #3 was alert and oriented on admission with slurred speech. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 5/19/22, Resident #3 was admitted to the facility with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The admitting nurse did not transcribe the order to the medication administration record per the hospital discharge summary. There was no order on the discharge summary for blood sugar monitoring, blood sugar was checked on admission and noted to be 177. On 5/20/22, the pharmacist consultant conducted an admission drug regimen review and identified the medication [MEDICATION(S)] was not listed on physician admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Medication Regimen Review was not addressed by the Director of Nursing due to a lack of understanding of the process. On 5/24/22, the physician completed an initial admission assessment of the resident and resident's medications and identified [MEDICATION(S)] as listed on the discharge summary. The physician determined the medication would remain on hold until further clarity was received on swallowing function and nutritional intake. On 5/24/2022, the [MEDICATION(S)] was not administered due to medication not being available. The nurse did contact the pharmacy to have it sent that evening, however, she did not notify the physician to obtain an order to give when the dose came in. Resident did not exhibit signs nor symptoms of [CONDITION(S)] at that time. The resident was sent to the hospital on the morning of 05/25/2022 prior to the physician obtaining clarification on swallowing function and nutritional intake, and before the medication was received. On the morning of 5/25/22, Resident #3 was unresponsive to verbal stimuli, cool and clammy to touch and blood sugar listed as high. The nurse practitioner was on site and aware of the resident's condition. The nurse practitioner examined the resident and gave new order to send Resident #3 to the emergency room for further evaluation. 911 was called, and the resident was transferred to the emergency room per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident representative was notified of transfer to the emergency room for evaluation. All residents newly admitted from the hospital and all residents with diabetes have the potential to be affected by the deficient practice. Actions taken to alter the process or system failure to prevent a serious adverse outcome for occurring or recurring: On 06/29/2022 the Corporate Clinical Director completed a root cause analysis to determine what led to the administration failures of: 1. Accurately transcribe admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Administer diabetes medications as listed on the hospital discharge summary. 3. Clarify medication orders with the attending physician or nurse practitioner. 4. Monitor blood sugars for a resident with Diabetes. 5. Address the consultant pharmacist Admission Medication Regime Review. The root cause was determined to be the lack of administrative oversight as a second check to ensure the facility was compliant for the below identified processes and systems. This review included assessment of processes and systems in place for Administration oversight to include: 1. Clinical Meetings 2. Admission Process 3. Medication Administration 4. Pharmacy Services 5. Physician Notification The changes implemented from the review are: 1. The clinical team to include the Director of Nursing, Quality Assurance Nurse, Nurse Facilitator, Nursing Supervisor, and Staff Development Coordinator will review new admission medications to include diabetic medications and blood sugar monitoring, physician notifications for medications unavailable, and medication omission report during clinical meeting 5 times per week to ensure accuracy of orders and administration of medications as ordered. 2. The pharmacist will now call the Director of Nursing with any medications omitted from the discharge summary that are identified during the new Admission Medication Regimen Review. The Director of Nursing will forward any discrepancies to the attending physician or nurse practitioner. On 6/29/22, the Administrator initiated an in-service with the Director of Nursing, Medical Records Director and the Minimum Data Set Nurses regarding: 1. The process for reviewing the Consultant Pharmacist New Admission Medication Regimen Review upon receipt to ensure all potential clinically significant medication issues identified by the pharmacist were addressed. On 6/29/22, the Corporate Clinical Director in-serviced the Administrator and Director of Nursing regarding: 1. The process for providing oversight through the clinical meeting a. Transcription of newly admitted resident medications per discharge summary to the medication administration record by reviewing the Admission Checklist, resident discharge summary and resident medication administration record. b. The nurse's responsibility to clarify orders for medications and blood sugar monitoring to include admission medication orders from the discharge summary with a physician or nurse practitioner if they are not clear and precise before transcribing to the MAR. c. Monitoring blood sugars for resident with diabetes. d. The Director of Nursing's responsibility to review and follow recommendations of the Consultant Pharmacist New Admission Medication Regimen Review. In-services will be completed by 6/29/22. After 6/29/22, the Administrator will ensure the remaining in-services for staff who have not worked or have not received the in-services are mailed certified mail with instructions to review, sign the in-service, and return to the staff facilitator and/or director of nursing prior to next scheduled work shift. Alleged Immediate Jeopardy Removal date: 6/30/22 On 6/30/22 the credible Allegation of Immediate Jeopardy removal was validated by onsite verification. Interview with the Director of Nursing (DON) revealed that new admission medications were reviewed 5 times per week during the clinical meetings. Interview with the Regional Pharmacy Consultant revealed that the DON was called with any medications omitted from the discharge summary that were identified during the admission Medication Regimen Review. A review of inservices and inservice sign in sheets as well as interviews verified that education was provided by the Corporate Clinical Director to the Administrator and DON regarding the process for providing oversight through the clinical meeting and the responsibility of the DON regarding the new admission Medication Regimen Reviews. Inservice records revealed this was completed as of 6/29/22. The facility's Immediate Jeopardy removal date of 6/30/22 was validated.

Based on record review and interviews with staff and the physician, the facility failed to act upon the consultant pharmacist's new admission Medication Regimen Review (MRR) that identified [MEDICATION(S)] (a medication used in the treatment of diabetes) 1000 milligrams twice daily listed on the hospital discharge summary was omitted from the facility's physician orders resulting in 12 missed doses of the medication for 1 of 2 residents reviewed for diabetes care (Resident #3). Resident #3 was unresponsive to verbal stimuli on 5/25/22 at 09:30 AM. Resident #3 was cool and clammy to touch with a blood sugar of Hi, indicating an abnormal reading with a level greater than 400 milligrams per deciliter. Resident #3 required hospitalization in the intensive care unit with a diagnosis of hyperglycemic state with a blood sugar reading of 711 milligrams per deciliter. Immediate Jeopardy began on 5/20/22 when the facility failed to act upon the Consultant Pharmacist's initial Medication Regimen Review (MRR) that identified [MEDICATION(S)] 1000 milligrams twice per day was not listed on the facility's physician orders. Immediate Jeopardy was removed on 6/30/22 when the facility provided and implemented an acceptable plan of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D to ensure that education is completed and monitoring systems in place are effective. The findings included: Review of Resident #3's discharge summary dated 5/19/22 from the hospital revealed a discharge medication list which included the following medication used to treat diabetes: [MEDICATION(S)] 1000 milligrams twice per day. Resident #3 was admitted to the facility on [DATE] with medical diagnoses which included in part stroke, diabetes, [CONDITION(S)] and pneumonia. Review of a pharmacy admission Medication Regimen Review dated 5/20/22 at 3:48 PM for Resident #3 revealed, in part, the following: Potentially clinically significant medication issue: the discharge summary listed order for [MEDICATION(S)] 1000 milligrams by mouth twice per day was not listed on the facility physician orders. Instructions on this admission MRR form indicated to act on the potential issues and place a copy of this form and the response taken into the resident's paper chart or electronic health record. If order changes were made, the pharmacy was to be notified by sending a complete order to the pharmacy. Review of physician history and physical note for Resident #3 dated 5/24/22 indicated that the discharge summary did not match the current regimen and the physician referenced the need to discuss with staff clarification of [MEDICATION(S)] on the discharge summary medication list that was not listed on the facility orders. Review of Resident #3's Medication Administration Record (MAR) for May 2022 revealed the medication [MEDICATION(S)] was not listed resulting in 12 missed doses. Review of the medication orders following the consultant pharmacist's Medication Regimen Review (MRR) revealed from 5/20/22 to 5/25/22 there was no follow up on the order for [MEDICATION(S)] 1000 milligrams by mouth twice per day. Review of Resident #3's nursing progress note written by Nurse #1 dated 5/25/22 at 9:30 AM revealed the following: resident was unresponsive to verbal stimuli, cool and clammy to touch with blood sugar of HI., indicating a blood sugar level of greater than 400 milligrams per deciliter. The nurse practitioner (NP) was notified and gave order to send Resident #3 to the hospital. Review of the emergency department note dated 5/25/22 for Resident #3 revealed a diagnosis of diabetes with hyperosmolar hyperglycemic state, a life-threatening condition in a diabetic patient who experiences high blood glucose levels caused by infection or illness which can develop over days or weeks. Lab report dated 5/25/22 at 10:56 AM indicated Resident #3's blood glucose level was 711 milligrams per deciliter. Resident #3 required admission to the hospital intensive care unit, required intravenous insulin to lower his blood sugar and received treatment for [CONDITION(S)], a widespread infection, due to pneumonia. Interview with the physician on 6/16/22 at 2:58 PM revealed he became aware on 5/24/22 that [MEDICATION(S)] was on the discharge summary list of medications but was not transcribed to the facility orders during his routine evaluation. He intended to discuss this with staff however Resident #3 was discharged to the hospital on 5/25/22. The physician stated that [MEDICATION(S)] would not have prevented Resident #3's elevated blood sugar reading on 5/25/22 which resulted in hospitalization . [CONDITION(S)], or widespread infection, could account for a highly elevated blood sugar reading. The physician stated he was not informed of the pharmacy admission Medication Regimen Review for Resident #3 dated 5/20/22 regarding [MEDICATION(S)]. Interview with the Director of Nursing (DON) on 6/16/22 at 3:32 PM revealed that the pharmacy admission MRR for new residents were sent to her email as well as the Minimum Data Set nurse's email. A copy was also sent via fax to the facility. The DON was unsure which fax machine the MRR was sent to as she stated there were problems with the fax machines in the facility. The DON revealed that she was to print the MRR from her email and give to the Unit Manager to address. The Unit Manager was responsible for addressing the pharmacy recommendations. The DON stated the admission MRR for Resident #3 was sent to her email on 5/20/22 and she overlooked it and did not address it. The DON revealed that the expectation was that the MRR for each newly admitted resident would be addressed as soon as possible. Interview with the Unit Manager on 6/16/22 at 4:22 PM revealed that there had been an ongoing issue with the pharmacy recommendations not being received and addressed. The Unit Manager stated sometimes the pharmacy recommendations were sent via email to the DON or medical records or sometimes they were faxed to the facility. The Unit Manager did not recall addressing the pharmacy recommendation for Resident #3. The Unit Manager stated that Resident #3 may have been discharged prior to the pharmacy recommendation being addressed. The Administrator was notified of Immediate Jeopardy on 6/28/22 at 2:12 PM. On 6/29/22 the facility provided the following credible allegation of Immediate Jeopardy Removal: Recipients who have suffered or are likely to suffer a serious adverse outcome as a result of the non-compliance: Resident #3 was alert and oriented on admission with slurred speech with diagnoses of [CONDITION(S)], type II diabetes, [CONDITION(S)], [CONDITION(S)], major depressive disorder, Hypertension, obesity, [CONDITION(S)], non-traumatic hemorrhage, and [CONDITION(S)]. On 5/19/22, Resident #3 was admitted to the facility with an order for [MEDICATION(S)] 1000 mg per tab, one tab by mouth 2 x daily. The admitting nurse did not transcribe the order to the medication administration record per the hospital discharge summary. On 5/20/22, the pharmacist consultant conducted an admission drug regimen review and identified the medication [MEDICATION(S)] was not listed on physician admission orders. This was documented on the Admission Medication Regimen Review form by the pharmacist and emailed to the Director of Nursing on 05/20/22. The Admission Medication Regimen Review was not addressed by the Director of Nursing due to a lack of understanding of the process. On 5/25/22, Resident #3 was unresponsive to verbal stimuli, cool and clammy to touch and blood sugar listed as high. The nurse practitioner was on site and aware of the resident's condition. The nurse practitioner examined the resident and gave new order to send resident #1 to the emergency room for further evaluation. 911 was called, and the resident was transferred to the emergency room per the physician's order. The resident was admitted to the hospital with the primary diagnosis of [CONDITION(S)] due to pneumonia. The resident representative was notified of transfer to the emergency room for evaluation. All residents who are newly admitted to the facility have the potential to be affected by the deficient practice. Actions taken to alter the process or system failure to prevent a serious adverse outcome for occurring or recurring On 6/29/22, the Pharmacist will review all current residents admitted between 5/19/22 to 6/28/22 medications, including diabetic medications. The Pharmacist will check the resident discharge summary and compare it to facility medication orders to ensure medications were transcribed accurately to the medication administration record upon admission. The Pharmacist will contact the director of nursing with all findings, and the director of nursing will contact the physician for any necessary clarifications. The clarification orders will be obtained, and the physician will complete documentation for any errors identified. The audit will be completed by 6/29/22. On 6/29/22, the Quality Assurance Nurse and the Nurse Supervisor will review the Consultant Pharmacist's New Admission Medication Regimen Review for all current residents admitted between 5/19/22 to 6/28/22 to ensure all potential clinically significant medication issues identified by the Pharmacist were addressed. The Quality Assurance Nurse and Nurse Supervisor will address all concerns identified during the audit by obtaining clarification orders from the physician. The audit will be completed by 6/29/22. On 6/29/22, the Administrator initiated an in-service with the Director of Nursing, Medical Records Director and the Minimum Data Set Nurses regarding: 1. The process for reviewing the Consultant Pharmacist New Admission Medication Regimen Review upon receipt to ensure all potential clinically significant medication issues identified by the pharmacist were addressed. In-services will be completed by 6/29/22. After 6/29/22, the Administrator will ensure the remaining in-services for staff who have not worked or have not received the in-services are mailed certified mail with instructions to review, sign the in-service, and return to the staff facilitator and/or director of nursing prior to next scheduled work shift. Alleged Immediate Jeopardy Removal date: 6/30/22 On 6/30/22 the credible Allegation of Immediate Jeopardy was validated by onsite verification. Record review and interview with the Regional Consultant Pharmacist verified the audit was completed of all residents admitted from 5/19/22 to 6/28/22 medications including diabetic medications. Audit of new admission Medication Regimen Reviews for current residents admitted between 5/19/22 to 6/28/22 was completed as of 6/29/22. Interview with the Director of Nursing (DON), Unit Manager and Staff Development Coordinator verified that 100% of the audits were completed as of 6/29/22. A review of inservices and inservice sign in sheets as well as staff interviews verified that education was provided by the Administrator to the DON, Medical Records Director and Minimum Data Set nurses regarding the process for review of the Consultant Pharmacist New Admission Medication Regimen Review. Inservice records revealed this was completed as of 6/29/22. The facility's Immediate Jeopardy removal date of 6/30/22 was validated.

Based on record review and interviews with facility staff, Medical Director, Nurse Practitioner, and Vascular Surgeon, the facility failed to maintain an effective pest control system resulting in maggot infestation of a resident's wound for 1 of 2 residents wounds (Resident #1) reviewed for pest control. Resident #1 was discharged to the emergency room (ER) on 6/12/22 with respiratory distress. He presented to the hospital with [CONDITION(S)] (a life-threatening complication of an infection) criteria with fever, [CONDITION(S)] (pulse over 100), and some altered mental status. When Resident #1's dressings were removed, and the wounds inspected, the left heel was infested with maggots. Resident #1 had multiple radiology tests (xrays, CT scans, ultrasounds) and it was determined the left heel wound was the source of the infection. Immediate Jeopardy began on 6/12/22 when the emergency room physician removed Resident #1's dressing on his left leg lower extremity and the heel wound was infested with maggots. The Immediate Jeopardy was removed on 6/18/22 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 level of D (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to implement fly reduction measures to include fly lights, air curtains, and handicap accessible doors to the courtyard. The findings included: The hospital discharge summary dated 5/24/22 indicated Resident #1 was admitted to the hospital on 5/4/22 for [CONDITION(S)] secondary to leg wound infections, [CONDITION(S)] of bilateral lower legs and bilateral infected heels wounds, severe chronic obstructive disease ([CONDITION(S)]), and [CONDITION(S)]. A progress note written by the hospital Wound Ostomy Care Nurse (WOCN) dated 5/24/22 revealed the posterior left heel pressure injury was unstageable but surrounded by healthy, intact, moist, pink skin; necrotic tissue in center of wound is thick, soft, black, and densely adhered. There was no odor or redness noted. He was discharged to the facility for wound care and subacute rehab in anticipation of home discharge when his strength improved. Resident #1 was admitted to the facility on [DATE] with diagnoses to include to include peripheral vascular disease and bilateral nonhealing heel ulcers. Review of Resident #1's admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact and required extensive assistance with activities of daily living (ADL's). Two venous ulcers were present on admission. Review of Resident #1's electronic medical record (EMR) revealed a physician's order dated 6/1/22 by the Vascular Surgeon to change bilateral lower extremity unna boot (the unna boot is a compressive dressing that fits like a boot leaving only the toes exposed and the wraps extend up the leg to just below the knee; it consists of a special dressing that is applied wet and hardens as it dries to conform to the leg, this is wrapped in kerlix and and secured with a self-adherent wrap which acts to secure and apply compression) wound dressings weekly. Cleanse right lower extremity with wound cleanser, pat dry with 4x4 gauze, apply xeroform to open areas on heels and cover with thick gauze pads and wrap with unna boot dressing once a week. Review of Resident #1's treatment administration record (TAR) revealed the treatment to cleanse left lower extremity (LLE) with wound cleanser, pat dry with 4x4 gauze, apply xeroform to open area on left heel, cover with large gauze pads, and wrap with unna boot every week and as needed was signed off by the Wound Care Nurse on 6/7/22. The treatment for the right lower extremity was the same and was also signed off by the Wound Care Nurse on 6/7/22. Review of Resident #1's emergency room record revealed a progress note dated 6/12/22 by the physician indicating maggot infestation of the left heel wound. Resident #1 was treated at the hospital for [CONDITION(S)] (the body's overwhelming and life-threatening response to an infection that can lead to tissue damage, organ failure death) with intravenous (IV) fluids and antibiotics. An interview with the Wound Care Nurse (WCN) was conducted on 6/15/22 at 2:55 PM. She stated Resident #1 was admitted to the facility with bilateral heel wounds and a wound on top of right foot and an area on right lower leg. She further stated the dressing change order was to apply xeroform to the heel wounds and wrap in unna boot (dressing that goes on wet and conforms to leg when it dries), and then wrap in kerlix and secure it with a self-adherent wrap which acts to secure and apply compression once a week. She stated she had changed Resident #1's dressing on 6/7/22 and his heels had been pink with some red areas and serosanguinous (reddish yellow) drainage. She indicated she didn't know how maggots would have gotten in the wound because she had not seen any flies when changing the dressing. She stated she didn't see how a fly could have gotten in the dressing. An interview and observation were conducted with Resident #2 on 6/16/22 at 10:00. She stated she has seen flies in her room a lot. She further stated she hated flies. A fly was observed in the room on the resident's right leg, foot and toes. Resident #2 was observed to have a dressing on the right foot. The fly was observed on the edge of the dressing and drainage was noted on the dressing. An interview was conducted on 6/16/22 at 10:15 AM with the Activities Director (AD). She stated every year in the spring the Residents would start asking for fly swatters. She further stated when the residents had complained at the May 2022 Resident Council Meeting about flies, she had shared the information with the interdisciplinary team (IDT) the next morning. AD indicated the fly swatters had been donated by a resident's family member and she was passing them out to residents that requested them. An interview was conducted with the Maintenance Director on 6/16/22 at 10:25 AM. He stated the contracted pest control company came to the facility monthly. He further stated the pest control tech would inspect the facility for pests and then would spray the chemicals every month. The Maintenance Director indicated the facility and corporate had a plan to install fly lights, and 4 handicap accessible doors for the smoking courtyard. He stated residents in wheelchairs kept the doors open longer to get out the doors to smoke. He stated they currently don't have a timeline for when the doors and fans will be completed because they are searching for a company to do the work. Review of the Pest Control log revealed the pest control tech had sprayed the facility on 5/13/22. An interview was conducted with the Medical Director (MD) on 6/16/22 at 10:45 AM. He stated he saw Resident #1 for a history and physical. He stated Resident #1 had been admitted with [CONDITION(S)] and bilateral chronic nonhealing heel wounds. The MD indicated Resident #1 was admitted to the facility with bilateral unna boots and an order by the Vascular Surgeon not to change the dressings on the heels or the unna boots. The MD stated the Vascular Surgeon had wanted to perform the first dressing change in his office on 5/31/22. The MD stated he never saw the wounds or the dressing change. The MD further stated if maggots were found in the wound at the hospital it would have had to have happened during the dressing change because the unna boot would be very hard to penetrate from the outside. He stated that obviously maggots were not in the wound when the Wound Care Nurse changed the dressing or she would have reported it to me. He indicated maggots were an abnormal finding in a heel wound and should not have been there. An interview was conducted with Unit Manager (UM) for the 700 and 800 halls on 6/16/22 at 1:10 PM. She stated Resident #1 had been on quarantine for 14 days due to his vaccination status. She further stated he was confined to his room and was only off the quarantine hall for 3 days before being discharged to the hospital. She indicated he had gone outside with his family a couple of days before he was discharged . An interview was conducted with the Vascular Surgeon on 6/16/22 at 3:12 PM. He indicated Resident #1 had been a patient of his for a very long time. He stated Resident #1 had chronic wounds on his legs and heels. The Vascular Surgeon further stated he had performed multiple vascular procedures on Resident #1 to increase blood flow to his lower extremities. He stated Resident #1's lower extremities were very swollen with weeping drainage. The Vascular Surgeon further stated he had read in the ER notes that maggots were found in the left heel wound. He stated he did not use medical maggots in his practice. He further stated that if maggots were under the unna boot dressing it had to have occurred during the dressing change. The Vascular Surgeon stated he was unsure if the maggots had caused the wound infection, but they certainly could have contributed to it. The Administrator, Director of Nursing (DON), and Regional Nurse Consultant were notified of Immediate Jeopardy on 6/16/22 at 2:05 PM. On 6/17/22 the facility provided the following credible allegation of Immediate Jeopardy Removal: F925 Recipients who have suffered or are likely to suffer, a serious adverse outcome as a result of the non-compliance. On 06/12/22 at approximately 7:30am Resident #1 had a change in condition, altered mental status, respiratory infection, and was unresponsive to verbal stimuli. The resident was arousable, very agitated, stated he wanted to sleep. The nurse made the physician aware with order to send to the emergency room for evaluation. At 7:44 pm the nurse made attempts to notify the family. On 6/12/2022 at approximately 11:00 pm, the 3-11:00 pm nurse called the hospital to check on the resident. The emergency room nurse stated the resident would receive continuation of care by his vascular surgeon for his bilateral non-healing leg wounds, [CONDITION(S)], [CONDITION(S)], and Chronic Obstructive Pulmonary Disease. The emergency room nurse also communicated that maggots were identified in the resident's left heel wound. The 3-11:00 pm nurse notified the Director of Nursing on the morning of 06/13/2022. On 06/13/2022, the Administrator and Director of Nursing initiated an investigation to determine the root cause of the maggots. There was no fly nor larva observed in the room nor on the resident during the dressing change with the application of the unna boot per physician order. The unna boot is a permeable dressing that is not vacuum sealed. The resident was able to move both lower extremities, was mobile throughout the facility and grounds, as well as had an outing with his family prior to discharge to theER on [DATE].Therefore the facility was unable to determine when or how a fly entered the wound. All resident with wounds are at risk related to non-compliance with maintaining an effective pest control system. On 6/13/2022 the Director of Nursing and the Wound Care Nurse initiated an audit to visualize all current residents with wounds. This audit was to ensure there were no signs and symptoms of worsening of the wound and no larvae in the wound bed. There were no other areas of concern identified during the audit. On 6/16/2022 100% audit of all resident rooms, common areas and all entrances to the facility was completed by the Maintenance Director to identify any concerns related to pest control. There were no other areas of concern identified during the audit. On 06/16/2022, the Maintenance Director contacted the Pest Control Company for additional treatment. On 06/16/2022 the Administrator contacted Support Services to order air curtains for the courtyard doors (completed order 06/17/2022), front entrance, kitchen exit door, and side door leading to the dumpster to aide in the prevention of flies entering the center. Support Services indicated that the air curtains will arrive by approximately 07/20/2022 due to being a special order, with subsequent installation by Support Services after receipt of items. The administrator will oversee the process to ensure timely completion of the receipt and installation of the air curtains. On 06/16/2022 the contracted pest control company arrived and treated the perimeter of the building as well as the perimeter of the internal courtyards with a broadcast spray chemical solution to kill and deter flies. Wall-mounted fly lights were ordered on 06/16/2022 by the pest control company, for the junction of corridors, and near frequently used exit doors. The pest control company indicated the wall mounted fly lights will arrive approximately 06/30/2022 and the Maintenance Director will install the wall mounted fly lights once received. Temporary wall mounted fly traps were mounted by the Maintenance Director at the frequently used exit doors on 06/17/2022. The administrator will oversee the process to ensure timely completion of the receipt and installation of the wall mounted lights. On 06/16/2022 quizzes were initiated with 100% of staff to include part time and contracted staff, by the Staff Development Coordinator regarding what to do if you observe pests to include flies. Quizzes will be completed by 06/17/2022. After 6/16/2022, the Administrator will ensure the quizzes are mailed to any remaining staff who has not worked and not received the quiz with instructions to complete and sign, and return to the staff development coordinator or Director of Nursing prior to next scheduled work shift. Any staff unable to successfully answer the quiz after two attempts will not be allowed to work until further retraining is completed and they are able to answer correctly. Actions taken to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring On 6/16/2022 100% in-service to include part time and contracted staff, was initiated by the Staff Facilitator with the Administrator, Medical Records, Accounts Receivable, Nurses, Nursing Assistants, Housekeeping staff, Social Worker, Accounts Payable, Therapy Staff, Maintenance Staff, receptionist, Medical Records and Supply Clerk in regards to Pest Control to include (1) Prevention of pest control concerns and (2) reporting pest control concerns into the electronic work order system and notification of Administrator, Director of Nursing and the Maintenance Director (3) The process of flies laying eggs and transitioning to maggots. In-services will be completed by 6/17/2022, in-services are mailed to any remaining staff who has not worked and not received the in-service with instructions to review, sign the in-service, and return to the staff facilitator or Director of Nursing prior to next scheduled work shift, no staff member will be allowed to work after 06/17/2022 until education has been completed. On 6/16/2022 an Inservice was initiated, by the Staff Development Coordinator with 100% of all nurses, CNAs, and therapist to include part time and contracted staff regarding observation and reporting of wound concerns to include dressing coming off and larvae observed in a resident's wound bed. In-services will be completed 06/17/2022, the Administrator will ensure the in-services are mailed to any remaining staff who has not worked and not received the in-service with instructions to review, sign the in-service, and return to the staff facilitator or Director of Nursing prior to next scheduled work shift, no staff member will work after 06/17/2022 until education has been completed. Immediate Jeopardy Removal Date-6/18/22 The facility alleges the removal of Immediate Jeopardy on 6/18/22. On 6/20/22 the credible allegation of Immediate Jeopardy removal was validated by onsite verification. Record review and Wound Care Nurse interview verified an audit was completed on 6/13/22 to visualize all current residents with wounds. This audit was to ensure there were no signs or symptoms of worsening of the wound and no larvae in the wound bed. No concerns were identified during the audit. Record review, observation, and interview with the Maintenance Director verified a 100% audit of all resident rooms, common areas and all entrances to the facility was completed on 6/16/22 to identify any concerns related to pest control. Review of the Pest Control company Summary of Service verified the facility was sprayed for flies on 6/16/22 and 20 additional fly lights were ordered and are supposed to be delivered and installed on 6/24/22. Temporary wall mounted fly lights were mounted by the Maintenance Director at the frequently used exit doors on 6/17/22. An observation on 6/20/22 verified the wall mounted fly lights were installed. An Interview with the Administrator verified Support Services were contacted to order air curtains for the courtyard doors, front entrance, kitchen exit door, and side door leading to dumpster to aide in the prevention of flies entering the facility. Review of the Order Summary and Order Confirmation verified the air curtains had been ordered. A review of in-services, and in-service sign in sheets as well as staff interviews verified education was provided to 100% of staff to include part time and contracted staff by the Staff Development Coordinator regarding (1) Prevention of pest control concerns (2) reporting pest control concerns into the electronic work order system and notification of Administrator, Director of Nursing (DON), and the Maintenance Director (3) the process of flies laying eggs and transitioning to maggots. In-services were completed on 6/17/22, in-services are mailed to any remaining staff who has not worked and not received the in-service with instructions to review, sign the in-service, and return to the staff facilitator or Director of Nursing prior to the next scheduled work shift, no staff member will be allowed to work after 6/17/22 until education has been completed. On 6/16/22 an in-service was completed by the Staff Development Coordinator with 100% of all nurses, nurse aides, and therapist to include part time and contracted staff regarding observation and reporting of wound concerns to include dressing coming off and larvae observed in a resident's wound bed. In-services were completed on 6/17/22, the Administrator will ensure the in-services are mailed to any remaining staff who have not worked and not received the in-service with instructions to review, sign, and return to the Staff Facilitator or the DON prior to next scheduled work shift, no staff member will work after 6/17/22 until education is completed. The facility's IJ removal date of 6/18/22 was validated.

