Every finding on record at PruittHealth-Carolina Point

F812 -EBased on observations and staff interviews, the facility failed to label, date, seal and/or remove expired food items stored for use in 1 of 1 walk-in cooler, the dry goods storage room, and 1 of 1 of 1 walk-in freezer and failed to ensure food service equipment was clean. These practices had the potential to affect food being served to residents. The findings included:a. An initial tour was conducted with the Dietary Manager on 2/8/26 at 10:17 AM. Observations made at the time of the initial tour identified the following concerns in the walk-in cooler:- Two crates of chocolate milk cartons (48) with the expiration date 2/7/26 remained in the refrigerator to be served. One 5-pound plastic bag of partially used shredded cheddar cheese was observed left open to air (not sealed). The bag was dated as opened on 2/5/26. An interview with the Dietary Manager on 2/8/26 at 10:17 AM during the tour indicated that she was new to the position and was working to get the staff on track by ensuring dates were checked each morning before serving breakfast and removing expired items before any food preparation. b. An observation made on 2/8/26 at the time of the initial tour (10:17 AM) identified the following concern in the dry food storage room: - An undated bag of rice, in a plastic bag left open to air.An interview with the Dietary Manager on 2/8/26 during the initial tour indicated that she had told the dietary staff to make sure all dry goods were tied up or sealed and dated with an open date to prevent contamination and keep bugs out.c. Additional observations were made during the initial tour with the Dietary Manager on 2/8/26 of the walk-in freezer, which identified the following concerns:- An open cardboard box containing 10 pounds of frozen chicken breast patties dated 2/7/26. The plastic bag inside the box was observed to be open to air (not sealed). The chicken breast patties appeared to have light edges, which may indicate freezer burn.- Three 5-pound rolls of frozen ground beef were placed on the wire rack and not dated.An interview with the Dietary Manager during the initial tour on 2/8/26 reported food items placed in the freezer should be dated by the date they were placed in the freezer and sealed. She further stated she would make sure ground beef was placed on a tray and dated when being frozen. d. Observations made during the initial tour with the Dietary Manager on 2/8/26 at 10:30 AM identified concerns with the cleanliness of equipment used within the Dietary Department. These included:- The free-standing rack for cutting boards was observed to have a dark brown buildup of debris between the sections where the cutting boards were placed. Some of the cutting boards were noted to be touching the dark brown debris. One side of the stove/oven was observed to have a dark brown, sticky grease buildup.- The bottom edge of the free-standing refrigerator had thick dust and debris built up at the bottom edges of the door.- The utility cart that held condiments and silverware was visibly soiled with dried debris, and crumbs were in between the individual compartments and outside edges.An interview with the Dietary Manager (DM) during the initial tour on 2/8/26 revealed that staff had not been checking to ensure each station was cleaned due to a lack of guidance after the previous dietary manager left suddenly. The DM further indicated that areas such as prep tables, coffee/condiment carts, and equipment needed more attention when cleaned by staff after use. An interview was conducted on 2/11/26 at 4:55 PM with the facility's Regional Director of Dietary Services. At that time, the findings of the Dietary Department's initial and follow-up tours were shared. Upon inquiry, the Regional Director reported that she would expect all food containers to be sealed and properly dated with open and expiration dates, and the Dietary Department should be cleaned, and any concerns identified during the observations should have been cleaned in accordance with the cleaning schedule and/or caught by the daily rounds of the department.

Based on observations, record reviews, and resident and staff interviews, the facility failed to provide podiatry services to 1 of 1 residents with diabetes who were reviewed for foot care (Resident #104). Findings included:Resident #104 was admitted to the facility on [DATE] with a diagnosis of type 2 diabetes with neuropathy, other circulatory complications, hemiplegia (loss of the use of the affected side of the body, and hemiparesis (weakness of the affected side of the body) following a nontraumatic subarachnoid hemorrhage (bleeding into the brain) affecting the left non-dominant side.The care plan dated 12/12/25 indicated impaired physical mobility and deconditioning related to recent hospitalization for hemiplegia, and a decline in activities of daily living related to stroke.The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #104 had moderately impaired cognition and required substantial to maximum assistance with activities of daily living.Nurse's progress notes from 12/1/25 to 2/9/26 did not indicate any notes regarding Resident #104's long toenails or an appointment for the podiatrist.A review of the shower book over the past three months (December 2025 to present) did not indicate that Resident #104 had her toenails trimmed or that they needed trimming.A review of the nurses' weekly skin assessments, (December 2025 to present), did not indicate that Resident #104 needed her toenails cut. The skin assessment sheets that are attached to the shower sheets were not checked for Resident #104 needing a nail trim.A review of the podiatry lists for the past six months (July 2025 and December 2025) did not indicate that the resident had been placed on any of them by the social worker. The Podiatrist next visit would be 2/12/26.An interview and observation with Resident #104 were done on 2/8/26 at 3:10 PM. The resident called out, Hey, can you help me? and indicated that her toes hurt. When observing Resident #104's toenails, it was noted that she was not wearing socks; her great toenails were long, thick, and jagged. The remaining toenails were also thick, long, and jagged.An interview with Nurse Aide (NA)4 on 2/9/26 at 11:38 AM indicated that she could not cut Resident #104's toenails; the nurse needed to do that. When asked how the nurse was informed when the toenails needed to be cut, she said the nurse aide told them, or sometimes the residents told the nurse themselves. Nurse Aide #4 was asked whether she had told the nurse that Resident #104's toenails needed to be cut during that day's care; she said no. Nurse Aide #4 indicated that Resident #104 had diabetes, and the nurse should have noticed that her toenails needed cutting during the skin assessment.An interview with the Charge Nurse on 2/9/26 at 2:48 PM indicated that she had not cut Resident #104's toenails, and the resident had not asked for her toenails to be cut. An interview on 2/10/26 at 11:25 AM with the social worker indicated that Resident #104 had not been identified as needing to see the podiatrist. It was further indicated that when the nurse conducts the skin assessment and determines that the resident needs to be seen by the Podiatrist, the nurse will inform the social worker that the resident needs to be added to the podiatrist's list. The podiatrist's list is sent when he informs the facility he will be coming on a specific date.An interview on 2/10/26 at 11:40 AM with Nurse Aide #5 regarding the policy for cutting toenails indicated that the aide was to tell the nurse if the resident needed their toenails cut. If the resident could not tell the nurse, or if the resident had diabetes, the resident had to be seen by the foot doctor. An observation and interview on 2/10/26 at 1:00 PM revealed that Resident #104's toenails had not been cut. She was asked if she would like to go to the foot doctor to have them cut, and she said yes. An interview on 2/10/26 at 10:18 AM with the Director of Nursing (DON) indicated that the residents with diabetes had their nails cut by podiatry. She then said she was not familiar with the resident and would make sure she was put on the podiatry list. She further stated that the nurses should have been assessing the residents' feet and either cutting them or having them placed on the podiatry list. An interview on 2/10/26 at 2:30 PM with the Administrator indicated that he was not sure why Resident #104 had not been on the podiatrist list and was unaware that she had needed to be seen by podiatry. The Administrator further stated that he would ensure Resident #104 was added to the list. The Administrator further indicated that he expected residents' toenails to be trimmed and that, if any issues arose, podiatry would be consulted. He further indicated that the nurses were responsible for ensuring the social worker received a current list of residents who needed to see the podiatrist, and that the social worker would ensure all residents were added to the next visit.

Based on record review, observations, and staff interviews, the facility failed to provide nail care for Resident #137 who required staff assistance for personal hygiene. This deficient practice affected 1 of 8 dependent residents reviewed for activities of daily living (Resident #137). The findings included:Resident #137 was admitted to the facility on [DATE] with diagnoses of recent partial amputation of right little finger and right ring finger on 1/18/26, end stage renal disease, Type 2 diabetes mellitus, and cerebrovascular accident. The admission Minimum Data Set (MDS) dated [DATE] showed Resident #137 was cognitively intact. He required substantial assistance for toileting hygiene and set up/clean up assistance with personal hygiene. Resident #137's care plan dated 2/6/26 had a focus for Activities of Daily Living self-care deficit with interventions that included check nails and ensure they are clean and have neat appearance and provide showers per schedule.During an observation and interview with Resident #137 on 2/8/26 at 3:00 PM, all nails on his left hand were observed to have smooth edges and extended approximately a quarter inch beyond the fingertips with thick black matter under each nail. Resident #137 stated he had not asked staff to trim or clean his nails but stated he did not like them long and dirty and wished the staff would cut them and clean them. During an observation of Resident #137 on 2/9/26 at 9:17 AM, all nails on his left hand were observed to have smooth edges and extended approximately a quarter inch beyond the fingertips with thick black matter under each nail. During an observation of Resident #137 on 2/10/26 at 9:34 AM, all nails on his left hand were observed to have smooth edges and extended approximately a quarter inch beyond the fingertips with thick black matter under each nail. A review of the bath/shower schedule revealed Resident #137 was scheduled for a bath on Thursdays and Saturdays on the 7:00 PM to 7:00 AM shift. There were no shower and personal hygiene sheets for Resident #137 for November 2025 through February 2026. An interview was conducted on 2/10/26 at 5:59 AM with Nurse Aide (NA) #7 and NA #9 who worked night shift (7:00 PM to 7:00 AM) and were assigned to Resident #137 on the scheduled shower/bath day. Nurse Aide #7 stated each resident was assigned a bath day and this was posted on the unit shower schedule. When the bath was completed the nurse aide would initial the Bath Check List if fingernails were cut or needed to be cut/trimmed, the resident refused bath care, or if anything was not able to be completed. Nurse Aide #7 stated she would notify the nurse if nails needed to be done because a resident might have diabetes and nail care would need to be completed by the nurse. Nurse Aide #7 and NA #9 both stated they did not notice the condition of Resident #137's fingernails. An interview was conducted on 2/11/26 at 1:00 PM with NA #4 who stated she had completed a bed bath for Resident #137 earlier that day. She stated she had not observed any personal care issues that should be reported to the nurse. She stated she did not recall his nails being long or dirty. An interview was conducted on 2/10/26 at 6:12 AM with Nurse #12 who was assigned to Resident #137. She was unaware of Resident #137's need for nail care. Nurse #12 stated no nurse aide had reported he required nail care and she did not observe the condition of his nails. She stated as Resident #137 had diabetes the nurse aide could provide hand washing assistance but not nail trimming. Nurse #12 did not know if he could clean his own nails and trim them if provided set up. An interview was conducted on 2/9/26 at 2:00 PM with the Unit Manager (Nurse #11) who stated when a resident was scheduled for a bath/shower it was expected that nail care, hair care, and shaving would be done. She stated the NA would let the nurse know if a resident needed nail care so the nurse could check if the resident had diabetes in which case the nurse would be responsible for providing nail care. Nurse #11 stated she had not looked at Resident #137's nails and was unaware if he was dependent on staff for nail care. She did not know why there were no shower/bath sheets for Resident #137. On 2/11/26, at 3:12 PM, an interview was conducted with the Director of Nursing (DON), who stated that when a resident was scheduled for a bath, the service included shaving, hair care, and nail care. She stated after completion of the bath or shower the nurse aide would complete the skin care sheet that stated, by signing this I agree that that shaving, hair, and nail care has been done. She further stated if the nurse aide noted long or dirty nails this would be reported to the nurse who would check if the resident had diabetes. If a resident had diabetes, the nurse would be responsible for cutting and cleaning of the nails. The DON indicated it was the Unit Manager's responsibility to complete a weekly audit to validate findings on the bath sheets. She stated clean and neat nails were an expectation and she did not know why no bath sheets were completed for Resident #137. The Administrator was interviewed on 2/22/26 at 5:32 PM. He stated it was unacceptable for residents to have dirty fingernails. He stated it was the responsibility of the Nursing Department to provide personal care, and the nursing staff should ensure residents have neat and clean nails.

Based on record review and interviews with the Medical Director, Nurse Practitioner (NP), Assistant Manager of Pharmacy Operations, residents and staff, the facility failed to have effective systems in place to ensure a twice a day dose of an antiseizure oral medication prescribed for the treatment of seizure was administered resulting in a seven-day delay of it being administered. Resident #1 did not change his condition. This occurred for 1 of 1 resident reviewed for significant medication error (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including seizure disorder and traumatic brain injury. Review of Resident 1's plan of care, dated [DATE], revealed he had a seizure disorder. The interventions included receiving medications as ordered. Record review of the physician's orders for Resident #1 revealed: [DATE] - Lacosamide (seizure medication), 200 mg (milligram), by mouth every 12 hours, Lacosamide 50 mg, by mouth every 12 hours, Levetiracetam (seizure medication), oral solution, 100 mg in mL (milliliter), to take 17.5 mL twice a day, [DATE] - Depakote (Anticonvulsant), tablets, 500 mg, to take 1 tablet daily. Review of the Medication Administration Record (MAR) for Resident #1 for [DATE] revealed that Lacosamide 50 mg, was not administered, because it was not available on [DATE] at 9 AM and 9PM, [DATE] at 9 AM and 9PM, [DATE] at 9 AM and 9PM, [DATE] at 9 AM and 9PM, [DATE] at 9 AM and 9PM, [DATE] at 9 AM and 9PM and [DATE] at 9 AM and 9PM. Record review of the communication to NP book revealed the note, dated [DATE], documented by Nurse #5, indicated the new prescription request for Lacosamide 50 mg for Resident #1. Record review of the Nurse Practitioner's (NP #1) notes, dated [DATE], revealed that it was a routine regulatory visit of Resident #1. NP #1 reviewed Resident 1's medications and did not place new orders. There was no documentation of the missing dose of Lacosamide 50 mg in NP 1's notes. Record review of the nurses' notes, dated [DATE] at 7:15 AM, revealed that Nurse #7 was noted Resident #1 was out of refills for Lacosamide 50mg tablet. Nurse #7 confirmed no refills with the pharmacy, communicated with the Medical Director and informed him of the missed doses of Lacosamide. The Medical Director sent a new prescription to the pharmacy and ordered blood tests. The family was notified about the delay in medication administration. Resident #1 did not have symptoms of seizure, maintained normal vital signs and attended activity alone with his family member. Record review of the nurses' notes, dated [DATE] at 11:30 AM, documented by Assistant Director of Nursing (ADON), indicated that Lacosamide 50mg tablets arrived at the facility on [DATE] at 11:00 AM. On [DATE] at 7:45 AM, during an interview, Nurse #1 indicated that she was assigned for Resident #1 on [DATE], 7 PM - 7 AM shift. At 9 PM, Nurse #1 administered 200 mg of Lacosamide, but did not have Lacosamide 50 mg tablet. Nurse #1 called the pharmacy and on-call physician, left messages about missing 50 mg of Lacosamide tablets. Nobody called her back during the shift. Nurse #1 documented in the MAR that 50 mg of Lacosamide was not available. Resident #1 was at his baseline, with no signs of seizure or agitation. On [DATE] at 7:55 AM, during the observation/interview, Resident #1 was in bed. He indicated that the last seizure episode occurred for him a few months ago. The resident did not recall if he recently missed his antiseizure medications. On [DATE] at 8:55 AM, during an interview, Nurse #2 indicated that on [DATE], Saturday, she was assigned for Resident #1 on 7 AM-7 PM shift. There were two separate orders for Lacosamide 200 mg and Lacosamide 50 mg twice a day for the resident. At 9 AM, Nurse #2 administered 200 mg of Lacosamide, but did not have 50 mg of Lacosamide available. She called the pharmacy and left a message. Nobody called her back. Nurse #2 could not recall if she notified the physician or family. Nurse #2 did not receive from the pharmacy a 50 mg dose of Lacosamide during her shift and notified the upcoming nurse. On [DATE] and [DATE], Nurse #2 was assigned for Resident #1 on the 7 AM-7 PM shifts, and 50 mg dose of Lacosamide was not available. Nurse #2 documented in the MAR that 50 mg of Lacosamide was not available. The resident was at his baseline, presenting no signs of seizure or agitation. On [DATE] at 10:00 AM, during an interview, Nurse #8 indicated he was assigned for Resident #1 on [DATE] and [DATE], on 7 AM to 7 PM shifts. The previous shift nurses reported that it was no 50 mg of Lacosamide available to administer. Nurse #8 administered 200 mg of Lacosamide per order and documented in the MAR that 50 mg of Lacosamide was not available. He did not notify the pharmacy or physician because he read the notes in the NP book about a new prescription request for 50 mg of Lacosamide. The resident did not have agitation, seizure activity or abnormal vital signs. On [DATE] at 12:45 PM, during the phone interview, Nurse #7 indicated that on [DATE] she was assigned for Resident #1 at 7 AM to 7 PM shift. At 9:30 AM, during the medication administration, Nurse #7 did not have 50 mg dose of Lacosamide for Resident #1. At 10 AM, the resident's family member came to visit and Nurse #7 notified her about the not available medication. Nurse #7 reported it to the Director of Nursing (DON), called the pharmacy and found that the new prescription for Lacosamide 50 mg was required. Nurse #7 contacted the provider on call, who sent the new prescription for Lacosamide 50 mg to the pharmacy. The 50 mg Lacosamide tablets arrived at the facility in the morning of [DATE]. Resident #1 remained at his baseline, did not have signs of agitation or seizure activity. On [DATE] at 3:45 PM, during the phone interview, Nurse #3 indicated that on [DATE], he was assigned for Resident #1 on 7 PM - 7 AM shift. During the shift change report at 7 PM, he learned that 50 mg dose of Lacosamide was not available for Resident #1, and thought the previous shift staff already communicated the issue with the pharmacy and physician. On [DATE], Nurse #3 was assigned for Resident #1 on 7 PM - 7 AM shift, did not have 50 mg dose of Lacosamide and put the request for new prescription to the communication with NP book. On [DATE], he was assigned for Resident #1 on 7 PM - 7 AM shift, and the 50 mg dose of Lacosamide was not available for Resident #1. The resident did not show signs of seizure, interacted with his family over the phone and was showed normal vital signs. On [DATE] at 9:00 AM, during the phone interview, the Medical Director indicated that he has known Resident 1 for about twenty years and was very familiar with his medication regimen. On [DATE], the staff informed him that the 50 mg of Lacosamide was missing for several days due to an expired prescription. The Medical Director immediately sent the new prescription for Lacosamide 50 mg to the pharmacy. The staff reported no negative changes in Resident 1's condition, behavior or seizure activity. Resident #1 did not have the negative outcome from missing 50 mg doses of Lacosamide, because he received the higher doses of Lacosamide (200 mg) and other antiseizure medications (Levetiracetam and Depakote). The Medical Director expected the staff to follow physician's order and communicate the delayed or missed medications administration to the provider on call. On [DATE] at 9:40 AM, during the phone interview, the Assistant Manager Pharmacy Operations indicated that the prescription for Lacosamide 50 mg, ordered in [DATE] was expired on [DATE]. Considering that, the pharmacy sent the multiple requests for new Lacosamide 50 mg tablets prescription to the provider on [DATE], [DATE] and [DATE]. The pharmacy received a new prescription for Lacosamide 50 mg tablets on the evening (after business hours) of [DATE] and dispensed the medication to the facility on [DATE]. On [DATE] at 10:00 AM, during an interview, the Director of Nursing (DON) expected the staff to implement a working system to make sure all the residents would have medications as ordered. On [DATE], when the 50 mg of Lacosamide was not available for the administration for Resident #1, the floor nurses should follow the Medication Administration policy, which requires to call the pharmacy, request the medication, and notify the provider and family. On [DATE], when the administration became aware of the missing doses of 50 mg of Lacosamide, the new prescription was immediately obtained, sent to the pharmacy and medication arrived at the facility on [DATE]. During the seven days of missing Lacosamide 50 mg doses, the staff closely monitored Resident #1, who remained at his baseline. On [DATE] at 10:20 AM, during an interview, the NP #1 indicated that she conducted the routine visit for Resident #1 on [DATE]. Upon assessment, the resident did not show agitation or signs of seizure activity. NP #1 did not recall reports from the staff or the notes in the NP communication book about the need for a new prescription for Lacosamide 50 mg. She was not aware of missing doses of Lacosamide 50 mg until [DATE]. The administrator provided the following Corrective Action Plan. Plan of Correction for Medication Administration, notification to physician/extender when medications are unavailable. o What corrective action will be accomplished for those residents found to have been affected by practice: Resident ordered to receive 200 mg (milligrams) and 50 mg (milligrams) Lacosamide at 9:00am and 9:00pm. Resident's 50mg Lacosamide was not noted to be in the medication cart on [DATE]. On [DATE] the nurse placed in the provider notebook that we needed a script for 50mg Vimpat. The different nurse contacted the provider extender on [DATE] to reorder the medication and the medication was received on [DATE]. The Medical Director was notified on [DATE] and ordered CMP and CBC which resulted on [DATE]. o How will the facility identify other residents having the potential to be affected by the same practice: On [DATE] the Director of Health Services and Nurse Managers reviewed all residents with anti-seizure medications to validate availability of medications. The timeframe for the review was from [DATE] thru [DATE], all medications were found to be available. o What measures will be put in place or systemic changes will be made to ensure that the deficient practice will not recur: On [DATE] the Assistant Director of Health Services and Nurse Managers began education to Nurses regarding, following the Six Rights of Medication Administration (right patient, right medication, right dose, right time, right route, right indication), notification to pharmacy, the physician, resident, and family when a medication is not available for prescribed administration and the six rights of medication administration. Any nurse scheduled to work a medication cart will be educated by [DATE] or prior to their next scheduled medication pass time. This education will be added to the general orientation for all newly hired Nurses. The Director of Health Services and/or nurse managers began education of nurses on [DATE] related to medication administration guidelines protocol, any nurse working a medication cart not educated by [DATE] will be educated prior to their next schedule medication pass. This education has been added to the general orientation for all newly hired nurses. On [DATE] The Director of Health Services and Nurse Management began the review of anti-seizure medication reviews to validate the availability and the administration of the medications to the resident per physician orders. This process will be completed weekly for four weeks then monthly until three months of sustained compliance is maintained quarterly thereafter. o How will the facility monitor its performance to make sure the solutions are sustained: The Director of Health Services provided the synopsis of the anti-seizure medication review to the Quality Assurance and Performance Improvement Committee at an Ad Hoc meeting on [DATE] and will report out monthly until three months of sustained compliance is maintained, then quarterly thereafter. The Clinical Competency Coordinator and/or Assistant Director of Health Services will present the percentage of newly hired nurses that have completed the 6 rights of medication administration, notification to the pharmacy, physician, physician extender, and Responsible Party, and medication administration guidelines protocol to the quality Assurance and Performance Improvement Committee monthly until three months of sustained compliance is maintained quarterly thereafter. o When will corrective action be complete: [DATE]. An onsite validation of the facility's Corrective Action Plan was completed on [DATE]. A review of the Medication Administration Audit dated [DATE] and [DATE] revealed the audit was completed and there were no concerns. Reviewed mandatory education, dated [DATE]-[DATE]: all Registered Nurses (RNs), Licensed Practical Nurses (LPNs) were educated prior to their next scheduled medication pass time, and the same training was added to the orientation process for new employees. The facility does not use the agency staff or medication aids. The medication administration observation for Resident #1 during the survey revealed he received all the medications according to physician's order. Staff interviewed were able to verbalize education training provided in reference to six rights of medication administration and prevention of medication errors. The QAA/QAPI committee meeting was conducted on [DATE], discussed the six rights of medication administration, pharmacy, provider notification and related guidelines to be followed. The facility was validated as being back into compliance as of [DATE]

Based on facility video recording, record reviews, and interviews with staff, Nurse Practitioner, Medical Director and the resident's responsible party (RP), the facility failed to protect a cognitively impaired and vulnerable female resident's (Resident #2) right to be free from sexual abuse by a cognitively impaired male resident (Resident #1). On 3/2/25 at 2:50 AM, Nurse Aide (NA) #1 walked past Resident #1 in the hallway. Resident #1 was sitting in his wheelchair with no clothes on and only a towel covering his waist. NA #1 did not intervene and/or redirect the resident. On 3/2/25 at 3:18 AM, Nurse #1 observed Resident #1 on Resident #2's bed. Resident #1 was naked and was kneeling on the bed near the foot board, leaning forward and trying to place his left 2nd and 3rd fingers inside Resident #2's vagina. Resident #2 was lying on her back with a shirt covering her upper body and was not wearing a brief. Resident #2's RP stated Resident #2 must have felt trapped in her bed, may have been scared and was unable to call for help or defend herself. A reasonable person expects to be protected from abuse in their home and would have experienced psychosocial harm with feelings such as fear, humiliation, anxiety, anger and depressed mood. This deficient practice was reviewed for 1 of 3 residents for abuse. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, viral hepatitis C without hepatic (liver) coma; viral hepatitis B without hepatic coma; Parkinsonism and psychophysiologic insomnia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had unclear speech, had difficulty making self-understood and was assessed as severely cognitively impaired. The assessment indicated the resident did not display any behaviors including wandering behavior during the look back period. Resident #1 required set up/clean up to supervision/touching assistance from staff for his activities of daily living. Resident#1 required set up/clean up assistance for transfer. Resident #1 had no range of motion impairment to his upper or lower extremities and used a wheelchair and walker for mobility. The resident was able to walk 150 feet with set up/clean up assistance from staff. A review of Resident #1's care plan included a focus for behavioral symptoms (start date 9/11/24) with a last revised date 12/17/24. Resident #1 was care planned for socially inappropriate/disruptive behavior related to exhibiting agitation and entering corridor without clothes. Interventions included replacing removed clothing, moving resident to a quiet calm environment and attempting to provide comfort measures for basic needs such as pain, hunger, and toileting when resident becomes socially inappropriate or disruptive. Resident #2 was readmitted to the facility on [DATE] with diagnoses that included dementia, paranoid schizophrenia, and bilateral hearing loss. Review of the quarterly MDS assessment dated [DATE] revealed Resident #2 was assessed as having moderate difficulty hearing, unclear speech and had difficulty making herself understood. Resident #2 was assessed as severely cognitively impaired and did not exhibit any behaviors including rejection of care. The assessment indicated Resident #2 had impairment on both her lower extremities related to range of motion and was dependent on staff and/or needed substantial/maximal assistance from staff for most of her activity of daily living. Resident #2 was assessed as always bowel and bladder incontinent. A review of Resident #2's care plan included a focus for behavioral symptoms (start date 6/29/23) with a last update on 12/3/24. The care plan indicated Resident #2 was at risk for impaired dignity related to removing her clothing due to impaired cognition. Interventions included dressing Resident #2 in a shirt from her wardrobe daily after her bath. Keeping the resident's room at a comfortable temperature to discourage resident from removing clothing. Providing for residents' dignity by pulling privacy curtain or closing the door when unclothed and replacing the removed clothing. The facility video recording was reviewed with the Administrator on 3/11/25. Review of the video recording revealed the following: 1) on 3/2/25 at 2:50 AM, Resident #1 was observed with no clothes, except for a towel around his waist, sitting in a wheelchair. Resident #1 was observed near the nursing station (far end of the hallway). Nursing assistant (NA) #1 was observed entering the hallway and walking past the resident. NA #1 was observed walking around the resident without intervening. 2) On 3/2/25 at 3:03 AM Resident #1 was observed entering Resident #2's room. 3) On 3/2/25 at 3:18 AM, Nurse #1 was observed walking from the far end of the hallway, towards Resident #2's room. Nurse #1 was observed stopping and standing at the doorway of Resident #2's room. Nurse #1 appears to be talking to someone inside the room. 4) On 3/2/25 at 3:20 AM, Resident #1 was observed naked, slowly walking towards his wheelchair which was near the doorway. Nurse #1 assisted Resident #1 in his wheelchair and removed the resident from Resident #2' room and into the hallway. Once in the hallway the towel was observed around Resident #1's waist. During a telephone interview on 3/11/ 25 at 10:45 AM, NA #1 indicated he was working on 3/1/25 from 7:00 PM to 7:00 AM, and was assigned to a different hallway. NA #1 further indicated he kept hearing a beeping sound that night and was in the hallway trying to find out which call light was beeping or if it was some other sound. NA #1 explained while he was passing the hallway, he observed Resident #1 with no shirt on and towel around the his waist, sitting in his wheelchair in the hallway. NA #1 stated he was not paying attention to what the resident was doing, or what he was wearing and passed around the resident. NA #1 further stated Resident #1 was not his assigned resident and he did not pay any attention to how the resident was dressed, if he was wearing briefs or pants. NA #1 stated he was made aware later that Resident #1 was observed on a bed with a female resident. Review of Resident #1's electronic health record revealed a nursing progress note, written by Nurse #1 dated 3/2/24 at 6:48 AM. Note indicated Resident#1 was found in another resident's room in a compromised position. Resident #1 was found on a female resident (Resident # 2) naked and his left (L) second and third fingers in her vagina. Resident was removed immediately from female resident and was placed on 1:1 supervision. The note also indicated Resident #1 had reported to Nurse #1 that Resident #2 had called him in. Review of Resident #2's electronic health record revealed a nursing progress note, written by Nurse #1 dated 3/2/25 at 6:17 AM. Note indicated Resident #2 was found with another resident in her room in a compromised position. The note indicated while Nurse #1 was doing her routine checks on 3/2/25 at 3: 22 AM, she found Resident #1 on top of Resident #2. Resident #1 was found naked with no clothes on. Resident #2 had her blouse on and nothing from waist down. Resident #2's incontinence brief was on the floor by the bed. Resident #2 had his left (L) second and third fingers in Resident #2's vagina. Resident #1 was immediately removed from the resident's room. Resident #2 was unable to explain what had happened due to her cognitive. Resident #2 was immediately assessed by Nurse #1 with another nurse. The note indicated Resident #2 did not complain of any pain, no moaning or facial grimacing, no tears, bruising, bleeding or any trauma was noted. Resident #2 placed under one-to-one supervision. Review of a full body assessment dated [DATE] at 4:08 AM by Nurse #1 revealed Resident #2 was assessed due to resident-to-resident sexual abuse. No negative findings were observed. During a telephone interview on 3/11/25 at 9:06 AM, Nurse #1 stated she worked the 7:00 PM - 7:00 AM shift on 3/1/25 and was assigned to the 500 hallway. Nurse #1 stated Resident #2 exhibited behavior at times of removing her brief and throwing it on the ground. Resident #2 was care planned for this behavior. Interventions included frequent nursing checks to ensure the resident was comfortable. Nurse #1 indicated on 3/2/25 during her rounds around 3:00 AM she observed Resident #1 in Resident #2's room. Nurse #1 stated Resident #2's bed was closer to the doorway. Nurse #1 further stated she was at the doorway, when she saw Resident #1 was on top of Resident #2's bed and was trying to place his fingers in Resident #2's vagina. Nurse #1 stated when she asked Resident #1 what he was doing from the doorway, he got off the bed and walked towards her and his wheelchair near the doorway. Nurse #1 indicated she assisted him in his wheelchair. Nurse #1 stated Resident #2 was wearing her blouse (her upper body covered), her legs were partially covered, and the adult brief was on the floor beside her bed. Nurse #indicated she called for immediate assistance. Resident #1 was taken back to his room and assessed by Nurse #2. Resident #2 was assessed by Nurse #1 and Nurse #3. Resident #2 did not exhibit any signs of fear, pain or discomfort. Nurse indicated both residents were placed on 1:1 supervision. Nurse #3 had notified the Administrator, Director of Nursing (DON), on-call physician and law enforcement. Nurse #1 stated Resident #1 had never exhibited behavior like coming out of his room naked or going into other resident's room. Resident #1 would usually sit outside his room in the hallway, near the nursing station and listen to his boombox. He usually went to bed between 11:00 PM and 12 midnight. Nurse #1 stated Resident #1 was offered ice and water in his room by the NA at around 10:00 PM. During a follow up interview on 3/11/25 at 12:32 PM, Nurse #1 stated Resident #1 was on his knees, kneeling on the bed, near the bottom on the bed (near the foot board). Nurse #1 stated she could see Resident #1 from the side position, he did not have an erection. He was naked and there was a towel at the base of the bed. Resident #2 was lying on her back on the bed and had a shirt covering her upper body. She had no brief on and there was a brief on the floor. Resident #2's right leg was exposed and left leg covered with the bed linen. Resident #1 was naked and he was leaning forward, extending his left hand to have his second and third fingers near Resident #2's vagina. Resident #1's hand was not inside but near the vagina. Nurse #1 stated when she called out Resident #1 picked up his towel. and walked towards the nurse. Resident #1's wheelchair was near the door and he walked and sat in his wheelchair. The resident was removed from the room and was in the hallway. Nurse #1 stated Resident #2 was smiling back at the nurse and saying okay, I am fine. When Resident #1 was asked what he was doing in the resident's room, he indicated he was called by Resident #2 into her room. During a telephone interview on 3/10/25 at 9:22 PM, NA #2 indicated she usually worked 2 to 3 nights a week and worked the 7:00 PM - 7:00 AM shift. She indicated she was working on the night of the incident (3/1/25). NA #2 stated, the nurse assigned to the hallway (Nurse #1) had called her and informed her to call the other nurse from a different hallway. NA #2 stated she had not witnessed the incident, but when she came back with the other nurses, she observed Resident #1 sitting in his wheelchair with a towel over his legs outside Resident #2's room. Resident #2 was lying in her bed, and her brief was on the floor near the bed. NA #2 further stated Resident #2 exhibited behaviors of removing her brief and throwing it on the floor. NA #2 indicated she did 2-hour incontinent checks to ensure the resident was not wet. NA #2 indicated she had checked the resident earlier that night and the resident did not need any incontinence care. NA #2 recalled Resident #2 was one-to-one monitoring and she was monitoring the resident for the rest of the night. Resident #2 slept the rest of the night without any issues. NA #2 stated Resident #1 needed very limited assistance related to his care. Resident #1 was able to walk in his room and would walk to the toilet independently. NA #2 further stated Resident #1 usually kept to himself and would be outside his room at night with a boombox. NA #2 indicated Resident #1 had never gone into any resident's room or had ever been inappropriate with a female resident. NA #2 stated she has never seen Resident #1 naked or inappropriately dressed at night. NA #2 indicated she did not recollect when she last saw the resident on the night of 3/1/25. During a telephone interview on 3/10/25 at 4:32PM, Nurse #2 stated he was working the 7:00 PM - 7:00 AM shift on 3/1/25 and was not assigned to the 500 hallway where the incident occurred. He indicated a Nurse Aide (name unknown) came to inform him at around 3:00 AM that there was an emergency on the 500 Hallway. Nurse #2 stated when he arrived in the hallway, he observed Resident #1 sitting in a wheelchair in the hallway, near Resident #2's room. Resident #1 was almost naked (towel around his waist and lap). The assigned Nurse to the hallway (Nurse #1) reported to him that she had found Resident #1 in Resident #2's bed with his fingers close to female resident's vagina. Nurse #1 appeared in disbelief that Resident #1 was in Resident #2's room. Nurse #2 stated he looked at Resident #2 from the doorway and Resident #2 appeared to be awake, was calm and smiling at staff. Resident #2 did not appear to be in any distress. Nurse #2 stated he took Resident #1 to his room (down the hall) and asked the resident why he was in another resident's room. Resident #1 appeared confused and stated, he was passing by the room and Resident #2 called him in. Nurse #2 stated he had completed a full body assessment, and no concerns were identified. Nurse #2 stated he usually sees Resident #1 sitting in the hallway with his boombox near his room. Nurse #2 indicated he had never seen the resident naked or going into other resident's room. During a telephone interview on 3/10/25 at 5:44 PM, Nurse #3 stated she worked the 7:00 PM to 7:00 AM shift and was working on 3/1/25. Nurse #3 stated she was not assigned to the hallway, however between 3:00 AM and 3:30 AM, one of the Nurse Aides (name unknown) came to her and reported that Nurse #1 had an emergency on her hall and needed assistance. Nurse #3 stated by the time she arrived in the hallway, Nurse #1 was reporting to Nurse #2. Resident #1 was in the hallway in front of Nurse #1. Nurse #3 indicated she was given report by Nurse #1 that Resident #1 was naked, in a comprising position, leaning forward, and extending his hand to put his fingers inside Resident #2's vagina. Nurse #3 stated Nurse #1 had asked the resident what he was doing, and he came walking towards her and indicated Resident #2 had called him in her room. Nurse #3 stated she notified the DON and received guidance to do a complete head-to-toe assessment for Resident #2 and report it to the on-call provider. Both residents were to be placed on 1:1 supervision. Nurse #3 stated Resident #1 was taken to his room by Nurse #2 and Resident #1 appeared to be confused. During an interview on 3/11/25 at 8:45 AM and a follow-up interview on 3/11/25 at 12:49 AM, Resident #2's responsible party/ emergency contact (RP) stated she was in shock when she was woken up in the middle of night with a phone call from the facility regarding the incident. Resident #2's RP indicated she was made aware of a male resident in Resident #2's bed. Resident #2's RP stated Resident #2 must have felt trapped in her bed, may have been scared, unable to call for help and waiting for all this to be over. Resident #2's RP further stated Resident #2 was not able to defend herself due to her mental and medical issues. Resident #2 must have been scared and upset that she could not defend herself. Initial Allegation Report dated 3/2/25 and completed by the Administrator was reviewed. The report indicated resident abuse occurred on 3/2/25. A male resident was found in bed with a female resident. No injury, no harm, and no change from either resident's baseline mental and /or physical status. Law enforcement was notified on 3/2/25 at 4:11 AM. A statement written by Clinical Competency Coordinator (Nurse) dated 3/3/25 was reviewed. Statement indicated Resident #1 was interviewed by the Nurse and Wound nurse regarding incident that occurred on 3/2/25. Resident #1 admitted that he went down the hall and went into a resident room and had inappropriate physical contact with another resident. Resident #1 described walking to the resident's room removing the resident's diaper (female resident) and inserting two of his fingers inside her vagina. The statement indicated that Resident #1 had stated that he used his right hand and fingers because his doctor recommended that he have sex. During an interview on 3/10/25 at 5:09 PM, the Director of Nursing (DON) stated she was previously the Clinical Competency Coordinator and had written the statement dated 3/3/25. DON indicated she and ADON (previously Wound Nurse) completed body assessments for Resident #1 on 3/2/25. The DON stated Resident #1 reported that a female resident gestured him to her room, and he went into the room. DON stated Resident #1 demonstrated the hand gesture made by the female resident. Resident #1 did not confirm that he had sex with the resident. Resident #1 stated he had used his hand and fingers because the doctor recommended that he have sex . Review of Resident #1's electronic health record revealed the Nurse Practitioner (NP) note dated 3/3/25 written by NP #2 indicated per nursing staff report, on 3/2/25 Resident #1 was sent to Emergency Department (ED) for psychiatric evaluation after the resident was discovered in another resident's room exhibiting inappropriate sexual behavior. The note indicated Resident #1 was alert, sitting in his wheelchair during the assessment and was at his baseline. It was noted nursing staff had implemented frequent rounding and closer monitoring of resident. The Psychiatric NP was made aware. The NP documented that per the Psychiatric NP recommendation medication was adjusted and new order were implemented to increase lithium to 450 milligrams (mg) by mouth two times a day, increase lorazepam from 1 to 2 mg by mouth two times a day and increase trazodone from 50 to 100 (mg) at night. During an interview on 3/10/25 at 1:45 PM, Nurse Practitioner (NP) #2 indicated she was notified by the on-call NP about the incident. Resident #2 had diagnosis of schizophrenia. Resident #1 was sent to the hospital for a psychological evaluation as this was the first time Resident #1 had exhibited any sexual behavior. NP #2 indicated Resident #1 returned to the facility without any new orders from the hospital. NP #2 stated during her assessment Resident #1 was at his baseline and anxious. NP #2 indicated she notified the psychiatric NP about Resident #1's episode of inappropriate sexual behavior with a female resident. Per Psychiatric NP recommendations the resident's medications were increased. Lithium was increased from 300 - 450 mg and trazodone was increased from 50 to 100 mg. Resident #1 was followed by the Psychiatric NP. Review of Resident #1's electronic health record revealed a Psychiatry progress note dated 3/6/25 written by Psychiatric NP #3. Note indicated Resident #1 was seen for a psychiatric medication follow up visit. Resident #1 had diagnoses of schizoaffective disorder, bipolar disorder and insomnia. Schizoaffective disorder was managed with a combination of medications. The note indicated lithium levels were found to be subtherapeutic, necessitating an increase in dosage from 300 mg to 450 mg. Resident #1 was calm and stable with no aggression or significant paranoia observed during assessment. During a telephone interview on 3/11/25 at 10:50 AM, Psychiatric NP #3 stated he was notified by the medical team to assess Resident #1 and Resident #2 due to inappropriate sexual behavior and abuse incident that occurred in the facility. After the incident Resident #1 was sent to the hospital for psychiatric evaluation and returned to the facility with no change in medication from hospital. NP #3 indicated at the time of assessment, when Resident #1 was asked about the incident, he did not make any sense. The resident was confused and upset about having 1:1 supervision. NP #3 stated the resident was educated on the reason for supervision. Psychiatric NP #3 stated he had made some changes for residents' medication to help the resident to calm down. NP indicated Resident #1 had not exhibited such inappropriate behavior prior to this incident. Review of Resident #2's electronic health record revealed a Nursing progress note dated 3/3/25 that indicated Resident #2 was assessed by the provider. Psychiatric services were notified with no med changes. Resident #2 denied any pain and/or discomfort and was not in any acute distress. Note indicated that the resident's blood was drawn for serum blood STD (sexually transmitted disease) panel testing. Review of Resident #2's electronic health record revealed a progress note written by NP #1 dated 3/3/25. Note indicated Resident #2 was seen for a sexual assault incident. Resident #2 unable to answer questions secondary to dementia. Resident denied any vaginal pain or any pain at the time of assessment. Resident#2 was pleasantly confused, and her mood was stable. Resident #2 had no recollection of the assault and had no acute complaints. The STD panel order pending. During an interview on 3/10/25 at 1:03 PM, Nurse Practitioner (NP) #1 stated she was made aware that a male resident had placed fingers in Resident #2's vagina. NP #1 indicated that during the physical examination Resident #2 appeared to be confused and was at her baseline. The physical examination of Resident #2 included thorough examination of the vaginal and peri areas and found no indication that any sexual contact had occurred. Resident #2 did not report any pain. Skin checks around the vagina revealed no scratches, or redness. NP #1 stated she did speak with Resident #2's family and they did not want the resident to be sent out to the hospital. Lab work regarding STD was ordered for the resident. Review of Resident #2's electronic health record revealed a psychiatric progress note written by Psychiatric NP #3 dated 3/6/25. The note indicated Resident #2 was seen for an acute psychiatric medication visit. Resident #2 had diagnoses of paranoid schizophrenia, depression, insomnia and dementia. During the assessment resident was stable, no hallucinations, no changes in mood and behavior. Resident #2 was unable to answer any questions appropriately due to cognitive impairment. NP #3 documented that staff should notify the provider of any change in mood and behavior. No medication changes were made. During a telephone interview on 3/11/25 at 10:50 AM, Psychiatric NP #3 stated he was notified about the sexual abuse incident that occurred in the facility. NP #3 stated usually during his visits, Resident #2 was not very alert and did not respond well. However, during the assessment on 3/6/25 Resident #2 was awake, seemed happy and smiling at the NP. NP #3 stated the resident was unable to provide details of the incident due to her cognitive impairment. Resident #2 was at her baseline and no change in mood or behavior was observed. He indicated no medication changes were made. Investigation Report dated 3/7/25 and completed by the Administrator was reviewed. The report indicated resident abuse occurred on 3/2/25, and the facility was notified on 3/2/25 at 3:38 AM. Report further indicated a male resident was found in bed with female resident. No injuries and/or change in baseline physically or mentally noted. Nursing staff did not notice any change in behavior. No mental anguish and physical injury/harm noted. Family reports no change in baseline at all daily since event. The incident occurred between Resident #1 and Resident #2 and was witnessed by Nurse #1. Resident #1 was sent to the hospital for psychiatric evaluation and was placed on 1:1 supervision until discharged from facility. Resident #2 responsible party refused twice to send the resident out to the hospital for evaluation. Resident #2 was evaluated by an in-house provider. Investigation completed on 3/7/25 by previous interim Director of Nursing (DON). The Allegation was substantiated. Nurse #1 and Nurse Aide (NA) 1 were terminated for failure to intervene and perform job duties that could have negated this event from occurring. Law enforcement and Adult protective services were notified on 3/2/25. During an interview on 3/10/25 at 3:35 PM, the Social Worker (SW) indicated she received a call from the Administrator on 3/2/25 at around 4:15 AM, that a male resident was in bed with a female resident. The SW indicated she completed the Brief Interview for Mental Status (BIMS) for all residents on 3/2/25. All residents who were alert and orientated with a Brief Interview for Mental Status Score (BIMS) of 10 and above completed an abuse questionnaire. The SW further indicated questionnaire included how they felt about their safety, care needs and who they need to contact at the facility with concerns. The audit was completed on 3/2/25 and there were no negative findings. During a telephone interview on 3/10/24 at 3:15 PM, the previous interim Director of Nursing (DON) stated she was notified on 3/2/25 at around 3:20 AM to 3:30 AM. The interim DON indicated a nurse reported that a male resident was with a female resident in her room. The interim DON indicated that initially the nurse had reported that Resident #1 had his 2 fingers inside Resident #1's private parts (vagina) and later Nurse #1 explained the incident and indicated the resident's fingers were near Resident #2's vagina. Interim DON indicated both residents were placed on 1:1 supervision for the rest of the night. The Administrator was notified of sexual abuse. The interim DON stated during the investigation; the video camera recordings were reviewed. Nurse #1 was sitting near the nurses' station possibly on her phone (head down). Resident #1's room was near the nursing station and Nurse #1 failed to see Resident #1 go out of his room into the hallway almost naked and failed to prevent this incident. Nurse #1 was terminated. Review of Resident #2's electronic health record revealed a progress note written by the Administrator dated 3/3/25. The note indicated Resident #2's responsible party (RP)/ emergency contact was notified about the sexual assault. The Administrator and the interim Director of Nursing (DON) discussed the incident with Resident #2's RP and informed the RP of the NP assessment, referral to Psychiatric NP, plan of care and other nursing care. The RP was provided options to send the resident to emergency room (ER) for SANE (sexual assault Nurse Examiner) exam and STD (sexual transmitted disease) testing. Resident #2's RP declined ER visit and indicated being content with NP evaluation and for STD panel to be drawn. During an interview on 3/11/25 at 8:30 AM, the Administrator stated he was notified by the previous interim DON on 3/2/25 at around 3:30 AM about the sexual abuse incident. DON reported that Nurse #1 had observed Resident #1 in Resident #2's room. Resident #1 was naked, and on Resident #2's bed. Both residents were placed on one-to-one supervision. Administrator further indicated during the investigation, the hallway video cameras were reviewed. Resident #1 was observed naked with a towel around his waist coming out of his room in his wheelchair. Resident #1's room was just opposite the nursing station. NA #1 was observed on camera, not intervening with Resident #1 in the hallway. NA #1 was observed to walk around the resident without addressing the resident. Nurse #1 was observed to be at the nursing station, sitting in a chair and unclear if she was sleeping or on phone. Nurse #1 was not overseeing the NAs assigned to her. Administrator indicated had NA #1 intervened or Nurse #1 seen Resident #1 t coming out of the room and had performed her duties, this could be avoided. Hence both staff were terminated. Administrator stated the Plan of correction was immediately implemented. Administrator indicated Resident #1 was sent to the hospital for psychiatric revaluation and returned to the facility on [DATE] later that night with no medication change. Resident #1 was assessed by the facility NP and Psychiatric NP and medication adjustment were made. Resident #1 was placed on 1:1 supervision until discharged from the facility on 3/6/25. The Administrator further stated he spoke with Resident #2's RP on 2 different occasions and the resident's family declined Resident #2 to be sent to the hospital. Resident #2 was assessed by the NP and Psychiatric NP and no medication changes were made. Resident #2 was assessed to be at her baseline. Resident #2's family had visited the resident on multiple occasions and they did not report any change in Resident #2's behavior or moods. All residents whose Brief Interview for Mental Status Score (BIMS) of 10 and above, completed the abuse questionnaire. Residents reported feeling safe and no concerns were reported to the Social Worker. All residents with a BIMS less than 10, a full body audit was completed by the Wound nurse and Clinical competency Coordinator who were Registered Nurses (RN) and no issues were reported. Abuse /Neglect, sexual abuse and reporting educational in-service were initiated for all staff by Clinical Competency Coordinator on 3/2/24. During a telephone interview on 3/11/25 at 11:28 AM, the Medical Director indicated he was aware of the sexual abuse incident the following morning. Medical Director stated the Nurse Practitioner had assessed Resident #2 and reported no injuries, bleeding or any bruising. Resident #2 did not exhibit any change in behavior and was at her baseline. Blood work was drawn and Resident #2's lab reports showed no negative findings. The Medical Director stated Resident #1 was sent to the hospital for psychiatric evaluation the following morning and returned later with no change in medication. Resident #1 had previously not shown any sexual inappropriate behavior. Resident #1 was assessed by NP #2 and no issues were reported. Medical Director indicated Resident #1, and Resident #2 were followed by the Psychiatric services. After psychiatric assessment Resident #1 had some medication changes made by Psychiatric services. Resident #2 had no changes made to her psychiatric medications. Resident #1 was discharged home with home health services per family request. The Administrator was notified of immediate jeopardy on 3/11/24 at 4:05 pm. The facility provided the following Corrective Action Plan: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 3/2/25, Nurse #1 entered Resident #2's room. Resident #1 was observed in bed with Resident #2. Resident # 2's brief was observed to be on the floor. Resident #2 was dressed in a top and bed covers were pulled up according to the s interview with Nurse #1. Resident #1 had his left hand near resident # 2's vagina. Nurse #1 immediately told Resident #1 to stop, and then Resident #1 walked towards Nurse #1 and sat back in his Wheelchair. Nurse #1 called for assistance from other staff members. Resident #1 was returned to his room immediately by Nurse #2, and a complete head-to-toe skin observation was completed on Resident #1 with no noted bruising, bleeding, pain, or concerns. This was done to ensure there was no skin impairment because of the incident. Resident #1 was immediately placed on 1:1 observation with a staff member. Resident #2 was assessed by Nurse #1 and another nurse to include complete head-to-toe observation and external genital observation with no redness, pain, swelling, bruising, or bleeding noted. Resident #2 was observed in a pleasant mood as evidenced by staff reporting that she was laughing, waving at them and gesturing at them. She

