Every finding on record at PruittHealth-Raleigh

Based on record review and interviews with resident and staff the facility failed to ensure a nurse followed professional standards of practice by ensuring that incorrect medications were not handed to a resident with the intent that they would be administered. The resident, who was cognitively intact, recognized the nurse's error in handing her the medications and gave the medications back to the nurse who had not recognized the error prior to attempting to carry through with the administration. This was for 1 (Resident # 2) of two residents whose medications were reviewed.The findings included:Record review revealed Resident # 2 was admitted to the facility on [DATE] with diagnoses which although not all inclusive included congestive heart failure, rheumatoid arthritis, and chronic obstructive pulmonary disease.Review of Resident # 2's Minimum Data Set assessment, dated 6/8/26, revealed Resident # 2 was cognitively intact.Resident # 2 was interviewed on 8/3/26 at 9:34 AM and 8/4/26 at 9:00 AM and reported the following information. On a date in July 2026, which she thought coincided to 7/6/26, Nurse # 4 had entered her room to give her nighttime medications. At the time, she (Resident # 2) had resided with Resident # 7. She (Resident # 2) had a health care background and was familiar with her medications. Nurse # 4 handed her (Resident # 2) a cup of pills to take. She (Resident # 2) looked at the pills before taking them and recognized that they were not her medications. She handed the cup of pills back and reported to Nurse # 4 that they were not her pills. Nurse # 4 at times entered the room with both Resident # 7's and her (Resident # 2's) pills at the same time. She (Resident # 2) had been concerned that Nurse # 4 had possibly given Resident # 7 her pills since she knew her pills had been incorrect. She (Resident # 2) asked Resident # 7 when she recognized the problem if she had gotten the right pills, and Resident # 7 responded she had already taken the pills given to her. Nurse # 4 left and returned with her (Resident # 2's) correct pills after it was called to her attention that the pills in the cup were not hers. Resident # 2 was concerned because there were other people who would have taken the pills without recognizing and questioning the error that was almost made. She recalled she told a staff member about what had happened but could not recall specifically who she had told and when.Nurse # 4 was interviewed on 8/3/26 at 8:50 PM and reported the following information. She recalled she had handed Resident # 2 the wrong cup of pills one night about a couple weeks back. She did not specify where the pills had come from and to whom the pills belonged. Resident # 2 had handed her the cup of pills back and let her know they were the wrong pills. Resident # 2 did not take them. She apologized to Resident # 2 and got her the correct pills. She recalled she had not mixed-up Resident # 7's and Resident # 2's pills because she had not yet given Resident # 7 her pills before attempting to administer Resident # 2 the wrong pills. Nurse # 4 was interviewed regarding what she thought contributed to her attempting to administer the wrong pills and reported she thought possibly staff had been talking to her and she was distracted.Resident # 7, whose 5/5/26 significant change Minimum Data Set assessment indicated the resident was cognitively intact, was interviewed on 8/5/26 at 10:00 AM and reported the following information. She recalled Resident # 2 saying to her (Resident # 7) one night that she (Resident # 2) had gotten the wrong cup of pills. At the time that Resident # 2 said this, she (Resident # 7) had already taken her pills but did not definitively recall anything that stood out with her pills as wrong and did not recall any unusual symptoms directly after taking the pills given to her that night.Interview with the Director of Nursing on 8/5/26 at 3:40 PM revealed the following information. She understood that mistakes can happen and staff can get distracted. The issue that Nurse # 4 had attempted to hand the wrong cup of pills to Resident # 2 had never been brought to her attention or that the resident had medication concerns in order that she could address the situation and see what had contributed to the incident.

Based on record review and interviews with staff, Responsible Party, and Physician the facility failed to ensure there was effective communication between facility staff and with the physician when a diabetic resident started to show new symptoms of tiredness and sluggishness so that his blood sugar would be checked and hypoglycemia would be identified and addressed. This was for 1 of 3 residents reviewed for professional standards of practice (Resident # 1). The findings included:Resident # 1 was admitted to the facility on [DATE] and had diagnoses which included diabetes, chronic respiratory failure, congestive heart failure, chronic obstructive pulmonary disease, history of stroke in 2001, chronic pain, history of atrial flutter and supraventricular tachycardia, history of pacemaker placement, history of bilateral shoulder surgery, venous insufficiency, and edema.Resident # 1's quarterly Minimum Data Set assessment, dated 7/1/26, coded Resident # 1 as cognitively intact. He was also assessed to be independent in his ability to roll in bed and needed supervision or touching assistance to walk 10 feet. He was occasionally incontinent of bowel and bladder.Resident # 1's care plan, revised on 7/6/26, revealed the facility identified Resident # 1 had a potential to have an alteration in his blood sugar secondary to his diabetes. This was added to the care plan on 2/8/24 and remained as an active problem when the care plan was reviewed on 7/6/26. One of the goals was that Resident # 1 would not exhibit any signs of symptoms or hypoglycemia, with examples listed on the care plan as diaphoresis, tremors, hunger, and personality changes. One of the interventions on the care plan was to monitor Resident # 1 for signs and symptoms of hypoglycemia.Review of labs revealed Resident # 1's hemoglobin A1c was 5.2 % on 5/28/26. (A hemoglobin A1C lab indicates the average blood sugar level over the past two to three months and helps show how well blood sugars are being managed. A result of less than 5.7 % is considered normal and indicates a person's diabetes is controlled.)Review of physician orders revealed when Resident # 1's hemoglobin A1C result was obtained on 5/28/26 he was receiving the diabetic medication glipizide extended release in a dosage amount of 10 mg daily which was started on 12/22/25.Further review of physician orders revealed Resident # 1 had an order, which originated on 12/22/25, for oxygen at 1 to 5 liters to maintain his oxygen saturation greater than 92 %.On 6/27/26 a new physician order was written for 5 mg glipizide extended release daily at 9:00 AM and was in effect until the resident's discharge.During an interview with Resident # 1's Responsible Party (RP) on 8/3/26 at 1:48 PM, the RP reported the following information. The resident's finger stick blood sugars were not routinely checked by the facility, but the resident still wanted to know daily what they were. Therefore, she had taken Resident # 1 a glucometer and he would check his blood sugar himself. During the last few weeks of Resident # 1's facility residency, Resident # 1 complained to her (the RP) that he was tired and would tell her that his blood sugar was low. One time when Resident # 1 reported to her (the RP) that his blood sugar was low, he indicated it was 87. (A blood sugar is considered low when a reading drops below 70.) She (the RP) took him butter scotch candy and told him that if he felt his blood sugar was low, he could suck on the candy and in turn he told her when he did that, he felt better. The RP reported Resident # 1 had not mentioned his low blood sugars to any of the facility staff, he was just addressing the problem himself by self-monitoring. She (the RP) had not reported the problem to anyone and stated every time she was at the facility she could not find anyone to tell. The RP did not provide specific dates or how many times she indicated she was at the facility and could not find anyone to tell about the problem. The RP confirmed that the facility physician and the staff had not been made aware of the resident's complaints or concerns of low blood sugars by her or the resident.Review of physician progress notes revealed Resident # 1's physician saw Resident # 1 on 7/21/26 and documented the following information. He had been asked to see Resident # 1 because of gross shivering. The resident reported he felt okay other than the shivering, and the resident blamed the shivering on improper covering during the night. His heart rate was regular, lungs were clear, and there had been a decrease in his edema. A urinalysis and culture would be obtained.Interview with Resident # 1's physician on 8/4/26 at 11:45 AM revealed the following information. He had been asked to see Resident # 1 on 7/21/26 because the resident was shivering and cold. Otherwise, Resident # 1 had no symptoms. Resident # 1 was covered and the shaking stopped by lunch time. He (the Physician) thought that Resident # 1 might be starting to get a urinary tract infection and therefore he ordered a urine test. Resident # 1 never reported he had been checking his own blood sugars or that he had been concerned his blood sugars were low. The Physician indicated Resident # 1 was a borderline diabetic and his last hemoglobin A1C, which was 5.2, indicated blood sugars were controlled and normal based on his lab.Review of physician progress notes revealed Resident # 1's Physician saw Resident # 1 again on 7/22/26 and documented the following information. Resident # 1's shaking had stopped the previous day, and his urinalysis did not suggest that the resident had a urinary tract infection. Upon exam he appeared at baseline and reported he felt weak. The shivering might be viral. The plan was to obtain a complete blood count (CBC) and complete metabolic count (CMP) that day.On 7/22/26 physician orders were entered for a complete blood count and comprehensive metabolic panel.Interview with Resident # 1's Physician on 8/4/26 at 11:45 AM revealed the following information. When he examined Resident # 1 on 7/22/26, Resident # 1 was almost back at baseline. The shivering had stopped. His only complaints were that he was weak and had left shoulder pain. The shoulder pain was a chronic condition. The urine test had not indicated the cause of any problem. Resident # 1's vital signs were normal with a blood pressure of 110/61, pulse 84, and no abnormal temperature. He (the Physician) therefore ordered a stat (right away/immediately) CBC and CMP. The physician was interviewed regarding how he entered orders and reported that sometimes he would enter his own orders or other times he would tell a nurse, and they would indicate it would be taken care of. Nurse # 1 was interviewed on 8/4/26 at 3:20 PM and reported the following information. On 7/22/26 she was the Unit Manager for the rehabilitation unit which was not where Resident # 1 resided and she was not aware of any acute problems the resident had been experiencing. Resident # 1's physician had seen her (Nurse # 1) that day and asked her if she could enter orders for Resident # 1 to have a CBC or CMP either that day or the following day. He did not indicate the labs should be done stat. Nurse #1 explained if blood work was to be drawn stat, then a resident's blood would be drawn and sent to the hospital for results the day the blood was drawn. Otherwise, the blood was drawn and picked up later that night to be run the next day by the facility's corporation's lab rather than the hospital. When she drew the lab work on 7/22/26 at 2:00 PM, Resident # 1 did not exhibit outward signs of a low blood sugar. He was not clammy and did not give other indications his blood sugar was low or any other signs of distress.A follow up interview with Resident # 1's Physician on 8/4/26 at 3:49 PM revealed he had intended the CBC and CMP to be done stat on 7/22/26 but he might not have relayed that correctly and therefore he would accept the responsibility for the labs not being done as he intended.During an interview with the Director of Nursing on 8/4/26 at 12:40 PM the DON reported that Resident # 1's