Every finding on record at PruittHealth-Neuse

Based on staff, and Nurse Practitioner interviews, the facility failed to provide care in a safe manner when the resident fell from the bed during incontinence care, reported left hip pain at a level of 10 out of 10 on a scale with 0 being no pain and 10 being the worst pain ever. The resident required evaluation at the emergency department where she was diagnosed with a closed left hip fracture (the upper part of the left thigh bone was broken, but the bone did not break through the skin). This deficient practice affected 1 of 3 residents (Resident #1) reviewed for accidents.Findings included: Resident #1 was admitted to the facility on [DATE]. His active diagnoses included sequelae of cerebral infarction (long-term health effects, lasting physical problems, or permanent conditions that remain after a person has an ischemic stroke) resulting in right sided hemiplegia, dysphagia (difficulty or discomfort when swallowing), abnormal posture, and cognitive communication deficits. The resident also experienced generalized muscle weakness, chronic pain syndrome, essential hypertension, type 2 diabetes with associated chronic kidney disease and neuropathic arthropathy, Charcot's arthropathy (a serious joint disease when nerve damage causes a loss of feeling), anxiety disorder, vascular dementia with behavioral disturbances, and other muscle spasms. Review of Resident #1's Minimum Data Set assessment dated [DATE] revealed Resident #1 was assessed to be severely cognitively impaired. He had other behavioral symptoms not directed towards others daily. He required substantial/maximal assistance with roll left and right. He was dependent on staff for eating, oral hygiene, toileting hygiene, shower/bathe self, upper and lower body dressing, putting on/taking off footwear, personal hygiene, and chair/bed-to-chair transfer. He was assessed to be always incontinent of bowel and bladder. He indicated he had pain or hurting any time in the last 5 days of the lookback period of the assessment. He was unable to answer if the pain affected his sleep, describe the pain frequency, pain intensity, or if the pain interfered with day-to-day activities. The staff assessment for pain revealed he had vocal complaints of pain in the last 5 days of the assessment lookback period. Indicators of pain or possible pain were observed 3 to 4 days of the assessment lookback period. He had no falls since admission/entry or reentry or prior assessment. Review of Resident #1's care plan dated 9/26/25 revealed Resident #1 was care planned to be at risk for activities of daily living decline related to a recent hospitalization for weakness and newly diagnosed diabetes mellitus and hypertension. The interventions included to provide two person assistance for bed mobility. He was also care planned for chronic pain. The interventions included that staff monitored him for pain, completed pain observations on admission and as needed, administered pain medications as ordered, evaluated the effectiveness of those medications, provided comfort measures, and reported to the physician when he did not experience adequate relief. On 10/2/25 he was also care planned to be at risk for falls. The interventions included placing his call light within reach, assisting him with toileting and transfers as needed, cueing him for safety awareness, and maintaining a safe environment. Review of Resident #1's physician's orders revealed Resident #1 was not on any blood thinner medications. Review of a progress note dated 5/12/26 at 9:41 PM, written by Nurse #1, revealed Nurse #1 found Resident #1 lying on his right side on the floor after responding to a code green in his room. Nurse Aide #1 reported that when she approached the resident to change his clothing and brief, she saw him positioned at the very edge of the bed and, due to his weight, she slowly slid him to the floor onto a mat. Resident #1 appeared anxious and scared but denied pain, and staff observed no bruising. Staff returned him to bed using a lift with three person assistance. They obtained vital signs, which were blood pressure of 167/87, pulse 90, respirations 18, temperature 97.9, and SpO2 98% (an estimate of the percentage of oxygen in your blood). The Director of Nursing, physician, and responsible party were notified. During an interview on 8/4/26 at 11:58 AM Resident #1 elected to not be interviewed or discuss the fall. During an interview on 8/4/26 at 11:15 AM Nurse Aide #1, who was with Resident #1 and lowered him to the fall mat on 5/12/26, stated she entered Resident #1's room on 5/12/26 to provide patient care. Nurse Aide #1 added that this was her first time working with Resident #1. She stated she was changing Resident #1's brief and was speaking with Resident #1 during the care she was providing. The nurse aide confirmed she was the only staff member in the room. She turned him to his left side, towards herself and the door. Nurse Aide #1 was on the left side of Resident #1's bed as she turned Resident #1 towards herself, and she was standing between Resident #1's stomach and pelvic area at the left side of the bed. Once Nurse Aide #1 got the brief under Resident #1, she then turned him to his right side. As Nurse Aide #1 turned Resident #1 to his right side, Resident #1 continued rolling and fell off the right side of his bed onto the fall mat, which was on the floor on the right side of the bed. As soon as Nurse Aide #1 saw Resident #1 was going off the right side of his bed; she ran around the bed and managed to assist in lowering Resident #1 to the fall mat. Resident #1 was going down kind of fast, and his legs had already hit the fall mat before Nurse Aide #1 could get ahold of Resident #1's arms to assist his upper body down to the fall mat. Nurse Aide #1 indicated because Resident #1 had impairment to his extremities, he was unable to control his momentum, causing him to roll quickly. This resulted in him falling from the bed. Nurse Aide #2 was on the hall and when Nurse Aide #1 called for help, Nurse Aide #2 came into the room and Nurse Aide #1 requested Nurse Aide #2 get Nurse #1, the nurse on the hall. Nurse Aide #1 remained with Resident #1, and the resident was asking to please get up in bed and Nurse Aide #1 kept asking if Resident #1 was hurting and telling Resident #1 to wait for the nurse to come. Resident #1 denied any pain or discomfort and just kept reiterating he wanted to get back in bed. Nurse #1 came into the room and, after Nurse #1 assessed Resident #1, Resident #1 was assisted back to bed via a lift and three-person assistance of Nurse Aide #1, Nurse Aide #2, and Nurse #1. Nurse #1's assessment did not identify any injuries at that time as Resident #1 denied pain or discomfort to Nurse #1 and continued to deny pain for the duration of Nurse Aide #1's shift which ended around 11 PM that night. When she returned to work on 5/14/26, Nurse Aide #1 was informed Resident #1 had a hip fracture as a result of this fall and was out at the hospital. Nurse Aide #1 stated after the incident she received a written warning and was educated on how to find resident care needs on the care plan which tells the nurse aides how many staff members are needed to assist a resident for bed mobility. She stated Resident #1 was a two-person assist with bed mobility at the time of this fall on 5/12/26, but Nurse Aide #1 was not aware of that when she was providing the care that resulted in his fall. Nurse Aide #1 was aware that for transfers, Resident #1 needed to be transferred via a lift with the assistance of two staff members; however, Nurse Aide #1 had thought once in bed, Resident #1 was a one person assist for bed mobility but that was incorrect. Nurse Aide #1 learned this once she received the education that was immediately completed for all staff following this incident. During an interview on 8/4/26 at 12:19 PM Nurse Aide #2 stated she was assigned a different hall from Resident #1 on 5/12/26. Nurse Aide #2 had finished patient care on her hall and went to Nurse Aide #1's hall because she knew Nurse Aide #1 needed assistance with providing care. She found Nurse Aide #1 in Resident #1's room and Resident #1 was already on his fall mat which was positioned on the floor to the right side of Resident #1's bed. She stated Nurse Aide #1 had been assisting Resident #1 with changing his brief. Nurse Aide #1 told Nurse Aide #2 to go get Nurse #1, the nurse on the hall, for assistance. Nurse Aide #2 got Nurse #1, and after the nurse assessed Resident #1, Nurse #1, Nurse Aide #1, and Nurse Aide #2 assisted Resident #1 back to bed via a lift. Resident #1 appeared shaken but calmed once he was in his bed. He indicated he was not in any pain or discomfort when staff asked him at that time. Nurse Aide #2 then returned to her hall to complete another round on her residents. She was off the next day, but when Nurse Aide #2 returned to work two days after the incident, there was an in-service for all staff teaching staff how to find how many staff were needed to assist a resident on the care plan. Nurse Aide #2 had to be educated prior to going to work. Nurse Aide #2 also found out later that day Resident #1 had sustained a hip fracture due to the fall on 5/12/26. She stated she had Resident #1 on multiple shifts and was aware he was a two-person assist but Nurse Aide #1 had not worked with him before and was not aware of this. She stated she did not know Nurse Aide #1 was providing care to Resident #1 alone or Nurse Aide #2 would have intervened. Nurse Aide #2 had cared for Resident #1 for about three weeks prior to the incident and had known at that time that he required two-person assist with bed mobility. Nurse #1, who responded to the fall, was out of the country and unavailable for interview. Review of Resident #1's Medication Administration Record for May 2026 revealed on 5/12/26 his nighttime pain evaluation was completed by Nurse #1. Resident #1 reported pain level of 0 out of 10 on a scale with 0 being no pain and 10 being the worst pain ever. Nurse #1, who completed Resident #1's nighttime pain evaluation on 5/12/26, was out of the country and unavailable for interview. During an interview on 8/4/26 at 3:01 PM Nurse Aide #3 stated she cared for Resident #1 on 5/13/26 from 7 AM to 3 PM. Resident #1 reported generalized pain to Nurse Aide #3 during morning care on 5/13/26 but it was difficult to assess as Resident #1 would not give a number and spoke generally and then would say he forgot and wanted to finish his morning care. After she completed Resident #1's care, she then reported his pain to Nurse Practitioner #1 who was on the hall to evaluate Resident #1 due to his fall. Nurse Practitioner #1 went to evaluate Resident #1 sometime before 10 AM. Nurse Aide #3 did not know what Nurse Practitioner #1 did but believed the nurse on the hall (whom she could not remember) gave Resident #1 pain medication because Resident #1 did not have any further complaints of pain for the rest of Nurse Aide #3's shift. Review of Nurse Practitioner #1's progress note dated 5/13/26 documented that Resident #1 was evaluated after a witnessed fall from bed. Initially, Resident #1 did not report pain, but by the following day Resident #1 complained of left leg pain, prompting nursing to administer as needed pain medication and obtain bilateral hip and femur X rays. Resident #1 demonstrated generalized extremity weakness, leg contractures, anxiety, and limited ability to provide history. Physical exam showed left leg pain, bilateral contractures, stable vital signs, and no respiratory or neurological changes aside from baseline deficits. The plan included monitoring his pain, medicating as needed, keeping the bed in a low position with a fall mat, reviewing pending X ray results, and sending him to the hospital if a fracture was identified. During an interview on 8/4/26 at 2:34 PM Nurse Practitioner #1 stated she was familiar with Resident #1. She further stated with Resident #1's frailty, broken bones, fractures, dislocations, bruising and hematomas, and even head contusion and concussion could be a result from falling. She stated Resident #1 was not on any blood thinners. Nurse Practitioner #1 stated she saw Resident #1 on 5/13/26 and requested an X-Ray of both hips and femurs. This was some time around 10 AM after being told he sustained a fall and a nurse or nurse aide informed her Resident #1 reported discomfort during care that morning but had denied pain immediately following the fall. The pain was reported to start the morning of 5/13/26 during morning care. Nurse Practitioner #1 did not recall Resident #1 indicating he was in any pain during her assessment of Resident #1. Upon observing Resident #1's hips, the rotation of his left leg made her concerned about a possible hip fracture. Nurse Practitioner #1 asked Unit Manager #1 to order bilateral femur and hip x-rays because of Nurse Practitioner #1's assessment of his hip, as well as the staff report of complaints of pain from Resident #1 that morning after the fall. Review of Resident #1's Medication Administration Record for May 2026 revealed on 5/13/26 at 11:56 AM Unit Manager #1 administered 1 tablet of 5-325 milligram hydrocodone-acetaminophen to Resident #1 due to a reported pain level of 9 out of 10 on a scale with 0 being no pain and 10 being the worst pain ever. During an interview on 8/4/26 at 2:52 PM Unit Manager #1 stated she was the day nurse for Resident #1 on 5/13/26 that morning because Nurse #3 had a dentist appointment and was coming to the facility late on 5/13/26. Unit Manager #1 stated Resident #1 did not verbalize pain to her when she asked if Resident #1 was in pain at around 11:40 AM; however, Nurse Practitioner #1 had asked her to order right and left hip and femur x-rays about an hour before she had been in Resident #1's room to complete a pain assessment. Due to this request, Unit Manager #1 palpated Resident #1's left hip and asked if he felt any tenderness or pain and Resident #1 said yes. Resident #1 rated the pain as a 9 out of 10 on a scale with 0 being no pain and 10 being the worst pain ever. Unit Manager #1 gave Resident #1 one as needed 5-325 milligram hydrocodone-acetaminophen tablet for the pain, and it was effective. Unit Manager #1 stated Resident #1 did not have further complaints of pain during the rest of her caring for the resident until Nurse #3, who she was covering for, came to the facility and took over the cart. Review of Resident #1's Medication Administration Record for May 2026 revealed on 5/13/26 his daytime pain evaluation was completed by Nurse #3. Resident #1 reported pain level of 0 out of 10 on a scale with 0 being no pain and 10 being the worst pain ever. During an interview on 8/4/26 at 3:09 PM Nurse #3 stated she had a dentist appointment on 5/13/26 and came to work late which was why Unit Manager #1 was on her cart for part of her shift. Nurse #3 stated she did not recall Resident #1 indicating any pain during that shift once Nurse #3 took over the medication cart after her dentist appointment. Review of the radiology report for Resident #1 dated 5/13/26 and received by the facility at 10:55 PM revealed no acute bony abnormality of the right hip and an acute transcervical fracture of the left femur (a sharp, sudden break across the middle portion of the left thigh bone's neck, right below the ball of the hip joint). Review of Resident #1's Medication Administration Record for May 2026 revealed on 5/13/26 his evening pain evaluation was completed by Nurse #2. Resident #1 reported pain level of 0 out of 10 on a scale with 0 being no pain and 10 being the worst pain ever. Review of Resident #1's Skilled Nursing Facility/Nursing Facility to Hospital Transfer Form completed by Nurse #2 dated 5/13/26 revealed Resident #1 was transferred to the hospital due to an acute transcervical fracture of the left femur (a sharp, sudden break across the middle portion of the left thigh bone's neck, right below the ball of the hip joint). This form also indicated Nurse #2 assessed Resident #1 for pain which Resident #1 reported as a 10 out of 10 on a scale with 0 being no pain and 10 being the worst pain ever. Nurse #2 administered one 5-325 milligram hydrocodone-acetaminophen tablet on 5/13/26 at 10:06 PM. Review of a progress note dated 5/13/26 11:58 PM by Nurse #2, recorded as late entry on 5/14/26 12:19 AM, showed that Nurse #2 documented Resident #1 received X rays of both hips and femurs on 5/13/26. The results indicated no acute bony abnormality of the right hip and an acute transcervical fracture of the left femur (a sharp, sudden break across the middle portion of the left thigh bone's neck, right below the ball of the hip joint). Nurse #2 notified the on call provider, who ordered the resident sent to the emergency department for evaluation. Nurse #2 also notified the resident's responsible party and the Director of Nursing. Staff prepared and sent the required paperwork, including the Notice of Involuntary Transfer or Discharge, Continuity of Care Document, Face Sheet, Bed Hold Policy, and SBAR (Situation, Background, Assessment, and Recommendation). Emergency medical services were called, and they transported Resident #1 at 11:56 PM. During an interview on 8/4/26 at 1:52 PM Nurse #2, who sent out resident to the emergency department, stated she could not really recall transferring Resident #1 to the emergency department. Nurse #2 stated she completed a pain assessment on Resident #1 during her first medication pass on 5/13/26 between 5:30 PM and 6:00 PM and Resident #1 denied pain. Nurse #2 did recall Resident #1 having pain, but Resident #1 would yell out from his room often including on 5/13/26. When Nurse #2 responded to Resident #1's yelling, Resident #1 would not remember why he was yelling out and would then deny pain. Nurse #2 would ask what Resident #1 needed and Resident #1 would ask Nurse #2 why she was asking in response. Nurse #2 would inform Resident #1 that she heard Resident #1 yelling but Resident #1 would then state he was not yelling. This made it very difficult to assess Resident #1's pain levels. Nurse #2 stated she did think she remembered that on 5/13/26, when she sent Resident #1 to the emergency department, Resident #1 was able to voice a complaint of pain to his left leg. Nurse #2 stated Resident #1 reported his pain was a 10 out of 10 and it was about 30 minutes before she got the x-ray results and called for the emergency medical services to take him to the hospital. Nurse #2 stated this second pain assessment was completed on Resident #1 during her second medication pass. This second pain assessment was completed around 10 PM when Resident #1 reported his pain. No nurse aides reported to her that he had any pain. Review of the hospital Discharge summary dated [DATE] revealed the hospital admitted Resident #1 from a skilled nursing facility after a fall that resulted in an acute transcervical fracture of the left femur, and the facility had already obtained an x ray confirming the injury. Orthopedic surgery assessed Resident #1's fracture and performed cannulated screw fixation (a surgical method used to mend broken bones using hollow metal screws guided into place by thin wires) on 5/15/26 after discussions with Resident #1, Power of Attorney, and daughter. Resident #1 tolerated the procedure well and returned to his baseline functional status. The care team monitored his vitals, reviewed imaging and labs, and documented no complications. They discharged Resident #1 on 5/17/26 back to the skilled nursing facility. During an interview on 8/4/26 at 3:52 PM the Director of Nursing stated she received a call on 5/12/26 in the evening and was told that a nurse aide was providing care to a resident and the resident slid from the bed. No injuries and no complaints of pain were reported at that time. The next day the Director of Nursing came to work and went to assess Resident #1. Resident #1 denied pain at that time but did have some edema to his left hip. She thought this was around 10 AM or 10:30 AM on 5/13/26 but was not sure of the time. Nurse Practitioner #1 was in the facility that morning and a staff member, she was unsure who, had informed Nurse Practitioner #1 that Resident #1 had complained of pain during morning care on 5/13/26. Later that evening, after the Director of Nursing had gone home, the Director of Nursing received a call that the x-ray had come back, and Resident #1 was being sent to the Emergency Department for a hip fracture. Before Nurse Aide #1 could return to work on 5/14/26 which was the next day Nurse Aide #1 worked, Nurse Aide #1 had counseling and 1 on 1 education about finding bed mobility assistance needs for residents on the care plan and following the care plan. The Director of Nursing stated on 5/13/26 she started her investigation of the fall and completed a root cause analysis. The Director of Nursing summarized that the root cause analysis identified Nurse Aide #1 had not followed the care plan and provided incontinent care to Resident #1 by herself instead of with two staff members as the care plan indicated which resulted in the fall. The Director of Nursing initiated staff in-services about how to find staff assistance needs on the care plan with all nurses and nurse aids and the importance of following the care plan. The Director of Nursing confirmed she did not complete a 100% audit or question residents, family, or staff to identify residents who could have been affected by this deficient practice. She stated she did initiate monitoring of staff 7 times per week for a month and then five times per week for the next 4 weeks, and finally 3 times per week for the next 4 weeks. The Director of Nursing monitored staff performing care to ensure the correct number of staff were performing bed mobility according to the care plan. The Director of Nursing would also ask the staff to demonstrate how to find the resident profile in their electronic records system so staff could identify how many staff were required for bed mobility for each resident. The Director of Nursing as well as the unit managers were responsible for completing the monitoring. The Director of Nursing concluded there were no concerns identified during this monitoring. During an interview on 8/4/26 at 4:12 PM The Administrator stated she came to work at the facility in July 2026 and was not working for the facility when the fall and investigation occurred. The Administrator was not very familiar with the specific situation, but the Director of Nursing had mentioned the facility had been addressing a concern about a nurse aide not following the plan of care resulting in a fall where a resident was lowered to the floor. The Administrator concluded Nurse Aide #1 should have checked the plan of care and not provided incontinent care to Resident #1 alone. The facility presented a corrective action plan that was not accepted due to not addressing how the facility would identify other residents having the potential to be affected by the same deficient practice.

Based on observation, record review, and staff and resident interviews, the facility failed to provide a prescribed assistive device, a spouted cup with handle, for 1 of 1 resident reviewed for assistive devices (Resident #65). Findings included: Resident #65 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis on one side) and hemiparesis (weakness on one side) following a nontraumatic intracranial (brain) hemorrhage affecting arm and leg of left side. A review of Resident #65's physician orders revealed an order dated 7/31/25 for the Resident to have a spouted cup with handle with all meals.Review of Resident #65's care plan last reviewed 9/25/25 revealed a problem of the Resident being at nutrition/hydration risk. The goal was for Resident #65 to remain adequately hydrated through the next review. Approaches included providing adaptive equipment with meal trays as ordered: spouted cup with handle. Review of Resident #65's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was moderately cognitively impaired, had impairment to one upper and one lower extremity and was independent with eating after the meal tray was set up. On 12/15/25 at 11:28 AM, Resident #65 was observed lying in her bed, her breakfast tray was still on the overbed table next to her. The diet slip on her breakfast tray indicated she should have a spouted cup with handle. Instead, her tray contained regular cups with lids and straws. She appeared not to have drunk any of the beverages on her tray. During an interview and observation on 12/15/25 at 12:42 PM, Nurse Aide (NA) #4 carried the lunch tray into Resident #65's room. NA #4 placed the lunch tray on the overbed table, removed the plate lid and began to walk away. When interviewed at the bedside, NA #4 was asked if she checked the diet slip to assure the lunch tray was correct. NA #4 stated she had not, explaining, they didn't really say anything. NA #4 was then asked to look at Resident #65's diet slip. She looked at it but did not notice that it indicated Resident #65 was supposed to have a spouted cup with handle. When asked if Resident #65 was supposed to have a spouted cup with handle, she said no. Then NA #4 looked again and said yes. When asked what was on the tray, NA #4 stated a regular cup. When asked what she did when a resident's tray did not match the diet slip, NA #4 stated she just leaves it and hopes for the best. NA #4 indicated she was trained on passing meal trays upon hire. In an interview with Resident #65 on 12/16/25 at 8:15 AM she indicated she sometimes spilled her drinks when they were in a regular cup with a lid and a straw and that it was easier for her to drink from the spouted cup with a handle. In an interview with the Director of Nursing (DON) on 12/16/25 at 2:03 PM she stated staff who were passing meal trays to residents were responsible for checking the diet slip against what was on the resident's tray to assure accuracy. The DON indicated that if the meal tray was incorrect, staff were to take the tray to the Dietary Manager to have it corrected. In an interview with the Dietary Manager on 12/16/25 at 3:01 PM, she stated that two dietary aides and the cook observed and checked trays before placing them on the meal cart, so she did not know why Resident #65 was served breakfast and lunch on 12/15/25 without spouted cups with handles. The Dietary Manager further stated she had many spouted cups with handles in the kitchen, so it was not a matter of low stock on those items. An interview was conducted on 12/18/25 at 9:08 AM with the Administrator. She stated NAs were trained to check a resident's diet slip against the meal tray before serving it to the resident as they were the last to see the tray before it was served.