Based on observations and interviews, the facility failed to maintain the dry goods storage area clean and failed to label and date food in one of one walk-in refrigerator. The facility also failed to ensure dietary staff facial hair coverings during food preparation in the kitchen. These practices had the potential to affect food served to residents. Findings included: 1. During an observation of the dry goods storage area on 10/14/24 at 9:15 AM, there was big white container with wheels. The white container had no lid. The was an opened paper bag inside the box. There was large amount white powdery substance on the floor, around and on the side of the white container. During an interview on 10/14/24 at 9:17 AM, the Dietary Manager indicated the white container contained sugar and added staff had accidentally dropped sugar on the floor during breakfast preparations. The Dietary Manager indicated the area should be cleaned immediately by the staff when any spills were made. 2. During an observation of the reach-in refrigerator on 10/14/24 at 9:20 AM, revealed there were three opened 46-ounce cartons of nectar thick tea that were not dated, one opened 46-ounce carton of honey thick tea that was not dated and one clear plastic four-quart container one fourth filled with diced fruit with no label or date on them. Review of the manufacture recommendations for thickened liquids, revealed the beverage should be refrigerated after opening and should be discarded within 72 hours. During an interview on 10/14/24 at 9:23 AM, the Dietary Manager stated the thickened liquids were used during mealtime for residents with physician orders. The diced fruit was fruit cocktail that was used during the previous meal. She indicated opened cartons of thickened liquids should be labeled with an opened date and stored in the refrigerator for 3 day. The Dietary Manager stated all left over food should be labeled with a used by date prior to be placed in the refrigerator. 3. During an observation on 10/14/24 at 9:25 AM, Dietary Aide #1 was observed working near the food preparation station. The Dietary Aide was assisting in food preparation for the lunch meal. The staff had facial hair (beard) that was not covered with a beard covering / guard while working in the kitchen. During an interview on 10/14/ 24 at 9:30 AM, the Dietary Aide #1 stated he had just started his shift and forgot to wear a beard covering. He indicated there were beard coverings available in the dietary manager's office. During an interview on 10/14/24 at 9:32 AM, the Dietary Manager stated there were boxes of beard covering available to dietary staff to use as needed. She indicated the staff had just started his shift and must have forgotten to wear one. During an interview on 10/17/24 at 1:00 PM, the Director of Nursing (DON), indicated all male staff when in kitchen should be wearing a beard covering if they have facial hair. The DON stated all thickened liquids should be dated when opened, placed in the refrigerator and discarded within 72 hours. The DON stated that hairnets and beard guards should be worn by staff while in the kitchen.

Based on observations, record reviews and staff interview the facility failed to accurately code the Minimum Data Set (MDS) assessments for Level II Preadmission Screening and Resident Review (PASRR) for 4 of 7 residents reviewed for MDS accuracy (Resident #43, Resident # 45, Resident #58, and Resident #61). Findings included: 1. Resident #43 was readmitted to the facility on [DATE]. Review of a comprehensive MDS assessment dated [DATE] revealed Resident #43 had no cognitive impairment and was not coded for PASRR Level II or for Level II PASRR screening and conditions as required by the RAI manual (Resident Assessment Instrument). A letter dated 2/2/23 from the North Carolina Department of Health and Human Services Division of Mental Health, Developmental Disabilities and Substance Abuse Services to the facility revealed Resident #43 had been determined to require a Level II PASRR. An interview with the Case Mix Director conducted on 10/17/24 at 11:59 AM revealed the MDS assessments were coded inaccurately, or the information was not available when coding as required by the RAI, and it was her expectation that all MDS assessments be coded as required by the RAI. An interview with the Administrator on 10/17/24 at 1:07 PM revealed that he expected all MDS assessments be coded correctly as directed by the RAI manual. 2. Resident #45 was readmitted to the facility 2/3/22. Review of a comprehensive MDS assessment dated [DATE] revealed Resident #45 had no cognitive impairment and was not coded for PASRR Level II or for Level II PASRR screening and conditions as required by the RAI manual (Resident Assessment Instrument). A letter dated 11/3/21 from the North Carolina Department of Health and Human Services Division of Mental Health, Developmental Disabilities and Substance Abuse Services to the facility revealed Resident #45 had been determined to require a Level II PASRR. An interview with the Case Mix Director conducted on 10/17/24 at 11:59 AM revealed the MDS assessments were coded inaccurately, or the information was not available when coding as required by the RAI, and it was her expectation that all MDS assessments be coded as required by the RAI. An interview with the Administrator on 10/17/24 at 1:07 PM revealed that he expected all MDS assessments be coded correctly as directed by the RAI manual. 3. Resident #58 was readmitted to the facility 12/27/23. A review of a comprehensive MDS assessment dated [DATE] revealed Resident #58 had no cognitive impairment and was not coded for PASRR Level II or for Level II conditions as required by the RAI manual. A letter dated 6/24/21 from the North Carolina Department of Health and Human Services Division of Mental Health, Developmental Disabilities and Substance Abuse Services to the facility revealed Resident #58 had been determined to require a Level II PASRR. An interview with the Case Mix Director conducted on 10/17/24 at 11:59 AM revealed the MDS assessments were coded inaccurately, or the information was not available when coding as required by the RAI, and it was her expectation that all MDS assessments be coded as required by the RAI. An interview with the Administrator on 10/17/24 at 1:07 PM revealed that he expected all MDS assessments be coded correctly as directed by the RAI manual. 4. Resident #61 was admitted to the facility 4/4/24. A review of a comprehensive MDS assessment dated [DATE] revealed Resident #61 had no cognitive impairment and was not coded for PASRR Level II or for Level II conditions as required by the RAI manual. A letter dated 8/23/21 from the North Carolina Department of Health and Human Services Division of Mental Health, Developmental Disabilities and Substance Abuse Services to the facility revealed Resident #61 had been determined to require a Level II PASRR. An interview with the Case Mix Director conducted on 10/17/24 at 11:59 AM revealed the MDS assessments were coded inaccurately, or the information was not available when coding as required by the RAI, and it was her expectation that all MDS assessments be coded as required by the RAI. An interview with the Administrator on 10/17/24 at 1:07 PM revealed that he expected all MDS assessments be coded correctly as directed by the RAI manual.

Based on observations, record reviews, and interviews with residents and staff, the facility failed to provide a resident with a cream gravy mix on her mechanical soft ground meats as specified on the meal ticket (Resident #68) and failed to provide food cut up into small pieces per the physicians order (Resident #22). This occurred for 2 of 2 sampled residents (Resident #68 and Resident #22). Findings included: 1. Resident #68 was admitted to the facility on [DATE] with diagnoses that included dysphagia. Review of the physician's orders for Resident #68 dated 10/5/23 read in part, consistent carbohydrate (CCHO)/ liberalized diabetic diet, and mechanical soft consistency. A review of the Minimum Data Set (MDS) assessment dated [DATE] marked as a quarterly assessment, revealed resident was assessed as severely cognitively impaired and was coded as receiving mechanically altered and therapeutic diet. During a dining observation and resident interview on 10/14/24 from 11:45 AM to 1:05 PM, Resident # 68 was observed sitting in the dining room for her lunch meal. Observation of the resident's meal tray revealed the resident received an alternate meal option. The resident's meal tray consisted of chicken cut in cubes, rice and green peas. The resident was observed to have difficulty swallowing the food and Resident #68 was not eating her lunch. Resident #68 stated to the surveyor that the meat, and rice was too dry to eat. Review of the meal ticket indicated CCHO/liberalized diabetic - mechanical soft diet. The ticket indicated mechanical soft ground for meats and cream gravy mix. There was no gravy provided with her lunch meal. During an interview on 10/14/24 at 12:55 PM, the Nurse Aide (NA) #4 indicated she was unsure why the resident did not receive a soft moist tray. NA #4 stated it was the responsibility of the dietary staff to check the resident's meal tray for accuracy (diet and texture) before sending tray to the residents in the dining room. During a dining observation and resident interview on 10/15/24 from 12:05 PM to 12:30 PM, Resident #68 was observed sitting in the dining room for lunch. Resident was served her lunch tray. Observation of the lunch tray revealed the resident was served ground hamburger patty with a very small dollop of white gravy in the center. Review of the meal ticket had alt written on it, indicating alternate meal option. The resident indicated the hamburger was too dry and not to her liking as it was hard to eat. During an observation and interview on 10/15/24 at 12:30 PM, the Dietary Manager observed the resident's tray and acknowledged the meat was dry. The Dietary Manager stated the dietary staff had not poured adequate gravy on the ground hamburger patty to make it soft. She then went into the kitchen and brought some gravy to be poured over the hamburger to make it soft. 2. Resident #22 was admitted to the facility on [DATE] with dysphagia, sequelae of cerebral infarction (stroke) and contractures of left elbow. Review of the physician orders dated 8/2/24 read in part Regular diet, regular consistency. Special instructions: cut food into bite size pieces. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed resident was assessed as cognitively intact. The assessment indicated resident needed set up/ clean up assistance for eating. During a dining observation on 10/14/24 from 11:45 AM to 1:05 PM, Resident #22 was observed sitting in the dining room for lunch. Observation of the resident's meal tray revealed a chicken patty, rice and green peas. Review of the meal ticket revealed there were no instructions to cut food into bite size pieces. The resident was observed consuming her meals slowly and trying to cut the meat with her fork. During a dining observation and resident interview on 10/15/24 from 12:05 PM to 12:30 PM, Resident #22 was observed sitting in the dining room for her lunch meal. Observation of the resident revealed the resident had only one tooth in her mouth. Observation of the resident's meal tray revealed a piece of baked chicken, mexican corn and vegetable blend. The meal ticket indicated no barbeque sauce and there were no instructions on the ticket to cut food into bite size pieces. Resident was observed trying to cut chicken with the fork and consuming small pieces of chicken. The resident indicated the baked chicken was very dry as it had no sauce or gravy on it and was having a hard time eating it. The resident indicated at times the staff cut her meat to bite size pieces. She indicated that she could not have the barbeque sauce. During an observation and interview on 10/15/24 at 12:30 PM, the Dietary Manager observed the resident's tray and she asked the resident if she would prefer some gravy and offered the resident some gravy. During an interview on 10/17/24 at 9:23 AM, the Dietary Manager stated the special instructions entered in the electronic health record (EHR) software do not always translate (transfer) to the dietary meal tracker software that printed the resident's meal tickets. She further stated that the special instructions were entered in the meal tracker software manually in the dietary meal tracker software. The Dietary Manager indicated that it was a human error, and the special instructions were not entered and did not reflect on the meal ticket. During an interview on 10/17/24 at 9:48 AM, the Director of Nursing (DON) indicated the meal tickets should match the physician orders, so that the residents received the diet ordered. She indicated the consistency of food should be checked by the dietary staff prior to being sent out to the dining table. DON stated the dietary staff, and the nursing staff should check the tray for accuracy before serving trays to the residents.

Based on record review and staff interviews, the facility failed to develop an individualized, person-centered activities of daily living (ADL) care plan that included how much staff assistance was needed to care for a resident who required total assistance with ADL for 1 of 8 sampled residents reviewed for ADL (Resident #49). Findings included: Resident #49 was admitted to the facility on [DATE] with diagnoses that included spondylosis, muscle weakness, lymphedema, and chronic pain syndrome. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had intact cognition and required substantial to maximum assistance with toileting hygiene, personal hygiene, shower/bathing, upper/lower body dressing, putting on and taking off footwear, bed mobility, and transfers. Resident #49's comprehensive care plans, last revised on 7/23/24, did not include a plan that addressed her need for assistance with ADL. An interview with the MDS Coordinator #1 was conducted on 10/16/24 at 2:31 PM. She revealed that MDS updates the nursing care plan for all residents. It was important for ADL assistance to be included in all residents' care plans, so that nursing staff were provided with the appropriate care details. MDS Coordinator #1 thought she remembered adding the ADL assistance plan during Resident #49's admission but could not recall what happened to the focus. During an interview with the Director of Nursing (DON) on 10/17/24 at 10:02 AM, she revealed that every resident should have an ADL care plan focus because of the level of assistance the facility provided. The interim Administrator was interviewed on 10/17/24 at 10:40 AM. He revealed that a focus on ADL assistance should have been included in Resident 49's care plan.

Based on record review, family, Nurse Practitioner, resident and staff interviews, the facility failed to notify the resident and the resident's Responsible Party of a medication change for 1 of 2 sampled residents (Resident #59). Findings included: Resident #59 was admitted to the facility on [DATE] with diagnoses that included stroke and atypical facial pain. The quarterly Minimum Data Set (MDS) dated [DATE] assessed Resident #59 with intact cognition. Review of Resident #59's profile revealed his family member was listed as his Responsible Party (RP). A nursing progress note dated 10/15/24 and recorded as a late entry on 10/16/24 by Nurse #1 revealed Resident #59 complained of increased pain to the left side of his face. Nurse Practitioner (NP) #3 was notified and prescribed 20 milligrams (mg) of Prednisone (steroid) one time followed by 5mg of Prednisone daily for a duration of three days. Also, the acetaminophen order was changed from 325mg every 12 hours to 650mg every 6 hours. A physician order with a start date of 3/13/24 and end date of 10/15/24 read, Acetaminophen 325mg - give 1 tablet by mouth twice daily for pain. A physician order with a start date of 10/15/24 read, Acetaminophen 325mg - give 2 tablets by mouth every 6 hours for pain. A physician order with a start and end date of 10/15/24 read, Prednisone 20mg - give 1 tablet by mouth once daily. A physician order with a start date of 10/15/24 and end date of 10/18/24 read, Prednisone 5mg - give 1 tablet by mouth once daily. During an interview on 10/16/24 at 1:04 PM, Nurse #1 revealed that Resident #59 was in a great deal of pain on 10/15/24, so she contacted NP #3 who then changed the Acetaminophen order and added Prednisone for 3 days. Resident #59 was not his own RP, and she was not able to contact the family because she was occupied with other residents and tasks. Resident #59 was interviewed on 10/15/24 at 9:17 AM. He revealed that his pain medication was changed at 5:00 AM in the morning. Resident #59 stated he was not told beforehand and did not know why it had changed. He indicated he had a great deal of facial pain on 10/15/24, but nothing was discussed about any medication changes. During a telephone interview on 10/16/24 at 12:38 PM, Resident #59's RP stated that he should be notified prior to all medication changes. The RP indicated that he was not told about the addition of Prednisone and the alteration to the Acetaminophen order prior to administration on 10/15/24. NP #3 was interviewed on 10/16/24 at 1:27 PM. She revealed that she was contacted by Nurse #1 on 10/15/24 regarding Resident #59's increased left-sided face pain. NP #3 indicated that Resident #59 was alert and oriented and his own RP. She stated she told Nurse #1 to discuss the changes with Resident #59 on 10/15/24. During an interview on 10/17/24 10:04 AM, the Director of Nursing (DON) revealed that the RP should be notified of any changes with medications. If a resident was considered cognitively intact, then any medication changes should be discussed with them, and nursing staff should inquire if they want their RP to be notified as well. The DON stated that Resident #59 should have been notified prior to the medication changes on 10/15/24 and asked if he wanted the RP to be notified as well. During an interview on 10/17/24 at 10:39 AM, the interim Administrator revealed that Nurse #1 should have notified Resident #59 and his RP of the medication changes that took place on 10/15/24.

Based on staff interviews and record review of resident trust accounts, the facility failed to convey funds within 30 days and forward the balance of funds to the estate of an expired resident for 2 of 3 residents reviewed for personal funds (Resident #281 and Resident #134). The findings included: 1. Resident #281 was admitted to the facility on [DATE] and expired on [DATE]. Review of the resident trust account for Resident #281 conducted on [DATE] revealed a balance of $125. 22 was not conveyed to the resident's estate within 30 days of her death on [DATE]. An interview was conducted on [DATE] at 12:00 PM, in conjunction with a record review with the Financial Counselor who revealed the check had not been sent to the Clerk of Court within the designated 30 days. The Financial Counselor stated that it was not discovered until an audit was done at the end of [DATE] that the funds had not been forwarded to the Clerk of Court. The Financial Counselor further stated after the completion of the audit, the facility did not communicate or correspond with the family that the money in the amount of $125.22 was available or had been forwarded to the Clerk of Court. A telephone interview was conducted on [DATE] at 1:15 PM with the former Administrator who stated the Financial Counselors were responsible for ensuring financial records for expired residents were reviewed and audited monthly to ensure all refunds dispersed to the proper agency, resident and/or representative in accordance with the federal regulations within 30 days. An interview was conducted on [DATE] at 2:32 PM, in conjunction with a record review with the Area [NAME] President and the Financial Counselor who stated the facility failed to forward the funds to the Clerk of Court and/or resident representative. The Financial Counselor stated the money should have been sent to the Clerk of Court within 30 days of death per policy. The Area [NAME] President stated the discrepancy was not discovered until an audit was done at the end of [DATE]. The Area [NAME] President also stated the monies would be sent out immediately. 2. Resident #134 was admitted to the facility on [DATE] and expired on [DATE]. Review of the resident trust account for Resident #134 conducted on [DATE] revealed a balance of $2,349.50 was not conveyed to the resident's estate within 30 days of her death on [DATE]. An interview was conducted on [DATE] at 12:00 PM, in conjunction with a record review with the Financial Counselor who revealed the check had not been sent out the check to the Clerk of Court within the designated 30 days. The Financial Counselor stated that it was not discovered until an audit was done at the end of [DATE] that the funds had not been forwarded to the Clerk of Court. The Financial Counselor further stated after the completion of the audit, the facility did not communicate or correspond with the family that the money in the amount of $2,349.50 was available or had been forwarded to the Clerk of Court. A telephone interview was conducted on [DATE] at 1:15 PM with the former Administrator who stated the Financial Counselors were responsible for ensuring financial records for expired residents were reviewed and audited monthly to ensure all refunds dispersed to the proper agency, resident and/or representative in accordance with the federal regulations within 30 days. An interview was conducted on [DATE] at 2:32 PM, in conjunction with a record review with the Area [NAME] President and the Financial Counselor who stated the facility failed to forward the funds to the Clerk of Court and/or resident representative. The Financial Counselor stated the money should have been sent to the Clerk of Court within 30 days of death per policy. The Area [NAME] President stated the discrepancy was not discovered until an audit was done at the end of [DATE]. The Area [NAME] President also stated the monies would be sent out immediately.

Based on record review and interview of the staff and Police Officer #1, the facility failed to protect a cognitively impaired dependent resident (Resident #1) from sexual abuse by a cognitively intact resident (Resident #2). On 3/19/24 Resident #2 was found in Resident #1's room by Nursing Assistant #1. Resident #2 was observed fondling Resident #1's penis with skin to skin contact from his hand. Resident #1 was unable to stop the sexual abuse due to his limited ability to move and he was non-verbal/unable to call for help. Resident #1 was incapable of consenting to the sexual act and could not express an adverse psychosocial outcome. A reasonable person expects to be protected from abuse in their home environment and sexual abuse would cause emotional trauma. This deficient practice affected 1 of 3 residents reviewed for abuse. Immediate Jeopardy began on 3/19/24 when staff failed to protect Resident #1 from sexual abuse. Immediate jeopardy was removed on 4/10/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of a D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure staff education is completed and monitoring systems put into place are effective. Findings included: A. Resident #1 was admitted to the facility on [DATE] with the diagnoses of quadriplegia (paralysis of the body below the neck) after skull fracture, Traumatic Brain Injury (TBI), aphasia (loss of ability to understand or express speech). Resident #1's quarterly Minimum Data Set, dated dated dated [DATE] indicated the resident was rarely/never understood. The resident had functional limitations in range of motion of his bilateral upper and lower extremities and was dependent on assistance with all activities of daily living. B. Resident #2's hospital discharge summary dated 2/20/24 documented the resident was homeless living in a shelter and had fallen due to advancing Parkinson's disease. The resident had significant risk for worsening of his medical and behavioral status and was at high risk for rehospitalization . Resident #2 was admitted to the facility on [DATE] with the diagnosis of Parkinson's disease. Resident #2's admission Minimum Data Set, dated dated dated [DATE] documented he had an intact cognition and no behaviors. The resident used a walker and a wheelchair for ambulation and was independent with set up. A nurse's note at 9:00 pm on 03/09/24 documented Resident #2 informed the Interim Director of Nursing that he was taking a cab to visit his sister who had just come to town. The Interim Director of Nursing informed the resident that it was late, and he should wait until tomorrow to visit. The resident stated, I'm not waiting until tomorrow, she already called my cab and it's upfront waiting for me. The resident proceeded to the front door where he was observed getting into a van. The resident refused to sign out. The resident was in no apparent distress at the time of departure from the facility. The resident's emergency contact was called. The person answering the phone commented that they had the wrong number. Resident #2's Emergency Department record dated 3/10/24 documented he was seen for leg and foot pain. The resident had a positive drug screen for cocaine. The facility allowed him to return to the facility on [DATE] and he was discharged from the hospital. The Interim Director of Nursing documented in the nurses' notes on 3/19/24 Resident #2 was observed by staff with inappropriate touching of Resident #1's private part. The resident was immediately separated and placed on one-to-one supervision in a room by himself. Resident #2 was interviewed, and he informed the Interim Director of Nursing he touched Resident #1's private part. Resident #2 also indicated that this was the first time he did anything like this here. On 4/4/24 at 2:12 pm an interview was conducted with Nursing Assistant (NA) #1. NA #1 stated she was assigned to Residents #1 and #2 on 3/19/24 during the abuse incident. During rounds shortly after the evening shift change, NA #1 entered Resident #1's room and observed Resident #1 lying in his bed near the door and Resident #2 was in his wheelchair sitting by the side of Resident #1's bed with his back to the door. The door was open. Resident #1's disposable undergarment was open and hospital gown in place, his (Resident #1's) penis was exposed, and Resident #2 had Resident #1's penis in his hand and was fondling it with one hand. She indicated Resident #1 was not saying anything or using his hands to stop Resident #2 during the incident. Resident #1's eyes were open. NA #1 stated she asked Resident #2 what he was doing, and Resident #2 commented Resident #1 told him he would pay him $3 to touch him. NA #1 informed Resident #2 that Resident #1 cannot speak and to get out of the room. Resident #2 was escorted out of the resident's room by NA #1 and placed on one-to-one supervision by another nursing assistant. NA #1 stated she had not known how long Resident #2 was in Resident #1's room or how long he (Resident #2) was touching his (Resident #1's) genitals. NA #1 further stated she was not familiar with Resident #2. He was a new admit for rehabilitation. NA #1 stated there appeared to be no harm to Resident #1 and she immediately reported the incident to the supervising nurse (Nurse #1). Resident #2 left the facility Against Medical Advice (AMA) after the incident the next day. Resident #1 was sent to the hospital for evaluation and transferred to another facility. NA #1 stated this was the first time she had observed Resident #1 in his room on her shift 3/19/24. Resident #2 was from another hall and not on her assignment. Their rooms were not close to each other, they resided on different halls (200 and 300). On 4/4/24 at 3:25 pm an interview was conducted with Nurse #1. Nurse #1 stated she was assigned to Resident #1 on 3/19/24 during the evening shift and was informed of the sexual abuse by NA #1. Nurse #1 stated she was informed that Resident #2 was observed by NA #1 molesting/holding the penis of Resident #1. Resident #2 was immediately removed from Resident #1's room by NA #1 and Nurse #1 observed Resident #2 in his room alone with one-to-one supervision by the nursing assistant. Nurse #1 stated she immediately informed the Administrator, and an investigation began. Resident #1 was examined by Nurse #1, and no injury was observed. Resident #1 was sent to the emergency room and the family were notified. Resident #2 was a new admit and there was no prior behavior of this type. The Resident #1 was oriented to self and situation and was non-verbal. On 4/8/24 at 1:46 pm an interview was conducted with Police Officer #1 from the Special Crime Victims Unit by phone. The Officer stated Resident #2 (perpetrator) admitted to sexual abuse Resident #1 when interviewed by the responding Officer. Officer #1 stated she tried to interview Resident #1 (victim) at another facility on 4/8/24 by using yes and no questions raising his hand. Resident #1 had limited participation and was non-verbal. Police Officer #1 further stated since the sexual abuse was observed by facility staff and Resident #2 admitted to the crime, the case will be presented to the District Attorney for prosecution. The whereabouts of Resident #2 were currently unknown. Police Officer #1 indicated she had just completed her investigation on 4/8/24 and there was no report completed at this time. Resident #2's nurse's note completed by the Interim Director of Nursing dated 3/20/24 at 1:34 pm documented the resident left the facility against medical advice at 1pm. The resident signed the AMA paperwork to leave and was provided with his medication. On 4/4/24 at 1:50 pm an interview was conducted with the Interim Director of Nursing (DON). The Interim DON stated on 3/19/24 Resident #2 was observed to inappropriately touch Resident #1's privates and admitted to touching Resident #1s penis when asked. Resident #2 left the facility against medical advice again on 3/20/24 shortly after the police questioned him. The resident signed the AMA paperwork and was provided with his medication. Resident #1's Nurse Practitioner (NP) progress note dated 3/20/24 at 6:03 pm documented a staff member observed Resident #2 touch Resident #1 inappropriately on his private part. Resident #1 had a cognitive deficit, was non-verbal and could not consent to Resident #2 touching him at his private part. Resident #2 was immediately placed on 1:1 supervision in a room by himself. Resident #1 was assessed and there was no evidence of physical harm noted. Resident #1 had a flat affect (facial expression) and was non-verbal. Resident #1 had a head-to-toe assessment, including skin check, and had no evidence of physical harm. The resident's representative and physician was notified. The physician requested Resident #1 be sent out to emergency room for evaluation. On 4/4/24 and 4/5/24 attempts were made to contact Resident #1's representative but were unsuccessful. On 4/4/24 at 1:40 pm an interview was conducted with the Administrator and Director of Nursing (DON). The Administrator stated Resident #1 was inappropriately touched in his genitals by Resident #2 on 3/19/24. The incident was considered abuse and was reported as required. Resident #2 was removed and placed on one-to-one supervision. Resident #1 was assessed for any injury, and none was found. Resident #1 went to hospital and had not returned to this facility; he was transferred to another facility at his responsible party's request. Resident #1 had limited ability to communicate with yes or no by raised hand from direct questions. Resident #1 had impaired cognition and was the victim of sexual assault/touching by Resident #2 who was alert and oriented. Resident #1 was unable to provide a statement. Resident #2 admitted to touching Resident #1's penis. Resident #2 had a sexual offender registry check which was negative. Resident #2 had no prior behavior other than the incident on 3/19/24. The police, resident's representative, and Adult Protective Services were notified. The responding police officer interviewed Resident #2 on 3/20/24 and he admitted to the abuse behavior and left the facility AMA shortly after. Since Resident #1 was not alert and was abused, the police referred the case to the Special Victims Unit (Police Officer #1). The Administrator was notified of immediate jeopardy on 4/5/24 at 1:54 pm. The facility provided the following credible allegation of immediate jeopardy removal with a completion date of 4/10/24: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and While completing routine room rounds, CNA (Certified Nursing Assistant) noted Resident #2 in Resident #1's room. Resident #2 was fondling Resident # 1's penis. Resident #2 was immediately removed from Resident #1's room. Resident #2 was immediately placed on 1:1 supervision. A full head to toe assessment was completed on 3/19/2024 by a licensed nurse on Resident #1 with no issues or areas of concern noted. Resident #1 was sent out to hospital for further evaluation on 3/19/2024 and he was discharged to another facility per family request. Abuse in-service to all staff was immediately initiated by Director of Health Services or designee on 3/19/2024 and Police and Adult Protective Services were notified. Resident #2 discharged Against Medical Advice after spoken to by law enforcement on 3/20/2024. The unit managers on 3/19/2024 completed a full audit on all residents. Unit managers completed head to toe assessments on 26 residents that were most vulnerable for potential abuse with BIMS (Brief Interview for Mental Status) of 9 and below looking for signs and symptoms of abuse or any appearance of fear during their assessment. No areas of concern were noted. Unit managers completed 68 safe survey interviews with the residents with BIMS of 10 and above asking if they had experienced any abuse, including sexual, in this facility. No areas of concern were noted. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 3/19/2024, an abuse in-service was initiated per Director of Health Services to ensure that all staff recognize, prevent and protect a resident's right to be free from abuse. This inservice and review of facility abuse policy with all staff initiated a heightened awareness for residents who are most vulnerable and assure that our partners are doing all that is within our control to create a standard of intolerance and to prevent any occurrences of any form of patient abuse. This in-service was completed on 4/9/24, any staff not completing this in-service by this date was removed from the schedule until completed. The Director of Health Services or designee is responsible for ensuring all staff inserviced. Department managers complete on-going routine room rounds. This room round screening form includes questioning alert and oriented residents if they have experienced any abuse or visualizing any signs of abuse from residents unable to respond. On 3/25/2024, the Licensed Nursing Home Administrator and Director of Health Services reviewed and updated facilities preadmission checklist to include Director of Health Services reviewing prior to admission, any potential admission with a history of homelessness, drug addiction and or behaviors. On 3/25/2024 the Admissions Director was notified of updated preadmission checklist. If any applicable items are found, this checklist is sent to the Director of Health Services for admission or denial. The Admissions Coordinator completes a sex offender registry check on all new admissions, anyone appearing on the sex offender registry is denied admission. On 3/25/2024 the Licensed Nursing Home Administrator notified the Director of Health Services to review facility activity report (this is a report within the facilities electronic records) Monday thru Friday, monitoring for, but not limited to behaviors, signs of aggression, wandering, and sexual deviations, etc. This review is discussed during morning clinical meeting, which includes the Director of Health Services, the Assistant Director, the Unit Managers, the Social Worker, and the MDS coordinator. This review is used to update resident care plans and implement medically needed interventions. Direct care staff is trained during orientation of necessary documentation needed, including but not limited to progress notes, point of care documentation, care plan updates, etc. This documented information in turn flows to the facility activity report for review. Date of Immediate Jeopardy removal: 4/10/24 Validation of the credible allegation was completed on 4/9/24: On 4/9/24 at 9:40 AM a tour of the facility was done. During this time there were no residents observed with outward signs of physical abuse. Multiple residents and staff were interviewed during this time. Residents reported they had not been abused or mistreated. Alert residents recalled that facility staff had interviewed them in recent weeks about abuse as per the facility's action plan. Some of the staff reported they had received in-service training per the facility's action plan. These staff members were able to express points covered in the abuse in-service material. Two of the interviewed facility staff, who were working on 4/9/24 reported they had not received abuse training since 3/19/24. A review of in-service training records revealed these two staff members' names did not appear on the facility's in-service sign in sheets for abuse training that had occurred between 3/19/24 and 3/25/24. The Director of Nursing was interviewed on 4/9/24 at 11:15 AM and reported she had not been the Director of Nursing (DON) at the time of the abuse in-services for staff. An Interim DON had completed the in-service training, and she could not find the list of current employees which the Interim DON had used to ensure all the staff had been in-serviced. The DON stated that she would confirm which employees were current at the facility and compare to the abuse in-service sign in sheets during onsite 4/9/24. During a follow up interview with the DON on 4/9/24 at 3:00 PM, the DON provided an updated list of current employees and reported that she had identified four more employees who had been working since 3/25/24 who had not been in-serviced. On 4/9/24 the DON in-serviced the two staff members identified by the surveyor and the additional four employees she had identified. The DON did this by providing in-person training or calling them on the phone on 4/9/24. This completed the facility's in-service training for all current working employees. During interviews with staff on 3/9/24, staff were interviewed regarding whether they had witnessed abuse. Staff reported they had not witnessed any type of abuse. Staff were knowledgeable regarding what they should do if they did witness abuse. Review of records revealed documentation that Resident #2 was placed on one-on-one supervision from 3/19/24 until his discharge from the facility on 3/20/24. On 4/9/24 the facility presented documentation of audits they had completed per their action plan. The facility also presented an updated preadmission checklist noting that prior to admitting a resident with homelessness, drug addiction, and/or behaviors that the Admissions' Coordinator must consult with the DON per their action plan. There was a signed acknowledgement by the Director of Admissions noting that she understood this new policy. Interview with the DON on 4/9/24 at 3:00 PM revealed that since 3/25/24 there had been no residents requesting admission who were homeless or had drug and/or behavioral problems. On 4/9/24 it was confirmed that Immediate Jeopardy had been removed as of 4/10/24 due to staff education being completed on 4/9/24 prior to the survey's exit.