Based on record reviews, observations, family interview and staff interviews, the facility neglected to follow manufacturer's guidelines by failing to attach and tighten the leg straps of the facility's mechanical lift around the resident's lower legs and failed to implement care plan and care guide interventions indicating use of 2 person assistance while transferring with the use of mechanical lift(sit to stand) and failed to ensure the resident had on non-skid footwear for 1 of 5 sampled residents reviewed for accidents. Resident #37 slipped during a transfer from the mechanical lift which allowed the lift's straps to slip around the resident ' s neck which caused the resident's face to turn purplish blue in color. Resident #37 was assessed at the facility and found to have no physical injuries. Immediate Jeopardy for Resident # 37 began on 6/23/2018 when the resident slipped while only one staff member was transferring her using a mechanical lift and staff failed to properly secure her to the lift and ensure she was wearing non-skid foot and the lift's straps slipped around the resident's neck causing the resident's face to turn purplish blue. Immediate Jeopardy was remove on 8/2/2018 when the facility provided an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity of D (not actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to allow for ongoing in- servicing or monitoring to be accomplished. The findings included: A review of the manufacturer's manual instructions for the mechanical lift used at the facility, dated (MONTH) 2013, included the following instructions: Position the mechanical lift and adjust the width of the base, so that the patient's feet can be centered on the footrest. The lower legs (below the knees) should be parallel to the lower-leg on the lift. Adjust the horizontal and vertical position of the pad for comfortable resistance just below the kneecaps. Attach and tighten the strap around the lower legs. Resident # 37 was admitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident # 37' s cognition had been severely impaired and she had required extensive assistance of one person for bed mobility. Resident #37 had been totally dependent with the assistance of 2 staff for transfers, dressing and toileting. The MDS indicated Resident #37 was not steady when moving from a seated position to a standing position and was only able to stabilize with staff assistance. The MDS indicated Resident #37 was not steady when moving on and off the toilet and had only been able to stabilize with staff assistance. The MDS indicated Resident #37 had no trial of a toileting program and she had been frequently incontinent of her bowels and bladder. Resident # 37's care plan, dated 5/23/2018 indicated Resident # 37 required assistance for mobility due to the aging process, short and long term memory deficits, physical limitations/non-ambulatory, weakness, unsteady balance during transitions. The interventions included the following: monitor for safety awareness, transfers using mechanical lift (sit to stand lift) with aid of 2 persons, report to nurse any decrease in ability to transfer safely and monitor for safety awareness A review of Resident #37's current Care Guide dated 5/23/2018 indicated the following: the resident required Activity of Daily Living (ADL) care, may require 2 person assist with toileting. Transfers: mechanical lift (sit to stand lift; vest size - L) with 2 person assist. The resident required non-skid footwear. A review of a nurse's note, dated 6/23/2018 and written by Nurse # 1, indicated Resident # 37 exhibited difficulty standing with a sit-to-stand lift per staff interview; 3 staff members assisted Resident # 37 onto the toilet when her feet slipped off mechanical lift. A review of the facility's incident log for Resident # 37 revealed no incident report had been completed after the 6/23/2018 incident. During an interview with Resident #37's Responsible Party (RP) on 7/31/2018 at 2:00 PM, the RP reported on 6/23/2018 he came to visit Resident #37 and found her almost choked on the mechanical lift ' s straps. The RP indicated another nursing assistant (NA), NA #3, had been asked to come to Resident #37's room and assisted in getting her safely down to the bathroom floor or toilet seat. The RP reported he had been concerned about Resident #37's safety while being transferred on a mechanical lift. He further indicated the staff did not follow the guidelines as required while using the mechanical lift because he had noticed on the day of the accident she had been transferred by one nurse aide instead of two. The RP further reported Resident #37 had not been wearing shoes or nonskid socks per the care guide and the strap around the lower legs had not been applied. During an interview with NA #1 on 8/1/2018 at 10:00 AM, NA # 1 reported she had been assigned to work with Resident # 37 on 6/23/2018. She indicated before lunch, she had been transferring the resident from the bed to the toilet with the sit-to-stand (mechanical lift) by herself. NA #1 reported Resident #37 started to slip from the lift before getting on the toilet. NA# 1 stated a family member had arrived for a visit and found Resident #37 had slipped from the mechanical lift. NA #1 stated the RP had started to assist to keep her from falling but had been unable to stop the resident from slipping and the strap from getting caught at the resident ' s neck. NA # 1 stated she left Resident # 37 on the lift in the bathroom to get more help from another staff member who had been in another resident ' s room at the end of the hall. NA #1 stated Medication Aide (MA) # 1 also came by the resident ' s bathroom but stood by the resident ' s room waiting for additional assistance to get the resident off the mechanical lift. NA #1 stated prior to the incident she had been in a panic to get Resident # 37 to the bathroom before the family ' s visit. She further added the family of Resident #37 had wanted Resident # 37 up in the mornings and she had no other person to ask for assistance. NA #1 added the day the resident had the accident the facility had been short of staff and she could not find anyone to assist her with transferring Resident # 37 on the mechanical lift. NA #1 stated Resident #37 is always dancing (unsteady while standing) while being transferred on the mechanical lift, making it a more difficult transfer. During an interview with NA #2 on 8/1/2018 at 10:20 AM, NA # 2 stated he came down to Resident # 37's room after he finished giving care to another patient. He had been told he needed to help Resident # 37 who had been left dangling from the mechanical lift. NA #2 indicated once he had arrived at Resident # 37's bathroom, he had noticed the resident ' s face was purplish blue and the lift ' s straps were by the resident ' s neck. NA # 2 reported he did not recall whether Resident # 37 ' s knees were touching the floor or not because everything had happened so fast. He further indicated the resident head was tilted towards the front of her body. NA # 2 stated after he had assisted the resident to a seated position on the toilet the resident ' s color in her face returned to normal. NA # 2 stated the resident ' s family member had been in the room but had not assisted with getting the resident off the mechanical lift. NA #2 added NA # 1 assisted him with getting Resident # 37 off the lift. He indicated Nurse # 1 assessed Resident # 37 after the resident had been removed from the mechanical lift and had been placed on the toilet. During an interview with MA #1 on 8/1/2018 at 10: 30 AM, MA # 1 stated NA # 1 had come out of Resident # 37's room and stated she needed help. MA #1 stated she had entered Resident # 37's room and she noticed the resident had been on the lift and had slipped down with her feet off the platform of the lift. MA # 1 indicated she had been waiting for NA # 1 to get more help as the patient had been constantly slipping. MA #1 added the resident ' s face had turned red in color as she slid down the lift. MA # 1 indicated the strap had slipped by the resident ' s neck. During an interview with Nurse #1 on 8/1/2018 at 11:10 AM, Nurse # 1 stated she had been assigned to care for Resident #37 on 6/23/2018. Nurse #1 stated NA # 1 reported to her they had difficulty during the transfer of Resident #37 from the bed to the toilet using the mechanical lift. Nurse #1 stated Resident # 37 had slid off the lift because the staff failed to use the leg straps and nonskid socks or shoes which caused the resident to slip some from the lift. Nurse #1 reported NA # 1 had been using the lift with no assistance. She further stated she had expected the NA # 1 to have asked for assistance when using the lift. She indicated the lift required 2 persons. Nurse # 1 stated the use of nonskid socks or shoes had always been required to prevent residents ' feet from slipping off the lift but they had not been used by NA # 1. Nurse #1 stated she had also felt the sit to stand lift was not appropriate for Resident # 37. Nurse # 1 indicated she had assessed Resident #37 after she had been transferred to the toilet by the NA's and stated she did not notice any injury to Resident #37. Nurse # 1 indicated she did not report the incident to the physician or the Director of Nursing (DON) because she did not think of Resident # 37's slip on the mechanical lift as an incident or accident. Nurse #1 stated in looking back at what had happened to the resident, she should have reported the incident to the physician, DON and completed an incident report. During an interview with the Physician on 8/1/2018 at 11:30 AM, the Physician indicated he had not been made aware of Resident #37's incident on 6/23/2018. The physician indicated his expectation would have been for the facility staff to have notified him of the incident emphasizing especially if the resident had turned purple blue during the incident. During an interview with the MDS nurse on 8/2/2018 at 9:30 AM, the MDS nurse reported Resident #37 had history of being unstable while being transferred on a sit to stand lift because her legs had been buckling (both of knees give out). The MDS nurse stated the family had insisted on the use of the sit to stand lift even though the staff at the facility had been aware it had not been appropriate for Resident # 37. During an observation of a mechanical lift transfer made on 8/2/2018 at 10:30 AM, Resident # 37's appeared confused with the instructions given her by NA # 4 to grasp the mechanical lift ' s sling bar. Resident # 37 had been noticed to be unsteady while standing on the lift. During an interview with NA #4 on 8/2/2018 at 10:40 AM, NA# 4 reported Resident #37 had been unstable while on the lift but she had been transferred using the sit to stand lift for a long time. NA #4 indicated Resident # 37 had usually been assisted to the toilet before breakfast and lunch. During the interview with the Staff Development Coordinator (SDC) on 8/2/2018 at 11:30 AM, the SDC stated NA # 2 reported to her, during the 08/01/2018 investigation of the incident involving Resident #37, when he had been asked to assist with Resident # 37 on 6/23/2018, she had seen the resident's face turned purple blue and the resident ' s veins bulged on her neck while she dangled on the mechanical lift. The SDC indicated she had thought a supervisor had investigated the incident after it happened on 6/23/2018 as she had overheard a conversation about the incident around the time it happened. She added she could not recall the exact date or the name of the supervisor. The SDC stated she had not been the SDC at the time of Resident # 37 ' s mechanical ' s lift accident. During an interview with the DON on 8/2/2018 at 12:30 PM, the DON reported she had not been aware of Resident #37's incident of 6/23/2018 when the resident had slipped off the lift. The DON indicated her expectation of nursing staff would have been to have completed an incident report so she could have started an in-service training on the proper use of a mechanical lift. During an interview with the Administrator on 8/2/2018 at 12:40 PM, the Administrator reported he had just learned about the incident of Resident #37's slip off the mechanical lift. The Administrator stated his expectation would have been for the staff to have reported the accident to the DON immediately so they could have begun an in-service on the proper use of the mechanical lift. The Administrator, Director of Nursing and Facility ' s nurse consultant were notified of the Immediate Jeopardy on 8/1/2018 at 4:30 pm. On 8/2/2018 the facility provided an acceptable credible allegation for immediate jeopardy removal that included the following: Corrective Actions On 8/1/18, interviews were initiated by the Social Workers with all alert and oriented residents. The resident concern process will be followed by the social worker and Administrator for all identified areas of concern by 8/2/18. On 8/1/18, a transfer observation of 100% of all residents to include resident # 37 utilizing mechanical lifts was initiated by the Minimum Data Set (MDS) coordinator, MDS nurses and therapy manager. The purpose of the observation is to ensure that the resident ' s current mechanical lift use is the safest method of transfer. The audit will be completed by 8/2/18. The MDS coordinator will re-evaluate the resident transfer method, update the resident care plan and care guide, and complete a therapy referral by 8/2/18 for any identified areas of safety concerns observed during the audit. On 8/1/18, a questionnaire was initiated with 100% of all nurses and nursing assistants by the Quality Improvement (QI) nurse. This questionnaire will be completed by 8/2/18. The MDS coordinator will re-evaluate the resident transfer method, update the resident care plan and care guide, and complete a therapy referral by 8/2/18 for any identified areas of safety concerns expressed during the questionnaire. After 8/2/18, all nurses and nursing assistants that have not completed the questionnaire will not be allowed to work until the questionnaire is completed. On 8/1/18, return demonstrations of mechanical lift transfer was initiated with 100% of all nurses and nursing assistants by the Staff Facilitator. The purpose of the return demonstrations are to ensure that staff are checking the resident care guide for the correct number of person to utilize for transfers and that the mechanical lift is being utilized per manufacture specifications during the transfer. After, 8/2/18, all nurses and nursing assistants that have not completed the return demonstration will not be allowed to work until the return demonstration is completed. On 8/1/18 an audit of all resident ' s incident reports to include resident # 37 from 6/23/18 to 8/1/18 was initiated by the MDS nurses and the treatment nurse to ensure all incidents have been thoroughly investigated to determine the root cause and appropriate interventions initiated to prevent further incidents. This audit will be completed by 8/2/18. The QI nurse will investigate the incident, implement interventions, and update the resident care plan and care guide by 8/2/18 for all identified areas of concern. On 8/1/18 an audit of all resident ' s progress notes to include resident # 37 from 6/23/18 to 8/1/18 was initiated by the QI nurse and the Registered Nurse (RN) supervisor to ensure that all documented incidents have an incident report, was investigated to determine the root cause and appropriate interventions were implemented to prevent further incidents. This audit will be completed by 8/2/18. The QI nurse will investigate the incident, implement interventions, and update the resident care plan and care guide by 8/2/18 for all identified areas of concern. On 8/01/18, an in-service was initiated for 100% of all staff to include nurses, nursing assistants, housekeeping, dietary, therapy, maintenance, pay roll, book keeper, social workers, was initiated by the Staff Facilitator regarding Neglect to include examples of neglect and prevention of neglect. This in-service was completed by 8/02/18. After 8/2/18, all staff to include nurses, nursing assistants, housekeeping, dietary, therapy, maintenance, pay roll, book keeper, social workers that have not worked and/or not received the in-services will be mailed the in-service via certified mail by the Payroll Bookkeeper. Instructions will be included in the in-service packet to read, sign the in-service, call the Staff Facilitator or Director of Nursing with any questions, and return the signed in-service to the Staff Facilitator or Director of Nursing prior to next schedule shift. Staff will not be permitted to work until the signed in services are received. On 8/1/18 an in-service was initiated by the Staff Facilitator with 100% of all nurses and nursing assistants regarding the safe handling and movement policy. This in-service included reading the resident care guide to identify the number of person required for resident transfer, reporting to the nurse when a transfer method is no longer safe, lowering the resident and not leaving the resident when sliding in the lift and how to safely strap and transfer resident in the mechanical lift per the manufacture specifications. The manufacture specification will be printed by the Staff Facilitator and reviewed with staff during the in-service. This in-service will be completed by 8/2/18. After 8/2/18, all nurses and nursing assistants that have not worked and/or not received the in-services will be mailed via certified mail by the Payroll Bookkeeper. Instructions will be included in the in-service packet to read, sign the in-service, call the Staff Facilitator or Director of Nursing with any questions, and return the signed in-service to the Staff Facilitator or Director of Nursing prior to next schedule shift. Staff will not be permitted to work until the signed in services are received. The Administrator, Director of Nursing, and Quality Improvement nurse was in serviced on the process of investigating incidents on 8/1/18 by the Facility Nurse Consultant. The in-service included to review the incident reports 5 days per week, how to pull a report from the risk management portal in the electronic records to identify incidents that have been documented by the nurses, printing the incident reports from the electronic records, flagging the incident for follow up, reading progress notes to identify all incidents, discussing incidents in the clinical morning meetings, determining the root cause of the incident, completion of incident reports, and implementing and monitoring interventions. An in-service was completed with the Director of Nursing on 8/2/18 regarding requirements for re -evaluating residents for change in transfer methods by the Facility Nurse Consultant. On 8/1/18 an in-service was initiated by the Staff Facilitator with 100% of all nurses regarding completion of incident reports and collecting witness statements. After 8/2/18, all nurses that has not worked and/or not received the in-service will be mailed the in-service via certified mail by the Payroll Bookkeeper. Instructions will be included in the in-service packet to read, sign the in-service, call the Staff Facilitator or Director of Nursing with any questions, and return the signed in-service to the Staff Facilitator or Director of Nursing prior to next schedule shift. Staff will not be permitted to work until the signed in services are received. The decision to monitor the system for prevention of accidents was made on 8/1/2018 by the Administrator and Director of Nursing. The RN Supervisor, the Staff Facilitator, Treatment nurse, Unit Facilitator and/or the QI nurses, will audit 10% of all residents requiring mechanical lifts for transfers to include resident # 37 to ensure staff are checking the resident care guide and utilizing the number of person identified on the care guide, staff are utilizing the mechanical lift per manufacture specification during the transfer, and ensure the current lift is the safest method of transfer 3 x a week for four weeks, then weekly for x 4 weeks, then monthly x 1 month utilizing a Lift Transfer Audit Tool. Any areas of concern will be immediately addressed by the RN Supervisor, the Staff Facilitator, the Unit Facilitator and/or the QI nurses to include staff retraining. The Director of Nursing will review and initial the Lift Transfer Audit Tools weekly x 8 weeks then monthly x 1 month. The Registered Nurse (RN) Supervisor, the Staff Facilitator, Treatment nurse, Unit Facilitator and/or the QI nurses will review all incidents reports and progress notes 3 x a week for 4 weeks, then weekly for x 4 weeks, then monthly x 1 month utilizing the Incident Audit Tool to ensure all identified incidents have been thoroughly investigated, incidents reports completed, and appropriate interventions implemented to prevent further accidents. The RN Supervisor, the Staff Facilitator, Treatment nurse, Unit Facilitator and/or the QI nurses will investigate the incident, implement interventions, and provide retraining for all identified areas of concern during the audit. The Director of Nursing will review and initial the Incident Audit Tool weekly x 8 weeks then monthly x 1 month. The Quality Improvement Organization will be contacted by the Director of Nursing on 8/02/18 for assistance in evaluation of specific steps to be taken to address neglect and prevention of accidents and training, staff position/title designated to be responsible for the steps, timeline for accomplishment of the steps, specific methodology to be used to evaluate the plan ' s success, and frequency of monitoring the effects of the plan initiation. The DON will present the findings of the Lift Transfer Audit Tools and the Incident Audit Tools to the Executive Quality Assurance (QA) committee monthly for 3 months. The Executive QA Committee will meet monthly for 3 months and review the Lift Transfer Audit Tools and the Incident Audit Tools to determine trends and/or issues that may need further interventions put into place and to determine the need for further frequency of monitoring. The decision to review the monitoring of prevention of accidents during the quality assurance committee meeting was made by the Administrator and Director of Nursing on 8/01/2018. Final date of compliance is 8/02/2018. The Administrator and DON will be responsible for the implementation of corrective actions to include all 100% audits, in services, and monitoring related to the plan of correction. The Credible Allegation for Immediate Jeopardy removal was validated on 8/2/2018, which removed the Immediate Jeopardy on 8/2/2018. During the Immediate Jeopardy removal validation process interviews were conducted with nursing staff present in the facility on 8/2/2018. The staff confirmed the recent in- services and training of the proper use of Mechanical lift. Reviews of the in-service records, audit tools, audits performed and facility assessments were made. Observations of residents' transfers were completed.