labs had not been sent back to the facility before the resident was transferred to the hospital the following day. She further reported at times it was difficult to get a copy of labs for a resident who was no longer their resident, but she would try to obtain a copy.On 8/4/26 the facility provided a copy of Resident # 1's labs that were drawn on 7/22/26 and were printed by the facility on 8/4/26 at 3:09 PM. Review of Resident # 1's CBC and CMP results revealed the labs were drawn at 2:00 PM on 7/22/26 and received by the lab on the following day (7/23/26) at 1:37 PM. There was a notation at the top of the CMP lab results which noted the CMP final lab was approved on 7/23/26 at 2:41 PM. There was a notation at the top of the CBC lab results which noted the CBC final lab was approved on 7/23/26 at 3:23 PM. According to the results Resident # 1's blood sugar level was 55 (reference normal range was 74 to 106) when Resident # 1's blood was drawn on 7/22/26 at 2:00 PM and his white blood count was 12.36 (normal range 4.23 to 9.07). (An elevated white blood count at times can indicate an infection.)Nurse Aide (NA) # 1 cared for Resident # 1 on the 7:00 AM to 7:00 PM shift on 7/22/26. Nurse Aide # 1 was interviewed on 8/3/26 at 3:59 PM and reported the following information. She normally took care of Resident # 1 and was familiar with him. Overall, Resident # 1 seemed fine on 7/22/26 and independently went outside by wheelchair like he typically did. He was usually alert and oriented and would converse and did so that day. He was a little bit confused that day. For example, Resident # 1 would ring the bell and ask for ice even though he had just done so and did not seem to recall he had. This was the only thing that appeared different to her (NA # 1) that day about Resident # 1 and NA # 1 did not specify that she had reported the one difference she had noted.Nurse # 2 had been assigned to care for Resident # 1 on the 7:00 PM to 7:00 AM shift which began on 7/22/26 and ended on 7/23/26. Nurse # 2 was interviewed on 8/4/26 at 10:54 AM and reported the following information. During the shift which began on 7/22/26 at 7:00 PM, the resident was at his baseline. He went outside that evening as he typically did. Once in bed he did not call. He usually wore oxygen and he would take it on and off himself at times. He might have spots of incontinent episodes, but he usually was continent.NA # 1 had cared for Resident # 1 on the shift which began at 7:00 AM on 7/23/26. During interview with NA # 1 on 8/3/26 at 3:59 PM, NA # 1 reported the following information about 7/23/26. That morning Resident # 1 talked some but not per his normal. He would not carry on a normal conversation by making a complete sentence and seemed out of it. When she talked to him, he would say huh. Normally he could stand up and get in his wheelchair. At times he would sleep with his feet thrown off the side of the bed. That morning when she checked on him, he had his feet thrown off the bed and he could not help move himself. She (NA # 1) had to get assistance from NA # 2 to move Resident # 1 in bed. His eyes were open, but he did not move from the position that she and NA # 2 assisted him to be in once he was positioned. He neither ate nor drank for breakfast. He also typically tried to use his urinal but was incontinent that morning. She recalled that she had told Nurse # 3 that he didn't look right and was not acting like himself. She did not specify if she had told Nurse # 3 that Resident # 1 had not eaten. She recalled that Nurse # 3 looked at Resident # 1. NA # 1 did not specify what time Nurse # 3 had looked at the resident. That morning Resident # 1's family member came in and the resident was sent to the hospital.NA # 2 was interviewed on 8/4/26 at 12:13 PM and reported the following information. Resident # 1 was not himself on the morning of 7/23/26. She recalled NA # 1 asking for her help right around breakfast time or shortly thereafter. Resident # 1 would look at her and NA # 1 but she did not recall Resident # 1 talking at all. They had to move him in the bed whereas normally he would sit up and eat breakfast. That morning he did not eat and seemed out of it. He also was incontinent and usually he would try to use the urinal.Review of nursing notes revealed Nurse # 3 documented the following information on 7/23/26 at 6:45 PM regarding his shift which began at 7:00 AM on 7/23/26. At the beginning of the shift Resident # 1 was observed to be tired and a little confused. Vital signs were temperature 96.1, pulse 93, respirations 20 and blood pressure 112/70. Oxygen saturation was 95 % on 5 liters of oxygen and when the oxygen was decreased to 2 liters dropped to 87 to 88 %. Resident # 1 also complained of pain and received pain medication along with his scheduled medications that morning. The physician was notified and orders were received to send Resident # 1 to the hospital for evaluation. Resident # 1's RP was visiting and was aware of the orders. Resident # 1 was transferred to the hospital for shortness of breath at 11:10 AM. There was no documentation that the resident's blood sugar was taken by facility staff before transport to the hospital.Nurse # 3 was interviewed on 8/4/26 at 9:43 AM and reported the following information regarding the shift which began on 7/23/26 at 7:00 AM. There had been nothing in report that Resident # 1 was experiencing problems on the previous shift. He (Nurse # 3) was giving medications that morning and was one room down from Resident # 1's room when he saw Resident # 1's RP enter Resident # 1's room, and he (Nurse # 3) directly followed the RP in the room. Resident # 1 appeared a lit bit tired and took his medications. He (Nurse # 3) asked the resident if he was in pain and the resident said yes and Resident # 1 was able to say his shoulder when asked where. He (Nurse # 3) tried to help fix him in bed and the resident yelled in pain. Nurse #3 indicated Resident # 1 would sometimes take his oxygen off. When Nurse # 3 looked at the oxygen setting it was set on 5 liters and typically his oxygen was at 2 liters. When he (Nurse # 3) decreased it to 2 liters, Resident # 1's saturation dropped down to around 90 %. NA # 1 also came into the room and indicated to him (Nurse # 3) that she had noticed a change in the resident. Nurse # 3 indicated he did not recall that NA # 1 had approached him and informed him of any difference that she (NA # 1) had noted prior to him and the RP entering the room. He (Nurse # 3) had not been made aware that Resident # 1 had not eaten that morning. Nurse # 3 was interviewed regarding what he would have done if he had been informed that Resident # 1 had not eaten and reported he would have tried to get him to eat. Nurse # 3 was asked if he would have checked the resident's blood sugar and replied he would have. Nurse # 3 further reported he was focused on the resident's respiratory status, his complaints of pain, and getting him transferred. He (Nurse # 3) left the room to call the physician and prepare paperwork to transport the resident to the hospital. Once EMS arrived, he followed them back into Resident # 1's room and talked with EMS, who told him the resident's blood sugar was low.On 7/23/26 at 10:44 AM a SBAR (Situation, background, assessment, and recommendation) form was completed prior to hospital transport by Unit Manager # 2. Resident # 1's situation was noted to be that he was short of breath. At the top of the form there were directions that included prior to calling a physician about a resident's situation that vital signs were to be taken. There were also directions that if a resident was diabetic a finger stick blood sugar should be obtained. This was checked as completed on the form but there were no results of a finger stick blood sugar on the form.Unit Manager # 2, who completed the SBAR form on 7/23/26, was interviewed on 8/3/26 at 3:20 PM and reported the following information. He knew Resident # 1 was being sent out for respiratory symptoms, and he had helped with the paperwork but had not gone into the room that morning or checked the resident's blood sugar before EMS arrived.Resident # 1's RP was interviewed on 8/3/26 at 1:48 PM and reported the following information. On 7/23/26 when she entered Resident # 1's room to visit him, Resident # 1 was in bed staring at the ceiling. He did not carry on a conversation with her and only answered yes and no to questions she asked him. Staff members came flying in the room when she got there. One was a male staff member, and she asked the staff members why Resident # 1 was like this. The male staff member adjusted Resident # 1's oxygen and checked his oxygen level and Resident # 1's oxygen level kept registering in the 80's with the adjustments. The male staff member left the room to arrange for Resident # 1 to be sent to the hospital. She (the RP) told Resident # 1 she would meet him at the hospital and the resident responded, okay. The RP indicated she left before EMS arrived and did not see the staff take the resident's blood sugar.The DON (Director of Nursing) was interviewed on 8/4/26 at 10:13 AM and reported the following information. Resident # 1 typically came to her if he was having problems. He had never told her that he was concerned about his blood sugars or that he was checking his blood sugars himself. Typically, Resident # 1 would be up sitting in his doorway in his wheelchair in the mornings. On the morning of 7/23/26 she saw the RP was in the room. By that time, Nurse # 3 had already been in to assess Resident # 1 and called the physician. He appeared sluggish but he would respond. Resident #1 told her he was not feeling good and called her by name. His breathing seemed more labored and when she asked him if he was short of breath, he shook his head. She knew Resident # 1 had a long history of severe respiratory problems and had similar problems with sluggishness in the past which required hospitalization and prior changes in status had been determined to be due to respiratory problems.Review of a 7/23/26 EMS report (Emergency Medical System Records) revealed EMS was called on 7/23/26 at 10:53 AM and were on the scene at 10:56 AM. They arrived in Resident # 1's room at 11:04 AM. The paramedic noted the following information. The fire department had arrived before them and reported Resident # 1's blood sugar was low. The paramedic noted a blood glucose reading of 33 prior to the EMS arrival by the fire department. Upon the paramedic's initial contact with Resident # 1, Resident # 1 was found awake and in no obvious distress. His skin was warm and dry. On 7/23/26 at 11:23 AM Glucagon 1 mg intramuscularly was given by EMS. At 11:34 AM Resident # 1's blood glucose registered 44. At 11:41 AM Resident # 1's blood sugar registered 62, and at 12:05 PM Resident # 1's blood sugar registered 71. Resident # 1 was transferred by non-emergent transport to the hospital (without lights and siren.)Review of hospital records for 7/23/26 to 7/29/26 revealed the following information. Resident # 1's initial triage vital signs in the ED (Emergency Department) were documented as temperature 99.5, pulse 110, respirations 30, and blood pressure 148/93. Initially in the ED, Resident # 1 was alert and oriented and able to report to the ED provider that his blood sugars had been low for about a week or so. The hospital discharge summary attributed Resident # 1's hypoglycemia to septic shock and glipizide.During interviews with Resident # 1's physician on 8/4/26 at 11:45 AM, 8/4/26 at 12:23 PM, and 8/4/26 at 3:49 PM the physician reported the following information. The resident's blood sugar should have been checked on 7/23/26 when the staff noted the change and were preparing to send him to the hospital. Nurse # 3 was an excellent nurse. Getting a resident out to the hospital could be chaotic at times and there was a lot to do and he could understand how it was missed being checked before EMS arrived. He (the Physician) also wanted to partially take some of the responsibility that the resident's blood sugar was not checked before EMS arrived because when staff called him with a change in status to send the resident out to the hospital on 7/23/26, he could have told them to check it. Not checking the resident's blood sugar before EMS arrived on 7/23/26 and not obtaining the labs on 7/22/26 stat as he had intended had not changed the outcome for Resident # 1 in anyway.