Based on record review and staff interviews, the facility's quality assurance (QA) process failed to implement, monitor, and revise as needed the action plan developed for the recertification/complaint investigation survey dated 7/13/22 in order to achieve and sustain compliance. This was for a recited deficiency from a complaint investigation survey on 4/9/24. The deficiency was in the area of abuse. The continued failure during federal surveys of record showed a pattern of the facility's inability to sustain an effective quality assurance program. The findings included: This tag is cross-referenced to: F600: Based on record review and interview of the staff and Police Officer #1, the facility failed to protect a cognitively impaired dependent resident (Resident #1) from sexual abuse by a cognitively intact resident (Resident #2). On 3/19/24 Resident #2 was found in Resident #1's room by Nursing Assistant #1. Resident #2 was observed fondling Resident #1's penis with skin to skin contact from his hand. Resident #1 was unable to stop the sexual abuse due to his limited ability to move and he was non-verbal/unable to call for help. Resident #1 was incapable of consenting to the sexual act and could not express an adverse psychosocial outcome. A reasonable person expects to be protected from abuse in their home environment and sexual abuse would cause emotional trauma. This deficient practice affected 1 of 3 residents reviewed for abuse. During a previous survey on 7/13/22 the facility failed to protect a resident's right to be free from mistreatment for 1 of 1 resident investigated for staff to resident abuse. The resident sustained a scratch on her face and nose from the altercation with the staff and was crying stating that the altercation made her feel scared and anxious. On 4/18/24 at 9:50 am an interview was conducted with the Administrator. The Administrator stated the abuse deficient practice on 3/19/24 was an unusual circumstance and not the same as the prior abuse deficient practice (7/13/22). The staff addressed the situation as best they could under the circumstances.

Based on observations, staff interviews, and record review the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following a recertification and complaint survey in April 2021, recertification and complaint survey in July 2022, complaint survey in June 2023 and subsequently recited in July 2023 on the current recertification and complaint survey. The recited deficiencies were in the areas of 1) develop an accurate assessment (F641) and 2) develop/ implement comprehensive care plan (F656). These deficiencies were recited in the current recertification and complaint survey. The continued failure of the facility during three federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance (QA) Program. The findings included: These tags were cross referenced to: 1. F 641 - Accuracy of Assessment: Based on staff interviews and record reviews, the facility failed to accurately complete a Minimum Data Set (MDS) assessment to reflect a resident's most recent weight obtained during the previous 30-day period for 1 of 5 residents (Resident #392) reviewed for Nutrition. During a complaint survey on 6/12/23, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the area regarding skin conditions for 1 of 1 resident reviewed for wound care. During a recertification and complaint survey on 7/13/22, the facility failed to accurately code the Minimum Data Set (MDS) assessment for 3 of 18 residents whose MDS assessments were reviewed. During the recertification survey on 4/29/21, the facility failed to accurately code the Minimum Data Set (MDS) assessment to indicate the Preadmission Screening and Resident Review (PASRR) Level II status for 5 of 18 residents whose MDS assessments were reviewed. 2. F656 - Develop implement comprehensive care plan: Based on record review and staff interviews, the facility failed to develop a comprehensive care plan which addressed the use of an anticoagulant medication for 1 of 6 residents (Resident #78) reviewed for unnecessary medications. During the previous recertification survey on 7/13/22, the facility failed to develop a comprehensive care plan for 2 of 18 residents reviewed for comprehensive care plans. An interview with the Administrator was conducted on 7/13/23 at 3:47 PM. The Administrator stated the Quality Assurance (QA) committee does 1) identifies areas of concern, 2) does a root cause analysis, 3) develops a plan, audits, and monitors that plan and 4) discusses the outcome. System changes and additional tasks would be put in place as needed to resolve the issue. The Administrator further stated that if there were repeated deficiencies that were identified then the area of concern would become a focus area. The old plan would be revisited and analyzed to see where the failures were, and where the breakdown happened. The root cause would be revisited and new interventions, monitoring tools would be put in place. He explained audits/education would be completed as needed and the team would continuously monitor until the deficient area concerns have been resolved.

Based on observations, staff interviews and record review, the facility failed to: 1) lock and secure one unattended medication cart for 1 of 2 medication carts observed (300-hall medication cart), 2) label a multi-use medication with resident name and opened date on 1 of 2 medication carts observed (500 Hall medication cart). The findings included: 1) a. An observation was conducted on 07/11/23 at 10:03 AM of 300-hall medication cart parked outside of room [ROOM NUMBER]. The lock mechanism was observed popped out in the unlocked position. Nurse #8 was in room [ROOM NUMBER] from approximately 10:03 AM until 10:06 AM. Confused residents were ambulating and propelling selves in wheelchairs in hall at and around medication cart. No staff were observed in the hall. b. An observation was conducted on 07/11/23 at 10:16 AM of 300-hall medication cart parked outside of room [ROOM NUMBER]. The lock mechanism was observed popped out in the unlocked position. Nurse #8 was in room [ROOM NUMBER] from approximately 10:16 AM until 10:25 AM. Confused resident was propelling herself in her wheelchair in hall at and around medication cart. No staff were observed in the hall. c. An observation was conducted on 07/11/23 at 10:48 AM of 300-hall medication cart parked outside of room [ROOM NUMBER]. The lock mechanism was observed popped out in the unlocked position. Nurse #8 was in room [ROOM NUMBER] from approximately 10:48 AM until 10:52 AM. Confused resident was propelling herself in her wheelchair in hall at and around medication cart. No staff were observed in the hall. During an interview with Nurse #8 on 07/11/23 at 10:54 AM, the nurse confirmed that she had forgot to lock the medication cart prior to walking away from it during the medication administration pass. She demonstrated the lock was not engaged by opening a top drawer. She stated the cart should have been locked when she stepped away. During an interview with the Director of Nursing (DON) on 07/12/23 at 2:37 PM she stated the medication carts should be secured when out of the nurse's line of sight. 2) A review of the 500-hall medication cart on 07/11/23 at 11:12 AM in the presence of Nurse # 4. The review revealed one multi-dose bottle of dry eye relief eye drops with no open date or name listed on the bottle. Nurse #4 discarded the bottle of dry eye relief eye drops. During an interview with Nurse #4 on 07/11/23 at 11:13 AM she stated someone brought the bottle of eye drops to her earlier from a resident ' s room. She further stated she forgot to remove them from the medication cart and discard them. During an interview with the Director of Nursing (DON) on 07/12/23 at 2:37 she stated the nursing staff were to label all multi-use medications with the resident ' s name and the date it was opened. She also stated there should not have been unlabeled eye drops on the medication cart.

Based on staff interviews and record reviews, the facility failed to develop a baseline care plan which included the minimum healthcare information necessary to properly care for 1 of 12 newly admitted residents reviewed (Resident #242). The findings included: Resident #242 was admitted to the facility on [DATE]. Her cumulative diagnoses included protein-calorie malnutrition, cirrhosis of the liver, and a recent history of severe sepsis with septic shock (the most severe form in which the infection causes low blood pressure and may result in damage to multiple organs). On 7/12/23 at 8:45 AM, the facility provided a copy of Resident #242's baseline care plan dated 11/2/22 for review. The baseline care plan for this resident addressed only three problems as follows: --Advanced Directives (Problem Start Date 11/2/22); --Pain (Problem Start Date 11/2/22); --Falls (Problem Start Date 11/2/22). The baseline care plan did not address the resident's initial goals based on her admission orders, physician orders, dietary orders, therapy services or social services. Resident #242 was discharged from the facility on 11/7/22. A comprehensive care plan was not yet developed or due at the time of her discharge. An interview was conducted on 7/13/23 at 11:47 AM with the facility's Director of Nursing (DON). During the interview, the DON reported completion of a baseline care plan was typically the responsibility of the hall nurse who was assigned to care for a newly admitted resident. She reported both the former Staff Development Coordinator and she herself frequently assisted with this task. Upon further inquiry, the DON stated she would expect a baseline care plan to include areas such as falls, pain, behaviors, psychotropic and anticoagulant medications, plus any other basic care information that would be needed to get the resident through until the comprehensive care plan was developed. The DON reported about one week ago the facility re-started a plan for auditing residents' medical records to ensure both the baseline and comprehensive care plans were accurate. A review of the care plan Performance Improvement Plan (PIP) revealed this plan was initiated on 6/29/23 with a target end date of 9/29/23. The PIP did not include details on the measures the facility would take or the systems it would alter to ensure that the problem would not recur. Audits for the admission baseline care plan review had not yet been initiated.

Based on staff interviews and record reviews, the facility failed to accurately complete a Minimum Data Set (MDS) assessment to reflect a resident's most recent weight obtained during the previous 30-day period for 1 of 5 residents (Resident #392) reviewed for Nutrition. The findings included: Resident #392 was admitted to the facility on [DATE] with a cumulative diagnoses which included vascular dementia and dysphagia (difficulty swallowing). The resident's admission Minimum Data Set (MDS) dated [DATE] documented her weight as 134 pounds. Resident #392's quarterly MDS dated [DATE] indicated her weight was also 134 pounds. Resident #392's weight history reported in the Vital Signs record of the resident's electronic medical record (EMR) included a measurement obtained and documented on 8/24/22 as 121.8 pounds. Resident #392's quarterly MDS assessment dated [DATE] reported the resident weighed 122 pounds (using mathematical rounding). The resident's next available weight documented in her EMR was obtained on 9/12/22 and noted as 122.4 pounds. According to Resident #392's EMR, she was again weighed on 9/19/22. The weight on that date was 115.2 pounds. Resident #392's quarterly MDS dated [DATE] reported her weight was 122 pounds. The weight documented on this MDS was not the most recent measure obtained in the last 30 days. An interview was conducted with the facility's Director of Nursing (DON) on 7/13/23 at 11:47 AM. During the interview, concern regarding the accuracy of Resident #392's weight recorded in the Swallowing / Nutritional Status section of her MDS assessment was discussed. The DON reported the facility did not currently have an MDS Nurse in place and relied on assistance from corporate and interim MDS nurses to help with the completion of the resident MDS assessments. An interview was conducted on 7/13/23 at 1:35 PM with the Regional MDS Coordinator. Upon inquiry, the Coordinator reviewed Resident #392's MDS assessments and weight history. When asked about the weight reported on her 9/22/22 MDS, the Coordinator stated she could not be certain the resident's 9/19/22 weight of 115.2 pounds was available for the MDS Nurse at the time she completed the 9/22/22 MDS assessment. She also stated that since both weights (122.4 pounds and 115.2 pounds) were obtained during the preceding 30 days, she thought either one may have been acceptable to report on the resident's MDS assessment.

Based on record review and staff interviews, the facility failed to develop a comprehensive care plan which addressed the use of an anticoagulant medication for 1 of 6 residents (Resident #78) reviewed for unnecessary medications. The findings included: Resident #78 was admitted to the facility on [DATE]. Her diagnoses included chronic obstructive pulmonary disease with acute exacerbation. A review of the resident's physician orders included an order dated 2/18/23 for 5 milligrams (mg) apixaban (an anticoagulant medication) to be given by mouth every 12 hours. The diagnosis of a pulmonary embolism (a sudden blockage in an artery going to the lung) was added to the resident's electronic medical record (EMR) on 2/18/23. The resident's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS assessment indicated Resident #78 had moderately impaired cognition. This assessment also reported the resident received an anticoagulant medication on 7 out of 7 days during the look back period. A review of Resident #78's current care plan (last reviewed and revised on 6/15/23) revealed the care plan did not address the resident's use of an anticoagulant medication. Documentation in Resident #78's EMR revealed her current medications on the date of the review (7/13/23) continued to include 5 mg apixaban to be given by mouth every 12 hours. An interview was conducted on 7/13/23 at 11:47 AM with the facility's Director of Nursing (DON). During the interview, the DON confirmed the resident's comprehensive care plan did not include an area of focus related to her use of an anticoagulant medication. Upon further inquiry, the DON stated Resident #78's care plan needed to address the use of an anticoagulant. The DON also reported about one week ago the facility re-started a plan for auditing residents' medical records to ensure both baseline and comprehensive care plans were accurate. A review of the facility's care plan Performance Improvement Plan (PIP) revealed the plan was initiated on 6/29/23 with a target end date of 9/29/23. However, the PIP did not include details on the measures the facility would take or the systems it would alter to ensure the problem would not recur.

Based on record review, and interviews with family, home health, and staff, the facility failed to assess a resident's home environment to identify and evaluate barriers at the discharge location and arrange for home health services to commence the day after discharge. Upon arrival home, the transport driver assisted Resident #222 out of the vehicle and onto the sidewalk in front of her residence. The residence had 6 stairs leading to the front door and no wheelchair ramp. The resident's husband was present at the residence. The facility transporter left before the resident ascended the stairs into the residence. Resident #222 was unable to ascend all the stairs due to weakness and her husband was unable to assist her. The Resident's husband called the Fire Department to assist with getting Resident #222 from the sidewalk into the residence. The resident was home for several hours but was unable to safely ambulate in her residence. Emergency Medical Services were called around 5:30 PM and transported the resident to the hospital where she was admitted for generalized weakness, dehydration, deconditioning and intravenous fluid administration. This deficient practice affected 1 of 2 residents (Resident #222) reviewed for discharge. Immediate jeopardy began on Friday, 4/1/2022 when Resident #222 was discharged from the facility and transported to her residence via facility transporter and facility transport van around 2:00 PM. The immediate jeopardy was removed on 7/14/2022 when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure monitoring of systems put into place related to the discharge planning process are effective and to complete staff training. The findings included: Resident #222 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #222's admission care plan initiated 2/22/2022 had a focus for discharge but it did not indicate where the resident expected to discharge. The resident's discharge goal was left blank. The second goal for discharge indicated the resident, family, caregiver would be able to verbalize understanding of the resident's discharge summary. The care plan also had a focus for barriers to discharge but it was not completed. Interventions for discharge planning included: Evaluate the competency and capacity of the caregiver. Involve resident, resident representative, and caregiver in the discharge process. Anticipate resident's needs post discharge. Resident teaching (left blank) Progress notes provided by the Social Worker (SW) revealed the following information: On 3/11/2022 the SW spoke with resident regarding a notice of Medicare Non-Coverage (NOMNC). Resident and husband both desired her to have more therapy and stated they would wait and hope the NOMNC would not be issued. SW reminded them of the need to plan ahead and try to get a first-floor apartment. Husband stated he could not afford to hire a mover. SW available to continue to advise on options and assist as needed for safe discharge. On 3/11/2022 the SW also documented the resident lived in a single-story apartment with 5 steps at entrance. SW documented the resident functioned at a wheelchair level, would not be able to install a ramp at the apartment complex she resided in, and would need to be able to navigate the steps. SW indicated the steps presented a barrier to safe discharge at that time. The SW indicated the resident had no children, only her husband to provide care at time of discharge. On 3/14/2022 NOMNC served to resident by SW with last date of care 3/16/2022. The resident stated she did not feel like she was ready to go home as she had just started walking and had 6 steps to enter her apartment with no possibility of a ramp. Resident stated she was looking forward to working with physical therapy on stairs. Resident stated she would speak to her husband regarding appealing. On 3/15/2022 SW documented she faxed appeal as well as referral for home health in preparation for discharge. On 3/16/2022 SW documented she spoke with the resident's husband regarding discharge plans. He stated there was no room in the residence for a wheelchair and preferred to discuss discharge after learning the outcome of the appeal. The husband stated there was no first-floor apartment available until summer and the resident would have to come home if the appeal was lost. The SW inquired about Medicaid eligibility and the husband stated they would not qualify for Medicaid due to assets. The SW recommended paid caregiver services and the husband stated they had no money for paid caregiver services. On 3/16/2022 SW documented a conversation with resident separate from her husband. Resident stated she needed more therapy to be able to climb her stairs however stated she would return home regardless of safety concerns if she lost her appeal. SW spoke to resident regarding the potential to remain in the facility and apply for Medicaid. Resident refused. SW offered assistance finding a senior apartment, but resident refused. On 3/17/2022 SW documented she contacted the resident's apartment complex manager regarding policy for ramps. The SW then called the resident's husband who stated he could not afford ramp rentals. An appointment was set up with resident and her husband to discuss possibility of Medicaid application. 3/18/2022 Resident and her husband met with SW regarding options for a safe and orderly discharge. Both were open to making room in the residence for a wheelchair and exploring ramp installation. The resident and her husband were given the address and contact number for the department of social services as well as contact information for local ramp rental companies. On 3/23/2022 NOMNC served to resident and appeals instructions reviewed. On 3/28/2022 SW documented resident was making progress toward discharge goal of 6 stairs to enter residence. Husband unable to secure ramp for residence at that time. Stairs continued to be a barrier at that time. On 3/29/2022 resident was served NOMNC with last date of care 3/31/2022. Resident stated she did not wish to appeal and planned to discharge home on 4/1/2022. There was no ramp in place at that time, but the resident stated she felt comfortable navigating steps. The plan was for resident to continue working with physical therapy through home health. The Physician Assistant (PA) who assessed Resident #222 on 3/30/2022 at 12:52 PM documented in the resident's medical record she saw the resident for discharge planning. For disposition the PA documented the following: Patient suffers from weakness and debility which impairs her ability to use stairs to get in and out of her home. A cane or walker will not resolve these issues with transfers into her home because of instability and risk of falling. A ramp that allows her to get in and out of her home is medically necessary to prevent falls and allow her to attend her medical appointments without requiring transportation from an ambulance company. Resident #222's medical record included a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . PT/OT to evaluate and treat as indicated, nursing for medication and wound management, and CNA for ADL assistance. Start of Care: 4/5/2022. The occupational therapy (OT) discharge summary for Resident #222 with end of care date 3/31/2022 revealed the resident did not meet activities of daily living (ADL) goals and was discharged with 50% ADL impairment. Pertinent OT goals included the resident will be modified independent in all aspects of self-care and activities of daily living within the home in order to return home with spouse safely. The OT discharge summary indicated the goal was not met. The summary also indicated she was discharged home with recommendations of home health. Resident #222's discharge included a discharge summary by physical therapy (PT) with end of care date 3/31/2022. The discharge revealed the resident was able to maintain balance while sitting and standing. The resident required partial assistance from another for mobility indoors and stairs. The discharge summary also revealed the resident used a wheeled walker as assistive device. For mobility with 4 steps, the resident required verbal cues, steadying and or contact guarding assistance for completing activity. The summary indicated she was discharged home with home health. On 6/21/2022 at 12:25 PM an interview was conducted with the Physical Therapy Director. She recalled Resident #222 and stated the resident was able to ambulate with walker and navigate 3 steps with stand by assist. She further stated Resident #222's discharge was hindered by insurance not covering many things like durable medical equipment, home health, and additional days for rehabilitation. Her husband was adamant they would not pay out of pocket for additional days in the facility and he would not allow the SW to apply for assistance on the resident's behalf. The Physical Therapy Director stated the SW assisted Resident #222 with multiple appeals, but all appeals were denied. When asked about stairs, the Physical Therapy Director stated the resident was able to ascend and descend 3 steps with stand-by assistance, but she was concerned the resident's husband, who was also had mobility issues, would not be able to provide the standby assistance the resident needed. A progress note by the SW dated 3/31/2022 indicated Home Health Provider #1 was able to accept resident's insurance with a start of care date 4/5/2022. An interview was conducted with the SW on 6/22/2022 at 9:19 AM. She stated there was difficulty getting home health set up due to the resident's insurance. The soonest home health could start was 4/5/2022. The resident's husband was aware of the 4/5/2022 start date. She stated the facility attempted to assist the resident with getting a wheelchair ramp, but the resident lived in a second-floor apartment and either could not afford, or the complex would not allow them to place a ramp. She stated they tried to get them to move to an apartment on the floor level, but the husband stated there would not be an apartment available until August and he did not have a means to move all of their things down to a ground level apartment. She stated the resident's husband stated several times he did not want to spend money or accept assistance to make it so the resident could return to the apartment. The SW stated the resident was able to transfer herself, walk with a walker, and navigate steps when she was discharged . She felt like it was a safe discharge at the time and the resident's husband was not going to pay for the resident to stay additional days. A second interview was conducted with the SW on 7/1/2022 at 3:00 PM. She stated she did not complete a home assessment for Resident #222 to assess for barrier to discharge. She further stated the facility quit doing home assessments during the pandemic and had only recently started completing home assessments again. When asked if she was aware the resident did not have a ramp in place at the time of her discharge, she stated she was aware there was no ramp in place at the time of discharge. When asked if a referral was made to Adult Protective Services at the time of the resident's discharge, she stated she did not make a referral. On 7/1/2022 at 2:15 PM a telephone interview was conducted with the Admissions Coordinator for Home Health Provider #1. She stated she received the referral for Resident #222 on 3/31/2022 and accepted the referral with a start date of 4/5/2022. She further stated that was the first available date they could start services due to staff shortages. Documentation provided by the Administrator indicated Home Health Provider #2 accepted the referral for wound care with a start date of 4/3/2022 and a nurse visit was scheduled for 10:30 AM to address the resident's dressing changes. On 6/22/2022 at 11:24 AM an interview was conducted with the Treatment Nurse. She stated she recalled Resident #222. She stated the resident got daily wound care for venous ulcers of bilateral lower legs. The Treatment Nurse stated the resident's venous ulcers were healing when she left the facility. She stated the resident could transfer from bed to wheelchair on her on and could stand bedside on her own. She was steady with assistance when using a walker. She did not believe resident would be steady enough to go up or down stairs. She did recall seeing the resident's husband and he had decreased mobility as well. Resident #222's discharge orders dated 3/11/2022 included a wound care order for acetic acid solution, 0.25%; amount 60 milliliters irrigation to be used as wound soak every other day on Monday, Wednesday, and Friday. On 7/6/2022 at 10:30 AM a telephone interview was conducted with the Admissions Coordinator for Home Health Provider #2. She stated she accepted the referral for Resident #222 on 3/31/2022 with start date of 4/3/2022. She could not recall if 4/3/2022 was the first date they could staff the referral or if that was the date the facility requested start of services. The resident's discharge Minimum Data Set (MDS) with observation end date 4/1/2022 indicated the resident was cognitively intact. She required two persons assistance for transfers, walked in her room only once or twice during the assessment period, locomotion in room was with set up only, locomotion in the facility occurred only once or twice during the assessment period, required assistance of one for dressing and toileting, and required the assistance of two persons for personal hygiene during the assessment period. Progress notes dated 4/1/2022 revealed Resident #222 left the facility via facility transport with medications, orders, and all belongings in hand. Husband stated he would meet resident at the home. Resident stated she was ready to go home. On 6/21/2022 at 1:50 PM an interview was conducted with the Facility Transporter. He stated he took Resident #222 home on 4/1/2022. He stated he could not remember if the resident was discharged with a wheelchair or walker. He stated he assisted her out of the vehicle and up to the curb. Her husband was waiting for her and said he could help her inside. He recalled the resident was able to get up the steps, 3-4, and she was on the top step when he pulled away from the curb. On 6/21/2022 at 5:02 PM a phone interview was conducted with Resident #222's husband who was also her responsible party (RP). He stated the facility did not ask to perform a home visit. He stated Resident #222 was transported from the facility to her residence on 4/1/2022 around 2:00 PM by the facility transporter. The transporter provided standby assistance for Resident #222 when she exited the transport van and when she stepped onto the curb. At that time, the transporter got into the van and drove off before Resident #222 ever got up the 6 steps to the residence. The husband stated Resident #222 was able to go up the first 4 steps but was unable to make it up the final 2 steps and into the residence. The husband called the local fire department who assisted the resident into the residence. He stated the resident sat in a chair in the living area of the residence for several hours but was unable to ambulate around the residence due to weakness. He further stated he had to call Emergency Medical Services (EMS) to transport the resident back to the hospital the evening of 4/1/2022. Fire Department and EMS records dated 4/1/2022 indicated they arrived on scene at 2:06 PM for a lift assist call. Upon arrival they found the resident on the stairs. The firemen assisted the resident to a stand position, but she still could not get up the stairs. The resident was assisted onto a stair chair and was lifted up the stairs. A second attempt was made to assist resident into the apartment, but she was unable to get over the step at the threshold of the residence. She was placed back on the stair chair and assisted into the residence. The resident was assisted to a stand and pivot into a recliner. Emergency Medics advised resident she should allow them to transport her to the emergency room (ER) for evaluation, but the resident and her husband refused. A second call to EMS was made on 4/1/2022 at 5:37 PM when they found the resident sitting in a chair in her bedroom. She was found to be hypotensive and [CONDITION(S)] and stated she was unable to get around her residence. The resident and her husband agreed to transport to hospital. Hospital records dated 4/1/2022 revealed Resident #222 was admitted to theER on [DATE] at 7:10 PM and was admitted to the hospital with what the admitting Physician referred to as , generalized weakness, deconditioning, and dehydration. Resident #222 was given intravenous fluids for dehydration and intravenous iron for [CONDITION(S)]. The hospital discharge summary dated 4/5/2022 indicated Resident #222 was discharged to a skilled nursing facility for ongoing physical therapy, occupational therapy and daily wound care. An interview was conducted with Nurse Practitioner (NP) #2 on 6/23/2022 at 9:15 AM. She stated she provided care for Resident #222 while she was in the facility but did not see Resident #222 on the date of her discharge. She further stated the last time she saw Resident #222 she could stand and pivot, but she never personally saw the resident ambulate any distance. On 6/23/2022 at 9:28 AM an interview with the Director of Nursing (DON). She stated she was not the DON in the facility at the time of Resident #222's discharge. She further stated she would have handled the situation differently. She stated she had provided education to the staff regarding situations where the resident does not want to stay in the facility, but the facility did not feel like the resident was ready to safely discharge. The Administrator was notified of immediate jeopardy on 7/7/2022 at 8:20 AM. The facility provided the following credible allegation of immediate jeopardy removal. The facility discharged resident home on 4/1/2022 via facility van transportation. Prior to discharge the facility failed to assess a resident's home environment for any discharge barriers or level of caregiver support. As the result of the facility's failure, the resident required Emergency Medical Services assistance which ended with the resident transferring to the hospital on the same day of discharge. Residents who have been discharged from the facility and residents with potential discharge to the community have the potential to be impacted. The Social Worker completed a review on 7/6/2022 of all community discharges, from 4/1/2022 through 7/5/2022, validating home health was offered, Durable medical equipment was ordered if needed, education provided to resident / responsible party, and that the post discharge follow up phone calls made to the residents / responsible party after discharge. Seventeen residents where discharged home from 4/1/2022 to current. Of the seventeen residents, thirteen were provided home health services with three residents declining home health and Durable medical equipment. The purpose of this audit was to ensure all other residents discharging to the community received a thorough discharge assessment which appropriately identified and addressed potential barriers of the discharge and were provided appropriate equipment and resources. The purpose of this review was to identify no other resident was affected by this practice. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. The facility has two residents discharging on 7/6/2022, resident number one is being discharged to home with granddaughter who is her care giver and her daughter who is the Responsible Party has taken Family Medical Leave for this transition. The Responsible Party declined a home evaluation by therapy stating she already has needed items in place. Resident / Responsible Party has signed a form stating her refusal for a therapy home evaluation. Home Health has been confirmed to start on 7/7/2022, Therapy Services and wound care consultation has been set up for home discharge. Per Physician Assistant discharge summary dated 7/6/2022, the resident is medically stable and cleared for discharge. Resident number two who is alert and oriented and his own Responsible Party, is being discharged home with a roommate, per their wishes, Against Medical Advice. They state they can receive the same services at home, and he will be able to sleep in his own bed and eat his own food. Therapy offered a home evaluation and resident has declined the evaluation. Resident was requested by the Nurse Navigator RN to stay in facility for at least twenty-four more hours for the facility to obtain home health services, but resident declined. Resident refused the medication when offered by the Director of Nursing stating he has everything he needs at home. The Physician Assistant saw the resident prior to discharge on 7/6/2022 and discussed risks involved with leaving the facility against medical advice. When the resident leaves the facility, Adult Protective Service APS was notified on 7/6/2022 by the Social Worker of the discharge against medical advice. The decision to make an APS referral was determined by the facility interdisciplinary team based on the resident's discharge against medical advice. This notification has been documented in the medical record. To correct the deficient practice the facility will initiate discharge planning upon admission with the resident and/or responsible party for determination of long-term placement or short-term placement with return to the community. For community discharges, community resources will be offered to include but not limited to Therapy screen to identify if a virtual, onsite home, or no site visit is needed for equipment and services needed at home, home health agencies, Therapy services, meals on wheels, community care services, outpatient clinics and social service agencies. Physician / Physician Extender will assess facility discharges to ensure that the resident is medically stable for discharge prior to discharge. For residents who choose to discharge back to the community against medical advice, the community resources will be offered to include but not limited to Therapy screen to identify if a virtual, onsite home, or no site visit is needed for equipment and services needed at home, home health agencies, Therapy services, meals on wheels, community care services, outpatient clinics and social service agencies. However, the decision to make an APS referral will be determined by the facility interdisciplinary team based on if the resident discharges against medical advice or if there is an unsafe situation creating a barrier to discharge. Interdisciplinary team will communicate the need for an APS referral to Social Worker / Nurse Navigator. Adult protective Services will be notified by a facility representative (Social Worker / Nurse Navigator) that the resident has discharged against medical advice. An Adult Protective Service referral may also be made if the Interdisciplinary team believes the resident may be in an unsafe situation. On 7/6/2022 the Home Safety Assessment screening form was reviewed and revised by the Vice President of Therapy Services and the Director of Clinical Operations for Therapy Services. This screening form includes a home safety assessment to determine the need for a virtual home visit, onsite home visit or if no visit is needed to determine residents' mobility within the home, equipment and or home modification needs in the home prior to discharge. This process ensures that the facility has thoroughly evaluated potential barriers of the discharge prior to discharge. The Therapy Outcome Coordinator began educating the Licensed Therapist on 7/6/2022 regarding the home screening evaluation, any therapist not educated by 11:00 pm 7/6/2022 will be removed from the schedule until education has been completed. The Therapy Outcome Coordinator will maintain a log of therapist educated and therapist not educated. On 7/6/2022 the Director of Health Services and / the clinical Competency Coordinator began educating the Interdisciplinary Team, including but not limited to the Social Worker, Activity Director, Nurse Managers / Coordinator, Therapy Outcomes Manager, Certified Dietary Manager, Nurse Navigator, Case Mix Director on discharge planning and making appropriate referrals per policy (Discharge Planning) to include the home safety assessment evaluations by therapy. Interdisciplinary Team members who have not been educated by 7/6/2022 11:00pm will be removed from the schedule until the education has been completed. The Director of Health Service is maintaining a log of employees educated. On 7/6/2022 the Director of Health Services and/or Clinical Competency Coordinator began education with the Social Worker and Nurse Navigator, on placing follow up phone calls to the community discharged residents / responsible party ensuring; resident is adapting back to home environment / prior level of care environment, appropriate level of caregiver support, and to identify any further resources they may require. These calls will be made 24 hours following discharge, then 72 hours post discharge, and then weekly for four weeks. Concerns voiced by the discharge resident and/or Responsible Party will be brought forth to the Interdisciplinary Team for follow up and any recommendations for additional services will be provided. On 7/6/2022 the Director of Health Services educated the van driver on ensuring residents are safely within the home prior to leaving the resident's property when the facility provides transportation. This includes assisting the resident into the home and that if the resident / responsible party refuses the van driver is to maintain visualization until the resident is inside the home. This education was provided to the one van driver currently employed. This education will be provided for all newly hired van drivers during general orientation prior to transporting residents. On 7/13/2022 the Director of Health Services educated the van driver on the discharge process to include, when facility is providing discharge transportation home, the resident is to be assisted into the home, and if assistance is refused, visualize the resident entering home. When the resident's family member / responsible party is to be providing transportation home, Therapy will assess, educate, and practice car transfers safely into and out of the vehicle. This process is already incorporated in the Discharge Location Checklist Form. When the resident is transported home through a contracted transportation company, Therapy will ensure a safe discharge by conducting a Home Safety Assessment and Safe Community Discharge checklist. The company will provide transportation to the resident's home and if the driver determines resident is unable to safely enter the dwelling, driver will notify the facility and/or EMS. Facility does post-discharge 24-hour follow-up calls for all discharges. The Administrator was responsible for the credible allegation. The facility's credible allegation of Immediate Jeopardy removal was validated on 7/13/22. The validation was evidenced by staff interviews, record reviews and review of in-service documentation to verify education had been provided to staff that addressed the process of discharge planning and making appropriate referrals. Interviews were conducted with the facility's van driver, Therapy Outcomes Manager, Nurse Managers, Physician Assistant, and Medical Director to discuss their role to ensure a safe discharge for residents. Although the facility's Nurse Navigator was no longer employed by the facility (as of 7/12/22), interviews with the Clinical Competency Coordinator, Director of Nursing and Social Worker confirmed the discharge responsibilities of the Nurse Navigator were currently being shared among them. The interventions for a safe community discharge included offering resources such as a Therapy screen to identify if a home site visit was required to assess the equipment and services needed at home; the resident being assessed by the physician/physician extender prior to discharge; and making a referral to Adult Protective Services (APS) if the resident was discharged Against Medical Advice (AMA) and/or under circumstances which suggested an unsafe discharge. Further measures to ensure a safe discharge to the community included addressing the resident's mode of transportation to his/her home via the facility van, a family member/responsible party, or through a contracted transportation company. The staff interviews confirmed follow-up phone calls were also being made to the community discharged residents to ensure their needs were being met. The Administrator was notified on 7/13/22 the credible allegation for the immediate jeopardy removal was validated on this date (7/13/22) with a removal date of 7/14/22.