Based on observation, record reviews, and interviews with the resident, staff, Medical Director and North Carolina Poison Control, the facility failed to ensure the environment was free of hazards when Resident #85 was observed with multipurpose cleaner on her bedside table. This occurred for 1 of 2 residents reviewed for supervision to prevent accidents (Resident #85).The findings included:Resident #85 was admitted to the facility on [DATE]. Her diagnoses included diabetes, depression, and chronic kidney disease.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #85 was moderately cognitively impaired. She used a wheelchair for mobility and needed assistance with all Activities of Daily Living (ADL). An observation on 12/15/25 at 12:10 PM revealed a 40-ounce bottle of multipurpose cleaner, approximately half full, on Resident #85's bedside table.The warning label on the bottle of multipurpose cleaner stated that it could cause moderate to serious eye irritation, skin irritation, and respiratory tract infection from vapors. It warned users to avoid eye and skin contact, wear gloves and eye protection, and wash their hands thoroughly after use. Key warnings also stated that eye contact caused moderate to serious irritation; skin contact caused irritation and required washing thoroughly with soap and water after use; inhaling vapor or mist irritated the nose, throat, and lungs; and ingesting the cleaner caused stomach distress, nausea, and vomiting.An interview with Resident #85 was conducted on 12/15/25 at 12:15 PM. She stated she used the multipurpose cleaner to clean spills in her room and ordered it from a local retailer who delivered it to her room at the facility.An interview with Nurse Aide #2 was held on 12/15/25 at 12:30 PM. She stated she was not aware Resident #85 had a bottle of multipurpose cleaner and added the resident should not have had the cleaner in her room as it could have caused harm to this resident or any resident if it was consumed or splatter got in the eye. An interview with Nurse #1 was held on 12/15/25 at 12:35 PM. She stated she did not recall seeing the multipurpose cleaner in Resident #85's room. She also stated if the aides, housekeepers, or nurses saw it, they should have removed it immediately.An interview with a representative from the North Carolina Poison Control Center was held on 12/17/25 at 11:45 AM. She stated ingestion of the multipurpose cleaner could have caused side effects depending on the amount consumed. She added that if the cleaner contacted the eyes, it would cause irritation, and the eyes would need irrigation and further evaluation based on exposure. An interview was held with the Medical Director on 12/16/25 at 11:30 AM. She stated she had no concerns about the resident's exposure to the cleaner because she did not believe the resident would ingest it. She added that if ingestion occurred, she would call poison control for treatment instructions. An interview with the Director of Nursing (DON) was held on 12/15/25 at 12:32 PM. She stated the resident should not have had the multipurpose cleaner at the bedside because it could have been harmful to any resident if ingested or splatter got in the eyes. She added Resident #85 ordered several items to be delivered to her room. The DON indicated Resident #85's roommate was non-ambulatory, did not self-propel in a wheelchair and was severely cognitively impaired.An interview with the Administrator was held on 12/16/25 at 11:20 AM. She stated Resident #85 had a history of ordering items to be delivered to her room. She added she was not aware Resident #85 had multipurpose cleaner on her bedside table and expected any staff member who saw it to remove it immediately as it could cause harm to a resident if ingested or if there was exposure to the eyes of a resident. She indicated that if staff observed the multipurpose cleaner in a room, they should remove it and report finding the multipurpose cleaner to the DON and Administrator.

Based on record review, staff, and the Responsible Party (RP) interviews, the facility failed to provide copies of a resident's medical records to the resident's RP within 2 working days after a request for 1 of 1 resident reviewed for medical record access (Resident #6). Findings include: Resident #6 was admitted to the facility on [DATE]. Review of Resident #6's admission record completed on [DATE] revealed a family member was listed as her RP and Power of Attorney. A review of nursing notes dated [DATE] revealed Resident #6 expired on this date. A review of a letter dated [DATE] written by Resident #6's RP and sent to the facility revealed a request for Resident #6 medical records. In a telephone interview with the RP on [DATE] at 10:37 a.m. she revealed she began requesting Resident #6's medical records from the facility's Medical Records Director a couple of months before [DATE]. She stated the Medical Records Director kept promising her that she would provide the records but did not. The RP stated she decided to engage legal help and signed a consent requesting for the records on [DATE]. An interview was conducted with the Medical Records Director on [DATE] at 1:57 p.m. She stated she did receive a letter with signed consent from Resident #6's RP via fax requesting a copy of all medical records on [DATE]. The Medical Records Director further stated that she mailed out the records on [DATE]. She revealed it was her understanding that since Resident #6 was no longer at the facility she had 90 days within which to provide the records and stated there was no delay releasing the records. During a telephone interview with the prior Administrator on [DATE] at 1:48 p.m. he stated that he did not remember why there was a delay in releasing requested medical records for Resident #6. He stated it was the responsibility of the Medical Records Director to oversee any records request. An interview was conducted with the Senior Nurse Consultant on [DATE] at 8:10 a.m. who stated that it was a problem if a medical records request was not fulfilled in 2 working days after a request was received at the facility. In a telephone interview with the current Administrator on [DATE] at 9:15 a.m. she stated it was the responsibility of the Medical Records Director to process requests. She further stated that she was not aware there were delays with requested medical records for Resident #6.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of smoking for 1 of 3 residents reviewed for MDS accuracy. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses including bipolar with manic delusions. The annual Minimum Data Set (MDS) dated [DATE] had Resident #1 coded as cognitively intact and did not use tobacco. The care plan dated 01/21/2025 had focus of Resident #1 not needing supervision with smoking and will propel self out of facility to smoking area. A review of the observation detail list dated 01/21/2025 revealed Resident #1 was observed to be a safe individual smoker that reviewed and understood the smoking policy. An interview with the Case Mix Coordinator was conducted on 04/25/2025 at 9:40 AM. She stated another nurse from the corporate office completed the MDS assessment for Resident #1 when she was out of work. Resident #1 does smoke, and it should have been coded yes for tobacco use. It must have been an oversite. An interview with Director of Nursing (DON) was conducted on 04/25/2025 at 11:47 AM. She stated Resident #1 was a smoker and it should have been coded as her being a tobacco user. The DON also stated they will have someone else review assessments before transmission. An interview with the Administrator was conducted on 04/25/2025 at 12:07 PM. The Administrator stated Resident #1 was a smoker. She also stated that she expected the MDS nurses to code the assessments correctly.

Based on record review and staff interviews, the facility failed to ensure Resident #1 did not smoke inside of the facility in accordance with their smoking policy for 1 of 3 residents sampled for accidents. On 4/13/2025 the resident was observed by staff in the lobby area of the facility lighting and beginning to smoke a cigarette. There were no residents with oxygen in the lobby area and Resident #1 was escorted outside by Nurse #2. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnosis including bipolar with manic delusions. A review of the smoking policy revised 12/12/2024 indicated that no one should be allowed to smoke inside any area of the healthcare center at any time. The care plan dated 1/21/2025 included a focus of Resident #1 not needing supervision with smoking and indicated she could self-propel out of facility to the smoking area. The interventions included that Resident #1 was able to keep her smoking materials in her room in a lock box. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was cognitively intact and had no behaviors or rejection of care. She was able to transfer herself independently and wheeled self independently in her manual wheelchair. The resident received antipsychotic, antidepressant and antianxiety medication. A review of the observation detail list completed by Nurse #1 dated 1/21/2025 revealed Resident #1 was observed to be a safe smoker who reviewed and understood the smoking policy. An interview with Nurse #1 was conducted on 4/24/2025 at 3:37 PM. The Nurse stated Resident #1 was observed to be a safe and independent smoker on 1/21/2025. Nurse #1 also stated Resident #1 read, understood, and agreed to the smoking policy. A telephone interview with Receptionist was conducted on 4/25/2025 at 9:36 AM. The Receptionist stated she worked evenings and weekends. On Sunday 04/13/2025 she observed Resident #1 light and smoke a cigarette in front of the lobby door. The Resident was not near any other residents with oxygen at the time and Resident #1 was asked by Nurse #2 to go outside and smoke because there was no smoking in the facility. Resident #1 stated that this was her home, and she could smoke where she wanted. Nurse #2 helped escort Resident #1 outside to finish smoking. Nurse #2 asked for Resident #1's smoking materials when she came back in the facility and the resident became combative with the nurse and the police were called. The Receptionist also stated that was the first time she ever witnessed the resident smoking in the building. The Receptionist further stated she had always observed Resident #1 carry her own cigarettes and lighter. An interview with Nurse #2 was conducted on 4/25/2025 at 1:10 PM. The Nurse stated she was familiar with Resident #1. She verified she witnessed Resident #1 smoking in the lobby on 4/13/2025, she told Resident #1 she could not smoke in the building, and she helped the resident go outside. She indicated there were no other residents around the lobby area with oxygen tanks. When Resident #1 came back in the facility after smoking, she (Nurse #2) asked for her lighter and cigarettes. Resident #1 refused to give them to her and the resident hit the nurse in the chest area when she was bent over looking for Resident #1's smoking materials. The police were called, and they could not get the materials from the Resident. Resident #1 was sent to the emergency room for evaluation due to escalating behaviors and was returned back to the facility and was put on one to one (1:1) supervision. Nurse #2 also stated prior to this 04/13/2025 incident, she had never seen Resident #1 smoke in the building. Resident #1 was out of the facility during the survey and could not be interviewed or observed. An interview with the Director of Nursing (DON) was conducted on 4/25/2025 at 1:49 PM. The DON stated residents were not allowed to smoke in the facility at any time. The current smoking policy was to have the residents give their smoking materials to the nurse, but residents who were grandfathered in from the old administration were allowed to keep their smoking materials in a lock box in their rooms. Those residents were care planned and assessed for safe smoking. She indicated that prior to this 04/13/2025 incident, Resident #1 had been allowed to retain her own smoking materials in her lockbox. The DON stated since this incident those privileges were rescinded for all residents who had been grandfathered in to prevent this from happening again. An interview with the Administrator was conducted on 4/25/2025 at 2:09 PM. The Administrator stated the Receptionist called her on 4/13/2025 and reported that Resident #1 was smoking in the lobby. She told them to call 911, try to get the lighter, and to get her out of the facility. There were no reports of residents in the lobby with oxygen. Nurse #2 was able to get Resident #1 out of the facility to smoke. The Administrator also stated there were no reports of Resident #1 smoking in the facility before 4/13/2025 but since she broke the smoking policy, she would not be able to keep her own smoking materials. The facility provided a corrective action plan that was not acceptable by the state agency. When addressing how corrective action will be accomplished for other residents found to have been affected by the deficient practice not all smokers were included. Also, the plan did not include who was responsible for the monitoring/audits, specific information regardng what or who they were monitoring, and the frequency and duration of monitoring and audits. Audits and monitoring must be specific to the deficient practice to determine if education and system changes put into place are effective.

Based on record review, and staff and Responsible Party (RP) interviews, the facility failed to notify the RP of a change in condition when the fingerstick blood sugar (FSBS) levels exceeded 500 milligrams per deciliter (a normal blood glucose level is 80-130 milligrams per deciliter) for 1 of 3 residents reviewed for notification of change (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included diabetes, dementia, and femur fracture. The admission nursing note dated 9/27/24 at 5:52 pm revealed Resident #1 was alert with noted confusion. Resident #1 had a physician order dated 9/27/24 for insulin lispro (fast-acting insulin) per sliding scale with the following instructions: If Blood Sugar is less than 70, call MD. If Blood Sugar is 141 to 180, give 2 Units. If Blood Sugar is 181 to 220, give 2 Units. If Blood Sugar is 221 to 260, give 2 Units. If Blood Sugar is 261 to 300, give 4 Units. If Blood Sugar is 301 to 350, give 4 Units. If Blood Sugar is 351 to 400, give 6 Units. If Blood Sugar is greater than 400, give 6 Units. If Blood Sugar is greater than 400, call MD. The FSBS (fingerstick blood sugar) was to be checked at 6:30 am, 11:30 am, 4:30 pm, and 9:00 pm every day. The Medication Administration Record (MAR) for 10/01/24 revealed Resident #1's FSBS was 565 mg/dL at 9:00 pm as noted by Nurse #3. The nursing progress note dated 10/02/24 at 3:01 am by Nurse #3 revealed Resident #1's initial HS (hour of sleep or at bedtime) FSBS was 546 milligrams per deciliter (mg/dL). The on-call provider was notified, and Nurse #3 was instructed to administer an additional 3 units of insulin lispro along with the ordered dose of 6 units of insulin lispro. The progress note further noted that Resident #1's FSBS was rechecked in 2 hours and the FSBS was 428 mg/dL. The on-call provider was once again notified and gave instructions to administer an additional 6 units of insulin lispro and recheck Resident #1's FSBS in two hours. Resident #1's FSBS was noted to be 298 mg/dL after the additional insulin lispro dose was administered. Nurse #3 further noted Resident #1 was asymptomatic. The MAR for 10/02/24 revealed Resident #1's FSBS at 9:00 pm was noted by Nurse #3 to be 519 mg/dL. The nursing progress note dated 10/03/24 at 2:20 am by Nurse #3 revealed Resident #1's FSBS at HS was 519 mg/dL. Nurse #3 administered the ordered rapid-acting insulin and notified the on-call provider. The on-call provider instructed Nurse #3 to administer an additional 8 units of rapid-acting insulin and recheck Resident #1's FSBS 2 hours after. Nurse #3 noted that Resident #1's FSBS after the additional 8 units of rapid-acting insulin was 364 mg/dL. Nurse #3 further noted Resident #1 was asymptomatic. The MAR for 10/03/24 revealed Resident #1's 9:00 pm FSBS was 515 mg/dL as recorded by Nurse #3. The nursing progress note dated 10/04/24 at 8:35 am by Nurse #3 revealed Resident #1's FSBS at HS was 515 mg/dL. Nurse #3 noted the on-call provider was notified and instructed Nurse #3 to administer an additional 8 units of insulin lispro and recheck Resident #1's FSBS in 2 hours. Nurse #3 further noted Resident #1's FSBS was rechecked and was 389 mg/dL and Resident #1 was asymptomatic. Review of the nursing progress notes from 10/01/24 through 10/04/24 revealed no documentation that Resident #1's RP was notified of the elevated blood glucose levels at 9:00 pm on 10/01/24, 10/02/24, or 10/03/24. A telephone interview was conducted with Resident #1's Responsible Party (RP) on 11/19/24 at 10:26 am who revealed she was not notified of Resident #1's elevated blood glucose levels on 10/01/24, 10/02/24, and 10/03/24. The RP stated she was notified by Nurse #3 on the morning of 10/05/24, when Resident #1 was transferred to the hospital unresponsive, that Resident #1 had experienced elevated blood glucose levels on several nights throughout the week. She stated she was not aware of how high Resident #1's blood glucose levels were during the week until she was at the hospital. The RP stated that had she been made aware of Resident #1's high blood glucose levels on the nights prior she would have requested Resident #1 be sent to the hospital. A telephone interview was conducted on 11/19/24 at 2:14 pm with Nurse #3 who revealed she did not notify Resident #1's RP of the elevated blood glucose levels when they occurred because it was the middle of the night, and it was not life threatening. She stated she would not have called the RP because the additional insulin that was administered did bring the blood glucose levels down. Nurse #3 stated she did notify Resident #1's RP about the elevated blood glucose levels throughout the week when she notified the RP that Resident #1 was sent to the hospital on the morning of 10/05/24. An interview was conducted on 11/19/24 at 2:40 pm with the Director of Nursing who revealed Nurse #3 should have notified Resident #1's RP of the elevated blood glucose levels.

Based on record review, staff interviews, Pharmacist, Nurse Practitioner, and Medical Director telephone interviews, the facility failed to administer scheduled antibiotic medication which resulted in 3 doses of the antibiotic being missed for 1 of 3 residents reviewed for medication administration (Resident #1). The findings included: Review of the hospital visit summary dated 9/22/24 through 9/27/24 revealed Resident #1 was noted to have had a urine culture completed on 9/23/24 with a positive culture result of Escherichia Coli (E. coli, a common bacteria that causes urinary tract infections). Resident #1 had a discharge diagnosis which included urinary tract infection and was not prescribed antibiotic medication upon discharge. Resident #1 was admitted to the facility on [DATE] with diagnoses which included femur fracture, urinary tract infection, and diabetes. Resident #1 was transferred to the hospital on 10/05/24 for further evaluation of altered level of consciousness. The Nurse Practitioner (NP) visit note dated 10/02/24 revealed Resident #1 had a urinary tract infection (UTI) listed on hospital diagnosis list with unknown treatment. The NP noted to continue to monitor for symptoms and would consider treatment as indicated. The Medical Director's History and Physical progress note dated 10/03/24 revealed Resident #1 had reported increased urinary frequency without dysuria (discomfort upon urination). The Medical Director further noted Resident #1 was diagnosed with a urinary tract infection prior to admission however it was unclear if Resident #1 was treated during the hospital stay. The Medical Director's treatment plan included an empiric (based on observation and experience) course of ciprofloxacin antibiotic and to continue to monitor for symptoms. Resident #1 had a physician order dated 10/03/24 at 2:29 pm for ciprofloxacin (antibiotic medication) 250 milligram (mg) tablet, give 1 tablet twice a day for urinary tract infection (UTI). The order had a start date of 10/03/24 with an end date of 10/09/24. The medication was scheduled to be administered at 9:00 am and 5:00 pm. A review of Resident #1's Medication Administration Record (MAR) for October 2024 revealed ciprofloxacin was not administered on 10/03/24 at 5:00 pm or 10/04/24 at 9:00 am and 5:00 pm. An interview was conducted with Nurse #1 on 11/19/24 at 8:30 am who was assigned to Resident #1 on 10/03/24 for the 7:00 am through 7:00 pm shift. Nurse #1 stated she was not aware the physician wrote an order for ciprofloxacin for Resident #1 during her shift, so she did not administer the medication. She stated when a physician order was entered a yellow box would come across the resident screen stating an order was waiting to be verified, but she did not verify physician orders. She stated the Unit Manager normally verified the physician orders for the residents. Nurse #1 stated she did not recall the order for Resident #1's antibiotic. An attempt to conduct a telephone interview with the Unit Manager on 11/19/24 at 8:54 am was unsuccessful. A telephone interview with Nurse #3 was conducted on 11/18/24 at 3:12 pm who was assigned to Resident #1 on 10/3/24 during the 7:00 pm through the 7:00 am shift and again on 10/04/24 during the 11:00 pm to 7:00 am shift. Nurse # 3 stated she was not sure when Resident #1's ciprofloxacin order was entered but she stated she verified the order on 10/04/24 at 10:02 pm when she saw the order. Nurse #3 stated she notified the on-call provider that the medication was delayed, and a new order was obtained to start the antibiotic on 10/05/24. Nurse #3 stated she was aware of how to verify physician orders, but she was unable to state why the order was not verified during her shift on 10/03/24. A telephone interview was conducted on 11/19/24 at 9:15 am with Nurse #2 who was assigned to Resident #1 on 10/04/24 from 7:00 am through 11:00 pm. Nurse #2 stated he often did not have time to review physician entered orders until the end of his shift, but he did know how to verify the orders. Nurse #2 stated he was not aware of an order for Resident #1 to receive ciprofloxacin at 9:00 am and 5:00 pm during his shift on 10/04/24. A telephone interview was conducted on 11/19/24 at 10:16 am with the Pharmacist who revealed Resident #1's ciprofloxacin order was not submitted by the facility to the pharmacy until 10/04/24 at 10:02 pm. The Pharmacist stated the pharmacy was unable to send the antibiotic medication for Resident #1 until the order was submitted by the facility. During a telephone interview on 11/19/24 at 10:41 am with the NP she revealed she and the Medical Director had discussed an antibiotic as treatment for a possible UTI that Resident #1 had prior to admission to the facility that may not have been treated fully. The NP stated she was not aware the ciprofloxacin was not administered to Resident #1 as ordered. A telephone interview was conducted on 11/19/24 at 10:53 am with the Medical Director who was assigned as the primary provider for Resident #1. The Medical Director reported that based on the hospital discharge summary Resident #1 had a UTI while hospitalized , but it was unclear if antibiotic therapy was completed. He stated Resident #1 had reported increased urinary frequency during his visit on 10/03/24 so he ordered an antibiotic in the event that the UTI was not treated in the hospital. The Medical Director stated he was not notified that Resident #1's ciprofloxacin was not administered as ordered. The Medical Director stated the medication should have been administered to Resident #1 as scheduled. An interview was conducted with the Director of Health Services on 11/19/24 at 9:36 am who revealed the nurses, or the Unit Manager were responsible to verify the physician orders. She stated when an order was entered into a resident's electronic record a notice would populate on the resident screen that a new order was pending verification. She stated to verify an order the nurse would have to review and confirm the order. The Director of Health Services stated that until the physician orders were verified the order would not be sent to pharmacy and would not show on the MAR to be administered. The Director of Health Services stated had Resident #1's ciprofloxacin order been verified when written the medication would have been available to be administered. The Director of Health Services stated she did not know why Resident #1's ciprofloxacin order was not verified by the nursing staff when ordered and she was unable to state how the order was missed. An interview was conducted with the Administrator on 11/19/24 at 1:30 pm who revealed the Director of Health Services was responsible to ensure physician orders were verified and the medications were available to be administered. The facility provided the following corrective action plan with a completion date of 10/09/2024. An Ad-Hoc (as needed) Quality Assurance and Performance Improvement (QAPI) meeting was held on 10/07/24 with the Administrator, Director of Health Services, Nurse Navigator, Unit Manager, and Corporate Clinical Director. The facility's corrective action plan was developed and implemented on 10/07/24. 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident #1 no longer resides in the facility. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected due to overlooked and unverified physician orders. An audit of all active resident physician orders was completed by the Director of Health Services on 10/08/24 to ensure all physician orders were verified (reviewed and confirmed) and accurately transcribed. No issues were identified. 3. Address what measures will be put into place or systematic changes made to ensure that the deficient practice will not reoccur. On 10/05/24 the Director of Health Services initiated education for licensed nurses regarding physician order verification. The education consisted of where to look for physician written orders, how to identify when orders were awaiting verification, and how to verify physician orders. The education was completed for 100% of the licensed nursing staff by 10/08/24. Education regarding physician order verification will be provided by the Director of Health Services or designee to all new hire licensed nurses in orientation or as indicated to ensure systems remain compliant. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The Nurse Navigator or designee will audit the Order Verification Reports for all resident physician orders to ensure verification and accuracy of the physician orders. The audits are to be conducted weekly for 12 weeks. The Director of Health Services or designee will report the findings to QAPI committee monthly for three months. The QAPI Committee will determine if sustained compliance has been achieved and if ongoing monitoring is needed. The corrective action plan completion date was 10/09/2024. The facility's corrective action plan was verified on 11/19/2024 by the following: Review of the weekly order verification reports initiated on 10/07/24 and completed weekly to date. Record review of the resident order audit completed on 10/08/24 was completed and validated. Random review of resident orders was completed with no concerns identified. Interviews with licensed nursing staff revealed they were educated on where to look for physician orders, how to verify physician orders, and confirming all new orders are verified. The compliance date of 10/09/2024 was validated.