Based on record reviews, observations, family interview, physician interview and staff interviews, the facility failed to attach and tighten the mechanical lift's leg straps around the lower legs per manufacturer's guidelines and failed to implement care plan and care guide interventions indicating use of 2 person assistance while transferring with the use of mechanical lift (sit to stand) and failed to ensure the resident had on non-skid footwear for 1 of 5 sampled residents reviewed for accidents. Resident #37 slipped during a transfer from the mechanical lift which allowed the lift's straps to slip around the resident's neck which caused the resident's face to turn purplish blue in color. Resident #37 was assessed at the facility and found to have no physical injuries. Immediate Jeopardy for Resident # 37 began on 6/23/2018 when the resident slipped while only one staff member was transferring her using a mechanical lift and staff failed to properly secure her to the lift and ensure she was wearing non-skid foot and the lift ' s straps slipped around the resident ' s neck causing the resident ' s face to turn purplish blue. Immediate Jeopardy was remove on 8/2/2018 when the facility provided an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a scope and severity of D (not actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to allow for ongoing in- servicing or monitoring to be accomplished. The findings included: A review of the manufacturer' s manual instructions for the mechanical lift used at the facility, dated (MONTH) 2013, included the following instructions: Position the mechanical lift and adjust the width of the base, so that the patient's feet can be centered on the footrest. The lower legs (below the knees) should be parallel to the lower-leg on the lift. Adjust the horizontal and vertical position of the pad for comfortable resistance just below the kneecaps. Attach and tighten the strap around the lower legs. Resident # 37 was admitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), dated [DATE], indicated Resident # 37's cognition had been severely impaired and she had required extensive assistance of one person for bed mobility. Resident #37 had been totally dependent with the assistance of 2 staff for transfers, dressing and toileting. The MDS indicated Resident #37 was not steady when moving from a seated position to a standing position and was only able to stabilize with staff assistance. The MDS indicated Resident #37 was not steady when moving on and off the toilet and had only been able to stabilize with staff assistance. The MDS indicated Resident #37 had no trial of a toileting program and she had been frequently incontinent of her bowels and bladder. Resident # 37's care plan, dated 5/23/2018 indicated Resident # 37 required assistance for mobility due to the aging process, short and long term memory deficits, physical limitations/non-ambulatory, weakness, unsteady balance during transitions. The interventions included the following: monitor for safety awareness, transfers using mechanical lift (sit to stand lift) with aid of 2 persons, report to nurse any decrease in ability to transfer safely and monitor for safety awareness A review of Resident #37's current Care Guide dated 5/23/2018 indicated the following: the resident required Activity of Daily Living (ADL) care, may require 2 person assist with toileting. Transfers: mechanical lift (sit to stand lift; vest size - L) with 2 person assist. The resident required non-skid footwear. A review of a nurse's note, dated 6/23/2018 and written by Nurse # 1, indicated Resident # 37 exhibited difficulty standing with a sit-to-stand lift per staff interview; 3 staff members assisted Resident # 37 onto the toilet when her feet slipped off mechanical lift. A review of the facility ' s incident log for Resident # 37 revealed no incident report had been completed after the 6/23/2018 incident. During an interview with Resident #37 ' s Responsible Party (RP) on 7/31/2018 at 2:00 PM, the RP reported on 6/23/2018 he came to visit Resident #37 and found her almost choked on the mechanical lift's straps. The RP indicated another nursing assistant (NA), NA #3, had been asked to come to Resident #37's room and assisted in getting her safely down to the bathroom floor or toilet seat. The RP reported he had been concerned about Resident #37 ' s safety while being transferred on a mechanical lift. He further indicated the staff did not follow the guidelines as required while using the mechanical lift because he had noticed on the day of the accident she had been transferred by one nurse aide instead of two. The RP further reported Resident #37 had not been wearing shoes or nonskid socks per the care guide and the strap around the lower legs had not been applied. During an interview with NA #1 on 8/1/2018 at 10:00 AM, NA # 1 reported she had been assigned to work with Resident # 37 on 6/23/2018. She indicated before lunch, she had been transferring the resident from the bed to the toilet with the sit-to-stand (mechanical lift) by herself. NA #1 reported Resident #37 started to slip from the lift before getting on the toilet. NA# 1 stated a family member had arrived for a visit and found Resident #37 had slipped from the mechanical lift. NA #1 stated the RP had started to assist to keep her from falling but had been unable to stop the resident from slipping and the strap from getting caught at the resident's neck. NA # 1 stated she left Resident # 37 on the lift in the bathroom to get more help from another staff member who had been in another resident's room at the end of the hall. NA #1 stated Medication Aide (MA) # 1 also came by the resident's bathroom but stood by the resident ' s room waiting for additional assistance to get the resident off the mechanical lift. NA #1 stated prior to the incident she had been in a panic to get Resident # 37 to the bathroom before the family ' s visit. She further added the family of Resident #37 had wanted Resident # 37 up in the mornings and she had no other person to ask for assistance. NA #1 added the day the resident had the accident the facility had been short of staff and she could not find anyone to assist her with transferring Resident # 37 on the mechanical lift. NA #1 stated Resident #37 is always dancing (unsteady while standing) while being transferred on the mechanical lift, making it a more difficult transfer. During an interview with NA #2 on 8/1/2018 at 10:20 AM, NA # 2 stated he came down to Resident # 37's room after he finished giving care to another patient. He had been told he needed to help Resident # 37 who had been left dangling from the mechanical lift. NA #2 indicated once he had arrived at Resident # 37 ' s bathroom, he had noticed the resident ' s face was purplish blue and the lift ' s straps were by the resident ' s neck. NA # 2 reported he did not recall whether Resident # 37 ' s knees were touching the floor or not because everything had happened so fast. He further indicated the resident head was tilted towards the front of her body. NA # 2 stated after he had assisted the resident to a seated position on the toilet the resident ' s color in her face returned to normal. NA # 2 stated the resident ' s family member had been in the room but had not assisted with getting the resident off the mechanical lift. NA #2 added NA # 1 assisted him with getting Resident # 37 off the lift. He indicated Nurse # 1 assessed Resident # 37 after the resident had been removed from the mechanical lift and had been placed on the toilet. During an interview with MA #1 on 8/1/2018 at 10: 30 AM, MA # 1 stated NA # 1 had come out of Resident # 37's room and stated she needed help. MA #1 stated she had entered Resident # 37's room and she noticed the resident had been on the lift and had slipped down with her feet off the platform of the lift. MA # 1 indicated she had been waiting for NA # 1 to get more help as the patient had been constantly slipping. MA #1 added the resident ' s face had turned red in color as she slid down the lift. MA # 1 indicated the strap had slipped by the resident ' s neck. During an interview with Nurse #1 on 8/1/2018 at 11:10 AM, Nurse # 1 stated she had been assigned to care for Resident #37 on 6/23/2018. Nurse #1 stated NA # 1 reported to her they had difficulty during the transfer of Resident #37 from the bed to the toilet using the mechanical lift. Nurse #1 stated Resident # 37 had slid off the lift because the staff failed to use the leg straps and nonskid socks or shoes which caused the resident to slip some from the lift. Nurse #1 reported NA # 1 had been using the lift with no assistance. She further stated she had expected the NA # 1 to have asked for assistance when using the lift. She indicated the lift required 2 persons. Nurse # 1 stated the use of nonskid socks or shoes had always been required to prevent residents' feet from slipping off the lift but they had not been used by NA # 1. Nurse #1 stated she had also felt the sit to stand lift was not appropriate for Resident # 37. Nurse # 1 indicated she had assessed Resident #37 after she had been transferred to the toilet by the NA's and stated she did not notice any injury to Resident #37. Nurse # 1 indicated she did not report the incident to the physician or the Director of Nursing (DON) because she did not think of Resident # 37 ' s slip on the mechanical lift as an incident or accident. Nurse #1 stated in looking back at what had happened to the resident, she should have reported the incident to the physician, DON and completed an incident report. During an interview with the Physician on 8/1/2018 at 11:30 AM, the Physician indicated he had not been made aware of Resident #37's incident on 6/23/2018. The physician indicated his expectation would have been for the facility staff to have notified him of the incident emphasizing especially if the resident had turned purple blue during the incident. During an interview with the MDS nurse on 8/2/2018 at 9:30 AM, the MDS nurse reported Resident #37 had history of being unstable while being transferred on a sit to stand lift because her legs had been buckling (both of knees give out). The MDS nurse stated the family had insisted on the use of the sit to stand lift even though the staff at the facility had been aware it had not been appropriate for Resident # 37. During an observation of a mechanical lift transfer made on 8/2/2018 at 10:30 AM, Resident # 37's appeared confused with the instructions given her by NA # 4 to grasp the mechanical lift' s sling bar. Resident # 37 had been noticed to be unsteady while standing on the lift. During an interview with NA #4 on 8/2/2018 at 10:40 AM, NA# 4 reported Resident #37 had been unstable while on the lift but she had been transferred using the sit to stand lift for a long time. NA #4 indicated Resident # 37 had usually been assisted to the toilet before breakfast and lunch. During the interview with the Staff Development Coordinator (SDC) on 8/2/2018 at 11:30 AM, the SDC stated NA # 2 reported to her, during the 08/01/2018 investigation of the incident involving Resident #37, when he had been asked to assist with Resident # 37 on 6/23/2018, she had seen the resident ' s face turned purple blue and the resident ' s veins bulged on her neck while she dangled on the mechanical lift. The SDC indicated she had thought a supervisor had investigated the incident after it happened on 6/23/2018 as she had overheard a conversation about the incident around the time it happened. She added she could not recall the exact date or the name of the supervisor. The SDC stated she had not been the SDC at the time of Resident # 37's mechanical ' s lift accident. During an interview with the DON on 8/2/2018 at 12:30 PM, the DON reported she had not been aware of Resident #37 ' s incident of 6/23/2018 when the resident had slipped off the lift. The DON indicated her expectation of nursing staff would have been to have completed an incident report so she could have started an in-service training on the proper use of a mechanical lift. During an interview with the Administrator on 8/2/2018 at 12:40 PM, the Administrator reported he had just learned about the incident of Resident #37's slip off the mechanical lift. The Administrator stated his expectation would have been for the staff to have reported the accident to the DON immediately so they could have begun an in-service on the proper use of the mechanical lift. The Administrator, Director of Nursing and Facility's nurse consultant were notified of the Immediate Jeopardy on 8/1/2018 at 4:30 pm. On 8/2/2018 the facility provided an acceptable credible allegation for immediate jeopardy removal that included the following: Corrective Actions: On 8/01/18, interviews were initiated by the Social Workers with all alert and oriented residents. The resident concern process will be followed by the social worker and Administrator for all identified areas of concern by 8/2/18. On 8/1/18, a transfer observation of 100% of all residents to include resident # 37 utilizing mechanical lifts was initiated by the Minimum Data Set (MDS) coordinator, MDS nurses and therapy manager. The purpose of the observation is to ensure that the resident ' s current mechanical lift use is the safest method of transfer. The audit will be completed by 8/2/18. The MDS coordinator will re-evaluate the resident transfer method, update the resident care plan and care guide, and complete a therapy referral by 8/2/18 for any identified areas of safety concerns observed during the audit. On 8/1/18, a questionnaire was initiated with 100% of all nurses and nursing assistants by the Quality Improvement (QI) nurse. This questionnaire will be completed by 8/2/18. The MDS coordinator will re-evaluate the resident transfer method, update the resident care plan and care guide, and complete a therapy referral by 8/2/18 for any identified areas of safety concerns expressed during the questionnaire. After 8/2/18, all nurses and nursing assistants that have not completed the questionnaire will not be allowed to work until the questionnaire is completed. On 8/1/18, return demonstrations of mechanical lift transfer was initiated with 100% of all nurses and nursing assistants by the Staff Facilitator. The purpose of the return demonstrations are to ensure that staff are checking the resident care guide for the correct number of person to utilize for transfers and that the mechanical lift is being utilized per manufacture specifications during the transfer. After, 8/2/18, all nurses and nursing assistants that have not completed the return demonstration will not be allowed to work until the return demonstration is completed. On 8/1/18 an audit of all resident's incident reports to include resident # 37 from 6/23/18 to 8/1/18 was initiated by the MDS nurses and the treatment nurse to ensure all incidents have been thoroughly investigated to determine the root cause and appropriate interventions initiated to prevent further incidents. This audit will be completed by 8/2/18. The QI nurse will investigate the incident, implement interventions, and update the resident care plan and care guide by 8/2/18 for all identified areas of concern. On 8/1/18 an audit of all resident's progress notes to include resident # 37 from 6/23/18 to 8/1/18 was initiated by the QI nurse and the Registered Nurse (RN) supervisor to ensure that all documented incidents have an incident report, was investigated to determine the root cause and appropriate interventions were implemented to prevent further incidents. This audit will be completed by 8/2/18. The QI nurse will investigate the incident, implement interventions, and update the resident care plan and care guide by 8/2/18 for all identified areas of concern. On 8/01/18, an in-service was initiated for 100% of all staff to include nurses, nursing assistants, housekeeping, dietary, therapy, maintenance, pay roll, book keeper, social workers, was initiated by the Staff Facilitator regarding Neglect to include examples of neglect and prevention of neglect. This in-service was completed by 8/02/18. After 8/2/18, all staff to include nurses, nursing assistants, housekeeping, dietary, therapy, maintenance, pay roll, book keeper, social workers that have not worked and/or not received the in-services will be mailed the in-service via certified mail by the Payroll Bookkeeper. Instructions will be included in the in-service packet to read, sign the in-service, call the Staff Facilitator or Director of Nursing with any questions, and return the signed in-service to the Staff Facilitator or Director of Nursing prior to next schedule shift. Staff will not be permitted to work until the signed in services are received. On 8/1/18 an in-service was initiated by the Staff Facilitator with 100% of all nurses and nursing assistants regarding the safe handling and movement policy. This in-service included reading the resident care guide to identify the number of person required for resident transfer, reporting to the nurse when a transfer method is no longer safe, lowering the resident and not leaving the resident when sliding in the lift and how to safely strap and transfer resident in the mechanical lift per the manufacture specifications. The manufacture specification will be printed by the Staff Facilitator and reviewed with staff during the in-service. This in-service will be completed by 8/2/18. After 8/2/18, all nurses and nursing assistants that have not worked and/or not received the in-services will be mailed via certified mail by the Payroll Bookkeeper. Instructions will be included in the in-service packet to read, sign the in-service, call the Staff Facilitator or Director of Nursing with any questions, and return the signed in-service to the Staff Facilitator or Director of Nursing prior to next schedule shift. Staff will not be permitted to work until the signed in services are received. The Administrator, Director of Nursing, and Quality Improvement nurse was in serviced on the process of investigating incidents on 8/1/18 by the Facility Nurse Consultant. The in-service included to review the incident reports 5 days per week, how to pull a report from the risk management portal in the electronic records to identify incidents that have been documented by the nurses, printing the incident reports from the electronic records, flagging the incident for follow up, reading progress notes to identify all incidents, discussing incidents in the clinical morning meetings, determining the root cause of the incident, completion of incident reports, and implementing and monitoring interventions. An in-service was completed with the Director of Nursing on 8/2/18 regarding requirements for re -evaluating residents for change in transfer methods by the Facility Nurse Consultant. On 8/1/18 an in-service was initiated by the Staff Facilitator with 100% of all nurses regarding completion of incident reports and collecting witness statements. After 8/2/18, all nurses that has not worked and/or not received the in-service will be mailed the in-service via certified mail by the Payroll Bookkeeper. Instructions will be included in the in-service packet to read, sign the in-service, call the Staff Facilitator or Director of Nursing with any questions, and return the signed in-service to the Staff Facilitator or Director of Nursing prior to next schedule shift. Staff will not be permitted to work until the signed in services are received. The decision to monitor the system for prevention of accidents was made on 8/1/2018 by the Administrator and Director of Nursing. The RN Supervisor, the Staff Facilitator, Treatment nurse, Unit Facilitator and/or the QI nurses, will audit 10% of all residents requiring mechanical lifts for transfers to include resident # 37 to ensure staff are checking the resident care guide and utilizing the number of person identified on the care guide, staff are utilizing the mechanical lift per manufacture specification during the transfer, and ensure the current lift is the safest method of transfer 3 x a week for four weeks, then weekly for x 4 weeks, then monthly x 1 month utilizing a Lift Transfer Audit Tool. Any areas of concern will be immediately addressed by the RN Supervisor, the Staff Facilitator, the Unit Facilitator and/or the QI nurses to include staff retraining. The Director of Nursing will review and initial the Lift Transfer Audit Tools weekly x 8 weeks then monthly x 1 month. The Registered Nurse (RN) Supervisor, the Staff Facilitator, Treatment nurse, Unit Facilitator and/or the QI nurses will review all incidents reports and progress notes 3 x a week for 4 weeks, then weekly for x 4 weeks, then monthly x 1 month utilizing the Incident Audit Tool to ensure all identified incidents have been thoroughly investigated, incidents reports completed, and appropriate interventions implemented to prevent further accidents. The RN Supervisor, the Staff Facilitator, Treatment nurse, Unit Facilitator and/or the QI nurses will investigate the incident, implement interventions, and provide retraining for all identified areas of concern during the audit. The Director of Nursing will review and initial the Incident Audit Tool weekly x 8 weeks then monthly x 1 month. The Quality Improvement Organization will be contacted by the Director of Nursing on 8/02/18 for assistance in evaluation of specific steps to be taken to address neglect and prevention of accidents and training, staff position/title designated to be responsible for the steps, timeline for accomplishment of the steps, specific methodology to be used to evaluate the plan ' s success, and frequency of monitoring the effects of the plan initiation. The DON will present the findings of the Lift Transfer Audit Tools and the Incident Audit Tools to the Executive Quality Assurance (QA) committee monthly for 3 months. The Executive QA Committee will meet monthly for 3 months and review the Lift Transfer Audit Tools and the Incident Audit Tools to determine trends and/or issues that may need further interventions put into place and to determine the need for further frequency of monitoring. The decision to review the monitoring of prevention of accidents during the quality assurance committee meeting was made by the Administrator and Director of Nursing on 8/01/2018. Final date of compliance is 8/02/2018. The Administrator and DON will be responsible for the implementation of corrective actions to include all 100% audits, in services, and monitoring related to the plan of correction. The Credible Allegation for Immediate Jeopardy removal was validated on 8/2/2018, which removed the Immediate Jeopardy on 8/2/2018. During the Immediate Jeopardy removal validation process interviews were conducted with nursing staff present in the facility on 8/2/2018. The staff confirmed the recent in- services and training of the proper use of Mechanical lift. Reviews of the in-service records, audit tools, audits performed and facility assessments were made. Observations of residents' transfers were completed.

Based on record reviews, observations, staff interviews, the facility failed to provide an assessment for safe smoking and smoking education to 1 of 7 sampled residents (#122) who smoked and utilized oxygen therapy, and failed to assess 6 of 6 sampled residents (#16, #125, #182, #59, #85, #212) on the smokers list for safe smoking to prevent accidents. Resident #122 was not harmed during the potentially hazardous incident and she remained at the facility. Immediate jeopardy began on 07/05/17 when Resident #122 went outside with her oxygen tank connected to back of her wheelchair with a cigarette and lighter in hand and had not been assessed for safe smoking or educated by staff on the dangers of smoking while using oxygen since her admission to the facility. Immediate jeopardy was removed on 09/22/17 at 9:48 AM when the facility provided and implemented an acceptable allegation of compliance. 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. Examples #2, #3, #4, #5, #6, and #7 are cited at no actual harm with potential for more than minimal harm that is not immediate jeopardy at the scope and severity of (E). The findings included: Review of the facility's Smoking Policy dated on 10/03/11 read in part It is the responsibility of Premier Nursing & Rehabilitation Center to ensure a safe environment for all Residents. Premier Nursing & Rehabilitation Center is a SMOKE FREE campus, this includes electronic cigarettes. If you are an individual who smokes and you are alert and oriented, you will be evaluated by staff and deemed safe to smoke off the premises. It is required that the resident must sign themselves out of the facility each time they go outdoors to smoke. All smoking paraphernalia must be locked up by nursing staff. Absolutely no paraphernalia is to be kept in the resident's room at any time. Staff is not permitted to assist with smoking. Failure to comply with this policy will result in discharge from the facility. 1. Resident #122 was admitted to the facility on [DATE] and readmitted into the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The 30 day Minimum Data Set assessment dated [DATE] indicated that Resident #122 had no short or long term memory problems, was cognitively intact and needed supervision for walking in her room and locomotion on and off the unit. The resident was coded as using a walker, a wheelchair and coded no for receiving Oxygen (O2). The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #122 had no short or long term memory problems and was cognitively intact. Record review of the physician's orders [REDACTED]. Resident #122 was listed on the smokers list that was provided by the facility. Resident #122's current care plan was initiated on 11/11/16, was reviewed and the resident was not care planned for smoking. Resident #122 was assessed for smoking upon admission based only on her cognitive status of being intact per information from MDS and Resident #122 could get to the smoking area independently. With this information, the resident was added to the smokers list per Director of Nursing interview on 9/21/17 at.9:40 AM. Resident #122's incident report dated on 07/05/17 at 4:08 PM was reviewed. The report revealed Resident observed to be smoking outside in parking lot while wearing O2 (Oxygen). Two staff members took cigarette away from resident. Resident brought back into building. The dangers of smoking while wearing O2 was explained to the resident. Resident stated she understood, but also states she only wanted one cigarette. Emergency contact and MD made aware. No injuries. Immediate Action taken: Cigarette taken from resident. Resident warned of dangers of smoking with O2. I was told resident was outside smoking with O2 on. I went to door and resident was smoking. Two other staff members were taking cigarette. Resident brought back into building and was warned of the dangers of smoking with O2 on. (Name of physician) was notified and RP (responsible party). The incident report was completed by Nurse #1. Nurse's notes dated 07/05/17 at 4:20 PM for Resident #122 were reviewed. The notes (written by Nurse #1) revealed Resident observed to be smoking outside in parking lot while wearing O2. Two staff members took cigarette away from resident. Resident brought back in building. The dangers of smoking while wearing O2 explained to resident. Resident stated she understood, but also states she only wanted one cigarette. Resident #122 emergency contact person and Medical Doctor (MD) made aware. Review of the social worker's (SW) notes dated on 07/06/17 at 5:04 PM revealed a cognitive assessment was conducted on Resident #122 due to her smoking while using oxygen. The note continued, SW also was informed by staff that resident was confused when outside smoking. Resident scored a 15 on her cognitive assessment (indicating Resident #122 was cognitively intact.) SW educated resident on the dangers of smoking with oxygen on. SW informed resident of company's smoking policy due to resident having a lighter in her top bedside dresser. Resident also stated she keeps her cigarettes in her room. Resident did not have cigarettes in her bedside dresser or room at the time, but only had the lighter. SW informed resident that all cigarette paraphernalia must be locked in the nursing cart and not to be kept in resident's rooms. SW gave resident's lighter to hall nurse and educated nurse of company's policy due to her being unaware of policy and new on the hall. SW also informed resident as to where her items would be kept. SW also informed resident that she would need to sign in and out when smoking. SW informed nurse to be watchful of resident going out smoking with oxygen and maybe remove resident's oxygen once going out to smoke. The SW was not available for interview during the investigation. On 09/20/17 at 9:55 AM, Resident #122 was interviewed. Resident #122 stated she has not been out to smoke in over a month due to health reasons. The resident further stated that she knows not to smoke with her oxygen turned on. She stated that her smoking materials are kept in med cart with the nurse on the hall. During the interview with Resident #122 she was observed receiving oxygen via nasal cannula. Observation on 09/20/17 at 9:55 AM revealed an oxygen sign posted on Resident #122's wheelchair and there was an oxygen sign posted on the left side of the door frame to the resident's room. On 09/20/17 at 2:50 PM, Nurse #1 was interview. Nurse #1 was assigned to Resident #122 on 07/05/17 (3:00 PM to 11:00 PM shift). Nurse #1 stated she did not give the resident cigarettes and a lighter on 07/05/17. Nurse #1 said that on 07/05/17 the Staff Development Coordinator (SDC) reported to her that the resident was smoking while her oxygen was turned on. The nurse further stated that she did not witness the resident's cigarette being lit. She stated that the resident was outside at the end of the building and not in the designated smoking area when the incident occurred. On 09/20/17 at 3:02 PM, Staff Development Coordinator Assistant (SDCA) was interviewed. The SDCA stated that she was in her office on 07/05/17 with the Staff Development Coordinator (SDC). The SDC saw the resident out their office window with her oxygen tank attached on back of her wheelchair and a cigarette in her hand. The SDCA further stated that the SDC told her to go outside and she would be there shortly. The SDCA went outside and took the unlighted cigarette from the resident and took her back in the building. The SDC followed shortly and assist getting the resident back into the building. The SDCA said she could not remember if the oxygen was turned on or whether the nasal cannula was attached to the resident's face. She further stated the SDC reported the incident to the 300 hall nurse (Nurse #1). On 09/20/17 at 3:10 PM, Nursing Assistant (NA) #1 was interviewed. NA #1 was assigned to Resident #122 on 09/20/17. NA #1 stated that she has never seen the resident go out and smoke. On 09/20/17 at 3:12 PM, Med Aide #1 (MA) was interviewed. The MA stated that she saw the resident in the smoking area about a month ago, with family members smoking. She further stated that she had never seen the resident attempt to smoke with her oxygen on. On 09/20/17 at 3:15 PM, Resident #122 was interviewed. Resident #122 stated that she thinks her cigarette was not lit on 07/05/17. She further stated that the nurse would have cut off her O2 before she went outside to smoke. On 09/20/17 at 3:42 PM, Resident #122's Medical Doctor (MD) was interviewed. The MD assigned to Resident #122 stated that the facility did call him on the day of the incident (07/05/17) and he assumed that the resident was smoking with O2, but he was not sure. The MD further stated that it was over two months ago, and he did not remember. On 09/20/17 at 5:05 PM, Resident #122's emergency contact representative was interviewed. Resident #122 emergency contact representative stated that she remembers the facility calling and saying the resident got in trouble for smoking with the O2 turned on. She further stated that she did not remember the facility saying that the cigarette was lit. She further stated that she assumed that the cigarette was lit. On 09/21/17 at 9:06 AM, Telephone interview with the Staff Development Coordinator (SDC). The SDC stated that she was in her office conducting orientation class on 07/05/17 and she saw Resident #122 out of her office window at the corner of the building (not in the designated smoking area) with a cigarette and lighter in her hand with the oxygen tank attached to the wheelchair. The SDC said she immediately told SDCA to go outside and get the cigarette and lighter from the resident. She further stated that she also went outside to get the resident and told the nurse on the 300 hall (Nurse #1) to write up the incident that the resident was outside with cigarette, lighter and O2 attached to wheelchair. The SDC stated that she told Nurse #1 to check the resident's room for cigarettes and lighters. She stated she did not tell Nurse #1 that the resident was smoking the cigarette. She further stated that the resident can ambulate and since she had been back to facility from hospital (6/6/17), she had not seen the resident go out to smoke. She stated that the resident came back from the hospital on oxygen. The SDC said she could not remember if the nasal cannula was in the resident's nose and she did not know if the tank was turned on. She was just alarmed when she saw resident with cigarette and lighter in her hands with oxygen tank attached to wheelchair. The SDC stated that the cigarette was not lit. The SDC further stated that before the resident's last hospital admission on 05/29/17 she was able to ambulate with a walker to go outside and smoke. On 09/21/17 at 9:40 AM, the DON was interviewed. The DON stated that there was no documented education to the resident prior to 07/05/17 related to smoking precautions while on oxygen. The DON further stated that the facility was considered a smoke free facility and residents who were admitted and smoked were assessed based on their cognition being intact and being able to get to the smoke area independently. On 09/21/17 at 3:30 PM, the Nurse #1 was interviewed. The Nurse #1 stated that she followed up with Resident #122's emergency contact representative who stated she sometimes she gave Resident #122 cigarettes and lighters. Observation was made on 09/22/17 at 11:00 AM of Resident #122 in her room sitting up in her wheelchair with oxygen sign posted on back of the wheelchair an oxygen sign posted on the right side of door frame to the resident's room. No observations were made of Resident #122 smoking during the four-day survey period. On 09/22/17 at 4:14 PM, the Director of Nurses (DON) was interviewed. DON stated that it is her expectation that the staff and residents that smoke follow the facility's policy on smoking. The DON further stated Resident #122 would be assessed and care planned, and that she expected all incident reports to be thoroughly investigated and completed accurately. The DON further stated that in the past the facility considered themselves as being smoke free since the residents were smoking at the end of the parking lot. The DON stated that all residents on the smokers list had to be cognitively intact and get to the designated smoke area without assistance from staff. On 09/22/17 at 5:25 PM, the Administrator was interviewed. The Administrator stated that the facility has revised the facility's smoking policy on 09/20/17 and it was his expectation that staff and residents follow the smoking policy and assessments for safe smoking be completed. The current Administrator was not employed at the facility during the time of the 07/05/17 incident with Resident #122. The Administrator and Director of Nursing were informed of the Immediate jeopardy on 09/21/17 at 11:00 AM. On 09/22/17 at 9:48 AM, the facility provided an acceptable allegation of compliance. Plan of correcting the specific deficiency. On 7/5/17 resident #, 122 was observed with a cigarette and oxygen on by the staff facilitator and staff facilitator assistant. The cigarette was not lit and was removed by the staff facilitator, and the resident was brought back into the facility on [DATE] by staff facilitator at 4:08 pm. On 7/5/17 the staff facilitator educated the resident on smoking while wearing oxygen. The staff facilitator notified the administrator and nurse on 7/5/17 4:20 pm. On 7/5/17 the assigned hall nurse made the physician and residents representative (RR) aware at 4:40 pm. Upon notification to the RR, they stated, we sometimes give her cigarettes to keep in her room. On 7/5/17 the assigned hall nurse and the nursing assistant searched the resident room and was unable to find any cigarette paraphernalia. The nurse later searched the room again and was not able to find any cigarette paraphernalia. On 7/5/17 the assigned hall nurse educated the RR on the risk for burns. The RR verbalized understanding. On 7/6/17 the social worker re-educated the resident on dangers of smoking with oxygen on and the smoking policy. On 9/21/17 the facility under the direction of the Registered Nurse (RN)-corporate clinical consultant initiated, a thorough investigation to ascertain the cause for the resident attempting to smoke with oxygen. Upon the conclusion of the investigation, it was determined the overall failure to assess the resident desire to smoke with oxygen, failure to follow the facility smoking policy related to being smoke-free and failure to communicate a determination in resident #122 desire to smoke. The facility also failed to communicate with families on brining in the smoking paraphernalia to residents. The procedure for implementing the acceptable plan of correction for the specific deficiency cited. 100 % of alert and oriented residents and residents with oxygen use were interviewed on 9/21/17 to identify any residents that smoke by the social worker. No resident was identified below the BIMS score of 13 as a smoker through interviews from staff and families. There are 27 alert and oriented residents and 20 residents with oxygen use. The social worker interviewed the 27 alert and oriented resident residents on 9/21/17 utilizing the following interview tool: 1. Do you smoke? 2. If yes do you wish to stop smoking? 3. If you wish to stop smoking, do you wish to have an intervention to stop smoking? 4. Have you been educated on the facility smoking policy? 5. Do you understand that smoking with Oxygen is dangerous and could cause and explosion? 6. Do you know where the designated smoking area is located? 