Based on record review, observation, Police, staff and resident interview, the facility failed to protect a resident's right to be free from mistreatment for 1 of 1 resident investigated for staff to resident abuse (Resident #14). Resident #14 sustained a scratch on her face and nose from the altercation with the staff and was crying stating that the altercation made her feel scared and anxious. Findings included: Resident #14 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #14's care plan (initiated on 7/12/21) was reviewed. The resident was care planned for the use of the Trilogy machine at bedtime and required continuous oxygen therapy related to [CONDITION(S)] with [CONDITION(S)]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #14's cognition was intact with Brief Interview for Mental Status (BIMS) score of 15, and she did not have any behaviors. The assessment further indicated that the resident was totally dependent on the staff for transfer and uses a wheelchair for mobility. Review of Facility Reported Incident (FRI) dated 3/3/22 revealed an allegation of abuse. The allegation detail was Nurse Aide (NA) #8 hit Resident #14 in the face. The facility's abuse investigation revealed that on 3/3/22 around 6 AM, NA #8 provided incontinent care for Resident #14. The resident requested to change her Trilogy mask to an oxygen tubing. The NA was unable to find the tubing and the resident became agitated, started yelling at the NA. The NA stated that the resident swung at her with her left arm and the NA instinctively grabbed resident's hand, leaned back, and let go of her hand. The resident pulled back and hit herself with her own left hand. The resident was wearing glasses and the nose piece of the glasses created the bruising under resident's eye. The resident stated that she felt anxious and expressed sadness that the altercation had happened. After conducting a thorough investigation, the allegation of abuse was substantiated, and NA #8 was terminated. The corrective actions taken following the incident were: the Nurse Practitioner (NP), Police, and the State were notified. Nurse #8 remained with the resident until the Police arrived for safety. Skin assessment conducted and Resident #14 was noted to have bruises under her right eye and nose and NA #8 was immediately suspended pending investigation. The facility had conducted an audit of all interviewable residents ensuring that residents were free from abuse. All staff were trained on preventing, identifying, and reporting allegations of abuse, neglect, misappropriation of resident property and injuries of unknown origin. The facility's corrective action did not include an audit of non-interviewable residents to ensure nobody had been affected and did not mention that a monitoring tool had been developed on what to audit, how to audit and who was responsible for the audit. Resident #14 was observed on 6/20/22 at 12:15 PM. She was up in wheelchair in her room and was on oxygen via nasal cannula. A Trilogy machine was observed at bedside. Resident #14 was observed to have right side paralysis. Resident #14 reported that sometime in March of 2022 (unable to remember exact date), NA #8 came to her room around 6 AM to provide incontinent care. She asked the NA to remove her Trilogy mask and to replace it with oxygen tubing. The NA stated that she looked and could not find an oxygen tubing in the room. The resident responded that the tubing was there last night and to look for it, but the NA insisted that she could not find it and for the resident to find it herself. When the NA was about to leave the room, the resident started yelling not to leave her without oxygen. Resident #14 stated that it scared her, she could not breath without the oxygen. The NA started yelling at her and hit her in the face causing her eyeglasses to break. She had scratches on her face that were bleeding when the nurse assessed her. The resident added that the Police was called, and he came and interviewed her. She added that she had a roommate at that time, but she was demented. Resident #14 indicated that the incident with NA #8 made her feel scared and anxious and she was crying, it reminded her of her history of abuse. She reported that she asked to be transferred to another nursing facility, but nobody was willing to accept her due to her Trilogy machine. Nurse # 8 was interviewed by telephone on 6/21/22 at 9:58 AM. Nurse #8 reported that he was working the night when NA #8 and Resident #14 had an altercation. He was at the nurse's station when NA #8 reported that she had an altercation with Resident #14. He went to Resident #14's room and observed Resident #14 crying and alleging that NA #8 hit her. When he assessed the resident, she had a small laceration on her face (right side under the eye) and a scratch on her nose with slight bleeding on them. Nurse #8 added that Resident #14 was alert and oriented, used trilogy machine at night and oxygen vial nasal cannula at daytime. The Nurse stated around 6 AM, her Trilogy mask was switched to a nasal cannula. Resident #14 was dependent on oxygen. Nurse #8 indicated that NA #8 reported that during the altercation, Resident #14 tried to hit her with her arm, and when she tried to block it, the resident hit her face with her arm. The Police was called, and NA #8 was suspended and then was terminated. Review of Nurse #8 written statement dated 3/3/22 revealed that NA #8 came to report the incident with Resident #14. NA informed him that she went to the resident's room to provide incontinent care and the resident requested her trilogy mask be replaced with nasal cannula. The NA could not find the cannula in the room. The NA indicated that the resident was getting agitated and started swinging at the NA. While the NA was avoiding being hit, she grabbed the resident's hand and in the process the resident's hand went back and hit her glasses which caused an injury to the resident's right eye. Nurse #8 further stated that when interviewed, Resident #14 revealed that NA #8 woke her up to be changed. The resident requested for the Trilogy mask to be taken off and replaced with the nasal cannula, but the NA could not find the cannula in the room. The resident asked the NA to get another one, but the NA responded that she had no time for it and the altercation started. The resident stated that NA hit her in the process. The report indicated that the NA took the oxygen tubing from the resident's electric wheelchair and that was the tubing the resident was using when Nurse #8 entered the room. Nurse #9 was interviewed by telephone on 6/22/22 at 8:35 AM. The Nurse stated that she was assigned to Resident #14 when the altercation between NA #8 and Resident #14 happened. The Nurse reported that NA #8 came and informed her to check on Resident #14. She went to the resident's room around 6 AM on 3/3/22. Resident #14 was crying alleging NA #8 hit her. She has a scratch on her face with blood under her right eye. She could not remember whether the resident was on Trilogy mask or nasal cannula that morning. Nurse #9 explained that Resident #14 was on Trilogy machine at night and around 6 AM every day, the Trilogy mask was changed to a nasal cannula. NA #8 was in resident's room the morning of 3/3/22 providing care. The resident asked the NA to change her Trilogy mask to a nasal cannula. The NA could not locate the nasal cannula in the room and the resident asked the NA to get another one and the NA replied, I don't have time for that. The resident got mad and started yelling and claimed that the NA hit her. When she interviewed NA #8, the NA stated that when the resident started swinging her left arm, she grabbed her left arm and when she let it go, her left arm hit her face causing her eyeglasses to break. Nurse #9 reported that she notified the Police who came and interviewed the staff and the resident. Review of Nurse #9 written statement (undated) revealed that at 6 AM on 3/3/22, NA #8 asked Resident #14 if she needed to be changed. The resident requested if she could change her Trilogy mask to a nasal cannula/oxygen tubing and the NA replied that she could not find it. The resident asked her to look, and the NA replied, I don't have the time, it was not in here. The resident told the NA Well, you need to look and the NA replied, you need to get up and look your d--- self. The resident reported that the NA knocked her glasses on her face. The written statement further indicated that NA #8 informed Nurse #9 that she and Resident #14 had an issue. The resident tried to hit her, and she grabbed the resident's hand and the momentum had caused the injury. NA # 8 was interviewed by telephone on 6/22/22 at 10:10 AM. The NA reported that it was around 6 AM on 3/3/22 when she went to check on Resident #14 during her last round. Resident #14 asked to change her Trilogy mask to a nasal cannula. She looked and could not find a nasal cannula in her room. The resident got mad and was upset saying that she could not breath without oxygen. She left the resident's room and informed the nurse to check on the resident as she was angry. The NA was unable to remember if she left the resident on a mask or nasal cannula that morning. She explained that when the resident started swinging her left arm, she grabbed it. When she let the resident's left arm go, her arm hit her face causing her eyeglasses to break. When the resident started yelling you hit me and she saw a scratch on the resident's face, she panicked and left the room to get the nurse. NA #8 commented that she should have left the room when the resident started yelling and swinging but she did not. Review of NA #8 written statement dated 3/3/22 revealed that she went in to provide care to Resident #14. The resident asked to change her Trilogy mask to nasal cannula, and she could find the nasal cannula in the room. The resident started yelling that it was there, and she told her to stop yelling and to tell her where the nasal cannula was. The NA tried to finish providing incontinent care, when the resident swung her hand to her face telling her to look for the nasal cannula. The NA grabbed the resident's hand, and it went back to her glasses which cut/scratched her face. She then went to get the nurse for help. The Social Worker (SW) was interviewed on 6/22/22 at 10:35 AM. The SW reported that she interviewed Resident #14 on 3/3/22 regarding the abuse allegation with NA #8. The resident was tearful during the interview and expressed sadness and when she asked her how are you feeling now, she replied that she was feeling anxious. The SW stated that a written statement of the interview was completed. Review of the SW written statement dated 3/3/22 revealed that at 6 AM Resident #14 was sleeping when NA #8 entered her room to provide incontinent care. The resident asked the NA to change her Trilogy mask to an oxygen tubing. NA #8 indicate that she could not find the tubing anywhere and the resident insisted that it must be there as it was there last night. The NA became impatient unable to find the tubing, told the resident, don't yell at me. The resident responded, you yell at me first. NA then said, I'll just leave you here then you can get up and find it yourself. Resident replied, you can't do that, I can't breathe without the oxygen. The resident stated that the Trilogy mask was removed, and the tubing was not applied. The argument continued over whether oxygen tubing was there and whether the NA would look for it or bring another tubing. The resident stated that the NA reached out and hit her in the eye with her hand. The resident was wearing glasses and the nose pad scratched and bruised her eye. The resident yelled several times you hit me and the NA reiterated each time you hit me first. The resident stated that she was paralyzed on her right side and was unable to hit anyone with that hand. The NA replied, you hit at me, you can do that. The Facility's Nurse Consultant and the Director of Nursing (DON) were interviewed on 6/22/22 at 11:10 AM. They both reported that the Administrator was not coming to the facility on Wednesday (6/22/22) and Thursday (6/23/22) but he will be available by calling him. The DON called the Administrator, and he was interviewed by telephone. When asked about their corrective action plan for the abuse allegation dated 3/3/22, he stated that he investigated the abuse allegation dated 3/3/22 on Resident #14 and had sent the 24 hour and 5 - day report to the State. An audit was completed on 3/3/22 by the SW by interviewing alert and oriented residents regarding abuse. Investigation was completed and was substantiated, and NA #8 was terminated. All staff were in-serviced on abuse. The Administrator added that the allegation of abuse was discussed on their March 2022 Quality Assurance (QA) meeting. When asked about their monitoring tool and if abuse was incorporated to their QA, he stated that he had the QA and would send it to the DON. He added that all the documents regarding the allegation of abuse with Resident #14 were in the folder including the staff statements, audits, and in-service records. Review of the documents regarding the abuse allegation dated 3/3/22 with Resident #14, provided by the DON revealed that the audit was completed for alert and oriented residents only with BIMS above 9 and not for confused residents with BIMS below 9. The March 2022 QA revealed allegation of abuse 3/3/22 - results from Interdisciplinary team (IDT) daily compliance rounds to be reviewed ongoing during monthly Quality Assurance Performance Improvement (QAPI) meeting ensuring all residents free from abuse. Monitoring will be on-going x (times) 3 months and concerns identified will be addressed during monthly QAPI meetings. There was no monitoring tool developed as to what to audit, how to audit and who will audit. The Facility's Nurse Consultant and the Director of Nursing (DON) were interviewed on 6/22/22 at 11:15 AM. The DON stated that she started as DON of the facility in May 2022. She reviewed the abuse investigation dated 3/3/22 and she identified that the facility missed to audit the confused residents with BIMS below 9 to ensure nobody was affected. She explained that the facility should have completed a head-to-toe assessment for all residents with BIMS below 9. The DON stated that when a resident's behavior started to escalate, the staff was expected to step back and let the resident calm down. This abuse allegation was substantiated since NA #8 failed to deescalate the resident's behavior; she restrained the resident instead by grabbing her arm. The DON further indicated that she had been monitoring for abuse by reviewing the 24-hour report, but she did not have any monitoring tool to document her audit. The Police was interviewed by telephone on 6/23/22 at 10:38 AM. The Police verified that he was dispatched to the facility on [DATE] due to allegation of assault. He met with Resident #14 and she was crying. The Police stated that the interview from the resident, nurse and NA #8 were written on his report. Review of the Police report was conducted. The report indicated that on 3/3/22 at approximately 6:19 AM, the Police was dispatched to the facility on a report of an assault. On arrival, the Police met with Nurse #9 who indicated that NA #8 and Resident #14 were involved in an altercation. NA #8 stated that when she was in Resident #14's room attempting to change the oxygen tubing, the resident yelled at her. The NA stated that she could not find the tubing and that was when the resident yelled. The NA asked the resident to stop yelling at her and the resident tried to hit her. The NA reported that she grabbed resident's arm and pushed back to avoid being hit and the resident was hit in the face. The Police interviewed Resident #14. He observed the resident was crying which made it difficult to understand at first. Once the resident calmed down, the resident explained that the NA hit her in the face. The resident stated that when the NA could not find the tubing, she told the resident I should just leave you're a- and struck her in the right side of her face. The resident reported that the NA told her to go ahead and report her because she did not care. Nurse #9 came in and assessed the resident. The nurse saw the marks on resident's face and stated that they were not there last night when she put the Trilogy mask on the resident. The resident had a bruise on her right eye along with other red marks in the same area that was consistent with the recent trauma. The Police report revealed that NA #8 was charged for abuse on an elderly person.

Based upon staff interview and medical record review it was determined that the facility failed to prevent staff to resident abuse when a staff member stretched the fingers of a resident to get her hand open while providing assistance with dressing for 1 of 1 resident's (Resident #1) reviewed for abuse. Resident #1 experienced a fractured finger and was treated at the hospital. Findings include: Resident #1 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. Review of the Resident's MDS (minimum data set assessment) dated 6/7/19, revealed that the scored 12 on the brief interview of mental status indicating that the resident had a mild memory deficit. She required staff assistance to complete activities of daily living including dressing. A nurse's note (NN) dated 6/4/19 7 AM-3 PM shift stated, Resident alert and oriented times 3 (Person, Place and Time), able to make needs known. Left, digit finger swollen and purplish in color. Outgoing nurse reported that resident was swollen from last night. Called provider to have an order to x-ray the finger. X-ray done and awaiting the results. Resident tolerated all meds and meal and will monitor per protocol. A nurse's note dated 6/4/19 at 12:48 PM stated, Resident x-ray result shows that 4th digit finger left hand was fractured. 911 called and resident sent to emergency room at 12:30 PM. NN dated 6/4/19 3 PM-11PM shift stated, Resident returned to facility via stretcher, denies pain, observed in stable condition. Resident observed with stabilizer on first finger. Review of a physician progress notes [REDACTED]. Staff reported that patient injured her finger while staff was trying to clean her up. Staff reported that she hit her hand on the siderail during the turning. Resident agreed to hitting her finger. She reported pain and demonstrated a decrease in movement. X-ray of left hand shows fracture of 4th finger. Review of the Radiology Interpretation dated 6/4/19 revealed Resident #1 had an x-ray of her left hand which showed an acute oblique intra-articular slightly displaced fracture in the head of the proximal phalanx 4th digit. Review of the hospital note dated 6/4/19 revealed that the resident had a left ring finger deformity, presents with a left ring finger head of the proximal phalanx fracture. While she was changing rested her hand on something and slipped, and experienced immediate pain and swelling of her left right finger. Review of the facility's investigation report of Resident #1's fractured finger with an end date of 6/11/19, revealed the allegation of staff to resident abuse was substantiated. The investigation specified Resident #1 was abused by the NA who provided care for her on 6/3/19 by stretching her fingers to pull her sweater off during the provision of care. Review of a statement dated 6/5/19, signed by the administrator stated, Administrator interviewed resident with family advocate present. Resident states at around 6:00PM on 6/3/19 the Nurse Aide came into her room to change her and get her ready for bed. Resident stated she told the aide she wanted her meds (medication) first. Resident states the aide said no I must change you first, resident refused to be changed as she was in pain. Resident states she grabbed ahold the rail because she did not want to be changed and started to scream, Stop, but aide did not listen. After some time, the resident's roommate came into the room then went to get nurse. Once nurse got into room the resident was changed. When asked by the Admin (Administrator) in the interview what happened to her hand resident states the aide pulled finger off rail and that is what injured her hand. During the survey Resident #1 was unavailable for interview due to transfer to another facility. Review of statement written dated 6/4/19 by NA #1 ho provided care for Resident #1 on 6/3/19 stated, Resident #1 was brought from the hospital and transferred on the bed by EMS (Emergency Services) on Monday evening at around 5:00. I changed her bed because she still had the sheets and Hoyer pad under her. When I was changing her clothes, she held on to her sweater and I tried to take it out. When she let go I put on her gown. Her roommate noticed that I was having a hard time, so she offered to call the nurse to come help. When I did the next rounds, she didn't complain of pain and everything was normal for the rest of the shift. An additional statement written by NA #1 who provided care for Resident #1 dated 6/12/19 regarding his care for Resident #1 on 6/3/19 stated I opened up her hand by stretching her fingers on both hands to pull the sweater off. During telephone interview on 6/27/19 at 6:54 PM with NA #1 who provided care for Resident #1 on 6/3/19 during 2nd shift, the NA stated, it was a normal shift. The NA reported that he was changing Resident #1's clothing and she was holding her sweater when he took it off. He stated that he did not know anything happened and the resident did not complain of pain during his shift. The NA reported that he provided care for the resident at 5:00 PM, 9:00 PM, and 11:00 PM with no complaints of pain. Interview with the facility administrator at 5:11 PM on 6/27/19 revealed that Resident #1's finger was x-rayed, and she was sent out to the emergency room . The administrator stated the facility investigated the resident's fractured finger and determined Resident #1's finger was injured when the NA #1 stretched her fingers to open her hand on 6/3/19. He stated that the NA involved in the incident was suspended on 6/4/19 and the facility implemented a corrective action plan to prevent reoccurrence. Facility Plan of Correction Date 6/4/19. Facility alleged date of compliance 6/12/19. Corrective Action for the resident involved, (Resident #1): Resident physician notified and gave order for an x-ray. Resident was x-rayed and sent to the hospital for a fractured finger, the resident returned to the facility the same day with a stabilizer for her finger. Identification of potentially affected resident and corrective actions taken: The Nursing Assistant who provided care for Resident #1 was suspended on 6/4/19. Administrator interviewed other alert and oriented residents on 6/5/19, residents who were not alert and oriented were assessed from head to toe by a nurse on 6/11/19. Measures put in place or systemic changes that were made to ensure that the deficient practice will not reoccur: 6/12/19, staff were in-serviced refusal of care and the facility abuse policy by the Administrator, Director of Nurses, Assistant Director of Nurses and Nursing Supervisor. Monitoring/Quality Assurance Plan: SW or designee will interview 10 alert and oriented residents as it relates to staff/resident abuse weekly for 4 weeks. Nurse or designee will perform 10 random skin audits for residents who are not alert and oriented weekly for 4 weeks. Nurse or designee will interview 10 random employees as it relates to the facility abuse policy weekly for 4 weeks. Facility administrator will report the results of the audits to the QAPI committee for further review and recommendations as needed and thereafter. Review of the facility's Plan of Correction on 6/27/19 revealed an Inservice Education Program Summary Record Form. The Program was title Refusal of Care /Abuse Policy. Program Content included, zero tolerance policy regarding abuse and stopping care immediately upon resident refusal of care. All employees are provided abuse and neglect training upon hire. Inservice attendance records were signed by staff and dated 6/12/19. Review of facility monitoring on 6/27/19 revealed Resident interviews were conducted on 6/17/19 and 6/25/19. Body audits were documented on 6/19 and 6/25/19. Staff interviews were documented as being completed on 6/17 and 6/25/19. Review of the facility tracking sheets revealed that monitoring/audits were conducted per the plan of correction. Interview with facility staff on 6/27/19 at 7:05 PM, 7:16 PM, and 7:34 PM revealed that they participated in abuse and neglect training and refusal of care a during the past month. Staff were able to appropriately state the correct response to resident refusal of care. Date of 6/12/19 was verified as the facility's date of correction.

Based on observations, record review and staff and resident interviews the facility failed to prevent a resident with dementia from exiting the facility while unsupervised for an unknown amount of time for 1 of 1 sampled residents reviewed for elopement (Resident #1). Resident #1 was found outside lying in a drainage ditch approximately 178 feet away from the facility. The resident was returned inside the facility and his body temperature was below normal at 90.5 degrees Fahrenheit (F.) and he was transported to the hospital for evaluation. Findings included: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed the resident was as cognitively intact with a brief interview of mental status (BIMS) of 14, no assessment for decision making. He had no previous or current wandering behavior. He required extensive assistance with transfers and ambulation on the unit and supervision off the unit. Review of a nursing note dated 3/19/19 that was written by Nurse # 2 revealed Resident #1 was up most of the night at the nurse's station. Nurse Aide returned him to his room at 4:00AM provided incontinent care. The nurse Aide returned to the room about 6:15 AM the resident wasn't there. Staff went room to room and bathrooms looking for Resident #1. He was found about 7:30 AM on the floor outside he was brought back into the building, he was cold to the touch and was assessed for injury. The note specified Resident #1 was so cold the thermometer was unable to provide a temperature, pulse 94 beats per minute, respirations 22 breaths per minute and blood pressure 175/102. He was covered with blankets and the Physician Assistant assessed Resident #1 and sent him to the hospital. On 3/26/19 at 9:07 AM during an interview via telephone with Nurse #2 indicated that Resident #1 had been up during the night of 3/19/19. Nurse #2 stated Nurse Aide # 2 assisted Resident #1 to bed at 4:00AM. She returned to check on him at 6:00AM and he was not in his room. She reported to me and we began to look for him in all rooms and halls. She had never seen him try to leave the building from any door. Another nurse found him outside the building and brought him in. He had no injury. He was cold, and she took his body temperature and it was 90.5 degrees F. Nurse #2 stated she called the doctor and he was sent to the hospital. Record review of the Resident Incident Report dated 3/19/19 for Resident #1, revealed the location of occurrence was, He was outside the building. His vital signs were recorded as temperature left blank, pulse 94 beats per minute, respirations 22 breaths per minute and blood pressure 175/102. The narrative of the incident stated, Resident left the building and went outside, we looked around the building in all rooms, bathrooms. We didn't see him, he was found outside on the floor. Review of the physician's note dated 3/19/19 no time, revealed blood pressure 178/114, heart rate 88beats per minute, body temp 90.6 degrees F. and respiratory rate 20 breaths per minute after outside for unknown amount of time. No injuries. Review of the temperature record on https://www.accuweather.com/en/us/durham-nc/ /march-weather/ 1 revealed the temperature in the(NAME)area, where the facility is located, during the morning of 3/19/19 was 34 degrees F. Record review of the Emergency Medical Service Response report dated 3/19/19 at 9:16 AM revealed chief complaint was hypothermia of Resident #1. He was confused and was alert to person, place, event, time and no physical abnormalities. His temperature at 9:25 AM was 93.3 degrees F, 9:36 AM was 94.4 degrees F. and at 9:46 AM was 95.8 degrees F., and Resident #1 was transported to the hospital at 9:53 AM. Record review of hospital discharge document dated 3/19/19 no time, revealed his end of visit vital signs were blood pressure 126/84, temperature 97.7 degrees F., pulse 87, and respirations 21 breaths per minute. He came in very cold, no serious injuries. Record review revealed Resident #1 was readmitted to the facility on [DATE]. Upon his return to the facility on [DATE] the staff assessed Resident #1 as being a high risk for elopement and a wander guard was placed on his ankle. During an interview and observation on 3/25/19 at 10:00 AM with Resident #1 was sitting in his room after breakfast. He watched his television. His demeanor was calm and approachable and he spoke quietly. The wander guard bracelet was observed on his right ankle above his sock. He was observed able to move his extremities normally. He was asked if he remembered being out of the building a couple days ago. He said Yes. He indicated that he went out the door on the 300 hall, he could not remember how he got out. He could not remember who let him back in. He stated that he was out for 10 or 15 minutes, he had not fallen and he remember was cold. He indicated that he could propel the wheelchair without assistance. On 3/27/19 at 11:38 AM via telephone Nurse Aide # 2 indicated she was assigned Resident #1 on 3/19/19. He was up and walked during that night. This was not his normal behavior. The last time she put him was when she put him to bed was 4:00AM. He laid down in his bed. She went to another room and returned to Resident #1's room at 5:45 AM. He was not in his room. She told another aide (not named) and we looked in the rooms. When she did not find him she told the nurse about 6:00AM. She had never seen him go to the doors. She had never seen anyone use the 300 hallway exit door. An Interview on 3/15/19 at 10:32 AM Nurse #1 indicated when he came on duty 3/19/19, the third shift staff was looking for Resident #1. He indicated that he walked out the front door turned left and left again to the side of the building that lead to the back of the building. He yelled Resident #1 name and he answered Yeah. He was found about 7:20AM, he had laid on top of rocks in a drainage ditch looking up at the sky with his arms crossed on his chest. The ditch had a small amount of water, and the sun was just coming up. Nurse # 1 indicated he had noted frost on the windshield of his car that morning it was not raining. It was cold out. Resident #1 was dressed in a hospital gown with a brief and socks. His shoes were placed about three feet from him neatly arranged, like he had taken them off and set them together. His right side of the gown was wet. He was cold to the touch. Nurse #1 stated he assessed Resident #1 prior to getting him up and put him into a wheel chair. Resident #1 denied any pain. He brought Resident #1 into the facility and returned him to Nurse #2. The aide who had him was NA #2. Nurse #1 stated that when Resident #1 had walked out of the facility he had no wheelchair. Normally, he used a wheelchair to propel. He walked short distances. He did not exit seek. He did wander in the facility. The 300 hall door was always locked with a key pad code. He did not know the code. That door was used by the ambulance or the funeral home. Usually, staff had not used the door. An Observation on 3/25/19 at 2:15 PM revealed the measurement of distance taken by the Maintenance Director (MTD) using a tape measure with Nurse #1 present to direct where Resident #1 was found on the ground on 3/19/19. The total distance from the door of the facility down the ramp to a rocky hill which sloped down to the opening of a large drainage pipe that emptied into a drainage ditch filled with rocks was 178 feet. He indicated that he had his assistant immediately checked the functioning of the door. The MTD stated that the assistant reported that the 300 hallway exit door had no malfunction. The (named) contractor that managed the door's lock system was called to check the system for malfunction. The MTD stated the contractor reported to him, There was no malfunction and the lock system was disengaged manually by someone. That was how the resident was able to exit undetected. No one was to use this door it was for maintenance use only or an emergency exit. He indicated that the contactor recommended an additional safety feature for the door that would prevent staff from disengaging the door. An interview on 3/25/19 10:26 AM with Nurse Aide (NA) #1 revealed she arrived at the facility on 3/19/19 at 7:00AM and Resident #1 was missing. He was found outside the 300 hall door by Nurse #1 he had on a hospital gown. She indicated that he was able to propel himself in the wheelchair through the building and was able to get up and walk. He didn't exit seek. All the doors had a code to get out. The alarm sounded when anyone goes outside the 300 door. During an observation on 3/25/19 at 10:26 AM at the 300 exit door revealed Resident #1 was able to stand unassisted and he pushed on the door. The door remained locked. No alarm sounded. Nurse Aide #1 stated she did not know the code to the key pad to get out. An interview on 3/25/19 at 2:05 PM Nurse # 3 indicated that she worked daily with Resident #1. He did not exit seek and was confused and wandered in the building. He got up and walked. On 3/26/19 at 10:47 AM Nurse Practitioner (NP) indicated that she was familiar with Resident #1 and his normal demeanor was to sit outside his room and socialize. He had not been observed as exit seeking. He was alert and able to answer questions accurately. He had short term memory loss and was able to ask questions but his ability to reason was poor. He varied day to day. His assessment for cognition was accurate. On 3/25/19 at 2:45 PM Maintenance Assistant indicated he was not at the building when Resident #1 was found. When he arrived he checked and all the switches had been reset and the 300 hallway's magnetic door lock was engaged. He found no malfunction of the system. Review of the contracted vender service report for the emergency exit door (300 hallway exit door) dated 3/20/19 revealed physical manipulation required (emergency switch engaged blocking open door, etc.) for door /mag lock not to work properly. On 3/25/19 at 4:48 PM Administrator indicated that Resident #1 was sent back to the facility from the hospital the same day, with no injury. An investigation was unable to determine who or why the 300 hallway exit door was disengaged. On 3/26/19 at 3:51 PM via telephone Nurse#4 indicated she supervised the second shift. She indicated that staff were not to go out the emergency doors to smoke or to go to their cars. All doors were to remain locked unless there was an emergency. The staff were aware how to operate the door locks during an emergency by flipping up the toggle switch and closing the plastic cover to stop the audible door alarm. On 3/27/19 at 10:07 AM the Administrator used a surveyor wheel from the therapy department to measure the distance from Resident #1 room to the 300 hall exit door, it was 55 feet. The distance from the exit door down the ramp to the drainage ditch where Resident #1 was found was 159 feet. During interview the Administrator indicated the lights came on with sensors in the evening the door had to be left unlocked for Resident #1 to exit. It was unknown who left the 300 hallway exit door unlocked. CORRECTIVE ACTION Resident #1 was assessed by nurse immediately when resident was located no physical injuries noted and resident was responsive to questions. Once Resident #1 was returned to room he was assessed by the Physician Assistant in the am, resident was transported to the hospital approximately 9:30 am. Resident returned the same day in the evening around 7:30 pm with no known injuries. Upon return, an elopement assessment was completed, his score was 15, a score of 15 means the resident, at the present moment, is at high risk for wandering. A wander guard was placed on resident #1 right ankle, care plan updated (to address the resident's new wander assessment and placement of wandergaurd), CNA Care intervention record form was updated, and picture of resident #1 was added to elopement risk book along with resident's demographics which include race, gender, ambulatory status, height, weight, and location of wander guard with expiration date. On 3/19/19, the assistant maintenance director completed a 100% audit of exit doors to ensure doors were functioning properly. All 8 out of 8 facility exit doors were checked, no issues were noted. On 3/20/19 starting at 915am, BFPE, a sprinkler/security/alarm company, completed a service check for all exit doors, no issues were noted after their inspection. The facility did investigate to determine how the resident walked outside without being detected by staff and determine the door's safety switch must have been disabled to allow exit and entry. The plastic cover of the switch does make a loud alarm sound when removed but stops when cover is replaced, noted to be working properly. Interviews with residents and staff no one heard alarms activated. On 3/19/19 licensed nurses completed elopement risk observation forms on 100% in house residents. MDS nurse and nurse management team reviewed elopement risk assessment. Any resident that scored 5 or above had care plan updated including elopement interventions. If resident scored above 5 and was unable to ambulate, non-mobile (Bed bound needing assistance from staff to get up and move throughout the facility), and/or total care with activities of daily living (not able to perform basic activities, i.e.; wash face, ambulate, nor wheel themselves in their wheelchairs without assistance from staff), they were not care planned as exit seeking. There were 56 residents with updated care plans for elopement risk. There were 72 residents that did not warrant an updated care plan for elopement risk. On 3/19/19 Administrator and Director of Health Services started in-services of licensed nursing staff and non-licensed personnel including certified nursing assistant, dietary staff, housekeeping staff, laundry personnel, maintenance, social service director and business office personnel on Elopement Prevention (ensuring facility doors are never disabled unless in an emergency), Missing person (Code Pink) including the procedure for searching the facility and procedure for notification of management. Any staff who has not been in-serviced as of 3/22/19 cannot work until in-service has been completed. If employee is on FMLA, on leave or are PRN, employees will be in-service upon return before next schedule shift. In-service will be added to orientation process. In-service was completed on 3/22/19. On 3/19/19 Administrator started to in-service all licensed nursing staff and non-licensed personnel including certified nursing assistant, dietary staff, housekeeping staff, laundry personnel, maintenance, social service director and business office personnel on facility door security (to include not disabling facility door alarms). Any staff who has not been in-serviced as of 3/22/19 cannot work until in-service has been completed. If employee is on FMLA, on leave or are PRN, employees will be in-service upon return before next schedule shift. In-service will be added to orientation process. In-service was completed on 3/22/19. On 3/19/19 Director of Health Services started in-service of all licensed nurses and non-licensed nursing staff (certified nursing assistant) for nursing staff for rounding/incontinence care every 2 hours. Any staff who has not been in-serviced as of 3/22/19 cannot work until in-service has been completed. If employee is on FMLA, on leave or are PRN, employees will be in-service upon return before next schedule shift. In-service will be added to orientation process. If employee is on FMLA, on leave or are PRN, employees will be in-service upon return before next schedule shift. In-service will be added to orientation process. In-service was completed on 3/22/19. On 3/21/19 Administrator started in-services of licensed nursing staff and non-licensed personnel including certified nursing assistant, dietary staff, housekeeping staff, laundry personnel, maintenance, social service director and business office personnel for any resident that is leaving a secure environment to unsecure environment always address/redirect residents. Any staff who has not been in-serviced as of 3/22/19 cannot work until in-service has been completed. If employee is on FMLA, on leave or are PRN, employees will be in-service upon return before next schedule shift. In-service will be added to orientation process. In-service was completed on 3/22/19. Maintenance director and/or assistant maintenance director will complete a daily check on all exit doors to ensure doors are functioning properly. Audits will be turned into the Administrator daily for review. On 3/19/19 the licensed nurses were trained and will check all exit doors every shift to ensure the doors are functioning correctly and alarms working. If the doors are not functioning properly the licensed nurse will notify the maintenance director and/or Administrator immediately and a staff member will man door until fixed. The facility door audit is turned into the facility Administrator every shift for review. Licensed nurses will complete head counts of assigned resident four times per shift, if a resident is noted missing or unable to locate, the licensed nurse is responsible to initiate Code Pink and notify Administrator immediately. The Resident Head count audit is turned into the administrator every shift for review. Upon admission/readmission an elopement risk observation form is completed and all residents who score above a 5, interventions will be put into place and their care plan will be up dated to reflect resident elopement status Maintenance director will track and trend the daily door checks and provide the analysis to the Quality Assurance and Performance Improvements Committee monthly until 3 months of substantiate compliance maintain then quarterly after. Administrator will track and trend the daily door checks from licensed nursing staff and provide the analysis to Quality Assurance and Performance Improvements Committee monthly until 3 months of substantiate compliance maintain then quarterly after. Administrator will track and trend the head counts of assigned residents from licensed nursing staff and provide the analysis to the Quality Assurance and Performance Improvements Committee monthly until 3 months of substantiate compliance maintain then quarterly after. The Director of Health Services will track and trend all admission/readmission elopement risk assessment and provide the analysis to Quality Assurance and Performance Improvements Committee monthly until 3 months of substantiate compliance maintain then quarterly after. Final date of compliance 3/22/19. The Administrator and Director of Nursing will be responsible for the implementation of corrective actions to include all 100% audits, in services, and monitoring related to the credible allegation of compliance for prevention of accidents. As part of the validation process on 3/25/19 through 3/27/19, the plan of correction was reviewed including the re-education of staff and observations of interventions put into place to ensure the door remained locked. Resident #1 was in the facility at the time of the investigation. Observation on 3/25/19 at 10:00 AM revealed he was in his room with a wandergaurd bracelet intact. Observations were made of other residents who were potential elopement risks. Interviews with licensed staff and nursing assistants revealed nurses and nurse aides were retrained to do a visual head count of the resident and check the emergency exit doors every two hours and nurses to document on audit sheets. A review of the monitoring tools revealed that the facility completed the audits of residents and the doors every two hours. The facility's alleged compliance date of 3/22/19 was verified.