Based on observation, record review and interviews with resident, staff, and pharmacist the facility failed to ensure that the dispensing of a resident's inhaler medication could be reconciled with the administration records of the inhaler medication for a cognitively intact resident who reported the inhaler was not consistently administered at night as ordered. This was for 1 (Resident # 2) of 2 residents whose medications were reviewed.The findings included:Record review revealed Resident # 2 was admitted to the facility on [DATE] and had a diagnosis of chronic obstructive pulmonary disease.Record review revealed Resident # 2 had an order, entered into the electronic medical record to start 3/7/26, for Advair Diskus bister with device 250-50 mcg/dose (micrograms/dose) one puff twice per day at 9:00 AM and 9:00 PM. (Advair Diskus is a maintenance inhaler used for chronic obstructive pulmonary disease.)Review of orders revealed Resident # 2 had an order, dated 4/27/26, for Advair Diskus blister with device 250-50 mg/dose one puff twice daily at 9:00 AM and 9:00 PM with the added directions to rinse mouth after use. (This was the same order begun on 3/7/26 with the additional instructions for rinsing of mouth.) Resident # 2's quarterly Minimum Data Set assessment, dated 6/8/26, revealed Resident # 2 was cognitively intact.Review of Resident # 2's July and August MARs (Medication Administration Records) revealed documentation the Advair inhaler was documented as administered as ordered.During interviews with Resident # 2 on 8/3/26 at 9:34 AM, 8/5/26 at 9:45 AM and on 8/5/26 at 1:35 PM, Resident # 2 reported she thought she was supposed to get her Advair inhaler twice per day. She did get it during the morning but did not consistently get it for the nighttime dose. She would get it here and now at night. She at times would get short of breath during the day but she could not say that that was necessarily attributed to missed doses of her Advair. She reported she had spoken to a staff member about other medication concerns but did not specify that she had specifically mentioned missed Advair inhaler doses.During an observation with Nurse # 6 of Resident # 2's Advair inhaler on 8/5/26 at 10:50 AM, it was observed that Resident # 2's current Advair inhaler being used was filled on 6/9/26 and opened on 7/6/26. There were 36 doses left in the dispensed 6/9/26 Advair inhaler out of 60 doses as of 8/5/26.During a follow up observation with Nurse # 6 on 8/5/26 at 1:25 PM, Nurse # 6 showed the surveyor that Resident # 2 had an unused Advair inhaler which was dispensed on 7/8/26 from the pharmacy and not yet in use. Nurse # 6 was interviewed why the dispensed inhaler from 6/9/26 was still in use and the 7/8/26 was not opened yet although it was 8/5/26. Nurse # 6 reported they were one ahead in getting inhalers for the resident.A pharmacist from the facility's pharmacy was interviewed on 8/5/26 at 12:45 PM and reported the following information. Their records showed Resident # 2's first Advair inhaler in the year 2026 was dispensed by the pharmacy on 3/6/26. Following that date, the other dispensing dates of Resident # 2's Advair inhaler were on 4/27/26, 6/9/26, and 7/8/26. The pharmacy sent a 30-day supply which was 60 doses in one inhaler each dispense time. If the dispensed 7/8/26 inhaler was still not in use, and the facility staff were still using the 6/9/26 Advair inhaler in August 2026 that should be a red flag. The pharmacist did not specify what the red flag would indicate. The DON was interviewed on 8/5/26 at 3:40 PM and reported the following information. She acknowledged that the dispensing and the documentation of the administration of the Advair did not mathematically make sense. She could not find documentation of explanations to account for more administration times than the facility would have had the Advair inhaler available for administration. The DON reported Resident # 2 had not made her aware of the missed nighttime doses she was reporting so that she could address the issue.

Based on record review and interviews with staff, Physician, and Pharmacist, for a resident whose most recent hemoglobin A1C indicated his diabetes was controlled, the facility failed to clarify when the Physician wrote a new order for diabetic medication without discontinuing the old diabetic medication order, which in turn would have indicated an increased daily dosage for the resident without a rationale. The resident unnecessarily received the increased daily diabetic dosage for multiple days prior to the consultant pharmacist questioning the order. This was for 1 of 2 sampled residents whose medications were reviewed (Resident # 1).The findings included:Resident # 1 was admitted to the facility on [DATE] and had diagnoses which included diabetes. Review of laboratory test results revealed Resident # 1's hemoglobin A1c was 5.2 % on 5/28/26. (A hemoglobin A1C indicates the average blood sugar level over the past two to three months and helps show how well blood sugars are being managed. A result of less than 5.7% is considered normal and indicates a person's diabetes is controlled.)Review of physician orders revealed when Resident # 1's hemoglobin A1C result was obtained on 5/28/26 he was receiving the diabetic medication glipizide extended release in a dosage amount of 10 milligrams (mg) daily. This order originated on 12/22/25.On 6/27/26 a new order was written by the physician for 5 mg glipizide extended release daily at 9:00 AM. Review of orders revealed that when the new 6/27/26 glipizide extended release order was written on 6/27/26, the previous order for glipizide 10 mg extended release was not discontinued.Review of physician orders revealed the glipizide 10 mg extended-release order was discontinued on 7/7/26.Review of Resident # 1's June and July 2026 Medication Administration Records revealed Resident # 1 was documented from 6/28/26 through 7/6/26 to receive both the 10 mg of glipizide extended release ordered on 12/22/25 and additionally was documented to receive the 5 mg of glipizide extended release ordered on 6/27/26, indicating a total dosage of 15 mg daily at 9:00 AM.Review of nursing progress notes from 6/27/26 to 7/6/26 revealed there was no indication or documentation Resident # 1 was having an increase in blood sugars which would warrant both dosages being given or that clarification was sought by the nursing staff when the new order was written for 5 mg glipizide extended release without discontinuation of the 10 mg glipizide extended release. Interview with Resident # 1's physician on 8/5/26 at 12:20 PM revealed he forgot to discontinue Resident # 1's glipizide 10 mg extended-release order when he decreased the resident's dosage to 5 mg extended release on 6/27/26. His intent was for a lower dose and not a higher dose of glipizide and he reported he took responsibility for the oversight in discontinuing the previous order. The physician reported the resident had not been harmed by receiving the increased dosage over the days when he received both dosages. Pharmacist # 1 was interviewed on 8/5/26 at 12:45 PM about whether the pharmacy called it to the facility staff's attention that there were no discontinuation orders for the glipizide 10 mg order on 6/27/26. Pharmacist # 1 reported the following information. The pharmacy's records showed they had received the new order for glipizide 5 mg extended release to begin on 6/28/26 at 9:00 AM. A pharmacist recognized the order to be a therapeutic duplication because the time the glipizide 5 mg extended release was to be given was ordered at 9:00 AM, which was the same time as the previous order of 10 mg glipizide extended release to be administered. Therefore, the pharmacy discontinued the 10 mg glipizide extended-release order on their end when they received the new order for 5 mg glipizide extended release. Pharmacist #1 explained it would have been the responsibility of the facility staff to recognize on their end that it was duplication of therapy and discontinue the order for 10 mg in their records.Interview with the Director of Nursing on 8/5/26 at 2:32 PM revealed that the Consultant Pharmacist (Pharmacist # 2), who reviewed residents' drug regimens every month, caught the duplication of therapy when Pharmacist # 2 did a monthly review of Resident # 1's medications and the order was discontinued when it was brought to the facility staff's attention in Pharmacist # 2's monthly review.

Based on observation, record review, and interviews with resident and staff, the facility failed to ensure a dependent resident could access a light switch located behind her bed for 1 of 1 resident reviewed for accommodation of needs (Resident #141).The findings included:Resident #141 was admitted to the facility on [DATE].An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #141 to be cognitively intact.During an observation on 1/12/2026 at 11:03 am revealed Resident #141 in bed, the overhead light was on, but no string was attached to overhead light. The light was attached to the wall, behind Resident #141's head.During an interview on 1/12/2026 at 11:04 am with Resident #141, the Resident stated that the string on her overhead light had been broken since she was admitted to the facility in December. Resident #141 stated that she slept with the light on all night and that she was able to sleep fine with the light on. Resident #141 further indicated that although the light being on did not bother her, she would like the option to turn it off. The Resident further stated that she did not recall submitting any grievances or reporting the overhead light to the staff. Resident stated she did not recall asking staff to turn the light off. During a joint observation and subsequent interview with the Maintenance Director on 1/14/2026 at 4:34 pm the Maintenance went to Resident #141's room and acknowledged that there was no way for Resident #141 or for the staff to turn the overhead light on or off, including during nighttime hours. When asked if there were any open work orders, he stated there were none for the hall Resident #141 resided. He stated that the overhead light issue was a simple fix. He stated that the process for reporting work orders required nursing staff to notify maintenance either verbally or by entering a work order. Maintenance Director stated that he had recently replaced lights on that hall but had not replaced the light in Resident #141 room because the facility was going to convert it to an office.An interview with Nurse Aide (NA) #1 on 1/15/2026 at 9:30 am, revealed that NA #1 assisted residents into bed during her 7:00 am to 7:00 pm shift. NA #1 stated that she asked residents whether they wanted the light on or off. NA #1 further stated that if there was a problem with a light, she would notify Maintenance. NA #1 stated that she was not aware that Resident #141 did not have a string or a way to control the overhead light, and she had not noticed the string was broken. She stated that if she had noticed the issue, she would have contacted Maintenance. NA #1 indicated the Resident had not informed her that the light string was broken or that she could not turn the overhead light on or off. NA #1 indicated that she was the NA that typically worked that hall and that she assisted Resident #141 to bed when she worked that hall.During an interview conducted on 1/15/2026 at 9:47 am, the Director of Nursing (DON) revealed she was not aware Resident #141 did not have a string on the overhead light. The DON stated she had not received any complaints from Resident #141 regarding the overhead light. The DON indicated that a work order would have been done if Resident #141 had told someone she was not able to operate the light. The interview further revealed that many residents sleep with a light on so nursing staff may not have immediately noticed that residents were unable to turn off the light.An interview was conducted with the Administrator on 1/15/2026 at 3:32 pm. The Administrator stated that Resident #141 did not complain about the light, thereby not alerting staff to the fact she could not turn it on or off. Administrator stated had the staff been aware, the light would have been promptly fixed.

Based on record review and staff interviews, the facility failed to ensure medications were administered according to the physician's orders and manufacturer's instructions for method of administration for 1 of 10 residents reviewed for medication administration (Resident #118). Findings included:Resident #118 was admitted to the facility on [DATE] with diagnoses that included Parkinsons disease, dementia and weakness.On 11/29/2025, the admission Minimum Data Set (MDS) assessment revealed Resident #118 was severely cognitively impaired. Eating and oral hygiene required substantial/maximal assistance. On 12/25/2025 a physician order stated that the resident takes medications whole in applesauce. A review of January 2026 active medications orders included Aspirin 81 milligrams (mg) delayed-release 1 tablet once a day, Carbidopa-levodopa 25-100 mg 2 tablets at 6:00 am, 10:00 am and 4:00 pm and Bisacodyl (stimulant laxative) 5 mg delayed-release 1 tablet at bedtime. Review of Resident #118's January 2026 Medication Administration Record (MAR) revealed there were no instructions to administer the medications whole in applesauce.A review of manufacturer's instructions (Kaiser Permanente) dated 1/26/2026 for delayed-release Aspirin and Bisacodyl indicated that the medications must never be chewed, crushed or broken as crushing destroys the enteric-coating and may cause severe stomach irritation. A review of nursing documentation revealed inconsistent medication administration practices. Nursing notes entered by Nurse #3 on 01/01/2026 at 11:55 am, 01/05/2026 at 11:56 am, 01/06/2026 at 06:57 pm and 01/09/2026 at 06:15 pm documented that Resident #118 resident tolerated medications administered whole in applesauce. A nursing note documented by Nurse #7 on 12/30/2025 at 11:56 pm indicated Resident #118 received medications crushed in applesauce. Nurse #3 documented on 1/11/2026 at 4:16 pm and 1/14/2026 2:06 pm Resident #118 received medications crushed in applesauce and Nurse #3 gave the resident his medications crushed in applesauce due to slow alertness. On 1/15/2026 at 4:17 pm, a phone interview with Nurse #4 revealed that she crushed all Resident #118's medications during second shift on 1/2/2026 (time unspecified) knowing the physician order regarding medication administration indicated whole in applesauce. She further stated that she crushed all medications without identifying which medications were safe to crush, despite acknowledging that some medications were extended release (Aspirin and Bisacodyl). Nurse #4 stated that even though Resident #118 could take his medication whole in applesauce, she felt Resident #118 took his medications best when they were crushed. On 1/15/2026 at 4:56 pm, a phone interview with Nurse #3 revealed that although she understood the order to be for medications to be given whole in applesauce, she crushed the resident's medications when the resident was having a slow day and he was taking more time to swallow the medication because of Parkinson's disease. Nurse #3 stated that resident was not having difficulty swallowing when she crushed the meds on 1/11/2026 and 1/14/2026. She stated that resident swallowed slowly or held the medicine in his mouth before swallowing. She stated she did not notify the physician or document a change in condition because Resident #118 was not having difficulty swallowing. Nurse #3 stated that she believed that she could use nurse discretion without contacting the provider.On 01/14/2026, attempts were made to contact Nurse #7 who was assigned to Resident #118 on 12/30/2025 from 7:00 pm to 7:00 am but were unsuccessful.A phone interview on 1/16/2025 at 3:38 pm with Nurse Practitioner (NP) revealed that a resident being slow to take medications was not an indication that medications needed to be crushed. She stated that resident had Parkinson's and his symptoms may wax and wane. The NP indicated if nursing staff felt he was having difficulty swallowing, they should write her a communication and she would evaluate resident. NP states that she did not receive any communication that Resident #118 was having difficulty swallowing or taking medications. The NP did not see a reason why Resident #118 could not take medications whole in applesauce as ordered. On 1/15/2026 at 3:58 pm, an interview with the Director of Nursing (DON) revealed that nurses were expected to administer medications as ordered. She stated that if a nurse determined it was unsafe for a resident to take medications whole, the nurse was expected to notify the physician or request a swallowing evaluation and obtain a new order.