7. Do you understand that smoking is not allowed outside of these areas? Six (6) residents were identified as smokers who do not wish for an intervention to stop smoking and one (1) that identifies as no longer a smoker. The identified residents smoking paraphernalia will be secured in the medication cart on the assigned resident's hall and only provided to the residents upon request to ensure safety. All six residents identified as smokers were educated on the following revised smoking policy on 9/21/2017 by the social worker to include the following: The six residents that are identified as smokers and twenty residents that are on oxygen were educated on the hazards of oxygen usage and smoking on 9/21/2017 by the social worker. The 6 residents were provided a smoking assessment on 9/20/17 by the Director of Nursing (DON) and the Minimum Data Set (MDS) nurse by resident observation, clinical assessment of the residents' ability, staff interviews and information gathered from the medical record to determine that the resident is safe to smoke independently or unsafe smoker and must be supervised. The results of the Smoking evaluations determined that there were five residents identified as Safe/independent smokers, one resident identified as a supervised smoker due to physical limitation and one resident identified as no longer a smoker. A Resident Council Meeting was called on 9/20/17 by the council president to discuss the update of the Smoking policy. There were Twenty-five residents that attended the resident council meeting in the activity room. Each of the six residents that were identified as smokers, care plans were updated on 9/21/17 by the MDS nurse to reflect the current smoking status. 100% review of physician orders, for the six resident identified who smoke, was completed on 9/21/17 by the Corporate Nurse Consultant to identify any resident with an order for [REDACTED]. 100% of progress notes from 7/1/17 to 9/21/17 were reviewed by the Corporate Consultant by 9/21/17 to identify any other residents who were smoking with oxygen. There were no other residents identified as smoking with oxygen. 100% of incident reports from 7/1/17 to 9/21/17 were reviewed by the Corporate Consultant by 9/21/17 to identify any other residents who were smoking with oxygen. There were no other residents identified as smoking with oxygen. On 9/21/17 the admissions process was updated to include the revised smoking policy by the administrator. The new admissions regardless of smoking status will be educated on and sign the acknowledgment of the revised smoking policy by the admissions coordinator. The resident smoking areas were sections off under a covered patio and smoking aprons, smoking blanket, National Fire Protection Association (NFPA) approved trash can, fire extinguisher and NFPA approved ash trays were placed within this area for resident use. All smoking materials to include cigarettes and lighters belonging to the resident will be housed and locked in the nurse medication cares and will only be accessible with the aid of the staff member. A bright colored sign was placed on the front entry door and the newly designated smoking area for family members and visitors to NOT provide residents with smoking paraphernalia by the maintenance director on 9/21/17. Any resident that assessed upon admission from the admitting nurse will have the smoking assessment completed by the licensed nurse and reviewed by the Director of nursing. The assigned hall nurse will review the orders to ensure resident does not have orders for oxygen. If the resident had an order, the nurse must notify the medical doctor to obtain an order to remove the oxygen while the resident is smoking. The Minimum data nurse will develop or update the care plan with the smoking safety interventions. Residents identified as supervised smokers will be evaluated upon admissions and quarterly after that by the MDS nurse to ensure no change to the smoking status. Any resident that is identified as an unsupervised/safe smoker will be assessed upon admission and reassessed monthly or as needed to ensure no changes to the smoking status. Notification of the changes in the smoking policy was sent via the United Stated Postal Service on 9/21/2017 to all resident representatives. All residents that scored a 13 to 15 on the BIMS was educated on the smoking policy and oxygen safety on 9/21/2017 by the social worker. 27 residents that are 13 to 15 of their minimum data set have signed the smoking policy on 9/21/17. The remaining 146 residents that are not alert and oriented and scored 12 or below on their BIMS will have the smoking policy and notification letter sent via United States Postal Service to their respective Resident Representatives (RR) on 9/21/17 by the business office. The designated resident smoking area is located outside, in the covered pavilion in the courtyard at the 100 hall exit. Smoking aprons, fire extinguishers, smoking blankets and fire proof smoking containers, to include red trashcans, are provided as safety measures. Red signage was to state NO Oxygen beyond this point have been placed in the designated smoking area on 9/21/17 by the maintenance director. All smoking paraphernalia has been removed from the six resident's possession with their permission and placed in a secured location by the Admission Coordinator on 9/21/17. A Red tag indicating oxygen usage will be placed on the mobility device for easy identification and safety by the maintenance director by 9/21/17 for all twenty residents with oxygen use. 100% in service was initiated by the Corporate Nurse Consultant on 9/20//17 for all staff, administrator, Account Receivable (AR), DON, ADON, QI nurse, Treatment nurses, Staff Facilitator, Staff Facilitator assistant, Admissions Coordinator, Payroll, receptionists, maintenance director, maintenance assistant, therapy staff, housekeeping, laundry, licensed nurses, nursing assistant, dietary staff, Geri Care aides, Activity Director, Activity assistant and activity aide on what to do if they witness a resident smoking on oxygen. This in service will be included in orientation, agency personnel training and annually after that. This in-service included that the staff member is to immediately remove the resident from potential harm, secure the resident safety and notify the nurse. The nurse will assess the resident and notify the physician and residents representative of the occurrence and complete the incident report and document in the medical record. The nurse will also notify the Administrator and Director of Nursing. Any resident identified as smoking while on oxygen and failure to follow the facility reviewed smoking policy will be issued a 30-day notification and placed on one to one supervision until discharge. Any employee that has not received the in service will be removed from the schedule until the in-service education has been provide. All in servicing will be completed by 09/22/17. A 100% in service was initiated to the licensed nurses on 9/21/17 by the Director of Nursing and will be completed by 9/22/17. Any employee that has not received the in service will be removed from the schedule until the in-service education has been provide. The in service included the following: Nurses Responsibility of Assuring resident safety to prevent smoking with oxygen When a newly admitted resident that smokes is on oxygen or a current resident that smokes receives a new order for oxygen, the nurse must immediately notify the MD and obtain an order to remove the oxygen while smoking. The Nurse is responsible for assuring that resident's smoking paraphernalia is securely locked in the medication cart. The nurse must assure that all oxygen equipment (nasal cannula and e-tank) is removed per physician order [REDACTED]. The nurse must assure that the oxygen is reapplied when the resident finishes smoking. 100% in service was initiated by the on 9/20/17 for all staff, administrator, Account Receivable (AR), DON, ADON, QI nurse, Treatment nurses, Staff Facilitator, Staff Facilitator assistant, Admissions Coordinator, Payroll, receptionists, maintenance director, maintenance assistant, therapy staff, housekeeping, laundry, licensed nurses, nursing assistant, dietary staff, Geri Care aides, Activity Director, Activity assistant and activity aide on revised Smoking Policy dated 9/20/2017. Any employee that has not received the in service will be removed from the schedule until the in-service education has been provide. All in servicing will be completed by 09/22/17. Premier Nursing and Rehabilitation Center smoking policy was revised on 9/20/17. On 9/21/17 the vice president of operations educated the new interim administrator and Director of Nursing on the requirement of root cause analysis and implementation of the plan of correction to protect all residents. The administrator, Director of Nursing or social worker will audit the residents smoking assessment, smoking policy and care plans monthly to assure accuracy and they continue to be appropriate to meet the safety meet the safety needs of residents. The Director of Nursing, administrator and Quality improvement nurse will review the incident report form to ensure a proper investigation, the follow-up to include an appropriate intervention initiated, for all incidents to included smoking with oxygen, documentation contained within the medical record and revised or updated care plan. On 9/21/17, the administrator, vice president of operations, and corporate clinical director will begin a weekly review of the completed Accident Hazards/Supervision Audit tool to ensure the systems for a safe environment to include a safe environment and implementation of the smoking policy and supervision for resident safety remains in place and are functioning properly. The review will be complete, as indicated by initiating the audit tool, for four weeks to ensure adequate supervision and oversight of the corporate clinical director and vice president of operations weekly until the quality assurance team review committee determines the facility has achieved substantial compliance and corporate oversight is no longer indicated. The quality improvement nurse or minimum data set nurse (MDS) will present the finding of the Accident Hazards/Supervision Audit Tool at the monthly Quality Improvement Committee Meeting. The Quality Improvement Committee or MDS nurse will review the results of the audits monthly X 6 months, identify trends, and utilize the five why root cause analysis and make recommendation for follow-up as needed. The quality improvement and or MDS nurse will present the findings of accident hazard/supervision audit tool to the Quality Assessment and Assurance (QAA) Committee quarterly meeting to equal six months. The quarterly QAA Committee will review the quality improvement recommendation and facilities follow-up to the recommendations. The quarterly QAA committee will perform additional root cause analysis as needed, make an additional recommendation, and provide oversight. The administrator will be responsible for ensuring the QAA Committee concerns, and recommendations are addressed through further training or other interventions are sustained to maintain regulatory compliance in the area of Free of Accidents Hazards/Supervision. The title of the person responsible for implementing the acceptable plan of correction. The administrator and Director of Nursing will be responsible for the implementation of the revised smoking policy, assessment of the resident who smoke and systematic changed for the prevention of incidents and accident. Corporate oversight will be provided by the corporate clinical director and vice president of operations to ensure the administrator and Director of Nursing implements and monitors the plan of correction. The credible allegation was verified on 09/22/17 at 4:55 PM when interviews with residents, nursing staff, administrative staff and non-nursing staff confirmed they had received in-service training on the facility's revised smoking policy to remove all oxygen tanks and tubing prior to going into the new designated smoking area, the new storage system for smoking materials, the available smoking equipment including smoking aprons, cigarette butt cans, fire extinguisher and fire blankets. Interviews were conducted on the 1st and 2nd shifts on 09/22/17. Observations revealed residents were smoking safely, and interviews revealed residents were to be evaluated for safe smoking upon admission. 2. Resident #16 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The Annual MDS assessment dated on 08/14/17 indicated that Resident #16 had no short or long term memory problems and was cognitively intact and needed extensive assistance with activities of daily living. The resident was coded as using a wheelchair. Resident #16 was assessed (MDS) for smoking upon admission based only on his cognitive status of being intact per information from MDS and Resident #16 could get to the smoking area independently. With this information, the resident was added to the smokers list (per Director of Nursing interview on 9/21/17 at.9:40 AM.) Resident #16 was not assessed for safe smoking until 09/20/17 per DON and record review. Resident #16's care plan dated on 08/14/17 was reviewed on 09/19/17 and the resident was not care planned for smoking. Resident #16 care plan was revised on 09/20/17 for safe and independent smoking. Resident #16 was listed on the smokers list that was provided by the facility. Observation was made of Resident #16 on 09/20/17 at 9:15 AM leaving his room and heading towards the exit door without getting smoking materials from the nurse or signing out. Observation was made of the Resident #16 on 09/20/17 at 9:20 AM to 9:53 AM in the designated smoking area safely smoking. Review of Resident #16 smoking evaluation dated on 09/20/17 revealed that the resident was a safe smoker and may smoke independently now and care plan was updated. On 09/20/17 at 9:55 AM, Resident #16 was interviewed. Resident #16 stated that he kept his cigarettes and lighter in his room and sometimes signed himself out and sometimes the nurse would sign him out. On 09/22/17 at 10:30 AM, Nurse #2 was interviewed. Nurse #2 stated that the resident goes out to smoke independently. Nurse #2 further stated that cigarettes and lighters for Resident #16 were kept on the medication carts. On 09/22/17 at 10:40 AM, NA #1 was interviewed. NA #1 stated that the resident goes out to smoke independently in the designated smoking area. On 09/22/17 at 4:14 PM, the Director of Nurses (DON) was interviewed. DON stated that it is her expectation that the staff and residents that smoke follow the facility's policy on smoking. The DON further stated Resident #16 would be assessed and care planned, and that she expected all incident reports to be thoroughly investigated and completed accurately. The DON further stated that in the past the facility considered themselves as being smoke free since the residents were smoking at the end of the parking lot. The DON stated that all residents on the smokers list had to be cognitively intact and get to the designated smoke area without assistance from staff. DON further stated that all residents on

Based on record review, staff interviews, resident ' s representative interview, and physician interview, the facility failed to notify the physician and resident ' s responsible party of a significant change in condition which resulted in hospitalization with [DIAGNOSES REDACTED].#1). Immediate Jeopardy (IJ) began on 6/24/17 when Resident #1 ' s physician and representative were not notified when a significant change in condition occurred which resulted in hospitalization and the [DIAGNOSES REDACTED]. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring and quality improvement measures. Findings included: Resident #1 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A review of the physician progress notes [REDACTED].#1 was admitted to the hospital on [DATE] for [MEDICAL CONDITION], urinary tract infection with the organism was E. faecalis (from stool), hydro[DIAGNOSES REDACTED] (injury to the kidney), acute [MEDICAL CONDITIONS] (high sodium), benign prostate hypertrophy ([MEDICAL CONDITION]), and urethral trauma. Resident #1 ' s recorded [DIAGNOSES REDACTED]. The quarterly Minimum (MDS) data set [DATE] revealed Resident #1 had a moderately altered cognition. The resident required one staff member assist for activities of daily living. The resident had tube feedings. The resident had an indwelling urinary catheter. The resident had no swallowing disorder. A nurses ' note dated 6/24/17 at 11:13 pm, written by Nurse #1, revealed Resident #1 was sounding congested with wheeze to right upper lobe. The resident offered no conversation. The urinary catheter noted to have low output of clear amber urine. The urinary catheter was leaking and unable to irrigate. The urinary catheter was changed with return of a large amount of clear amber urine. Slight bleeding was noted after insertion. Resident #1 ' s flow sheet vital signs dated 6/24/17 at 5:08 pm were temperature 98.5 and pulse 41. A second attempt to obtain a pulse on the resident was documented as unable to determine. An interview was conducted on 6/30/17 at 5:45 pm with Nurse #1. Nurse #1 stated that she was on duty 6/24/17 the 3pm-11pm shift and was responsible for Resident #1. Nurse #1 stated she was an agency nurse and was not familiar with the resident. Resident #1 had been moved from another hall recently. Nurse #1 noticed that the resident was alert but confused and drowsy. Nurse #1 was not aware that confusion and being nonverbal was not the resident ' s normal state. The resident was congested and Nurse #1 turned him, directed him to cough and provided fluids. The resident did not take any fluids. The NA ' s were assigned to take the vital signs and empty the urine bag and record the amount. Nurse #1 stated that the NA had not reported anything unusual about Resident #1 that evening. During report Nurse #1 learned from Nurse #2 that the resident was not at his baseline level of consciousness. After Nurse #1 had a shift report discussion with the oncoming nurse (Nurse #2), Nurse #1 realized that the resident had a change in condition from the beginning of the shift. On 7/1/17 at 11:00 am an interview was conducted with Nursing Assistant (NA) #3. NA #3 stated that she was on duty 6/24/17 during the 3pm-11pm shift. NA #3 stated that Resident #1 was recently transferred from another hall and she was not familiar with him. NA #3 attempted to take the resident ' s vital signs with an automatic blood pressure cuff and the pulse was 41 with no other reading. A second attempt to take the resident ' s vital signs was done with no reading. NA #3 informed Nurse #1 of the 41 pulse and inability to obtain the vital signs about 5:30 pm. NA #3 stated that Nurse #1 informed her to try again later. NA #3 had not observed Nurse #1 assess the resident or take vital signs. NA #3 stated that the resident appeared lethargic and non-verbal and she thought that was his baseline. NA #3 stated that when she asked Nurse #1 questions, Nurse #1 replied I am an agency nurse, I don ' t do that. NA #3 stated that to her knowledge the resident ' s vital signs were not attempted again during her shift. Review of the nurse ' s notes dated 6/24/17 revealed there was no note to indicate the physician or responsible party was notified of the resident ' s condition between 3:00 PM and 11:00 PM. Nurse ' s note dated 6/25/17 at 1:08 am, written by Nurse #2, revealed Resident #1 was not responding normally (verbally). His temperature was 101.4, the [DEVICE] was draining a black grainy substance, and his lungs sounded wet. The resident was suctioned without effectiveness. The resident was noted to be weak and had blood in his urine. The physician was faxed and made aware and provided an order to transfer to the hospital. The resident ' s representative was called and notified. Transport was called for transportation to the hospital. The emergency department (ED) nurse was given report. An interview was conducted on 7/1/17 at 9:50 am with Nurse #2. Nurse #2 stated she worked on 6/24/17 during the 11pm-7am shift. Resident #1 ' s usual baseline was alert and able to make his needs known verbally and otherwise. Nurse #2 stated that on 06/24/17 she received report from that Nurse #1 that she was not familiar with the resident. Nurse #2 stated she went into Resident #1 ' s room at the start of shift (around 11:00 pm) and noticed that he had an altered mental status. Resident #1 would not speak to Nurse #2 and had a black substance coming from the [DEVICE]. Nurse #2 assessed the resident and found that he had a temperature of 101.4 and pulse oximetry of 96% on room air. Nurse #2 stated she had not taken the resident ' s blood pressure, pulse, and/or blood glucose. Nurse #2 stated she called to inform the resident ' s physician and the resident ' s representative of the resident ' s condition. The resident ' s physician ordered to transfer the resident to the hospital on [DATE] at 11:35 pm. The resident was transferred to the hospital at 11:50 pm. On 7/1/17 at 1:30 pm an interview was conducted with the Administrator and Director of Nursing (DON). The Administrator stated the physician was expected to see each resident on admission, every month, within a week of re-admission, and when there were staff concerns. The nursing staff expectation was to call the attending physician for any resident change in assessment. The DON stated that the attending physician was called when Resident #1 had a change in assessment on 6/24/17 and an order to transfer Resident #1 to the emergency department was obtained 6/25/17. The DON stated she was not aware that the resident had a pulse of 41 at 5:08 pm on 6/24/17. The Emergency Department (ED) Physician ' s initial assessment note dated 6/25/17 at 1:01 am revealed Resident #1 was referred from the facility for blood pressure issues. The ED physician evaluated the resident to have altered mental status. The emergency medical service (EMS) reported to the physician that the resident was febrile, [MEDICAL CONDITION] (fast heart rate), hypotensive, and tachypneic (fast breathing). The Physician ' s evaluation of the resident condition was toxic and tachypnea with distress. The resident had altered mental status and did not answer questions, but opened eyes to loud voice. The resident had signs and symptoms of [MEDICAL CONDITION]. After 2 liters of [MEDICATION NAME] ringer ' s intravenous fluid resuscitation the systolic blood pressure improved to 110. The resident ' s [MEDICATION NAME] ([MEDICAL CONDITION]) was elevated at 8.6 with a very poor prognosis. The labs showed leukocytosis with an associated bandemia (significant infection), and acute kidney injury with pre-renal azotemia (kidney injury). The resident ' s chest x-ray also showed a left lower lobe pneumonia. At time of arrival the urinary catheter had such thick discharge that the urine could not even be extracted. Moreover, the resident was transported to the ED with a chief complaint by facility staff of altered mental status and no notation that the resident was febrile, hypotensive, [MEDICAL CONDITION], and severely septic. The white blood cells were grossly elevated at 27.5 (acute infection), blood urea nitrogen was 90 (severe dehydration) and creatinine was 2.78 (kidney injury). Upon the resident ' s admission to the hospital from the ED, the clinical impression was [MEDICAL CONDITION], elevated lactic acid level, pre-renal azotemia, [MEDICAL CONDITION], acute kidney injury, and lobar pneumonia with an unspecified organism. The resident was critically ill and was admitted to the intensive care unit. A review of Resident #1 ' s hospital discharge summary dated 7/1/17 revealed the resident presented to the ED with pyuria, no urine output, [MEDICAL CONDITION], fever, and a fast heart rate. The hospital course [DIAGNOSES REDACTED]. The resident required fluid resuscitation and vasopressors to maintain his blood pressure. The resident was treated and improved. The resident ' s communication was limited by [MEDICAL CONDITION] and dementia. The resident was alert at time of discharge. On 7/5/17 at 10:40 am an interview was conducted with Resident #1 ' s representative. The representative stated that she was the power of attorney. The resident had his urinary catheter for years at home. The resident ' s representative stated she was not notified of the resident ' s change in condition on 06/24/17 until the time of transport to the ED on 06/25/17. On 7/5/17 at 12:35 pm an interview was conducted with Resident #1 ' s physician. He stated that he was Resident #1 ' s attending at the facility. The physician stated that he saw the resident once a month and as needed after each hospitalization . The physician ordered a urology consultation after the 4/14/17 hospital admission and urology saw the resident on 4/21/17. The physician stated he was not informed by the facility or the ED physician of the ED physician ' s recommendation for a [MEDICATION NAME] and the penile erosion. The physician had received calls from the ED physician when there were concerns, but not for this occasion. The physician had not spoken to the resident ' s representative. The physician had received a fax around midnight with Resident #1 ' s change in status and spoke to the nurse to provide an order to transfer to the emergency department. On 7/24/17 at 11:08 am another interview was conducted with Resident #1 ' s physician. The physician stated delayed treatment of [REDACTED]. Resident #1 had co-morbidities and delayed treatment made him at risk for long term and permanent organ injury and damage. Because Resident #1 had co-morbidities waiting to get treatment was worse for his outcome. The resident should have been transferred right away when the 41 pulse was identified on evening shift. The delayed care begun at 5:05 pm on 6/24/17 when the vital signs were undetectable by the nursing assistant. The physician was not notified of the resident ' s change in assessment until 11:30 pm on 6/24/17. The Administrator, Director of Nursing (DON), and Corporate Clinical Director were notified of the IJ on 7/24/17 at 11:46 am. On 7/25/17 at 2:41 pm the facility provided the following credible allegation of compliance: On the 3-11 pm shift on 6/24/17 nursing assistant #1 obtained resident #1's pulse and recorded at forty-one (41) beats per minute. Nursing Assistant (NA) #1 was interviewed by the surveyor on 7/24/17. NA #1 stated, Resident #1's blood pressure was unable to be obtained, and nurse #1 was notified and nurse #1 stated to re-check again. Nurse # 1 failed to assess the resident on the 3-11pm shift. Nurse #2 on the 11-7am shift assessed resident #1 and sent to the local hospital for evaluation on 6/24/17 and documented in the electronic medical record at 1:08 am on 6/25/17 of the resident transfer to the local hospital. NA #1 upon an interview with the regional vice president and corporate clinical consultant on 7/24/17 was specifically questioned if she had re-checked the pulse stating, I am unable to recall anything to include the vital signs. The interview further revealed, NA #1 stating, I failed to re-call any information specific to resident #1 vital signs as stated to the surveyor on 7/24/17 at 5:00 pm. Upon the conclusion of the interview with the regional vice president and corporate clinical director, NA #1 walked out of the facility with no intent to return on 7/24/15 at 5:15 pm. On 6/24/17 resident #1 was assessed by nurse #1 and was noted as sounding congested with wheezing to the right upper lobe, low urine output and leaking urine around the Foley catheter. On 6/24/17 nurse #1 attempted to irrigate resident #1 Foley catheter but was unsuccessful. On 6/24/17 nurse #1 discontinued resident #1 Foley catheter with #14fr/10cc Foley and reinserted with a return of clear amber urine and noted slight bleeding after insertion. On 6/25/17 1:08 am nurse #2 went into resident #1 room and found resident #1 not responding normally. On 6/25/17 nurse #2 assessed resident #1 with a temperature of 101.1 Fahrenheit, observation of [DEVICE] noted with draining grainy black substance and wet lungs sounds. On 6/25/17 nurse #2 suctioned resident #1 but it was not effective and observed resident #1 to be weak with blood noted in urine. On 6/25/17 nurse #2 notified a transport company to transport resident #1 to the emergency room . On 6/25/17 the transport company transported resident #1 to the hospital to be evaluated. On 6/25/17 nurse #2 faxed the Medical Doctor (MD) and made the MD aware of Resident #1 condition and transport to the emergency room (ER). On 6/25/17 nurse #2 reported resident #1 condition to the ER nurse. On 6/30/17 the Licensed Practical nurse-admissions Coordinator notified the MD of Resident #1's change in condition from 6/25/17 and the condition of resident #1 upon discharge and hospitalization to the local hospital. On 6/25/17 resident #1 was assessed by the local hospital ER. Resident #1 was admitted on [DATE] and remained in acute care through 7/1/17. Resident #1 was discharged back to the facility from the local hospital on [DATE] with a discharging [DIAGNOSES REDACTED]. The agency nurse was removed from the schedule on 6/26/17 and placed on the do not return list to the facility from the staffing agency. The DON notified the agency on 6/30/17 of the nurse's failure to assess the resident and the facilities requirement for nurse #1 not return. By 7/5/17, NA #1 was re-educated on notification to the licensed nurse of abnormal vital signs and changes in condition. 100% of all residents were assessed by the Assistant Director of nurses (ADON), Unit Facilitator, Minimum Data Set (MDS) nurse and treatment nurse and completed on 7/1/17 using a resident census for catheter care, any acute change in condition to include, but not limited to, signs and [MEDICAL CONDITION] and/or infected catheters, altered mental status, new onset of cough, lethargy, abnormal vital signs, no urine output and unresponsiveness. 100% of all residents to include resident #1 documentation of vital signs (VS) in the electronic medical record from 6/1/17 through 7/24/17 were reviewed by the facility clinical consultant, DON, quality improvement (QI) nurse, MDS nurses, staff facilitator and unit facilitator will be completed 7/25/17 to determine if all residents' documentation of vital signs were within the resident's baseline. If the resident's vital signs present as abnormal these residents will be reported to the nurse with an assessment of the resident, MD notification, and documentation in the medical record. The DON, QI nurse, MDS nurses, staff facilitator, treatment nurses, Licensed Practical Nurse (LPN), LPN admission coordinator and Unit Facilitator will complete an assessment of all residents by 7/25/17 with documentation of abnormal vital signs that were not reported and/or not assessed. 100% of all residents' vital signs, to include resident #1, will be obtained by the DON, QI nurse, administrative NA, ward clerk-NA, Staff facilitator assistant-NA, staff facilitator, supply clerk-NA, Social Worker-NA, MDS nurses, LPN-admission coordinator and NA Transporter to determine if all residents' vital signs are within the resident's baseline by 7/25/17. If any resident vital signs are found to be abnormal and not to be within their base line, a complete clinical assessment will be completed for other signs and symptoms of acute change in condition. The MD will be notified of the changed in condition and documentation in the medical record by the DON, QI nurse, MDS nurses, staff facilitator and unit facilitator will be completed by 7/25/17. The 100% review of the nurse progress notes, by the DON, ADON, unit facilitators and the QI nurse was completed on 7/3/17, the audit ensured all identified residents with acute changes, to include but not limited to, sign and symptoms [MEDICAL CONDITION], and/or infected catheters, altered mental status, new onset of a cough, lethargy, abnormal vital signs, no urine output, and unresponsiveness, were assessed and provided appropriate interventions and that the MD and residents representative were notified via phone, with voice to voice conversation, no message left for MD, and appropriate documentation is in the medical records. No acute changes in condition were identified that were not appropriately addressed by the DON, ADON, unity facilitators and the QI nurse. A bright colored sign was posted by the facility clinical consultant at each nurse's station on 7/3/17, as a visual guideline for the responsibility of the licensed nurse, for voice to voice notification to the physician for changes in resident condition, to include sign and symptoms of dehydration,[MEDICAL CONDITION], and infected catheters. The bright colored sign was changed and reposted by the facility clinical consultant at each nurse's station on 7/24/17 to include but not limited to, signs and symptoms [MEDICAL CONDITION], and infected catheters, altered mental status, new onset of a cough, lethargy, abnormal vital signs, no urine output, and unresponsiveness. The nurse will notify the attending physician of the assessment findings and carry out any orders given with notification documented in the electronic chart. The resident ' s representative will be notified of any changes in the resident condition with the notification documented in the electronic chart. 100% in-service of all licensed nurses, to include agency nurse was initiated on 7/1/17 and was completed by 7/5/17 by the DON and staff facilitator regarding notification of physician for changes in resident's condition. These notifications included the following: Notify Physician (speak with the physician) by telephone: 1. Acute Change in Resident Condition occur, 2. Changes in Cognitive Status occur, Changes in Behavior occur, 3. Changes in Oral Intake to include fluids occur, Changes in Immune System occur, 4. Changes in Normal Body Functioning occur, 5. PANIC laboratory values occur, 6. Resident's Condition Warrants based upon nurse's assessments, to include signs and symptoms of dehydration,[MEDICAL CONDITION], and/or infected catheter. If you are unable to reach Attending Physician, you may call the On-call for the physician. If you are unable to reach attending or on-call physician, you may call the facility's Medical Director. If unable to reach the Attending Physician, the on-call physician or the Medical Director then call 911 and the DON must be notified. Notification of the physician of these types of changes in a resident's condition by fax or leaving a message is not acceptable! Documentation of the notification of the attending physician will be documented in the resident's chart. 100% of licensed nurses, to include agency nurses, were in-serviced by the staff facilitator by 7/3/17 on; when there is an acute change in condition, the resident must be sent to the ER via 911 not via non-emergent transport company. These acute changes in condition include, but not limited to, altered mental status [MEDICAL CONDITION]. A full set of vital signs, to include, temperature, pulse, respirations, oxygen saturation, and blood pressure must be obtained and verbal notification via phone to the MD. Always give the emergency room nurse a detailed report. An E-Interact Change in condition tool and an E-Interact transfer form (a tool that is used to give detailed description of the residents change in condition that results in transfer to the hospital) must be completed for all acute changes in condition and transfer to the hospital and a copy sent to the ER with the resident or faxed a copy to the ER if completed after the resident is sent the hospital. The licensed nurse is responsible for assessing, document, provide appropriate interventions and notify the MD and residents representative of any acute changes in condition, to include, but not limited to, signs and symptoms of [MEDICAL CONDITION] and/or infected catheters, altered mental status, new onset of cough, lethargy, abnormal vital signs, no urine output and unresponsiveness and/or any other significant clinical information, noted. If the licensed nurse is unable to reach the attending physician, the on-call MD must be called. If unable to contact the attending or the on-call MD, the nurse must call the Medical Director. If unable to reach, voice to voice, the attending physician, the on-call or the medical director, then 911 for transport will be called and the DON MUST be notified. 100% of licensed nurses, to include agency nurses, were in-serviced by the staff facilitator by 7/3/17 on; when there is an acute change in condition, the resident must be sent to the ER via 911 not via non-emergent transport company. These acute changes in condition include, but not limited to, altered mental status [MEDICAL CONDITION]. A full set of vital signs, to include, temperature, pulse, respirations, oxygen saturation, and blood pressure must be obtained and verbal notification via phone to the MD. Always give the emergency room nurse a detailed report. An E-Interact Change in condition tool and an E-Interact transfer form (a tool that is used to give detailed description of the residents change in condition that results in transfer to the hospital) must be completed for all acute changes in condition and transfer to the hospital and a copy sent to the ER with the resident or faxed a copy to the ER if completed after the resident is sent the hospital. Questionnaires were initiated on 7/4/17 by the DON with 100% of all license nurses completed by 7/7/17 for validation of understating regarding assessing for acute changes in condition and MD and resident ' s representative Notification to include: 1. How is the physician to be notified of a change with the resident? 2. What can be considered a change in the resident that the physician would be called? 3. If you are unable to speak with the physician what do you do? 4. If unable to speak with the attending physician or the on-call physician, who would you call? 5. Where is the notification of the physician documented? 6. How do assess for a change in condition? 7. If a resident has a clinical deterioration, how would they be transported to the ER? 100% of the licensed nurses will have their questionnaires reviewed by the Registered Nurse facility consultants by 7/24/17. Any identified licensed nurse that are unable to correctly answer the questionnaire will be re-trained by the DON and required to complete and new questionnaire. If upon the second attempt, the licensed is unable to correctly answer the questionnaire, the licensed nurse will be removed from the schedule until remediation is provided. IJ was removed on 7/25/17 at 3:23 pm when the facility implemented a credible allegation of compliance when interviews with direct care nursing staff and non-nursing staff confirmed they had received in service training, conducted audits and posted information for staff regarding changes in resident conditions as specified in the facility ' s credible allegation of compliance.