Based on record review, staff interview, and physician interview the facility failed to provide and administer a medication ordered for pain ([MEDICATION NAME]) for 10 days, failed to provide and administer ordered admission medications (Meropenum) for 8 days and ([MEDICATION NAME]) for 3 days; and failed to provide assessments and treatments for a PICC (peripherally inserted central catheter) for 8 out of 10 days for 2 of 2 residents (Resident #181 and #128) missing 25 of 30 opportunities to provide care. 1.Resident #181 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Nursing Home Admission History and Physical dated 10/9/14 indicated Resident #181 had a bilateral lower extremity chronic wound infection and acute and chronic pain. The October 2014 signed admission Physician order [REDACTED]. [MEDICATION NAME] 300 milligrams (mg) three times a day. [MEDICATION NAME] 50 mg every 6 hours as needed. Take 1 tablet for moderate pain, 2 for severe pain. [MEDICATION NAME] 10 mg every 6 hrs as needed. The physician progress notes [REDACTED].#181 was seen due to increased burning sensation in legs. The physician discontinued [MEDICATION NAME] and started [MEDICATION NAME] for her nerve pain. The Physician Interim Orders dated 10/14/14 indicated: [MEDICATION NAME] 4 mg (by mouth) 30 minutes before dressing change once daily. The Physician Interim Orders dated 10/15/14 indicated [MEDICATION NAME] 10 mg (by mouth) x 1 dose now - extreme pain. [MEDICATION NAME] 50 mg (by mouth every 6 hours as needed) mild pain. [MEDICATION NAME] 100 mg (by mouth every 6 hours as needed) moderate pain. [MEDICATION NAME] 10 mg (by mouth every 6 hours as needed) severe pain. The Minimum Data Set ((MDS) dated [DATE] indicated Resident #181 was cognitively intact, had wounds, received scheduled and as-needed pain medication in the last 5 days, experienced pain frequently, the pain made it hard for her to sleep and her worst pain was a 10/10. The Physician Interim Orders dated 10/16/14 indicated: (Discontinue) [MEDICATION NAME] 4 mg (by mouth 30 minutes before dressing change). Start [MEDICATION NAME] 5 mg (by mouth 30 minutes before dressing change) once daily. (Discontinue) [MEDICATION NAME]. (Discontinue) [MEDICATION NAME]. [MEDICATION NAME] 25 mg (by mouth every night at bedtime) - (pain). (Discontinue) [MEDICATION NAME]. (Discontinue) [MEDICATION NAME]. [MEDICATION NAME] 10 mg (by mouth every 4 hours as needed) pain. [MEDICATION NAME] 50 mg (by mouth every 4 hours as needed) pain. Review of the 24-hour Chart Check Form signed by Nurse #15 and dated 10/16/14 stated, "New orders" and indicated, by a checkmark, that the new orders were placed on the MAR. Review of the Medication Administration Record (MAR) indicated [MEDICATION NAME] 25 mg for pain was ordered on [DATE] and was first signed off as being administered on 10/26/14. The physician progress notes [REDACTED].#181 was seen due to continued complaint of severe pain in both of her legs. The physician added [MEDICATION NAME] for pain management. The Physician Interim Orders dated 10/20/14 indicated: ([MEDICATION NAME]) 15 mg (by mouth twice a day). The physician progress notes [REDACTED].#181's pain was improved but she was awakening at night with pain. The physician increased her [MEDICATION NAME] at night. The Physician Interim Orders dated 10/24/14 indicated: (Discontinue [MEDICATION NAME]) ([MEDICATION NAME]) 15 mg (by mouth every morning). ([MEDICATION NAME]) 30 mg (by mouth at bedtime). The Physician Interim Orders dated 10/25/14 indicated: May hold [MEDICATION NAME] 25 mg (by mouth at bedtime) until available from pharmacy. The October 2014 Medication Administration Record (MAR) revealed Resident #181 received 49 doses of as-needed pain medication between 10/8/14 and 10/31/14. The pain evaluation done every shift documented moderate to severe pain every day. The physician progress notes [REDACTED].#181 was seen because of episodes of crying and that the resident stated "she was only crying (because) she continues to have pain in (both lower legs)." The physician increased her [MEDICATION NAME] for her chronic nerve pain and bilateral leg ulcers. The Physician Interim Orders dated 11/5/14 indicated: (Discontinue [MEDICATION NAME]). [MEDICATION NAME] 50 mg (by mouth at bedtime) for neuropathic pain. The Physician Interim Orders dated 11/11/14 indicated: (Discontinue [MEDICATION NAME]). [MEDICATION NAME] 75 mg (by mouth at bedtime). During an interview on 12/10/14 at 3:26 pm with the acting Director of Nursing (DON) she stated, "Two nurses check the chart. The (night) nurse on the floor checks every new order that has come in (that 24-hour period)." She further indicated that there is no set time for the night (7 pm - 7 am) nurse to do the 24-hour chart check, but that the check for new orders should go all the way back to 7 pm the previous day so that no orders are missed. She also indicated that the [MEDICATION NAME] is not a stock medication or available in the e-kit (emergency kit), should have been ordered from the pharmacy and should have been given to the resident as ordered. During an interview with Unit Coordinator #1 on 12/11/14 at 12:25 pm she stated, "The nurse will fax (the physician order) to the pharmacy no matter what time the order is written and then will write it on the MAR. The night supervisor does a chart check to ensure all orders are sent to the pharmacy and put on the MAR." After reviewing Resident #181's 10/16/14 [MEDICATION NAME] order, she indicated a nurse did not sign off as receiving the order or faxing it to the pharmacy on 10/16/14, or any date since that time. She further stated, "If a written order does not arrive after it is sent to the pharmacy and is not in the e-kit, we write a hold order until it comes. I remember Nurse #2 mentioning the missed [MEDICATION NAME] to me. I don't recall why it was not given. [MEDICATION NAME] is not in the e-kit (and would have to come from the pharmacy)." During an interview with the DON on 12/11/14 at 4:15 pm she stated, "I would expect the order would have been caught by the night nurse doing the chart check." During an interview with Nurse #2 on 12/12/14 at 1:00 pm, regarding Resident #181's 10/16/14 [MEDICATION NAME] order she stated, "I found (the missed order) when I was working on the hall on the 25th. A line was drawn on the MAR and (the medication was not) on the cart." She indicated the nurse working on the 16th must have written it on the MAR but never signed or faxed the order to the pharmacy and the resident never received the medication. Nurse #15 was unavailable for interview. 2.Resident #128 was admitted to the facility from an acute hospital on [DATE]. His [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #128 was cognitively intact but required extensive assistance from staff for his activities of daily living. Resident #128 was not coded in the MDS as receiving intravenous medication under special procedures nor was he care planned for a PICC line on admission. A hospital discharge summary dated 10/18/2014 included the discharge [DIAGNOSES REDACTED]. The sputum culture grew Pseudomonas and Resident #128 was treated at the hospital with Meropenum (antibiotic) every 12 hours 10/5/2014 through 10/18/2014 and [MEDICATION NAME] (antibiotic) twice a day 10/2/2014 through 10/18/2014. The discharge medications included: Meropenem 500 mg (milligram) injections infuse 2 grams into venous catheter (e.g. PICC) every 12 hours for 10 days and [MEDICATION NAME] 300 mg/ 5 ml (milliliters) nebulizer solution. Inhale 5 ml every 12 hours for 3 days. A medication list for Resident #128 provided by the hospital on [DATE] included: (in part) the medications Meropenem and [MEDICATION NAME]. A record review of the Medication list that was faxed to the pharmacy from the facility on 10/18/2014 attached to Resident #128 ' s FL2 (Level of Care Screening Tool) was the medication reconciliation list from the hospital dated 10/18/2014. Page 2 (not labeled) was not included: Insulin ([MEDICATION NAME]), [MEDICATION NAME] (Atrovent), Meropenem, [MEDICATION NAME], and [MEDICATION NAME]. A record review of Resident #128 ' s physician's order [REDACTED].#4 and verified by Nurse #5 noted to be transcribed in two different hand writings included: Meropenem 500 mg injections infuse 2 grams into venous catheter every 12 hours for 10 days and [MEDICATION NAME] 300 mg/5 ml nebulizer. Inhale 5 ml every 12 hours for 3 days. The Physician order [REDACTED]. A record review of Resident #128 ' s Medication Record dated 10/18/2014 included: Meropenem 500 mg injections infuse 2 grams into venous catheter every 12 hours for 10 days and [MEDICATION NAME] 300 mg/5 ml nebulizer. Inhale 5 ml every 12 hours for 3 days. The designated boxes for nurse staff initials that indicated the medication was administered were blank from the PM of 10/18/2014 through the AM of 10/26/2014 for the Meropenem missing 16 of 20 opportunities. The boxes for the [MEDICATION NAME] were blank or initialed with a circle around the initials that indicated not administered over a time span from 10/19/2014 to 10/24/2014 missing 6 out of 6 opportunities to administer the medication. The Medication Record was unclear as to what 3 days the nursing staff intended to administer the [MEDICATION NAME]. A record review of the facility log for medication received from the pharmacy revealed that on 10/18/2014 fifteen medications were dispensed to the facility for resident #128. Meropenem and [MEDICATION NAME] were not included. 10/19/2014 through 10/26/2014 was reviewed and Meropenem and [MEDICATION NAME] were not dispensed. On 10/27/2014 Meropenem quantity of 4 was dispensed for Resident #128. A record review of Resident #128 ' s Admission/Nursing Observation Form dated 10/18/2014 included an IV (intravenous) /PICC under Devices/Special Treatments. In addition the assessment noted the PICC line in the left arm on the Body Audit section. A record review of a Body Audit Form dated 10/18/2014 signed by Nurse #4 did not include an assessment of the PICC. A record review of Resident #128 ' s admission nurse note dated 10/18/2014 written by Nurse #5 revealed all medications were verified by the Physician and faxed to the pharmacy. All medications were received from the back up pharmacy. Resident #128 was on multiple nebulizer treatments and inhalers. He was on antibiotic [MEDICATION NAME](oral antibiotic). The admission nurse note did not include an assessment or treatment for [REDACTED]. A record review of Resident #128 ' s 24 hour chart check form verifying that a second nurse checked all of Resident #128 ' s medications revealed Nurse #1 signature initialed on 10/18/2014, 10/19/2014, 10/23/2014 and 10/24/2014. Nurse # 12 signature initialed on 10/20/2014. Nurse # 7 signature initialed on 10/21/2014. Nurse # 9 signature initialed on 10/22/2014. The dates 10/25/2014 and 10/26/2014 were left blank. A record review of Resident #128 ' s nurse note dated 10/18/2014 written by Nurse # 1 did not include an assessment or treatment for [REDACTED]. It included: tolerated all meds well; awaiting [MEDICATION NAME] delivery from pharmacy; resident (#128) on [MEDICATION NAME]; and nebulizer treatment given. A record review of Resident #128 ' s Skilled Daily Nurses Note dated 10/19/2014 included a full system assessment for each shift and was signed by Nurse #3 for day shift and Nurse #1 for night shift. It did not include assessment or treatment of [REDACTED]. The boxes under services provided for central/peripheral IV therapy and teach/care IV catheter sites were not marked to indicate applicable for Resident #128. A narrative written by Nurse #3 included the use of multiple nebulizer treatments and Nurse #1 ' s notation included: tolerated medications well. A record review of Resident #128 ' s Physician Admission History and Physical dated 10/20/2014 included notation of the PICC. A record review of Resident #128 ' s Skilled Daily Nurses Note dated 10/20/2014 included a full system assessment for each shift and was signed by Nurse #6 for day shift. It did not include assessment or treatment of [REDACTED]. The boxes under services provided for central/peripheral IV therapy and teach/care IV catheter sites were not marked to indicate applicable for Resident #128. A narrative from Nurse # 6 included breathing treatments x 4 today. A record review of Resident #128 ' s Skilled Daily Nurses Note dated 10/21/2014 included a full system assessment for each shift and was signed by Nurse #7 for night shift. It did not include assessment or treatment of [REDACTED]. The boxes under services provided for central/peripheral IV therapy and teach/care IV catheter sites were not marked to indicate applicable for Resident #128. A narrative written from Nurse #7 included: tolerated medications well and scheduled breathing treatment given. A record review of Resident #128 ' s Skilled Daily Nurses Note dated 10/22/2014 included a full system assessment for each shift and was signed by Nurse #8 for day shift. It did not include assessment or treatment of [REDACTED]. The boxes under services provided for central/peripheral IV therapy and teach/care IV catheter sites were not marked to indicate applicable for Resident #128. Addition nurse note narratives from Nurse #9 and Nurse #1 did not include assessment or treatment for [REDACTED]. A narrative written by Nurse #8 included tolerated scheduled medications; Nurse # 9 as needed [MEDICATION NAME] administered; and Nurse #1 tolerated medications well and nebulizer treatment given. A record review of Resident #128 ' s Skilled Daily Nurses Note dated 10/23/2014 included a full system assessment for each shift and was signed by an unidentified nurse. It did not include assessment or treatment of [REDACTED]. The boxes under services provided for central/peripheral IV therapy and teach/care IV catheter sites were not marked to indicate applicable for Resident #128. A record review of Resident #128 ' s Skilled Daily Nurses Note dated 10/24/2014 included a full system assessment for each shift and was signed by Nurse #3 for day shift and Nurse #1 for night shift. It did not include assessment or treatment of [REDACTED]. The boxes under services provided for central/peripheral IV therapy and teach/care IV catheter sites were not marked to indicate applicable for Resident #128. A narrative written by Nurse #3 included tolerated medications and breathing treatments and Nurse #1 included tolerated all medications well and nebulizer treatment given. A record review of Resident #128 ' s Skilled Daily Nurses Note dated 10/25/2014 included a full system assessment for each shift and a nurse note narrative from Nurses #9 and #10. It did not include assessment or treatment of [REDACTED]. The boxes under services provided for central/peripheral IV therapy and teach/care IV catheter sites were not marked to indicate applicable for Resident #128. A record review of Resident #128 ' s Skilled Daily Nurses Note dated 10/26/2014 included a full system assessment for each shift and was signed by Nurse #2. The boxes under services provided for central/peripheral IV therapy and teach/care IV catheter sites were not marked to indicate applicable for Resident #128. A nurse note narrative written by Nurse #12 at 12:00 PM included the resident was alert and oriented and stated " I don ' t feel well " . Resident #128 ' d vital signs were assessed and orders ' were received from the Physician for blood work and radiology. A nurse note narrative written by Nurse #9 at 3:55 PM revealed his interpretation of the radiology report. Orders were received to start a peripheral intravenous access (PIV); start Meropenem as ordered at hospital; and to replace PICC line when possible. A record review of Resident #128 ' s Skilled Daily Nurses Note dated 10/27/2014 included a narrative by Nurse #11. The Physician ordered resident #128 to be sent to the hospital for an evaluation of the PICC and Resident #128 was transported at 1:15 PM. A record review of a facility communication tool (SBAR Communication Form) dated 10/27/2014 included Resident #128 ' s had no blood return from the PICC line and was transported to the hospital. A record review of the facility Nursing Home to Hospital Transfer Form dated 10/27/2014 included no blood return to PICC and the primary reason for transfer was de-clog/replace PICC. A record review of hospital emergency department discharge date d 10/27/2014 included a [DIAGNOSES REDACTED]. Nurse #1 was Resident #128 ' s nurse on 10/18/2014, 10/19/2014 10/23/2014 and 10/24/2014. She was out of the country and unavailable for an interview during the survey. On 12/12/2014 at 1:48 PM an interview with Nurse #2 revealed she worked for 4 years as the admission nurse for a sister facility and was no longer employed. Nurse #2 reported she did not care for Resident #128 the week of 10/18/2014 through 10/26/2014 until the evening (10/26) when she found the error. She reported on 10/23/2014 a nurse in orientation worked the hall even though Nurse #2 ' s name remained on the schedule. The Meropenum on 10/26/2014 was delivered from a specialty pharmacy through the back up. The regular pharmacy delivered additional doses on 10/27/2014. Resident #128 was " oriented to person and place but he was sick. I am not sure he was able to understand that time had passed. I asked Resident #128 to show me his PICC line. The PICC dressing was nasty and it was not a facility dressing. " On 12/12/2014 at 1:18 PM an interview with Nurse #3 who cared for Resident #128 on 10/19/2014 and 10/24/2014 revealed she did not recall the Meropenum order nor does she recall Resident #128 having a PICC line. On 12/12/2014 at 11:22 PM an Interview with Nurse #4 revealed she was no longer employed at the facility. Nurse #4 was the treatment nurse on 10/18/2014 and helped Nurse #5 with Resident #128 ' s admission process. She recalled faxing the orders to the pharmacy, and transcribing orders to the telephone order sheet that were on formulary. She did not transcribe all of Resident #128 ' s Physician orders. Nurse #5 was Resident #128 ' s nurse on 10/18/2014 and was not available for an interview during the survey. Nurse #6 was Resident #128 ' s nurse on 10/20/2014 and was not available for interview during the survey. On 12/11/2014 at 1:29 PM an interview with Nurse #7 revealed she worked with Resident #128 on 10/21/2014 and 10/23/2014. She reported she ignored the order because the time said 9:00 AM. She looked at the administration time but not the order. Nurse #7 reported she did not check for a PICC line on Resident #128. Nurse #8 was Resident #128 ' s nurse on 10/22/2014 and was not available for interview during the survey. Nurse #9 was a supervising nurse who completed an assessment on Resident #128 Skilled Daily Nurses Note on 10/23/2014. He was not available for interview during the survey. Nurse #10 was Resident #128 ' s nurse on 10/25/2014 and was not available for interview during the survey. Nurse #11 was Resident #128 ' s nurse on 10/26/2014 and was not available for an interview during the survey. Nurse #12 was identified by the facility corporate administration team as one of the nurses that cared for Resident #128 the week of 10/18/2014 through 10/26/2014 based on the staff schedule. Nurse #12 ' s signature or initials were not identified and she was unavailable for an interview during the survey. Nurse #13 was identified by the facility corporate administration team as one of the nurses that cared for Resident #128 the week of 10/18/2014 through 10/26/2014. On 12/12/2014 at 2:28 PM an interview with Nurse #13 revealed she had not worked on Resident #128 ' s hall 10/18/2014 through 10/26/2014. She reported she returned to the hall on the first morning Resident #128 received his antibiotic through a PIV. Nurse #13 confirmed her signature initials on Resident #128 ' s Medication Record for 10/27/2014. . Nurse #14 was identified by the facility corporate administration team as one of the nurses that cared for Resident #128 the week of 10/18/2014 through 10/26/2014 (10/21 and 10/22) based on the staff schedule. Nurse #12 ' s signature or initials were not identified and she was unavailable for an interview during the survey. On 12/10/2014 at 1:05 PM an interview with Unit Coordinator #1 revealed all nursing staff members were responsible for PICC line care that included: flush with the SASH (Saline/Antibiotic/Saline/[MEDICATION NAME]) protocol, dressing changes and monitor site for redness. The nursing staff was responsible for transcribing the Physician order [REDACTED]. It was Unit Coordinator #1 expectation that the responsibility of the nurses was to make sure the orders were transcribed and if the order was not written then the nurse was to call and get an order for [REDACTED]. She reported she did not look at Resident #128 ' s POF or Medication Record because she was not working on his admitted . On 12/10/2014 at 1:06 PM an interview with the Acting Director of Nursing (DON) revealed she agreed with Unit Coordinator #1 ' s statements and expectations. The facility policy was different than the nursing practice. The staff follows the Physician order [REDACTED]. Weekly body audits/skin assessments were done weekly and on a rotating staff schedule and the floor nurse was responsible for the PICC dressing changes. The Acting Director of Nursing (DON) revealed her expectation was the staff review the Medication Record and look at every page. An interview on 12/10/2014 at 4:54 PM with the Physician indicated the resident had a [DIAGNOSES REDACTED]. The Physician received a call from Unit Coordinator #1 on 10/26/2014. She reported to the Physician that Resident #128 had not been receiving his antibiotic Meropenem. The Physician reported he ordered the Meropenum at that time and extended the end date for the medication. The PICC line was replaced because it was occluded from lack of use. It was not flushed but it should have been. " Do I wish (the nurses) had provided the antibiotic? Yes. It was important that he (Resident #128) received the antibiotic. I do not think his condition deteriorated during the time he did not receive the medication, but it was important for him to receive the medication, so we started a peripheral IV for him to get the medication when we realized it had not been given " . The Physician agreed there was a process issue. On 12/12/2014 at 3:40 PM an interview with the Acting DON revealed her expectation of the staff during the admission process was the nurse staff reviewed the admission discharge summary and verified the medications/treatments with the Physician and transfer the orders to the Physician order [REDACTED]. If the pharmacy called for clarification then the nurse was to clarify the order with the Physician and resubmits an order on a telephone order sheet. The Acting DON reported that some staff will send both the discharge summary and the POF. The Pharmacy will disregard the discharge summary. The pharmacy will not send the medications or bill for medications based on receiving the discharge summary. When the medications are received the nursing staff would check against the POF and when they place the medications in the (medication cart) drawer they check the medications against the Medication Record. If something was missing the expectation was to call the Pharmacy or go to the back up pharmacy. Her expectation was for the nurse staff to view the orders during the routine medication pass and to know what medications they were giving. The nurse staff needed to read the medications listed on the Medication Record regardless of what the (designated) time said. The nursing staff was responsible for a 24 hour chart check (for order verification). The night shift nurse staff does the 24 hour chart check. The nurse who transcribed the orders was not to be the nurse to sign off or complete order verification. It was not best practice for multiple nurses to be involved in the admission process/transcription of medications. It was the responsibility of the nurses to take care of Resident #128, keep him safe, and provide the care needed.

Based on record review, staff interview, physician interview the facility failed to administer admission medications (Meropenum) for 8 days and ([MEDICATION NAME]) for 3 days; failed to obtain and administer a medication ordered for pain ([MEDICATION NAME]) for 10 days; and failed to administer a stock medication ordered for supplement and wound healing (multivitamin) for 14 days for 3 of 3 residents (Resident #128, #181 and #75). Findings included: 1. Resident #128 was admitted to the facility from an acute hospital on [DATE]. His [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #128 was cognitively intact but required extensive assistance from staff for his activities of daily living. Resident #128 was not coded in the MDS as receiving intravenous medication under special procedures. A hospital discharge summary dated 10/18/2014 included the discharge [DIAGNOSES REDACTED]. The sputum culture grew Pseudomonas and Resident #128 was treated at the hospital with Meropenum (antibiotic) every 12 hours 10/5/2014 through 10/18/2014 and [MEDICATION NAME] (antibiotic) twice a day 10/2/2014 through 10/18/2014. The discharge medications included: Meropenem 500 mg (milligram) injections infuse 2 grams into venous catheter every 12 hours for 10 days and [MEDICATION NAME] 300 mg/ 5 ml (milliliters) nebulizer solution. Inhale 5 ml every 12 hours for 3 days. A medication list for Resident #128 provided by the hospital on [DATE] included: (in part) the medications Meropenem and [MEDICATION NAME]. A record review of Resident #128 ' s physician's order [REDACTED].#4 and verified by Nurse #5 noted to be transcribed in two different hand writings included: Meropenem 500 mg injections infuse 2 grams into venous catheter every 12 hours for 10 days and [MEDICATION NAME] 300 mg/5 ml nebulizer. Inhale 5 ml every 12 hours for 3 days. A record review of Resident #128 ' s Medication Record dated 10/18/2014 included: Meropenem 500 mg injections infuse 2 grams into venous catheter every 12 hours for 10 days and [MEDICATION NAME] 300 mg/5 ml nebulizer. Inhale 5 ml every 12 hours for 3 days. The designated boxes for nurse staff initials that indicated the medication was administered were blank from the PM of 10/18/2014 through the AM of 10/26/2014 for the Meropenem missing 16 of 20 opportunities. The boxes for the [MEDICATION NAME] were blank or initialed with a circle around the initials that indicated not administered over a time span from 10/19/2014 to 10/24/2014 missing 6 out of 6 opportunities to administer the medication. The Medication Record was unclear as to what 3 days the nursing staff intended to administer the [MEDICATION NAME]. A record review of the facility log for medication received from the pharmacy revealed that on 10/18/2014 fifteen medications were dispensed to the facility for resident #128. Meropenem and [MEDICATION NAME] were not included. 10/19/2014 through 10/26/2014 was reviewed and Meropenem and [MEDICATION NAME] were not dispensed. On 10/27/2014 Meropenem quantity of 4 was dispensed for Resident #128. A record review of Resident #128 ' s admission nurse note dated 10/18/2014 written by Nurse #5 revealed all medications were verified by the Physician and faxed to the pharmacy. All medications were received from the back up pharmacy. Resident #128 is on multiple nebulizer treatments and inhalers. He is on antibiotic [MEDICATION NAME](oral antibiotic). Nurse #1 was Resident #128 ' s nurse on 10/18/2014, 10/19/2014 10/23/2014 and 10/24/2014. She also signature initialed the 24 hour chart check form for Resident #128 on admission 10/18/2014 verifying that she checked all of Resident #128 ' s admission medications. She was out of the country and unavailable for an interview during the survey. On 12/12/2014 at 1:48 PM an interview with Nurse #2 revealed she did not care for Resident #128 the week of 10/18/2014 through 10/26/2014 until the evening (10/26) when she found the error. She reported on 10/23/2014 a nurse in orientation worked the hall even though Nurse #2 ' s name remained on the schedule. The Meropenum on 10/26/2014 was delivered from a specialty pharmacy through the back up. The regular pharmacy delivered additional doses on 10/27/2014. The [MEDICATION NAME] was not reordered. On 12/12/2014 at 1:18 PM an interview with Nurse #3 who cared for Resident #128 on 10/19/2014 and 10/24/2014 revealed she did not recall the Meropenum order. On 12/12/2014 at 11:22 PM an Interview with Nurse #4 revealed she was no longer employed at the facility. Nurse #4 was the treatment nurse on 10/18/2014 and helped Nurse #5 with Resident #128 ' s admission process. She recalled faxing the orders to the pharmacy, and transcribing orders to the telephone order sheet that were on formulary. She did not transcribe all of Resident #128 ' s Physician orders. Nurse #5 was Resident #128 ' s nurse on 10/18/2014 and was not available for an interview during the survey. Nurse #6 was Resident #128 ' s nurse on 10/20/2014 and was not available for interview during the survey. On 12/11/2014 at 1:29 PM an interview with Nurse #7 revealed she worked with Resident #128 on 10/21/2014 and 10/23/2014. She reported she ignored the order because the time said 9:00 AM. She looked at the administration time but not the order. Nurse #8 was Resident #128 ' s nurse on 10/22/2014 and was not available for interview during the survey. Nurse #10 was Resident #128 ' s nurse on 10/25/2014 and was not available for interview during the survey. Nurse #11 was Resident #128 ' s nurse on 10/26/2014 and was not available for an interview during the survey. Nurse #12 was identified by the facility corporate administration team as one of the nurses that cared for Resident #128 the week of 10/18/2014 through 10/26/2014 based on the staff schedule. Nurse #12 ' s signature or initials were not identified and she was unavailable for an interview during the survey. Nurse #13 was identified by the facility corporate administration team as one of the nurses that cared for Resident #128 the week of 10/18/2014 through 10/26/2014. On 12/12/2014 at 2:28 PM an interview with Nurse #13 revealed she had not worked on Resident #128 ' s hall 10/18/2014 through 10/26/2014. She reported she returned to the hall on the first morning Resident #128 received his antibiotic through a PIV. Nurse #13 confirmed her signature initials on Resident #128 ' s Medication Record for 10/27/2014. . Nurse #14 was identified by the facility corporate administration team as one of the nurses that cared for Resident #128 the week of 10/18/2014 through 10/26/2014 (10/21 and 10/22) based on the staff schedule. Nurse #12 ' s signature or initials were not identified and she was unavailable for an interview during the survey. On 12/10/2014 at 1:05 PM an interview with Unit Coordinator #1 revealed all nursing staff members are responsible for transcribing the Physician order. She reported she did not look at Resident #128 ' s POF or Medication Record because she was not working on his admitted . On 12/10/2014 at 1:06 PM an interview with the Acting Director of Nursing (DON) revealed her expectation was the staff review the Medication Record and look at every page. An interview on 12/10/2014 at 4:54 PM with the Physician indicated the resident had a [DIAGNOSES REDACTED]. The Physician received a call from Unit Coordinator #1 on 10/26/2014. She reported that Resident #128 had not been receiving his antibiotic Meropenem. The Physician reported he ordered the Meropenum at that time and extended the end date for the medication. " Do I wish (the nurses) had provided the antibiotic? Yes. It was important that he (Resident #128) received the antibiotic. I do not think his condition deteriorated during the time he did not receive the medication, but it was important for him to receive the medication, so we started a peripheral IV for him to get the medication when we realized it had not been given. " The Physician agreed there was a process issue. On 12/12/2014 at 3:40 PM an interview with the Acting DON revealed her expectation of staff was when the medications were received the nursing staff would check against the POF and when they place the medications in the (medication cart) drawer they are to check the medications against the Medication Record. If something was missing the expectation was to call the Pharmacy or go to the back up pharmacy. Her expectation was for the nurse staff to view the orders during the routine medication pass and to know what medications they were giving. The nurse staff needed to read the medications listed on the Medication Record regardless of what the (designated) time said. The nursing staff was responsible for a 24 hour chart check (for order verification). The night shift nurse staff does the 24 hour chart check. The nurse who transcribed the orders was not to be the nurse to sign off or complete order verification. It was not best practice for multiple nurses to be involved in the admission process/transcription of medications. It was the responsibility of the nurses to take care of Resident #128, keep him safe, and provide the care needed. 2. Resident #181 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Nursing Home Admission History and Physical dated 10/9/14 indicated Resident #181 had a bilateral lower extremity chronic wound infection and acute and chronic pain. The October 2014 signed admission Physician order [REDACTED]. [MEDICATION NAME] 300 milligrams (mg) three times a day. [MEDICATION NAME] 50 mg every 6 hours as needed. Take 1 tablet for moderate pain, 2 for severe pain. [MEDICATION NAME] 10 mg every 6 hrs as needed. The physician progress notes [REDACTED].#181 was seen due to increased burning sensation in legs. The physician discontinued [MEDICATION NAME] and started [MEDICATION NAME] for her nerve pain. The Physician Interim Orders dated 10/14/14 indicated: [MEDICATION NAME] 4 mg (by mouth) 30 minutes before dressing change once daily. The Physician Interim Orders dated 10/15/14 indicated [MEDICATION NAME] 10 mg (by mouth) x 1 dose now - extreme pain. [MEDICATION NAME] 50 mg (by mouth every 6 hours as needed) mild pain. [MEDICATION NAME] 100 mg (by mouth every 6 hours as needed) moderate pain. [MEDICATION NAME] 10 mg (by mouth every 6 hours as needed) severe pain. The Minimum Data Set ((MDS) dated [DATE] indicated Resident #181 was cognitively intact, had wounds, received scheduled and as-needed pain medication in the last 5 days, experienced pain frequently, the pain made it hard for her to sleep and her worst pain was a 10/10. The Physician Interim Orders dated 10/16/14 indicated: (Discontinue) [MEDICATION NAME] 4 mg (by mouth 30 minutes before dressing change). Start [MEDICATION NAME] 5 mg (by mouth 30 minutes before dressing change) once daily. (Discontinue) [MEDICATION NAME]. (Discontinue) [MEDICATION NAME]. [MEDICATION NAME] 25 mg (by mouth every night at bedtime) - (pain). (Discontinue) [MEDICATION NAME]. (Discontinue) [MEDICATION NAME]. [MEDICATION NAME] 10 mg (by mouth every 4 hours as needed) pain. [MEDICATION NAME] 50 mg (by mouth every 4 hours as needed) pain. Review of the 24-hour Chart Check Form signed by Nurse #15 and dated 10/16/14 stated, "New orders" and indicated, by a checkmark, that the new orders were placed on the MAR. Review of the Medication Administration Record (MAR) indicated [MEDICATION NAME] 25 mg for pain was ordered on [DATE] and was first signed off as being administered on 10/26/14. The physician progress notes [REDACTED].#181 was seen due to continued complaint of severe pain in both of her legs. The physician added [MEDICATION NAME] for pain management. The Physician Interim Orders dated 10/20/14 indicated: ([MEDICATION NAME]) 15 mg (by mouth twice a day). The physician progress notes [REDACTED].#181's pain was improved but she was awakening at night with pain. The physician increased her [MEDICATION NAME] at night. The Physician Interim Orders dated 10/24/14 indicated: (Discontinue [MEDICATION NAME]) ([MEDICATION NAME]) 15 mg (by mouth every morning). ([MEDICATION NAME]) 30 mg (by mouth at bedtime). The Physician Interim Orders dated 10/25/14 indicated: May hold [MEDICATION NAME] 25 mg (by mouth at bedtime) until available from pharmacy. The October 2014 Medication Administration Record (MAR) revealed Resident #181 received 49 doses of as-needed pain medication between 10/8/14 and 10/31/14. The pain evaluation done every shift documented moderate to severe pain every day. The physician progress notes [REDACTED].#181 was seen because of episodes of crying and that the resident stated "she was only crying (because) she continues to have pain in (both lower legs)." The physician increased her [MEDICATION NAME] for her chronic nerve pain and bilateral leg ulcers. The Physician Interim Orders dated 11/5/14 indicated: (Discontinue [MEDICATION NAME]). [MEDICATION NAME] 50 mg (by mouth at bedtime) for neuropathic pain. The Physician Interim Orders dated 11/11/14 indicated: (Discontinue [MEDICATION NAME]). [MEDICATION NAME] 75 mg (by mouth at bedtime). During an interview on 12/10/14 at 3:26 pm with the acting Director of Nursing (DON) she stated, "Two nurses check the chart. The (night) nurse on the floor checks every new order that has come in (that 24-hour period)." She further indicated that there is no set time for the night (7 pm - 7 am) nurse to do the 24-hour chart check, but that the check for new orders should go all the way back to 7 pm the previous day so that no orders are missed. She also indicated that the [MEDICATION NAME] is not a stock medication or available in the e-kit (emergency kit), should have been ordered from the pharmacy and should have been given to the resident as ordered. During an interview with Unit Coordinator #1 on 12/11/14 at 12:25 pm she stated, "The nurse will fax (the physician order) to the pharmacy no matter what time the order is written and then will write it on the MAR. The night supervisor does a chart check to ensure all orders are sent to the pharmacy and put on the MAR." After reviewing Resident #181's 10/16/14 [MEDICATION NAME] order, she indicated a nurse did not sign off as receiving the order or faxing it to the pharmacy on 10/16/14, or any date since that time. She further stated, "If a written order does not arrive after it is sent to the pharmacy and is not in the e-kit, we write a hold order until it comes. I remember Nurse #2 mentioning the missed [MEDICATION NAME] to me. I don ' t recall why it was not given. [MEDICATION NAME] is not in the e-kit (and would have to come from the pharmacy)." During an interview with the DON on 12/11/14 at 4:15 pm she stated, "I would expect the order would have been caught by the night nurse doing the chart check." During an interview with Nurse #2 on 12/12/14 at 1:00 pm, regarding Resident #181's 10/16/14 [MEDICATION NAME] order she stated, "I found (the missed order) when I was working on the hall on the 25th. A line was drawn on the MAR and (the medication was not) on the cart." She indicated the nurse working on the 16th must have written it on the MAR but never signed or faxed the order to the pharmacy and the resident never received the medication. Nurse #15 was unavailable for interview. 3.Resident #75 was originally admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The Admission/Nursing Observation Form dated 10/3/14 indicated the resident [MEDICAL CONDITION] to the right knee and had a peripherally-inserted central catheter (PICC) in his right arm. The Minimum Data Set ((MDS) dated [DATE] indicated the resident had a surgical wound, was on a therapeutic diet, received an antibiotic 7 of 7 look-back days, and was on intravenous (IV) medication. Review of the Resident's labwork dated 10/13/14 revealed a low [MEDICATION NAME] level of 2.8 grams per deciliter (g/dL). The normal [MEDICATION NAME] reference range noted on the labwork was 3.5-5.2 g/dL. The Physician order [REDACTED]." The order was written as a telephone order from the physician by the dietician and was signed by the physician assistant on 10/15/14. The order did not have a signature of a "nurse receiving order." Review of the 24-hour Chart Check Form dated 10/15/14 indicated (by a circle with a diagonal slash through it) that there were no medications written within 24 hours, no medications transferred to the Medication Administration Record (MAR), and was initialed by Nurse #1. Review of the MAR indicated a daily multivitamin was ordered on [DATE] and was first signed off as being administered on 10/29/14. Review of the Resident's labwork dated 10/31/14 revealed a low [MEDICATION NAME] level of 3.1 g/dL. The normal [MEDICATION NAME] reference range noted on the labwork was 3.5-5.2 g/dL. During an interview on 12/10/14 at 3:26 pm with the acting Director of Nursing (DON) she stated, "Two nurses check the chart. The (night) nurse on the floor checks every new order that has come in (that 24-hour period)." She further indicated that there is no set time for the night (7 pm - 7 am) nurse to do the 24-hour chart check, but that the check for new orders should go all the way back to 7 pm the previous day so that no orders are missed. She also indicated that the MVI is a stock medication, available to nurses at all times in the facility and should have been given to the resident as ordered. During an interview with Physician #1 on 12/10/14 at 5:15 pm regarding Resident #75's MVI he stated, "The (MVI) is a nice adjunct and it is important for him. I would expect that it would have been given." The physician indicated the MVI would have been important for this resident due to multiple factors, including his infection and his low [MEDICATION NAME] level. During an interview with Unit Coordinator #1 on 12/11/14 at 12:25 pm she stated, "The nurse will fax (the physician order) to the pharmacy no matter what time the order is written and then will write it on the MAR. The night supervisor does a chart check to ensure all orders are sent to the pharmacy and put on the MAR." After reviewing Resident #75's 10/15/14 MVI order, she indicated a nurse did not sign off as receiving the order on 10/15/14, or any date since that time, and Nurse #2 signed on 10/27/14 indicating she sent the order to the pharmacy. During an interview with the DON on 12/11/14 at 4:15 pm she stated, "I would expect the order would have been caught by the night nurse doing the chart check." During an interview on 12/12/14 at 12:32 pm with Nurse #3, the 7 am - 7pm nurse who was assigned to Resident #75 on 10/15/14, she stated, "We have had several reminders about looking at the orders, taking them off, and getting the orders double checked. I do not specifically remember this missed medication or anyone speaking to me about it." During an interview on 12/12 12:44 pm with Nurse #2, regarding Resident #75's 10/15/14 MVI order, she stated, "When I was doing the MAR checks for November is when I caught the error. (The night nurse) is supposed to check every chart on the hall (every) night. (The 10/15/14 order) was a couple of pages back in the orders."

Based on record review and staff interview the facility failed to provide assessments and treatments for a PICC (peripherally inserted central catheter) for 8 out of 10 days for 1 of 1 residents (Resident #128) missing 15 of 20 opportunities to assess for infection and flush the line for patency which resulted in the PICC being occluded and required replacement. Findings included: Resident #128 was admitted to the facility from an acute hospital on [DATE]. His [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #128 was cognitively intact but required extensive assistance from staff for his activities of daily living. Resident #128 was not coded in the MDS as receiving intravenous medication under special procedures nor was he care planned for a PICC line on admission. A hospital discharge summary dated 10/18/2014 included the discharge [DIAGNOSES REDACTED]. The discharge medications included Meropenem (antibiotic) 500 mg injections infuse 2 grams into venous catheter (e.g. PICC) every 12 hours for 10 days. A record review of Resident #128 ' s Admission/Nursing Observation Form dated 10/18/2014 included an IV (intravenous) /PICC under Devices/Special Treatments. In addition the assessment noted the PICC line in the left arm on the Body Audit section. A record review of Resident #128's physician's order [REDACTED].#4 and verified by Nurse #5 did not include treatment for [REDACTED]. A record review of a Body Audit Form dated 10/18/2014 signed by Nurse #4 did not include an assessment of the PICC. A record review of Resident #128's admission nurse note dated 10/18/2014 written by Nurse #5 did not include an assessment or treatment for [REDACTED]. A record review of Resident #128's nurse note dated 10/18/2014 written by Nurse # 1 did not include an assessment or treatment for [REDACTED]. A record review of Resident #128's Skilled Daily Nurses Note dated 10/19/2014 included a full system assessment for each shift and was signed by Nurse #3 for day shift and Nurse #1 for night shift. It did not include assessment or treatment of [REDACTED]. The boxes under services provided for central/peripheral IV therapy and teach/care IV catheter sites were not marked to indicate applicable for Resident #128. A record review of Resident #128's Physician Admission History and Physical dated 10/20/2014 included notation of the PICC A record review of Resident #128's Skilled Daily Nurses Note dated 10/20/2014 included a full system assessment for each shift and was signed by Nurse #6 for day shift. It did not include assessment or treatment of [REDACTED]. The boxes under services provided for central/peripheral IV therapy and teach/care IV catheter sites were not marked to indicate applicable for Resident #128. A record review of Resident #128's Skilled Daily Nurses Note dated 10/21/2014 included a full system assessment for each shift and was signed by Nurse #7 for night shift. It did not include assessment or treatment of [REDACTED]. The boxes under services provided for central/peripheral IV therapy and teach/care IV catheter sites were not marked to indicate applicable for Resident #128. A record review of Resident #128's Skilled Daily Nurses Note dated 10/22/2014 included a full system assessment for each shift and was signed by Nurse #8 for day shift. It did not include assessment or treatment of [REDACTED]. The boxes under services provided for central/peripheral IV therapy and teach/care IV catheter sites were not marked to indicate applicable for Resident #128. Addition nurse note narratives from Nurse #9 and Nurse #1 did not include assessment or treatment for [REDACTED]. A record review of Resident #128's Skilled Daily Nurses Note dated 10/23/2014 included a full system assessment for each shift and was signed by an unidentified nurse. It did not include assessment or treatment of [REDACTED]. The boxes under services provided for central/peripheral IV therapy and teach/care IV catheter sites were not marked to indicate applicable for Resident #128. A record review of Resident #128's Skilled Daily Nurses Note dated 10/24/2014 included a full system assessment for each shift and was signed by Nurse #3 for day shift and Nurse #1 for night shift. It did not include assessment or treatment of [REDACTED]. The boxes under services provided for central/peripheral IV therapy and teach/care IV catheter sites were not marked to indicate applicable for Resident #128. A record review of Resident #128's Skilled Daily Nurses Note dated 10/25/2014 included a full system assessment for each shift and a nurse note narrative from Nurses #9 and #10. It did not include assessment or treatment of [REDACTED]. The boxes under services provided for central/peripheral IV therapy and teach/care IV catheter sites were not marked to indicate applicable for Resident #128. A record review of Resident #128's Skilled Daily Nurses Note dated 10/26/2014 included a full system assessment for each shift and was signed by Nurse #2. The boxes under services provided for central/peripheral IV therapy and teach/care IV catheter sites were not marked to indicate applicable for Resident #128. A nurse note narrative written by Nurse #12 at 12:00 PM included the resident was alert and oriented and stated " I don ' t feel well." Resident #128's vital signs were assessed and orders were received from the Physician for blood work and radiology. A nurse note narrative written by Nurse #9 at 3:55 PM revealed his interpretation of the radiology report. Orders were received to start a peripheral intravenous access (PIV); start Meropenem as ordered at hospital; and to replace PICC line when possible. A record review of Resident #128's Skilled Daily Nurses Note dated 10/27/2014 included a narrative by Nurse #11. The Physician ordered resident #128 to be sent to the hospital for an evaluation of the PICC and Resident #128 was transported at 1:15 PM. A record review of a facility communication tool (SBAR Communication Form) dated 10/27/2014 included Resident #128's had no blood return from the PICC line and was transported to the hospital. A record review of the facility Nursing Home to Hospital Transfer Form dated 10/27/2014 included no blood return to PICC and the primary reason for transfer was de-clog/replace PICC. A record review of hospital emergency department discharge date d 10/27/2014 included a [DIAGNOSES REDACTED]. Nurse #1 was Resident #128's nurse on 10/18/2014, 10/19/2014 10/23/2014 and 10/24/2014. She was out of the country and unavailable for an interview during the survey. On 12/12/2014 at 1:48 PM an interview with Nurse #2 revealed she worked for 4 years as the admission nurse for a sister facility and was no longer employed. She reported she did not care for Resident #128 the week of 10/18/2014 through 10/26/2014 until the evening (10/26) when she found the error. She reported on 10/23/2014 a nurse in orientation worked the hall even though Nurse #2's name remained on the schedule. Resident #128 was "oriented to person and place but he was sick. I am not sure he was able to understand that time had passed. I asked Resident #128 to show me his PICC line. The PICC dressing was nasty and it was not a facility dressing." On 12/12/2014 at 11:22 PM an Interview with Nurse #4 revealed she was no longer employed at the facility. Nurse #4 was the treatment nurse on 10/18/2014 and helped Nurse #5 with Resident #128's admission process. She recalled faxing the orders to the pharmacy, and transcribing orders to the telephone order sheet that were on formulary. She did not transcribe all of Resident #128's Physician orders. Nurse #5 was Resident #128's nurse on 10/18/2014 and was not available for an interview during the survey. On 12/10/2014 at 1:05 PM an interview with Unit Coordinator #1 revealed all nursing staff members were responsible for PICC line care that includes: flush with the SASH (Saline/Antibiotic/Saline/[MEDICATION NAME]) protocol, dressing changes and monitor site for redness. The nursing staff was responsible for transcribing the Physician order [REDACTED].#1 expectation that the responsibility of the nurses was to make sure the orders were transcribed and if the order was not written then the nurse was to call and get an order for [REDACTED]. On 12/10/2014 at 1:06 PM an interview with the Acting Director of Nursing (DON) revealed she agreed with Unit Coordinator #1's statements and expectations. The staff was supposed to follow the Physician order [REDACTED]. Weekly body audits/skin assessments were done weekly and on a rotating staff schedule and the floor nurse was responsible for the PICC dressing changes. An interview on 12/10/2014 at 4:54 PM with the Physician revealed the PICC line was replaced because it was occluded from lack of use. It was not flushed but it should have been. On 12/12/2014 at 3:40 PM an interview with the Acting DON revealed her expectation of staff during the admission process was the nurse staff reviewed the admission discharge summary and verified the medications/treatments with the Physician and transfer the orders to the Physician order [REDACTED]. It was the responsibility of the nurses to take care of Resident #128, keep him safe, and provide the care needed.