Based on observations, record review, and staff interviews, the facility failed to provide an ongoing resident centered activities program in the memory care unit of the facility for 1 of 1 resident reviewed for activities (Resident #27). The findings included: Resident #27 was admitted to the facility on [DATE] with diagnoses which included dementia and depression. She resided on the memory care unit of the facility (a locked unit for individuals with dementia). The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #27 had severe cognitive impairment. Resident #27's assessment of daily and activity preferences revealed it was important for her to have reading material, listen to music, be around pets, keep up with news, be around groups of people, go outside and participate in religious services. Resident #27's care plan last reviewed on 11/18/25 revealed no goals or interventions related to activities. Review of the Kardex (resident care guide) for Resident #27 revealed no mention of activities. Review of Resident #27's record revealed no documentation of attendance at group activities, 1-1 individual sessions or self-directed activities. An observation conducted on 1/12/26 at 2:57 PM revealed Resident #27 was sitting in the hallway looking out the window. An observation conducted on 1/14/26 at 2:53 pm revealed Resident #27 was sitting in the common area of the memory care unit. The unit television was on but Resident #27 was not watching it. An interview was conducted with Nurse #1 on 1/14/26 at 3:37 pm who revealed the Activities staff did not conduct activities in the memory care unit. She stated sometimes staff would bring supplies to the unit. Nurse #1 reported that sometimes nursing staff would play music or cut on the television for the residents. She stated sometimes nursing staff would assist the residents in playing bingo, but it would be at times that would cause minimum disruption to the unit. Nurse #1 stated activities such as bingo in the late afternoon would make getting residents ready for bed difficult. She stated the activities were not individualized for each resident as noted on the MDS and were based on requests from residents who would make a request to the nurses on the unit for a movie or to play bingo. Nurse #1 stated there was no documentation for activities provided by nursing staff on the memory care unit. The Activity Director was interviewed on 1/14/26 at 3:58 pm who reported that he was unable to conduct activities in the memory care unit because he provided activities to the main units of the facility. He stated staff in the memory care unit would provide activities such as painting or bingo to the residents. The Activities Director stated there was a Life Enrichment Coordinator who also assisted with activities on the main units of the facility. He reported there was no calendar for activities in the memory care unit because he was not providing activities to the residents. The Activities Director stated he had not been doing activity assessments for residents in the memory care unit because he did not know they needed to be done. An unsuccessful attempt was made to contact the Life Enrichment Coordinator on 1/15/26 at 1:01 PM. During an interview with the Administrator and Corporate Nurse Consultant on 1/14/26 at 4:24 pm the Corporate Nurse Consultant revealed during a pre-survey review conducted on 1/6/26 the Corporate Nurse Consultant identified issues with the activities program in the memory care unit such as the Activities Director not having necessary certification, no activity assessments completed, no specialized activities in the memory care unit and no one to one activity documentation for residents. The Administrator stated prior to the pre-survey review she believed the Life Enrichment Coordinator was assisting with activities in the memory care unit. She stated in talking with the Activities Director during the survey, she discovered this was not accurate. The Administrator further stated she believed the Activities Director did not receive the necessary education for his role. The Administrator reported the Activity Director had been employed as the Activity Assistant in the past, but she believed the former Activities Director had not educated him fully on what the role entailed. The Activities Director received his Activity Director certification on 1/9/26.

Based on record reviews and interviews with the Pharmacy Consultant and staff interviews, the facility failed to have effective systems in place for the return of controlled medications to the pharmacy which resulted in the controlled medication being diverted from the medication cart for 1 of 1 resident reviewed for pharmacy services (Resident #13). The findings included: Resident #13 was admitted to the facility on [DATE] and discharged on 1/7/25. Review of a certificate of inventory and destruction form with no date completed by Nurse #2 revealed she had started a return to pharmacy of 11 tablets of 5 mg oxycodone HCL for Resident #13 discharged on 1/7/25. Review of the facility reported incident investigation dated 1/23/25 revealed the narcotic count for the 100-hall medication cart was not correct the evening of 1/18/25 during narcotic reconciliation completed by the off going Nurse #1 and oncoming Nurse #2. The 100-hall medication cart was found to be missing one narcotic count sheet for oxycodone HCL (hydrochloride) for Resident #13. An investigation was initiated, all medication carts were audited, and the missing narcotic count sheet for Resident #13 was not found. In a telephone interview with Nurse #1 on 6/24/25 at 6:34 pm she stated she worked on the 100-hall medication cart on 1/18/25 from 7:00 am until 7:00 pm. Nurse #1 stated Nurse #2 came in for her shift at 7:00 pm and found the discrepancy of missing oxycodone HCL during the narcotic reconciliation process. Nurse #1 further stated Nurse #2 called the Director of Nursing (DON) and reported the discrepancy. Nurse #1 stated Nurse #2 would not let her talk with the DON and Nurse #1 waited for approximately 20 minutes for her ride, clocked out and left the facility. Nurse #1 explained Nurse #2 had started a return of Resident #13's narcotic medications on 1/17/25 but did not finish. Nurse #1 stated Resident #13's narcotic count sheet and the oxycodone HCL tablets were in a plastic bag in the narcotic drawer on 1/18/25 at the beginning of her shift at 7:00 am. Nurse #1 stated she thought she had put the plastic bag which contained the oxycodone HCL and narcotic count sheet for Resident #13 back in the narcotic drawer of the medication cart but was not sure. Nurse #1 stated she did not know what happened to the narcotics and was not sure if she threw them away or put them in the recycling bin. Nurse #1 stated she was terminated on 1/23/25 because of the missing medications and leaving the medication cart unlocked. In a telephone interview with Nurse #2 on 6/25/25 at 11:56 am, stated the narcotic count on the 100-hall medication cart was correct at the end of her shift on 1/18/25 at 7:00 am. Nurse #2 indicated she was the off going nurse and Nurse #1 was the oncoming nurse. Nurse #2 explained she returned to the facility on 1/18/25 at 7:00 pm. Nurse #2 stated during the narcotic count reconciliation she found the discrepancy of missing oxycodone HCL during the narcotic reconciliation process. Nurse #2 further stated Nurse #1 said she did not take the narcotics, and she (Nurse #2) could check her bag. Nurse #2 called the DON and reported the discrepancy. Nurse #2 further stated the DON asked to speak with Nurse #1 and Nurse #1 refused and left the facility. Nurse #2 indicated the narcotic count was correct on 1/18/25 at 7:00 am and Resident #13's oxycodone HCL and narcotic count sheet was in the narcotic drawer on the medication cart. Nurse #2 stated Resident #13's oxycodone HCL and narcotic count sheet was not packaged in a bag and the narcotic count sheet was in the notebook. Nurse #2 stated she had started a return of narcotics but could not remember the date she started this return of narcotics or the resident's name. Nurse #2 further stated it was all the nurses' responsibility to return discharged and/or discontinued medications to the pharmacy. During an interview with Nurse #3 on 6/25/25 at 8:53 am, she stated she worked on the 100-hall medication cart on 1/17/25 from 7:00 am until 7:00 pm and the narcotic count was correct with 11 tablets remaining and the narcotic count sheet was in the narcotic binder. Nurse #3 explained that Nurse #2 called her on 1/18/25 around 7:00 pm and reported to her Nurse #1 did not want to count narcotics with her at the beginning of her shift around 7:00 pm. Nurse #3 stated Nurse #2 reported to her that Nurse #1 left the facility and did not finish the reconciliation of narcotics and Nurse #2 finished the reconciliation herself and found the discrepancy and reported this to Nurse #3 on 1/18/25. Nurse #3 stated she did not come to the facility on 1/18/25 when Nurse #2 called her concerning the discrepancy but came to the facility on 1/19/25 (Sunday) and notified the police of the missing narcotics. Review of the police report dated 1/19/25 revealed the police department was notified on 1/19/25 at 3:49 pm regarding larceny of medication from the facility. It was documented a follow-up investigation would be conducted at a later date and time regarding the security camera footage. The security footage was not available to view. No charges were filed on this date due to lack of evidence; however, if further evidence was discovered charges would be pursued. During a telephone interview with the Pharmacy Consultant on 6/25/25 at 10:37 am, stated she was made aware of the missing narcotics and narcotic count sheet on 1/18/25 by the Director of Nursing (DON). The Pharmacy Consultant explained that the nursing staff fill out a pharmacy certificate of inventory and destruction form with the resident's name/discharge date /medication strength/quantity/reason for return. The Pharmacy Consultant further explained that the resident's discharged medications were placed in a safe in the DON's office. The Pharmacy Consultant stated these medications were picked up monthly. In an interview with the Director of Nursing (DON) on 6/25/25 at 8:35 am, she stated the discrepancy with the narcotic count was reported to her by Nurse #2 on 1/18/25 at approximately 7:00 pm. The DON further stated she tried to speak with Nurse #1 on 1/18/25 and Nurse #1 refused to speak with her. Nurse #2 reported to her that Nurse #1 left the faciity on 1/18/25. The DON indicated she called Nurse #1 on 1/19/25 and Nurse #1 did not answer. The DON explained that narcotic/medication cart keys were to be always kept with a nurse on their person. Two nurses are responsible for completion of the narcotic count at change of shifts: one outgoing and one oncoming nurse. She further explained any discrepancy found must be reported immediately and an investigation would be started. The DON indicated she, and the Administrator started the investigation process on 1/20/25. The DON stated the nurses from either shift can return discontinued/discharged medications and the process should be done from start to finish which involved: filling out a pharmacy certificate of inventory and destruction form with the resident name/discharge date /medication and strength/quantity/reason for return/2 sets of nurse initials. The count sheet and medication are put into a bag and medications are given to her. She is the 3rd signature verifying count. If the return was started on the night shift (7:00 pm until 7:00 am) the medications and count sheets are kept in the narcotic drawer of the medication cart until the next day. The DON states she keeps the medications in a locked safe in her office until the pharmacy comes to pick them up and Pharmacy comes monthly for controlled medications. The DON indicated she expected the nursing staff to complete the return process once it was started and the medications that are discontinued or from a resident's discharged to be completed as soon as the medication is discontinued and when the resident is discharged from the facility. An interview with the Administrator on 6/25/25 at 3:00 pm stated her expectation was for nursing staff to count narcotics on the cart each shift, and both ongoing and oncoming staff sign off the narcotic count was completed and was correct. The Administrator indicated the nursing staff should have returned Resident #13's discharged medication as soon as he was discharged from the facility. The facility provided the following corrective action plan with a compliance date of 1/23/25. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #13 was missing oxycodone, as identified on 1/18/25. Resident #13 was sent to the hospital on 1/7/25 and did not return to the facility following his hospital admission. Per record review, Resident #13 did receive his oxycodone, as ordered, prior to his discharge to the hospital. The oxycodone was to be returned to the pharmacy as the patient had already discharged on 1/7/25. The oxycodone for Resident #13 was billed to the facility, therefore no misappropriation was substantiated during this investigation. Nurse #1 was identified as the nurse responsible for the medication cart on 1/18/25 when the oxycodone was identified as missing. Nurse #1 was placed on suspension on 1/18/25 pending investigation. Nurse #1 was terminated from employment on 1/23/25 due to negligence in performing her job duties. Nurse #1 did not work between 1/18/25 and 1/23/25. The facility Nursing Home Administrator made a report to the NC Board of Nursing related to the job performance issues identified for Nurse #1, on 2/10/25. Nurse #2 reported to the Director of Nursing (DON) that the card of oxycodone and the narcotic count sheet for the missing oxycodone was also missing from the narcotic count book. Nurse #2 stated that she counted with Nurse #1 at 7:00 a.m. on 1/18/25 and both the card of oxycodone and the narcotic count sheet were present at that time. Nurse #2 stated that at 7:00 p.m. on 1/18/25, both the card of oxycodone and the narcotic count sheet were missing. Nurse #3 stated she worked on the 100 hall on 1/17/25. Nurse #3 stated that at 7:00 p.m. on 1/17/25 she completed the narcotic count with Nurse #2. Nurse #3 stated that at that narcotic count, the card of oxycodone for Resident #13 was present with 11 tablets remaining and that the narcotic count sheet was present in the binder. Nurse #4 reported that he picked up a set of keys from his computer keyboard and had them in his pocket when he went on break, at approximately 3:30 p.m. on 1/18/25. Nurse #4 stated when he returned from break he identified that the keys were for Nurse #1 med cart, and he returned them to her. Nurse #4 stated at no time did he access the med cart assigned to Nurse #1 on 1/18/25. The DON confirmed with the pharmacy that they sent 30 tablets of oxycodone to the facility on [DATE]. The DON reviewed the medication administration record (MAR) for Resident #13 and there are 19 tablets signed out from that card of oxycodone. This card of oxycodone could not be located at the facility on 1/18/25 and the narcotic count sheet for the narcotic count binder is also missing for that card. Local Police Department was notified of the missing oxycodone on 1/18/25. Adult Protective Services was notified of the missing oxycodone on 1/18/25. The North Carolina Department of Health and Human Services was notified of the missing oxycodone on 1/18/25. All licensed nurses received education, on 1/24/25, provided by the Clinical Competency Coordinator, RN, regarding the following: Medication Cart and Narcotic Security Policy and Procedure for Controlled Substances Controlled inventory count sheets Policy and Procedure for return of controlled substances to the pharmacy Nurses who did not receive the mandatory training on 1/24/25 received the training prior to the start of their next shift. New nurses, hired after 1/24/25, will receive this training during general orientation. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. Social Services interviewed all current residents with a BIMS score of 10, or higher, related to medication Administration and pain management, on 1/18/25. None of the residents interviewed indicated a concern with not getting their pain meds when they request them, or when they are ordered. The Director of Nursing (DON) obtained a list of all as needed pain medication orders from the pharmacy for the past 30 days, on 1/18/25. The Director of Health Services completed an audit, on 1/18/25, of the PRN (as needed) sign-out sheets to identify any concerns related to use of as needed medications and also compared the narcotic sign out sheets to the Medication Administration Record (MAR) to identify any missing documentation. Per the audit, all as needed (PRN) medications were administered in compliance with the physician order, however, there was a pattern identified of Nurse #1 signing out her resident's as needed medications on the controlled drug record but failing to sign them out on the medication administration record in the resident record. Address what measures will be put in place or systemic changes made to ensure that the deficient practice will not recur. All licensed nurses received education, on 1/24/25, provided by the Clinical Competency Coordinator, RN, (CCC) regarding the following: Medication Cart and Narcotic Security Policy and Procedure for Controlled Substances Controlled inventory count sheets Policy and Procedure for return of controlled substances to the pharmacy Nurses who did not receive the mandatory training on 1/24/25 received the training prior to the start of their next shift. New nurses will receive this education material during their General Orientation to the facility, provided by the Clinical Competency Coordinator, RN. The facility reviewed the incident and investigation at a Quality Assurance Performance Improvement committee meeting on 1/23/25. The Quality Assurance Performance Improvement committee did not offer any additional recommendations for corrective measures. The Director of Health Services, or Assistant Director of Health Services began monitoring shift change narcotic count documentation and controlled inventory count sheets at the time of identification of this incident on 1/18/25, to ensure that the policy and procedure for Medication Cart and Narcotic Security, controlled substances and inventory count sheets were followed at shift change. The consulting pharmacist was also notified of the incident at the time the facility identified it and requested to increase monitoring of Medication and Narcotic security, controlled inventory count and the policy and procedure for controlled substances. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The Director of Health Services or Assistant Director of Health Services will complete monitoring of the shift change narcotic count documentation and controlled inventory count sheets, 5 times per week, for four weeks, starting on 1/23/25. After 4 weeks, audits will be completed once per week, for 8 weeks. Additional monitoring will be determined by the facility Quality Assurance Performance Improvement committee, to ensure sustained compliance. Monitoring will also include observation of medication cart security and medication administration record as needed documentation. The Director of Health Services will be responsible for reporting audit results to the Nursing Home Administration at the facility Quality Assurance Performance Improvement committee meeting. All future areas of concern identified related to medication and narcotic security, controlled inventory count sheets, or the policy and procedures for controlled substances will be thoroughly investigated and corrective measures will be taken as appropriate. Date of compliance: 1/23/25 On 6/25/25 the facility's plan of correction (POC) was validated by the following: Social Services interviewed residents on 1/18/25 related to pain medication administration and pain management. No concerns were identified. The DON completed audits of PRN pain medication on 1/18/25 and no concerns were noted; however, a pattern was noted for Nurse #1 failing to document PRN pain medication administration on the medication administration record (MAR) in the resident record. Adult Protective Services, The North Carolina Department of Health and Human Services, and the local Police Department were notified on 1/8/25. Interviews and record review verified education was conducted for staff as indicated in the corrective action plan. The facility's compliance date was validated as 1/23/25.

Based on record review, staff interviews, the facility failed to ensure the medical record was accurate regarding administration of Oxycodone Hydrochloride (HCL) (an opioid medication which is a controlled substance) for 1 of 1 resident (Resident #13) reviewed for accuracy of medical records. The findings included: A physician's order for Resident #13 dated 12/6/24, read Oxycodone HCL 5 mg to be administered 1 tablet every 6 hours as needed for moderate to severe pain. A review of the narcotic controlled substance count record for Resident #13 revealed Nurse #1 signed out one Oxycodone HCL 5 mg on the following dates: - 12/8/24 at 9:30 am - 12/11/24 at 8:45 am - 12/12/24 at 8:00 am - 12/17/24 at 1:30 pm - 12/20/24 at 3:00 pm - 12/22/24 at 9:00 am - 12/22/24 at 6:00 pm - 12/24/24 at 8:00 am A review of the Medication Administration Record (MAR) for Resident #13 revealed no documentation by Nurse #1 for the Oxycodone HCL 5 mg on the following dates: - 12/8/24 at 9:30 am - 12/11/24 at 8:45 am - 12/12/24 at 8:00 am - 12/17/24 at 1:30 pm - 12/20/24 at 3:00 pm - 12/22/24 at 9:00 am - 12/22/24 at 6:00 pm - 12/24/24 at 8:00 am In a telephone interview with Nurse #1 on 6/24/25 at 6:34 pm, stated she could not remember if she signed out the medication on the MAR on those dates. In an interview with the DON on 6/25/25 at 8:35 am stated her expectation was for the nursing staff to document medication administration accurately and promptly after the medication was given. The facility provided the following corrective action plan. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. On 1/18/25 the Director of Health Services (DHS) identified that the Medication Administration Record (MAR) documentation for the oxycodone did not reconcile with the narcotic count sheet for Resident #13. During the facility investigation the DHS confirmed that there was a pattern of Nurse #1 signing out her resident PRN medication on the controlled drug record but failing to sign them out on the MAR in the resident record. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. The Director of Health Services (DHS) obtained a list of all as needed PRN pain medication orders from the pharmacy for the past 30 days, on 1/18/25. The DHS completed an audit, on 1/18/25, of the PRN sign out sheets to identify any concerns related to documentation of PRN medications on the MAR. Per the audit, all as needed (PRN) medications were proved to be accurately documented on the MAR excluding Nurse #1s documentation. Address what measures will be put in place or systemic changes made to ensure that the deficient practice will not recur. All licensed nurses received education, on 1/24/25, provided by the Clinical Competency Coordinator, RN, (CCC) regarding accurate documentation on the MAR. Medication aides were not utilized at the facility. Nurses who did not receive the mandatory training on 1/24/25 received the training prior to the start of their next shift. New nurses will receive this education material during their General Orientation to the facility, provided by the CCC. The facility reviewed the documentation at a QAPI meeting on 1/23/25. The QAPI did not offer any additional recommendations for corrective measures. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The DHS will complete monitoring of documentation on the MAR of narcotics, 5 times per week, for four weeks, starting on 1/23/25. After 4 weeks, audits will be completed once per week, for 8 weeks. Additional monitoring will be determined by the facility QAPI committee, to ensure sustained compliance. Monitoring will also include observation of medication cart security and MAR PRN documentation. The DHS will be responsible for reporting audit results to the Nursing Home Administration at the facility QAPI meeting. Correction Date 1/23/25 On 6/25/25 the facility's plan of correction (POC) was validated by the following: The DON completed audits of PRN pain medication on 1/18/25 and no concerns were noted; however, a pattern was noted for Nurse #1 failing to document PRN pain medication administration on the medication administration record (MAR) in the resident record. Interviews and record review verified education was conducted for staff as indicated in the POC. The facility reviewed the documentation at a QAPI meeting on 1/23/25. The QAPI did not offer any additional recommendations for corrective measures. The DON continued monitoring of documentation on the MAR of narcotics, 5 times per week, for four weeks, starting on 1/23/25. After 4 weeks, audits were completed once per week, for 8 weeks. Additional monitoring was determined by the facility QAPI committee, to ensure sustained compliance. Monitoring also included observation of medication cart security and MAR PRN documentation. The DON was responsible for reporting audit results to the Nursing Home Administration at the facility QAPI meeting. The facility's compliance date was validated as 1/23/25.