Based on record review, and staff, resident, family member, Pharmacist, Psychiatric Nurse Practitioner (NP), and Nurse Practitioner (NP) interviews the facility failed to administer prescribed medications for 1 of 1 resident (Resident # 45) reviewed for significant medication errors. Resident #45 was not administered 10 consecutive doses of lorazepam (anti-anxiety medication) during the time period of 7/29/24 through 8/01/24 when the order was erroneously discontinued on the Medication Administration Record (MAR) by the Director of Nursing (DON) which caused Resident #45 to experience increased anxiety. Resident #45 was assessed by the NP on 8/01/24 due to severe anxiety and noted the resident was crying and asking for his medication. Findings included: Resident #45 was admitted to the facility on [DATE] with a diagnosis that hypertension (high blood pressure), anxiety disorder, and asthma. Review of Physician orders dated 6/1/24 indicated Resident #45 had been prescribed lorazepam, 1 mg (milligram) tablet, take one tablet 4 times a day for anxiety disorder. Review of the Physician orders dated indicated Resident #45 had been prescribed lorazepam 1 mg per 1ml (milliliter) to be given orally in a syringe for anxiety as needed (PRN). Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #45 was severely cognitively impaired and was coded to receive an anxiolytic (medication to treat anxiety). Review of the 2024 July and August Medication Administration Record (MAR) revealed Resident #45 was not administered a total of 10 doses of his prescribed lorazepam (a medication to treat anxiety) on 7/29/24 (2 doses), 7/30/24 (4 doses), 7/31/24 (4 doses), and 8/1/24 (2 doses). This was evidenced by the absence of nursing initials on the MAR for the dates of the missed doses. The order on the MAR had a discontinue date of 7/29/24. Additionally, the MAR revealed Resident #45 was not administered any doses of PRN lorazepam. Review of the Controlled Drug Record for Resident #45's lorazepam 1 mg tablet revealed that Nurse #7 signed on 7/29/24 at 8 pm and on 7/30/24 at 9 pm that 2 doses of lorazepam had been administered. These doses were not signed off as administered on the MAR. During an interview with Nurse #7 on 09/10/24 at 11:00 am he stated that he did not recall if he had administered lorazepam 1 mg tablet to Resident #45 on 7/29/24 or 7/30/24. He further indicated that if he did not have an order for it, he would not have administered it. In an interview with Nurse # 5 on 9/10/24 at 2:47 pm she stated she had worked 7/31/24 and saw that Resident #45's lorazepam had been discontinued so she did not administer it because the order needed to be renewed. She stated she put in a request for the NP to see him and renew the lorazepam. She stated that she did not administer the PRN lorazepam on 7/31/24 because he had not been anxious. The interview further revealed that one day (date unknown) during the first part of July the family had asked that Resident #45's lorazepam dose be held so he would not be drowsy when the family visited that day, but they had not asked that it be stopped. During an interview with Nurse #4 on 9/10/24 at 3:53 pm she stated that when the pharmacy refill review request (a record of orders that are scheduled to be refilled) came electronically on 7/29/24 that it got messed up by someone (she did not know who), and Resident #45's scheduled lorazepam had been discontinued and had to be restarted. She stated when it had been brought to her attention by nursing staff that his lorazepam had been discontinued, she notified the NP to get it reordered on 8/1/24. She recalled that a hydroxyzine order had been received from the NP to be given until the scheduled lorazepam had been reordered. She further indicated that no one had reported to her that he had been overly anxious, and if he had been he had an order for PRN lorazepam that he could have received. In an interview with Resident #45 on 9/10/24 at 8:19 am he stated he recalled that he had not received his prescribed anxiety medication for several days one time but could not recall the name of the medication or the exact dates. He stated he went bezerk and that was what happened when staff forgot to give him his anxiety medication. He further clarified that it made him feel bad overall but could not further describe how he felt. He stated that the nurse (he could not recall her name) gave him some sort of a concoction and that made him feel better, and he had felt fine since. Review of a NP progress note written by the NP dated 8/1/24 read in part, I was called to see [Resident #45] due to his severe anxiety. [Resident #45] was crying and asking for his medications. [Resident #45] was given hydroxyzine [a non-narcotic medication that helped to reduce anxiety] 50 mg by mouth stat [immediately]. Apparently, his Ativan [lorazepam] has been abruptly discontinued. Initially I was told it was by his [family member's] desire but on further investigation it was discontinued from the MAR. The [lorazepam] was resumed as ordered. Review of Physician orders dated 8/1/24 indicated that Resident #45 was prescribed hydroxyzine 25 mg tablets, give 2 tablets 50 mg stat one time dose for anxiety. The order had a start and stop date of 8/1/24. A review of the August MAR revealed that lorazepam, 1 mg to be administered four times a day was reordered and transcribed to the MAR for Resident #45 on 8/1/24, and it was administered as ordered. An interview with Nurse #3 on 9/11/24 at 8:44 am she stated on 8/1/24 she was assigned to administer medications to Resident #45 and administered a dose of hydroxyzine 50 mg as a stat (immediately) as one time dose for anxiety, but could not remember what time she had given it. She stated Resident #45 had increased anxiety on 8/1/24 and she could not remember if he had been crying or what his behaviors had been on 8/1/24 because he often became anxious. She stated she did not recall if he had lorazepam ordered at that time or if she had administered it. She further indicated that she did not routinely work with Resident #45, so it was difficult to recall the exact details of the day. In an interview with the NP on 9/10/24 at 9:18 am she stated that Resident #45 sometimes became groggy when he took the lorazepam, and she was told by nursing staff that his family member wanted the lorazepam stopped. She further stated a nurse told her the facility had not renewed the lorazepam because Resident #45's family member had not wanted it renewed. She could not recall the name of the nurse. She stated that lorazepam should not have been abruptly stopped because it could have caused a rebound of anxiety. She further indicated that she had ordered hydroxyzine when she learned the lorazepam had been discontinued and reordered the lorazepam. An interview with the Director of Nursing (DON) on 9/11/24 at 8:04 am revealed that she had erroneously discontinued Resident #45's lorazepam on 7/29/24. She stated that the pharmacy sent an alert that Resident #45 had 2 lorazepam orders, so she had reviewed the orders and had not realized that one of the lorazepam orders had been for PRN lorazepam 1 mg per 1 milliliter (ml) to be given orally in a syringe, and she thought it was a duplicate lorazepam order and discontinued the scheduled lorazepam 1 mg to be given 4 times a day. She stated that on 8/1/24 a nurse (she did not recall the name) notified her that the order for Resident #45's scheduled lorazepam had been discontinued so she asked the Nurse #4 to notify the NP to reorder the lorazepam and she did. The interview further revealed that Resident #45's family had not contacted her to ask that the lorazepam order be discontinued. She further indicated that the lorazepam should not have been discontinued and Resident #45 should have received scheduled lorazepam on 7/29/24, 7/30/24, 7/31/24, and 8/1/24. She stated the lorazepam 1 mg tablets had been available for administration and had not yet been returned to the pharmacy. During an interview with Resident #45's family member on 9/11/24 at 9:26 am she stated that Nurse # 4 notified her on 8/1/24 that Resident #45 had become combative, yelled, cursed, and they could not get him to calm down and the doctor ordered a medication to calm him down. She stated she did not know what medication had been ordered. The interview further revealed that she had not asked the facility to stop his lorazepam and had only asked the facility to hold one dose around the 7/19/24 so family could visit. She stated that when he did not get his scheduled lorazepam that he became combative and upset. In an interview with the Psychiatric Nurse Practitioner on 9/10/24 at 12:09 pm she stated Resident #45 had been ordered lorazepam to be given on a routine scheduled basis, as well as lorazepam to be given on an as needed (PRN) basis, so he should not have missed any doses of his lorazepam. She further stated she would have expected that the nurses would have given him the PRN lorazepam if they did not have an order for the scheduled lorazepam. She stated that she did not discontinue the scheduled lorazepam, and was unaware it had been discontinued. She stated lorazepam should not have been stopped abruptly as it could have caused increased agitation for the resident. In an interview with the Pharmacist on 9/10/24 at 02:10 pm he stated that according to his records the order for lorazepam for Resident #45 had been discontinued by the Director of Nursing (DON) on 7/29/24 and it had been reordered on 8/1/24 by the Nurse Practitioner. He further stated that lorazepam should not have been stopped abruptly and should have been titrated (dose lowered by over a period of several days) to a lower dose and then tapered off before it had been stopped. He stated if it had been abruptly stopped that Resident #45 could have experienced irritability, tremors, sweating, panic attacks, headaches, and worsened anxiety. In an interview with the Administrator on 9/11/24 at 1:25 pm she stated Resident #45 should have received his medications as ordered and not missed doses. She stated that nurses administered medication according to the order on the MAR. She further indicated the error occurred because of the way the medication re-order system was set up and that the lorazepam had been restarted for Resident #45 when they became aware it had been stopped.

Based on record review and staff interviews the facility failed to provide a complete Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF/ABN) by omitting the estimated cost of services for 2 of 2 residents reviewed for beneficiary notices (Resident #286 and Resident #287). Findings included: a. Resident # 286 was admitted to the facility on [DATE]. Medicare part A services began on 12/27/23. The medical record revealed a CMS-10123 Notice of Medicare Non-Coverage letter (NOMNC) was signed by Nurse #2 as issued to Resident # 286's representative via phone on 3/11/24. The notice indicated that Medicare coverage for skilled services was to end 3/13/24. Resident #286 remained in the facility when Medicare coverage ended. Review of Resident #286 's record indicated the SNF/ABN form dated 3/11/24 had no estimated cost of services documented on the form. b. Resident #287 was admitted to the facility on [DATE]. Medicare part A services began on 6/14/24. The medical record revealed a CMS-10123 Notice of Medicare Non-Coverage letter (NOMNC) was signed by Resident #287 and on 8/12/24. The notice indicated that Medicare coverage for skilled services was to end on 8/16/24. Resident #287 remained in the facility when Medicare coverage ended. Review of Resident # 287's record indicated the SNF/ABN form dated 8/12/24 had no estimated cost of services documented on the form. During an interview with Nurse #2 on 9/11/24 9:17 am she stated that she completed the SNF ABNs for Resident #286 and Resident #287. She further stated that she was not aware that the estimated cost needed to be included on the SNF/ABN form. She concluded she would begin to include the estimated cost in the future. During an interview with the Administrator in Training on 9/10/24 at 3:13 pm, he stated if estimated costs was to be included in the SNF/ABN then it should have been completed for Resident #286 and Resident #287. He stated the Social Worker and Nurse #2 had been responsible to complete the SNF/ABN forms. During an interview with the Administrator on 09/10/24 03:29 pm she stated she had not been aware that the estimated costs had not been completed for Resident #286 and Resident #287. She further indicated that the costs should have been completed.

Based on record review and staff interview, the facility failed to accurately code a significant change in status Minimum Data Set (MDS) assessment following hospice election for 1 of 1 resident (Resident #56) reviewed for hospice. The findings included: Resident #56 was readmitted to the facility on [DATE] with diagnoses that included acute respiratory failure, acute pneumonitis (pneumonia) and Alzheimer's dementia. A review of Resident #56's hospice election form revealed she was admitted to hospice on 8/19/24. A review of Resident #56's electronic health record revealed a significant change Minimum Data Set (MDS) was completed on 8/19/24. The MDS did not indicate the resident had been admitted to hospice. In an interview with the MDS nurse on 9/11/24 at 8:17 AM She further stated she learned about significant changes in morning meeting every day and she was aware Resident #56 had been admitted to hospice. The MDS nurse revealed the significant change MDS that was completed on 8/19/24 should have indicated the resident was admitted to hospice. She was not sure how it was missed. In an interview with the Administrator on 9/11/24 at 8:39 AM she stated the MDS completed on 8/19/24 should have captured that Resident #56 was admitted to hospice.

Based on observation, record review, and resident and staff interviews, the facility failed to provide a safe transfer for 1 of 1 resident (Resident #285) reviewed for supervision to prevent accidents. On 8/26/24 Resident #285 was assessed by Physical Therapist #1 to have required a mechanical lift transfer. The mode of transfer had not changed and on 9/5/24 Nursing Assistant (NA) #1 and NA #2 transferred Resident #285 from the bed to a chair without the use of a mechanical lift. Findings included: Resident #285 was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure with hypoxia (low oxygen levels in the body), anxiety, muscle weakness, unsteady on feet, shortness of breath, and pneumonia. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #285 was moderately cognitively impaired. She was dependent on staff for transfers from bed to chair. She required the use of supplemental oxygen. Review of a care plan for Resident #285 dated 8/23/24 revealed she was at risk for falls related to cardiac dysrhythmia (abnormality of heart rhythm), and generalized weakness. Interventions included assist for toileting and transfers as needed. Review of the physical therapy initial evaluation and plan of treatment for Resident #285 dated 8/26/24 revealed Resident #285's baseline for sitting to standing was patient unable to stand despite max A +2 [maximum assistance of 2 persons]. The evaluation further revealed Resident #285 was unable to ambulate. In an interview with Physical Therapist (PT) #1 on 9/10/24 at 11:22 am she stated she had evaluated Resident #285 on 8/26/24 and had determined a mechanical lift was the safest mode of transfers because Resident #285 could not stand safely related to weakness and unsteadiness on her feet. She stated a two-person physical assist without the use of a mechanical lift put Resident #285 at a risk for falls related to poor physical strength. The interview further revealed NA #1 told PT #1 she transferred Resident #285 without the use of a mechanical lift on 9/5/24 and that concerned her because NA #1 should have used a mechanical lift. In an interview with Resident #285 on 9/11/24 at 9:58 am she stated on 9/4/24 the therapist (not sure which one) told her she wanted Resident #285 out of bed for therapy on 9/5/24 and to let the Nursing Assistants (NAs) know when they came to get her up to use the mechanical lift. Resident #285 stated that on 9/5/24 NA#1 and NA #2 came to assist her out of bed, and she told them to use a mechanical lift for the transfer and NA #1 told her they (NA #1 and NA #2) were sent to get her out of bed and into the chair and that was what they were doing. She stated when NA #1 and NA #2 assisted her to stand up to transfer to the chair she could feel herself falling and staff grabbed her by her underarms and it hurt like hell and it scared her because she thought she was going to fall. The interview further revealed that Resident #285 had pneumonia and had difficulty breathing and the exertion from the transfer made her short of breath. In an interview with NA #1 on 9/10/24 at 11:12 am she stated she transferred Resident #285 from the bed to a chair without the use of a mechanical lift on 9/5/24 because she had not been aware at that time that Resident #285 required a mechanical lift. She stated Resident #285's care card had indicated that she was a two person assist for transfers. She indicated that NA #2 assisted her to transfer Resident #285. She stated Resident #285 held onto a walker during the transfer, became short of breath, could not pivot to turn, and sit in the chair. NA #1 explained she and NA #2 assisted Resident #285 to sit on the side of bed until she could regain her breath and then they continued with the transfer to the wheelchair. NA #1 indicated Resident # 285 did not tell her that she should have used a mechanical lift until after she had been transferred into the chair. She stated on 9/5/24, after the transfer had occurred, Physical Therapist (PT) #1 told her that Resident #285 should have been transferred using a mechanical lift. During an interview with NA #2 on 9/11/24 at 11:08 am she stated she assisted NA #1 on 9/5/24 to transfer Resident #285 from the bed to a wheelchair. She indicated they did not use a mechanical lift for the transfer because Resident #285's care card indicated she had been a two person assist for transfers and did not indicate a mechanical lift had been required. She stated when she arrived at Resident #285's room on 9/5/24 to assist NA #1 with the transfer that Resident #285 was sitting on the side of the bed with her legs over the edge of the bed and feet on the floor. She stated when they assisted the resident stand up the resident stated, I can't do it, I can't do it, so they assisted her to sit back down on the bed by holding her under each arm, on each side of the resident. She stated NA #1 told Resident #285 they were going to transfer her to the chair and asked if she was ready and Resident #285 agreed she was. She stated Resident #285 stood up and NA #1 and NA #2 assisted her to pivot to the chair and sat her down. They stated the resident was able to bear weight during the transfer, but they helped her maintain her balance. She stated after Resident #285 was seated in the wheelchair that she was short of breath and that concerned her, so she checked on her frequently afterward until she was no longer short of breath. In an interview with Certified Occupational Therapy Assistant (COTA) #1 on 9/11/24 at 10:05 am she stated that on 9/4/24 she told Resident #285 to tell the NA staff to use a mechanical lift when they got her up for therapy on 9/5/24. The COTA stated after Resident #285 was out of bed, the resident told her NA #1 and NA#2 had transferred her without the use of a mechanical lift. She stated Resident #285 could not bear weight to stand related to weakness so she should have been transferred with a mechanical lift. She stated Resident #285 had not had a change in her transfer status since she had been admitted . She stated if there had been a change in how Resident #285 transferred a therapist would have communicated that to the nursing staff verbally. The interview revealed there had not been a formal process in place for therapy to communicate modes of transfer to nursing staff. In a follow-up interview with PT #1 on 9/11/24 at 10:45 am she confirmed she documented in her physical therapy progress notes on 8/26/24 Resident #285 was not safe to bear weight and that she verbally notified the nurse on duty that day. She stated she did not recall which nurse she spoke to. In a follow-up interview with Nurse #6 on 9/11/24 at 11:51am she stated she worked on 8/26/24 when therapy did the initial evaluation on Resident #285, but she did not recall if a therapist told her to transfer Resident #285 with a mechanical lift. She further indicated therapists would tell the NAs how to transfer a resident and the NAs would tell the nurse so the nurse could update the care plan. She stated she was not told how Resident #285 should transfer at any time and had not updated the care plan. In an interview with the Director of Nursing (DON) on 9/11/24 at 8:21 am she stated if a resident required a mechanical lift for transfers that they should be transferred with a mechanical lift unless therapy changed the mode of transfer. She stated therapy communicated verbally to the nursing staff about how a resident should be transferred. In a follow up interview with the DON on 09/11/24 at 1:03 pm she stated that on admission a nurse assessed a resident to see how they would transfer until therapy assessed the resident. She stated therapy usually assessed residents the next day after admission and determined how the resident should be transferred and then therapy would tell the nurse. She stated that the safest mode of resident transfers was also discussed in morning meeting with the interdisciplinary team each day. She stated there was not a set system on how to communicate on how to transfer residents and without a system someone could be transferred incorrectly. She explained therapy initially assessed Resident #285 and assessed her mode of transfer to be a mechanical lift. She said the facility needed a process to communicate about transfers after a resident was assessed by therapy. She further indicated when NA #1 and NA #2 noticed Resident #285 became short of breath they should have reported the resident being short of breath to the nurse before they continued with the transfer. She stated when therapy notified Nurse #6 Resident #285 should be transferred with the use of a mechanical lift that Nurse #6 should have notified the DON or MDS nurse so they could have updated the care plan. During an interview with the Administrator on 9/11/24 at 1:32 pm she stated Resident #285 had been assessed by nursing when admitted and Resident #285 required two-person assistance to transfer out of bed, and that was put on the care plan. She stated therapy did not always make the determination on how a resident should be transferred.

Based on observation, record review, staff and Physician interview the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 27 opportunities, resulting in a medication error rate of 7.41%, for Medication Administration. Both errors were for medications received by Resident #77. Findings included: a. A review of Resident #77's medication orders dated 7/29/24 revealed he was prescribe one 325 mg (milligram) aspirin by mouth once daily. Further review of the resident's orders revealed he was to be given medications whole in puree (meaning not to crush the medications and to place the medication in a food to help with administration such as applesauce). On 9/10/24 at 8:35 AM Nurse #1 was observed as she prepared and administered four medications to Resident #77. The medications administrated included one enteric coated aspirin 325 mg. All of the resident's medications were crushed and administered to the resident in applesauce. In an interview with Nurse #1 on 9/10/24 at 9:28 AM she stated she had been crushing Resident #77's medications as he had been having trouble swallowing them whole. Nurse #1 revealed she used an enteric coated aspirin instead of a regular aspirin as that was what she had in her cart, and she should have gone to the medication storage room for the correct aspirin. b. A review of Resident #77's medication orders dated 7/29/24 revealed he was prescribed one Metoprolol Succinate extended release tablet 50 mg by mouth once daily. Further review of the resident's orders revealed he was to be given medications whole in puree (meaning not to crush the medications and to place the medication in a food to help with administration such as applesauce). On 9/10/24 at 8:35 AM Nurse #1 was observed as she prepared and administered four medications to Resident #77. The medications administrated included one Metoprolol Succinate extended release tablet 50 mg to be given by mouth. All of the resident's medications were crushed and administered to the resident in applesauce. In an interview with Nurse #1 on 9/10/24 at 9:28 AM she stated she had been crushing Resident #77's medications as he had been having trouble swallowing them whole. She further stated she knew she should not have crushed Metoprolol Succinate extended release because that changes it from a long acting to a short acting medication. She further revealed she should have contacted the Physician or Nurse Practitioner to change his order from taking medication whole to crushed. An interview with the Pharmacist on 9/10/24 at 2:03 PM revealed Metoprolol Succinate extended release should not be crushed as it changes it to immediate release and can lower the residents blood pressure and/or pulse. He stated enteric coated aspirin should not be crushed as the enteric coating protects the stomach lining. He further revealed if a residents orders changed from taking medications whole to crushed, he would recommend an equivalent medication that can be crushed. He stated the pharmacy did not receive a request for recommendations for crushable medications for Resident #77. An interview with the Director of Nursing (DON) on 9/10/24 at 9:22 AM revealed Metoprolol Succinate extended release should not have been crushed as it changes it from a long-acting medication to a short acting one that could cause a drop in blood pressure or pulse for the resident. The DON stated the nurse should have known not to crush it. She further stated she expected nursing to follow the orders in the electronic medication administration record including how residents took their medications. If a resident needed a change from taking medications whole, to taking them crushed, nursing would contact the Physician or Nurse Practitioner for that order and any changes from medications that could not be crushed to an equivalent medication that could be crushed. In an interview with the Physician on 9/11/24 at 8:02 AM he stated Metoprolol Succinate extended release should not be crushed as it could cause the resident's blood pressure and/or pulse to drop. He further stated Resident #77 did not have an order for enteric coated aspirin and enteric coated aspirin should not be crushed if it was given. The Physician revealed Resident #77 did not have an order for medications to be crushed but had an order for them to given whole in puree.