Based on record review, staff interview, physician and pharmacist interview the facility failed to aquire by procedure, receive, and administer the admission medications (Meropenem) for 8 days and (Tobramycin) for 3 days as ordered; failed to obtain from the pharmacy and administer a medication ordered for pain (Elavil) for 10 days; and failed to administer a stock medication ordered for supplement and wound healing (multivitamin) for 14 days for 3 of 3 residents (Resident #128, #181 and #75). Findings included: 1. Resident #128 was admitted to the facility from an acute hospital on [DATE]. His [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #128 was cognitively intact but required extensive assistance from the staff for his activities of daily living. Resident #128 was not coded in the MDS as receiving intravenous medication under special procedures. A hospital discharge summary dated 10/18/2014 included the discharge [DIAGNOSES REDACTED]. The sputum culture grew Pseudomonas and Resident #128 was treated at the hospital with Meropenum (antibiotic) every 12 hours 10/5/2014 through 10/18/2014 and Tobramycin (antibiotic) twice a day 10/2/2014 through 10/18/2014). The discharge medications included: Meropenem 500 mg (milligram) injections infuse 2 grams into venous catheter every 12 hours for 10 days and Tobramycin 300 mg/ 5 ml (milliliters) nebulizer solution. Inhale 5 ml every 12 hours for 3 days. Medication List: START: 1) Pulmicort 2) Performist 3) Novolog 4) Atrovent 5) Meropenem 6) Tobramycin 7) Warfarin CHANGE: 1) Albuterol Inhaler 2) Albuterol Nebulizer 3) Lasix 4) Lactulose 5) Sodium Polystrene CONTINUE: 1) Aspirin 2) Carvedilol 3) Ciprofloxacin 4) Creon 5) Hyper-Sal 6) Magnesium Oxide 7) Metformin 8) Nitrostat 9) Norvasc 10) Omeprazole 11) Tramadol 12) Trazadone STOP 1) Dulera 2) Spiriva A record review of Resident #128 ' s medication reconciliation from the hospital dated 10/18/2014 included: STOP: 1) Dulera 2) Spiriva START: 1) Pulmicort 2) Performist 3) Novolog 4) Atrovent 5) Meropenem 6) Tobramycin 7) Warfarin CHANGE: 1) Albuterol Inhaler 2) Albuterol Nebulizer 3) Lasix 4) Lactulose 5) Sodium Polystrene CONTINUE: 1) Aspirin 2) Carvedilol 3) Ciprofloxacin 4) Creon 5) Hyper-Sal 6) Magnesium Oxide 7) Metformin 8) Nitrostat 9) Norvasc 10) Omeprazole 11) Tramadol 12) Trazadone A medication list for Resident #128 provided by the hospital on [DATE] included: (in part) the medications Meropenem and Tobramycin. A record review of the Medication list that was faxed to the pharmacy from the facility on 10/18/2014 attached to Resident #128 ' s FL2 (Level of Care Screening Tool) was the medication reconciliation list from the hospital dated 10/18/2014. Page 2 (not labeled) was not included: Novolog, Atrovent, Meropenem, Tobramycin, and Warfarin. A record review of Resident #128 ' s physician's order [REDACTED].#4 and verified by Nurse #5 noted to be transcribed in two different hand writings included: Meropenem 500 mg injections infuse 2 grams into venous catheter every 12 hours for 10 days and Tobramycin 300 mg/5 ml nebulizer. Inhale 5 ml every 12 hours for 3 days. A record review of Resident #128 ' s Medication Record dated 10/18/2014 included: Meropenem 500 mg injections infuse 2 grams into venous catheter every 12 hours for 10 days and Tobramycin 300 mg/5 ml nebulizer. Inhale 5 ml every 12 hours for 3 days. The designated boxes for nurse staff initials that indicated the medication was administered were blank from the PM of 10/18/2014 through the AM of 10/26/2014 for the Meropenem missing 16 of 20 opportunities. The boxes for the Tobramycin were blank or initialed with a circle around the initials that indicated not administered over a time span from 10/19/2014 to 10/24/2014 missing 6 out of 6 opportunities to administer the medication. The Medication Record was unclear as to what 3 days the nursing staff intended to administer the Tobramycin. A record review of the facility log for medication received from the pharmacy revealed that on 10/18/2014 fifteen medications were dispensed to the facility for resident #128. Meropenem and Tobramycin were not included. 10/19/2014 through 10/26/2014 was reviewed and Meropenem and Tobramycin were not dispensed. On 10/27/2014 Meropenem quantity of 4 was dispensed for Resident #128. A record review of Resident #128 ' s admission nurse note dated 10/18/2014 written by Nurse #5 revealed all medications were verified by the Physician and faxed to the pharmacy. All medications were received from the back up pharmacy. Resident #128 is on multiple nebulizer treatments and inhalers. He is on antibiotic therapy Cipro (oral antibiotic). Nurse #1 was Resident #128 ' s nurse on 10/18/2014, 10/19/2014 10/23/2014 and 10/24/2014. She also signature initialed the 24 hour chart check form for Resident #128 on admission 10/18/2014 verifying that she checked all of Resident #128 ' s admission medications. She was out of the country and unavailable for an interview during the survey. On 12/12/2014 at 1:48 PM an interview with Nurse #2 revealed she worked for 4 years as the admission nurse for a sister facility and was no longer employed. She reported having more knowledge about the admission process than the floor nurses at the facility. Nurse #2 reported during the admission process the medications are verified with the physician and then transcribed to the POF which carbon copies to the Medication Record. A second nurse checked the accuracy of the medications transcribed and then the POF was faxed to the pharmacy. If the pharmacy was closing the facility could fax the discharge summary as long as it included the resident room number, date of birth, allergies [REDACTED]. The pharmacy delivered to the facility between 8 PM and 10 PM. The nurse was supposed to make sure all the medications were delivered. If not then the nurse was to call the back up pharmacy. The back up pharmacy only accepted POF. Nurse #2 reported she did not care for Resident #128 the week of 10/18/2014 through 10/26/2014 until the evening (10/26) when she found the error. She reported on 10/23/2014 a nurse in orientation worked the hall even though Nurse #2 ' s name remained on the schedule. The Meropenum on 10/26/2014 was delivered from a specialty pharmacy through the back up. The regular pharmacy delivered additional doses on 10/27/2014. On 12/12/2014 at 11:22 PM an Interview with Nurse #4 revealed she was no longer employed at the facility. Nurse #4 was the treatment nurse on 10/18/2014 and helped Nurse #5 with Resident #128 ' s admission process. She recalled faxing the orders to the pharmacy, and transcribing orders to the telephone order sheet that were on formulary. She did not transcribe all of Resident #128 ' s Physician orders. Nurse #5 was Resident #128 ' s nurse on 10/18/2014 and was not available for an interview during the survey. On 12/10/2014 at 1:05 PM an interview with Unit Coordinator #1 revealed all nursing staff members were responsible for transcribing the Physician order. She reported she did not look at Resident #128 ' s POF or Medication Record because she was not working on his admitted . On 12/10/2014 at 1:06 PM an interview with the Acting Director of Nursing (DON) revealed her expectation was the staff review the Medication Record and look at every page. On 12/10/2014 at 3:45 PM an interview with Pharmacist #1 reveled Resident #128 ' s FL2/discharge summary was received at the Pharmacy on 10/18/2014 at 1:56 PM and the Physician order [REDACTED]. Resident #128 ' s medications were dispensed from the FL2. On 12/11/2014 at 2:05 PM an interview with Pharmacist #1 revealed the pharmacy closes on Saturday at 2 PM. If an order came in at 1:56 PM the pharmacy would fill the medication order and deliver it to the facility. If an order came in after 2 PM then the Pharmacy would review it on Monday morning. The facility was responsible for calling the back up pharmacy on the weekend. In regards to a second fax the pharmacy discourages the facility from sending the POF and encourages telephone order sheets. Only one full admission order would have been completed if a second was sent the pharmacy would only looked at the telephone order sheets. The pharmacy did receive Resident #128 ' s POF and " it did included the Meropenum and Tobramycin but we did not process the order because we already processed the admit orders off of the FL2/discharge summary " . In addition the pharmacy received 4 pages of telephone order sheets and the Meropenem or Tobramycin were not transcribed on those. Pharmacist #1 reported to her knowledge the facility knows the process. On 12/12/2014 at 10:34 AM an interview with the Pharmacy Director revealed the pharmacy will allow but discourage a faxed hospital discharge summary as orders. We will accept the hospital discharge summary as long as it included a written verification with a Physician or a verbal order from a Physician. The pharmacy has asked the facility to not send two sets of orders. The facility needed to choose either the discharge summary or the POF. Anything sent after needed to be a telephone order communication. If the pharmacy gets a second set of admission orders [REDACTED] On 12/12/2014 at 3:40 PM an interview with the Acting DON revealed her expectation of staff during the admission process was the nurse staff reviewed the admission discharge summary and verified the medications/treatments with the Physician and transfer the orders to the Physician order [REDACTED]. If the pharmacy called for clarification then the nurse was to clarify the order with the Physician and resubmits an order on a telephone order sheet. The Acting DON reported that some staff will send both the discharge summary and the POF. The Pharmacy will disregard the discharge summary. The pharmacy will not sent the medications or bill for medications based on receiving the discharge summary. When the medications are received the nursing staff would check against the POF and when they place the medications in the (medication cart) drawer they check the medications against the Medication Record. If something was missing the expectation was to call the Pharmacy or go to the back up pharmacy. Her expectation was for the nurse staff to view the orders during the routine medication pass and to know what medications they are giving. The nurse staff needed to read the medications listed on the Medication Record regardless of what the (designated) time said. The nursing staff was responsible for a 24 hour chart check (for order verification). The night shift nurse staff does the 24 hour chart check. The nurse who transcribes the orders was not to be the nurse to sign off or complete order verification. It was not best practice for multiple nurses to be involved in the admission process/transcription of medications. It was the responsibility of the nurses to take care of Resident #128, keep him safe, and provide the care needed. 2. Resident #181 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Nursing Home Admission History and Physical dated 10/9/14 indicated Resident #181 had a bilateral lower extremity chronic wound infection and acute and chronic pain. Review of the facility's pharmacy Ordering and Receiving information dated 10/7/14 provided the pharmacy address, phone number, fax number, hours of operations, and after-hours emergency service number and stated: ? New orders - faxed by 5 pm - delivered same day and by 2 pm on Saturdays. ? All new orders must be written on the Interim Order form. Fill in name, date, time, and initials of person faxing on top of the Order form. ? Fax to the pharmacy and keep the fax confirmation report. ? All medication orders must be faxed to the pharmacy. The Physician Interim Orders dated 10/16/14 indicated: Elavil 25 mg (by mouth every night at bedtime) - (pain). Review of the 24-hour Chart Check Form signed by Nurse #15 and dated 10/16/14 stated, "New orders" and indicated, by a checkmark, that the new orders were placed on the MAR. Review of the Medication Administration Record (MAR) indicated Elavil 25 mg for pain was ordered on [DATE] and was first signed off as being administered on 10/26/14. The Physician Interim Orders dated 10/25/14 indicated: May hold Elavil 25 mg (by mouth at bedtime) until available from pharmacy. During an interview on 12/10/14 at 3:26 pm with the acting Director of Nursing (DON) she stated, "Two nurses check the chart. The (night) nurse on the floor checks every new order that has come in (that 24-hour period)." She further indicated that there is no set time for the night (7 pm - 7 am) nurse to do the 24-hour chart check, but that the check for new orders should go all the way back to 7 pm the previous day so that no orders are missed. She also indicated that the Elavil is not a stock medication or available in the e-kit (emergency kit), should have been ordered from the pharmacy and should have been given to the resident as ordered. During an interview with Unit Coordinator #1 on 12/11/14 at 12:25 pm she stated, "The nurse will fax (the physician order) to the pharmacy no matter what time the order is written and then will write it on the MAR. The night supervisor does a chart check to ensure all orders are sent to the pharmacy and put on the MAR." After reviewing Resident #181's 10/16/14 Elavil order, she indicated a nurse did not sign off as receiving the order or faxing it to the pharmacy on 10/16/14, or any date since that time. She further stated, "If a written order does not arrive after it is sent to the pharmacy and is not in the e-kit, we write a hold order until it comes. I remember Nurse #2 mentioning the missed Elavil to me. I don't recall why it was not given. Elavil is not in the e-kit (and would have to come from the pharmacy)." During an interview with the DON on 12/11/14 at 4:15 pm she stated, "I would expect the order would have been caught by the night nurse doing the chart check." During an interview with Nurse #2 on 12/12/14 at 1:00 pm, regarding Resident #181's 10/16/14 Elavil order she stated, "I found (the missed order) when I was working on the hall on the 25th. A line was drawn on the MAR and (the medication was not) on the cart." She indicated the nurse working on the 16th must have written it on the MAR but never signed or faxed the order to the pharmacy and the resident never received the medication. 3.Resident #75 was originally admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Review if the facility's pharmacy Ordering and Receiving information dated 10/7/14 provided the pharmacy address, phone number, fax number, hours of operations, and after-hours emergency service number and stated: ? New orders - faxed by 5 pm - delivered same day and by 2 pm on Saturdays. ? All new orders must be written on the Interim Order form. Fill in name, date, time, and initials of person faxing on top of the Order form. ? Fax to the pharmacy and keep the fax confirmation report. ? All medication orders must be faxed to the pharmacy. The Physician order [REDACTED]." The order was written as a telephone order from the physician by the dietician and was signed by the physician assistant on 10/15/14. The order did not have a signature of a "nurse receiving order." Review of the 24-hour Chart Check Form dated 10/15/14 indicated (by a circle with a diagonal slash through it) that there were no medications written within 24 hours, no medications transferred to the Medication Administration Record (MAR), and was initialed by Nurse #1. Review of the MAR indicated a daily multivitamin was ordered on [DATE] and was first signed off as being administered on 10/29/14. During an interview on 12/10/14 at 3:26 pm with the acting Director of Nursing (DON) she stated, "Two nurses check the chart. The (night) nurse on the floor checks every new order that has come in (that 24-hour period)." She further indicated that there is no set time for the night (7 pm - 7 am) nurse to do the 24-hour chart check, but that the check for new orders should go all the way back to 7 pm the previous day so that no orders are missed. She also indicated that the MVI is a stock medication, available to nurses at all times in the facility and should have been given to the resident as ordered. During an interview with Unit Coordinator #1 on 12/11/14 at 12:25 pm she stated, "The nurse will fax (the physician order) to the pharmacy no matter what time the order is written and then will write it on the MAR. The night supervisor does a chart check to ensure all orders are sent to the pharmacy and put on the MAR." After reviewing Resident #75's 10/15/14 MVI order, she indicated a nurse did not sign off as receiving the order on 10/15/14, or any date since that time, and Nurse #2 signed on 10/27/14 indicating she sent the order to the pharmacy. During an interview with the DON on 12/11/14 at 4:15 pm she stated, "I would expect the order would have been caught by the night nurse doing the chart check." During an interview on 12/12/14 at 12:32 pm with Nurse #3, the 7 am - 7pm nurse who was assigned to Resident #75 on 10/15/14, she stated, "We have had several reminders about looking at the orders, taking them off, and getting the orders double checked. I do not specifically remember this missed medication or anyone speaking to me about it." During an interview on 12/12 12:44 pm with Nurse #2, regarding Resident #75's 10/15/14 MVI order, she stated, "When I was doing the MAR checks for November is when I caught the error. (The night nurse) is supposed to check every chart on the hall (every) night. (The 10/15/14 order) was a couple of pages back in the orders."

Based on record review and interviews with staff, the facility failed to give in-stock, scheduled and as-needed, medications to 1 of 4 sampled residents, (Resident #6), until a day after admission. Findings included: The Emergency Medication Kits (E-Kits) policy dated May 2013 stated, "In order to prevent patient/resident harm or discomfort an emergency supply of medications will be maintained in the healthcare center. This emergency supply of medications will typically include medications required to be started before the routine pharmacy delivery will arrive." Resident #6 was admitted on [DATE] at 2:15 pm. Her [DIAGNOSES REDACTED]. The Admission/Nursing Observation Form dated 8/30/14 indicated the resident was alert, oriented, anxious, agitated, sad/crying, and restless. Her speech was clear. She took antianxiety and antidepressant medications for which there were supporting diagnoses. The Medication Administration Record [REDACTED] [MEDICATION NAME] 40-25 mg po daily. Scheduled at 9:00 am. [MEDICATION NAME] 5 mcg subcutaneous injection (sq) twice a day. Scheduled at 9:00am and 5:00pm. [MEDICATION NAME] 10 mg po three times a day. Scheduled at 8:00 am, 2:00 pm, and 8:00 pm. [MEDICATION NAME] 25 mg po every morning. Scheduled at 9:00 am. [MEDICATION NAME] 15 units sq four times a day. Scheduled at 9:00 am, 1:00 pm, 5:00 pm, and 9:00 pm. [MEDICATION NAME] 30 units sq at hour of sleep. Scheduled at 9:00 pm. [MEDICATION NAME] 20 mg po daily. Scheduled at 9:00 am. [MEDICATION NAME] 40 mg po daily. Scheduled at 9:00 am. [MEDICATION NAME] Mix 70-30 15 units sq twice a day. Scheduled at 9:00 am and 5:00 pm. [MEDICATION NAME] 200 mg po at hour of sleep. Scheduled at 9:00 pm. [MEDICATION NAME] 150 mg po every morning. Scheduled at 9:00 am. Record review of the 8/30/14 MAR indicated [REDACTED]. The MAR indicated [REDACTED] Tylenol 650 mg po every 4 hours as-needed for mild pain. [MEDICATION NAME] 5 mg po every 4 hours as-needed for moderate pain. [MEDICATION NAME] 10mg po every 4 hours as-needed for severe pain. [MEDICATION NAME] 2 mg po every 8 hours as-needed for anxiety. Record review of the 8/30/14 MAR indicated [REDACTED]. There were no other as-needed medications signed as being given. Nurse #1's note dated 8/30/14 and un-timed stated, "(Resident #6) arrived around 2:15pm from (the hospital). (Resident) was crying and very emotional over several different things. She was impossible to calm. She (complained of) pain. I got (as-needed) pain (medication) from e-kit and when I returned she was going off (because) nobody answered the intercom. Told her I had to finish my med pass for the rest of my residents and then I would sit down and write her MAR indicated [REDACTED]. I explained to resident that we have e-kit backup." During an interview with Nurse #1 on 10/21/14 at 2:22pm she stated, "I was not on the hall after 7:00 pm. Nurse #2 was the nurse that took over. We were explaining to (Resident #6) that we would get her whatever she needed. She was just upset. I left around 7:00 pm from her hallway. I gave the orders to Nurse #2 to do a second check on her medications. I faxed the discharge summary to the pharmacy prior to 5pm. They will fill the meds from the discharge summary and call us if there are questions. The pharmacy cut off for new orders is 5pm on Saturday. The resident was very upset. I gave her [MEDICATION NAME] for pain at 6pm." Nurse #2's note dated 8/30/14 and untimed stated, "Resident rang call light and requested 'Tylenol' twice. Requests were fulfilled." During an interview with Nurse #2 on 10/21/14 at 2:40 pm she stated, "I wonder what time I wrote the note. I am not sure why I wrote 'twice'. She was ringing the call bell many times. If she asked for Tylenol, she got Tylenol. I did not have a clear understanding of how to document the standing orders until recently. Her Tylenol was a standing order so I did not document it on the MAR." During an interview with Nurse #2 on 10/22/14 at 8:47 am she indicated she could not remember why she did not give the resident's ordered medications to her on the first day/evening of her admission. She further indicated when a resident is admitted that available medications should be taken out of the e-kit to give the resident until all the medications are sent from the pharmacy. Nurse #3's note dated 8/31/14 at 7:30 am stated, "(Family member) expressed concern about resident not receiving medications. Writer called back-up pharmacy to deliver meds to facility, (family member) notified." Nurse #3's note dated 8/31/14 at 11:00 am stated in part,"Husband delivered home meds to staff until meds delivered and available from pharmacy." During an interview with Nurse #3 on 10/21/14 at 2:55 pm she stated, "Sometimes the meds aren't here on the weekend. We will call the pharmacy back-up. I was manager on duty. I was asked for assistance with the resident and checked the cart to see what meds were not available from pharmacy. The ones not available the husband did bring in." Nurse #3 indicated the resident received her medications out of the e-kit on 8/31/14 and the same medications available on 8/31/14 from the e-kit were available on 8/30/14 from the e-kit. During an interview with the Interim Director of Nursing (DON) on 10/21/14 at 2:07 pm she stated, "(Nurses) put the meds on an order for [REDACTED]. Sometimes we have the meds even prior to the resident's arrival. There are back-up meds here too. We have an emergency kit (for routine medications) and the narcotic emergency kit with [MEDICATION NAME], stuff like that. August 30th was a Saturday so we would have had to get her meds from the back-up pharmacy. When (nurse's) give a standing order, they should document it and add it to the MAR." During an interview with the Interim DON on 10/22/14 at 8:47 am she indicated her expectations were that a newly-admitted resident get their medications on the day of admission unless they are not available in the e-kit. She indicated Resident #6's anti-anxiety and muscle relaxer medications would not have been in the e-kit but that her other medications would have been available. She indicated her expectations were that a resident admitted at 2:15 in the afternoon would receive their medications that day. The Interim DON indicated there was no available documentation regarding medications taken out of either of the e-kits on 8/30/14. During an interview with the Vice President of Clinical Services on 10/24/14 at 11:29 am she stated, "(The nurses) should have called the local pharmacy back-up to get her meds if the meds were not available in the e-kit." She indicated she did not have a specific policy about the time frame in which a newly-admitted resident should receive medications, but she would expect that the resident would have received her meds on 8/30/14, whether by the e-kit or pharmacy delivery.

Based on record review, staff and resident interview the facility failed to maintain the most current practice for catheter insertion of a male based on published literature for 1 of 1 resident (Resident # 3) which resulted in the inflation of the catheter balloon in the urethra resulting in hospitalization due to rapid heart rate, fever and blood in the urine. Findings included: Facility Policy for Catheters: Insertion of Male Issued November 2012 and copyrighted 2006 Policy: To provide safe and hygienic measures for those patients/residents that requires use of indwelling catheters. Responsible Parties: The Licensed Nurses are responsible for implementation of the policy. Procedure: Read in Part 16. Raise the penis upright, then gently advance catheter until urine flows. Place free end of catheter in sterile container. 17. Proceed as follows, depending on type of catheter: ? For Foley catheters, carefully: i. Take a pre-filled syringe and insert into lumen for balloon inflation. ii. Withdraw catheter slightly to be sure balloon has inflated. A published policy and current Standard of Practice according to the University of Colorado Denver (2009), Male Insertion Procedure: Read in Part 1. Grasp the penis in an upright position and insert the lubricated catheter firmly into the meatus, advancing the catheter to the bifurcation at the ' Y ' of the catheter (all the way in). A slight lean toward the umbilicus may be necessary if resistance in advancing the catheter is met at the prostate. 2. The return of urine does not assure that the catheter is placed correctly in males, since there is residual urine in the penis. Inserting the catheter to the bifurcation of the ' Y ' is standard for assurance of proper placement. 3. If catheter placement is in question (i.e. no urine return or unable to fully insert the catheter) do not inflate the balloon and contact the physician. 4. If resistance is met do not attempt forceful catheter insertion; apply continuous gentle pressure. (University of Colorado Denver, 2009) Resident #3 was admitted to the facility on [DATE] His History included Urinary Tract Infection, [MEDICAL CONDITIONS] Bowel and Bladder and a neurological condition that did not allow him to have sensation below the neck. Resident #3 ' s annual Minimum Data Set ((MDS) dated [DATE] revealed he was cognitively intact and required extensive assistance from two staff members for his activities of daily living. A record review of Resident #3 ' s nurse note written by Nurse #1 on 2/24/2014 at 7:30 PM included catheter changed this shift. A record review of Resident #3 ' s nurse note on 2/25/2014 included the following: Resident was noted to have diaphoresis this shift. Hematuria was also noted increased HR (heart rate) noted when V/S (vital signs) taken. Order received from the Physician Assistant (PA) to send the resident to the emergency room . Resident left by EMS (Emergency Medical Services) @ 4 PM V/S Blood Pressure 129/78, Temperature 96.9, HR 142, and Respirations 20. Record review of hospital record dated 2/25/2014 for Resident #3 included Resident #3 reported he woke up this morning feeling unwell, weak, fatigued, diaphoretic, with subjective fever. He was [MEDICAL CONDITION] (fast heart rate) at his Skilled Nursing Facility and had gross blood in his catheter. He presented to the emergency department with hematuria, fever of 101.3, [MEDICAL CONDITION] and diaphoresis. A radiology study revealed the catheter balloon was inflated in the bulbar urethra (the most proximal end of the anterior urethra). Physical exam revealed the catheter bag had bright red urine prior to the exchange of an indwelling catheter and yellow urine after. It was noted that Resident #3 had a systemic response to the catheter balloon inflated in the urethra and remarkably improved after the catheter was exchanged (exchange refers to changing out the indwelling catheter). The physician progress notes [REDACTED].#3 ' s most recent hospital [DIAGNOSES REDACTED]. Resident #3 responded quickly to replacement of the (catheter) and antibiotic treatment. An Interview on 4/29/2014 at 1:30 PM with Resident #3 concerning the events on 2/24/2014 revealed Resident #3 believed Nurse #1 put the catheter in and blew the balloon up. Resident #3 did not know if the catheter was inserted all the way during the procedure. He reported he was not moved out of the bed by the staff or put in a position to cause a tug after the catheter was inserted and the leg strap was secured; to cause the balloon of the catheter to move from the bladder to the urethra/prostate. An interview on 3/11/2014 at 12:35 PM with Nurse #1 revealed on 2/24/2014 Resident #3 could not feel pain. She assessed no bleeding, felt no resistance and did assess urine in the catheter tube prior to inflating the balloon. On 2/25/2014 Nurse #1 noticed bleeding at the catheter insertion site and told the PA. Nurse #1 revealed Resident #3 was also having an issue with his heart rate and he was sent to the hospital. Nurse #1 revealed her knowledge of the procedure for inserting a catheter; clean the area, raise the penis, insert the catheter till you get urine coming out, then inflate the balloon. Nurse #1 did not state she advanced the catheter after the return of urine or advance the catheter all the way in to the " Y " bifurcation. A second interview on 5/1/2014 with Nurse #1 revealed she placed the catheter in Resident #3 around 4 PM on 2/24/2014 Nurse #1 reports feeling no resistance while inflating the balloon. She reports inflating the balloon when she saw urine return (urine in the catheter tubing) 150 to 200 cc clear urine. Nurse #1 reported she first noticed blood in the catheter bag mid morning on 2/25/2014. An interview on 3/11/2014 at 2:07 PM with a Nurse #5 revealed her knowledge of the procedure for inserting an indwelling catheter. The steps included: wash hands, provide privacy, clean with soap and water, get the bag ready, open sterile kit, put on sterile gloves, clean using the antiseptic, lubricate the catheter, ask about pain, assess for blockage or pressure (If there is pressure stop.), look for urine indicating the catheter in the bladder, insert some more, and then inflate the balloon. An interview on 3/12/2014 at 10:15 AM with Nurse #6 revealed her knowledge of the procedure for inserting an indwelling catheter. She reported after you clean and insert the catheter you have reached the bladder when urine comes out, you advance the catheter more and then fill the balloon, and assess the resident for pain. An interview on 3/11/2014 at 11:35 AM with the Director of Health Services (DHS) revealed he was aware of the complaint concerning Resident #3 ' s indwelling catheter and the DHS completed an investigation. The DHS added Resident #3 will now go to Urology for his catheter change.

Based on record review, observation, staff and resident interview the facility failed to ensure the proper insertion of an indwelling catheter in a male resident for 1 of 2 residents (Resident #3) resulting in hospitalization due to rapid heart rate, fever and blood in the urine. Findings included: Facility Policy for Catheters: Insertion of Male Issued November 2012 and copyrighted 2006 Policy: To provide safe and hygienic measures for those patients/residents that requires use of indwelling catheters. Responsible Parties: The Licensed Nurses are responsible for implementation of the policy. Procedure: Read in Part 16. Raise the penis upright, then gently advance catheter until urine flows. Place free end of catheter in sterile container. 17. Proceed as follows, depending on type of catheter: ? For Foley catheters, carefully: i. Take a pre-filled syringe and insert into lumen for balloon inflation. ii. Withdraw catheter slightly to be sure balloon has inflated. Resident #3 was admitted to the facility on [DATE]. His history included Urinary Tract Infection, [MEDICAL CONDITIONS] Bowel and Bladder and a neurological condition that did not allow him to have sensation below the neck. Resident #3 ' s annual Minimum Data Set ((MDS) dated [DATE] revealed he was cognitively intact and required extensive assistance from two staff members for his activities of daily living. Resident #3 ' s Care Plan included he was at risk for complications related to the presence of the indwelling catheter. A record review of Resident #3 ' s nurse note written by Nurse #1 on 2/24/2014 at 7:30 PM included catheter changed this shift. There was no additional documentation found in Resident #3 ' s medical record regarding the indwelling catheter or color, clarity or amount of urinary output on 2/24/2014 until the following note on 2/25/2014. A record review of Resident #3 ' s nurse note on 2/25/2014 (untimed) included the following: Resident was noted to have diaphoresis this shift. Hematuria was also noted increased HR (heart rate) noted when V/S (vital signs) taken. Order received from the Physician Assistant (PA) to send resident to the emergency room . Resident left by EMS (Emergency Medical Services) @ 4 PM V/S Blood Pressure 129/78, Temperature 96.9, HR 142, and Respirations 20. The physician progress notes [REDACTED].#3 ' s most recent hospital [DIAGNOSES REDACTED]. Resident #3 responded quickly to the replacement of the (catheter) and antibiotic treatment. An interview on 4/29/2014 at 1:30 PM with Resident #3 concerning the events on 2/24/2014 revealed Resident #3 believed Nurse #1 put the catheter in and blew the balloon up. Resident #3 did not know if the catheter was inserted all the way during the procedure. He reported he was not moved out of the bed by the staff or put in a position to cause a tug after the catheter was inserted and the leg strap was secured. (There was no resident activity following insertion of the catheter that would have caused the inflated balloon to move from the bladder to the urethra/prostate). An interview on 3/11/2014 at 12:35 PM with Nurse #1 revealed on 2/24/2014 Resident #3 could not feel pain. She assessed no bleeding, felt no resistance and did assess urine in the catheter tube prior to inflating the balloon. On 2/25/2014 Nurse #1 noticed bleeding at the catheter insertion site and told the PA. Nurse #1 revealed Resident #3 was also having an issue with his heart rate and he was sent to the hospital. Nurse #1 revealed her knowledge of the procedure for inserting a catheter was to clean the area, raise the penis, insert the catheter until you get urine coming out, and then inflate the balloon. Nurse #1 did not verbalize she followed the current standard of practice for catheter insertion in a male. A policy and procedure published by the University of Colorado Denver (2009), included the return of urine does not assure that the catheter is placed correctly in males, since there is residual urine in the penis. Inserting the catheter to the bifurcation of the ' Y ' (all the way in) is standard for assurance of proper placement. A second interview on 5/1/2014 with Nurse #1 revealed she placed the catheter in Resident #3 around 4:00 PM on 2/24/2014. Nurse #1 reported feeling no resistance while inflating the balloon. She reported inflating the balloon when she saw urine return (urine in the catheter tubing) 150 to 200 cc clear urine. Nurse #1 reported she first noticed blood in the catheter bag mid-morning on 2/25/2014. The 24 hour report form dated 2/24/2014 revealed notation from the night shift that the catheter was intact and drained 300cc of urine on the shift. The report did not notate color or clarity. Record review of hospital record dated 2/25/2014 for Resident #3 included Resident #3 reported he woke up this morning feeling unwell, weak, fatigued, diaphoretic, with subjective fever. He was [MEDICAL CONDITION] (fast heart rate) at his Skilled Nursing Facility and had gross blood in his catheter. He presented to the emergency department with hematuria, fever of 101.3, [MEDICAL CONDITION] and diaphoresis. A radiology study revealed the catheter balloon was inflated in the bulbar urethra (the most proximal end of the anterior urethra). Physical exam revealed the catheter bag had bright red urine prior to the exchange of an indwelling catheter and yellow urine after. It was noted that Resident #3 had a systemic response to the catheter balloon inflated in the urethra and remarkably improved after the catheter was exchanged (exchange refers to changing out the indwelling catheter). An interview on 3/11/2014 at 11:35 AM with the Director of Health Services (DHS) revealed he was aware of the complaint concerning Resident #3 ' s indwelling catheter and the DHS completed an investigation. The DHS added Resident #3 will now go to Urology for his catheter change. A record review of the staff in-service dated 2/25/2014 revealed a signature log for 104 nurse, nurse aides, and rehab staff members. The program content included: Catheter will be changed per MD order; catheter insertion will follow company ' s policy; Nurse will insert catheter gently until urine is withdrawn from catheter; Catheter must be secured per policy; Nurse will observe for signs and symptoms of pain or discomfort during catheter insertion and after catheter is inserted every shift; for residents who are paraplegic or quadriplegic nurse will observe for any signs or symptoms of sympathetic nervous system responses that may indicate discomfort, this includes excessive sweating, increased temperature etc; all staff will observe residents with catheters to ensure catheter bag is placed in privacy bag; and non clinical staff will report findings to nurse as appropriate. The policies the nurse staff were re-educated on were Catheter: Insertion of Male, Catheter: Insertion of Female, and Catheter Reinsertion of Female. The policies for male catheter insertion included in step number 16 gently advance catheter until urine flows. An interview on 4/30/2014 at 11:52 AM with the DHS revealed the in-service dated 2/25/2014 was not only about the insertion of catheters. It was broaden to include the insertion of catheters for the nurses; catheter care for nurses and nurse aids; abnormal signs and symptoms, leg strap, and privacy bag for nurses, nurse aids, and the rehabilitation staff. The DHS reported he felt it was better to broaden the education to all departments and all aspects of indwelling catheters. The in-services for staff took place in small group and individual review as staffing changed. The date on the signature log was the start of the in-services. The DHS reported it took 7 to 10 days to in-service the 104 staff members. The in-service provided by the DHS did not stay specific to the proper insertion of an indwelling catheter in a male or include advancing the catheter after the return of urine to assure proper placement.

Based on interviews with staff, infectious disease nurse, the physician, and laboratory personnel, and record review, the facility failed to monitor kidney function and antibiotic blood levels while a resident was on intravenous (IV) [MEDICATION NAME] resulting in the facility giving the medication even while the resident exhibited signs of nephrotoxicity (damage to the kidney) and acute [MEDICAL CONDITION] and resulting in hospitalization of 1 of 3 residents that needed medication monitoring (Resident #1). Findings included: Lexi-Comp Geriatric Dosage Handbook, 17th edition revealed that [MEDICATION NAME]'s monograph designated this medication as a "High Alert Medication: The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drug classes which have heightened risk of causing significant patient harm when used in error." Monitoring of [MEDICATION NAME] was described as "initial intravenous dosing should be based on actual body weight; subsequent dosing adjusted based on serum trough (lowest level before next dose) of [MEDICATION NAME]." Lexi-Comp monograph for [MEDICATION NAME] revealed that it may cause nephrotoxicity, if serum creatinine concentrations demonstrate increase of 50% from baseline in 2 or more sequential lab tests. The patient should be identified as having [MEDICATION NAME] induced nephrotoxicity. Resident #1 had a hospital stay from 11/22/13 until 12/3/13. Review of the hospital record titled "Interim Summary" of 12/03/13 revealed the resident received IV [MEDICATION NAME] at the hospital to treat [MEDICAL CONDITION] (MRSA) infection. The resident had a [MEDICATION NAME] Trough (blood [MEDICATION NAME] levels within 30 minutes of the next scheduled dose) of 16.9 (target level of 10-20 ug (micrograms/ ml)) and creatinine (a laboratory test used to check kidney function) level of 1.27 (Normal Range for a creatinine test would be 0.5-1.0 mg/deciliter) on 12/2/13. Review of the Discharge/Transfer Summary signed by the physician on 12/3/13 revealed the resident did have acute [MEDICAL CONDITION] associated with [MEDICATION NAME] dosing. The resident did improve after IV hydration and that she would need to have continued followup for her creatinine with weekly labs. Resident #1 was admitted from the hospital to the facility on [DATE] at 6:26 PM. Her cumulative [DIAGNOSES REDACTED]. The resident arrived at the facility with hospital discharge orders of 12/3/13 for "[MEDICATION NAME] 1500 mg (milligrams) to be infused intravenously daily for 4 weeks. Check [MEDICATION NAME] trough levels, complete blood count (CBC), basic metabolic chemistry (BMP) once a week- goal is ((creatinine) level of 10-20 ug (micrograms/ ml))." A BMP is necessary to obtain a value for creatinine. Review of the facility's Physician order [REDACTED]. Send the results to (name of the infectious disease physician group)." Record review of the attending physician's progress note dated 12/4/13 at 10:27 AM revealed, under assessment and plan: "MRSA bacteremia (blood infection) Patient currently on Vanco(mycin) for 4 weeks; (facility) pharmacy to dose. Vanco; f/u (follow- up) with (the infectious disease physician group) in 4 weeks." A lab report of 12/5/13 was faxed to the facility on [DATE] and included a creatinine of 1.23 and a [MEDICATION NAME] trough of 24.7. A nurse's note of 12/5/13 on the lab results revealed that the nurse spoke with PA (physician's assistant) from the attending physician's group. New orders were issued to recheck BMP (basic metabolic panel) on 12/09/13 (Monday) and fax to the facility pharmacy. There was no documentation in the resident's record to indicate that the lab results of 12/5/13 were sent to the infectious disease physician group. Review of the facility's "Physician Interim Orders" of 12/6/13 revealed orders to do [MEDICATION NAME] trough 30 minutes prior to dose administration twice a week on Monday and Thursday, to fax all lab results to the infectious disease physician group within 24 hours and not to change the [MEDICATION NAME] dose without consulting with the group. A lab report of 12/09/13 was faxed to the facility on [DATE] and included a creatinine of 4.20 (high) and a [MEDICATION NAME] trough of 67.3 (high). There was a statement at the top of the lab report that read "results reported to (name), (facility) receptionist on 12/9/13 at 3:49 PM, Vanct ([MEDICATION NAME] trough) =67.3 H (high)." Review of the resident's Medication Record revealed the resident received 1500 mg of [MEDICATION NAME] on 12/9/13, 12/10/13, 12/11/13 and 12/12/13. An interview with a representative from the lab company on 12/23/13 at 12:30 PM, revealed that the report should not have been given to the receptionist. This was not a standard operating procedure; it should have been given to a nurse. There was no documentation either in the nurse's notes or on the lab report that the results were reported to the infectious disease physician group or to the attending physician. Another lab test was done on 12/12/13 drawn at 5:30 AM. A nurse's note indicated that on 12/12/13 at 4:26 PM the facility received a phone call from the lab for critical [MEDICATION NAME] trough of 79.6 and creatinine of 4.5. Results were called to the infusion nurse at the infectious disease physician group. The infusion nurse requested and was provided the previous 12/9/13 lab results. A nurse's note of 12/12/13 at 5:49 PM indicated the facility received a call from the infusion nurse at the infectious disease physician group who stated that she spoke with the doctor and he ordered the resident to be sent to the hospital emergency room . A nurse's note dated 12/12/13 at 7:43 PM revealed the resident left the faciity on a stretcher via ambulance. Review of the hospital records revealed the laboratory results from the emergency department on 12/12/13 at 11 PM indicated the resident's creatinine was 4.55 and [MEDICATION NAME] trough level was at 56.7. The hospital records indicated that the resident received IV fluids. The resident returned to the facility on [DATE] at 5:30 AM. Review of the facility nurse's note dated 12/13/13 at 5:30 AM revealed the resident returned to the facility with no new orders and to continue on [MEDICATION NAME] IV. Review of the nurse's note dated 12/13/13 at 4:20 PM indicated that a [MEDICATION NAME] trough was done. The laboratory company called and said that it was more than 80 and that the laboratory company will call back and confirm. Review of the nurse's note dated 12/13/13 at 6:02 PM revealed the resident was sent to the hospital for critical [MEDICATION NAME] level. A physician order [REDACTED]. The hospital records of 12/13/13 revealed, under "Medical decision Making", the resident had acute [MEDICAL CONDITION] that was continually worsening. The Etiology was likely secondary to [MEDICATION NAME]. The creatinine was 4.6. The hospital history and physical of 12/13/13 revealed the resident had a [MEDICATION NAME] trough of 74. The resident was given IV fluids and electrolytes. The resident was returned to the facility on [DATE]. In an interview with the infusion nurse at the infectious disease physician group, on 12/20/13 at 3 PM, she stated that the doctors at their group preferred to do their own dosing and that was why the discharge document stated to fax the results of labs to the group within 24 hours. She stated when she did not hear from the facility on 12/6/13 about the lab test that should have been done on 12/05/13 (Thursday); she called the facility to clarify the group's expectations. During an interview on 01/08/13 at 12:30 PM, the Director of Nursing (DON) stated the infusion nurse from the infectious disease physician group notified him on 12/12/13 that the laboratory results of [MEDICATION NAME] trough and creatinine were not reported to the infectious disease physician group on 12/09/13. The DON stated he started an investigation. The DON revealed the receptionist denied receiving any laboratory results on 12/09/13. The DON then called the facility laboratory company and they stated the information about leaving it with the receptionist was printed on the lab reports of 12/09/13. The DON stated that the laboratory results should only be given to nursing staff. This has been entered into the lab's record system. He stated he could not prove either story. He was unsure where the laboratory results had been stored from 12/09/13 to 12/12/13. But when the laboratory results of 12/12/13 came in, a nurse was notified and she did contact the infectious disease physician group. When the infusion nurse asked on 12/12/13 for the previous lab values of 12/09/13, the facility nurse was able to find them on the chart and convey them to the infusion nurse. The DON stated that the nurse that did not send the 12/09/13 reports to the infectious disease physician group was no longer employed at the facility. Interview with this staff member was not possible. The DON felt the nurse did not follow the physician order [REDACTED]. As a result, the resident continued to receive 1500mg of [MEDICATION NAME] a day. An interview with the attending physician on 12/20/13 at 10:30 AM revealed she received a call from infectious disease physician group, saying that they were to dose the [MEDICATION NAME] and a clarification telephone order was written on 12/06/13 to shift in responsibility of [MEDICATION NAME] dosing to the infectious disease physician group.