Based on record review and interviews with staff, resident, Contracted Transportation Company, and the Physician, the facility failed to protect Resident #1's right to be free of neglect for 1 of 3 residents reviewed for accidents. On 4/25/25 at approximately 4:30 PM during transportation back to the facility from a medical appointment in the contracted transport van the resident's wheelchair flipped backwards landing horizontal on the floor of the van. Resident #1's head hit the van floor and her back sustained impact when the wheelchair backrest (the support structure for the user's back) hit the floor. The Contracted Transport Driver was not qualified to complete a clinical assessment of injury. He asked the resident if she was okay, set the wheelchair upright, secured the wheelchair in the van, and continued the trip back to the facility. The resident reported during the entire ride back to the facility the Contracted Transport Driver repeatedly stated that he was going to be fired for what happened. Upon return to the facility, the Contracted Transport Driver notified facility staff the resident was complaining of pain in her back, but deliberately withheld information about the resident suffering a fall. After the Contracted Transport Driver left the facility, the resident informed staff of the fall and complained of pain rated a 10 out of 10 (with 10 being the worst pain possible) in her neck, shoulders, and back. Staff reported they had never seen Resident #1 in pain like that before and that she was moaning and crying out. Opioid pain medication was administered but it was not effective to relieve the pain. The resident was transferred to the hospital where she was evaluated in the Emergency Department (ED) at approximately 7:32 PM. The resident was identified with a fracture at the superior endplate (flat surface at the top of each vertebra) of the L1 (lumbar spine region, first vertebra). Disregarding the need for Resident #1 to be clinically assessed for injury prior to moving the resident had a high likelihood of resulting in further injury. The Contracted Transport Driver's decision to withhold information essential for the staff to be notified of in order for a clinical assessment to be completed to determine the necessary care the resident required delayed care and extended the time period the resident suffered severe pain without treatment. These deliberate actions taken by the Contracted Transport Driver constituted neglect. Immediate Jeopardy began on 4/25/25 when the Contracted Transport Driver neglected to have Resident #1 assessed for injury by a medical professional prior to being moved following a fall in the contracted transport van. Immediate jeopardy was removed on 5/08/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The findings included: The tag is cross-referenced to: F684: Based on record review, interviews with staff, resident, Contracted Transportation Company, and the Physician, the Contracted Transport Driver failed to have Resident #1 assessed for injury by a qualified professional prior to moving the resident following a fall in the transportation van and to notify the facility nursing staff of the fall in order for the resident to be clinically assessed for injuries from the fall. Resident #1 returned to the facility on [DATE] at approximately 5:30 pm and notified staff that her wheelchair had flipped backwards while being transported back to the facility and the Contracted Transport Driver lifted her and her wheelchair up from the floor and returned her to the facility. Resident #1 suffered pain rated a 10 out of 10 (with 10 being the worst pain possible) in her neck, shoulders, and back. The resident was transferred to the hospital where she was identified with a fracture at the superior endplate (flat surface at the top of each vertebra) of the L1 (lumbar spine region, first vertebra). There was a high likelihood of further injury from moving a resident after a fall prior to a clinical assessment of injury and not informing staff of the fall delayed treatment for the resident. This deficient practice affected one of three residents reviewed for accidents (Resident #1). An initial report completed by the Administrator was submitted to the State Agency on 5/01/25 for an allegation of neglect. The Contracted Transport Driver was noted as the accused individual. The report indicated on 4/25/25 Resident #1 was transported from dialysis back to the facility by the Contracted Transport Driver and after Resident #1 returned she reported she had fallen in the van and had back pain. The Contracted Transport Driver returned Resident #1's paperwork to the nurse and made no report of an incident during transport. The resident was sent to the ED for evaluation. On 5/01/25 the facility was notified that Resident #1 sustained an acute fracture related to the fall during transport on 4/25/25. During an interview with Nurse #2 on 5/05/25 at 1:05 pm she stated that after she was notified of Resident #1's fall on 4/25/25 by Nurse Aide #1 she immediately went to assess the resident. She revealed that Resident #1 appeared to be panicked, like talking all over the place and rambling. She indicated the resident seemed hesitant to report what happened, almost nervous like not looking at her [Nurse #2] when she asked her about what happened on the ride back from dialysis. An interview was conducted on 5/08/25 at 9:01 am with Resident #1 who revealed that during the entire ride back to the facility after the fall on 4/25/25 the Contracted Transport Driver kept saying he was going to be fired for what happened. The initial report submitted on 5/1/25 for an allegation of neglect related to the 4/25/25 fall for Resident #1 was reviewed with the Administrator on 5/05/25 at 2:29 pm. The Administrator was unable to state why she completed and submitted the initial report for neglect but she stated it was not neglect on the role of the facility. She stated the facility confirmed Resident #1's fall and injury had occurred but she did not feel the facility was responsible for the actions of the Contracted Transport Driver. The Administrator further stated that she did not identify anything, on their end, that the facility would have done differently. On 5/05/25 at 4:51 pm the Administrator was notified of immediate jeopardy. The facility provided the following Immediate Jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On 4/25/25 Resident #1 had a fall in the Contracted Transportation Van and the Contracted Transport Driver moved the resident prior to having the resident assessed for injuries by a qualified professional. Upon return to the facility the Contracted Transport Driver informed the staff the resident wanted to go to bed and did not feel good but he failed to notify the facility nursing staff of the fall in order for the resident to be clinically assessed for injuries from the fall. On 4/25/25 at 5:30 p.m., Resident #1 reported to Nurse #2 that her back was hurting and stated that her wheelchair flipped back in the contracted transportation van, the driver forgot to lock her wheelchair down, and she bumped her head. Nurse #2 went directly to evaluate Resident #1 and identified that the resident was tearful and reported pain. Nurse #2 completed a neurological assessment of Resident #1, which was normal. Resident #1 was given Tramadol for pain at 5:45 p.m. for pain. Nurse #2 contacted the primary Medical Doctor (MD) for Resident #1 to report the resident complained of pain in her back, neck and shoulder. The MD provided an order to transport Resident #1 to the Emergency Department (ED) for evaluation. Nurse #2 called Emergency Medical Services (EMS) for transportation to the ED and Resident #1 left for the ED at 6:45 p.m. Nurse #2 contacted the Responsible Party (RP) to report the incident that occurred in the contracted van, the resident report of pain and the MD order to transport the resident to the ED. Resident #1 remained in the Hospital undergoing a Cat Scan on 4/25/25 with negative results for acute diagnosis. Due to continued complaints of pain at the Hospital, the Hospital completed an MRI on 4/29/25 which identified a lumbar 1 fracture. The Health Information Management (HIM) Director contacted the Contracted Transportation Company Owner on 4/25/25 at approximately 5:45pm to report Resident #1's allegation that Resident #1 stated her wheelchair flipped back and she hit her head. On 4/25/25 the Contracted Transportation Company Owner provided a statement to the Facility in an email from the Contracted Transportation Company Owner. The email from the Contracted Transportation Company Owner described an interview that the Contracted Transportation Company Owner had with the Contracted Transport Driver following the incident on 4/25/25 with Resident #1. Per the Contracted Transportation Company Owner, the Contracted Transport Driver reported that Resident #1's wheelchair tilted backwards causing her to fall and hitting her head and back. The Contracted Driver reported he immediately stopped, asked Resident #1 if she was OK, sat her chair upright and returned her to the facility. The Contracted Transport Driver stated Resident #1 reported to him that she was OK. Per the Contracted Transportation Company Owner, the Contracted Transport Driver did not follow the policy by notifying 911 to assess the resident for injury prior to moving the resident and not notifying the facility of the fall. The Contracted Transportation Company Owner reported that the Contracted Transport Driver was terminated due to gross negligence and is ineligible for rehire. The Director of Nursing (DON) will review all facility falls within the last 30 days to verify that all residents were assessed by a licensed nurse for injury following a fall and non-medical staff notified staff who were qualified to perform clinical assessments prior to the resident being moved. The facility will complete an investigation for any concerns that are identified and take appropriate follow-up action based upon the results of the investigation. The Administrator will assume responsibility to ensure the investigation and follow-up are completed. 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 will have effective systems in place to provide the necessary care and services to all resident and to protect all residents from neglect. The Administrator spoke with the Contracted Transportation Company Owner regarding the need for education and documentation on 5/6/25. The Transportation Vendor who will be utilized for appointment transportation will provide training for all contract transport drivers who transport residents from the facility starting on 5/6/25. Training will be provided by the Contract Transportation Vendor Supervisors and will include notifying 911 to assess the resident for injury prior to moving the resident and the requirement to notifying the facility of falls by calling the facility at the time of the fall after calling 911. On 5/7/25 the Contract Transportation Vendor Supervisors will complete training on identifying and reporting neglect, including examples of what constitutes neglect. Effective 5/6/25 all contract transport drivers this Transportation Vendor sends to the facility will have this training completed prior to being assigned transportation trips for the facility residents. Training documentation will be provided to the Administrator by the Contracted Transportation Company Owner or Designee to be maintained at the facility. Newly hired contract transport drivers for this vendor will be provided this training by the Contracted Transportation Company Owner or Designee prior to being assigned transportation trips for the facility residents. On 5/6/25 100% of facility staff received re-education regarding the facility policy for Abuse Identification, including indicators of neglect, and reporting neglect, including examples of what constitutes neglect. Department Supervisors will provide this education for their respective staff on 5/6/25. All staff who did not complete this training on 5/6/25 will have the training provided prior to working their next shift, provided by their respective Department Supervisor. The Clinical Competency Coordinator will be responsible for tracking to ensure that 100% of staff receive the training. This training will be provided during general orientation for all newly hired staff after 5/6/25. On 5/6/25 100% of facility staff received re-education provided by the Administrator regarding the facility policy not to move the resident after a fall until he/she has been examined by a licensed nurse for possible injuries. Department Supervisors will provide this education for their respective staff on 5/6/25. All staff who did not complete this training on 5/6/25 will have the training provided prior to working their next shift, provided by their respective Department Supervisor. The Clinical Competency Coordinator will be responsible for tracking to ensure that 100% of staff receive the training. This training will be provided during general orientation for all newly hired staff after 5/6/25. On 5/6/25 100% of the facility's transport drivers will receive training related to ensuring the resident is assessed by a qualified professional in the event the fall occurs during transportation and prior to moving the resident. Per the policy, they should move to the side of the road and call 911 for resident assessment by a qualified professional. Per policy, the facility transport driver will notify the facility of any fall that occurs during transport. The facility's Transport Driver training was provided by the facility Maintenance Director on 5/6/25. Newly hired facility transportation drivers will be provided training related to ensuring the resident is assessed by a qualified professional in the event the fall occurs during transportation and prior to moving the resident. Per the policy, they should move to the side of the road and call 911 for resident assessment by a qualified professional. Per policy, the facility transport driver will notify the facility of any fall that occurs during transport provided by the Maintenance Director. Alleged date of immediate jeopardy removal: 5/08/25 Onsite validation of the immediate jeopardy removal plan was completed as follows: The Administrator verified that effective 5/05/25 the facility ceased use of the vendor for the company that provided transportation for Resident #1 on 4/25/25. A review of the facility provided documentation revealed an audit of falls within the last 30 days was completed by the Director of Nursing as outlined in their removal plan. The audits included review for documentation that a licensed nurse assessed the resident for injury following a fall and that non-medical staff notified qualified staff to perform a clinical assessment prior to the resident being moved. There were no concerns identified. Review of the contracted transportation company's education documentation revealed all staff had completed education on 5/06/25 regarding the notification of 911 to assess the resident for injury prior to moving, and to notify the facility of any van related incident after calling 911. Further review of the education documentation revealed the contracted transportation company completed education on 5/07/25 on identification of neglect and reporting of neglect. The education included examples of neglect. The education was verified by sign-in sheets from both service locations. Newly hired contract transport drivers for this vendor will be provided this training by the Contracted Transportation Company Owner or Designee prior to being assigned transportation trips for the facility residents. The Administrator confirmed this was the only contracted transportation company the facility currently used for transportation effective 5/05/25. Review of the facility education materials and sign-in sheets were reviewed and confirmed that education was provided to all facility staff, which included transportation staff, was completed on the facility policy for Abuse Identification which included how to identify neglect, reporting neglect, and examples of neglect. The staff sign-in sheets were reviewed and were completed by all facility staff in all departments, which included contracted staff. The Clinical Competency Coordinator will be responsible for tracking to ensure that 100% of staff receive the training. This training will be provided during general orientation for all newly hired staff after 5/6/25. A review of the facility education was conducted regarding the facility policy related to falls, with focus to not move a resident after a fall until examined by a licensed nurse for possible injury. Staff sign-in sheets were reviewed and completed by all facility staff including contracted staff. The Clinical Competency Coordinator will be responsible for tracking to ensure that 100% of staff receive the training. This training will be provided during general orientation for all newly hired staff after 5/6/25. Review of the education materials and sign-in sheets for the facility transportation staff were reviewed regarding the procedure if a fall should occur during transport. The education included that the resident was to be assessed by a qualified professional before moving a resident, to move the transportation vehicle to a safe location and call 911. The education further noted that facility transportation staff were to notify the facility of any falls that occur during transports. Newly hired facility transportation drivers will be provided training related to ensuring the resident is assessed by a qualified professional in the event the fall occurs during transportation and prior to moving the resident. Per the policy, they should move to the side of the road and call 911 for resident assessment by a qualified professional. Per policy, the facility transport driver will notify the facility of any fall that occurs during transport provided by the Maintenance Director. Interviews were conducted on 5/08/25 with facility staff and contracted facility staff to confirm that education was received regarding abuse and neglect education which included definitions and examples, and reporting of resident neglect. Interviews were conducted on 5/08/25 with the facility transportation staff who confirmed education was completed regarding management of resident falls during transports including not moving a resident without being assessed by medical professional, reporting incidents to the facility, and abuse and neglect which included examples of neglect. The facility's immediate jeopardy removal date of 5/08/25 was validated.