Based on observations and staff interviews the facility failed to keep medications in a locked treatment cart for 1 of 2 treatment carts observed (Treatment Cart #1). Findings included: During observation on 9/9/24 at 3:33 PM Treatment Cart #1 was observed to be unlocked and unattended on the 100 hall with the locking mechanism popped out in the unlocked position. At 3:33 PM a resident rolled to the cart and stopped approximately 5 feet from it and remained there through the observation. At 3:34 PM a nurse aide pushing a resident in a wheelchair and a restorative aide walked past the unlocked treatment cart. At 3:35 PM a visitor walked past the unlocked treatment cart. At 3:35 PM the MDS Nurse walked to the unlocked treatment cart, noted it was unlocked, and locked Treatment Cart #1. During an interview on 9/9/24 at 3:36 PM the MDS Nurse stated Treatment Cart #1 was being used by Treatment Nurse #1. She stated it should be locked when unattended and was why she locked it when she saw it was not locked as she was passing by. During an interview on 9/9/24 at 3:40 PM Treatment Nurse #1 stated treatment carts were to be locked when unattended. He stated he did not have a reason the treatment cart was left unlocked. During observation on 9/9/24 at 3:44 PM with Treatment Nurse #1, the treatment cart was observed to contain calmoseptine ointment, triamcinolone acetonide cream 0.1%, Mometasone Furoate Cream 0.1%, nystatin ointment 100,00 units per gram, nystatin topical powder 100,000 units per gram, sodium hypochlorite solution 0.50%, hydrogen peroxide, wound cleanser, triamcinolone cream 0.1%, corn starch powder, wound solution, ketoconazole shampoo 2%, and 1.5% dimethicone. During an interview on 9/10/24 at 7:54 AM the Director of Nursing stated treatment carts were to be locked when unattended.

Based on observation, record review and staff interview the facility failed to implement their policies and procedures for hand hygiene when Nurse #1 failed to perform hand hygiene before donning gloves and after glove removal for 1 of 2 Nurses observed for hand hygiene during medication administration. Findings included: A review of the facility policy titled Medication Administration: Hand Hygiene dated 10/17/2023 stated in part: During medication administration .use hand hygiene before and after glove removal. The policy definition of hand hygiene stated: The cleansing of hands by using the organization-approved, alcohol-based hand sanitizer or by washing hands with soap and water. An observation was started on 9/10/24 at 8:15 AM of Nurse #1 administering medications to a resident. She performed hand hygiene with alcohol based sanitizer upon leaving the room. During the second observation at 8:30 AM on 9/10/24, after collecting the needed supplies and medications, Nurse #1 was accompanied to the resident's room. Once in the room, Nurse #1 set down the glucose monitoring supplies, a cup of water and the medication cup, put on disposable gloves and proceeded with handing Resident #18 the medication cup and water. Nurse #1 was observed administering medications and performing a blood glucose test on Resident #18. Nurse #1 did not perform hand hygiene before putting on gloves. After Resident #18 took his medication, Nurse #1 completed the blood glucose test, removed her gloves and threw them away before proceeding to the medication cart in the hallway. Nurse #1 did not perform hand hygiene after removing her gloves. In an interview with Nurse #1 on 9/10/24 at 12:00 PM she stated she was aware she should have performed hand hygiene before donning gloves to perform the blood glucose test and after removing her gloves after the test. She further revealed she did not perform hand hygiene because she was nervous and had a bad headache. An interview with the Infection Preventionist on 9/10/24 at 12:06 PM revealed Nurse #1 should have washed her hands after removing gloves when done with the blood glucose test. In an interview with the Director of Nursing (DON) on 9/10/24 at 10:21 AM she stated Nurses are trained in infection control upon hire and at least yearly. She further stated Nurse #1 should have washed her hands and donned gloves before performing the blood glucose test and should have washed her hands after removing her gloves when done with the test.

Based on record review and staff interviews, the facility failed to protect the resident's right to be free from misappropriation of a controlled medication, (30 Oxycodone 5 milligram (mg) pills), which were prescribed by the Physician for pain for 1 of 3 residents reviewed for misappropriation of property (Resident #10). The findings included: The resident was admitted to the facility on [DATE]. The Physicians order for Resident #10 dated 8/8/23 was one tablet of Oxycodone 5mg every four hours as needed for moderate to severe pain. Review of a quarterly Minimum Data Set, dated dated dated [DATE] revealed Resident #10 was moderately cognitively impaired. A review of the facility internal investigation report dated 9/15/23 revealed the Director of Nursing (DON) received a phone call from Nurse #6 on 9/7/23 at 7:33 AM and she stated they were counting narcotics at change of shift and there was a card of narcotic medication unaccounted for. The medication belonged to Resident #10. The DON stated she notified the Administrator and Nurse Consultant. She further revealed the facility notified law enforcement and Pharmacy on 9/13/23. In an interview with Resident #10 on 4/23/24 at 4:15 PM he stated he was not aware that any of his medication had been missing in September. He further stated he did not recall going without narcotic medication at any time, nor did he recall being charged for any medication. In an interview with the DON on 4/23/24 at 10:44 AM she stated all narcotics are kept double locked. In this case the Nurse would have two keys, one to unlock the cart and one to unlock the narcotic drawer. She further stated Nurse #4 and an orientee (Nurse #5) were working on that cart that night, and they both passed voluntary drug screening tests during the investigation by the facility. The DON revealed staff searched all medication carts and med rooms for the missing medication. Nurses #4, #5 and #6 could not be reached for interviews. The law enforcement officer was unavailable for interview. Observations during the survey revealed medication carts to be locked when not in use. An interview with the Pharmacist on 4/23/24 at 1:12 PM revealed he was notified of missing narcotic medication belonging to Resident #10 on 9/13/23. He came to the facility the same day to help staff investigate the incident. The Pharmacist further stated he was unable to locate the medication. In an interview with the Administrator on 4/24/24 at 2:15 PM, she stated she was made aware of the missing narcotic medication on 9/7/23 and helped staff search for it. She further stated the narcotic count sheet had been moved to the back of the three-ring binder but was unable to determine who had moved it. She had reviewed facility camera recordings, and the cart was parked out of view for some of the shift. The Administrator revealed the narcotic count should always be correct. She stated the facility covered the cost to replace the medication. The Administrator revealed they completed trainings that included misappropriation upon hire.

Based on record review and staff interviews, the facility failed to submit an initial or investigation (5 day) report to the state regulatory agency and did not notify Adult Protective Services (APS) regarding an allegation of misappropriation of resident property. They further failed to report to Law Enforcement within 24 hours of discovery of misappropriation of resident property for 1 of 3 residents (Resident #10) reviewed. Findings included: A review of the facility internal investigation report dated 9/15/23 revealed the Director of Nursing (DON) received a phone call from Nurse #6 on 9/7/23 at 7:33 AM and she stated they were counting narcotics at change of shift and there was a card of narcotic medication unaccounted for. The medication belonged to Resident #10. The DON further revealed the facility notified law enforcement on 9/13/23. The report did not indicate if APS was notified. An interview with the DON on 4/23/24 at 10:44 AM revealed she received a phone call from Nurse #6 on 9/7/23 who stated a card of a narcotic medication was missing during the shift change medication count. The DON stated she notified the Administrator. In a follow up interview with the DON on 4/24/24 at 11:09 AM she stated she did not send an initial report or 5-day investigation report to the state regulatory agency as she did not realize it was a reportable incident. She stated she did not report it to APS for the same reason. The DON revealed she did not think about the incident as being classified as misappropriation of resident property. She further stated she did not notify law enforcement for 5 days because she spent that time looking for the missing medication. In an interview with the Administrator on 4/24/24 at 2:15 PM she stated she did not report the misappropriation to the state regulatory agency by sending an initial report or a 5-day investigation report. She further stated she did not notify APS. The Administrator revealed she did not think to categorize the missing medication as misappropriation as she was thinking more of diversion. She indicated that the delay in notification to law enforcement was because they were searching for the missing medication.

Based on observations, record review, and resident and staff interviews, the facility's Quality Assessment and Assurance Committee (QAA) failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the recertification and complaint investigation surveys of 4/21/22 and the complaint investigation surveys of 8/30/23 and 2/21/24. This was for 3 recited deficiencies in the areas of Safe/Clean/Comfortable/Homelike Environment (F584), Reporting of Alleged Violations (F609), and Infection Control (F880). The continued failure during 2 or more federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program. The tag is cross-referenced to: F584: Based on observations, resident and staff interviews, the facility failed to provide a room free of a strong smell of urine which reached out into the hallway. This was evident in 2 of 3 rooms reviewed for a safe, clean, homelike environment (Rooms 307 and room [ROOM NUMBER]). During a recertification and complaint investigation survey of 4/21/22 the facility was cited for failing to keep walls, resident furniture and sinks in good condition. During a complaint investigation survey of 8/30/23 the facility was cited for failing to: clean and repair water damage to resident vanities; prevent leaking plumbing in resident hand sinks and toilets; clean a flat, black substance on resident walls near toilet plumbing and behind raised wallpaper; and repair wallpaper that was wet to touch and separated from the wall behind toilets. F609: Based on record review and staff interviews, the facility failed to report an allegation of misappropriation of resident property to the state regulatory agency and Adult Protective Services (APS). They further failed to report to Law Enforcement within 24 hours of discovery of misappropriation of resident property for 1 of 3 residents (Resident #10) reviewed. During a complaint investigation survey of 2/21/24 the facility was cited for failing to report an allegation of staff to resident abuse within the required time frame of 2 hours. F880: Based on observations, and staff interviews, the facility failed to implement their policies and procedures for wearing Personal Protective Equipment (PPE) when 3 of 3 Nursing staff members (Nurse #1, Nurse #2, and Nurse #3) were observed not wearing (PPE) when providing care to 1 of 1 resident (Resident #21). During a recertification and complaint investigation survey of 4/21/22 the facility was cited for not following isolation precautions for a resident who had orders to be on isolation enteric precautions. During an interview with the Administrator on 4/24/24 at 2:05 PM she stated the QA (Quality Assurance) committee met monthly and consisted of the Administrator, Director of Nursing, Medical Director and the Directors of the facility's departments. When an area of concern was identified during an IDT (Interdisciplinary Team) meeting, a PIP (performance improvement project), including audits with results was submitted to the QA committee every month until the concern was resolved. She further stated that as oversight, the corporate consultants also have access to this information to audit, submit recommendations, and follow-up to the QA Committee. The Administrator revealed that overcoming certain citations such Environment and Infection Control are difficult as they encompass so many potential issues. She further stated that the facility must ask permission from corporate for the funds to fix walls and replace resident furniture. The Administrator revealed they received a citation for failure to report on 2/21/24 and it was because the fax would not go through for several hours. They have since found that sending a fax from Human Resources works faster.

Based on observations, and staff interviews, the facility failed to implement their enhanced barrier precautions policies and procedures for wearing Personal Protective Equipment (PPE) when 3 of 3 Nursing staff members (Nurse #1, Nurse #2, and Nurse #3) were observed not wearing (PPE) when providing care to 1 of 1 resident (Resident #21). Findings included: The facility's enhanced barrier precautions guidelines effective date 4/01/24 read in part that enhanced barrier precautions were in effect for chronic wounds, internal devices, and lines. Infection Control signage posted on Resident #21's room door read in part 'Enhanced Barrier Precautions. Providers and staff must also wear gloves and a gown for the following High-Contact Resident Care Activities.' The high contact resident care activities list included device care or use: urinary catheter, feeding tube, tracheostomy; wound care: any skin opening requiring a dressing. During an observation on 4/23/24 at 8:59 AM, Nurse # 1 and Nurse #2 were observed to provide wound care on Resident #21's right and left buttock, suprapubic (above the pubic bone) urinary catheter care, gastrointestinal tube care, and tracheostomy care. Nurse #1 and Nurse #2 did not don a gown for any observed resident care. An interview on 4/23/24 at 9:33 AM with Nurse #1 and Nurse #2 revealed they had had enhanced barrier training. They stated they had not donned a gown for any of Resident #21's observed care. They stated they had not done so due to nervousness about being observed. During an observation on 4/23/24 at 10:22 AM, Nurse #3 was observed to provide a tube feeding with water flushes for Resident #21. She did not don a gown for any observed resident care. She stated that she had not because 'people don't really' and she had fallen out of practice with wearing a gown for residents with enhanced barrier precautions. She stated she was aware that Resident #21 had an enhanced barrier precautions sign on his door but did not realize that it included tube feeding. An interview on 4/24/24 at 10:05 AM with the Administrator revealed the staff have had enhanced barrier precautions training and she thought they were just nervous, and it was human error they had not worn a gown during resident care. An interview on 4/24/24 at 11:10 AM with the Director of Nursing revealed that the staff have had enhanced barrier precautions training, and she did not know why they had not worn gowns during resident care.

Based on observations, resident and staff interviews, the facility failed to provide a room free of a strong smell of urine which reached out into the hallway. This was evident in 2 of 3 rooms reviewed for a safe, clean, homelike environment (Rooms 307 and room [ROOM NUMBER]). Findings included: 1a. During an observation on 4/22/24 at 10:41 AM the 300 hallway and room [ROOM NUMBER] smelled strongly of urine. No soiled briefs or linens were observed in the room, and the resident was not visibly soiled. An observation and interview on 4/23/24 at 2:23 PM with Resident #22 revealed a strong smell of urine from the resident in room [ROOM NUMBER] and outside the room in the 300 hall. 1b. During an observation on 4/22/24 at 10:41 AM the 300 hallway and room [ROOM NUMBER] smelled strongly of urine. An observation on 4/23/24 at 2:23 PM revealed a strong smell of urine from room [ROOM NUMBER] and outside the room in the 300 hall. Resident #23 was not able to be interviewed. No soiled briefs or linens were observed inside the room, and the resident was not visibly soiled. An interview on 4/23/24 at 1:38 PM with the Housekeeping Director revealed she was aware of the strong smell of urine in the facility on 4/22/24 and on the 300 hall on 4/23/24. She stated the residents in rooms [ROOM NUMBERS] refused to allow housekeeping to clean their rooms. She also stated that Resident #23 urinated in trashcans and on the furniture. She stated some days the urine smell in the facility was worse than others. An interview on 4/23/24 at 2:23 PM with Nursing Assistant (NA) #1 revealed that she worked on the 300 hall frequently. She stated that the urine smell was really bad on 4/22/24 especially on 300 hall. She stated that Resident #23 refused care frequently and urinated in trashcans and cups. An interview on 4/23/24 at 2:46 pm with NA #2 revealed that she worked on the 300 hall at times. She stated that rooms [ROOM NUMBERS] frequently had a strong urine odor. An interview on 4/23/24 at 3:02 PM with Nurse #7 revealed she worked on the 400 hall which was adjacent to the 300 hall. She stated that the residents in rooms [ROOM NUMBERS] were resistive to care and their rooms usually had a strong urine odor. An interview on 4/24/24 at 8:05 AM with the Maintenance Director revealed he was aware of the strong urine odor on the 300 hall. He stated that the residents in rooms [ROOM NUMBERS] refused to allow housekeeping to clean their rooms. He stated that the floor tiles probably needed to be replaced to get the odor out. An interview on 4/24/24 at 9:39 AM with Nurse #8 revealed he usually worked at the 300 hall nurses' station and the resident in rooms 314 refused care so the 300 hall frequently had a strong urine odor. An interview on 4/24/24 at 10:05 AM with the Administrator revealed that she was aware of the strong odor of urine in rooms [ROOM NUMBERS] and the 300 hall. She stated that she would get room [ROOM NUMBER] floor retiled to see if that would help. She stated that the facility had made multiple attempts to get the residents to permit their rooms to be cleaned. An interview on 4/24/24 at 11:10 AM with the Director of Nursing revealed that she was aware the urine odors on the 300 hall. She stated the residents in rooms [ROOM NUMBERS] had behaviors and refused to have their rooms cleaned.