Based on record review, staff interviews, and physician interview, the facility failed to assess an acute change in condition, failed to initiate necessary care and treatment for [REDACTED].#1). Immediate Jeopardy (IJ) had begun on 6/24/17 when Resident #1 was not assessed and not provided treatment for [REDACTED]. The Administrator, DON, and Corporate Clinical Director were notified of the IJ on 7/24/17 at 11:46 am. IJ was removed on 7/25/17 at 2:41 pm when the facility provided and implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring and quality improvement measures. Findings included: Resident #1 ' s recorded [DIAGNOSES REDACTED]. The quarterly minimum (MDS) data set [DATE] revealed Resident #1 had a moderately altered cognition. The resident required one staff member assist for activities of daily living. The resident had tube feedings. The resident had an indwelling urinary catheter. Resident #1 ' s care plan dated 6/7/17 revealed Resident #1 was at risk for [MEDICAL CONDITION] or urinary stasis. The interventions were to monitor for signs and symptoms of UTI, [MEDICAL CONDITION] and output less than intake. The last set of vital signs were dated 6/24/17 at 5:08 pm, temperature 98.5, pulse 41, and second a second attempt to obtain vital signs was documented unable to determine. On 7/1/17 at 11:00 am an interview was conducted with NA #3. NA #3 stated that she was on duty 6/24/17 the 3pm-11pm shift. NA #3 stated that Resident #1 was recently transferred from another hall and she was not familiar with him. NA #3 attempted to take the resident ' s vital signs on 6/24/17 at 5:08 pm with an automated blood pressure/pulse cuff and the pulse was 41 with no other reading. A second attempt to take the resident ' s vital signs was done with a reading of unable to determine. NA #3 informed Nurse #1 of the 41 pulse and inability to obtain the vital signs. NA #3 stated that Nurse #1 informed her to try again later. NA #3 had not observed Nurse #1 assess the resident or take vital signs. NA #3 stated that the resident appeared lethargic and non-verbal and she thought that was his baseline. NA #3 stated that when she asked Nurse #1 questions, Nurse #1 replied I am an agency nurse, I don ' t do that. The vital signs were not attempted again. Nurses ' note dated 6/24/17 at 11:13 pm revealed Resident #1 offered no conversation. The urinary catheter was noted to have no output. The urinary catheter was leaking and unable to irrigate due to blockage. The urinary catheter was changed with return of a 2700 cubic centimeters (large) of clear amber urine. Slight bleeding was noted after insertion.An interview was conducted on 6/30/17 at 5:45 pm with Nurse #1. Nurse #1 stated she worked 3pm-11pm shift on 6/24/17 and that the resident ' s urinary catheter was not flowing, was leaking around the catheter, and replaced the urinary catheter with a large volume of urine return at the end of her shift. Nurse #1 was an agency nurse and was not familiar with the resident. Nurse #1 was not aware that confusion and being nonverbal was not the resident ' s normal cognition. During report Nurse #1 learned from Nurse #2 that the resident was not at his baseline mentation. After shift report discussion with the oncoming nurse (Nurse #2), Nurse #1 realized that the resident had a change in condition from the beginning of her evening shift 3pm-11pm. Nurse ' s note dated 6/25/17 at 1:08 am revealed Resident #1 was not responding normally (verbally). His temperature was 101.4, the gastrostomy tube was draining a black grainy substance, and his lungs sounded wet. The resident was suctioned without effectiveness. The resident was noted to be weak and had blood in his urine. The physician was faxed and made aware. The resident ' s representative was called and notified. Transport was called for transportation to the hospital. The emergency department (ED) nurse was given report. An interview was conducted on 7/1/17 at 9:50 am with Nurse #2. Nurse #2 stated she worked on 6/24/17 the 11pm-7am shift. Resident #1 ' s usual baseline was alert to situation and was able to make his needs known verbally and otherwise. Nurse #2 stated that she received report from Nurse #1 that Nurse #1 was not familiar with the resident. Nurse #2 went into Resident #1 ' s room at the start of shift and noticed that he had an altered mental status. Resident #1 would not speak to Nurse #2 and had a black substance coming from the [DEVICE]. Nurse #2 assessed the resident and found that he had a temperature of 101.4. Nurse #2 had not taken the resident ' s blood pressure, pulse, and/or blood glucose. Nurse #2 stated she called the physician and the resident ' s representative. A physician order [REDACTED]. The resident was transferred at 11:50 pm. Nurse #2 called routine transport and not emergency medical services because the routine transport was quicker. The facility had to wait for EMS in the past. The ED Physician ' s initial assessment note dated 6/25/17 at 1:01 am revealed Resident #1 was referred from the facility for blood pressure issues. The ED physician evaluated the resident to have altered mental status. The physician ' s evaluation of the resident condition was toxic and tachypnea with distress. The resident had signs and symptoms of [MEDICAL CONDITION]. The urinary catheter had pus draining directly into the catheter bag and appeared to probably be the source of infection. After 2 liters of [MEDICATION NAME] ringer ' s intravenous fluid resuscitation the systolic blood pressure improved to 110. At time of the resident ' s arrival the urinary catheter had thick discharge and the urine could not be extracted. The resident was transported to the ED with a chief complaint by facility staff of altered mental status and no notation that the resident was febrile, hypotensive, [MEDICAL CONDITION], and severely septic. A basic ambulance unit was used to transport the resident. The hospital discharge summary dated 7/1/17 revealed Resident #1 had the [DIAGNOSES REDACTED]. On 7/24/17 at 9:35 am an interview via telephone was conducted with the Resident #1 ' s physician. The physician stated that he was not informed that the resident ' s pulse was 41 on 6/24/17 at 5:05 pm. The physician stated that the delay in assessment and treatment would have caused permanent organ injury due to the septic shock. The failure to report the resident ' s abnormal vital signs happened on the evening shift and had not met expectation. The resident had multiple co-morbidities and could not tolerate a delay in treatment for [REDACTED]. On 7/1/17 at 1:30 pm an interview was conducted with the Administrator and Director of Nursing (DON). The staff expectation was to call the attending physician for any resident change in assessment. The DON sated that the physician was called when Resident #1 had a change in assessment on 6/24/17 night shift. The facility provided the following credible allegation: On the 3-11 pm shift on 6/24/17 nursing assistant #1 obtained resident #1's pulse and recorded at forty-one (41) beats per minute. Nursing Assistant (NA) #1 was interviewed by the surveyor on 7/24/17. NA #1 stated, Resident #1's blood pressure was unable to be obtained, and nurse #1 was notified and nurse #1 stated to re-check again. Nurse # 1 failed to assess the resident on the 3-11pm shift. Nurse #2 on the 11-7am shift assessed resident #1 and sent to the local hospital for evaluation on 6/24/17 and documented in the electronic medical record at 1:08 am on 6/25/17 of the resident transfer to the local hospital. NA #1 upon an interview with the regional vice president and corporate clinical consultant on 7/24/17 was specifically questioned if she had re-checked the pulse stating, I am unable to recall anything to include the vital signs. The interview further revealed NA #1 states, I failed to re-call any information specific to resident #1 vital signs as stated to the surveyor on 7/24/17 at 5:00 pm. Upon the conclusion of the interview with the regional vice president and corporate clinical director, NA #1 walked out of the facility with no intent to return on 7/24/15 at 5:15 pm. On 6/24/17 resident #1 was assessed by nurse #1 and was noted as sounding congested with wheezing to the right upper lobe, low urine output and leaking urine around the Foley catheter. On 6/24/17 nurse #1 attempted to irrigate resident #1 Foley catheter but was unsuccessful. On 6/24/17 nurse #1 discontinued resident #1 Foley catheter with #14french/10 cc Foley and reinserted with a return of clear amber urine and noted slight bleeding after insertion. On 6/25/17 1:08 am nurse #2 went into resident #1 room and found resident #1 not responding normally. On 6/25/17 nurse #2 assessed resident #1 with a temperature of 101.1 Fahrenheit, observation of [DEVICE] noted with draining grainy black substance and wet lungs sounds. On 6/25/17 nurse #2 suctioned resident #1 but it was not effective and observed resident #1 to be weak with blood noted in urine. On 6/25/17 nurse #2 notified a transport company to transport resident #1 to the emergency room . On 6/25/17 the transport company transported resident #1 to the hospital to be evaluated. On 6/25/17 nurse #2 faxed the Medical Doctor (MD) and made the MD aware of Resident #1 condition and transport to the emergency room (ER). On 6/25/17 nurse #2 reported resident #1 condition to the ER nurse. On 6/30/17 the Licensed Practical nurse-admissions Coordinator notified the MD of Resident #1's change in condition from 6/25/17 and the condition of resident #1 upon discharge and hospitalization to the local hospital. On 6/25/17 resident #1 was assessed by the local hospital ER. Resident #1 was admitted on [DATE] and remained in acute care through 7/1/17. Resident #1 was discharged back to the facility from the local hospital on [DATE] with a discharging [DIAGNOSES REDACTED]. The agency nurse was removed from the schedule 6/26/17 and placed on the do not return list to the facility from the staffing agency. The Director of Nursing (DON) notified the agency on 6/30/17 of the nurse's failure to assess the resident and the facilities requirement for nurse #1 not return. By 7/5/17, NA #1 was re-educated on notification to the licensed nurse of abnormal vital signs and changes in condition On 6/25/17 the local hospital emergency department notes the ER doctor alleged neglect related to failure to recognize signs and symptom [MEDICAL CONDITION]. A twenty-four (24) hour report was completed by the Administrator and faxed to the Health Care Personnel related to the allegation of Neglect on 6/30/17. On 6/30/17, an investigation was initiated by the administrator, and DON related to the ER Physicians allegation of neglect and completed on 7/10/17. A thorough investigation was conducted by the administrator. The administrator concluded the investigation on 7/10/17 and determined the allegation of neglect was substantiated for failure to recognize signs and symptom [MEDICAL CONDITION]. The facility administrator completed five (5) day report substantiating the neglect allegation and faxed to the Health Care Personnel Investigation on 7/10/17. The facility under the direction of the Registered Nurse (RN)-corporate clinical consultant had initiated on 7/3/17 a thorough investigation to ascertain the root cause for failure to asses, report and intervene in Resident #1 care and services to maintain the highest level of functioning. The root cause of the investigation determined communication on the part of NA #1 and nurse #1. The facility staff facilitator and DON in-serviced on notification of vital signs, assessments and communicating to the nurse abnormalities in vital signs or changes in condition to facilitate proper communication. The nurse from agency that was placed on the do not return to the facility list will not speak with the facility DON, corporate consultant or administrator. The facility is unable to determine any further actions that were or were not taken in regards to resident #1 care due to NA #1 not remembering per the statement on 7/24/17 and nurse #1 refusing to return calls to the facility. On 7/3/17, all alert and oriented residents were interviewed on neglect by both Social Workers with question to include: 1. Do you know what it means to be neglected? If no, please explain definition of neglect to resident. 2. Do you feel that the facility has been neglectful in providing care, providing adequate fluids, observing for clinical changes and notify the MD promptly of any changes? There are 20 alert and oriented residents that were interviewed and no negative findings from the interviews were reported. 100% of all residents were assessed by the Assistant Director of nurses (ADON), Unit Facilitator, Minimum Data Set (MDS) nurse and treatment nurse and completed on 7/1/17 using a resident census for catheter care, any acute change in condition to include, but not limited to, signs and [MEDICAL CONDITION] and/or infected catheters, altered mental status, new onset of cough, lethargy, abnormal vital signs, no urine output and unresponsiveness. 100% of all residents to include resident #1 documentation of vital signs (VS) in the electronic medical record from 6/1/17 until 7/24/17 were reviewed by the facility clinical consultant, DON, quality improvement (QI) nurse, MDS nurses, staff facilitator and unit facilitator will be completed 7/25/17 to determine if all residents' documentation of vital signs were within the resident's baseline. If the resident's vital signs present as abnormal these residents will be reported to the nurse with an assessment of the resident, MD notification, and documentation in the medical record. The DON, QI nurse, MDS nurses, staff facilitator, treatment nurses, Licensed Practical Nurse (LPN), LPN admission coordinator and Unit Facilitator will complete an assessment of all residents by 7/25/17 with documentation of abnormal vital signs that were not reported and/or not assessed. 100% of all residents' vital signs, to include resident #1, will be obtained by the DON, QI nurse, administrative NA, ward clerk-NA, Staff facilitator assistant-NA, staff facilitator, supply clerk-NA, Social Worker-NA, MDS nurses, LPN-admission coordinator and NA Transporter to determine if all residents' vital signs are within the resident's baseline by 7/25/17. If any resident vital signs are found to be abnormal and not to be within their base line, a complete clinical assessment will be completed for other signs and symptoms of acute change in condition. The MD will be notified of the changed in condition and documentation in the medical record by the DON, QI nurse, MDS nurses, staff facilitator and unit facilitator will be completed by 7/25/17. The 100% review of the nurse progress notes, by the DON, ADON, unit facilitators and the QI nurse was completed on 7/3/17, the audit ensured all identified residents with acute changes, to include but not limited to, sign and symptoms [MEDICAL CONDITION], and/or infected catheters, altered mental status, new onset of a cough, lethargy, abnormal vital signs, no urine output, and unresponsiveness, were assessed and provided appropriate interventions and that the MD and residents representative were notified via phone, with voice to voice conversation, no message left for MD, and appropriate documentation is in the medical records. No acute changes in condition were identified that were not appropriately addressed by the DON, ADON, unit facilitators and the QI nurse. A bright colored sign was posted by the facility clinical consultant at each nurse's station on 7/3/17, as a visual guideline for responsibility of the licensed nurse, for voice to voice notification to the physician for changes in resident condition, to include signs and symptoms of dehydration,[MEDICAL CONDITION], and infected catheters. The bright colored sign was changed and reposted by the facility clinical consultant at each nurse's station on 7/24/17 to include but not limited to, sign and symptoms [MEDICAL CONDITION], and infected catheters, altered mental status, new onset of a cough, lethargy, abnormal vital signs, no urine output, and unresponsiveness. 100% in-service was initiated by the staff facilitator on 7/3/17 for all staff, administrator, Account Receivable (AR), DON, ADON, QI nurse, Treatment nurses, Staff Facilitator, Staff Facilitator assistant, Admissions Coordinator, Payroll, receptionists, maintenance director, maintenance assistant, therapy staff, housekeeping, laundry, licensed nurses, nursing assistant, dietary staff, Geri Care aides, Activity Director, Activity assistant and activity aide on Examples of Nursing Home Neglect; Nursing home neglect can vary among individual cases, but below are examples of neglect: When a resident is repeatedly ignored, left alone, or accidentally snapped at by an overstressed employee. When a resident does not receive adequate help with laundry, cleaning, bathing, brushing their teeth, or other forms of hygienic practices. When the nursing home neglects to provide reasonable food, water, or a safe and clean environment. When the nursing home fails to provide adequate attention, prevention to include dehydration, UTI's and infections, or medication for concerns such as pressure ulcers, infections, cuts, diabetes, cognitive diseases, and mobility concerns. Signs of Nursing Home Neglect. Warning signs of nursing home neglect MAY include: 1. Sudden weight loss, 2. Bedsores, or pressure ulcers, 3. Injuries from nursing home falls, 4. Dehydration, 5. Malnutrition, 6. Withdrawn resident behavior, or unusual changes in behavior, 7. Changes in personal hygiene or appearance efforts, 8. A growing lack of friendly interaction with the nursing home staff, 9. A growing lack of friendly interaction with the other nursing home residents, Environmental hazards, such as poor lighting, slippery floors, unsafe mobility equipment, or unsafe furniture in the nursing home patient's room. The in-service was completed on 7/5/17. Prevention of Nursing Home Neglect: The nursing home resident should be monitored for changes in mobile, mental, and physical ability, as well as any developing medical concerns. Any changes noted in the resident should be reported to the nurse. The nurse must report the changes immediately to the MD and Resident Representative and provide appropriate interventions to address the change and prevent further decline and document in the medical records. If a resident has an acute medical change, the resident should be sent out via 911 with verbal notification to the physician. No staff, administrator, AR bookkeeper, DON, ADON, QI nurse, Treatment nurses, Staff Facilitator, Staff Facilitator assistant, Admissions Coordinator, Payroll, receptionists, maintenance director, maintenance assistant, therapy staff, housekeeping, laundry, licensed nurses, nursing assistant, dietary staff, GCA's, Activity Director, Activity assistant and activity aide, will be allowed to work until receiving the in-service on sign and symptoms [MEDICAL CONDITION] and dehydration. The staff facilitator will include the training into the facility orientation for new hires on 7/24/17. 100% in-servicing of all licensed nurses, to include agency nurses, and nursing assistants were initiated by the DON on 7/1/17 regarding signs and symptoms [MEDICAL CONDITION] and dehydration and were completed by 7/5/17. This in-service included the following: Dehydration is defined as a condition in which water or fluid loss (output) far exceeds fluid intake. Due to aging, it becomes difficult to identify the early signs and symptoms of dehydration. These signs and symptoms tend to be unreliable and nonspecific. Signs/Symptoms of Dehydration: Dizziness on sitting/standing, Dry mucous membranes, Confusion or change in mental status, Constipation, Decreased urine output, Fever, Decreased skin turgor. What [MEDICAL CONDITION]?[MEDICAL CONDITION] is a life-threatening illness caused by your body's response to an infection. Your immune system protects you from many illnesses and infections, but it's also possible for it to go into overdrive in response to an infection. Early identification of the signs and symptoms [MEDICAL CONDITION] in the geriatric population (within 1 hour) is essential for implementing early treatment for [REDACTED]. What are the symptoms [MEDICAL CONDITION]? Symptoms [MEDICAL CONDITION] include: a fever above 101ºF or a temperature below 96.8ºF, heart rate higher than 90 beats per minute, breathing rate higher than 20 breaths per minute, probable or confirmed infection. You must have two of these symptoms before a doctor can [MEDICAL CONDITION]. [MEDICAL CONDITION]: [MEDICAL CONDITION] occurs when there's organ failure. You must have one or more of the following signs to be diagnosed with [REDACTED]. Septic shock: Symptoms of septic shock include the symptoms of [MEDICAL CONDITION], plus a very low blood pressure. With any change in condition of the resident, it must be reported to the nurse for assessment and implementation of treatment. 100% in-service of all licensed nurses, to include agency nurse was initiated on 7/1/17 and was completed by 7/5/17 by the DON and staff facilitator regarding notification of physician for changes in resident's condition. These notifications included the following: 1. Notify Physician (speak with the physician) by telephone: 2. Acute Change in Resident Condition occur, 3. Changes in Cognitive Status occur, 4. Changes in Behavior occur, Changes in Oral Intake to include fluids occur, 5. Changes in Immune System occur, 6. Changes in Normal Body Functioning occur, 7. PANIC laboratory values occur, 8. Resident's Condition Warrants based upon nurse's assessments, to include signs and symptoms of dehydration,[MEDICAL CONDITION], and/or infected catheter. If you are unable to reach Attending Physician, you may call the On-call for physician. If you are unable to reach attending or on-call physician, you may call the facility's Medical Director. If unable to reach the Attending Physician, the on-call physician or the Medical Director then call 911 and the DON must be notified. Notification of the physician of these types of changes in a resident's condition by fax or leaving a message is not acceptable! Documentation of the notification of the attending physician will be documented in the resident's chart. 100% of licensed nurses, to include agency nurses, were in serviced by the staff facilitator by 7/3/17 on; when there is an acute change in condition, the resident must be sent to the ER via 911 not via non-emergent transport company. These acute changes in condition include, but not limited to, altered mental status [MEDICAL CONDITION]. A full set of vital signs, to include, temperature, pulse, respirations, oxygen saturation, and blood pressure must be obtained and verbal notification via phone to the MD. Always give the emergency room nurse a detailed report. An E-Interact Change in condition tool and an E-Interact transfer form (a tool that is used to give detailed description of the residents change in condition that results in transfer to the hospital) must be completed for all acute changes in condition and transfer to the hospital and a copy sent to the ER with the resident or faxed a copy to the ER if completed after the resident is sent the hospital. The licensed nurse is responsible for assessing, document, provide appropriate interventions and notify the MD and resident representative of any acute changes in condition, to include, but not limited to, signs and [MEDICAL CONDITION] and/or infected catheters, altered mental status, new onset of a cough, lethargy, abnormal vital signs, no urine output and unresponsiveness and/or any other significant clinical information, noted. If the licensed nurse is unable to reach the attending physician, the on-call MD must be called. If unable to contact the attending or the on-call MD, the nurse must call the Medical Director. If unable to reach, voice to voice, the attending physician, the on-call or the medical director, then 911 for transport will be called and the DON MUST be notified. Questionnaires were initiated on 7/4/17 by the DON with 100% of all license nurses completed by 7/7/17 for validation of understating regarding assessing for acute changes in condition and MD and residents representative Notification to include: 1. How is the physician to be notified of change with the resident? 2. What can be considered a change in the resident that the physician would be called? 3. If you are unable to speak with the physician what do you do? 4. If unable to speak with the attending physician or the on-call physician, who would you call? 5. Where is the notification of the physician documented? 6. How do assess for a change in condition? 7. If a resident has a clinical deterioration, how would they be transported to the ER? 100% of the licensed nurses will have their questionnaires reviewed by the Registered Nurse facility consultants by 7/24/17. Any identified licensed nurse that are unable to correctly answer the questionnaire will be re-trained by the DON and required to complete and new questionnaire. If upon the second attempt, the licensed is unable to correctly answer the questionnaire, the licensed nurse will be removed from the schedule until remediation is provided. The facility ' s credible allegation was validated on 7/25/17 when interviews with direct care nursing staff and non-nursing staff confirmed they had received in service training, conducted audits and posted information for staff regarding changes in resident conditions as specified in the facility ' s credible allegation of compliance.