Based on interviews with staff, infectious disease nurse, the physician, and laboratory personnel, and record review, the facility failed to notify the attending physician and the infectious disease physician group of elevated kidney function blood tests and elevated antibiotic blood levels while a resident was on intravenous (IV) [MEDICATION NAME] resulting in the facility giving the medication even while the resident exhibited signs of nephrotoxicity (damage to the kidney) and acute [MEDICAL CONDITION] and resulting in hospitalization of 1 of 3 residents that needed medication monitoring (Resident #1). Findings included: Resident #1 had a hospital stay from 11/22/13 until 12/3/13. Review of the hospital record titled "Interim Summary" of 12/03/13 revealed the resident received IV [MEDICATION NAME] at the hospital to treat [MEDICAL CONDITION] (MRSA) infection. Review of the Discharge/Transfer Summary signed by the physician on 12/3/13 revealed the resident did have acute [MEDICAL CONDITION] associated with [MEDICATION NAME] dosing. The resident would need to have continued followup for her creatinine with weekly labs. Resident #1 was admitted from the hospital to the facility on [DATE] at 6:26 PM. Her cumulative [DIAGNOSES REDACTED]. Review of the facility's Physician Orders dated 12/3/13 revealed an order for [REDACTED]. Send the results to (name of the infectious disease physician group)." A lab report of 12/5/13 was faxed to the facility on [DATE] and included a creatinine of 1.23 and a [MEDICATION NAME] trough of 24.7. A nurse's note of 12/5/13 on the lab results revealed that the nurse spoke with PA (physician's assistant) from the attending physician's group. New orders were issued to recheck BMP (basic metabolic panel) on 12/09/13 (Monday) and fax to the facility pharmacy. There was no documentation in the resident's record to indicate that the lab results of 12/5/13 were sent to the infectious disease physician group. Review of the facility's "Physician Interim Orders" of 12/6/13 revealed orders to do [MEDICATION NAME] trough 30 minutes prior to dose administration twice a week on Monday and Thursday, to fax all lab results to the infectious disease physician group within 24 hours and not to change the [MEDICATION NAME] dose without consulting with the group. A lab report of 12/9/13 was faxed to the facility on [DATE] and included a creatinine of 4.20 (high) and a [MEDICATION NAME] trough of 67.3 (high). There was a statement at the top of the lab report that read "results reported to (name), (facility) receptionist on 12/9/13 at 3:49 PM, Vanct ([MEDICATION NAME] trough) =67.3 H (high)." Review of the resident's Medication Record revealed the resident received 1500 mg of [MEDICATION NAME] on 12/9/13, 12/10/13, 12/11/13 and 12/12/13. There was no documentation in the records to show the attending physician or the infectious disease physician group was notified of the elevated laboratory results. An interview with a representative from the lab company on 12/23/13 at 12:30 PM, revealed that the report should not have been given to the receptionist. This was not a standard operating procedure; it should have been given to a nurse. There was no documentation either in the nurse's notes or on the lab report that the results were reported to the infectious disease physician group or to the attending physician. Another lab test was done on 12/12/13 drawn at 5:30 AM. A nurse's note indicated that on 12/12/13 at 4:26 PM the facility received a phone call from the lab for critical [MEDICATION NAME] trough of 79.6 and creatinine of 4.5. Results were called to the infusion nurse at the infectious disease physician group. The infusion nurse requested and was provided the previous 12/9/13 lab results. A nurse's note of 12/12/13 at 5:49 PM indicated the facility received a call from the infusion nurse at the infectious disease physician group who stated that she spoke with the doctor and he ordered the resident to be sent to the hospital emergency room . A nurse's note dated 12/12/13 at 7:43 PM revealed the resident left the faciity on a stretcher via ambulance. Review of the hospital records revealed the laboratory results from the emergency department on 12/12/13 at 11 PM indicated the resident's creatinine was 4.55 and [MEDICATION NAME] trough level was at 56.7. The hospital records indicated that the resident received IV fluids. The resident returned to the facility on [DATE] at 5:30 AM. Review of the facility nurse's note dated 12/13/13 at 5:30 AM revealed the resident returned to the facility with no new orders and to continue on [MEDICATION NAME] IV. Review of the nurse's note dated 12/13/13 at 4:20 PM indicated that a [MEDICATION NAME] trough was done. The laboratory company called and said that it was more than 80 and that the laboratory company will call back and confirm. A physician order was written on 12/13/13 to send the resident to the hospital emergency department for critical [MEDICATION NAME] level. The hospital records of 12/13/13 revealed, under "Medical decision Making", the resident had acute [MEDICAL CONDITION] that was continually worsening. The Etiology was likely secondary to [MEDICATION NAME]. The creatinine was 4.6. The hospital history and physical of 12/13/13 revealed the resident had a [MEDICATION NAME] trough of 74. The resident was given IV fluids and electrolytes. The resident was returned to the facility on [DATE]. In an interview with the infusion nurse at the infectious disease physician group, on 12/20/13 at 3 PM, she stated that the doctors at their group preferred to do their own dosing and that was why the discharge document stated to fax the results of labs to the group within 24 hours. She stated when she did not hear from the facility on 12/6/13 about the lab test that should have been done on 12/05/13 (Thursday); she called the facility to clarify the group's expectations. During an interview on 01/08/13 at 12:30 PM, the Director of Nursing (DON) stated the infusion nurse from the infectious disease physician group notified him on 12/12/13 that the laboratory results of [MEDICATION NAME] trough and creatinine were not reported to the infectious disease physician group on 12/09/13. The DON stated he started an investigation. The DON revealed the receptionist denied receiving any laboratory results on 12/09/13. The DON then called the facility laboratory company and they stated the information about leaving it with the receptionist was printed on the lab reports of 12/09/13. The DON stated that the laboratory results should only be given to nursing staff. This has been entered into the lab's record system. He stated he could not prove either story. He was unsure where the laboratory results had been stored from 12/09/13 to 12/12/13. But when the laboratory results of 12/12/13 came in, a nurse was notified and she did contact the infectious disease physician group. When the infusion nurse asked on 12/12/13 for the previous lab values of 12/9/13, the facility nurse was able to find them on the chart and convey them to the infusion nurse. The DON stated that the nurse that did not send the 12/09/13 reports to the infectious disease physician group was no longer employed at the facility. Interview with this staff member was not possible. The DON felt the nurse did not follow the physician order of 12/06/13 to fax all lab results to the infection disease physician group. As a result, the resident continued to receive 1500mg of [MEDICATION NAME] a day. An interview with the attending physician on 12/20/13 at 10:30 AM revealed she received a call from infectious disease physician group, saying that they were to dose the [MEDICATION NAME] and a clarification telephone order was written on 12/06/13 to shift in responsibility of [MEDICATION NAME] dosing to the infectious disease physician group.

Based on record reviews, staff interviews, Emergency Medical Services (EMS) interview and hospital staff interviews the facility failed to provide the correct Resident's demographic, history, and advanced directive information, for full code status, to allow a medical team to use every possible measure to sustain life for 1 of 4 residents (Resident #1) reviewed for acute care transfer to the hospital. Immediate Jeopardy began on [DATE] at 7:00 AM when facility staff provided the Emergency Medical Services team, the Face Sheet, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]' s acute episode of respiratory distress and transport to the hospital. Immediate jeopardy was removed on [DATE] at 6:51 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and to ensure monitoring systems put into place are effective. Findings included: Resident#1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A record review revealed a 2 page document for Advance Directives. On page 1 which was titled Advance Directives Checklist, the Power of Attorney had checked ' I have not executed an advance directive, and do not wish to discuss advance directives further at this time ' and signed the page. On page 2 titled, Consent Form for " Do not Resuscitate " Order the Power of Attorney had signed the area that read Full Code; a term for when a medical team uses every possible measure to sustain life, dated [DATE]. The Minimum Data Set discharge assessment dated [DATE] indicated Resident #1 was cognitively intact. Review of the clinical record revealed that on [DATE] he was transferred to a Hospital after a 911 call for an episode of coughing, shortness of breath, and wheezing. The clinical record indicated he returned to the facility on [DATE]. There were no changes made to Resident#1 ' s Advance Directive Order. On [DATE] a second 911 call was made for breathing problems and EMS was dispatched to the facility. Review of nurse note from [DATE] revealed at 7:00 AM the resident was in his room yelling for help. The nurse ' s note indicated that upon exam Resident #1 ' s skin was clammy and the resident was gasping for air. Vital signs readings included an oxygen saturation of 64% so a respiratory treatment was initiated. A recheck of the oxygen saturation increased the oxygen saturation value to 80%. The note said the resident lost consciousness and EMS was called. The note also said an order was received to send the resident to the hospital. An interview was conducted on [DATE] 2:15 PM with Nurse#1, the Resident's primary nurse on [DATE]. Nurse#1 said he was called to the Resident's room by the nurse aid. When Nurse #1 approached the Resident's room, he could hear the resident calling for help. Nurse#1 assessed the resident, recognized his trouble breathing and provided a breathing treatment. Resident#1's pulse oximtery reading was low, the breathing treatment did not improve the resident ' s condition, and the resident was in and out of consciousness so 911 was called. Nurse#1 reported having made copies of the medical record in a centralized copy room and handing them to EMS transport. He spoke to the EMS team about Resident#1's recent hospitalization on [DATE] and provided the EMS team with the discharge summary from [DATE]. Nurse#1 reported that during his chart completion he realized the chart sent with the EMS team was incorrect, at the same time the hospital was calling for identity clarification of the resident that was sent to the hospital. Nurse#1 stated that he clarified over the phone with the hospital staff that Resident#1 was the correct resident, that Resident#1 was a full code, and to provide services if needed. Nurse#1 announced he would be at the hospital in 15 minutes with the correct papers and to retrieve the do not resuscitate (DNR) paper belonging to Resident #2. When asked, Nurse#1 indicated that prior to the incident he was unaware of the Resident#1's code status/advance directives. Record review of EMS transport log on [DATE] revealed the EMS team was dispatched at 6:46 AM, arrived at the nursing home at 6:58 AM, left the facility at 7:35 AM, and arrived at the hospital at 7:42 AM. EMS record log documented the following: 6:59 AM, skin cool and pale with excessive moisture; lungs sound normal; capillary refill absent; blood pressure ,[DATE]; pulse 90bpm (beats per min) weak and regular; respirations 36 per minute and labored; and a normal heart rhythm with some premature beats. 7:14 AM reported an absent blood pressure; pulse 172bpm; respirations 34 per minute and labored; and a fast abnormal heart rhythm. 7:25 AM reported an absent blood pressure; pulse 166bpm; respirations 35 per minute and shallow; and a fast abnormal heart rhythm. 7:35 AM reported an absent blood pressure; pulse 114bpm weak and irregular; respirations 32 per minute shallow and irregular; and a change in the abnormal heart rhythm. 7:39 AM reported an absent blood pressure; pulse 44bpm weak and regular; respirations 4 per minute to absent; and a slow abnormal heart rhythm. 7:42 AM reported an absent blood pressure; pulse 40bpm weak and regular; respirations 13 per minute with EMS assisted ventilation; and a slow abnormal heart rhythm. The EMS trip log indicated that Resident#1 experienced multiple changes in condition during transport and the changes were treated with continuous high flow Oxygen; intravenous fluids (IVF); multiple electrocardiograms (EKG) a test to check the hearts electrical activity; [MEDICATION NAME] (a medication to treat irregular heartbeats); continuous positive airway pressure ([MEDICAL CONDITION]); a nasal airway to support breathing efforts; and finally the EMS team member#1 assisted Resident# 1's with his breathing by providing breaths. EMS team member#1's narrative notes revealed Resident#1 was sitting in a wheelchair with nasal cannula at 3 liters per minute. Resident#1 was in obvious respiratory distress with an increased work of breathing, abdominal retractions, eyes wide open, not blinking, and only making sounds when asked his name. The facility staff reported Resident# 1 was just in the hospital for the respiratory problems but the staff was unsure of the diagnosis. EMS team member#1 also reported staff said they were unsure of his specific information such as demographics, diagnosis, medications, and allergies and they would give EMS the paperwork. Resident#1 was agitated and pulled at the oxygen mask. Residen#1 stated he felt a little better after the medications. Resident#1 stated "hurry up lets go." During transport Resident#1's Glasgow Coma Scale (GCS) decreased. (GCS is a tool for recording the conscious state of a person). The notes stated Resident#1's breathing had become "agonal" (an inadequate pattern of breathing associated with extreme distress). Due to the event an EMS internal report was written by EMS team member#1. The internal report included, "Code 3 transport to (hospital). During transport pt (patient) condition deteriorated rapidly until pt (patient) had only agonal respirations and weak central pulses. Due to DNR, I chose to support pt respiratory efforts with (a tube in the nose to protect the airway) and (a mask placed over the nose and mouth to force oxygen in to the lungs) instead of placing an advanced airway (a tube inserted into the lungs that allowes a paramedic to have control of the airway). I also did not have my partner pull over and call for additional assistance as we would not be performing cardio [MEDICAL CONDITION] resucitation (CPR)." The report also included, " Upon further review it was found that a total of three pts (patients ') information had been given to us by (the facility). The majority of paperwork belonged to (Resident #2) including the DNR, DNR acknowledgement form, MAR 's (Medication Administration Record), and demographics sheet. Several pages of labs belonged to a female (Resident#3) and the discharge summary from (other hospital) belonging to (Resident# 1). Several minutes of confusion went by as the pt ' s identity was attempted to be acertained. Finally (hospital nurse) found pt wallet in pants pocket (with) photo ID. Pt then firmly identified as (Resident #1). " During an interview on [DATE] at 3:27 PM EMS team member#1 revealed when directed to Resident#1's room she found the man slumped in chair, unable to speak, with no radial pulse; she was unable to obtained vital signs. EMS team member#1 asked the facility staff about medications, allergies, and [MEDICATION NAME] and the staff provided a do not resucitate order (DNR). Another staff member reported Resident#1 recent history and a previous admission for the same condition and provided a copy of that hospital discharge. At approximately 7:30 the resident was loaded into the ambulance. EMS team member #1 said, " He (Resident #1) said ' I ' m fixing to go out ' and I told him I'd take care of him. " EMS team member #1 said Resident#1, " looked terrified. " EMS team member #1 also said, " In the truck his heart rate turned to ,[DATE]bpm which is bradicardic (very slow heart rate). His lungs went from clear to a fluid filled sound so I provided a [MEDICAL CONDITION]. His breathing was so slow and then it stopped all together. At the time knowing he had a DNR I could not intubate. I chose a nasal airway. " The EMS team member reported she assisted with his breathing the whole way to the hospital. She recalled at 7:40 am he stopped breathing adequately and she took over breathing efforts for about 3 minutes. When asked about the difference in care with a person who was full code, EMS team member#1 said, "Yes, I would have placed a more advanced airway" She indicated she would have been able to monitor his carbon [MEDICATION NAME] level, respiratory rate and had definitive control of his airway. She added that if she had known of his history of blood clots, and diabetes she would have handled the patient differently. She said, if she had the differential diagnoses, "I would have been on higher alert with my path of treatment." EMS team member #1 said the EMS team would have spent much less time at the facility because there was, "a greater likelihood of a [MEDICAL CONDITION] rather than just an exacerbation of [MEDICAL CONDITION]." EMS team member#1 then described the events in the emergency room (ER). She reported the ER physician was at Resident#1 ' s bedside and was looking through the stack of paperwork and discovered the Resident #2 ' s February Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. EMS team member#1 said the emergency room team started CPR but still did not place an advance airway. She indicated it was the ER physician who first recognized that some of the documents belonged to other residents. EMS team member#1 stated, " There were at least 30 sheets of paper, 25 for one person, 2 or 3 for a female (Resident#3) and we were still under the asumption that the person on the bed was the man with the DNR. " About that time the charting nurse discovered the man's wallet and correctly identified him by his picture identification. EMS team member#1 stated, "The DNR was not his, the face sheet was not his, the MAR indicated EMS team member#1 reported she announced the resident ' s name provided in the paperwork at the facility several times and no one said anything. The Hospital records from [DATE] revealed an initial [DIAGNOSES REDACTED]. The physician summary indicated that immediatelly after arrival the patient had lost pulses and there was an initial confusion over the identity of the patient from the facility and the code status. The report stated the patient arrived with a DNR form from a different person. The patients condition was such that it required the doctors full attention. The ER provided an advanced air way and performed CPR on the patient. Advanced medical equipment and medications were used to maintain Resident#1 ' s life. After discussion with the family the decision was made to withdraw care. Resident #1 expired at 5:55 PM. On [DATE] at 8:00 AM an interview was conducted with attending physician in the emergency room . The physician said EMS brought in the resident identification and DNR " and we were not too aggressive because of golden ticket (DNR form). " The ER physician looked through the papers and saw several different names, she saw a rescinded DNR, and she recognized the Face Sheet identified the patient as Caucasian and the patient in the ER was African American. The physician added that there were lab results with a female name. The physician stated that she called out the names of Resident#2 and Resident#3 and as staff undressed the patient a nurse found a wallet with the identification of Resident#1. The physician said the hospital placed a call to Resident #1's next of kin. She added that the family of Resident#1 identified him as a full code and said "help him as much as you can." During an interview on [DATE] at 12:06 PM the Director of Nursing (DON) stated, "This was not a systemic failure. It was an honest mistake. "The DON added," I did go back and see if we have ever had any concern of wrong records being sent. " He indicated that out of 58 hospital transfers since [DATE] the paperwork was correct for 57 of those residents. Resident #1 was the only error. He also indicated non-mandatory in-services about hospital transfer records were initiated on [DATE]. The DON also said, "The nurse did everything possible after the hospital called." On [DATE] at 5:31 PM the Administrator said that when this incident was reviewed they, "felt this was and isolated incident and decided not to take it to QA (the Quality Assurance Committee). " During an interview on [DATE] 11:39 AM, Nurse#2 revealed that EMS was already in the facility when he arrived to work. Nurse #2 said EMS asked what Resident#1's other [DIAGNOSES REDACTED]." Nurse #2 added, "He (Resident#1) kept saying ' I need to go (to the hospital). I'm short of breath 'over and over." The resident was passing in and out of consciousness. Review of Hospital medical records revealed Resident #1 died on [DATE] at 5:55 PM. [DIAGNOSES REDACTED]. On [DATE] 5:46 PM the Director of Nursing revealed his expectations would be that two staff members would cross check the transfer papers for correct identification so the correct information would go out. On [DATE] 5:47 PM the Administrator revealed that he would expect his staff to have the accurate information and for it to be verified. On [DATE] at 5:40 PM, the Administrator was notified of the Immediate Jeopardy. Credible Allegation of Compliance IMMEDIATE CORRECTIVE ACTION Named resident is no longer in the facility METHODS TO IDENTIFY ANY OTHER RESIDENTS WHO MIGHT BE AFFECTED Advance directive audits were completed for all residents on [DATE] by the Assistant Director of Health Services. Senior Care Partner, Clinical competency Coordinator and Unit managers. Moving forward, advance directive audits will be completed for all new admissions, re-admissions and then quarterly for all residents by Senior Care Partner quarterly, using advance directives audit tool. SYSTEMIC CHANGES ? Director of Health Services, Assistant Director of Health Services, Clinical Competency Coordinator, Unit managers and Shift Supervisor initiated in-service education session on [DATE], with licensed nurses on all shifts to stress the importance of ensuring correct information is sent with the resident at the time of transfer. This includes a copy of; Resident ' s face sheet, Resident Transfer Form, Medication Administration Records, [DIAGNOSES REDACTED]. ? As of [DATE], 34 nurses out of 52 licensed nurses have been educated on acute care transfer & release of medical records acknowledgement form. Licensed nurses will be educated before their next working shift. ? Charge nurse will cross check/double check Medical records sent to the hospital with another staff witness; using the " acute care transfer & release of medical records acknowledgment form " this form identifies documents sent with the EMS to the ED at the time of transfer. ? Acute care transfer & release of medical records acknowledgment form will be maintained in the resident medical records. ? Staff will be made aware of advanced Directives located under the advance directive tab in a resident medical record and by way of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] MONITORING PROCESS ? Director of Health Services, Assistant Director of health Services and/or unit managers will review clinical records for hospital transfers to ensure that the " Acute care transfer & release of medical records acknowledgment form " is utilized appropriately monthly x 3 months then quarterly thereafter. ? Utilization of Acute care transfer & release of medical records acknowledgment form will be tracked monthly and discussed in our QAPI process. ? Additional action planning will be implemented by the QAPI committee as necessary Alleged Date of Compliance [DATE] Immediate jeopardy was abated on [DATE] at 6:51 PM when interviews with nursing staff confirmed they had received in-service training on advance directives which included full code status or DNR for residents. The nursing staff were able to explain the use of the transfer packet and all forms to be sent with a resident going to the hospital. Nurses also said the contents of the transfer packet were to be checked by two facility staff to ensure only correct resident information was included. Record reviews were done to verify Advance Directives were available in the records of current residents. Administrative staff provided copies of inservices conducted and attendance records. Advance Directive audits were completed for all residents. Another resident, who was transfered out for an acute episode on [DATE], was reviewed and the new facility policy had been implemented. The Acute Care Transfer Checklist tool was reviewed as well as the tracking tool for Utilization of Acute Care transfer form.

Based on observation, staff interviews and the review of medical and hospital records, the facility failed to establish the transfer needs as well as the transfer mode for 1 of 4 residents (Resident #3) reviewed for falls and to ensure that nurse aides used a safe transfer technique to prevent injuries. The immediate jeopardy began on Resident #3 on 12/30/2011 and was identified on 1/6/2012 at 7:55pm. Immediate Jeopardy was removed on 1/7/2012 at 9:00pm, after the Credible Allegation was validated through staff interviews, record review and observations. The facility will remain out of compliance at a level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) The findings include: Resident #3 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. She also had 81mg of aspirin and 75mg of Plavix administered to her daily. The Admission Minimum Data Set (MDS) was not completed; however there was a nursing assessment, dated 11/22/2011 which indicated that Resident #3 was confused with short term memory problems. She was totally dependent on one person to assist her with bed mobility and totally dependent on two persons to assist her with transfers. A review of Resident #3's chart revealed a Fall Risk Assessment completed on 11/14/2011 with a score of 14. The guideline on the assessment stated that when residents score 10 or more, interventions should be promptly put in place. The Lift Evaluation Form, completed on 11/14/2011, stated that she could bear weight and could follow simple commands and had moderate upper body strength. The Interim Care Plan dated for 11/14/2011 indicated that she was at risk for falls. Her goal was to not sustain injury related to falling over the next 30 days. Approaches to be used included a Fall Risk Screen on admission; keep environment safe and utilize safety devices such as bed and chair alarms. The nurse's notes were reviewed. It revealed that on 11/15/2011, between 10:00pm and 6:00am, Resident #3 was very confused and attempted to get out of bed several times. She was confused and a bed alarm was put into place. On 11/16/2011, the notes recorded that a new order has been written for physical therapy services for evaluation and treatment. Resident #3 was recommended to receive gait training, wheelchair management secondary to weakness and falls. "Patient still very confused and tries so many times to get out of bed. Patient on total for transfers and activities of daily living (ADL)." On the 11/16/2011 Physical Therapy Plan of Care, Therapist #1 indicated a recent referral to physical therapy due to Resident #3 showing a significant decline in bed mobility, transfer, and gait over several months due to medically complex conditions resulting from medical problems. She was listed as a balance precaution, including a falls risk. She had modified independence with bed mobility (rolling side to side); bed mobility (supine-sit) and exhibited a static sitting balance (able to maintain balance without balance loss or upper extremity supports). She needed maximum assistance to transfer from bed to wheelchair. On the 11/17/2011 Plan of Care Assessment by Therapist #2 Resident #3 was mentioned to exhibit sliding her hips forward in a chair and leaning to the side while seated in her wheelchair. It further stated that she demonstrated decreased posture in wheelchair. Yet she was able to complete all functional transfers with maximum assistance. On 11/29/2011, an Occupational Therapy Daily Treatment Note stated that "Patient needs maximum cues for hand placement with poor posture and leaning forward." On the 12/8/2011 Occupational Therapist Progress Report, Therapist #2 indicated that Resident #3 was receiving treatment for [REDACTED]. Her goal was to tolerate upright standing maintaining proper postural alignment and weight distribution for 10 minutes to increase upper body trunk strength, standing tolerance and to increase interaction in her environment. She would also achieve effective postural alignment while seated in wheelchair for over 3 hours utilizing adaptive equipment as needed to affect hips sliding forward in chair and leaning to side. During the survey, Therapist #2 was on vacation and was unavailable for interview. An undated Nursing Assistant Care Record revealed that Resident #3 needed the assistance of one for transfers and needed the assistance of one to two persons, for repositioning. Safety devices to be used included a bed and chair alarm, which should be in place throughout the day. On 12/15/2011, the chart reflected that a physician's telephone was written for a bed and chair alarm on at all times for safety. On 12/25/2011 at 12:00am, the nurse's notes revealed that Resident #3 was observed on the floor with no apparent injury. She was assisted back to bed and attempted to get out of bed twice. She was brought to the nurse ' s station for monitoring. The fall investigative summary, dated 12/25/2011 relayed that the charge nurse had to reposition Resident #3 after she made two attempts earlier to get out of bed, unassisted. Later that shift, Resident #3 was found on the floor on the side of her bed by the charge nurse. The Interim Care Plan reflected the fall on 12/25/11. An Incident Fall Report, 12/26/2011, documented that Resident #3 was observed at 4:00pm on the floor beside her bed. She stated that she slid from her wheelchair and fell . She had no apparent injury. Under the section equipment in use, not applicable was written. On the 12/26/2011 Follow-Up Investigation summary, it confirmed that Resident #3 slid from her wheelchair. It indicated when asked, Resident #3 was unable to recall why she slid out of the chair. The Interim Care Plan reflected the fall on 12/26/11. On 12/30/2011, the nurse's notes revealed that at 7:45am, nurse aide #1 (NA#1) notified Nurse #1 that Resident #3 had fallen on the floor in her room. She told her that she had positioned Resident #3 on the side of her bed. NA#1 told Nurse #1 that she made sure she was stable while repositioning her wheelchair, but Resident #3 fell forward, head first and on to the floor. Bleeding was noted from her upper lip and a hematoma on her the right side of her eye. She noted no loss of consciousness and that the nurse practioner who was in the building was immediately notified and came to the room to assess Resident #3's injuries. A call was made for emergency transport and she was taken to the hospital at 8:15am. The fall investigation report from 12/30/2011 was reviewed. It stated that Administrative Staff #1 spoke with NA #4 and "Advised her that unsecure residents unable to sit on side of bed unsupported could result in resident's harm. Employee instructed to never leave resident unsecure on side of bed or standing if resident unable to support self. Employee further instructed to have all necessary equipment/supplies necessary prior to resident transfer." The hospital's emergency department notes were reviewed and revealed that Resident #3 was admitted on [DATE] at 8:42am for evaluation and treatment after her fall. The initial physical assessment noted that she had a large hematoma inside her upper lip as well as a large hematoma noted to the right eye. At 11:39am, she received sutures for facial laceration repair. The Inpatient Consult Note, dated 12/31/2011 stated that Aspirin and Plavix would be held for at least one week due to a head bleed. The consult note also stated that "fractures do not appear to be operative." The hospital discharge summary, dated 1/6/2012 reported that Resident #3 was treated in the Intensive Care Unit and had a discharge [DIAGNOSES REDACTED]. A CAT scan of the maxillofacial (mid-face) revealed a comminuted fracture through the floor of the right orbit extending into the lamina papyracea (thin orbital plate). It noted that there was blood within the right maxillary sinus. As well as fracture fragments were minimally inferiorly displaced. On 1/5/2012 at 1:50pm, Nurse Aide #1 was interviewed. She stated that she used to work with Resident #3 and that when she sat in her wheelchair; she witnessed her leaning forward or to her side. She commented that Resident #3 did not have good balance and had trouble moving her legs. On 1/5/2012 at 2:05pm, Nurse #2 was interviewed. She stated that she worked with Resident #3 who had cognitive impairments. She used a wheelchair, which had an alarm on it because Resident #3 would lean in her chair. On 1/5/2012 at 3:10pm, Nurse Aide #2 was interviewed. She shared that she worked with Resident #3 often and that she often summoned the help of another aide to use a mechanical lift to transfer Resident #3. She thought that Resident #3 was paralyzed from the waist down and stated that whenever she placed her in bed, she made sure that she laid vertically on the mattress with pillows behind her back for support. She commented that she took that measure "Because I think she would fall out of bed if I sat her on the side. She doesn't have good tone." Furthermore, she stated that Resident #3 would lean to her left side whenever she sat in her chair and she would see her trying to stand up but she couldn't rise from her seat. On 1/6/2012 at 10:13am, Nurse #1 was interviewed. She shared that she worked with Resident #3 often on first shift weekdays and on weekends. She stated that Resident #3 needed extensive assistance with transfers, yet one person was capable of transferring her. She had observed Resident #3 leaning in her wheelchair. She was also known to scoot forward in her wheelchair, so a chair alarm was always in place. The morning of the accident on 12/30/2011, she was called to the room by NA #1. She found Resident #3 on the floor and saw blood coming from her mouth and a hematoma on her forehead. Resident #3 was not able to respond to her name. She took her vital signs and contacted the nurse practioner, to examine her. She was immediately transported to the hospital for assessment and treatment. Administrative Staff #1 was interviewed on 1/6/2012 at 11:40am. She relayed that Resident #3 should have never been sitting on the side of the bed on 12/30/2011. She stated that Resident #3 had poor trunk control and was known to lean forward. Also said that her equipment (wheelchair) was not set prior to attempting to transfer her from the bed to the wheelchair. In addition, she added that the aide could have reviewed her ADL book for information on the resident or come talk to a nurse. On 1/6/2012 at 12:21pm, Administrative Staff #2 was interviewed. She acknowledged that some of the assessments (activities and social services) were done for Resident #3 on 11/22/2011 but she did not complete the MDS until 1/5/2012. She stated that whenever a comprehensive assessment gets completed, she must do a Care Plan. The Interim Care Plan stays on the chart until a comprehensive care plan gets developed. She acknowledged that the comprehensive care plan for Resident #3 was completed on 1/5/2012. Therapist #3 also worked with the resident providing occupational supports. She stated during an interview on 1/6/2012 at 12:41pm, that she did not have concerns about her positioning in her wheelchair, but stated that Resident #3 probably could not sit upright without back support. She commented, "If she didn't have that support she will tumble backwards or forward, toward the momentum." Therapists #1 and #4 were interviewed on 1/6/2012 at 1:17pm. Therapist #4 stated that Resident #3 participated in physical therapy about 4x a week. Therapist #1 added that Resident #3's lower extremities were fairly weak and sometimes rigid however, she was not paralyzed. Therapist #4 stated that during their sessions she noted a general decline in Resident #3's abilities and she mentioned to the nurse as well as the nurse practioner that Resident #3 was not improving and seemed to be regressing. Therapist #1 added that on one occasion, she recalled seeing Resident #3 leaning over in her wheelchair, while she was seated in the hallway, as if she was trying to reach for something like her shoes. She further stated that Resident #3 did not have trunk control or stability to sit up by herself without back support. She also didn ' t think she had very much safety awareness. Nurse Aide #3 was interviewed on 1/6/2012 at 2:53pm. He stated that he began to work with Resident #3 in December and worked with her on 2nd and 3rd shifts. He shared that she needed a mechanical lift for transfers and he would sometimes assist NA #2 when she had to move her. He felt that Resident #3 had good positioning in her wheelchair, but he would see her lean forward when she got sleepy. On 1/10/2012 at 10:37am, a telephone interview was conducted with Nurse Aide #4. She stated that she worked with the resident twice; around the time of her admission and on 12/30/2011. She stated that she wasn't that familiar with Resident #3's health conditions but that she knew that she had dementia, couldn't walk but was told that she could stand with assistance. She stated that she gathers her source of information to care for a resident from the nurse or she could go read the chart. The Nurse Aide Care Guide, she commented were kept in the nourishment room closet and it provided information about the type of assistance the resident needed. Her knowledge of Resident #3 was that she was considered total care, needing one staff to assist her and that she could sit on her own. She stated that Resident #3 did not require a mechanical lift for transfers. NA #4 continued by saying that although she was only assigned to Resident #3 twice, she had observed her previously, while she sat on the hall or in the television room. She recalled that Resident #3 could sit on her own in her wheelchair, and didn't slouch. She would witness her sitting on the edge of her chair and would have to reposition her and tell her to scoot back in her chair. NA #4 shared that she had seen Resident # lean forward in her wheelchair, with both hands on her armrest as if she wanted to get up. She stated that she honestly didn't know if she was a high fall risk because she didn't wear a yellow wrist band, which was used as an indicator to alert staff that a resident was identified as a fall risk. She felt that Resident #3 could sit on the side of the bed. During the interview, Nurse Aide #4 explained that on the morning of 12/30/2011 she was giving Resident #3 a bed bath and getting her dressed. She shared that Resident #3 was alert and they were able to converse. She stated that after she gave her a bath, she sat her up on the side of the bed, then stood in front of her, repositioning her clothes and styling her hair. NA #4 had the wheelchair, placed behind her, as the aide stood. She stated that the bed was placed at standard height and that Resident #3 was able to sit with the soles of her feet touching the floor. (The Nursing assessment dated [DATE] indicated that Resident #3 stood 5'4" tall.) She continued by stating that she did not have to hold Resident #3 while she provided grooming over a 3 to 5 minutes period, because she was able to maintain good trunk control. However she stated that when she removed her hands from Resident #3's shoulders, in order to turn around and move the wheelchair, Resident #3 had fell forward from her seated position on the bed and hit her face on the floor. On 1/13/12 at 11:37am, a follow up telephone interview was conducted with NA #1. She stated that aides can become familiar with a resident's needs by viewing the care guide located in each resident's closet or the nurse's will instruct the aide during their shift report. When NA #1 worked with Resident #3, she stated that she wore a yellow wrist band, to help identify her as at risk for falls. She shared that therapy had informed her that Resident #3 was a "leaner" , who could pivot but would need assistance. She continued by saying, "On paper it said that she (Resident #3) was a one person transfer but if you couldn't handle all of the leaning, then you would need someone else to help you." She shared that she never had transfer techniques for Resident #3 demonstrated to her, but was informed of her standing deficit. On 1/17/12 at 12:17pm, a follow up telephone interview was conducted with Administrative Staff #2. She commented that when a fall occurs, the nurse immediately updates the interim care plan with writes down interventions. The Unit Manager reviews the plan and the nurses make Administrative Staff #2 aware of any changes so that she can transfer the incidents and interventions onto the comprehensive care plan. She shared that on 12/25/11, staff intervened after Resident #3 fell out of bed, by bringing her to the nurse's station for supervision. After her fall on 12/26/11, staff intervened by placing a chair alarm on her wheelchair. She further commented that wrist bands are not used to identify residents at risk for falls. She stated that they rely on their Falls Risk Assessment, which had scored Resident #3 with a high score of 14 at the time of her admission, which placed her at risk for falls. On 1/17/12 at 1:00pm, a follow up telephone interview was conducted with Administrative Staff #1. She stated that the facility does not use a band system to identify residents at risk for falls. She shared that all licensed staff are able to update the nurse aide care guides with any information about falls and interventions to be used. The care guides are kept in the resident's closet or in the ADL book. She also shared that on 12/26/11; a chair alarm was added as a fall intervention, after Resident #3 fell that day. On a follow up telephone interview conducted on 1/17/12 at 2:56pm and 4:45pm, with Therapist #4, she stated that therapist can make recommendations for mechanical lifts but that the nurse makes the final decision and Resident #3 did not require a lift. She shared that Resident #3 was very inconsistent with her transfer skills, whereas some days she needed max assist of two persons and on other days, she needed less. In her role, Therapist #4 never gave any specific instructions on how to transfer Resident #3 to the nurse aides. She further shared that on 11/22/11, she worked with Therapist #2 to adjust Resident #3's wheelchair to help with self-propelling. On 12/16/11, she stated that she shared her concerns that Resident #3 had a functional decline with the nurse (name unknown) and nurse practioner; she reiterated her concerns to the nurse (name unknown) on 12/18/11. Therapist #1 was interviewed by telephone on 1/18/12 at 12:12pm. He stated that he primarily worked with Resident #3 to strengthen her ability to sit in a wheelchair and to assist her with toilet and grab bar transfers. In his role, he never gave instructions to the nurse aides on the manner used to transfer her from a sitting position to her wheelchair. He added that on 11/21/11 he recognized that Resident #3 needed a smaller wheelchair and replaced hers with an 18 x 18 wheelchair, so that the seat height was closer to the ground and this would aide her in placing her feet firmly on the floor, to allow her to self-propel. On 11/22/11 he made another adjustment, with the assistance of Therapist #4, to lower the seat 1 to 2 inches, to prevent Resident #3 from scooting forward in her wheelchair and to keep her body aligned properly. He shared that when Resident #3 was transferred out of her wheelchair, she could sit for a few seconds, but he stated "I never felt comfortable taking my hand off of her, she was still max assist for transfers." On 1/18/12 at 12:22pm, a follow up telephone interview was conducted with Therapist #3. She stated that Resident #3 did not require a mechanical lift because she had the ability to help transfer, stand and reach but needed guidance and (human) support to transport. She further commented that she never gave instructions to the nurse aides on positioning Resident #3 without back support. On 1/18/12 at 12:26pm, Therapist #1 participated in a follow up telephone interview. She shared that she was the evaluating therapist for Resident #3 whereas Therapist #4 administered the plan of care. She shared that the extremities of Resident #3 were all within functional limits and that she did not have any contractures. However, she did need upper extremity support from something (i.e. wheelchair back) or someone. She added that depending on the day that you worked with Resident #3, she might need the max assist of one or two persons. For this reason, she did not demonstrate any transfer techniques to any of the nurse aides, since Resident #3 was so inconsistent with her transfers. The Administrators were notified of the Immediate Jeopardy on 1/6/2012 at 7:55pm. The facility provided a Credible Allegation of Compliance on 1/7/2012 at 9:00pm. The allegation of compliance indicated: Credible Allegation of Compliance: 1. Resident #3 was evaluated by the Nurse Practioner. 2. An order was written for resident #3 to be transferred to the hospital for evaluation. 3. Resident #3 was transferred to the hospital by ambulance. 4. Resident #3 was admitted to the hospital on [DATE]. 5. The employee involved in the occurrence was verbally counseled and no longer is employed. 6. The investigation identified that the employee involved turned away from the resident to reposition the wheel chair for transfer and resident fell to the floor. Others with Potential to be effected: 1. All residents fall risk assessments have been reviewed and revised as required, by the Director of Health Services, Unit Managers, Wound Care Nurse and Senior Nurse Consultant to identify the high fall risk residents on 1/7/12. Sixty-three out of One Hundred and Nine residents have been identified as high risk for falls. The Fall Risk assessment includes resident ' s level of consciousness, history of falls, ambulation status, vision status, gait/balance, blood pressure, medications and predisposing disease. 2. Residents identified with a high fall risk have been evaluated for interventions and implementation of the interventions to prevent further occurrences are in place i.e., mat, alarms, positioning devices on 1/7/12. 3. Residents identified as a high fall risk who have not previously been screened for trunk balance will be screened by United Rehab Department for trunk control and balance beginning on 1/7/11 and continuing until all high risk residents have been completed. 4. Care plans have been reviewed by the Director of Nursing, Unit Managers, Wound care nurse and clinical reimbursement director on 1/7/12 and revised accordingly if interventions have not been previously identified. 5. The Nursing Assistant care guides have been reviewed by the Director of Health Services, Unit Managers, Wound Care Nurse and Senior Nurse Consultant on 1/7/12, the residents ' interventions related to fall prevention has been added to the Nurse Aide care guide. 6. The Director of Nursing, Unit Manager, and/or Clinical Care Competency Coordinator began education related to interventions placed on the C.N.A care guide was started on 1/6/12 and will continue until all staff has been educated. The nursing assistant is to check the ADL care guide prior to each shift; the ADL care guides are located at the nurse ' s station in a specific binder and the ADL care guide is updated by the charge nurses, Clinical reimbursement director, Director of Health Services, and/or Unit Managers with order changes and significant change of condition. All nursing staff will receive education on the ADL care guide prior to beginning their next scheduled shift. 7. Education related to the assistance the resident requires for transfers was started on 1/6/12 that included placement of the assistance the resident requires for transfers on the ADL care guide and will continue until all staff has been completed. Nursing Assistants will receive education prior to beginning their next scheduled shift. This education was provided by the Director of Nursing, Unit Manager and/or Clinical Competency Coordinator. 8. The Director Health Services, Unit Managers, Senior Care Partner, Clinical Competency Coordinator, Senior Nurse Consultant are observing certified nursing assistants to validate they are transferring residents according to the care plan and ADL care guide, this is to include the utilization of support or unsupported trunk control and amount of assistant required during transfers. 9. Education related to Event reporting to include investigation of how the event occurred was started on 1/6/12 for all Licensed Nurses, nursing assistance and other ancillary staff will continue until all staff has been completed. All Licensed and Nursing staff will receive education prior to beginning their next scheduled shift. This education was provided by the Director of Health Services, Unit Managers and/or the Clinical Competency Coordinator. Measures and Systemic Changes 1. An incident occurrence investigation form that identifies what the resident was doing prior to the occurrence, statement from resident of what occurred and statements from staff members with a synopsis of what led to the occurrence has been initiated on 1/6/12. This incident occurrence investigation is to be initiated by the Charge Nurse on duty at the time of the occurrence. 2. The Administrator and/or Director of Health Services will review and summarize each incident occurrence investigation daily Monday through Friday with summarization on the investigation form. 3. Education related to updating care plans, Nurse Aide care guides related to resident transfers has been added to the general orientation for Licensed Nurses and Nursing Assistance. 4. Education related to incident occurrence investigations and incident occurrence reporting has been added to general orientation for all staff. 5. All incident occurrences will be brought to the stand up meeting daily Monday through Friday by the unit managers for review of the occurrence documentation for completeness, interventions and summarization. 6. Care plans will be reviewed and /or revised in the daily morning meetings Monday through Friday by the Director of Nursing, Unit Managers, and/or Case Mix Director of all residents with occurrences and/ or significant change of condition. 7. Director of Health Services, Unit Managers, Clinical Competency Coordinator and/or Senior Care Partner will observe 10 residents per day to validate the Nursing Assistants are providing resident care in accordance with the resident care plan. Monitoring 1. The Director of Health Services and/or Administrator will audit documentation of occurrences for intervention and implementation of the interventions and investigation completion and significant changes to ensure they have been identified on the ADL care guide and care plan, daily for seven days then weekly for four weeks then monthly thereafter. 2. The Clinical Reimbursement Consultant (CRC) will audit the facilities significant change MDS ' s and care plans for accuracy weekly for four weeks then monthly thereafter. 3. The Senior Nurse Consultant (SNC) will audit the occurrence logs and review the charts for interventions and implementation of interventions and investigation weekly for four weeks then monthly thereafter. 4. The Director of Nursing / Unit Manager will audit the Fall Risk assessments, Care Plans and ADL care guides for fall prevention interventions daily for seven days, weekly for four weeks then monthly thereafter. 5. The audits conducted by the Director of Health Services, Unit Managers, Clinical Competency Coordinator and/or Senior care partner regarding resident observation to ensure the nursing assistants are providing care in accordance with the resident care plan will be conducted daily for seven days then weekly for four weeks then monthly. The results of the observation audits will be monitored monthly by the Performance Improvement committee for compliance. 6. Daily and weekly audits of the documentation of all occurrences and all significant changes, the Clinical Reimbursement Consultant accuracy audits and the Senior Nurse Consultant audit of the occurrence logs for interventions, implementation and investigations will be monitored monthly by the Performance Improvement Committee for compliance. 7. All audited findings from the DHS/Administrators documentation of occurrences and significant changes, CRC accuracy, and SNC review of the charts for interventions and implementation of interventions and investigation, education in general orientation will be reviewed in the monthly Performance Improvement committee meeting for patterns and trends and further interventions developed as necessary to ensure continued compliance. The credible allegation was verified 1/7/2012 at 7:00pm, as evidenced by staff interviews on preventing falls, reviewing Certified Nurse Aide Care Guides, completing fall investigation reports and reviewing Fall Risk assessments. Review of in-service records for Performing Safe Transfers, Event Reporting (to include how the event occurred), and Developing Care Plans, Updated Fall Risk Assessments, and Updated Care Guides indicated participation by 48% of nursing, housekeeping, dietary and therapy staff. Residents were identified and re-screened by Therapy on 1/7/2012 to determine if they were at risk for falls due to balance while sitting. 69 Residents were identified as high risk and/or with trunk control issues. Their charts were reviewed for updated care guides, care plans, fall risk assessments as well as observation of interventions to be used to prevent falls. A revision dated 1/7/2012 was made to the Incident Fall Report to include an Accident Occurrence Investigation Summary that identifies what the resident was doing prior to the occurrence, statement from the resident of what occurred and statements from staff members with a synopsis of what led to the occurrence.