Based on observation, record reviews and family, staff, Medical Director (MD), and Nurse Practitioner (NP) interviews the facility failed to provide care in a safe manner for 1 of 5 residents (Resident #1) reviewed for supervision to prevent accidents. Resident #1 was diagnosed with cerebellar ataxia (a condition that causes poor muscle control that causes clumsy movements), and functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord) and was dependent on staff for assistance with care. On 1/18/24 Nursing Assistant (NA) #1 was providing Resident #1 with care when the resident experienced spastic/uncontrolled movements and the resident fell off the side of the bed striking his head on a bedside table causing a laceration on his forehead above his left eye before he fell on to the fall mat on the floor. Resident #1 was transferred to the Emergency Department and was treated for a left frontal scalp hematoma (a pool of mostly clotted blood) with a significant laceration with active bleeding that required 7 sutures for closure. Immediate jeopardy began on 1/18/24 when NA #1 failed to provide care safely to Resident #1. The immediate jeopardy was removed on 3/15/24 when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower level and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place were effective. Findings included: Resident #1 was admitted to the facility on [DATE] with a diagnosis that included stroke with right side hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness of one side of the body), functional quadriplegia, cerebellar ataxia, muscle weakness, lack of coordination and intellectual disability. The quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #1's cognition was severely impaired, and he was dependent on staff for activities of daily living (ADL) assistance, dressing, and bed mobility. He was coded to have received antiplatelets and had 1 fall with no injury since prior assessment on 8/7/23. He did not have behaviors. Review of the care plan for Resident #1 dated 10/20/23 included the following: - At risk for falls related to muscle weakness, cerebral vascular accident (stroke) with right sided hemiplegia, functional quadriplegia, intellectual disability, and cerebellum ataxia with a goal that Resident #1 would not have negative outcomes related to falls without appropriate nursing intervention through the next review (start date 2/28/23) with interventions that included to use a wider bed, floor mats beside bed, assist with toileting and transfers, keep the environment safe, and call light within reach. - Impaired physical mobility and required 1-2 person assist with ADLs related to right side hemiplegia with interventions that included to provide 1-2 person assist with ADLs as needed. In an interview with Nurse #2 on 3/12/24 at 12:08 pm it was revealed that Resident #1 had a diagnosis of cerebellar ataxia, had a recent deterioration in his condition and had become more spastic (uncontrolled movement) with increased muscle spasms and became more agitated at times. She stated he was at risk of falls because of his diagnosis. She indicated that some of the staff interventions used were: they approached him calmly as not to startle him, they kept his bed in a low position, padded the side rails with pillows, checked for incontinence and changed him as needed, and had floor mats on both sides of the bed to help prevent self-injury. The interview further revealed that Resident #1 had a wider bed to help prevent falls and that staff got him up in a chair and took him to activities to help keep him occupied and so they could keep a closer eye on him. Nurse #2 stated that a family member familiar to him visited daily and that helped. The interview further revealed that many different fall interventions had been exhausted for Resident #1 and he was reviewed in fall meetings regularly and medication reviews were done, and medications were adjusted as necessary. Nurse #2 stated he was prescribed lorazepam 0.5 milligrams at bedtime for anxiety and baclofen to help control his muscle spasms. Review of an Event Witness Statement dated 1/18/24 at 10:50 am written by NA #1 read went into the room and took his [Resident #1's] shirt off, he started moving around and fell off the bed. The statement was signed as witnessed by Nurse #3. Review of a Facility Event Investigation Form dated 1/18/24 at 10:50 am completed by Nurse #3 and signed by the Director of Nursing (DON) revealed that Nurse #3 responded to an NA's call for assistance because a resident had fallen out of bed. The review further revealed that Resident #1 was being assisted with dressing and changing when he started jumping and fell off of bed. The record had a hand drawn diagram that indicated that Resident #1 laid on the floor between both beds with a night stand near his head, it was noted that he was on his left side with his arms up by his chest, legs outstretched, and with blood on the floor coming from under him from an area on the upper left forehead. The record review further indicated that the care plan was updated to include 2 or more persons when ADL care was provided or for bed mobility. The form was dated and signed by the DON as investigation completed on 1/23/24. Review of a nurse's progress noted dated 1/18/24 at 3:12 pm written by Nurse #3 revealed that she was called to Resident #1's room by the NA and Resident #1 was on the floor between the beds in his room. The review further revealed he had fallen off his bed when the NA attempted to change and dress him. He was noted to have bled from an area on the left side of his forehead. 911 was called and Resident #1 was transported to the hospital for evaluation and treatment. Review of a nurse's progress noted dated 1/18/24 at 3:28 pm written by Nurse #3 revealed that pressure was applied to Resident #1's head for bleeding, and he grimaced when pressure was applied. In a phone interview with NA #1 on 3/12/24 at 4:22 pm she stated that she was assigned to Resident #1 on 1/18/24 when he fell out of bed. She stated that she went into his room to give him a bath. She indicated he let her take his shirt off and at that point in time he started making his movements like he did. She explained that was when she remembered that he had a history of flailing around with agitated movements when he received care so she was going to go get someone to assist her. She indicated she left the side of the bed without lowering the bed. She stated that he then went off the other side of the bed so she ran out of the room to go get the nurse. NA #1 stated that Nurse #3 came into the room. She stated that when he started to move around in bed after she removed his shirt that she talked to him so he would not move as much. She indicated that she had his bed up to a working height that permitted her to provide care on the same plane (level) as Resident #1 when he fell . She further stated that Resident #1 typically moved around a lot but would let her do his care but this day he moved so fast that he fell off the other side of the bed (opposite from where she was standing) and hit his head on the bedside table before he fell on to the floor mats that were beside his bed. She stated that she then ran over to where he laid on the floor and asked him if he was ok and he said he was. NA #1 indicated that there was blood everywhere, on the privacy curtain, on the floor, and on his head and upper body. The interview further indicated that NA #1 recalled that Resident #1 had moved around a lot since she started working at the facility in July of 2023 and because of that 2 people usually worked with Resident #1. She further stated that she knew she should use 2 people when she provided care to Resident #1 because when she became employed at the facility other staff (no specific staff names provided) told her that. She indicated that there were no staffing issues on the morning of 1/18/24 when she provided care to Resident #1. She explained that she was not thinking that day and was just moving to get her patient care completed and as soon as she removed his shirt that she thought she needed to go get someone else to assist her when he started with his agitated movements. In a phone interview with the Administrator on 3/14/24 at 3:11 pm she stated that NA #1 wanted the surveyor to call her back so that she could clarify some information that she had given in a previous interview on 3/12/24 at 4:22 pm. The Administrator stated that NA #1 had never left the bedside on 1/18/24 when the resident fell out of the bed. In a follow up phone interview with NA #1 on 3/14/24 at 3:31 pm she indicated that her statement in a phone interview on 3/12/24 at 4:22 PM was correct but clarified that she never left his bedside prior to the fall. She explained that she stood beside the bed the entire time. She stated that she took his shirt off and thought in my head that she needed to go get someone to help when he got agitated. NA #1 stated that she stood beside his bed but did not grab him or hold him when he thrashed around because she did not want to restrain him but didn't want him to fall off the bed so she hovered her hand over his body without touching him. She stated she was on the side of the bed closest to the door and kept her hand hovered over him and that he thrashed toward her side of the bed. She felt that if she stood there and hovered her hand over him that she was not restraining him and if he moved to her side of the bed that he would not fall and hit the floor. She indicated that he then suddenly sat up and threw himself toward the opposite side of the bed and fell off the bed (from where NA #1 was standing) before she could stop him. She rationalized that when he sat up, she thought he was going to lay back down but he didn't and he instead flung himself off the opposite side of the bed. During an interview with Nurse #3 on 3/12/24 at 3:09 pm she stated that Resident #1 would get anxious when he was left alone or if staff tried to change him. She stated that his behavior was childlike and when he became anxious or agitated that he would swing his body, arms, and legs and that he could fall out of the bed. She described his movements as flailing and that he would flail and move around a lot when staff tried to provide care. She stated that interventions were in place for him that included lower bed position and fall mats on the floor. The interview further revealed that he had a fall in January 2024, but she could not recall the date, when NA #1, who was unfamiliar with him and did not know how anxious he would get, assisted him with morning care and he flipped himself off the bed. She stated that NA #1 had the bed raised while she gave him care and worked without assistance with him the day he fell . After he fell his care plan was changed so that 2 or more staff assisted Resident #1 when care was provided. She recalled that blood was everywhere, and she called a code green (to indicate a fall) and after she saw the amount of blood that she called 911 (EMS-Emergency Medical Services) and stayed with him until EMS arrived. Nurse #3 further indicated that she attempted to get a brief on him after he fell when he was on the floor while she waited for EMS to arrive, but he twisted all around and she could not. She stated that he had a laceration to his left forehead that bled a lot. In an interview with a family member on 3/12/24 at 3:00 pm it was revealed that Resident #1 fell out of his bed on 1/18/24 and was taken to the hospital where he received sutures to his forehead. She stated that she arrived at the facility on 1/18/24, the day he fell off the bed, just before he was transported to the hospital and that his face was covered with blood. Review of hospital emergency department (ED) records dated 1/18/24 revealed Resident #1 was received in the ED on 1/18/24 at 1:11 pm from EMS (Emergency Medical Services) with a chief complaint of a fall out of bed with a laceration above the left eye. Resident #5 was assessed to have the worst possible pain as rated on a numeric/faces pain scale (a pain scale that assigns a number to a face to assess pain in an individual that is unable to report pain. A 0 point 'happy face' represents the absence or lack of pain. A 10 point 'crying face' represents the worst possible or most excruciating pain). The physician was called to the bedside immediately due to the nature of Resident #1's laceration. He was assessed by the physician to have a large hematoma above his left eye with a significant laceration that actively bled and the bleeding was not well controlled with applied pressure. Resident #1 was placed in a C (cervical) collar (to prevent movement of the head and neck) and lidocaine (a medication to numb) and epinephrine (a medication to constrict blood vessels) were ordered to get as rapid a closure [of the laceration] as possible. 7 sutures were placed to close the laceration. Resident #1 received fentanyl (pain medication) 25 micrograms/0.5 milliliters via intravenous push (medication given all at one time). A CT (computerized tomography) brain scan (a diagnostic imaging exam that uses X-ray technology to produce images of the inside of the body) was done with the findings of a left frontal scalp hematoma (a pool of mostly clotted blood) with no intercranial (in the brain) bleeding. Resident #1 was discharged back to the facility from the hospital on 1/18/24 at 6:03 pm. In an interview with the DON on 3/13/24 at 10:17 am it was revealed that the facility provided fall prevention training for staff when every fall occurred. She stated that it was discussed in the training how the fall happened, how the fall could be prevented, if the care plan needed to be updated, and how many staff should have been used. She indicated that Resident #1 received care using the number of staff that he was care planned for at the time of the fall which was 1-2 staff members. During an interview with NA #2 on 3/13/24 at 1:31 pm she stated that Resident #1 moved around a lot during his care and that she noticed that his movement increased around the time he had a fall but did not recall if the increased movement started prior to his fall in January 2024. She described his movement as jerk-like and stated that when he was rolled over in bed that he would jerk his body and swing his arms and legs. She stated that he had always had these types of movements since he was admitted about a year ago but it had gotten worse. She stated that he had always required 2 staff to assist with all his care since he was admitted to the facility about a year ago because he moved a lot. NA #2 stated that she believed it was not safe to work with Resident #1 without assistance from another staff for the safety of Resident #1 and the staff since he kicked and moved around so much during ADL care and when he was handled in any way. She indicated that that staff had received training specific to his care periodically since he was admitted prior to his fall in January of 2024. She was unable to provide specific dates that training occurred prior to the 1/18/24 fall. She further indicated that the trainings were informal and usually in a group and delivered verbally by nurse supervisors, usually after he had a fall or any change in care needs. The training typically included things like to keeping the bed in a low position, using floor fall mats beside his bed, and to always use 2 staff when care was provided. In an interview with NA #3 on 3/13/24 at 1:56 pm she stated that she had worked at the facility for about 9 months and that she had often worked with Resident #1. She stated that she and other staff had always used 2 people when they transferred or did ADL care with Resident #1 because he got agitated and had muscle spasms in his legs and that his limbs started to move around and he flopped like a fish out of water and she could not contain him alone. She further stated that his condition had worsened since the beginning of 2024. She stated that NA's were taught how to go into the computer to see the care plan and she could see how many people were needed to assist a resident, but that they received in-services each time Resident #1 had a fall and were educated verbally by a nurse supervisor to get assistance when she worked Resident #1 so she did. In an interview with the Administrator on 3/13/24 at 4:15 pm she stated that at the time of the fall that Resident #1 was a 1-2 person assist. She stated that the care plan had been updated on 2/7/24 from a 1-2 person assist to a 2 or more person assist after his fall on 1/18/24. In an interview with the MD on 3/14/24 at 3:41 pm it was revealed that Resident #1's falls were directly related to his diagnosis of cerebellar ataxia and that his spasticity had increased recently so his medication baclofen had been increased in the past few months but she was unsure of the date. She stated that he was at risk for falls related to his diagnosis. In an interview with NP #2 on 3/15/24 at 1:35 pm revealed that Resident #1 had a diagnosis of spinal cerebellar ataxia which caused uncontrolled movements and that his condition had worsened in the past few months. The Administrator was notified of immediate jeopardy on 3/13/24 at 3:53 pm The facility provided the following credible allegation of immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On 01/18/2024 at 10:50AM, at the time of the fall, the bed was the proper height for providing activities of daily living (ADL) care for Resident #1 (proper bed height can vary from resident to resident and based upon the height of the care provider); NA # 1 was at bedside and in the process of changing the resident's shirt. The following safety precautions were in place at the time of the incident: siderail, fall mats on floor on both sides of bed, and safety wedges in place bilaterally for edge of bed awareness. During this provision of care, Resident # 1 began flailing, fell out of bed and hit the bedside table resulting in a laceration to left eyebrow. NA #1 called for assistance and three staff members responded (registered nurse (RN), licensed practical nurse (LPN), certified nursing assistant (CNA). 911 was called and Resident #1 was transported to the emergency room (ER) at 3:12PM. Resident # 1 returned to the facility at 1:27AM on 01/19/2024. Resident # 1 fell from his bed secondary to uncontrollable flailing due to exacerbation of his diagnosis of cerebral ataxia. On 01/18/2024, prior to resident's return to the facility, room furnishings were rearranged by an LPN to prevent further injury and assist in facilitating an optimally safe environment. On 01/19/2024, pharmacy recommended an adjustment to Resident # 1's dosage of medication used for muscle spasms; nurse practitioner (NP) approved recommendation; new order implemented. On 01/20/2024, Clinical Competency Coordinator (CCC) completed education with CNAs regarding safety awareness and precautions while providing ADL care. Education included the importance of understanding the resident's physical and cognitive condition/ limitations in providing safe care. CNAs have access to care needs and interventions through the tablets provided for CNA documentation. On 02/07/2024, an additional fall mat was placed on the left side of bed. On 02/07/2024, care plan was updated to reflect, provide 2 or more person assist with ADLs as needed. On 02/15/2024, mattress with bolsters in place for edge of bed reminder. On 02/20/2024, a pharmacy consultant conducted medication review for purposes to reduce falls. Vitamin D added. Per the National Institute of Medicine, Vitamin D has a direct influence on muscle strength and is regulated by specific vitamin D receptors in muscle tissue .Insufficient vitamin D is associated with lower physical performance and greater declines in physical functioning . On 03/02/2024 & 03/03/2024, Director of Health Services (DHS)/ Director of Nursing (DON) conducted a review of residents at high risk for falls (as identified by our Electronic Health Record (EHR) clinical risk insight report) related to diagnosis and/ or physical/ cognitive limitations. Safety interventions were reviewed to ensure individual needs for assistance with ADLs are being met and are identified on the care plan as well as the CNAs documentation tool. Individual resident needs for assistance with ADLs may be identified through any of the following, but are not limited to: care plan meetings, multiple nursing resident assessment tools, Minimum Data Set assessments, therapy evaluations, residents' history and physical, etc. Any outstanding interventions were entered as identified during the audit process by the respective auditing clinical manager; the CNA documentation tool is automatically updated when a care plan intervention is added or updated in the EHR. On 03/06/2024, medical director (MD)/ NP reviewed medications for purposes to reduce falls. Medication used to decrease anxiety was added to the resident's medication regimen. All residents have the potential to be affected if staff fail to follow safe resident care practices. Safe resident care practices include but are not limited to the following: bed in optimal position for resident safety, bed at appropriate height during the provision of ADL care, after providing ADL care staff are to ensure all ordered fall interventions are in place prior to leaving the room, staff are to utilize tablets to access resident specific safe care interventions, etc. 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 03/13/2024, CCC provided education (additional to education provided on 01/20/2024) to RNs, LPNs, and CNAs which included checking room environment for safety prior to leaving the room (e.g., ensuring bed is in optimum position for individual resident safety, any fall interventions are in place prior to leaving room, etc.). Staff who did not receive education were removed from the schedule until education can be provided. Facility does not utilize agency staff. On 03/14/2024 & 03/15/2024, clinical staff (RNs, LPNs, & CNAs) educated by the CCC on the importance of optimizing resident safety during the provision of ADL care and post care. Education included the following but not limited to: understanding resident limitations/ capabilities, knowledge of where and how to locate resident specific safety interventions, gathering care products prior to initiating resident care, after care has been started resident is not to be left unattended, after care is provided checking the environment to ensure all safety interventions are in place (e.g., fall mats, bed in lowest position (if applicable to resident need), etc.). Staff who did not receive education were removed from the schedule until education can be provided. This education will be added to new clinical team member orientation; classroom orientation is completed prior to unit/ room assignments. On 03/13/2024, an ad hoc Quality Assurance and Process Improvement (QAPI) meeting was held. Attendees were Administrator, Admin-in-Training (AIT), Director of Health Services (DHS), Unit Coordinators, Infection Preventionist (IP), CCC, Skin Integrity Nurse, and Senior Nurse Consultant (via conference call). Items discussed included: creating a safety task force reviewing all ADL care plans to ensure interventions reflect current and individualized resident needs. The task force will focus on resident safety during ADL care utilizing visual observation rounds, the clinical event log, the resident care plan, and a quality assurance (QA) tracking tool. On 03/13/2024 & 03/14/2024, clinical managers completed 100% audit of ADL care plans to ensure any resident specific safety interventions are in place and appropriate. Audit outcome reflected a need to improve timely entry of new safety interventions (e.g., fall mats, wedges, etc.). Any outstanding interventions were entered as identified during the audit process by the respective auditing clinical manager. On 03/14/2024, CCC provided education to the Nursing Staff (Licensed Nurses and C.NAs) on providing ADL care in compliance with individual safety interventions per the residents' plan of care. Nurses and CNAs are to review the CNA Care profile in electronic health record (EHR) available on documentation devices for information on resident specific care needs. Staff who did not receive education were removed from the schedule until education can be provided. Facility does not utilize agency staff. CCC monitors education for completion. Effective 03/14/2024, CCC will provide education to new clinical team members orientation (RNs, LPNs, CNAs) regarding the importance of understanding your residents and meeting their individual needs. This education will include where and how to find information on interventions needed for the provision of safe care for each resident. Classroom orientation is completed prior to unit/ room assignments. Date of Immediate Jeopardy Removal: 3/15/24 The credible allegation of immediate jeopardy removal was verified on 3/15/24. Interviews were conducted with a sample of Nursing Assistants and Nurses to verify education was conducted for Nurses and NAs regarding safe delivery of care for residents. Documentation of in-service records was reviewed. A review of audits of ADL care plans dated 3/13/24 and 3/14/24 were verified to be completed. In an interview with the Clinical Competency Coordinator on 3/15/24 at 4:05 pm, he stated that all Nurses, Nursing Assistants, and therapists had been educated on providing care for all residents, how to access the electronic medical record and find the care plan and if in doubt to ask a nurse, supervisor or therapy. He stated that he was responsible for orienting new nurses and nursing assistants on providing safe care to residents for all residents. He further stated that orientation had been updated to include Resident Safety Awareness/training for nursing staff that included falls, what to do, interventions, and who to notify. An observation of the Resident #1's room and environment revealed that Resident #1 was in bed and fall mats were in place on both sides of the bed, the bed was in a low position, furniture had been arranged a safe distance away from the bed, side rails hand been padded, and mattress bolsters were in place at the edges of the bed. A family member of Resident #1 was in the room sitting at his bedside. During the survey, observations were made of care being provided to multiple residents and no concerns were identified with the safe provision of care. The facility's immediate jeopardy removal date of 3/15/24 was validated.

Based on record review, and staff, resident, Medical Director (MD), and Nurse Practitioner (NP) interviews the facility failed to administer prescribed narcotic pain medication for 1 of 2 residents (Resident # 3) reviewed for pain management. Resident #3 was admitted on [DATE] and did not receive his prescribed pain medication for 5 days after he was admitted to the facility resulting in the resident experiencing increased pain rated as a 7 on a 0-10 pain scale (on a numeric pain scale designed to evaluate pain in individuals using a number value with 0 being no pain and 10 being the worst pain possible). Findings included: Resident #3 was admitted to the facility on [DATE] with a diagnosis that included chronic osteomyelitis (serious infection of the bone). Review of Physician orders dated 12/1/23 indicated that Resident #3 was prescribed oxycodone 10 milligram (mg) tablet, take one tablet every four hours PRN (as needed) for chronic pain. Review of the December 2023 Medication Administration Record (MAR) revealed that on 12/1/23, 12/2/23, 12/3/23, 12/4/23, and 12/5/23 that Resident #3 did not receive his PRN oxycodone. This was evidenced by an x mark placed in the date box that indicated that the medication had not been administered. A pain assessment had been completed by Nurse #4 on 12/3/23 for Resident #3 and was documented as a 7. In a phone interview with Nurse #4 on 3/14/24 at 11:12 am it was revealed that he did not recall Resident #3 or if he had pain because he worked the short-term rehabilitation unit, and his residents only stayed a short time and there was a lot of turnover of residents. He stated that he did not recall if or what he may have communicated to the Physician about Resident #3's pain medication. He stated that if the pain medication was not available the nurses could have gotten it out of the pyxis (a locked medication dispenser intended to be utilized when a resident was out of or did not have a medication until their medication was delivered from the pharmacy), or they could have contacted the Physician to get something else ordered that could be pulled from back up medication supply until the Resident #3's medication became available. He stated that he could not recall if he had asked for an alternative medication for Resident #3. Record review of a Request for Treatment dated 12/5/23 completed by Nurse #3 for Resident #3 indicated that Nurse #3 made a written request to the contract physicians' group requesting that oxycodone 10 mg tablets be called into the pharmacy ASAP (as soon as possible) to make sure scripts were in so she could get them out of the pyxis. In a phone interview with Nurse #3 on 3/14/24 at 3:18 pm she stated that she was assigned to care for Resident #3 on 12/5/23 and that he did not complain of pain but wanted to know where his oxycodone was. She stated he would ask her when it would come each time she brought him his routine scheduled medications throughout the day. She further indicated that Resident #3 was calm and not freaking out and she let him know that his pain medication would be in that night. Nurse #3 stated that she was surprised when she came in to work that his medications were not in yet. She further indicated that when she learned that his pain medication had not been delivered that she filled out a Request for Treatment form that she faxed to the provider to get the signed orders so the pharmacy would send his pain medication. Record review of pharmacy delivery records indicated that Resident #3's medication, oxycodone 10 mg tablets, were signed as delivered to the facility on [DATE] and received by Nurse #6. The MAR indicated that Resident #3 received his first dose of oxycodone on 12/6/23 at 12:26 am. There was no documented pain level. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was cognitively intact and was coded to receive an opioid pain medication. He was assessed to have no pain. Review of a nurse progress note dated 12/18/23 written by Nurse #3 revealed that Resident #3 was discharged to the hospital on 12/18/23 and he did not return to the facility. In a phone interview with Resident #3 on 3/14/24 at 9:29 am he stated that he had pain every day after admission until his pain medication came in. He described the pain in his hips, back, and shoulders as a 7 or 8 on a 0-10 pain scale. Resident #3 stated that he finally started to receive his pain medication around the 5th day after admission and then his pain level became more tolerable and stated that a pain level of 7 or 8 was not tolerable to him. He stated that he was offered acetaminophen, but he could not take that because of other health issues. Resident #3 stated that after his pain medication came in from the pharmacy that things calmed down for him. An interview with the Director of Nursing on 3/13/24 at 4:30 pm revealed that she was unaware that Resident #3 did not get his narcotic pain medication for 5 days and that a resident should not have had to go 5 days without a pain medication. In an interview with the Administrator on 3/13/24 at 4:45 pm she stated that she would have expected that Resident #3 would have received his medications as ordered and not missed doses. The interview further revealed the facility had a pyxis on-site that nurses could access to obtain needed medications. She stated that if the resident's pain medication was not available that the nurse could have called the Physician to get an order for something that was available in the pyxis until his medication was available. In a phone interview with the facility Medical Director (MD) on 3/14/24 at 3:41 pm it was revealed that other than the pain that Resident #3 had to endure for the 5 days without the medication that he did not suffer any harm from the missed doses of pain medication. During a phone interview with NP #1 on 3/15/24 at 2:11pm she stated that she was not aware that Resident #3 did not get his prescribed narcotic pain medication as ordered and that Resident #3 should not have had to wait 5 days for his medications to become available to him.