Based on record review, staff interviews, the resident ' s representative interview, and physician interview, the facility failed to recognize the resident ' s change in condition and failed to provide the hospital with a complete assessment of the resident ' s changes resulting in a delay of treatment, hospitalization , and [MEDICAL CONDITION] for 1 of 3 residents (Resident #1). Immediate Jeopardy (IJ) had begun on 6/24/17 when Resident #1 was not assessed and not provided treatment for [REDACTED]. The Administrator, DON, and Corporate Clinical Director were notified of the IJ on 7/24/17 at 11:46 am. IJ was removed on 7/25/17 at 2:41 pm when the facility provided and implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring and quality improvement measures. Findings included: Resident #1 ' s recorded [DIAGNOSES REDACTED]. The quarterly minimum (MDS) data set [DATE] revealed Resident #1 had a moderately altered cognition. The resident required one staff member assist for activities of daily living. The resident had tube feedings. The resident had an indwelling urinary catheter. Resident #1 ' s care plan dated 6/7/17 revealed Resident #1 was at risk for [MEDICAL CONDITION] or urinary stasis. The interventions were to monitor for signs and symptoms of UTI, [MEDICAL CONDITION] and output less than intake. The care plan also revealed indwelling catheter at risk for infection related to diagnoses. The interventions were to empty the drainage bag each shift, catheter care per facility protocol, change catheter per physician order, monitor for signs and symptoms of infection, and to monitor and record intake and output. A review of the urinary output flow sheet for 6/23/17 revealed 0 output at the end of night shift. A review of the urinary output flow sheet for 6/24/17 revealed 1400 cubic centimeters output for day shift. On 7/5/17 at 11:09 am an interview was conducted with NA #4. NA #4 stated that she was very familiar with Resident #1. NA #4 was on duty 7am-3pm shift on 6/24/17. The resident was alert as usual with no confusion and able to make his needs known verbally and otherwise. The resident ' s urine catheter was draining a dark yellow urine. The resident was washed and dressed and declined to get up to his wheelchair. The urine was emptied from the drainage bag and recorded. NA #4 stated that there was nothing unusual about the resident on the 6/24/17 day shift and nothing reported from night shift. On 7/5/17 at 11:38 am an interview was conducted with Nurse #4. Nurse #4 stated that she was very familiar with Resident #1. Nurse #4 was on duty 7am-3pm shift on 6/24/17. The resident was his normal self. The resident did not complain of pain and was able to make his needs known verbally and with hand gesture. Nurse #4 stated that the resident ' s mentation was at his baseline. The resident ' s urine catheter was draining a small amount of dark yellow urine. The characteristics of the urine was only documented by exclusion, when abnormal. The last set of vital signs recorded was dated 6/24/17 at 5:08 pm, temperature 98.5, pulse 41, and second a second attempt to obtain vital signs was documented unable to determine. Nurses ' note dated 6/24/17 at 11:13 pm revealed Resident #1 was sounding congested with wheeze to right upper lobe early in the evening shift. The resident offered no conversation. The urinary catheter was noted to have no output. The urinary catheter was leaking and unable to irrigate due to blockage. The urinary catheter was changed with return of a large amount of clear amber urine. Slight bleeding was noted after insertion. A review of the urinary output flow sheet for 6/24/17 revealed 0 output for evening shift. An interview was conducted on 6/30/17 at 5:45 pm with Nurse #1. Nurse #1 stated she worked 3pm-11pm shift on 6/24/17 and that the resident ' s urinary catheter was not flowing, was leaking around the catheter, and replaced the urinary catheter with a large volume of urine return at the end of her shift. Nurse #1 was an agency nurse and was not familiar with the resident. Resident #1 had been moved from another hall recently. Nurse #1 noticed that the resident was alert but confused, drowsy, and non-verbal. Nurse #1 was not aware that confusion and being nonverbal was not the resident ' s normal cognition. The resident was congested and Nurse #1 turned him, directed him to cough and provided fluids. Nurse #1 stated that the resident ' s lungs had some rhonchi. The resident had a large amount of urine return. The NA ' s were assigned to take the vital signs, empty the urine bag and record the amount. Nurse #1 stated that the NA had not reported anything unusual about Resident #1 that evening. During report Nurse #1 learned from Nurse #2 that the resident was not at his baseline mentation. After shift report discussion with the oncoming nurse (Nurse #2), Nurse #1 realized that the resident had a change in condition from the beginning of her evening shift 3pm-11pm. On 7/1/17 at 11:00 am an interview was conducted with NA #3. NA #3 stated that she was on duty 6/24/17 the 3pm-11pm shift. NA #3 stated that Resident #1 was recently transferred from another hall and she was not familiar with him. NA #3 attempted to take the resident ' s vital signs on 6/24/17 at 5:08 pm with an automated blood pressure/pulse cuff and the pulse was 41 with no other reading. A second attempt to take the resident ' s vital signs was done with a reading of unable to determine. NA #3 informed Nurse #1 of the 41 pulse and inability to obtain the vital signs. NA #3 stated that Nurse #1 informed her to try again later. NA #3 had not observed Nurse #1 assess the resident or take vital signs. NA #3 stated that the resident appeared lethargic and non-verbal and she thought that was his baseline. NA #3 stated that when she asked Nurse #1 questions, Nurse #1 replied I am an agency nurse, I don ' t do that. The vital signs were not attempted again. A review of the urinary output flow sheet for 6/24/17 revealed 2675 cubic centimeters output for night shift. Nurse ' s note dated 6/25/17 at 1:08 am revealed Resident #1 was not responding normally (verbally). His temperature was 101.4, the gastrostomy tube was draining a black grainy substance, and his lungs sounded wet. The resident was suctioned without effectiveness. The resident was noted to be weak and had blood in his urine. The physician was faxed and made aware. The resident ' s representative was called and notified. Transport was called for transportation to the hospital. The emergency department (ED) nurse was given report. An interview was conducted on 7/1/17 at 9:50 am with Nurse #2. Nurse #2 stated she worked on 6/24/17 during the 11pm-7am shift. Resident #1 ' s usual baseline was alert and able to make his needs known verbally and otherwise. Nurse #2 stated that on 06/24/17 she received report from that Nurse #1 that she was not familiar with the resident. Nurse #2 stated she went into Resident #1 ' s room at the start of shift (around 11:00 pm) and noticed that he had an altered mental status. Resident #1 would not speak to Nurse #2 and had a black substance coming from the [DEVICE]. Nurse #2 assessed the resident and found that he had a temperature of 101.4 and pulse oximetry of 96% on room air. Nurse #2 stated she had not taken the resident ' s blood pressure, pulse, and/or blood glucose. Nurse #2 stated she called to inform the resident ' s physician and the resident ' s representative of the resident ' s condition. The resident ' s physician ordered to transfer the resident to the hospital on [DATE] at 11:35 pm. The resident was transferred to the hospital at 11:50 pm. The ED Physician ' s initial assessment note dated 6/25/17 at 1:01 am revealed Resident #1 was referred from the facility for blood pressure issues. The ED physician evaluated the resident to have altered mental status. The emergency medical service (EMS) reported to the physician that the resident was febrile (temperature), [MEDICAL CONDITION] (fast heart rate), hypotensive, and tachypneic (fast, labored respiratory rate). The physician ' s evaluation of the resident condition was toxic and tachypnea with distress. The resident had signs and symptoms of [MEDICAL CONDITION]. The urinary catheter had pus draining directly into the catheter bag and appeared to probably be the source of infection. The resident had rhonchorous (mucous) respirations in upper airway. Fluids and antibiotics were started. Cultures of the blood and urine were obtained. After 2 liters of [MEDICATION NAME] ringer ' s intravenous fluid resuscitation the systolic blood pressure improved to 110. The labs showed leukocytosis with an associated bandemia (significant infection), and acute kidney injury with pre-renal azotemia (kidney injury). The resident ' s chest x-ray also showed a left lower lobe pneumonia. At time of the resident ' s arrival the urinary catheter had thick discharge and the urine could not be extracted. The resident was transported to the ED with a chief complaint by facility staff of altered mental status and no notation that the resident was febrile, hypotensive, [MEDICAL CONDITION], and severely septic. A basic ambulance unit was used to transport the resident. The white blood cells were grossly elevated at 27.5 (acute infection), blood urea nitrogen was 90 (severe dehydration) and creatinine was 2.78 (kidney injury). The resident was critically ill and admitted to the intensive care unit. The hospital discharge summary dated 7/1/17 revealed Resident #1 had the [DIAGNOSES REDACTED]. The creatinine lab result at discharge was back to baseline at 0.76 and the blood urea nitrogen was 20 (hydrated). The resident suffered a [MEDICAL CONDITION] secondary to septic shock. On 7/1/17 at 1:30 pm an interview was conducted with the Administrator and Director of Nursing. The staff expectation was to call the attending physician for any resident change in assessment. The DON sated that the physician was called when Resident #1 had a change in assessment on 6/24/17 night shift. On 7/5/17 at 12:35 pm an interview was conducted with the physician. He stated that he was Resident #1 ' s attending at the facility. The physician stated that he saw the resident once a month and as needed after each hospitalization . The physician stated he was not informed by the facility or the ED physician of the ED physician ' s recommendation for a [MEDICATION NAME]. The physician had received calls from the ED physician when there were concerns, but not for this occasion. The physician stated that the resident was evaluated by the urologist on 4/21/17 and two subsequent visits. The physician stated he would leave the plan of treatment up to the urologist. The physician expected facility staff to call him when the resident had a change in assessment or any concerns. On 7/24/17 at 11:08 am another interview was conducted with Resident #1 ' s physician. The physician stated delayed treatment of [REDACTED]. Resident #1 had co-morbidities and delayed treatment made him at risk for long term and permanent organ injury and damage. Because Resident #1 had co-morbidities waiting to get treatment was worse for his outcome. The resident should have been transferred right away when the 41 pulse was identified on evening shift. The delayed care begun at 5:05 pm on 6/24/17 when the vital signs were undetectable by the nursing assistant. The facility provided the following credible allegation: On the 3-11 pm shift on 6/24/17 nursing assistant #1 obtained resident #1's pulse and recorded at forty-one (41) beats per minute. Nursing Assistant (NA) #1 was interviewed by the surveyor on 7/24/17. NA #1 stated, Resident #1's blood pressure was unable to be obtained, and nurse #1 was notified and nurse #1 stated to re-check again. Nurse # 1 failed to assess the resident on the 3-11pm shift. Nurse #2 on the 11-7am shift assessed resident #1 and sent to the local hospital for evaluation on 6/24/17 and documented in the electronic medical record at 1:08 am on 6/25/17 of the resident transfer to the local hospital. NA #1 upon an interview with the regional vice president and corporate clinical consultant on 7/24/17 was specifically questioned if she had re-checked the pulse stating, I am unable to recall anything to include the vital signs. The interview further revealed NA #1 states, I failed to re-call any information specific to resident #1 vital signs as stated to the surveyor on 7/24/17 at 5:00 pm. Upon the conclusion of the interview with the regional vice president and corporate clinical director, NA #1 walked out of the facility with no intent to return on 7/24/15 at 5:15 pm. On 6/24/17 resident #1 was assessed by nurse #1 and was noted as sounding congested with wheezing to the right upper lobe, low urine output and leaking urine around the Foley catheter. On 6/24/17 nurse #1 attempted to irrigate resident #1 Foley catheter but was unsuccessful. On 6/24/17 nurse #1 discontinued resident #1 Foley catheter with #14french/10 cc Foley and reinserted with a return of clear amber urine and noted slight bleeding after insertion. On 6/25/17 1:08 am nurse #2 went into resident #1 room and found resident #1 not responding normally. On 6/25/17 nurse #2 assessed resident #1 with a temperature of 101.1 Fahrenheit, observation of [DEVICE] noted with draining grainy black substance and wet lungs sounds. On 6/25/17 nurse #2 suctioned resident #1 but it was not effective and observed resident #1 to be weak with blood noted in urine. On 6/25/17 nurse #2 notified a transport company to transport resident #1 to the emergency room . On 6/25/17 the transport company transported resident #1 to the hospital to be evaluated. On 6/25/17 nurse #2 faxed the Medical Doctor (MD) and made the MD aware of Resident #1 condition and transport to the emergency room (ER). On 6/25/17 nurse #2 reported resident #1 condition to the ER nurse. On 6/30/17 the Licensed Practical nurse-admissions Coordinator notified the MD of Resident #1's change in condition from 6/25/17 and the condition of resident #1 upon discharge and hospitalization to the local hospital. On 6/25/17 resident #1 was assessed by the local hospital ER. Resident #1 was admitted on [DATE] and remained in acute care through 7/1/17. Resident #1 was discharged back to the facility from the local hospital on [DATE] with a discharging [DIAGNOSES REDACTED]. The agency nurse was removed from the schedule 6/26/17 and placed on the do not return list to the facility from the staffing agency. The Director of Nursing (DON) notified the agency on 6/30/17 of the nurse's failure to assess the resident and the facilities requirement for nurse #1 not return. By 7/5/17, NA #1 was re-educated on notification to the licensed nurse of abnormal vital signs and changes in condition On 6/25/17 the local hospital emergency department notes the ER doctor alleged neglect related to failure to recognize signs and symptom [MEDICAL CONDITION]. A twenty-four (24) hour report was completed by the Administrator and faxed to the Health Care Personnel related to the allegation of Neglect on 6/30/17. On 6/30/17, an investigation was initiated by the administrator, and DON related to the ER Physicians allegation of neglect and completed on 7/10/17. A thorough investigation was conducted by the administrator. The administrator concluded the investigation on 7/10/17 and determined the allegation of neglect was substantiated for failure to recognize signs and symptom [MEDICAL CONDITION]. The facility administrator completed five (5) day report substantiating the neglect allegation and faxed to the Health Care Personnel Investigation on 7/10/17. The facility under the direction of the Registered Nurse (RN)-corporate clinical consultant had initiated on 7/3/17 a thorough investigation to ascertain the root cause for failure to asses, report and intervene in Resident #1 care and services to maintain the highest level of functioning. The root cause of the investigation determined communication on the part of NA #1 and nurse #1. The facility staff facilitator and DON in-serviced on notification of vital signs, assessments and communicating to the nurse abnormalities in vital signs or changes in condition to facilitate proper communication. The nurse from agency that was placed on the do not return to the facility list will not speak with the facility DON, corporate consultant or administrator. The facility is unable to determine any further actions that were or were not taken in regards to resident #1 care due to NA #1 not remembering per the statement on 7/24/17 and nurse #1 refusing to return calls to the facility. On 7/3/17, all alert and oriented residents were interviewed on neglect by both Social Workers with question to include: 1. Do you know what it means to be neglected? If no, please explain definition of neglect to resident. 2. Do you feel that the facility has been neglectful in providing care, providing adequate fluids, observing for clinical changes and notify the MD promptly of any changes? There are 20 alert and oriented residents that were interviewed and no negative findings from the interviews were reported. 100% of all residents were assessed by the Assistant Director of nurses (ADON), Unit Facilitator, Minimum Data Set (MDS) nurse and treatment nurse and completed on 7/1/17 using a resident census for catheter care, any acute change in condition to include, but not limited to, signs and [MEDICAL CONDITION] and/or infected catheters, altered mental status, new onset of cough, lethargy, abnormal vital signs, no urine output and unresponsiveness. 100% of all residents to include resident #1 documentation of vital signs (VS) in the electronic medical record from 6/1/17 until 7/24/17 were reviewed by the facility clinical consultant, DON, quality improvement (QI) nurse, MDS nurses, staff facilitator and unit facilitator will be completed 7/25/17 to determine if all residents' documentation of vital signs were within the resident's baseline. If the resident's vital signs present as abnormal these residents will be reported to the nurse with an assessment of the resident, MD notification, and documentation in the medical record. The DON, QI nurse, MDS nurses, staff facilitator, treatment nurses, Licensed Practical Nurse (LPN), LPN admission coordinator and Unit Facilitator will complete an assessment of all residents by 7/25/17 with documentation of abnormal vital signs that were not reported and/or not assessed. 100% of all residents' vital signs, to include resident #1, will be obtained by the DON, QI nurse, administrative NA, ward clerk-NA, Staff facilitator assistant-NA, staff facilitator, supply clerk-NA, Social Worker-NA, MDS nurses, LPN-admission coordinator and NA Transporter to determine if all residents' vital signs are within the resident's baseline by 7/25/17. If any resident vital signs are found to be abnormal and not to be within their base line, a complete clinical assessment will be completed for other signs and symptoms of acute change in condition. The MD will be notified of the changed in condition and documentation in the medical record by the DON, QI nurse, MDS nurses, staff facilitator and unit facilitator will be completed by 7/25/17. The 100% review of the nurse progress notes, by the DON, ADON, unit facilitators and the QI nurse was completed on 7/3/17, the audit ensured all identified residents with acute changes, to include but not limited to, sign and symptoms [MEDICAL CONDITION], and/or infected catheters, altered mental status, new onset of a cough, lethargy, abnormal vital signs, no urine output, and unresponsiveness, were assessed and provided appropriate interventions and that the MD and residents representative were notified via phone, with voice to voice conversation, no message left for MD, and appropriate documentation is in the medical records. No acute changes in condition were identified that were not appropriately addressed by the DON, ADON, unit facilitators and the QI nurse. A bright colored sign was posted by the facility clinical consultant at each nurse's station on 7/3/17, as a visual guideline for responsibility of the licensed nurse, for voice to voice notification to the physician for changes in resident condition, to include signs and symptoms of dehydration,[MEDICAL CONDITION], and infected catheters. The bright colored sign was changed and reposted by the facility clinical consultant at each nurse's station on 7/24/17 to include but not limited to, sign and symptoms [MEDICAL CONDITION], and infected catheters, altered mental status, new onset of a cough, lethargy, abnormal vital signs, no urine output, and unresponsiveness. 100% in-service was initiated by the staff facilitator on 7/3/17 for all staff, administrator, Account Receivable (AR), DON, ADON, QI nurse, Treatment nurses, Staff Facilitator, Staff Facilitator assistant, Admissions Coordinator, Payroll, receptionists, maintenance director, maintenance assistant, therapy staff, housekeeping, laundry, licensed nurses, nursing assistant, dietary staff, Geri Care aides, Activity Director, Activity assistant and activity aide on Examples of Nursing Home Neglect; Nursing home neglect can vary among individual cases, but below are examples of neglect: When a resident is repeatedly ignored, left alone, or accidentally snapped at by an overstressed employee. When a resident does not receive adequate help with laundry, cleaning, bathing, brushing their teeth, or other forms of hygienic practices. When the nursing home neglects to provide reasonable food, water, or a safe and clean environment. When the nursing home fails to provide adequate attention, prevention to include dehydration, UTI's and infections, or medication for concerns such as pressure ulcers, infections, cuts, diabetes, cognitive diseases, and mobility concerns. Signs of Nursing Home Neglect. Warning signs of nursing home neglect MAY include: 1. Sudden weight loss, 2. Bedsores, or pressure ulcers, 3. Injuries from nursing home falls, 4. Dehydration, 5. Malnutrition, 6. Withdrawn resident behavior, or unusual changes in behavior, 7. Changes in personal hygiene or appearance efforts, 8. A growing lack of friendly interaction with the nursing home staff, 9. A growing lack of friendly interaction with the other nursing home residents, Environmental hazards, such as poor lighting, slippery floors, unsafe mobility equipment, or unsafe furniture in the nursing home patient's room. The in-service was completed on 7/5/17. Prevention of Nursing Home Neglect: The nursing home resident should be monitored for changes in mobile, mental, and physical ability, as well as any developing medical concerns. Any changes noted in the resident should be reported to the nurse. The nurse must report the changes immediately to the MD and Resident Representative and provide appropriate interventions to address the change and prevent further decline and document in the medical records. If a resident has an acute medical change, the resident should be sent out via 911 with verbal notification to the physician. No staff, administrator, AR bookkeeper, DON, ADON, QI nurse, Treatment nurses, Staff Facilitator, Staff Facilitator assistant, Admissions Coordinator, Payroll, receptionists, maintenance director, maintenance assistant, therapy staff, housekeeping, laundry, licensed nurses, nursing assistant, dietary staff, GCA's, Activity Director, Activity assistant and activity aide, will be allowed to work until receiving the in-service on sign and symptoms [MEDICAL CONDITION] and dehydration. The staff facilitator will include the training into the facility orientation for new hires on 7/24/17. 100% in-servicing of all licensed nurses, to include agency nurses, and nursing assistants were initiated by the DON on 7/1/17 regarding signs and symptoms [MEDICAL CONDITION] and dehydration and were completed by 7/5/17. This in-service included the following: Dehydration is defined as a condition in which water or fluid loss (output) far exceeds fluid intake. Due to aging, it becomes difficult to identify the early signs and symptoms of dehydration. These signs and symptoms tend to be unreliable and nonspecific. Signs/Symptoms of Dehydration: Dizziness on sitting/standing, Dry mucous membranes, Confusion or change in mental status, Constipation, Decreased urine output, Fever, Decreased skin turgor. What [MEDICAL CONDITION]?[MEDICAL CONDITION] is a life-threatening illness caused by your body's response to an infection. Your immune system protects you from many illnesses and infections, but it's also possible for it to go into overdrive in response to an infection. Early identification of the signs and symptoms [MEDICAL CONDITION] in the geriatric population (within 1 hour) is essential for implementing early treatment for [REDACTED]. What are the symptoms [MEDICAL CONDITION]? Symptoms [MEDICAL CONDITION] include: a fever above 101ºF or a temperature below 96.8ºF, heart rate higher than 90 beats per minute, breathing rate higher than 20 breaths per minute, probable or confirmed infection. You must have two of these symptoms before a doctor can [MEDICAL CONDITION]. [MEDICAL CONDITION]: [MEDICAL CONDITION] occurs when there's organ failure. You must have one or more of the following signs to be diagnosed with [REDACTED]. Septic shock: Symptoms of septic shock include the symptoms of [MEDICAL CONDITION], plus a very low blood pressure. With any change in condition of the resident, it must be reported to the nurse for assessment and implementation of treatment. 100% in-service of all licensed nurses, to include agency nurse was initiated on 7/1/17 and was completed by 7/5/17 by the DON and staff facilitator regarding notification of physician for changes in resident's condition. These notifications included the following: 1. Notify Physician (speak with the physician) by telephone: 2. Acute Change in Resident Condition occur, 3. Changes in Cognitive Status occur, 4. Changes in Behavior occur, Changes in Oral Intake to include fluids occur, 5. Changes in Immune System occur, 6. Changes in Normal Body Functioning occur, 7. PANIC laboratory values occur, 8. Resident's Condition Warrants based upon nurse's assessments, to include signs and symptoms of dehydration,[MEDICAL CONDITION], and/or infected catheter. If you are unable to reach Attending Physician, you may call the On-call for physician. If you are unable to reach attending or on-call physician, you may call the facility's Medical Director. If unable to reach the Attending Physician, the on-call physician or the Medical Director then call 911 and the DON must be notified. Notification of the physician of these types of changes in a resident's condition by fax or leaving a message is not acceptable! Documentation of the notification of the attending physician will be documented in the resident's chart. 100% of licensed nurses, to include agency nurses, were in serviced by the staff facilitator by 7/3/17 on; when there is an acute change in condition, the resident must be sent to the ER via 911 not via non-emergent transport company. These acute changes in condition include, but not limited to, altered mental status [MEDICAL CONDITION]. A full set of vital signs, to include, temperature, pulse, respirations, oxygen saturation, and blood pressure must be obtained and verbal notification via phone to the MD. Always give the emergency room nurse a detailed report. An E-Interact Change in condition tool and an E-Interact transfer form (a tool that is used to give detailed description of the residents change in condition that results in transfer to the hospital) must be completed for all acute changes in condition and transfer to the hospital and a copy sent to the ER with the resident or faxed a copy to the ER if completed after the resident is sent the hospital. The licensed nurse is responsible for assessing, document, provide appropriate interventions and notify the MD and resident representative of any acute changes in condition, to include, but not limited to, signs and [MEDICAL CONDITION] and/or infected catheters, altered mental status, new onset of a cough, lethargy, abnormal vital signs, no urine output and unresponsiveness and/or any other significant clinical information, noted. If the licensed nurse is unable to reach the attending physician, the on-call MD must be called. If unable to contact the attending or the on-call MD, the nurse must call the Medical Director. If unable to reach, voice to voice, the attending physician, the on-call or the medical director, then 911 for transport will be called and the DON MUST be notified. Questionnaires were initiated on 7/4/17 by the DON with 100% of all license nurses completed by 7/7/17 for validation of understating regarding assessing for acute changes in condition and MD and resident ' s representative Notification to include: 1. How is the physician to be notified of change with the resident? 2. What can be considered a change in the resident that the physician would be called? 3. If you are unable to speak with the physician what do you do? 4. If unable to speak with the attending physician or the on-call physician, who would you call? 5. Where is the notification of the physician documented? 6. How do assess for a change in condition? 7. If a resident has a clinical deterioration, how would they be transported to the ER? 100% of the licensed nurses will have their questionnaires reviewed by the Registered Nurse facility consultants by 7/24/17. Any identified licensed nurse that are unable to correctly answer the questionnaire will be re-trained by the DON and required to complete and new questionnaire. If upon the second attempt, the licensed is unable to correctly answer the questionnaire, the licensed nurse will be removed from the schedule until remediation is provided. The facility ' s credible allegation was validated on 7/25/17 when interviews with direct care nursing staff and non-nursing staff confirmed they had received in service training, conducted audits and posted information for staff regarding changes in resident conditions as specified in the facility ' s credible allegation of compliance.