Based on record review, interviews with staff, resident, Contracted Transportation Company, and the Physician, the Contracted Transport Driver failed to have Resident #1 assessed for injury by a qualified professional prior to moving the resident following a fall in the transportation van and to notify the facility nursing staff of the fall in order for the resident to be clinically assessed for injuries from the fall. Resident #1 returned to the facility on [DATE] at approximately 5:30 pm and notified staff that her wheelchair had flipped backwards while being transported back to the facility and the Contracted Transport Driver lifted her and her wheelchair up from the floor and returned her to the facility. Resident #1 suffered pain rated a 10 out of 10 (with 10 being the worst pain possible) in her neck, shoulders, and back. The resident was transferred to the hospital where she was identified with a fracture at the superior endplate (flat surface at the top of each vertebra) of the L1 (lumbar spine region, first vertebra). There was a high likelihood of further injury from moving a resident after a fall prior to a clinical assessment of injury and not informing staff of the fall delayed treatment for the resident. This deficient practice affected 1 of 3 residents reviewed for accidents (Resident #1). Immediate Jeopardy began on 4/25/25 when Resident #1 was not assessed by a medical professional for injury prior to being moved following a fall in the contracted transport van. Immediate jeopardy was removed on 5/07/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included a left above the knee amputation, right below the knee amputation, and dependence on dialysis. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #1 had severe cognitive impairment. Resident #1 was dependent upon staff for transfers and used a wheelchair for mobility. Resident #1 was not coded for pain or for the use of opioid pain medication. The nursing progress note written by Nurse #2 dated 4/25/25 at 6:54 pm revealed Resident #1 returned from her dialysis appointment at approximately 5:30 pm and the Contracted Transport Driver reported that Resident #1's back was hurting and she wanted to go to bed. Nurse #2 noted that staff entered the room to assist Resident #1 to bed and she started moaning and crying out that her back hurt. Resident #1 explained that her wheelchair flipped backwards while being transported back to the facility because the Contracted Transport Driver forgot to lock the wheelchair down. Nurse #2 noted that Resident #1 reported a pain score of 10 out of 10 for her back from top of neck all the way down the back, neck, and shoulders and was administered the as needed (PRN) tramadol (opioid pain medication) at 5:45 pm. Nurse #2 noted the Medical Doctor was notified and she received an order to send Resident #1 to the emergency department for evaluation. Nurse #2 noted that EMS (emergency medical services) was called and arrived at the facility within ten minutes. The nursing progress note further reported that Resident #1 continued to yell out in pain while Nurse #2 prepared the paperwork and notified her Responsible Party. Nurse #2 reported that Resident #1 was transferred to the hospital at 6:45 pm. Review of the Controlled Drug Record revealed Nurse #2 administered 2 tramadol 50 milligram (mg) tablets for pain to Resident #1 on 4/25/25 at 5:45 pm. A telephone interview was conducted on 5/05/25 at 1:05 pm with Nurse #2 who was assigned to Resident #1 on 4/25/25 when she returned from the dialysis appointment. Nurse #2 stated she was at the nursing station when the Contracted Transport Driver approached the desk with Resident #1 and the dialysis communication book and reported that Resident #1's back hurt and she wanted to go to bed. Nurse #2 stated the Contracted Transport Driver left the dialysis communication book at the desk and left the facility. Nurse #2 stated that at no time did the Contracted Transport Driver report that Resident #1's wheelchair had tipped backwards during the return trip to the facility or that Resident #1 had hit the floor of the van. Nurse #2 stated she contacted the Physician and they discussed the option of in-house radiology testing but they decided it was best to send Resident #1 to the hospital because her pain was all over. She stated Resident #1 was medicated with pain medication but she was in such pain and continued to cry out while waiting for the ambulance to arrive. Nurse #2 stated she notified the Director of Nursing of the incident. Resident #1 was interviewed on 5/08/25 at 9:01 am and revealed she had some difficulty talking about the incident because she was so upset by what happened. Resident #1 stated when the Contracted Transport Driver went to take a turn or something she felt her wheelchair tip backwards and then the only thing she could see was the ceiling of the van. Resident #1 stated the Contracted Transport Driver pulled the van over and came to check on her and asked if I (Resident #1) was okay. Resident #1 stated she could not even say anything at that time, she stated she felt confused and in shock. Resident #1 stated that somehow the Contracted Transport Driver was able to pick her and her wheelchair up from the floor while she was still sitting in it and put her and the wheelchair back upright. Resident #1 stated the Contracted Transport Driver then hooked her wheelchair to the floor and drove her back to the facility. Resident #1 stated when she got back to the facility her pain was at least 10 out of 10 so she had to tell the staff what happened when she was transported by the Contracted Transport Driver. An attempt to interview the Contracted Transport Driver on 5/07/25 was unsuccessful. The Director of Nursing (DON) was interviewed on 5/05/25 at 2:08 pm. The DON stated she was at the facility when the Contracted Transport Driver brought Resident #1 back from the dialysis appointment on 4/25/25. She stated she was notified by Nurse #2 of the van incident with Resident #1, but she stated when she went to find the Contracted Transport Driver he had already left the facility so she was unable to obtain a statement. The DON stated she asked the Health Information Management (HIM) Director to contact the Contracted Transportation Company and report Resident #1's incident. The DON stated she was told by staff that the Contracted Transport Driver never reported the van incident when he returned Resident #1 to the facility. An interview with the HIM Director was conducted on 5/05/25 at 2:21 pm. She reported she contacted the Contracted Transportation Company as requested by the DON and reported the incident that involved Resident #1 on 4/25/25. The HIM Director stated the Contracted Transportation Company obtained the statement from the Contracted Transport Driver and the company provided the information to the facility. The Contracted Transportation Company provided the facility with a written statement from the company which included a statement from the Contracted Transport Driver dated 4/25/25 regarding the incident. The statement revealed Resident #1 was picked up on 4/25/25 at approximately 4:30 pm for transport back to the facility by the Contracted Transport Driver. He reported that as he took off, the wheelchair tilted over backwards causing Resident #1 to fall hitting her head and back. The statement further noted that the Contracted Transport Driver immediately stopped, asked the resident if she was okay, set the wheelchair upright, secured it to the van floor, and returned Resident #1 to the facility. He further noted that he wanted to report the incident to the facility management but Resident #1 asked him not to tell anyone because she did not want to get anyone in trouble. The statement concluded that the Contracted Transport Driver was terminated due to not reporting the incident, not securing Resident #1's wheelchair, and gross negligence. A telephone interview was conducted on 5/05/25 at 1:56 pm with the Contracted Transportation Company's Office Manager who revealed they had provided the facility with the information regarding the incident with Resident #1 and at this time they had no further information to provide. The EMS record dated 4/25/25 revealed the facility contacted EMS for Resident #1's emergent transport to the hospital at 6:40 pm and they arrived at the facility at 6:54 pm. The signs and symptoms listed on the report indicated acute pain due to trauma. The resident stated she was hurting all over and she was unable to describe the pain. Staff indicated Resident #1 had received 2 tramadol prior to EMS arrival. EMS departed the facility with Resident #1 at 7:11 pm and arrived at the hospital at 7:27 pm. Review of the hospital record dated 4/25/25 through 5/01/25 revealed Resident #1 was seen in the emergency room provider on 4/25/25 at approximately 7:32 pm after sustaining a fall in the transportation van with reports of head, neck, chest, abdominal, and back pain. A computed tomography (CT) scan of the cervical spine without intravenous contrast was completed on 4/26/25 at 4:45 am with no acute findings. The hospital record further noted that Resident #1continued to report pain all over and on 4/29/25 a magnetic resonance imaging (MRI) was performed on 4/29/25 which showed a fracture at the superior endplate of L1 without height loss (a less severe fracture that is not fully compressed). Resident #1 did not require any surgical interventions and was stable for transfer back to the facility on [DATE]. Resident #1's discharge activity level was noted as tolerated and she was prescribed oxycodone (opioid pain medication) 5 mg tablet every 4 hours as needed for moderate or severe pain for 5 days and a lidocaine 4% pain patch daily. A telephone interview was conducted with NA #3 on 5/05/25 at 1:18 pm who was assigned to Resident #1 on 4/25/25 during the 3:00 pm through 11:00 pm shift. NA #3 stated when she went to Resident #1's room she (Resident #1) was crying out every time she was touched and she had never seen Resident #1 in pain like that before. NA #3 stated when she was told what happened in the van she could not understand why the Contracted Transport Driver did not report what happened to Resident #1 when he dropped her off at the facility. During an interview on 5/05/25 at 1:50 pm with NA #1 she revealed that she was working on 4/25/25 when Resident #1 returned from dialysis. NA #1 stated the Contracted Transport Driver came to the nursing station desk and he reported that Resident #1 had been crying like this and was not feeling good. She stated Resident #1 was visibly upset and when she was back in her room Resident #1 reported what had occurred on the transport van. NA #1 immediately notified Nurse #2. NA #1 stated the Contracted Transport Driver had the audacity to stand right in front of her face and not say one word about what happened to Resident #1 in the van when it was obvious Resident #1 was in extreme pain. An interview was conducted on 5/08/25 at 12:34 pm with the Physician who revealed he had been the medical provider for Resident #1 for over 3 years at the facility. The Physician indicated that Resident #1 should have been assessed before being moved since the Contracted Transport Driver was not able to know if Resident #1 had been injured at the time and it could have worsened an injury. The Physician stated when he spoke with Nurse #2 the initial plan was to obtain in-house radiology testing for Resident #1. He stated they discussed that since the nurse was at the bedside she was best to determine Resident #1's pain level and current status so they made the decision to send the resident to the hospital for the testing because of the extreme pain throughout her body. The Physician stated Resident #1 was very sharp and alert and he would see her 2-3 times per week at the facility to manage her chronic and acute illnesses. He stated Resident #1 was normally very clear in her cognition and speech and she was a reliable source of information. A follow-up interview was conducted on 5/08/25 at 1:15 pm with the DON who stated the Contracted Transport Driver should have called 911 when Resident #1's wheelchair tipped backwards and he should have reported it to the facility. During an interview on 5/05/25 at 2:29 pm with the Administrator she revealed she had confirmed the incident occurred but the Contracted Transport Driver did not report the incident to any staff at the facility when he returned Resident #1 from the dialysis appointment. The Administrator stated the Contracted Transport Driver should have had Resident #1 assessed at the time of the incident and immediately report the incident to the facility. On 5/05/25 at 4:51 pm the Administrator was notified of immediate jeopardy. The facility provided the following Immediate Jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On 4/25/25 Resident #1 had a fall in the Contracted Transportation Van and the Contracted Transport Driver moved the resident prior to having the resident assessed for injuries by a qualified professional. Upon return to the facility the Contracted Transport Driver informed the staff the resident wanted to go to bed and did not feel good but he failed to notify