Based on record review, and staff, resident, Pharmacist, Medical Director (MD), and Nurse Practitioner (NP) interviews the facility failed to obtain narcotic medications from the pharmacy for 1 of 10 resident (Resident # 3) reviewed for pharmacy services. This caused Resident #3 to miss 5 days of pain medication, 4 days of anti-anxiety medication and 3 days of sedative/hypnotic medication that resulted in increased pain, anxiety, and inability to sleep for Resident #3. Findings included: Resident #3 was admitted to the facility on [DATE] with a diagnosis that included atrial fibrillation (an irregular rapid heart rate), anxiety disorder, chronic osteomyelitis (serious infection of the bone), and insomnia. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was cognitively intact and was coded to receive an opioid, anxiolytic, and hypnotic. Review of Physician orders dated 12/1/23 indicated that Resident #3 was prescribed lorazepam 1 mg tablet, take one tablet 3 times a day for anxiety disorder, oxycodone 10 mg tablet, take one tablet every four hours PRN (as needed) for chronic pain, and zolpidem 10 mg tablet, take one table at bedtime for obstruction sleep apnea. Review of the December 2023 Medication Administration Record (MAR) revealed that on 12/1/23, 12/2/23, 12/3/23, 12/4/23, and 12/5/23 that Resident #3 did not receive his PRN oxycodone and on 12/2/23, 12/3/23, 12/4/23, and 12/5/23 he did not receive his scheduled lorazepam. The review further revealed that he did not receive his scheduled zolpidem on 12/1/23, 12/2/23, or 12/3/23. This was evidenced by nursing initials placed in parenthesis and a reason documented on the MAR as Not Administered: Drug/Item Unavailable. Record review of pharmacy delivery records indicated that the medications Zolpidem 10 mg tablets, lorazepam 1 mg tablets, and oxycodone 10 mg tablets were signed as delivered to the facility on [DATE] and received by Nurse #6. Review of a nurse progress note dated 12/18/23 written by Nurse #3 revealed that Resident #3 was discharged to the hospital on 12/18/23 for an unrelated concern and he did not return to the facility. In an interview with Nurse #3 on 3/13/24 at 3:23 pm she stated that she was unsure why the pharmacy did not send the medication and thought that they were waiting for a Physician to approve it. The interview further revealed that the hospital should have sent written prescriptions for the narcotics to the facility with Resident #3 but that they did not always do that. Nurse #3 stated that the pharmacy is notified when a newly admitted residents orders are entered into the EMR and recalled that they were waiting for the hard script (written narcotic prescription signed by the prescriber) and that the providers for the facility would not provide a written prescription for narcotics until the provider evaluated the resident. She further indicated that the process was that a nurse would put a note in the providers mailbox and the provider would get it the next morning and would evaluate the resident and then write a hard script. Nurse #3 further indicated that they had a backup medication system (a locked medication dispenser intended to be utilized when a resident was out of or did not have a medication until their medication was delivered from the pharmacy) at the facility but that she did not know the process of how to get into the system to get medications for a resident. Nurse #2 indicated that the pharmacy had to have the active signed written prescription before they would send a narcotic medication. In an interview with the Unit 2 Coordinator on 3/13/24 at 3:28 pm it was revealed that Resident #3 was admitted in the evening on 12/1/23 and that the hospital did not send the signed hard scripts with him for the narcotics. She stated that it was facility policy that the facility physician or nurse practitioners could not send narcotic prescriptions to the pharmacy until a provider had seen and evaluated the resident. The Unit 2 Coordinator provided a fax confirmation that showed the facility faxed the hard scripts to the pharmacy on 12/1/23 at 9:41 pm. Review of a fax transaction form dated 12/1/23 revealed the facility had faxed Resident #3's hard scripts for his narcotic medication to the pharmacy at 9:41pm and that the result was OK. The faxed form had handwriting that read came from [hospital name] on 12/1 scripts not signed please send in new scripts for all meds attached so resident can have scheduled and as needed. Attached to the form were 3 unsigned hard scripts for lorazepam 1 mg, oxycodone 10 mg, and zolpidem 10 mg. This form was not signed by the sender. In a phone interview with Resident #3 on 3/14/24 at 9:29 am he stated that he had pain every day until his pain medication came in. He described the pain in his hips, back, and shoulders as a 7 or 8 on a 0-10 pain scale. Resident #3 stated that he finally started to receive his pain medication around the 5th day after admission and then his pain level became more tolerable and stated that a pain level of 7 or 8 was not tolerable to him. The interview further revealed that Resident #3 could not sleep until his zolpidem came in and that he had been taking lorazepam for 4 or 5 years and that his atrial fibrillation could get worse if he did not have his lorazepam. Resident #3 stated that after these medications came in from the pharmacy that things calmed down for him. An interview with the DON on 3/13/24 at 4:30 pm revealed that she was unaware that Resident #3 did not get his narcotic medication for 5 days and that the process was that if a resident was admitted without a hard script from where they discharged from that staff should have to called the facility's on-call provider to get an order to get something out of the facility's back up medication supply. She stated that the pharmacy would then have called the nurse on duty to give her a code to get the narcotic from the back-up medication supply. She further stated that nothing should have prevented staff from calling the Physician to get an e-script (electronic prescription) sent by the Physician to the pharmacy or that the Physician could have sent a STAT (urgent or rush) order and it would have been directed to a back-up pharmacy that was just across the street from the facility and that pharmacy would have delivered the medication to the facility. The interview further revealed that the facility did not have a policy that stated that a Physician was required to see and evaluate a resident before they wrote a hard script or sent an e-script to the pharmacy for a narcotic. In an interview with the Administrator on 3/13/24 at 4:45 pm she stated that if a resident was admitted late on a Friday that she hoped that the hospital would have sent a hard script or would have e-scripted the order to the pharmacy. She further added that for the same night delivery of a medication that the pharmacy would have had to receive the order by 3:00 pm the same day. The interview further revealed the facility had a pixis (a locked machine that contained a supply of back up medications) on-site that nurses could access to obtain needed medications. She stated that if the resident was admitted without the hard script that the nurse could have called the Physician to get an order for something that was available in the pixis until their medication was available. She stated that the facility did not have a policy that stated that the Physician had to see and evaluate a resident before they could write a hard script for a narcotic medication but that she had heard that the contracted physician group required that. In a phone interview with Nurse # 4 on 3/14/24 at 11:12 am it was revealed that he stated that he did not recall Resident #3 because he worked the short-term rehabilitation unit and his residents only stayed a short time and there was a lot of turnover of residents. He stated that he did not recall if or what he may have communicated to the Physician about Resident #3's medications. He stated that when residents were admitted late on a Friday that the facility had issues with getting signed hard scripts from the on-call Physician. He stated that an alternative would be that if the medication was not in the back-up supply that they could get something else ordered that could be pulled from back up medication supply until they could get the hard scripts signed, but if the on-call Physician or provider did not have the ability to do an e-script then they were stuck. He stated that he could not recall if he asked for an alternative medication for Resident #3. Nurse #4 described his process to ensure that he does not run out of medications for a resident is that when he counted narcotics with another nurse that he noted how low a narcotic was getting and he would go to the medical provider that was on that day and get new prescriptions and that he did the same process with newly admitted residents. He further stated that if a resident came in late on Friday and the prescriptions were not signed that he could not pull the medication from back-up supply if they did not have an active e-script and without a signed prescription there was nothing that he could do. He stated if the order got e-scripted on a Friday night that it would not have arrived until Saturday night. He further indicated that he thought the problem was a process issue. In a phone interview with Nurse #3 on 3/14/24 at 3:18 pm she stated that she was assigned to care for Resident #3 on 12/5/23 and that wanted to know where his lorazepam and oxycodone were. She recalled he was prescribed lorazepam 3 times a day and would ask her if they were in his medication cup when she brought him his medications. She stated he would ask her when they would come it. She further indicated that Resident #3 was calm and not freaking out and she let him know that his medications would be in that night (12/5/23). Nurse #3 stated that she was upset that his medications had not come in yet because she had worked on Friday but not the weekend and was surprised when she came in that his medications were not in yet and she wanted to know why. She further indicated that she then filled out a Request for Treatment form that she faxed to the provider to get the signed orders. Record review of a Request for Treatment dated 12/5/23 completed by Nurse #3 for Resident #3 indicated that Nurse #3 made a written request to the contract physicians' group requesting that oxycodone 10 mg tablets, and lorazepam 1 mg tablets be called into the pharmacy ASAP (as soon as possible) to make sure scripts are in and we can get them out of the pyxis. In a phone interview with the facility Medical Director (MD) on 3/14/24 at 3:41 pm it was revealed that getting signed hard scripts from the hospital for residents at discharge had been a night [NAME], that the resident was supposed to come from the hospital with a 3 or more day supply of prescribed narcotics but they never came with anything and the policy for the facility is that if you don't get prescriptions sent in to their pharmacy that you will not get the medication until the next day, especially narcotics. The interview further revealed that the contracted physicians' group that she was employed by did require that a Physician see and evaluate a resident before a hard script for a narcotic was written, but that she did not require that and permitted her NP's to write a hard script for a narcotic even if the resident had not been see and evaluated by the Physician. She stated that the NP should have had enough confidence in the nurse to believe the nurse and should have e-scripted the order to the pharmacy. The MD further indicated that medical providers are always on call 24 hours a day 7 days a week to include holidays so staff could have called at any time and talked to a provider to get an e-script. She stated that, other than anxiety and pain that Resident #3 had to endure for the 5 days without the medication that he did not suffer any harm from the missed doses of medication. In a phone interview with Nurse # 5 on 3/15/24 at 9:51 am revealed that she did not recall Resident #3 but there was a protocol for obtaining medication for newly admitted residents. She stated that they used to have access to the pyxis and would just go pull the medication that the resident needed. She stated that now the process is they faxed the medication list to the pharmacy, and the medications came in later that night. She stated that lately that she could not get into the new pyxis to pull medications out for residents. The interview further revealed that if she received a hard script not signed by a physician that she would call the on-call physician to get an order sent to the pharmacy and the pharmacy would send a code to the nurse so that she could pull the narcotic from the new pixis. She stated an on-call physician could be reached 24 hours a day 7 days a week. In a phone interview with the pharmacist 3/15/24 at 11:14 am it was revealed that that the faxed prescriptions for Resident #3 were not received by the pharmacy until after 2:00 pm on Saturday 12/2/23 so no one at pharmacy saw the prescriptions until Monday 12/4/23. The pharmacist stated their records indicated that Resident #3's hard scripts came over at 5:30 pm on Saturday after their cut off time of 2 pm. He further stated that the pharmacy is closed on Sundays, so they didn't see the order and follow-up until Monday 12/4/23. He stated the original faxed hard scripts received by the pharmacy on 12/2/23 were not signed by the prescriber so the prescription could not be filled on 12/4/23. He indicated that on 12/4/23 that the pharmacy notified a nurse at the facility by phone that they needed new signed hard scripts. He stated that on 12/5/23 the pharmacy received the signed hard scripts from the facility MD and that the medications were sent to the facility that night. The interview further revealed that the facility should have used the back-up pharmacy after the established cut off times of 5:50 pm on weekdays and 2:00 pm on Saturdays. The Pharmacist stated that the facility should have notified the Physician that they needed signed hard scripts and the physician could have sent the signed hard scripts to the back-up pharmacy. He stated the nurses would not have been able to access the pyxis because the hard scripts had not been signed. During a phone interview with NP #1 on 3/15/24 at 2:11pm it was revealed that she was familiar with Resident #3 and that the contracted physicians' group had a triage line for after hours and the facility had instruction on how to use this line and could call it 24 hours a day 7 day a week. She indicated that facility nurses recently told her that they did not know about the triage line or that they could have called it. She stated that the staff should have called the DON who could have provided them with that triage number.

Based on record review, and staff, resident, famiy, Pharmacist, Medical Director (MD), and Nurse Practitioner (NP) interviews the facility failed to administer prescribed medications for 1 of 10 resident (Resident # 3) reviewed to ensure residents are free from significant medication errors. Resident #3 was admitted on [DATE] and did not receive his prescribed pain medication for 5 days, his anti-anxiety medication for 4 days, and did not receive his prescribed sedative/hypnotic medication for 3 days after he was admitted to the facility which caused Resident #3 to experience pain, anxiety, and inability to sleep. Findings included: Resident #3 was admitted to the facility on [DATE] with a diagnosis that included atrial fibrillation (an irregular rapid heart rate), anxiety disorder, chronic osteomyelitis (serious infection of the bone), and insomnia. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed Resident #3 was cognitively intact and was coded to receive an opioid, anxiolytic, and hypnotic. Review of Physician orders dated 12/1/23 indicated that Resident #3 was prescribed lorazepam 1 mg tablet, take one tablet 3 times a day for anxiety disorder, oxycodone 10 milligrams (mg) tablet, take one tablet every four hours PRN (as needed) for chronic pain, and zolpidem 10 mg tablet, take one table at bedtime for obstruction sleep apnea. Review of the December 2023 Medication Administration Record (MAR) revealed that on 12/1/23, 12/2/23, 12/3/23, 12/4/23, and 12/5/23 that Resident #3 did not receive his PRN oxycodone and on 12/2/23, 12/3/23, 12/4/23, and 12/5/23 he did not receive his scheduled lorazepam. The review further revealed that he did not receive his scheduled zolpidem on 12/1/23, 12/2/23, or 12/3/23. This was evidenced by nursing initials placed in parenthesis and a reason documented on the MAR as Not Administered: Drug/Item Unavailable. Record review of pharmacy delivery records indicated that the medications Zolpidem 10 mg tablets, lorazepam 1 mg tablets, and oxycodone 10 mg tablets were signed as delivered to the facility on [DATE] (no time indicated) and received by Nurse #6. Review of a nurse progress note dated 12/18/23 written by Nurse #3 revealed that Resident #3 was discharged to the hospital on 12/18/23 for an unrelated concern and he did not return to the facility. In an interview with Nurse #3 on 3/13/24 at 3:23 pm During the interview Nurse #3 had difficulty accessing the information in the electronic medical record (EMR) and asked for assistance from Nurse #2 who indicated that the parenthesis around a nurse initial on MAR indicated that the medication was not given. She further stated that Resident #3 did not receive his first dose of oxycodone until 12/6/23 and that it had been documented that the medication was not available on the dates prior to 12/6/23 and there were no notes that indicated that a provider had been contacted. In a phone interview with a family member of Resident #3 on 3/14/24 at 9:24 am she indicated that Resident #3 was no longer a resident at the facility. She stated that he did not have pain medication for the first 5 days after he was admitted to the facility the staff told her that the discharge Physician at the hospital should have ordered the medications that Resident #3 required. She stated that he was in pain most of the time all the time due to osteomyelitis in his hip and femur, and degeneration in his spine and shoulders. She stated that he had pain from the day he was admitted to the facility and that he consistently reported to the staff that his pain level was at a 7 out of 10 (on a numeric pain scale designed to evaluate pain in individuals using a number value with 0 being no pain and 10 being the worst pain possible). She stated that his pain was controlled after he started to receive his pain medications. In a phone interview with Resident #3 on 3/14/24 at 9:29 am he stated that he had pain every day until his pain medication came in. He described the pain in his hips, back, and shoulders as a 7 or 8 on a 0-10 pain scale. Resident #3 stated that he finally started to receive his pain medication around the 5th day after admission and then his pain level became more tolerable and stated that a pain level of 7 or 8 was not tolerable to him. He stated that he was offered acetaminophen, but he could not take that because of his kidneys and liver problems, and he could not take ibuprofen because it did not work for him. The interview further revealed that Resident #3 could not sleep until his zolpidem came in and that he had been taking lorazepam for 4 or 5 years and that his atrial fibrillation could get worse if he did not have his lorazepam. Resident #3 stated that after these medications came in from the pharmacy that things calmed down for him. An interview with the DON on 3/13/24 at 4:30 pm revealed that she was unaware that Resident #3 did not get his narcotic medication for 5 days after he was admitted and that a resident should not have had to go 5 days without a pain medication or any other medication. In an interview with the Administrator on 3/13/24 at 4:45 pm she stated that she would have expected that Resident #3 would have received his medications as ordered and not missed doses. She indicated that if a resident was admitted late on a Friday that she hoped that the hospital would have sent a hard script or would have e-scripted the order to the pharmacy. She further added that for the same night delivery of a medication that the pharmacy would have had to receive the order by 3:00 pm the same day. The interview further revealed the facility had a pixis (a locked machine that contained a supply of back up medications) on-site that nurses could access to obtain needed medications. She stated that if the resident was admitted without the hard script that the nurse could have called the Physician to get an order for something that was available in the pyxis until their medication was available. She stated that the facility did not have a policy that stated that the Physician had to see and evaluate a resident before they could write a hard script for a narcotic medication but that she had heard that the contracted physician group required that. In a phone interview with Nurse #3 on 3/14/24 at 3:18 pm she stated that she was assigned to care for Resident #3 on 12/5/23 and that he did not complain of pain and just wanted to know where his lorazepam and oxycodone were. She recalled he was prescribed lorazepam 3 times a day and he would ask her if they were in his medication cup when she brought him his medications. She stated he would ask her when his medications would come in. She further indicated that Resident #3 was calm and not freaking out and she let him know that his medications would be in that night (12/5/23). Nurse #3 stated that she was upset that his medications had not come in yet because she had worked on Friday but not the weekend and was surprised when she came in that his medications were not in yet and she wanted to know why. During a phone interview with NP #1 on 3/15/24 at 2:11pm it was revealed that she was not aware that Resident #3 did not get his prescribed narcotics as ordered and she would have expected that Resident #3 would not have had to wait 5 days for his medications to become available to him.

Based on record review, resident, and staff interviews, the facility failed to maintain a resident's dignity by not answering a call light and allowing the resident to sit on the floor for an extended period causing Resident #31 to feel afraid, neglected, shaky, and upset. This occurred for 1 of 8 residents reviewed for dignity (Resident #31). Findings included: Resident #31 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #31 was moderately cognitively impaired. Transfers did not occur. Resident #31 was interviewed on 7-10-23 at 12:08pm. The resident discussed having a fall in May 2023 or June 2023 in the middle of the night. The resident discussed how she had put her call light on to be assisted into bed, but she stated after waiting 30 minutes, she decided to try and transfer herself. She stated she forgot to lock her wheelchair and as it started rolling, she tried to sit back down but sat on the edge of the wheelchair. Resident #31 explained she was holding on to one of the arms on the wheelchair and the side rail of the bed. She stated her call light was still on. Resident #31 stated she sat in that position for an hour before staff answered her call light. Resident #31 stated she knew the time because she had looked at the clock on her wall. The resident continued to explain once staff had answered her call light, the nurse (Nurse #3) was unable to assist her back into bed, so the nurse lowered her to the floor, and she had to wait another hour on the floor until Nurse #3 was able to find assistance to help her back to bed. The resident stated she felt afraid and neglected. A telephone interview occurred with Nurse #3 on 7-12-23 a 3:04pm. The nurse discussed she had answered Resident #31's call light on 5-20-23 and when she walked into the resident's room, she had found the resident sitting on the edge of her wheelchair with her buttocks almost touching the floor. Nurse #3 stated she could not say how long the resident's call light had been on. Nurse #3 continued to explain she was unable to transfer the resident into the bed or back into the wheelchair, so she lowered Resident #31 to the floor. She stated the resident was shaky and upset. The nurse discussed leaving the resident's call light on but stated when no one was coming to help, she sent Resident #31's roommate out to look for help. Nurse #3 said the roommate could not find anyone, so she left the room and was able to find Nursing Assistant (NA #5) to assist in getting Resident #31 back to bed. She stated it took a while to get the resident back to bed but said she did not think it was quite an hour. NA #5 was interviewed by telephone on 7-13-23 at 8:27am. NA #5 stated he was not present when Resident #31 fell but had been asked by Nurse #3 to go to Resident #31's room and assist in placing her back in the bed. The NA stated the resident was cold and had asked for a blanket, but he said he picked her up and placed her back in bed then covered her with her blankets. During an interview with the Director of Nursing (DON) on 7-13-23 at 10:12am, the DON discussed the facility policy of everyone answering call lights. She stated she was aware Nurse #3 had to lower the resident to the floor, but not aware Resident #31 had waited an hour for assistance when she was on the edge of her wheelchair or that the resident laid on the floor for an hour waiting for Nurse #3 to find assistance. The DON stated she expected staff to be answering call lights as soon as possible. The Administrator was interviewed on 7-13-23 at 12:17pm. The Administrator discussed staff carrying walkie talkies so they can request help when needed and stated she did not know why Nurse #3 had not used her walkie talkie on 5-20-23 when Resident #31 had fallen. She also commented that she could not say why it took an hour for staff to answer Resident #31's call light. The Administrator explained there was a system in place (the walkie talkies) for staff to ask for assistance and if the employees had worked the process/system it should have only taken 5-7 minutes to get Resident #31 back in bed. She also stated she expected staff to answer call lights as soon as possible.

Based on record review and resident, staff, and resident representative interviews the facility failed to protect Resident #8's right to be free from abuse for 1 of 3 sampled residents reviewed for abuse (Resident #8). On an unknown date in October 2022, Nursing Assistant (NA) #7 was witnessed by NA #8 to have grabbed hair on the top of Resident #8's head and pulled the resident's hair after Resident #8 had allegedly made derogatory statements to NA #7. A reasonable person would have experienced feelings such as intimidation, fear, humiliation, embarrassment, and/or dehumanization (deprivation of human qualities such as compassion). Findings included: Resident #8 was admitted to the facility on [DATE] with multiple diagnoses that included vascular dementia. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #8 was severely cognitively impaired. The facility's 24-hour initial report dated 10-24-22 written by the Administrator documented approximately two weeks ago NA #7 was observed pulling Resident #8's hair. The facility's 5-day report dated 10-27-22 written by the Administrator documented on the morning of 10-24-22 an initial allegation was made that NA #7 had been observed pulling Resident #8's hair. The 5-day report documented the allegation had been substantiated and Resident #8's representative had been notified. On 7-10-23 at 1:57pm Resident #8 was interviewed. The resident stated she did not remember the incident back in October 2022 and said she had not been hurt by any staff members. Resident #8's representative was interviewed by telephone on 7-11-23 at 8:35am. The representative stated Resident #8 had severe dementia and would not have remembered the incident. She stated the Administrator had notified her NA #7 had pulled Resident #8's hair hard. The representative discussed seeing Resident #8 a few days after she was informed of the incident and stated Resident #8 was fine and could not remember the incident. NA #8 was interviewed by telephone on 7-11-23 at 2:26pm. NA #8 confirmed she had been orienting with NA #7 in October 2022 when the incident occurred but stated she could not remember the exact date. The NA discussed entering Resident #8's room with NA #7 to place Resident #8 back in bed. She stated she did not hear Resident #8 make any derogatory remarks to NA #7 but saw NA #7 grab Resident #8's hair on the top of her head and pull it. She stated Resident #8 said ow. NA #8 explained what she had said to NA #7 I didn't think we were allowed to do that and stated she walked out of the room. During a telephone interview with NA #9 on 7-11-23 at 3:55pm, the NA discussed not witnessing the incident but explained NA #7 had told her about the incident. NA #9 explained it was her second night of orientation with NA #7 and they were on break when NA #7 told her Resident #8 called her the N word. She stated NA #7 told her she got so mad and pulled Resident #8's hair, then left the room to obtain hot sauce. NA #9 stated NA #7 told her when she returned to Resident #8's room, she had put the hot sauce on a wet wipe and wiped Resident #8's vagina. An interview with Nurse #5 occurred on 7-12-23 at 10:07am. Nurse #5 stated she performed the skin assessment on 10-24-22 and found no abnormalities. A telephone interview occurred with NA #10 on 7-12-23 at 10:42am. NA #10 explained she had been in Resident #8's room with NA #7 and NA #8 in October 2022 it was either the 17th, 19th, or 21st of October. The NA stated she had been providing care to Resident #8's roommate when she heard Resident #8 say ouch you're hurting me. She stated by the time she looked over towards Resident #8, she did not see anything happening. NA #10 discussed seeing NA #8 walk out of the room looking very upset but said she did not know why. An attempt was made to contact NA #7 but there was no working phone number available. The DON was interviewed on 7-12-23 at 10:17am. The DON discussed on 10-24-22 at 8:00am when she came to work, the previous Human Resource Coordinator had informed her NA #7 had been calling saying staff were accusing her of putting hot sauce in Resident #8's brief. The DON stated when she interviewed NA #8, the NA told her NA #7 had grabbed Resident #8's hair on the top of her head and pulled the hair down towards the resident's face. She stated she also interviewed NA #10, who was present in the room but did not say she saw NA #7 pull Resident #8's hair. The DON explained none of the employees could say what day the incident occurred, but she had narrowed down the time frame through NA #8's orientation schedule to be within two weeks prior to 10-24-22.