Based on record review, staff interviews, and physician interview, the facility administration failed to provide the leadership and management necessary to ensure 1 of 3 resident(s) (Resident #1) received adequate care to prevent hospitalization with the [DIAGNOSES REDACTED]. Immediate Jeopardy (IJ) began on 6/24/17 when Resident #1 was not assessed and not provided treatment for [REDACTED]. The Administrator, Director of Nursing (DON), and Corporate Clinical Director were notified of the IJ on 7/24/17 at 11:46 am. IJ was removed on 7/25/17 at 3:23 pm when the facility provided and implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring and quality improvement measures. Findings included: This tag is cross referenced to: 1. a. F157: Based on record review, staff interviews, resident ' s representative interview, and physician interview, the facility failed to notify the physician and resident ' s responsible party of a significant change in condition which resulted in hospitalization with [DIAGNOSES REDACTED].#1). b. F224: Based on record review, staff interviews, and physician interview, the facility failed to assess an acute change in condition, failed to initiate necessary care and treatment for [REDACTED].#1). c. F309: Based on record review, staff interviews, the resident ' s representative interview, and physician interview, the facility failed to recognize the resident ' s change in condition and failed to provide the hospital with a complete assessment of the resident ' s changes resulting in a delay of treatment, hospitalization , and [MEDICAL CONDITION] for 1 of 3 residents (Resident #1). The Administrator, Director of Nursing (DON), and Corporate Clinical Director were notified of the IJ on 7/24/17 at 11:46 am. The facility provided a credible allegation of compliance on 7/25/17 at 2:41 pm as follows: The facility under the direction of the Registered Nurse (RN)-corporate clinical consultant initiated on 7/3/17, a thorough investigation to ascertain the root cause for failure to asses, report and intervene in Resident #1 care. The root cause of the investigation determined communication on the part of NA #1 and nurse #1's failure to assess Resident #1 on the 3-11pm shift. The root cause analysis determined that on the 3-11 pm shift on 6/24/17 nursing assistant #1 obtained resident #1's pulse and recorded at forty-one (41) beats per minute. Nursing Assistant (NA) #1 was interviewed by the surveyor on 7/24/17. NA #1 stated, Resident #1's blood pressure was unable to be obtained, and nurse #1 was notified and nurse #1 stated to re-check again. Nurse # 1 failed to assess the resident on the 3-11pm shift. Nurse #2 on the 11-7am shift assessed resident #1 and sent to the local hospital for evaluation on 6/24/17 and documented in the electronic medical record at 1:08 am on 6/25/17 of the resident transfer to the local hospital. NA #1 upon an interview with the regional vice president and corporate clinical consultant on 7/24/17 was specifically questioned if she had re-checked the pulse stating, I am unable to recall anything to include the vital signs. The interview further revealed, NA #1 stating, I failed to re-call any information specific to resident #1 vital signs as stated to the surveyor on 7/24/17 at 5:00 pm. Upon the conclusion of the interview with the regional vice president and corporate clinical director, NA #1 walked out of the facility with no intent to return on 7/24/15 at 5:15 pm. On 6/24/17 resident #1 was assessed by nurse #1 and was noted as sounding congested with wheezing to the right upper lobe, low urine output and leaking urine around the Foley catheter. On 6/24/17 nurse #1 attempted to irrigate resident #1 Foley catheter but was unsuccessful. On 6/24/17 nurse #1 discontinued resident #1 Foley catheter with #14fr/10cc Foley and reinserted with a return of clear amber urine and noted slight bleeding after insertion. On 6/25/17 1:08 am nurse #2 went into resident #1 room and found resident #1 not responding normally. On 6/25/17 nurse #2 assessed resident #1 with a temperature of 101.1 Fahrenheit, observation of [DEVICE] noted with draining grainy black substance and wet lungs sounds. On 6/25/17 nurse #2 suctioned resident #1 but it was not effective and observed resident #1 to be weak with blood noted in urine. On 6/25/17 nurse #2 notified a transport company to transport resident #1 to the emergency room . On 6/25/17 the transport company transported resident #1 to the hospital to be evaluated. On 6/25/17 nurse #2 faxed the Medical Doctor (MD) and made the MD aware of Resident #1 condition and transport to the emergency room (ER). On 6/25/17 nurse #2 reported resident #1 condition to the ER nurse. On 6/30/17 the Licensed Practical nurse-admissions Coordinator notified the MD of Resident #1's change in condition from 6/25/17 and the condition of resident #1 upon discharge and hospitalization to the local hospital. On 6/25/17 resident #1 was assessed by the local hospital ER. Resident #1 was admitted on [DATE] and remained in acute care through 7/1/17. Upon the conclusion of the investigation it was determined overall root cause of the failure to communicate a determination in resident #1 acute change in condition and for nurse #1 to assess and to intervene appropriately and notification of the Medial Doctor and resident representative. The agency nurse was removed from the schedule on 6/26/17 and placed on the do not return list to the facility from the staffing agency. The DON notified the agency on 6/30/17 of the nurse's failure to assess the resident and the facilities requirement for nurse #1 not return. By 7/5/17, NA #1 was re-educated on notification to the licensed nurse of abnormal vital signs and changes in condition. NA #1 is no longer an employee of the facility due to NA#1 walking out on 7/24/17. In services were initiated on 7/25/17 by the RN-corporate clinical consultants and regional vice president to address the root cause analysis conclusions to include communication, acute changed in condition, and proper notification to the MD and resident representative. On 7/3/17, the corporate clinical director and facility consultant met with the Director of Nursing (DON), administrator, unit facilitator, Social Worker (SW), Quality Improvement (QI) Nurse, Medical Director and Staff Facilitator to develop and initiate a plan of action in regards to hydration, urinary tract infections [MEDICAL CONDITION], Foley catheters, assessing acute change in condition, neglect, MD notification, transportation services [MEDICAL CONDITION] to ensure the facility uses its resources effectively and efficiently to obtain and maintain the highest practical wellbeing of each resident. On 7/3/17 the formal Quality Improvement (QI) committee members (administrator, DON, QI nurse, SW, Staff Facilitator, Medical Director and nurse unit facilitator) discussed: abuse/neglect policy procedure, acute changes in condition and MD notification. Under the direction of the Registered Nurse corporate clinical director and regional Vice president, the committee recommended and implemented on 7/3/17 the plan of action to include the following: 1. In servicing to include agency nurses on ensure the prevention of neglect of residents, 2. Posting a bright colored sign as a guideline for licensed nurses, to include agency nurses as a visual guide for the responsibility of the licensed nurse to notify the MD via voice to voice notification of acute changes in condition, 3. Recognizing acute change in and assessing for acute changes in condition. 4. Regarding notification of physician for changes in resident condition. 5. Providing the detailed report to emergency room nurse. 6. Appropriate use of transport services. 7. Completing Change in condition E-Interact tool and Transfer E-Interact tool. All recommendations will be completed by 7/25/17 by the Director of Nursing (DON), administrator, unit facilitator, Quality Improvement (QI) Nurse, Medical Director and Staff Facilitator. On 7/25/17, the regional vice president (RVP), the corporate clinical director and the facility consultant met with the administrator and director of nursing (DON) to review the significance of the immediate jeopardy and expedited protection of the residents. The administrator and DON were further in serviced by the RVP on 7/25/17, on performing root cause analysis to determine potential systemic failure and implement an immediate plan to protect the residents from neglect. On 7/25/17 the RVP in serviced the administrator and the DON on ensuring residents are free from neglect, ensuring that staff are trained on neglect, Medical Doctor (MD) notification, recognizing acute change in condition, to [MEDICAL CONDITION] and assessing acute changes in condition, to include obtaining vital signs, and utilizing appropriated transportation services. On 7/3/17 the corporate consultants directed the initiation of the following audits to see if other residents had been affected: 1. Resident assessment audits for acute changes in condition, to [MEDICAL CONDITION], altered mental status, new onset of a cough, lethargy, and unresponsiveness. 2. Catheter audits, to include urine output. 3. Interviews with alert and oriented residents regarding neglect. 4. Progress note review for 30 days for acute changes in condition. The results of the audits were reviewed by the corporate consultants on 7/24/17 and demonstrated there were no other residents found to be effected. On 7/3/17 the corporate consults directed the initiation of questionnaires with all licensed nurses, for validation on understanding regarding assessing for acute changes in condition and MD notification and resident representative. The corporate consultant reviewed all questionnaires on 7/24/17 with one licensed nurse identified as unable to correctly answer all questions on the questionnaire. The identified licensed nurse that was unable to correctly answer the questionnaire no longer works at the facility as of 7/24/17. 1. On 7/24/17 the corporate consultants directed the initiation of the following audits to see if other residents had been affected: 2. Obtaining resident vital signs 3. Review the electronic medical record to ensure the documentation of the vital had occurred and were within the baseline. 4. Any resident that presented with vital signs that were not within baseline from 6/1-7/24/17 will be assessed by 7/25/17 by a licensed nurse and implement intervention as appropriate. In servicing with all nursing assistants (NA): 1. Reporting to nurse any changes in condition, to include vital signs. 2. Vital sign parameters. 3. Review of 24 hours reports sheets/progress notes for changes in condition. 4. Discussion of acute change in condition and residents sent to the hospital during the daily clinical meeting. In service to facilitate communication and address the five whys of the root cause analysis of NA's to licensed nurses on vital signs that are not within the base line and nursing assessment with notification to the MD and resident representative. Beginning on 7/3/17, the regional vice president, corporate clinical director, and corporate consultants, began providing oversite to the facility and monitoring to ensure the facility has systems in place to provide the leadership and management necessary to meet the residents needs by the following: 1. Reporting to nurse any changes in condition, to include vital signs. 2. Vital sign parameters. 3. Review of 24 hours reports sheets/progress notes for changes in condition. 4. Discussion of acute change in condition and residents sent to the hospital during the daily clinical meeting. And the regional vice president, corporate clinical director, and corporate consultants, began providing oversite to the facility and monitoring to ensure the facility has systems in place to provide the leadership and management necessary to meet the residents needs by the following: 1. In servicing to include agency nurses on ensure the prevention of neglect of residents, 2. Posting a bright colored sign as a guideline for licensed nurses, to include agency nurses as a visual guide for the responsibility of the licensed nurse to notify the MD via voice to voice notification of acute changes in condition, 3. Recognizing acute change in and assessing for acute changes in condition. 4. Regarding notification of physician for changes in resident condition. 5. Providing the detailed report to emergency room nurse. 6. Appropriate use of transport services. 7. Completing Change in condition E-Interact tool and Transfer E-Interact tool. The Quality Improvement Organization will be contacted by the Director of Nursing on 7/25/17 for assistance in determining the root cause of the deficient practice and the communication problem on why nurse #1 on the 3-11 pm shift failed to assess, evaluation of the acknowledgement of the issues being addressed, specific steps to be taken to address the issues, staff position/title designated to be responsible for the steps, timeline for accomplishment of the steps, specific methodology to be used to evaluate the plan ' s success, and frequency of monitoring the effects of the plan initiation. On 7/25/17 at 2:00 pm an interview was conducted with the Administrator. The Administrator stated the he was interim status as of 3/24/17. The facility was implementing changes for the plan of correction. The Administrator and management was overseeing the element of the plan, in-services, and monitoring. The Administrator would ascertain ongoing evaluation, implementation, and changes as needed. All elements of the plan of correction would be the topic for the monthly Quality Improvement committee meeting. Quality Improvement committee members were the Administrator, DON, Quality Improvement Nurse, Social Work, Staff Facilitator, Medical Director, and Nurse Unit Facilitator. IJ was removed on 7/25/17 at 3:23 pm when the facility implemented a credible allegation of compliance when interviews with direct care nursing staff and non-nursing staff confirmed they had received in service training, conducted audits and posted information for staff regarding changes in resident conditions as specified in the facility ' s credible allegation of compliance.

Based on record reviews, physician and staff interviews, the facility failed to immediately notify one of one sampled resident (Resident #1) physician and responsible party of a right hip pain . The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had long and short term memory problems, decision making skills were moderately impaired and he needed limited assistance with 2 persons with bed mobility and transfer. Review of the injury of unknown origin report dated 7/19/2016 documented Resident noted to have a bruise to right hip, got an x- ray noted to have fracture to right femur. NA (Nurse Aide) #9's statement dated 7/20/2016 documented I took care of the resident on Friday 7/15/2016. There were no incidents. I didn't see any bruise on the resident's body. He didn't appear to be in any pain. NA #1's statement dated 7/20/2016 documented Friday 11-7 shift 7/15/2016 during care on Resident #1 he showed no sign of pain. During the interview on 7/28/2016 at 1:40 PM, Nurse #1 who is also the Assistant Director of Nursing (ADON) was assigned to work with the resident on the second shift on Saturday 7/16/2016 reported that the resident was sitting in his recliner and the Nurse Aide reported to her that the resident was in pain. She added that she gave the resident the prn (as needed) medication and reported the resident's pain to the 11-7 shift nurse. The nurse stated she did not notify the doctor or the responsible party of the resident's pain. NA #4's statement dated 7/19/2016 documented When caring for the resident on Saturday July 16th 2016 11-7 shift I noticed that he was experiencing a vast amount of pain when changing him. It was extremely unbearable for him to move or for me to move him. Reported it to the ADON (Assistant Director of Nursing) During the interview on 7/28/2016 at 3:08 PM, NA #4 reported she was assigned to work with Resident #1 on 7/16/2016 on third shift. She reported that the resident was in an excruciating pain at about 11 PM. NA #4 added that she reported the concern to the nurse. She also reported that on Sunday 7/17/2016 morning, the resident was in so much pain and she did not reposition the resident. NA #4 added she had to rip the resident's pull up in order to provide the incontinence care. NA #2's statement dated 7/19/2016 documented I was the sitter for 7-3 on 7/17/2016. The 11-7 sitter told me the resident was in pain most of the night (R leg) when I had him he was in pain I told Nurse #2, my nurse, and she gave him something for pain. He was in bed all shift for me. During the interview on 7/28/2016 at 3:30 PM, NA #2 reported that she was assigned to work with the resident on Sunday 7/17/2016 during the second shift. She reported at 3: 00 PM when she was trying to turn the resident he would holler with pain yelling don't touch me. According to the MAR (Medication Administration Record) for July the resident was prescribed pain medication PRN (as needed medication) [MEDICATION NAME] 800 mg (milligram). The MAR indicated [REDACTED]. Nurse Aide (NA) #1's statement dated 7/18/2016 documented On Sunday night 11-7 shift 7/17/2016 during the care on Resident # 1 the resident yelled out with pain. I stopped care and ask resident what's wrong where he was hurting, I noticed when turning him from the right side he shouted. I asked resident again show me where it hurts. Review of the incident report completed by the DON (director of nursing) dated 7/18/2016 documented Received report from oncoming day shift Nurse Aide on 7/18/16 that the resident had a bruise to upper right hip. Resident noted to have pain to right side knee and hip and favored his right side while in bed, resident remained in bed, leg stabilized moaned, did not want to be repositioned. Under immediate action taken subheading the report indicated Pain medication provided, MD (Medical Doctor) called, X-ray ordered, Responsible party were called on 7/18/16. The injury of unknown origin first appeared with the resident's complaint of pain on 7/16/2016 during third shift. During the interview with Nurse #3 on 7/28/2016 at 3:20 PM, She reported she was assigned to work with the resident on 7/18/2016 second shift. Nurse # 3 stated it was reported to her on 7/18/2016 first shift nurse that the resident had been refusing to get out of bed for 2 days. She added the first shift nurse reported to her that she had gotten an order for [REDACTED]. Nurse # 3 added when she received the result after the x-ray was taken, she called 911 to transport the resident to the emergency room at about midnight. Review of the x-ray report dated 7/18/2016 indicated there is acute trans cervical [MEDICAL CONDITION] femur. No dislocation or subluxation. The visualized bony structures appear unremarkable. Review of the Hospital discharge summary dated 7/28/2016 documented The patient presented to the emergency department via EMS (Emergency Medical Services) from the nursing home secondary to a fall with subsequent right [MEDICAL CONDITION]. The resident's discharge plan indicated: Right [MEDICAL CONDITION] post mechanical fall. The patent is postoperative day # 6. The patient is awaiting rehabilitation placement. During the interview on 7/28/2016 at 2:15 PM, the Physician reported that he was not notified about the change in the resident's level of pain until Monday 7/18 /2016 around 3pm. He added that the nurse should have notified him of the resident's pain on Saturday 7/16/2016 when they noticed that the resident continued to be in excruciating pain after attempting prn (as needed medication). Physician also added that the medication that was being given to the resident was not enough to stop the resident's pain since the pain was as a result of a fracture. Review of the facility's investigation report revealed the facility submitted to the Health Care Personnel Investigation (HCPI) a 24 hour report on 7/19/2016 and a 5 day report on 7/25/2016. The report was indicating an investigation on Resident #1's injury of unknown origin. During the interview on 7/28/2016 at 3:40 PM, The Director of Nursing (DON) reported she was made aware of the resident's fracture on 7/18/2016 during first shift around 10am. She stated the doctor was made aware of the x-ray results and the resident was sent out to the emergency room . She also acknowledged that the staff should have reported to the doctor on Saturday 7/16/2016 the change in the level of resident's pain than later on Monday. She also added the family should have been notified on Saturday of the change in the resident's pain when it was first noticed. The DON also reported she conducted an investigation to find the cause of the resident's fracture and she could not identify the cause. She reported she faxed to the state agency a 24 hour report on 7/19/2016 and 5 days report on 7/25/2016 reporting injury of unknown origin. She also reported she had completed a plan of correction to make sure the incident does not happen again. The corrective action for past non-compliance dated 7/25/2016 included: Resident # 1 had a bruise of unknown origin on 7/18/2016, and x-ray showed a femur fracture of a left hip. Resident # 1 currently is discharged from facility to the hospital. A 100% body assessment audit of all resident with Brief Interview for Mental Status (BIMS) score of less than 13 were checked and assessment completion date is 7/22/2016 by hall nurses. All resident with BIMS score of 13-15 were interviewed for possible abuse, neglect or injuries and the completion date is 7/22/2016 by the Social worker. Staff facilitator assistant, and/or administrator reviewed all clinic notes, entries, and 24 hour summaries for possible injuries, changes in conditions and increased pain occurrence for the last 30 days. The completion date is 7/19/2016 by Director of Nursing (DON). Corrective action taken per policy. 100% in-servicing of all nurses will be provided by the staff facilitator on abuse, reporting abuse, types of abuse, changes in condition assessment and timely treatment which will include the doctor and responsible party notification, as well as documentation for changes in condition prior to reporting to duty. The staff will be unable to take the floor until the completion of the in-servicing. 100% in-service of all Nurse's Aide will be provided by the staff facilitator on abuse, reporting abuse, types of abuse, reporting changes in condition to chain of command, documentation for changes in condition in appropriate portals prior to reporting to duty and the staff will be unable to take the floor until completion of in-service. All newly hired staff will be in -serviced upon hire by staff facilitator. Face to face director of nursing meeting will be conducted with nurses and Nurse Aide. They will be discussing documentation, changes in condition, and resources for reporting any nursing concerns to the administrative staff if they do not feel their concerns or issues are not being addressed. The completion date for Nurses and Nurse Aides is 7/25/2016 and for the DON is 7/25/2016. Any employee unable to attend the meeting will be in-serviced prior to reporting to duty and will not be able to take the floor until completion of the in-service. Incident interventions and daily charting will be monitored by DON, ADON (Assistant Director of Nursing), and Supervisor nurse daily from Monday through Friday. The resident population which includes Resident # 1 upon return to the facility will be monitored indefinitely, using a 24 hour shift summary QI (Quality Improvement) tool. Concerns will be addressed immediately and retraining will be conducted for any identified areas of concern by Staff facilitator, DON, ADON, and/ or QI nurse. The completion date is 10/18/2016 This will be monitored by the executive committee weekly x 4 and monthly x 2, and concerns will be addressed appropriately. The completion date is 10/18/2016 As part of the validation process on 7/28/2016, the entire plan of correction was reviewed including re-education of staff .The named resident was not at the facility during the validation. Interviews of the nurse aides and nurses revealed they were aware of reporting of change in the residents' condition which included reporting to the physician of increase in the level of pain on residents and the family member. A review of the monitoring tools revealed that the facility had completed the 100 % in-service of reporting of residents change in condition.