Based on staff interviews and record review, the facility failed to develop a comprehensive care plan for 1(Resident #3) of 3 cognitively impaired residents with a history of falls and who received antiplatelets drugs (aspirin & [MEDICATION NAME]). The findings include: The immediate jeopardy began for Resident #3 on 12/05/2011(the date the comprehensive care plan was due after her admission) and was identified on 1/6/2012 at 7:55pm. Immediate Jeopardy was removed on 1/7/2012 at 9:00pm, after the Credible Allegation was validated through staff interviews, record review and observations. The facility will remain out of compliance at a level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) Resident #3 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. She also had 81mg of aspirin and 75mg of [MEDICATION NAME] administered to her daily, which are antiplatelet drugs used to prevent blood clots; a contributor of [MEDICAL CONDITION]. The Admission Minimum Data Set (MDS) was not completed; however there was a nursing assessment, dated 11/22/2011 which indicated that Resident #3 was confused with short term memory problems. She was totally dependent on one person to assist her with bed mobility and totally dependent on two persons to assist her with transfers. A review of Resident #3's chart revealed a Fall Risk Assessment completed on 11/14/2011 with a score of 14. The guideline on the assessment stated that when residents score 10 or more, interventions should be promptly put in place. The Interim Care Plan dated for 11/14/2011 indicated that she was at risk for falls. Her goal was to not sustain injury related to falling over the next 30 days. Approaches to be used included a Fall Risk Screen on admission; to keep the environment safe and utilize safety devices such as bed and chair alarms. The nurse's notes were reviewed. It revealed that on 11/15/2011, between 10:00pm and 6:00am, Resident #3 was very confused and attempted to get out of bed several times. She was confused and a bed alarm was put into place. On 11/16/2011, the notes recorded that a new order has been written for physical therapy services for evaluation and treatment. Resident #3 was recommended to receive gait training, wheelchair management secondary to weakness and falls. "Patient still very confused and tries so many times to get out of bed. Patient on total for transfers and activities of daily living (ADL)." On the 11/16/2011 Physical Therapy Plan of Care, Therapist #1 indicated a recent referral to physical therapy due to Resident #3 showing a significant decline in bed mobility, transfer, and gait over several months due to medically complex conditions resulting from medical problems. She was listed as a balance precaution, including a falls risk. She had modified independence with bed mobility (rolling side to side); bed mobility (supine-sit) and exhibited a static sitting balance (able to maintain balance without balance loss or upper extremity supports). She needed maximum assistance to transfer from bed to wheelchair. On the 11/17/2011 Plan of Care Assessment by Therapist #2 Resident #3 was mentioned to exhibit sliding her hips forward in a chair and leaning to the side while seated in her wheelchair. It further stated that she demonstrated decreased posture in wheelchair. Yet she was able to complete all functional transfers with maximum assistance. On 11/29/2011, an Occupational Therapy Daily Treatment Note stated that "Patient needs maximum cues for hand placement with poor posture and leaning forward." On the 12/8/2011 Occupational Therapist Progress Report, Therapist #2 indicated that Resident #3 was receiving treatment for [REDACTED]. Her goal was to tolerate upright standing maintaining proper postural alignment and weight distribution for 10 minutes to increase upper body trunk strength, standing tolerance and to increase interaction in her environment. She would also achieve effective postural alignment while seated in wheelchair for over 3 hours utilizing adaptive equipment as needed to affect hips sliding forward in chair and leaning to side. During the survey, Therapist #2 was on vacation and was unavailable for interview. An undated Nursing Assistant Care Record revealed that Resident #3 needed the assistance of one for transfers and needed the assistance of one to two persons, for repositioning. Safety devices to be used included a bed and chair alarm, which should be in place throughout the day. Administrative Staff #1 was interviewed on 1/6/2012 at 11:40am. She relayed that Resident #3 should have never been sitting on the side of the bed on 12/30/2011. She stated that Resident #3 had poor trunk control and was known to lean forward. In addition, she added that Nurse Aide #4 could have reviewed her ADL book for information on the resident or come talk to a nurse. On 12/25/2011 at 12:00am, the nurse's notes revealed that Resident #3 was observed on the floor with no apparent injury. She was assisted back to bed and attempted to get out of bed twice. She was brought to the nurse ' s station for monitoring. The fall investigative summary, dated 12/25/2011 relayed that the charge nurse had to reposition Resident #3 after she made two attempts earlier to get out of bed, unassisted. Later that shift, Resident #3 was found on the floor on the side of her bed by the charge nurse. The Interim Care Plan reflected the fall on 12/25/11. An Incident Fall Report, 12/26/2011, documented that Resident #3 was observed at 4:00pm on the floor beside her bed. She stated that she slid from her wheelchair and fell . She had no apparent injury. Under the section equipment in use, not applicable was written. On the 12/26/2011 Follow-Up Investigation summary, it confirmed that Resident #3 slid from her wheelchair. It indicated when asked, Resident #3 was unable to recall why she slid out of the chair. The Interim Care Plan reflected the fall on 12/26/11. On 12/30/2011, the nurse's notes revealed that at 7:45am, nurse aide #4 (NA#4) notified Nurse #1 that Resident #3 had fallen on the floor in her room. She told her that she had positioned Resident #3 on the side of her bed. NA#4 told Nurse #1 that she made sure she was stable while repositioning her wheelchair, but Resident #3 fell forward, head first and on to the floor. Bleeding was noted from her upper lip and a hematoma on her the right side of her eye. She noted no loss of consciousness and that the nurse practioner who was in the building was immediately notified and came to the room to assess Resident #3 ' s injuries. A call was made for emergency transport and she was taken to the hospital at 8:15am. The fall investigation report from 12/30/2011 was reviewed. It stated that Administrative Staff #1 spoke with NA #4 and "Advised her that unsecure residents unable to sit on side of bed unsupported could result in resident's harm. Employee instructed to never leave resident unsecure on side of bed or standing if resident unable to support self. Employee further instructed to have all necessary equipment/supplies necessary prior to resident transfer." The hospita s emergency department notes were reviewed and revealed that Resident #3 was admitted on [DATE] at 8:42am for evaluation and treatment after her fall. The initial physical assessment noted that she had a large hematoma inside her upper lip as well as a large hematoma noted to the right eye. At 11:39am, she received sutures for facial laceration repair. The Inpatient Consult Note, dated 12/31/2011 stated that Aspirin and [MEDICATION NAME] would be held for at least one week due to a head bleed. The consult note also stated that "fractures do not appear to be operative." The hospital discharge summary, dated 1/6/2012 reported that Resident #3 was treated in the Intensive Care Unit and had a discharge [DIAGNOSES REDACTED]. A CAT scan of the maxillofacial (mid-face) revealed a comminuted fracture through the floor of the right orbit extending into the lamina papyracea (thin orbital plate). It noted that there was blood within the right maxillary sinus. As well as fracture fragments were minimally inferiorly displaced. On 1/6/2012 at 12:21pm, Administrative Staff #2 was interviewed. She acknowledged that some of the assessments (activities and social services) were done for Resident #3 on 11/22/2011 but she did not complete the MDS, including the Care Area Assessment (CAA) until 1/5/2012. She stated that whenever a comprehensive assessment gets completed, she must do a Care Plan. The Interim Care Plan stays on the chart until a comprehensive care plan gets developed. She acknowledged that the comprehensive care plan for Resident #3 was completed on 1/5/2012. Therapist #3 worked with the resident providing occupational supports. She stated during an interview on 1/6/2012 at 12:41pm, that she did not have concerns about her positioning in her wheelchair, but stated that Resident #3 probably could not sit upright without back support. She commented, "If she didn ' t have that support she will tumble backwards or forward, toward the momentum." Therapists #1 and #4 were interviewed on 1/6/2012 at 1:17pm. Therapist #4 stated that Resident #3 participated in physical therapy about 4x a week. Therapist #1 added that Resident #3's lower extremities were fairly weak and sometimes rigid however, she was not paralyzed. Therapist #4 stated that during their sessions she noted a general decline in Resident #3's abilities and she mentioned to the nurse as well as the nurse practioner that Resident #3 was not improving and seemed to be regressing. Therapist #1 shared that on one occasion; she recalled seeing Resident #3 leaning over in her wheelchair, while she was seated in the hallway, as if she was trying to reach for something, like maybe her shoes. She further stated that Resident #3 did not have trunk control or stability to sit up by herself without back support. She also didn't think she had very much safety awareness. On 1/10/2012 at 10:37am, a telephone interview was conducted with Nurse Aide #4. She stated that she worked with the resident twice; around the time of her admission and on 12/30/2011. She stated that she wasn't that familiar with Resident #3's health conditions but that she knew that she had dementia, couldn't walk but was told that she could stand with assistance. She stated that she gathers her source of information to care for a resident from the nurse or she could go read the chart. The Nurse Aide Care Guide, she commented were kept in the nourishment room closet and it provided information about the type of assistance the resident needed. Her knowledge of Resident #3 was that she was considered total care, needing one staff to assist her and that she could sit on her own. She stated that Resident #3 did not require a mechanical lift for transfers. NA #4 continued by saying that although she was only assigned to Resident #3 twice, she had observed her previously, while she sat on the hall or in the television room. She recalled that Resident #3 could sit on her own in her wheelchair, and didn't slouch. She would witness her sitting on the edge of her chair and would have to reposition her and tell her to scoot back in her chair. NA #4 shared that she had seen Resident # lean forward in her wheelchair, with both hands on her armrest as if she wanted to get up. She stated that she honestly didn't know if she was a high fall risk and that she felt that Resident #3 could sit on the side of the bed. During the interview, Nurse Aide #4 explained that on the morning of 12/30/2011 she was giving Resident #3 a bed bath and getting her dressed. She shared that Resident #3 was alert and they were able to converse. She stated that after she gave her a bath, she sat her up on the side of the bed, then stood in front of her, repositioning her clothes and styling her hair. NA #4 had the wheelchair, placed behind her, as the aide stood. She stated that the bed was placed at standard height and that Resident #3 was able to sit with the soles of her feet touching the floor. (The Nursing assessment dated [DATE] indicated that Resident #3 stood 5'4 " tall.) She continued by stating that she did not have to hold Resident #3 while she provided grooming over a 3 to 5 minutes period, because she was able to maintain good trunk control. However she stated that when she removed her hands from Resident #3's shoulders, in order to turn around and move the wheelchair, Resident #3 had fell forward from her seated position on the bed and hit her face on the floor. On 1/13/12 at 11:37am, a follow up telephone interview was conducted with NA #1. She stated that aides can become familiar with a resident's needs by viewing the care guide located in each resident's closet or the nurse's will instruct the aide during their shift report. She shared that therapy had informed her that Resident #3 was a "leaner", who could pivot but would need assistance. She continued by saying, "On paper it said that she (Resident #3) was a one person transfer but if you couldn't handle all of the leaning, then you would need someone else to help you." On 1/17/12 at 12:17pm, a follow up telephone interview was conducted with Administrative Staff #2. She commented that when a fall occurs, the nurse immediately updates the interim care plan with writes down interventions. The Unit Manager reviews the plan and the nurses make Administrative Staff #2 aware of any changes so that she can transfer the incidents and interventions onto the comprehensive care plan. She shared that on 12/25/11, staff intervened after Resident #3 fell out of bed, by bringing her to the nurse's station for supervision. After her fall on 12/26/11, staff intervened by placing a chair alarm on her wheelchair. On 1/17/12 at 1:00pm, a follow up telephone interview was conducted with Administrative Staff #1. She shared that all licensed staff are able to update the nurse aide care guides with any information about falls and interventions to be used. She added that the care guides are kept in the resident's closet or in the ADL book. Therapist #2 was interviewed by telephone on 1/18/12 at 12:12pm. He stated that he primarily worked with Resident #3 to strengthen her ability to sit in a wheelchair and to assist her with toilet and grab bar transfers. On 11/21/11 and 11/22/11, he modified her wheelchair by adding a longer seat cushion, which was then lowered closer to the ground, thus allowing her feet to touch the floor, which helped her to self-propel and kept her trunk properly aligned. He shared that when Resident #3 was transferred out of her wheelchair, she could sit for a few seconds, but he stated "I never felt comfortable taking my hand off of her, she was still max assist for transfers " The Administrators were notified of the Immediate Jeopardy on 1/6/2012 at 7:55pm. The facility provided a Credible Allegation of Compliance on 1/7/2012 at 9:00pm. The allegation of compliance indicated: Credible Allegation of Compliance: Others with Potential to be effected: 1. Care plans have been reviewed by the Director of Nursing, Unit Managers, Wound care nurse and clinical reimbursement director on 1/7/12 and revised accordingly if interventions have not been previously identified. 2. The Director of Nursing, Unit Manager, and/or Clinical Care Competency Coordinator began education related to interventions placed on the N.A care guide was started on 1/6/12 and will continue until all staff has been educated. The nursing assistant is to check the ADL care guide prior to each shift; the ADL care guides are located at the nurse ' s station in a specific binder and the ADL care guide is updated by the charge nurses, Clinical reimbursement director, Director of Health Services, and/or Unit Managers with order changes and significant change of condition. All nursing staff will receive education on the ADL care guide prior to beginning their next scheduled shift. 3. Education related to the assistance the resident requires for transfers was started on 1/6/12 that included placement of the assistance the resident requires for transfers on the ADL care guide and will continue until all staff has been completed. Nursing Assistants will receive education prior to beginning their next scheduled shift. This education was provided by the Director of Nursing, Unit Manager and/or Clinical Competency Coordinator. Measures and Systemic Changes 1. Education related to updating care plans, Nurse Aide care guides related to resident transfers has been added to the general orientation for Licensed Nurses and Nursing Assistance. 2. All accidents occurrences will be brought to the stand up meeting daily Monday through Friday by the unit managers for review of the occurrence documentation for completeness, interventions and summarization. 3. Care plans will be reviewed and /or revised in the daily morning meetings Monday through Friday by the Director of Nursing, Unit Managers, and/or Case Mix Director of all residents with occurrences and/ or significant change of condition. 4. Director of Health Services, Unit Managers, Clinical Competency Coordinator and/or Senior Care Partner will observe 10 residents per day to validate the Nursing Assistants are providing resident care in accordance with the resident care plan. Monitoring 1. The Director of Health Services (DHS) and/or Administrator will audit documentation of occurrences for intervention and implementation of the interventions and investigation completion and significant changes to ensure they have been identified on the ADL care guide and care plan, daily for seven days then weekly for four weeks then monthly thereafter. 2. The Clinical Reimbursement Consultant (CRC) will audit the facilities significant change MDS ' s and care plans for accuracy weekly for four weeks then monthly thereafter. 3. The Senior Nurse Consultant (SNC) will audit the occurrence logs and review the charts for interventions and implementation of interventions and investigation weekly for four weeks then monthly thereafter. 4. The Director of Health Services / Unit Manager will audit the Fall Risk assessments, Care Plans and ADL care guides for fall prevention interventions daily for seven days, weekly for four weeks then monthly thereafter. 5. The audits conducted by the Director of Health Services, Unit Managers, Clinical Competency Coordinator and/or Senior care partner regarding resident observation to ensure the certified nursing assistants are providing care in accordance with the resident care plan will be conducted daily for seven days then weekly for four weeks then monthly. The results of the observation audits will be monitored monthly by the Performance Improvement committee for compliance. 6. Daily and weekly audits of the documentation of all occurrences and all significant changes, the Clinical Reimbursement Consultant accuracy audits and the Senior Nurse Consultant audit of the occurrence logs for interventions, implementation and investigations will be monitored monthly by the Performance Improvement Committee for compliance. 7. All audited findings from the DHS/Administrators documentation of occurrences and significant changes, CRC accuracy, and SNC review of the charts for interventions and implementation of interventions and investigation, education in general orientation will be reviewed in the monthly Performance Improvement committee meeting for patterns and trends and further interventions developed as necessary to ensure continued compliance. The credible allegation was verified 1/7/2012 at 7:00pm, as evidenced by staff interviews on preventing falls, reviewing Nurse Aide Care Guides, completing fall investigation reports and reviewing Fall Risk assessments. Review of in-service records for Performing Safe Transfers, Event Reporting (to include how the event occurred), and Developing Care Plans, Updated Fall Risk Assessments, and Updated Care Guides indicated participation by 48% of nursing, housekeeping, dietary and therapy staff. Residents were identified and re-screened by Therapy on 1/7/2012 to determine if they were at risk for falls due to balance while sitting. 69 Residents were identified as high risk and/or with trunk control issues. Their charts were reviewed for updated care guides, care plans, fall risk assessments as well as observation of interventions to be used to prevent falls. A revision dated 1/7/2012 was made to the Incident Fall Report to include an Incident Occurrence Investigation Summary that identifies what the resident was doing prior to the occurrence, statement from the resident of what occurred and statements from staff members with a synopsis of what led to the occurrence.

Based on family, EMT, staff interviews, and record review, the facility failed to assess change in condition timely and intervene for 1 of 1 (Resident #1) sampled residents experiencing hypothermia. The facility failed to ensure a functioning heating unit in the room of Resident #1 (room [ROOM NUMBER]). Immediate jeopardy began on [DATE]. The facility was notified of immediate jeopardy on [DATE] at 3:59 pm. Immediate jeopardy was removed at [DATE] at 4:50 pm when the facility provided a credible allegation of compliance. The facility remained out of compliance at scope/severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete staff training and implement monitoring. Findings include: Resident #1 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Resident #1 resided in room [ROOM NUMBER]. room [ROOM NUMBER] was a private room. His [DATE] admission minimum data set assessment indicated he had severe cognitive impairment. He was non-ambulatory and required extensive assistance with transfers and mobility. He used a wheelchair for locomotion in the facility. His [DATE] care plan for " poor safety awareness secondary to [DIAGNOSES REDACTED]. that may warrant increased supervision/assistance and notify the physician, resident uses a wheelchair for long distance mobility. " His [DATE] care plan for " potential for side effects and/or adverse reaction to [MEDICAL CONDITION] drug use secondary to [DIAGNOSES REDACTED]. " His temperature ranged from 96.9 and 97.4 on [DATE]. No temperature was documented for [DATE]. From [DATE] to [DATE] his daily temperature ranged from 96.4 to 98.1 degrees. Weather.com indicated [DATE] outdoor temperature high was 60 with a low of 46 with wind. On [DATE] the high temperature was 66 with a low of 42. On [DATE] the high temperature was 67 with a low of 44. On [DATE] at 4:49 pm, the Maintenance Director #1 stated the corridor temperatures were maintained at 73 degrees. The heat in individual rooms was individually controlled. MD #1 stated he did not routinely check the temperatures in individual resident rooms. During an interview, on [DATE] at 4:24 pm, Nurse #1 (evening nurse [DATE] and [DATE]) stated Resident #1 was blind and confused. Nurse #1 stated he would frequently attempt to stand from his wheelchair. She stated Resident #1 was kept at nursing station until ,[DATE] pm to provide close supervision. On [DATE] at 7:30 am, Nurse #2 (evening nurse for [DATE]) stated Resident #1 had dementia and was blind. Nurse #2 stated Resident #1 would be agitated and reach with his hand and attempt to get out of his wheelchair. He stated Resident #1 ' s speech was difficult to understand. During an interview, on [DATE] at 1:33 pm, a family member of Resident #1 stated room [ROOM NUMBER] felt cold when he visited on [DATE] in the afternoon. The family member stated the heating unit was not working and was unplugged. The family member stated concerns about the heating unit not working was reported to nursing staff on two occasions. On [DATE] at 4:17 pm, NA #1 (evening NA for [DATE]) stated Resident #1 would sit in his wheelchair with a seatbelt. Resident #1 would try to pick up things from the floor. She stated Resident #1 could not see and required assistance to get in bed. She stated Resident #1 was placed in bed at 10:00 pm. During an interview, on [DATE] at 8:09 am, Nurse #4 (night nurse for [DATE] and [DATE]) stated Resident #1 had attempted to pull heating unit off the wall in room [ROOM NUMBER]. She did not recall the date. Nurse #4 stated the heating unit was left off all the time she cared for him. Nurse #4 indicated she routinely cared for Resident #1. Resident #1 was at the nursing station on the night of [DATE] from 2 am until 4 am. Nurse #4 indicated Resident #1 was placed at nursing station so staff could observe him directly. On [DATE] at 8:30 am, NA #2 (night NA for [DATE] and [DATE]) stated Resident #1 did not sleep at night. Resident #1 would be restless and agitated. On [DATE] at 1:00 am she placed Resident #1 in his wheelchair by the nursing station. Resident #1 was wearing a tee shirt, pajama bottoms and a pair of non-skid socks. Resident #1 was placed back in bed at 3:30 am. NA#2 stated the heater was not plugged in. NA #1 stated Resident #1 had attempted to pull the cover off the heating unit. NA #1 did not know the specific date. NA #2 stated when Resident #1 did attempt to pull heating unit cover off, the unit was unplugged because if was a fire hazard. During an interview, on [DATE] at 12:17 pm, NA #3 (day NA for [DATE]) stated Resident #1 was restless and agitated at 6:30 am. NA #3 indicated Resident #1 would routinely have episodes of agitation. NA #3 stated she got the resident dressed and out of bed at 6:45 am. Resident was wearing sweat pants, tee shirt and flannel sweater. Resident was placed at the nursing station in his wheelchair. After breakfast he was sleepy and was placed back in bed. NA #3 stated she called Nurse #3 to the room because she could not get a BP on Resident #1. NA #3 thought that something was wrong with Resident #1 due to his sleepiness. NA #4 assisted in getting him back in bed. On [DATE] at 12:48 pm, NA #4 (day NA for [DATE]) stated she assisted NA #3 to get Resident #1 in bed. NA #4 stated she took his shoes off and found his feet were cold. He was placed on his bedspread and two blankets to cover him. During an interview, on [DATE] at 12:28 pm, Nurse #3 (day shift nurse on [DATE]) stated she responded to Resident #1 ' s room at 9:30 am. Resident #1 was lethargic and Nurse #3 stated she was unable to obtain a BP or pulse oximetry (device measures oxygen in the blood). Nurse #3 stated she was unable to obtain an oral or tympanic (ear) temperature. Nurse #3 stated she did not put any oxygen on Resident #1. Nurse #3 stated Resident #1 had ,[DATE] blankets on. Nurse #3 stated she did not put any more blankets on him. Nurse #3 stated she was assisted by Nurse #5 in assessing Resident #1. On [DATE] at 8:57 am, Nurse #5 (day shift nurse on [DATE]) stated she went to Resident #1 ' s room at 9:45 am with Nurse #3. Nurse #5 stated Resident #1 had socks on his feet which were dangling off the bed. Resident #1 had two blankets covering him. Nurse #5 stated his feet were cold to touch. Nurse #5 stated the heating unit was unplugged. Nurse #5 stated she plugged it in, put in heat mode but the unit kept blowing cold air. Nurse #5 stated she unplugged the unit. Nurse #5 stated Resident #1 had a HR of 44 but she was unable to obtain a BP. Nurse #5 stated she did not put any other blankets on Resident #1 until EMS arrived. During an interview, on [DATE] at 12:59 pm, Nurse #6 (day supervisor on [DATE]) stated she had been called to Resident #1 ' s room by Nurse #5. Nurse #6 stated Resident #1 was lethargic and cold. Nurse #6 stated she was able to obtain a BP of 70/palpable. Nurse #6 indicated the heating unit was not on or plugged in. Nurse #6 stated she did not place any more blankets on Resident #1. Nurse #6 stated she was not in the room when EMS arrived. A [DATE] at 9:45 am nursing note stated " The CNA asked us to check resident as he did not seem himself. We went into the resident ' s room, he was found on his back. Resident was responsive to stimuli. Myself and the other nurse began to assess resident. I noticed his feet were cold; the other nurse was at the head of the bed checking for pulses. We took resident vitals and began to stimulate him and stabilize him. Resident began to move to stimuli, touching chest and attempting to move our hands from his body as were palpating for pulses and taking blood pressures (BP). We received consent to send him to ER for further evaluation. " The recorded vitals were heart rate (HR) 44 and respiratory rate (RR) of 16. EMS record revealed they arrived on the scene at 10:30 am. EMS record indicated call to 911 was placed at 10:18 am. Resident #1 ' s BP was ,[DATE], HR was 88 weak and irregular and his rectal temperature was 85.1 degrees Fahrenheit. The EMS report stated " Facility staff person stated that she had come in to find the room cold and patient ' s heater unplugged. Facility staff stated that when they plugged it in the found it blowing cold air. Facility staff person stated that this was her first day and that she was not sure how long the heat in patient ' s room had been off. Room temperature noted to be approximately ,[DATE] degrees. " The report indicated that EMS staff instructed staff to get warm blankets and wrapped the patient in blankets and a comforter. On [DATE] at 11:00 am, EMT #1 stated EMS responded to facility for Resident #1 at 10:30 am. EMT #1 stated the room felt cold. She stated the heating unit was not on when they arrived. EMT #1 stated she was wearing a jacket and the room felt cold to her. She stated Resident #1 was hypotensive, confused and agitated. Resident #1 ' s skin was cold and dry. The rectal temperature was 85.1. EMT #1 stated staff was instructed to place warm blankets on Resident #1. The [DATE] ER records stated " staff found patient with cold air blowing from heating, unsure as to how long this had been a problem. Check patient ' s vital signs and found to be hypotensive 70/palpable and unable to obtain a temperature, found with cold skin. " The ER note indicated a rectal temp of 85.5 degrees with a BP of ,[DATE]. His skin was cold, dry and slightly pale. The [DATE] hospital discharge summary primary [DIAGNOSES REDACTED]. Secondary [DIAGNOSES REDACTED]. Resident #1 was discharged back to the facility under comfort care. Comfort measures were put in place during his hospitalization due to hypothermia. The clinical record indicated Resident #1 died in the facility on [DATE]. On [DATE] at 1:30 pm, the administrator stated on [DATE] staff notified her of the hospitalization of Resident #1. The administrator had MD#1 to check the heater in room [ROOM NUMBER]. The MD #1 found the unit unplugged and a black mark on the outlet cover. The Mode knob was not functioning properly. The heating unit was replaced on [DATE]. During an interview, on [DATE] at 8:43 am, Maintenance Director (MD) #1 stated on [DATE] (after the incident with Resident #1) he received a call that the heating unit in room [ROOM NUMBER] was not working. MD #1 stated no pieces of the unit were off. The unit was unplugged. When the unit was turned on the mode knob was stuck and had to be fixed. MD #1 stated on 2 other occasions he had to put the cover back on the unit. MD #1 could not recall the dates of these occurrences. On [DATE] at 1:30 pm, the Director of Nursing (DON) stated the heating unit in room [ROOM NUMBER] had been unplugged for safety reasons. The DON was unable to explain any measures put in place to keep Resident #1 warm when in his room. The DON was unable to explain how long the heating unit had been unplugged. The administrator was notified of Immediate Jeopardy on [DATE] at 3:59 pm. The facility provided a credible allegation of compliance on [DATE] at 4:50 pm. The allegation of compliance stated: After the notice of the immediate jeopardy the facility started in-servicing all staff, on [DATE], on hypothermia and on what to do when a heating unit is unplugged for any reason. The Clinical Competency Coordinator, began in-servicing all staff, on [DATE], on hypothermia including signs and symptoms of hypothermia which include cold extremities, confusion, lethargy, and shivering. Treatments for hypothermia to include remove person from environment, communicate with the resident if room is at desired temperature, apply blankets and cover head, warm fluids to drink, monitor vital signs, complete a skin assessment to assess extremities and call 911 if indicated. All staff will be in-serviced by [DATE]. Staff that has not had the hypothermia in-service will not be permitted to work until in-service is completed. The Clinical Competency Coordinator began in-servicing all staff, on [DATE], on what to do if they observe a resident tampering with the heating unit (i.e. removing the cover from the unit, playing with knobs, kicking at the units and/or unplugging the unit). If staff observed the behavior they are to remove the resident immediately and the following will be preformed: a behavior screen completed and screen forwarded to the Social Worker, the nursing supervisor notified for appropriate intervention, Maintenance Director will be notified if items need corrected with the unit. Behavioral screens will be reviewed by the Social Services Director for placement on the behavioral management program. In-service also included what to do if the unit needs to be unplugged (i.e. apply extra blankets to the bed, move resident to a different room, and notifying the Maintenance Director and the Administrator and/or Director of Health services). All staff will be in-serviced by [DATE]. Staff that has not had the heating units in-service will not be permitted to work until in-service is completed. In-servicing on what to do when a heating unit is unplugged will be added to our general orientation. The Social Services Director began conducting behavioral screens on [DATE], to identify behaviors that interfere with the functional capacity and maximum quality of life, on all residents to assess the potential behavior of tampering with the heating units. Any residents with identified behavior such as removing cover from heating unit, tampering with the knobs, or attempting to unplug the unit will be placed on the behavioral management program, and monitored weekly by the interdisciplinary team. Interventions, one on one activity, placing resident in common areas when behaviors are observed, check unit when resident is tampering with unit to ensure proper function, will be put in place for any identified behaviors and communicated to the direct care staff via Behavior Management Communication sheet that is placed in front of the CNA ADL care plan. Behavior screens will be completed on all residents by [DATE]. As a result of the behavioral screen, 2 out of 105 residents (these residents are in the same room) were identified at risk of tampering with the heating unit. These residents were placed on the behavioral management program, interventions were put in place, communication added to the ADL Care plans book and care plan was updated. These residents will be reviewed weekly by the interdisciplinary team. The Clinical Competency Coordinator, began in-servicing, on [DATE], nursing staff (licensed and unlicensed) on acute change of condition including indication and assessing change of condition, who to report change of condition to, and documentation of change of condition. All staff will be in-services by [DATE]. Staff that has not had the change in acute condition in-service will not be permitted to work until in-service is completed. The Social Services Director will review findings from the behavioral screens with the Administrator and/or Director of Health services in the daily interdisciplinary team meetings. The credible allegation was verified [DATE] at 5:00 pm, as evidenced by staff interviews on identifying hypothermia, interventions to treat hypothermia, change in condition, and documentation of change in condition and reporting of malfunctioning heating units. Staff interviews included identifying residents with potential for tampering with heating units and response to behavior. Review of behavioral screening sheet was completed on each resident. Two residents were identified and placed in behavioral management program. Review of in-service records for hypothermia and air/heating units indicated nursing and maintenance and housekeeping staff were inserviced on identifying risk of hypothermia, treatment of [REDACTED].

Based on family, EMS and staff interviews and record review, the facility failed to ensure 1 of 89 resident heating units was functioning properly (room 107) resulting in Resident #1 becoming hypothermic. Immediate jeopardy began on 10/22/11. The facility was notified of immediate jeopardy on 10/31/11 at 3:59 pm. Immediate jeopardy was removed at 11/2/11 at 4:50 pm when the facility provided a credible allegation of compliance. The facility remained out of compliance at scope/severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete staff training and implement monitoring. Findings are: During an interview, on 10/27/11 at 1:33 pm, a family member of Resident #1 stated room 107 felt cold when he visited on 10/21/11 in the afternoon. The family member stated the heating unit was not working and was unplugged. The family member stated concerns about the heating unit not working was reported to nursing staff on 2 occasions. On 10/27/11 at 4:49 pm, the Maintenance Director (MD)#1 stated the corridor temperatures were maintained at 73 degrees. The heat in individual rooms was individually controlled. MD #1 stated he did not routinely check the temperatures in individual resident rooms. He does not routinely check the heating units in the rooms. During an interview, on 10/28/11 at 8:09 am, Nurse #4 (night nurse for 10/20/11 and 10/21/11) stated Resident #1 had attempted to pull heating unit off the wall in room 107. She did not recall the date. Nurse #4 stated the heating unit was left off all the time she cared for him. On 10/28/11 at 8:30 am, NA #2 (night NA for 10/20/11 and 10/21/11) stated the heater was not plugged in room 107. NA #1 stated Resident #1 had attempted to pull the cover off the heating unit. NA #1 did not know the specific date. NA #2 stated when Resident #1 did attempt to pull heating unit cover off the heating unit. NA #1 did not know the specific date. NA #2 stated when Resident #1 did attempt to pull heating unit cover off, the unit was unplugged because if was a fire hazard. On 10/28/11 at 8:57 am, Nurse #5 (day shift nurse on 10/22/11) stated the heating unit was unplugged in room 107. Nurse #5 stated she plugged it in, put in heat mode but the unit kept blowing cold air. Nurse #5 stated she unplugged the unit. The EMS report stated " Facility staff person stated that she had come in to find the room cold and patient ' s heater unplugged. Facility staff stated that when they plugged it in the found it blowing cold air. Facility staff person stated that this was her first day and that she was not sure how long the heat in patient ' s room had been off. Room temperature noted to be approximately 40-50 degrees. " On 11/1/11 at 11:00 am, EMT #1 stated EMS responded to facility for Resident #1 at 10:30 am. EMT #1 stated the room felt cold. She stated the heating unit was not on when they arrived. EMT #1 stated she was wearing a jacket and the room felt cold to her. On 10/28/11 at 1:30 pm, the administrator stated on 10/22/11 staff notified her of the hospitalization of Resident #1. The administrator had MD#1 to check the heater in room 107. The MD #1 found the unit unplugged and a black mark on the outlet cover. The Mode knob was not functioning properly. The heating unit was replaced on 10/22/11. During an interview, on 10/28/11 at 8:43 am, Maintenance Director #1 stated on 10/22/11 (after the incident with Resident #1) he received a call that the heating unit in room 107 was not working. MD #1 stated no pieces of the unit were off. The unit was unplugged. When the unit was turned on the mode knob was stuck and had to be fixed. MD #1 stated on 2 other occasions he had to put the cover back on the unit. MD #1 could not recall the dates of these occurrences. The administrator was notified of Immediate Jeopardy on 10/31/11 at 3:59 pm. The facility provided a credible allegation of compliance on 11/2/11 at 4:50 pm. The allegation of compliance stated: When the facility was notified by EMS, on 10/22/11, that the resident, residing in room 107, was hypothermic the Maintenance Director conducted a 100% audit of the 89 heating units to ensure proper functioning. In-servicing by the Maintenance Director on reporting units not working and use of maintenance work orders and maintenance log began for all staff. Completing the work orders and maintenance logs is currently part of general orientation. On October 22, 2011 Maintenance Director completed a 100% audit of the 89 heating units in the building. The results revealed the following: room 107 not working (was changed out), room 110 had a loose control knob, room 118 the covering over the control knobs was removed and laying on top of the unit, room 211 not working (unit is not open at current time), room 307 old unit (noisy and needs cleaning), room 315 loose knob, room 612 needs cleaning, room 610 needs left side filter, room 608 loose lid to controls, room 604 loose knob, room 601 not blowing warm air(unit was fixed), and room 501 had different knob. The identified concerns have been corrected as of 11/2/11. After the notice of the immediate jeopardy the facility started a second audit of the 89 heating units on 10/31/11 and finished on 11/1/11 to ensure proper functioning of the unit. Results are as follows: room 115 control knobs were not working and unit was changed out immediately. Monitoring of the 89 heating units will be completed daily times four weeks, weekly times four weeks and then monthly there after. Monitoring of units to include proper functioning, to include proper functioning of the switches, the unit distributes warm and cool air, the filters are clean, and that the units are plugged into the outlets. Audit will be conducted by Maintenance Director and/or week-end supervisor. Any issues identified will be corrected immediately including the temperature of room at the time of discovery and temperature after the issues is corrected. Results from the monitoring will be reviewed with the Administrator and /or Director of Health Services. Monitoring of the maintenance logs accuracy will be verified during preventive maintenance completed by Maintenance Director per policy. Identified areas will be corrected immediately and the Administrator and/or Director of Health Services will be notified of any inaccuracies between the identified items and the maintenance logs. The credible allegation was verified 11/2/11 at 5:00 pm, as evidenced by staff interviews identifying how to report and respond to heating/air unit malfunction. Review of in-service records for air/heating units indicated nursing and maintenance and housekeeping staff were inserviced on what to do if heating unit needs to be unplugged and reporting maintenance concerns for heating/air units. Review of maintenance audit indicated all heating units were functioning. The unit in 115 had been replaced due to nonfunctioning control knob.