Based on record review, staff and resident interviews the facility failed to maintain a resident's dignity by not providing incontinence care which made the resident feel terrible and that staff did not care about her. This occurred for 1 of 3 residents (Resident #174) reviewed for dignity and respect. Findings included: Resident #174 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #174 was moderately cognitively impaired and required dependent assistance with one person for toileting and bathing. The MDS also coded Resident #174 always incontinent of bowel and bladder. Resident #174 was interviewed on 4-18-22 at 3:00pm. The resident discussed on 4-16-22 she had received incontinence care at 3:00pm from the Nursing Assistant (NA) #1 who worked 7:00am to 3:00pm. She stated she had not received incontinence care again until 7:00am on 4-17-22. Resident #174 stated she was aware of the time because of the clock that was on the wall in front of her bed. She explained she had put her call light on for assistance around 7:30pm and a NA had come in, shut off the light and told her she would be back. The resident stated no one came back so she put her light on again around 10:00pm, but no one answered. Resident #174 described her bed linen; floor and her gown were soaked with urine. She stated she was unable to sleep, felt terrible, and that staff did not care about her. During an interview with NA #1 on 4-19-22 at 3:40pm, NA #1 confirmed she had been assigned to Resident #174 on 4-16-22 on the 7:00am to 3:00pm shift. She also confirmed she had provided incontinence care to Resident #174 around 3:00pm on 4-16-22. NA #1 discussed Resident #174 was not known to have large output of urine and did not require more than every 2-hour checks. The NA stated when she returned to work on 4-17-22 at 7:00am, she was assigned to Resident #174. She stated she made her initial round shortly after 7:00am and found Resident #174 drenched in urine. She said the resident was upset and had told her no one had been in all night to provide her care. The NA explained Resident #174's gown, sheets, and pad were soaked with urine, and she could see brown/yellow dried rings of urine under the recent wet urine. NA #1 stated she did not remember any urine on the floor. She stated she provided a bath and changed the resident's linens. NA #2 was interviewed on 4-20-22 at 9:30am by telephone. NA #2 confirmed she was assigned to Resident #174 on 4-16-22 on the 11:00pm to 7:00am shift. She explained she was assigned 25 residents that night and could not remember if Resident #174 had put on her call light for assistance or when she had provided incontinence care to Resident #174. NA #2 also explained she was not always able to provide care to every resident when she had 25 or more assigned to her. The NA confirmed Resident #174 would put on her call light when she needed incontinence care or she stated, sometimes I just go in to check. She stated she could not remember when she had provided incontinence care but now stated she thought maybe around 5:00am. The NA stated Resident #174 was not known to have a large output of urine that required more than every 2-hour checks. An attempt was made to contact the nurse who worked on 4-16-22 from 11:00pm to 7:00am with no return call. An interview with NA #4 occurred on 4-19-22 at 2:30pm. NA #4 stated Resident #174 would put on her call light when she required incontinence care. She also said Resident #174 was not known to have a large output of urine and did not require more than every 2-hour checks. The NA discussed Resident #174 had to wait 2-3 hours for care to be provided if the facility only had 2-3 NAs working. During an interview with the Director of Nursing (DON) on 4-21-22 at 10:12am, the DON stated resident #174 can be a heavy wetter so care could have been done. She also stated Resident #174, nor NA #1 had brought the issue to her attention.

Based on record review, observation, resident and staff interviews the facility failed to provide incontinence care for a dependent resident resulting in the resident feeling terrible and that staff did not care about her. This occurred for 1 of 3 residents (Resident #174) reviewed for incontinence care. Findings included: Resident #174 was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission minimum Data Set (MDS) dated [DATE] revealed Resident #174 was moderately cognitively impaired. The MDS had coded Resident #174 for verbal behaviors towards others 1-3 days out of 7 but not for refusal of care. Resident #174 was also coded as always incontinent of bowel and bladder and coded as dependent for toileting and bathing with one person assist. Review of Resident #174's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #174 was interviewed on 4-18-22 at 3:00pm. The resident discussed on 4-16-22 she had received incontinence care at 3:00pm from the Nursing Assistant (NA) who worked 7:00am to 3:00pm. She stated she had not received incontinence care again until 7:00am on 4-17-22. Resident #174 stated she was aware of the time because of the clock that was on the wall in front of her bed. She explained she had put on her call light for assistance, but no one answered. Resident #174 described her bed; floor and her gown were soaked with urine. She stated she was unable to sleep, felt terrible, and that staff did not care about her. Observation of incontinence care occurred on 4-19-22 at 2:15pm with NA #4. The resident's skin was observed to be intact with no redness. Resident #174's brief was noted to be wet but not saturated. An interview with NA #4 occurred on 4-19-22 at 2:30pm. NA #4 discussed checking her residents every 2 hours for incontinence care but stated if there were not enough staff, the resident may have to wait 2-3 hours for care to be provided. She stated Resident #174 would put on her call light when she required incontinence care and said Resident #174 did not require more frequent incontinence care. During an interview with NA #1 on 4-19-22 at 3:40pm, NA #1 confirmed she had been assigned to Resident #174 on 4-16-22 on the 7:00am to 3:00pm shift. She also confirmed she had provided incontinence care to Resident #174 around 3:00pm on 4-16-22 and that Resident #174 was not known to have a large output of urine. The NA stated when she returned to work on 4-17-22 at 7:00am, she was assigned to Resident #174. She stated she made her initial round shortly after 7:00am and found Resident #174 drenched in urine. She said the resident was upset and had told her no one had been in all night to provide her care. The NA explained Resident #174's gown, sheets, and pad were soaked with urine, and she could see brown/yellow dried rings of urine under the recent wet urine. NA #1 stated she did not remember any urine on the floor. She stated she provided a bath and changed the resident's linens. NA #2 was interviewed on 4-20-22 at 9:30am by telephone. NA #2 confirmed she was assigned to Resident #174 on 4-16-22 on the 11:00pm to 7:00am shift. She explained she was assigned 25 residents that night and could not remember if Resident #174 had put on her call light for assistance or when she had provided incontinence care to Resident #174. The NA confirmed Resident #174 would put on her call light when she needed incontinence care or she stated, sometimes I just go in to check. She stated she could not remember when she had provided incontinence care but now stated she thought maybe around 5:00am. The NA stated Resident #174 was not known to have a large output of urine that required more than every 2-hour checks. During an interview with the Director of Nursing (DON) on 4-21-22 at 10:12am, the DON stated resident #174 can be a heavy wetter so care could have been done. She also stated Resident #174, nor NA #1 had brought the issue to her attention.

Based on record review, residents, family, facility staff, [CONDITION(S)] staff and physician interviews, the facility failed to prevent a significant medication error by administering insulin to the wrong resident for 1 of 2 residents (Resident #1). Resident #1 did not have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Immediate jeopardy began on 9/03/21 when the facility failed to prevent a significant medication error by administering insulin to the wrong resident for 1 of 2 residents (Resident #1). Resident #1 was sent to the [CONDITION(S)] center and they sent him to the hospital for [CONDITION(S)]. The immediate jeopardy was removed on 9/30/21 when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure that the education and the monitoring systems put in place to remove the immediate jeopardy are effective and to correct current deficient practice as identified. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's Minimum Data Set, dated dated dated [DATE] indicated the resident was cognitively intact and was coded to have received no injections of any type. A review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #2's Minimum Data Set, dated dated dated [DATE] indicated the resident was cognitively intact and was coded to have received insulin injections for 7 days during the look back period. A review of Resident #2's physician orders' indicated he was ordered [MEDICATION(S)] 70/30 insulin 10 units twice a day at 9:00 AM and 5:00 PM. [MEDICATION(S)] is a combination insulin medication administered to treat Diabetes Mellitus which starts to work within 10 to 20 minutes after injection. It peaks in 2 hours and continues to work for as long as 24 hours. An interview on 9/21/21 at 2:24 PM with Resident #1 revealed he had been given an injection on 9/03/21 around 9:00 AM which he stated Nurse #1 told him was insulin. He said the nurse entered the room with some medications in a cup and a shot around 8:30 AM or 9:00 AM. He stated that Resident #2 told Nurse #1 the shot was for him and not Resident #1. Resident #1 stated he told the nurse he did not take insulin, but she gave him the injection anyway in his right arm. He stated that Nurse #1 told him it was insulin. Resident #1 stated Nurse #1 also gave him oral medication pills in a cup at the same time. An interview on 9/21/21 at 12:32 PM with Resident #1's family member revealed he had told her that Nurse #1 had given him his roommate's insulin shot on 9/03/21. An interview on 9/22/21 at 10:41 AM with Resident #2 revealed he had not received his scheduled insulin on 9/03/21 at 9:00 AM. Resident #2 stated he had not seen or heard Resident #1 talk to Nurse #1 about insulin or get a shot on 9/03/21. Resident #2 also stated he had not talked to Resident #1 about insulin. Resident #2 stated he told Nurse #1 he had not received his morning insulin dose on 9/03/21, but she didn't say anything, and he did not receive his insulin. Per record review, Resident #2 was ordered [MEDICATION(S)] 70/30 insulin 10 units subcutaneous twice a day at 9:00 AM and 5:00 PM and the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 9/21/21 at 3:15 PM with Nurse #1 revealed she had given Resident #2 his scheduled insulin around 9:00 AM on 9/03/21 and she stated she had not given Resident #1 insulin. She stated she verified resident's identity for medication administration through the electronic pictures and resident names on the outside of the door. She stated she called the resident by his name on 9/03/21 to verify the resident. Nurse #1 stated Resident #2 did not tell her that he had not received his insulin on 9/03/21. Another interview on 9/23/21 at 4:30 PM with Nurse #1 revealed she had given Resident #2 his morning insulin in his right arm on 9/03/21. She stated Resident #2 never said anything to her about not getting his insulin that morning. She reaffirmed she verified resident's identity by the picture on the electronic record and by the name tags on the outside of the door. Another interview on 9/23/21 at 5:37 PM with Nurse #1 with the Director of Nursing (DON) and the Administrator present revealed she did not believe she had made a medication error. Resident #1's [CONDITION(S)] records for 9/03/21 read in part that [CONDITION(S)] was started at 10:50 AM and blood sugar was checked at 1:45 PM with a reading of 64. The next blood sugar reading was at 4:00 PM with a reading of 49. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 9/21/21 at 12:55 PM with [CONDITION(S)] Nurse #1 revealed she had assumed care of Resident #1 when he was halfway through his [CONDITION(S)] on 9/03/21. She stated she received in report that his blood sugar was low, and he had been given an oral shake. Then his blood sugar came up a little and he was given an oral glucose. She stated that Resident #1 told her he had been given insulin at the facility even though he did not take insulin. She stated his blood sugar dropped again and the nephrologist gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The [CONDITION(S)] nurse also stated Resident #1 had no signs or symptoms of [CONDITION(S)] while in her care. An interview on 9/24/21 with [CONDITION(S)] Nurse #2 revealed Resident #1 told her a facility nurse had given him a shot on 9/03/21 before he went to [CONDITION(S)]. She stated she called the facility Director of Nursing (DON) on 9/03/21 and told her that Resident #1 reported he had received a shot. The DON informed the [CONDITION(S)] Nurse that the resident did not receive insulin and she would investigate. Resident #1's hospital Emergency Department (ED) records dated 9/03/21 read in part that the chief complaint was resident stated he was given the roommates insulin this morning at the facility and became hypoglycemic at [CONDITION(S)]. On Resident #1's arrival to the ED his blood sugar was 170. The record further read that Resident #1 was having labile blood glucose readings and [CONDITION(S)] and he was started on [MEDICATION(S)] 5% with half-normal saline. Some of his blood glucose readings were: 69, 118, 99, 106, 67, 86 and 68. Another paragraph read Did have nursing staff call the facility they had some difficulty finding out what his roommate's insulin was, but they were able to find out it was 70/30. An interview on 9/23/21 at 3:04 PM with Nurse #2 revealed Resident #2 had told her the night of 9/03/21 that he had not received his morning insulin. She stated she was not sure what happened, and she reported it to Nurse #1 the next day. An interview on 9/21/21 at 3:30 PM with the facility Physician revealed he did not know why Resident #1's blood sugar would be low if he had not received insulin. He also stated he did not know of another reason for his blood sugar to drop that low and he believed it was likely that the resident got a dose of insulin. He stated Resident #1 was alert and oriented with some dementia but if he voluntarily told the [CONDITION(S)] staff and the hospital staff that he got an insulin injection he believed him. The Physician stated he was unaware of Resident #1 having any [CONDITION(S)] episodes, but he did run low normal blood sugars. He stated his [CONDITION(S)] could have been related to [CONDITION(S)] but did not think it was likely since it had not happened before, and resident stated he got an insulin injection. Another interview on 9/29/21 at 9:00 AM with the facility Physician confirmed he did not remember the DON telling him anything about Resident #1 receiving insulin or his [CONDITION(S)]. An interview on 9/25/21 at 8:58 AM with the [CONDITION(S)] Center Nephrologist revealed that the [MEDICATION(S)] used for [CONDITION(S)] contains glucose to help prevent [CONDITION(S)]. Resident #1 was only at that [CONDITION(S)] center a few times but had no hypoglycemic issues. He stated he thought the [CONDITION(S)] was highly unlikely a result of [CONDITION(S)] even if the resident had only eaten a little bit prior to [CONDITION(S)]. An interview on 9/23/21 at 2:22 PM with the Director of Nursing (DON) indicated she was unaware of the medication error until 9/15/21. She stated she talked to Resident #2 on 9/03/21 when she went to pack up Resident #1's belongings and Resident #2 did not tell her he had not received his morning insulin. She stated, I can't say if it did or didn't happen. The DON stated she told the [CONDITION(S)] nurse on 9/03/21 that the resident had not received insulin as none was ordered for him. She stated she 'didn't think anything about it' at the time since the resident had no order for insulin. Another interview on 9/23/21 at 5:37 PM with DON revealed she did not believe that Nurse #1 made a medication error. She also stated she couldn't say exactly what was said during her conversation with [CONDITION(S)] Nurse #2.The DON also stated she did not know why the hospital thought Resident #1 received 70/30 insulin. An interview on 9/23/21 at 2:15 PM with the Administrator revealed she was on vacation at the time of this investigation and that the DON completed the investigation. Another interview on 9/23/21 at 5:37 PM with the DON and Administrator revealed that the DON did not believe Nurse #1 had made a medication error. Neither the DON nor the Administrator can explain why Resident #1 stated he received a shot and Resident #2 stated he had not received his insulin on 9/03/21. The DON further stated that Nurse #1 story had never changed, and she believed her. In the absence of the Administrator, the DON was notified of immediate jeopardy on 9/27/21 at 4:00 PM. the facility provided the following credible allegation of immediate jeopardy removal. Credible Allegation for F760 for removal of immediate jeopardy completed on 9/30/21. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and Resident #1 was admitted to the facility on [DATE] from the hospital with an AIC of 4.2 and a mean blood glucose of 68.7 per hospital records. On 9/3/21 Resident #1 consumed 50% of his breakfast, received his medication by the Licensed Practical Nurse per medication administration record. Resident #1 was transferred to the [CONDITION(S)] center for scheduled [CONDITION(S)] and was placed on [CONDITION(S)] at 10:47am, residents blood sugar at 1:45pm was 64, resident #1 was removed from [CONDITION(S)] at 2:51pm, and blood sugar was rechecked at 4:00pm with results of 49. The [CONDITION(S)] Nurse stated that Resident #1 told her he had been given insulin at the facility even though he did not take insulin. The [CONDITION(S)] center then transferred the resident to the hospital emergency room where his blood sugar was 170 upon entrance to the emergency room . The emergency department records dated 09/03/21 noted Resident #1 told the nurse at [CONDITION(S)] he was given his roommate's (Resident #2) insulin prior to sending him to [CONDITION(S)]. The [CONDITION(S)] center called on 9/3/21 and spoke with the Director of Health Services and requested to know what insulin resident # 1 received, the Director of Health Services stated he was not on insulin and was not on oral diabetic medication either. The hospital contacted the Director of Health Services and requested to know what type of insulin resident #1 received that morning, the Director of Health services stated that Resident #1 did not receive any insulin. The Director of Health Services interview with the Nurse who administered the medication to resident #1, stated she only gave Resident #1 his medications and did not administer insulin to resident #1. All residents have the potential to be affected by medication administration errors. 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 9/23/21 the Director of Health Services and Clinical Competency Coordinator began education to the Registered / Licensed Nursing Staff and Certified Nursing Assistants on resident identification utilizing the policy medication administration; general guidelines which states to utilize two forms of identification; the Matrix picture of residents, call resident by name or utilize other healthcare personnel for identification. As of 9/27/21 any Registered / Licensed Nurse and/or Certified Nursing Assistant not educated will be removed from the schedule until the education regarding medication administration (identification of residents) is completed. The education regarding medication administration: general guidelines has been added to the general orientation for all Registered / Licensed Nurses and Certified Nursing Assistants regarding resident identification practices. The Director of Health Services is responsible for tracking, trending, and ensuring all Registered / Licensed Nurses and Certified Nursing Assistants have completed the education and will maintain an employee roster identifying completion of education provided. On 9/28/21 the Director of Health Services and/or Nurse Managers began educating the Registered and Licensed Nurses on the five rights of medication pass procedure, including Right Resident, Right Medication, Right Route, Right Dose, and Right Time. Any Registered / Licensed Nurse who has not completed this education by 9/29/21 11:59pm will be removed from the schedule until the education regarding medication administration and the five rights of medication pass is completed. The Director of Health Services is responsible for tracking to ensure all Registered / Licensed Nurses have completed the education and will maintain an employee roster identifying completion of education provided. The Director of Health Services and/or Nurse Managers were made aware 9/29/21 that they are responsible for educating any Registered / Licensed Nurse if they didn't receive the education for five rights of medication pass procedure by 9/29/21. The education regarding medication administration and the five rights of medication pass has been added to the general orientation for all Registered / Licensed Nurses. On 9/24/21 the Clinical Competency Coordinator completed a review of Matrix Care electronic records to ensure all residents had a valid picture that corresponded to the resident for identification purposes. The Senior Nurse Consultant validated on 9/27/21 that all current residents in Matrix Care electronic medical record have a current picture for identification purposes. The Director of Health Services and Nurse managers began auditing the Registered / Licensed Nurses daily on 9/23/21 during medication administration to ensure compliance to the policy. This includes observations from the Director of Health Services and Nurse Managers that Registered / License Nurses are utilizing two points of identification when administering medication to residents to validate the correct resident receives the correct medication. Alleged date of IJ removal 9/30/21. The credible allegation was verified on 10/04/21 as evidence by record review and staff interviews. Interviews were conducted with a sample of staff members to verify education was conducted for all employees regarding medication administration. Documentation of in-service records were reviewed. An observation of medication administration was conducted. All of the evidence indicated the facility had removed the immediate jeopardy by 9/30/21.