Based on record reviews, physician and staff interviews, the facility failed to provide appropriate pain management which caused one of one sampled resident (Resident #1) to have pain related to a fractured right hip for 3 days. The findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had long and short term memory problems, decision making skills were moderately impaired and he needed limited assistance with 2 persons with bed mobility and transfer. Resident #1's care plan dated 6/13/2016 documented the resident was at risk for falls. The care plan documented following interventions: Assist resident to negotiate barriers, assist the resident with transfers and ensure the environment is free of clutter as possible. The resident care plan also indicated the resident required occasional assistance to maintain maximum function of self-sufficiency for transferring. The care plan documented the following interventions: Transfer independent at times, may need 2 person assist due to behaviors, monitor for safety awareness. Further review of the care plan revealed the resident was not care planned for pain management. Review of the MAR (Medication Administration Record) for the month of July 2016 revealed the resident was prescribed pain medication PRN (as needed medication) [MEDICATION NAME] 800 mg (milligram) for pain. Further review of MAR indicated [REDACTED]. The resident was given medication for pain on 7/15/2016 at 8:00 AM and 7/17/2016 at 8:00 PM. Review of the injury of unknown origin report dated 7/19/2016 documented Resident noted to have a bruise to right hip, got an x- ray noted to have fracture to right femur. NA (Nurse Aide) #9's statement dated 7/20/2016 documented I took care of the resident on Friday 7/15/2016. There were no incidents. I didn't see any bruise on the resident's body. He didn't appear to be in any pain. NA #1's statement dated 7/20/2016 documented Friday 11-7 shift 7/15/2016 during care on Resident # 1 he showed no sign of pain. NA #6's statement dated 7/20/2016 documented On Saturday 7/16/2016 I worked on the resident's unit and the resident was in his recliner the whole day and complaining of knee pain. We did stand him once to change him. On Sunday 7/17/2016 he was in bed the whole day. NA #5's statement dated 7/19/2016 documented Saturday 7/16/2016 , I came in 3:00 PM the resident had a sitter and a Nurse Aide when I left at 7:00 PM, the other Nurse Aide came on at 7: 00 PM but was later asked to be the sitter. I noticed the resident was holding his knee and said he was hurting. Nurse was notified, later that evening the resident wouldn't turn to be changed. Sunday I came in he was hurting bad, I asked the sitter why he is holding his right side. I came on Monday I was told he had bruises on his right. NA #7's statement date 7/20/2016 documented 7/16/2016 I came in 11: 00 PM resident was in his chair and the other Nurse Aide said she was waiting for the Nurse to bring him some pain medication. She said the resident cannot walk or get up out of the chair, so I said I will help walk him to his bed and we did and he was in a lot of pain. On 7/16/2016 I came in at 3:00 PM he was in bed I stay until 7: 00 AM and he was in bed the all-time. His pain was bad we then tried to change him with another Nurse Aide. During the interview on 7/28/2016 at 1:40 PM, Nurse # 1 who was assigned to work with the resident on the second shift on Saturday 7/16/2016 reported that the resident was sitting in his recliner and the Nurse Aide reported to her that the resident was in pain. She added that she gave the resident the prn (as needed) medication and reported the resident's pain to the 11-7 shift nurse. During the interview on 7/28/2016 at 3:08 PM, NA # 4 reported she was assigned to work with Resident # 1 on 7/16/2016 on third shift. She reported that the resident was in excruciating pain at about 11 PM. NA # 4 added that she reported the concern to the nurse. She also reported that on Sunday 7/17/2016 morning, the resident was in so much pain and she did not reposition the resident. NA # 4 added she had to rip the resident's pull up in order to provide the incontinence care NA #1's statement dated 7/18/2016 documented On Sunday night 11-7 shift 7/17/2016 during the care on Resident #1 the resident yelled out with pain. I stopped care and ask resident what's wrong where he was hurting, I noticed when turning him from the right side he shouted. I asked resident again show me where it hurts. NA #3's statement dated 7/19/2016 documented On Saturday 7/16/2016 I came in to do 1 on 1 on the resident and got report from another Nurse Aide that I would not have too much problems with the resident. The resident stayed in his chair the entire time and he didn't really seem to be in to too much pain except for when he would attempt to get up. I saw no reason to report the pain since I had already been told he was in pain I figured it had already been reported. NA #4's statement dated 7/19/2016 documented When caring for the resident on Saturday July 16th 2016 11-7 shift I noticed that he was experiencing a vast amount of pain when changing him. It was extremely unbearable for him to move or for me to move him. Reported it to the ADON (Assistant Director of Nursing). Nurse #2's statement with no date documented note for 7/17/16, Sunday: resident was in bed with eyes closed most of the day, received in report that resident has right knee joint pain and that resident also has arthritis and receives pain medication for it. Nurse #1's statement dated 7/18/2016 documented This writer on 7/18/2016 was walking the hall with 7-3 nurse on spark unit when 7-3 Nurse Aide approached this writer and 7-3 Nurse. Nurse Aide stated, 11-7 Nurse Aide stated this resident has been having hip pain all night. 7-3 Nurse Aide stated resident had bruise on right hip and asked if this writer had been notified. This writer stated she had not been notified of any bruise or hip pain. The 11-7 Nurse Aide at 7:20 AM only stated to this writer that resident's knee had been bothering him again. Nurse's note dated 7/18/2016 at 3:36 PM documented Resident remains on one to one monitoring. Resident has complaints of pain to right hip and right knee. Pain medication administered per order. Pain is still present. The writer assessed slight bruising to right upper hip. The writer notified the doctor of the residents condition-orders received for resident to receive an x-ray and prn (as needed) ice. Review of the incident report completed by the DON (director of nursing) dated 7/18/2016 documented Received report from oncoming day shift Nurse Aide on 7/18/16 that the resident had a bruise to upper right hip. Resident noted to have pain to right side knee and hip and favored his right side while in bed, resident remained in bed, leg stabilized moaned, did not want to be repositioned. Under immediate action taken subheading the report indicated Pain medication provided, MD (Medical Doctor) called, X-ray ordered, Responsible party were called on 7/18/16. The injury of unknown origin first appeared with the resident's complaint of pain on 7/16/2016 during third shift. During the interview on 7/28/2016 at 2:29 PM, the Dietary aide #1 who was a sitter for Resident #1 on 7/18/2016 reported the resident was in so much pain on Monday 7/18/2016 at dinner time. She added the resident was not able to sit in upright position to eat his dinner. Dietary aide #1 further reported she expressed her concern to the nurse aide who was assigned to the resident about the resident's pain. During the interview with Nurse #3 on 7/28/2016 at 3:20 PM, She reported she was assigned to work with the resident on 7/18/2016 second shift. Nurse #3 stated it was reported to her on 7/18/2016 by the first shift nurse that the resident had been refusing to get out of bed for 2 days. She added the first shift nurse reported to her that she had gotten an order for [REDACTED]. Nurse #3 added when she received the result after the x-ray was taken, she called 911 to transport the resident to the emergency room at about midnight. Review of the x-ray report dated 7/18/2016 indicated there is acute trans cervical [MEDICAL CONDITION] femur. No dislocation or subluxation. The visualized bony structures appear unremarkable. Nurse's note dated 7/20/2016 documented Resident noted to be out of facility in hospital due to right [MEDICAL CONDITION] with follow up with interventions upon return, MD (Medical Director) and RP (Responsible Party) aware. Review of the Hospital discharge summary dated 7/28/2016 documented The patient presented to the emergency department via EMS (Emergency Medical Services) from the nursing home secondary to a fall with subsequent right [MEDICAL CONDITION]. The resident's discharge plan indicated: Right [MEDICAL CONDITION] post mechanical fall. The patent is postoperative day # 6. The patient is awaiting rehabilitation placement. During the interview on 7/28/2016 at 2:15 PM, the Physician reported that he was not notified about the change in the resident's level of pain until Monday 7/18 /2016 around 3pm. He added that the nurse should have notified him of the resident's pain on Saturday 7/16/2016 when they noticed that the resident continued to be in excruciating pain after attempting prn (as needed medication). Physician also added that the medication that was being given to the resident was not enough to stop the resident's pain since the pain was as a result of a fracture. During the interview on 7/28/2016 at 3:40 PM, The Director of Nursing (DON) reported she was made aware of the resident's fracture on 7/18/2016. She stated the doctor was made aware of the x-ray results and the resident was sent out to the emergency room . She also acknowledged that the staff should have reported to the doctor on Saturday 7/16/2016 the change in the level of resident's pain than later on Monday. She also added the family should have been notified on Saturday of the change in the resident's pain when it was first noticed. The DON also reported she conducted an investigation to find the cause of the resident's fracture and she could not identify the cause. She reported she faxed to the state agency a 24 hour report on 7/19/2016 and 5 days report on 7/25/2016 reporting injury of unknown origin. She also reported she had completed a plan of correction to make sure the incident does not happen again. The corrective action for past non-compliance dated 7/25/2016 included: Resident # 1 had a bruise of unknown origin on 7/18/2016, and x-ray showed a femur fracture of a left hip. Resident # 1 currently is discharged from facility to the hospital. A 100% body assessment audit of all resident with Brief Interview for Mental Status (BIMS) score of less than 13 were checked and assessment completion date is 7/22/2016 by hall nurses. All resident with BIMS score of 13-15 were interviewed for possible abuse, neglect or injuries and the completion date is 7/22/2016 by the Social worker. Staff facilitator assistant, and/or administrator reviewed all clinic notes, entries, and 24 hour summaries for possible injuries, changes in conditions and increased pain occurrence for the last 30 days. The completion date is 7/19/2016 by Director of Nursing (DON). Corrective action taken per policy. 100% in-servicing of all nurses will be provided by the staff facilitator on abuse, reporting abuse, types of abuse, changes in condition assessment and timely treatment which will include the doctor and responsible party notification, as well as documentation for changes in condition prior to reporting to duty. The staff will be unable to take the floor until the completion of the in-servicing. 100% in-service of all Nurse's Aide will be provided by the staff facilitator on abuse, reporting abuse, types of abuse, reporting changes in condition to chain of command, documentation for changes in condition in appropriate portals prior to reporting to duty and the staff will be unable to take the floor until completion of in-service. All newly hired staff will be in -serviced upon hire by staff facilitator. Face to face director of nursing meeting will be conducted with nurses and Nurse Aide. They will be discussing documentation, changes in condition, and resources for reporting any nursing concerns to the administrative staff if they do not feel their concerns or issues are not being addressed. The completion date for Nurses and Nurse Aides is 7/25/2016 and for the DON is 7/25/2016. Any employee unable to attend the meeting will be in-serviced prior to reporting to duty and will not be able to take the floor until completion of the in-service. Incident interventions and daily charting will be monitored by DON, ADON (Assistant Director of Nursing), and Supervisor nurse daily from Monday through Friday. The resident population which includes Resident # 1 upon return to the facility will be monitored indefinitely, using a 24 hour shift summary QI (Quality Improvement) tool. Concerns will be addressed immediately and retraining will be conducted for any identified areas of concern by Staff facilitator, DON, ADON, and/ or QI nurse. The completion date is 10/18/2016 This will be monitored by the executive committee weekly x 4 and monthly x 2, and concerns will be addressed appropriately. The completion date is 10/18/2016 As part of the validation process on 7/28/2016, the entire plan of correction was reviewed including re-education of staff .The named resident was not at the facility during the validation. Interviews of the nurse aides and nurses revealed they were aware of reporting of change in the residents' condition which included reporting to the physician of increase in the level of pain on residents and the family member. A review of the monitoring tools revealed that the facility had completed the 100 % in-service of reporting of residents change in condition.

Based on observation, record review and staff interviews, the facility failed to provide supervision on the Alzheimer ' s Unit to prevent a resident from pushing another resident down and being verbally abusive and aggressive to other residents for 1 of 1 sampled residents with aggressive behaviors (Resident #4). Resident #4 was admitted to the facility ' s locked unit on 09/03/10 with a [DIAGNOSES REDACTED]. Review of the Resident ' s Progress Notes revealed that on the day of admission (09/03/10) at 7:50 PM a resident yelled at Resident #4 and Resident #4 grabbed the other resident ' s arm, pushed her against the wall and stated: " I ' ll kill you, you m.f. " The record showed that the two residents were separated by a nurse and redirected and Resident #4 was put on q (every) 15 minute checks. The Physician for Resident #4 was notified and an adjustment was made to the Resident ' s medication. The Progress Notes showed that the 2 residents were separated, Resident #4 was redirected and he calmed down shortly after the altercation. The form used by staff to sign off on the q (every)15 minute checks showed that this intervention was discontinued at 6:45 AM on 09/06/10. The Progress Notes showed that on 09/14/10 at 5:44 PM a nurse heard Resident #2 yelling and before the nurse could run down the hallway, Resident #4 pushed Resident #2 to the floor and the resident sustained [REDACTED]. The residents were redirected and both were put on 15 minute checks. The Physician for Resident #4 was made aware and there were no new orders given. The form used by staff to sign off on the q (every)15 minute checks showed the last check at 6:45 AM on 09/16/10. The Investigation Follow-Up Report under Interventions Taken to Prevent Reoccurrence listed the following interventions: Q (every) 15 minute checks, behavior monitoring and redirection of the resident. The Admission Minimum Data Set (MDS) assessment dated [DATE] showed that the Resident had short and long term memory problems and had poor decision making skills requiring cues and supervision. The MDS indicated that the Resident had persistent anger with self or others and had behaviors of wandering and of being verbally and physically abusive. The Resident Assessment Protocol (RAP) Summary for Cognitive Loss/Dementia dated 09/16/10 revealed that the Resident had a progressive decline in intellectual functioning with deficit in memory, judgement, decision making and thought processes related to a [DIAGNOSES REDACTED]. The RAP for Mood State read in part: " admitted from home to our Spark Unit. Has been aggressive verbally and physically since admission. " The RAP for Behavioral Symptoms read in part: " Will curse/yell at staff and residents. Physically aggressive by pushing other residents. " The Care Plan for Resident #4 for behaviors dated 09/16/10 listed a problem with ineffective coping with verbal and physical aggression and combativeness related to anger and a change in routine with a goal to reduce incidents of aggression and angry outbursts. The Care Plan included the following interventions: Document summary of each episode. Note cause and successful interventions, include frequency and duration. Help resident identify activities that tend to decrease angry behavior and encourage their utilization. If strategies are not working, leave resident and reapproach. A Progress Note dated 09/18/10 at 9:23 PM indicated that the Resident was yelling and cursing at staff when asked to sit down for dinner and the Resident was redirected. There was no information documented as to how the Resident was redirected or the results of the intervention. The Progress Notes revealed that on 10/02/10 at 10:23 PM Resident #4 was cursing at other residents. When staff redirected the Resident, he began pushing and swinging at staff. There was no information documented as to how the Resident was redirected or what interventions were successful to reduce the Resident ' s agitation. Progress Notes showed that on 10/04/10 at 6:28 PM Resident #4 was observed pulling on Resident #5. When redirected by staff the resident started yelling, cursing, threatening and swinging at staff. Resident #4 was redirected by staff. There was no documentation as to how the Resident was redirected, how long the agitation persisted and what interventions were successful to reduce the Resident ' s agitation. The Progress Notes showed that on 10/05/10 at 5:47 PM a nursing assistant was bringing Resident #6 to the dining room and the Resident said " Hi there " to Resident #4. Resident #4 raised his hand toward Resident #6 and stated: " I am going to slap you in your face. " When the Resident was redirected by staff he became verbally abusive to the staff. The Progress Note read in part: " (Name of Physician) made aware of residents behavior and prev (previous) behavior throughout week. " The Progress Notes showed that the Physician made an adjustment to the Resident ' s medication and ordered a urinalysis and urine culture. The laboratory report dated 10/06/10 showed that the urinalysis/urine culture were negative. There was no documentation to indicate what interventions were successful at reducing the Resident ' s agitation or the duration of the Resident ' s agitation. The Care Plan for Resident #4 showed that the following interventions were added to the Care Plan on 10/06/10: Approach the resident slowly and from the front. Discuss resident ' s options for appropriate channeling of anger with resident. Give resident clear, concise explanation of anything about to occur; avoid information overload since the angry aggressive resident cannot assimilate many details. Remove resident from public area when behavior is disruptive/unacceptable. Talk with resident in a low pitch, calm voice to decrease/eliminate undesired behavior and provide diversional activity. Remove to a quiet area; reassure resident of personal safety and stay with resident during periods of anger if appropriate or if resident wishes. Progress Notes showed that on 10/06/10 the social worker met with the family of Resident #4 regarding the family member ' s concern about his medications saying that she did not want the resident to be like a Zombie. A meeting was scheduled with the Resident ' s Physician to discuss the family member ' s concern. The Progress Notes showed that on 10/11/10 at 5:34 PM, Resident #4 was observed cursing at Resident #6. The Resident was observed by staff to attempt to kick Resident #6 but no contact was made and Resident #4 was redirected to the spark court yard with a staff member. Progress Notes showed that on 10/13/10 at 5:21 PM Resident #4 was observed arguing with Resident #2. A nursing assistant ran down the hall to intervene and Resident #4 pushed Resident #2 who fell and hit her head on the wall. The Progress Notes read in part: " (Name of Physician) called made aware of incident zero new orders at this time MD stated that he had a family meeting with residents family. " Resident #2 was noted to have a large hematoma to the back of the head and the Resident was sent to the hospital for evaluation. The Emergency Department Record for Resident #2, dated 10/13/10 showed that the Resident had a large hematoma on the right occiput with no bleeding. A CT (Computerized Tomography) scan of the cervical spine and of the head was negative and the Resident returned to the facility. The Investigation Follow-Up Report listed the incident as a resident to resident altercation. The Contributing Factors listed were as follows: Physically abusive behavior, verbally abusive behavior, socially inappropriate behavior, Alzheimer ' s Disease. The Interventions Taken to Prevent Reoccurrence listed the following: Behavior monitoring, Q (every) 15 minute checks and laboratory studies. The Progress Notes dated 10/13/10 at 6:18 showed that Resident #4 had been placed on q 15 minute checks related to behaviors. Progress Notes showed that on 10/13/10 at 7:16 PM Resident #4 was standing beside Resident #7 who was sitting in a chair in the dining room. Resident #7 asked Resident #4 to move. A nurse in the dining room asked Resident #4 to come to where she was and the Resident became angry and started running at Resident #8. When the nurse tried to intervene, Resident #4 attempted to hit the nurse and verbally threatened the nurse. Resident #4 pushed a table at Resident #7 and attempted to throw a chair at staff. Resident #4 was redirected into the hallway and to his room and the physician was paged. The physician ' s response was to repeat a urinalysis and urine culture and to send the Resident to the emergency room if he was violent again that night. There were no additional interventions documented in the Progress Notes or on the Care Plan to prevent future resident to resident altercations. The record showed that on 10/14/10 at 4:00 PM a nurse heard Resident #4 yelling and threatening to slap someone in the face. The nurse went to the TV room and observed Resident #4 pushing on the head of Resident #6. Resident #4 was redirected away from other residents. There was no injury to Resident #6. The Physician was made aware who instructed staff to have a family member come in and sit with the Resident or send him to the Emergency Department. The Progress Notes showed that a staff member took the Resident to the Spark Unit courtyard until the family member arrived. The notes showed that the family member came in and took the Resident out of the facility. The notes showed that the family member and Resident returned to the unit at 6:15 PM. There were no further Progress Notes until 10/15/10 when another resident to resident altercation occurred. Progress Notes showed that on 10/15/10 at 4:24 PM that Resident #4 was walking towards the nursing station and Resident #2 was pointing at his pants and Resident #4 became combative. A nursing assistant attempted to deter the Resident but he started swinging and pushed Resident #2 to the ground. The staff called for additional help and Resident was redirected and separated with difficulty and placed on one to one observation until the ambulance arrived. The Physician was notified who adjusted the Resident ' s medication and instructed staff to send Resident #4 to the emergency room for evaluation of his behaviors. A review of the Emergency Department Record for Resident #4 dated 10/15/10 showed that Resident #4 was seen in the ED for combative behavior, had received medication one hour prior to being seen in the ED and was calm when seen by the ED Physician. A Chest X-ray and laboratory tests were done and were all essentially normal. The Resident was discharged back to the facility where he was placed on one to one monitoring by staff and PRN (as needed) medication was ordered by the Physician. The Progress Notes showed that after the altercation with Resident #4 on 10/15/10 at 4:24 PM, Resident #2 complained of pain to the head, back and hip and was sent to the ER where a CT of the C-spine and X-rays of the right hip were done. The ER clinical impression was Blunt head trauma and right hip and forearm contusions. Resident #2 was returned to the facility. The Investigation Follow-Up report showed the following interventions: Medication adjustment, behavior monitoring, MD (medical doctor) evaluation, 1 to 1 monitoring for Resident #4. Progress Notes showed that on 10/15/10 at 4:48 PM a meeting was held with Resident #4 ' s family member, the Physician, Administrator, Social Worker and Nursing staff to discuss the Resident ' s aggressive behaviors. The possibility of the need to pursue other placement was discussed if the Resident ' s behaviors could not be controlled. There were no additional interventions for behaviors documented in the Care Plan since the revision dated 10/06/10. The Progress Notes showed that Resident #4 returned to the facility from the Emergency Department on 10/15/10 at 11:12 PM was assisted to bed and was calm and quiet at that time without aggressive behaviors. The notes showed that a new order was received from the Resident ' s Physician for a PRN (as needed) medication for combative/aggressive behavior. Progress Notes showed that on 10/19/10 at 4:25 PM, Resident #4 ran after Resident #2. Resident #4 was redirected and started pushing the one on one staff member. PRN medication was administered. The next Progress Note dated 10/19/10 at 9:36 PM showed that the Resident was in bed and there were no further behaviors. A Social Work Progress Note dated 10/20/10 at 8:08 AM read: " Information faxed to (name of treatment center) as well as (name of facility) for possible transfer. " Progress Notes showed that on 10/20/10 at 5:38 PM the nurse observed Resident #4 go into the TV room and walk up to Resident #5 and yell and cuss at the Resident. The nurse stood in between the two residents and Resident #4 was guided to a chair. Resident #4 started to push the nurse and the one to one staff member. The notes indicated that the Resident was taken outside to separate him from other residents and PRN medication was administered. The Progress Notes showed that on 10/20/10 at 10:30 PM the medication had been effective. Progress Notes showed that on 10/21/10 at 5:21 PM, Resident #4 became agitated and combative pushing on the one on one staff member and cursing. The staff member attempted to redirect the Resident who continued to push on the staff member and curse. The Progress Notes showed that the Resident was taken outside and a PRN medication was administered. Progress Notes dated 10/21/10 at 9:29 showed that the medication had been effective and there were no further behaviors. On 10/22/10 at 5:03 PM the Progress Notes showed that Resident #4 had increased agitation and was swinging and cursing at staff. The Resident was redirected but continued to be very agitated and pacing the halls and cursing. A PRN medication was administered. Progress Notes showed dated 10/22/10 showed that the medication had been effective and there were no further behaviors. A Progress Note dated 10/23/10 at 9:59 PM showed that Resident #4 became combative during care and was cursing, striking out and attempted to bite the one on one staff member. There were no additional interventions documented in the Progress Notes or on the Medication Administration Record. The Progress Notes dated 10/24/10 at 7:45 PM showed that Resident #4 struck out at a female resident with a closed fist. No contact was made with the female resident and the one on one staff member was able to redirect Resident #4 with no difficulty. There was no information documented as to how the Resident was redirected. A Progress Note dated 10/25/10 at 4:18 PM showed that Resident was noted to be pushing against the one on one staff member. A nurse attempted to redirect the Resident who was pushing against and swinging at staff. The one on one staff member told the nurse that Resident #4 was going toward Resident #2 and when redirected he became agitated and aggressive. PRN medication was administered. There were no additional notes to indicate how the Resident was redirected or if the interventions were successful. On 10/23/10 at 9:00 AM Nurse #3 stated that Resident #4 can be resistant to care and combative with staff and residents. The Nurse stated that when the Resident was combative they separate him from other residents and notify the Director of Nursing and the Administrator. The Nurse stated: " (Name of Resident #4) sundowns real bad. " The Nurse stated that Resident #4 and Resident #2 clash and sometimes Resident #2 will get in his face and yell and he reacts. We try to keep them apart. The Nurse stated that you cannot anticipate when he will get aggressive. On 10/27/10 at 9:13 AM, Nursing Assistant (NA) #3 stated: " I talk to (name of Resident) in a quiet voice. He is usually pretty good with me. I explain to him what he needs to do. If he gets anxious I try to get him away from the other residents. He starts getting more agitated around 2:30 -3:00 PM after his (name of family member) leaves. " The NA stated that there was a communication problem with Resident #4 and Resident #2. The NA stated that Resident #2 understands English but speaks mostly in another language. The NA stated that they had an inservice on dealing with residents with agitation about 2 weeks ago that she felt was very helpful. On 10/27/10 at 10:04 AM Resident #2 was observed to sitting in a chair in front of the nurse ' s station. The Resident was smiling and pleasant. Resident #4 was observed to enter a common area from the court yard with a staff member and started walking down the hall towards where Resident #2 was sitting. The staff member redirected Resident #4 away from the area and away from Resident #2. On 10/27/10 at 10:17 NA #3 stated that the staff has been doing one on one monitoring of Resident #4 since the last incident with Resident #2 on 10/15/10 On 10/27/10 at 10:25 AM Resident #2 was observed walking in the hall with a walker toward a common area where Resident #4 was. Staff was observed to redirect Resident #2 away from that area and continued walking with the Resident in another direction. On 10/27/10 at 11:48 an interview was conducted with the Administrator, Director of Nursing (DON) and the Nurse Consultant. The Administrator stated that Resident #4 ' s Responsible Party (RP) did not want the Resident doped up and the RP was told that they could not manage the Resident without medication. The DON stated that the RP would come in and take the Resident out of the facility for awhile and then bring him back to a locked unit, the Resident would have to adjust all over again and his behaviors increased after the RP brought him back. The DON stated that they had asked the RP to not take the Resident out and the RP was not taking him out as much. The Administrator stated that the Resident had been on one on one monitoring since 10/15/10 and that they were looking to transfer the Resident to a more appropriate facility but had been unsuccessful. The Administrator stated that the Resident was sent to the ED on 10/15/10 for evaluation and that the Physician spoke to the ED Physician via telephone to alert him to the problems the facility was having with the Resident. The Administrator stated that the Resident was returned to the facility without additional orders for medications or anything. The Administrator stated that a meeting was held with the RP who had agreed to allow the Physician to treat the Resident with medications. The DON stated that the Resident was sun downing and that staff tried to keep Resident #4 and Resident #2 separated. The DON stated that they had contacted a facility that would not accept Resident #4 and listed that the reason was due to one on one monitoring. In an interview with the Social Worker (SW) and the Administrator on 10/27/10 at 12:10 PM the SW stated that she had contacted two separate facilities regarding placement for Resident #4. The SW produced a denial letter she stated she received on 10/26/10. The letter read in part: " Reason: 1:1 monitoring. " The SW stated that the facility recently accepted a Resident from them that was one on one monitoring and she planned to call the facility to find out why they would not accept this resident. The Administrator stated that the Admission Nurse went to the Resident ' s home prior to admission to see if the Resident was appropriate for the Alzheimer ' s Unit and the Resident and the RP were calm. The Administrator stated that residents on the Spark Unit were spontaneous and unpredictable and they try to screen residents very carefully prior to admitting them to the unit. An interview was conducted with the QI (Quality Improvement) Nurse on 10/27/10 at 2:46 PM who stated that they were still seeking other placement for Resident #4. The Nurse stated that after one incident they called the police but they were unable to do anything due to the Resident ' s mental status. The DON stated in an interview on 10/27/10 at 3:44 PM that on 09/14/10 Resident #2 was aggressive toward Resident #4 and he pushed her down. The DON stated that Resident was new to the unit and felt that he needed time to adjust to the unit and the other residents needed time to adjust to him. The Administrator stated in an interview on 10/27/10 at 5:21 PM that the RP gave the Physician permission to order medications for Resident #4 after the second incident with Resident #2. The Administrator stated that after the third time the problem was a pattern and felt that they needed to take additional action and placed Resident #4 on one on one monitoring and tried to place the Resident in a more appropriate facility. The Administrator stated that the staff on the Spark Unit were trained to deal with aggressive residents and trained to redirect them as necessary.