Based on record review and staff interviews, the facility's administration failed to act on an allegation of a significant medication error, failed to determine the validity of the significant medication error allegation, and failed to identify the need to prevent further medication errors for 1 of 2 residents (Resident #1). Immediate jeopardy began on 9/03/21 when the facility failed to determine the validity of the significant medication error allegation which occurred on 9/03/21 and did not identify the need for preventative measures. The immediate jeopardy was removed on 9/30/21 when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure that the education and the monitoring systems put in place to remove the immediate jeopardy are effective and to correct current deficient practice as identified. Findings included: This tag was cross referenced to: 1a. F760. Based on record review, residents, facility staff, [CONDITION(S)] staff and physician interviews, the facility failed to prevent a significant medication error by administering insulin to the wrong resident for 1 of 2 residents (Resident #1). Resident #1 did not have a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Initial Allegation Report signed by the Director of Nursing (DON) revealed the facility became aware of the incident on 9/15/21 at 12:00 AM. The fax confirmation report was dated 9/15/21 at 4:37 PM. Review of the Investigation Report signed by the DON was hand dated as 9/20/21. Attachments for the Investigation Report were a signed statement from Nurse #1 dated 9/15/21 and a signed statement from the DON dated 9/15/21. An interview on 9/23/21 at 8:00 AM with the Director of Nursing (DON) indicated she was unaware of the medication error until 9/15/21. The DON stated she told the [CONDITION(S)] nurse on 9/03/21 that the resident had not received insulin as none was ordered for him. She stated she 'didn't think anything about it' at the time since the resident had no order for insulin. She also stated on 9/03/21 she reviewed Resident #1's current medications with the Emergency Department (ED) and she was aware the ED was 'under the impression he had received insulin, but they did not say how he had received it'. She also stated she told the ED that he had not received insulin on 9/03/21. The DON stated she had not contacted Resident #1 or the roommate, Resident #2 during this investigation. She stated the facility Physician was notified of an unsubstantiated medication error. An interview on 9/23/21 at 2:15 PM with the Administrator revealed she was first made aware of the medication error allegation on 9/15/21. She further stated she was on vacation at the time of this investigation and that the DON completed the investigation. In the absence of the Administrator, the DON was notified of immediate jeopardy on 9/27/21 at 4:00 PM. The facility provided the following credible allegation of immediate jeopardy removal. Credible Allegation for F835 for removal of immediate jeopardy completed on 9/30/21. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and Resident #1 was admitted to the facility on [DATE] from the hospital with an AIC of 4.2 and a mean blood glucose of 68.7 per hospital records. On 9/3/21 Resident #1 consumed 50% of their breakfast, received his medication by Nurse #1 per the medication administration record. Resident #1 was transferred to the [CONDITION(S)] center for scheduled [CONDITION(S)] and was placed on [CONDITION(S)] at 10:47am, residents blood sugar at 1:45pm was 64, resident #1 was removed from [CONDITION(S)] at 2:51pm, and blood sugar was rechecked at 4:00pm with results of 49. The [CONDITION(S)] Nurse stated that Resident #1 told her he had been given insulin at the facility even though he did not take insulin. The [CONDITION(S)] center then transferred the resident to the hospital emergency room where his blood sugar was 170 upon entrance to the emergency room . The emergency department records dated 09/03/21 noted Resident #1's told the nurse at [CONDITION(S)] he was given his roommate's (Resident #2) insulin prior to sending him to [CONDITION(S)]. The [CONDITION(S)] center called on 9/3/21 and spoke with the Director of Health Services and requested to know what insulin Resident # 1 received, the Director of Health Services stated he was not on insulin and was not on oral diabetic medication either. The hospital contacted the Director of Health Services and requested to know what type of insulin resident #1 received that morning, the Director of Health services stated that Resident #1 did not receive any insulin. The Director of Health Services interview on 9/3/21 with Nurse #1 who administered the medication to resident #1 on 09/03/21, stated she only gave Resident #1 his medications and did not administer insulin to resident #1. The Director of Health Services received a call on 9/3/21 from the emergency room nurse asking what medications Resident #1 received of the roommate, Resident #2. The Director of Health Services replied to the emergency room Nurse that Resident #1 did not receive resident #2 medications. On 9/15/21 at 3:33 pm Resident #1's family member sent an email to the Area Vice President of the facility making a formal complaint of negligence - the doctor on call there in the emergency room said the facility ([CONDITION(S)] center) reported he was accidently given wrong medication that was insulin which belonged to his roommate. The Area Vice President forwarded the email to the facility Administrator on 9/15/21 at 3:40 pm. On 9/15/21 at 4:37 pm the Director of Health Services reported the allegation of neglect to the State Agency and began her investigation regarding the allegation of Resident #1 receiving the incorrect medication on 9/3/21. Upon the Director of Health Services review and interview with the assigned Nurse #1, it was documented that resident received the correct medication and Nurse #1 stated she gave the correct medication to Resident #1. Resident #1 and Resident #2 were not residents of the facility on 9/15/21. The Director of Nursing attempted to contact Resident #2 who did not answer the phone and the voice mail stated the party you are trying to reach is unavailable. The Physician was notified on 9/15/21 by the Director of Health Services of the allegation and the physician did not have a comment. The Night shift 11:00 PM to 7:00 AM nurses who were scheduled on 9/3/21 were interviewed by the Director of Nursing on 9/15/21 and both stated they had not given resident #1 any insulin. Resident #1 was not interviewed during the investigation. On 9/20/21 at 2:59pm The Director of Health Services completed the investigation of alleged neglect and reported the findings and submitted supporting documentation (statement from Nurse #1, resident # 1 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . All residents have the potential to be affected by medication administration errors and facility investigations. 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 Administrator and Director of Nursing were educated by the Senior Nurse Consultant on 9/27/21 on the current grievance policy effective date 1/1/1997 and revised 3/25/2019; specific to prompt efforts to resolve the grievance, in addition to taking immediate action to prevent further potential violations of any patients' rights while the violation is being investigated. Grievances can be from residents, family members, staff members related to resident concerns and/or any entity that has a concern related to resident care and wellbeing, including concerns and complaints called to any corporate entity. The Quality Assurance and Performance Improvement Plan specific to Systematic Analysis and Systemic Action - using a systemic approach to determine when in-depth analysis is needed for identifying contributing causal factors that underlie variations in performance, this approach can utilize the 5 why approach, which drills down to causative factor by asking why the event occurred until a causative root cause analysis is identified. The Fishbone approach is a visual drill down to illustrate the relationship between a given outcome and all the factors that may influence that outcome, this reviews the organizational culture, human factors, information and communication factors, training and competency factors, care plan and assessment, equipment factors, policy and procedure factors and environmental factors. The initiation of the grievance policy with timely investigation and the utilization of the QAPI - systemic analysis and systemic action by the Administrator will be utilized to determine appropriate investigation efforts and reporting criteria starting 9/27/21. On 9/27/21 The Administrator will review all grievances and sign the grievance log and state reportable events weekly to ensure complaints are thoroughly investigated per policy. The Senior Nurse Consultant will review the facility Administrator's findings of the grievance and state reportable investigations to ensure a thorough investigation has been completed monthly. Alleged date of IJ removal 9/30/21 The credible allegation was verified on 10/04/21 as evidence by record review and staff interviews. Interviews were conducted with a sample of staff members to verify education was conducted for all employees regarding the grievance and investigation procedures. Documentation of in-service records were reviewed. All of the evidence indicated the facility had removed the immediate jeopardy by 9/30/21.

Based on observations, record review, and staff interviews, the facility failed to prevent 1 of 1 residents (Resident # 1), who was assessed as being at risk for elopement, from exiting the facility unsupervised. Immediate Jeopardy began on 8/11/12 when Resident # 1 left the facility unsupervised and fell on a main road near the facility. Resident # 1 was transported to the emergency room by Emergency Medical Services (EMS). Resident # 1 sustained two lacerations on the face requiring stitches and abrasions on both knees. Resident # 1 also sustained a "new bleed", having suffered a subarachnoid hemorrhage prior to admission to the facility. Resident # 1 exited the facility through a side exit door being used as the main entrance during the renovation of the facility lobby and main entrance. The side exit door was secured by a magnetic lock and required the input of a code number by staff to allow entrance or exit by that door. Immediate Jeopardy was identified on 8/15/12 at 5:12 PM and was removed on 8/16/12 at 7:57 PM when the facility provided and implemented a credible allegation of compliance. The facility remains out of compliance at a lower scope and severity level of D (an isolated deficiency, with no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems put in place and completion of employee training. The findings are: 1. Resident # 1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].# 1 had severe cognitive impairments and ambulated independently. A review of the Elopement Risk assessments of 7/7/12 and 7/10/12 identified Resident # 1 as being at risk for elopement. A review of the Interdisciplinary (IDT) Progress Notes of 7/10/12 revealed, "Oriented to person only. No safety awareness. Alarm in place. Also has wander guard as he has attempted to open locked door at end of unit." A review of the MD Progress Notes for 7/12/12 revealed, "5. Agitation: mild, trying to leave, wants to go home." "Obs (observation): vss (vital signs stable), heent (head, eyes, ears, nose, throat) wnl (within normal limits), usually pacing in room as to (sic) pacing @ (at) doorways." A care plan dated 7/16/12 addressed the risk of elopement with the goal of "Will not elope from health care center (initials of facility). Interventions included: Do not allow resident to leave hcc (health care center) alone without signing out or supervision; approach resident in a warm and positive manner when confused and attempting to leave hcc w/o (without) supervision; maintain locks on doors are in proper working order; keep wander guard bracelet in proper working order; attempt to redirect resident when noted with increase (sic) confusion (activities, toilet, snack, etc...); check wander guard placement q (every) shift; check wander guard functioning daily; notify MD is (sic) warranted. A review of the Nurses Notes, written by Nurse # 1, for 8/11/12 4:00 PM revealed: "(Nursing Assistant/NA # 1), 7-3 CNA (certified nursing assistant), asked me had I seen (Resident # 1). I told her no, not in the last 10 min (minutes). I last saw (Resident # 1) sitting in his bedside chair. She informed me that she had received a call from someone that (Resident # 1) may be on a stretcher on (name of street) in front of the hospital. Immediately she begin (sic) searching the building. I went to my Supervisor (Nurse # 2) RN to inform her of the above info. We got in her car & drove to (hospital). Together we identified (Resident # 1). He was being treated for [REDACTED]. Informed his nurse who is (sic) was & to contact us when he is able to be d/c (discharged ). Returned to the facility. (Administrator), (Resident # 1's family member) & (name of Resident # 1's attending physician) were notified. Appx. (approximately) 1 PM, I had re-directed Rt. (resident) back down the hallway to his room from the water fountain @ the end of the 100 hall. Sat c (with) Rt. in his room for a few minutes talking (with) him. @ appx. 1:30 PM, Rt was sitting in his room talking (with) his roommate's visitor." During an interview on 8/15/12 at 4:16 PM, Housekeeping Aid (HA) # 1 stated she was the one who called back to the facility asking if the resident was there. HA # 1 stated she had clocked out of the facility at 2:35 PM. When she reached the main road, she saw two paramedics loading someone into an ambulance. HA # 1 stated she thought she recognized the shoes and shorts of the patient, and thought it was Resident # 1. HA # 1 stated she called the facility and talked with (NA # 1), Resident # 1's 7-3 nursing assistant, asking if Resident # 1 was in his room. NA # 1 said Resident # 1 was not in his room. During an interview on 8/15/12 at 3:24 pm, NA # 1 stated, "About 2:20 PM, I saw (Resident # 1) in his room and he said he was okay. I went to do my charting and answered the facility phone. It was (HA # 1) from the 100 hall. She asked me if (Resident # 1) was in his room. I asked her why, she said she saw his shoes on the stretcher. I checked his room and he was not there. I went to find the charge nurse and supervisor, looking for him on the way. I had checked on him 10-15 minutes prior to the phone call and he was in his room." During an interview on 8/15/12 at 4:03 PM, Nurse # 1 stated she was Resident # 1's regular 7-3 nurse on the 100 hall. Nurse # 1 stated, "In the past, (Resident # 1) typically spends most of his time in his room or near it. At 1:00 PM (on 8/11/12), he had been at the water fountain. I walked him back to his room and sat a couple of minutes with him. Between 1:00 PM and 2:20 PM, I looked in his room while I went up and down the hall passing meds and answering callbells, and he was in there. One time he was talking to his roommate's visitor. The last time I saw him was about 2:20 PM. He was sitting in his room and the visitor was gone. I went to another room on a separate hall, and to the nurses station to talk with pharmacy on the phone. I had finished talking with the pharmacy at 2:40 pm when (NA # 1) came and told me she couldn't find the resident. (NA # 1) said she had gotten a call from someone outside the facility asking if the resident was in his room because there was an ambulance on the road loading up someone they thought might be him. The nursing assistant said he was not in his room. While the staff were searching the halls, the supervisor and I went to the hospital to see if it was him. By the time we got to the hospital it was about 2:45 PM. It was him. They were just starting to treat him and we talked to him." During an interview on 8/16/12 at 3:42 PM, Nurse # 2 stated she was the 7-3 Supervisor on 8/11/12. Nurse # 2 stated she had seen Resident # 1 walking on the 100 hall about 20 minutes before being notified he wasn't in the building. Nurse # 2 stated Nurse # 1 reported to her that Resident # 1 was not in his room or on the 100 hall, but may be at the hospital. Nurse # 2 stated she sent staff looking for Resident # 1 inside the facility and on the facility grounds, and she and Nurse # 1 went to the hospital and identified him. Nurse # 2 stated she observed Resident # 1 in the emergency room around 2:50 PM. A review of the Emergency Medical Service (EMS) report revealed the dispatch center received a call about the resident on 8/11/12 at 2:32 PM. EMS was enroute at 2:33 PM and reached Resident # 1 at 2:35 PM. The EMS report revealed upon arrival on scene, ""Pt (patient) lying on right side with an abrasion above right eye. Witness stated Pt fell into hwy (highway)." The EMS examination revealed Resident # 1 had bleeding abrasions on the head and both lower legs. Resident # 1 was transported at 2:40 PM and arrived at the hospital at 2:41 PM. A review of the emergency room (ER) records for 8/11/12 2:50 PM revealed: "It is noted that pt (patient) has a tracking arm band. (Name of facility) called to inquire if they are missing any residents. Person who answers phone states that they are missing (Resident # 1). Informed nursing home that pt is here in ED (emergency department) after being found lying on (name of road). " emergency room records for 8/11/12 2:56 PM revealed: "Patient found lying in street, patient has wonder (sic) off from nursing home. Patient has laceration to ferhead (sic). NH (nursing home) staff arrived shortly after patient and state they have been looking for him." ER records for 8/11/12 2:58 PM revealed Resident # 1 required laceration repair of "a 1.0 cm (centimeter) lac (laceration) of the right eye" requiring two sutures, and another laceration, size not given, over the right eye requiring three sutures. A review of the ER CT (Computed tomography) Scan report dated 8/11/12 revealed: "Scattered areas of petechial hemorrhage. (Petechial refers to small purplish spots on a body surface, such as the skin or a mucous membrane, caused by a minute hemorrhage). Some of the changes in the posterior left parietal lobe (the middle section of the brain) and occipital lobe (the back section of the brain) may be chronic and could be calcification. There is a new petechial hemorrhage in the high right frontal lobe." A review of the ER Physician's note for 8/11/12 5:55 PM revealed: "Long discussion with the patient's (family member). Informed him that the patient does have a small brain bleed that could possibly become enlarged and could cause death. (Family member) says at this time he wants no further medical treatment and that the patient is DNR (do no resuscitate), comfort care. He is understanding that the patient could possibly die from this bleed." Resident # 1 was discharged to the facility. Observations on 8/15/12 at 1:06 PM revealed Resident # 1 seated in a wheelchair near the nurses station with 1:1 supervision. Resident # 1 was alert and verbal. Resident # 1 had bruising over the right eye with sutures intact. Resident # 1 had healing abrasions on both knees. A personal alarm and a wander guard bracelet were noted. Observations of 8/17/12 at 11:40 AM revealed Resident # 1 ambulating independently in his room with 1:1 supervision. Observation of the 100 hall exit/entrance door on 8/16/12 revealed the door was located on the side of the building and was being used as the main door while the facility lobby and entrance was being renovated. Egress to the lobby entrance was blocked inside the facility, and the lobby entrance door was locked. The 100 hall exit /entrance door opened into a small reception area. The 100 hall began at the right end of the reception area, around a corner to the left. The exit/entrance door was not visible to anyone standing in the 100 hall unless they were about to enter the reception area. The door locked automatically when closed due to a magnetic lock access system. A digital keypad was mounted on the wall beside the door. The door access system required a numeric code to be entered on the keypad to unlock the release bar across the door. The door could not be opened by pulling on the handle from the outside, or by pushing on the release bar from the inside, unless the door code had been entered first. Observations of the facility on 8/16/12 revealed the facility was located 0.1 mile from a main boulevard intersection, next to the hospital. According to the EMS report of 8/11/12, Resident # 1 was found lying in front of the hospital. During an interview on 8/15/12 2:00 PM, the Administrator stated the 100 hall exit/entrance door was monitored by reception staff in the reception area Monday - Friday 8:30 AM - 5:00 PM, and by the evening receptionist from 4:00 PM - 8:00 PM. On the weekends, the door was monitored by the Floor Tech (FT) assigned to that end of the 100 hall from 7:00 AM - 10:00 AM. Administrative staff monitored the door from 10:00 AM - 2:00 pm. A Floor Tech was resumed monitoring the door from 2:00 pm - 10:00 PM. No one was assigned to the door after 10:00 PM. The Administrator stated that unless a wanderer knew the code, there was no way they could get out. The Administrator stated they had not figured out who had opened the door and let Resident # 1 walk out with them. The Administrator stated staff knew not to give the door code to visitors or family members, but felt it was possible long term residents / family members could have known the code. An observation on 8/15/12 of the door monitoring tool utilized since 8/11/12 revealed the form was not completely filled out and did not indicate when staff monitoring the exit / entrance door on the 100 hall took breaks, returned from breaks, or who relieved them, or whether the door was being monitored during breaks. The Administrator was notified of the Immediate Jeopardy on 8/15/12 at 5:15 PM. The facility provided a credible allegation of compliance on 8/16/12 at 6:43 PM. The allegation of compliance indicated: Immediate Actions: 1. A Nursing Assistant was with the resident at 2:20 pm in the facility. 2. Resident went out the temporary entrance door, which had a functioning mag lock in place, sometime between 2:20 - 2:30pm. The facility assumed a visitor let him out due to fact the mag (magnetic) locks were functioning properly and the resident did not know the code. 3. Resident ambulated 0.1 miles to the business sign where (the main boulevard and the facility road) meet. 4. Resident fell while stepping off the curb onto the boulevard. 5. Emergency Medical Services (EMS) received a call at 2:32 pm, EMS services responded at 2:35pm. 6. He was transported to the medical center by EMS at 2:40 pm. 7. The resident was signed into the medical center at 2:48 pm, noted to have a laceration to his upper right forehead, received two 5-0 sutures, above right eye three 5-0 sutures placed. 8. The Residents Family Member requested Resident be sent back to the nursing facility. ER Diagnosis: [REDACTED]. 9. Resident was returned to facility around 7:00 pm on 8/11/12 and placed on 1:1 observation from 8/11/12 through 8/16/12. At which time no further exit seeking behaviors have been identified since 8/11/12. The 1:1 supervision was provided by the nursing staff (Licensed Nurses and Certified Nursing Assistants) 24 hours a day 7 days per week beginning 8/11/12. The nursing staff providing 1:1 was relieved for breaks by another staff member (Department Managers, housekeepers). 10. Nursing staff monitored neuro checks on resident for 48 hours after fall. The staff began neuro checks at 7:00 pm on 8/11/12 and continued every four hours X 5, then every eight hours X 3. 11. The facility placed a staff member to monitor the temporary entrance/exit door on 8/11/12 at 2:30 pm. The temporary entrance/exit door will be monitored until the permanent entrance / exit is opened, then the temporary door will be monitored by the management system for that door as well as all other exit doors. The staff member monitoring the door is relieved for breaks by another staff member. During the weekdays the receptionist monitors the temporary entrance door from 8:30 am -8:00 pm, the floor tech monitors from 8:00 pm - 11:00 pm, then the nursing staff monitor from 11:00 pm - 8:30 am. During the weekends the Floor tech monitors the door from 7:00 am - 10:00 am, the administrative manager on duty from 10:00 am - 2:00 pm, then housekeeping from 2:00 pm - 10:00 pm, then nursing staff from 10:00 pm - 7:00 am. The staff monitoring the door remains at the reception area with direct visualization of the door, their responsibilities include watching the door, letting visitors in and out of the facility and answering the phone. 12. The monitoring form being utilized 8/11/12 identified the date, employee time they began monitoring the door, time out for breaks and the employee relieving the assigned employee for break, (the employee monitoring the door request to be relieved for a break by calling the nursing and request coverage) also signs in and out, then the assigned employee signs back in. This form accounts for all minutes of the day and identifies who was monitoring the door twenty four hours a day. Identification of others: 1. 100% of the residents had an elopement risk assessments completed on 8/13/12, eleven residents currently had wander guards and one new resident was identified during the completion of the elopement risk assessments. The elopement risk assessments will be completed quarterly by Licensed Nursing staff 2. Residents identified as " at risk " for elopement had their care plans reviewed and updated as indicated on 8/13/12. 3. The wander guard books were reviewed to ensure the residents had current demographic and updated pictures as indicated on 8/13/12. 4. Demographic sheets that state the resident height, weight, hair color and eye color was added to the wander guard book on 8/13/12. The wander guard books are maintained at each nurses ' station and at the receptionist desk. 5. All staff education was started on 8/11/12 related to not propping doors open for any reason. This education continues until 100% of the staff has been completed. Staff will receive this education on their next scheduled day to work. 6. All Staff education was started on 8/13/12 related to not distributing the door security codes to any visitor. This education will continue until 100% of the staff has been completed. Staff will receive this education on their next schedule day to work. 7. Facility Staff were reeducated starting on 8/15/12 on the door monitoring tool which identifies the time the assigned staff started monitoring the door, when they left the area and who relieved them. 8. A letter explaining that the door codes will not be made available to anyone but staff, for the safety of the residents was mailed to family members / responsible parties on 8/16/12. The door codes were changed on 8/11/12 at approximately 3:30 pm. 9. The Maintenance Director checked all exit doors mag locks to ensure they are locking on 8/11/12 and has continued to check all mag lock doors daily to ensure the mag locks are functioning properly since 8/11/12, the maintenance director will continue to check the mag logs on all the doors ongoing. The mag lock doors include the doors at the end of the hallways on 100 hall, 300 hall, and 400 hall. Testing the doors include pushing on them to open without punching the code to release the mag lock. 10. The Wander guarded door will be monitored daily by taking the wander guard checker to the wander guarded door to ensure it locks down. This will continue daily and ongoing. The Residents with wander guard bracelets have their bracelets checked daily by the Maintenance department and/or nursing department by utilizing a wander guard checker that lights up to identify that the wander guard bracelet / door is functioning as indicated by the yellow light. The wander guard bracelet check is documented on the door alarm device daily testing report form. System changes: 1. The Wander guarded door will be monitored daily by taking the wander guard checker to the wander guarded door to ensure it locks down. This will continue daily and is ongoing. The Residents with wander guard bracelets have their bracelets checked daily by the Maintenance department and/or nursing department by utilizing a wander guard checker that lights up to identify that the wander guard bracelet/door is functioning as indicated by the yellow light. The wander guard bracelet check is documented on the door alarm device daily testing report form. 2. Education to new staff members on " Not providing the families and/or visitors the codes to the doors " will be provided during staff orientation upon hire by the Clinical Competent Coordinator, beginning 8/12/12. 3. Education related to not propping any door open will be provided during staff orientation upon hire by the Clinical Competency Coordinator, beginning 8/11/12. 4. The Administrator / Director of Health Services and/or Director of Maintenance will review the Wander Guard Books weekly for 4 weeks then monthly thereafter to ensure the residents picture and demographic sheet is maintained in the book, beginning 8/13/12. 5. Families will be notified on admission that the door codes will not be given to family members and/or any visitor for the safety of the residents by the Admissions Director, Social Service Director and/or Administrator, beginning 8/13/12. 6. The Administrator will review the exit door monitoring tool signature log daily for one week then weekly for four weekly them monthly thereafter to ensure the form identifies all times are accounted for, beginning 8/12/12. 7. The Maintenance Director will change the door codes bi-weekly for three months then monthly thereafter or as directed by the performance improvement committee, beginning 8/11/12. Monitoring Interventions were integrated into QA on 8/13/12. 1. The monitoring of the exit door monitoring tool will be taken to the performance committee meeting by the Administrator monthly for review and recommendations. 2. The percentage of staff educated related to not propping doors open will be taken to the Performance Improvement committee by the Administrator and/or Director of Health Services monthly to ensure 100% of employees who have worked have completed the education. 3. The percentage of employees educated on NOT providing the door codes to visitors will be taken to the Performance Improvement committee by the Administrator and/or Director of Health Services monthly to ensure 100% of employees who have worked have completed the education. 4. The percentage of staff related to education for the exit door monitoring tool will be taken to performance improvement by the Administrator monthly to ensure 100% of employees who have worked have completed the education.