the facility nursing staff of the fall in order for the resident to be clinically assessed for injuries from the fall. On 4/25/25 at 5:30 p.m., Resident #1 reported to Nurse #2 that her back was hurting and stated that her wheelchair flipped back in the contracted transportation van, the driver forgot to lock her wheelchair down, and she bumped her head. Nurse #2 went directly to evaluate Resident #1 and identified that the resident was tearful and reported pain. Nurse #2 completed a neurological assessment of Resident #1, which was normal. Resident #1 was given Tramadol for pain at 5:45 p.m. for pain. Nurse #2 contacted the primary Medical Doctor (MD) for Resident #1 to report the resident complained of pain in her back, neck and shoulder. The MD provided an order to transport Resident #1 to the Emergency Department (ED) for evaluation. Nurse #2 called Emergency Medical Services (EMS) for transportation to the ED and Resident #1 left for the ED at 6:45 p.m. Nurse #2 contacted the Responsible Party (RP) to report the incident that occurred in the contracted van, the resident report of pain and the MD order to transport the resident to the ED. Resident #1 remained in the hospital undergoing a CT Scan on 4/25/25 with negative results for acute diagnosis. Due to continued complaints of pain at the hospital, the hospital completed an MRI on 4/29/25 which identified a lumbar 1 fracture. The Health Information Management (HIM) Director contacted the Contracted Transportation Company Owner on 4/25/25 at approximately 5:45pm to report Resident #1's allegation that Resident #1 stated her wheelchair flipped back and she hit her head. On 4/25/25 the Contracted Transportation Company Owner provided a statement to the Facility in an email from the Contracted Transportation Company Owner. The email from the Contracted Transportation Company Owner described an interview that the Contracted Transportation Company Owner had with the Contracted Transport Driver following the incident on 4/25/25 with Resident #1. Per the Contracted Transportation Company Owner, the Contracted Transport Driver reported that Resident #1's wheelchair tilted backwards causing her to fall and hit her head and back. The Contracted Driver reported he immediately stopped, asked Resident #1 if she was OK, sat her chair upright and returned her to the facility. The Contracted Transport Driver stated Resident #1 reported to him that she was OK. Per the Contracted Transportation Company Owner, the Contracted Transport Driver did not follow the policy by notifying 911 to assess the resident for injury prior to moving the resident and not notifying the facility of the fall. The Contracted Transportation Company Owner reported that the Contracted Transport Driver was terminated due to gross negligence and is ineligible for rehire. The Director of Nursing (DON) will review all facility falls within the last 30 days to verify that all residents were assessed by a licensed nurse for injury following a fall and non-medical staff notified staff who were qualified to perform clinical assessments prior to the resident being moved. The facility will complete an investigation for any concerns that are identified and take appropriate follow-up action based upon the results of the investigation. The Administrator will assume responsibility to ensure the investigation and follow-up are completed. 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 will have effective systems in place for residents to be assessed in the event of an accident and for non-medical staff to notify facility staff who are qualified to perform clinical assessments for injury following a fall prior to the resident being moved. The Administrator spoke with the Contracted Transportation Company Owner regarding the need for education and documentation on 5/6/25. The Transportation Vendor who will be utilized for appointment transportation will provide training for all contract transport drivers who transport residents from the facility starting on 5/6/25. Training will be provided by the Contract Transportation Vendor Supervisors and will include notifying 911 to assess the resident for injury prior to moving the resident and the requirement to notify the facility of falls by calling the facility at the time of the fall after calling 911. Effective 5/6/25 all contracted transport drivers this Transportation Vendor sends to the facility will have this training completed prior to being assigned transportation trips for the facility residents. Training documentation will be provided to the Administrator by the Contracted Transportation Company Owner or Designee to be maintained at the facility. Newly hired contract transport drivers for this vendor will be provided this training by the Contracted Transportation Company Owner or Designee prior to being assigned transportation trips for the facility residents. On 5/6/25 100% of facility staff received re-education provided by the Administrator regarding the facility policy not to move the resident after a fall until he/she has been examined by a licensed nurse for possible injuries. Department Supervisors will provide this education for their respective staff on 5/6/25. All staff who did not complete this training on 5/6/25 will have the training provided prior to working their next shift, provided by their respective Department Supervisor. The Clinical Competency Coordinator will be responsible for tracking to ensure that 100% of staff receive the training. This training will be provided during general orientation for all newly hired staff after 5/6/25. On 5/6/25 100% of the facility's transport drivers will receive training related to ensuring the resident is assessed by a qualified professional in the event the fall occurs during transportation and prior to moving the resident. Per the policy, they should move to the side of the road and call 911 for resident assessment by a qualified professional. Per policy, the facility transport driver will notify the facility of any fall that occurs during transport. The facility's Transport Driver training was provided by the facility Maintenance Director on 5/6/25. Newly hired facility transportation drivers will be provided training related to ensuring the resident is assessed by a qualified professional in the event the fall occurs during transportation and prior to moving the resident. Per the policy, they should move to the side of the road and call 911 for resident assessment by a qualified professional. Per policy, the facility transport driver will notify the facility of any fall that occurs during transport provided by the Maintenance Director. Alleged date of immediate jeopardy removal: 5/07/25 Onsite validation of the immediate jeopardy removal plan was completed as follows: Review of the facility documentation revealed an audit of falls within the last 30 days was completed as outlined in their removal plan. The audits included review for documentation that a licensed nurse assessed the resident for injury following a fall and that non-medical staff notified qualified staff to perform a clinical assessment prior to the resident being moved. No concerns were identified. Review of the contracted transportation company's education documentation revealed all staff had completed education on 5/06/25. The education included notification of 911 to assess the resident for injury prior to moving, and to notify the facility of any van related incident after calling 911. The education was verified by sign-in sheets from both service locations. Newly hired contract transport drivers for this vendor will be provided this training by the Contracted Transportation Company Owner or Designee prior to being assigned transportation trips for the facility residents. The Administrator confirmed this was the only contracted transportation company the facility currently used for transportation effective 5/05/25. The Administrator verified that effective 5/05/25 the facility ceased use of the vendor for the company that provided transportation for Resident #1 on 4/25/25. Review of the facility education materials and sign-in sheets were reviewed to confirm that education was provided to all facility staff was completed on resident occurrences (falls). The education included not moving a resident after a fall until the resident has been examined by a licensed nurse for possible injury. The Clinical Competency Coordinator will be responsible for tracking to ensure that 100% of staff receive the training. This training will be provided during general orientation for all newly hired staff after 5/6/25. Review of the facility education materials and sign-in sheets were reviewed regarding the facility transportation staff in the event of a fall. The education included to call 911, a resident was to be assessed by a qualified professional in the event of a fall during transport, not to move the resident until the resident had been assessed for injury, and to notify the facility of the incident. Newly hired facility transportation drivers will be provided training related to ensuring the resident is assessed by a qualified professional in the event the fall occurs during transportation and prior to moving the resident. Per the policy, they should move to the side of the road and call 911 for resident assessment by a qualified professional. Per policy, the facility transport driver will notify the facility of any fall that occurs during transport provided by the Maintenance Director. Interviews were conducted on 5/08/25 with facility staff, facility transportation staff, and contracted facility staff to confirm that education was received regarding how to manage a resident occurrence. The facility's immediate jeopardy removal date of 5/07/25 was validated.

Based on record review and interviews with staff, resident, Contracted Transportation Company, and the Physician, the facility failed to ensure a resident was safely secured in the contracted transport van during the return trip from an appointment back to the facility. On 4/25/25 the Contracted Transport Driver failed to secure Resident #1's wheelchair in accordance with the manufacturer's instructions prior to departing with the resident from the dialysis clinic. During travel, Resident #1's wheelchair flipped backwards landing with the backrest of wheelchair (the support structure for the user's back) on the floor of the van. Resident #1 remained in the wheelchair during the fall resulting in her head hitting the van floor and her back sustaining impact when the backrest of the wheelchair hit floor. Resident #1 suffered pain rated a 10 out of 10 (with 10 being the worst pain possible) in her neck, shoulders, and back. Staff reported the resident was moaning and crying out and that they had never seen Resident #1 in pain like that before. The resident was transferred to the hospital where she was identified with a fracture at the superior endplate (flat surface at the top of each vertebra) of the L1 (lumbar spine region, first vertebra). Resident #1 returned to the facility on [DATE] and continued to need opioid pain medication to control her pain. This deficient practice affected 1 of 3 residents reviewed for accidents (Resident # 1). Immediate jeopardy began on 4/25/25 when the Contracted Transport Driver failed to secure Resident #1's wheelchair to the floor securement system in the transportation van. Immediate jeopardy was removed on 5/07/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The findings included: The manufacturer's detailed instructions for wheelchair tie-downs were noted to identify the four anchor points in the vehicle designed for securing wheelchairs, position the wheelchair in the designated securement area, connect the tie-down straps to the floor anchor points, and then to the wheelchair's securement points (two at the front and two at the rear of the chair) with a minimum of four tie-down points. The instructions further noted to tighten the tie-downs to ensure the wheelchair was firmly secured and the occupant was properly restrained before driving. Resident #1 was admitted to the facility on [DATE] with diagnoses which included a left above the knee amputation, right below the knee amputation, and dependence on dialysis. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #1 had severe cognitive impairment. Resident #1 was dependent upon staff for transfers and wheelchair mobility. Resident #1 was not coded for pain or for the use of opioid pain medication. Resident #1 had a physician order dated 3/22/25 for ibuprofen (a nonsteroidal anti-inflammatory medication used to relieve pain and inflammation) 200 milligram (mg) tablet; administer 2 tablets every 4 hours as needed (PRN) for pain. Resident #1 had a physician order dated 4/04/25 for tramadol (opioid pain medication) 50 mg tablet; administer 2 tablets for left hip pain every 6 hours as needed. Review of the April 2025 Medication Administration Record (MAR) and pain monitoring revealed Resident #1 was administered the PRN tramadol 11 times and the PRN ibuprofen 2 times and her pain level varied from 0 to 7 from 4/01/25 through 4/24/25. The nursing progress note dated 4/25/25 at 6:54 pm written by Nurse #2 revealed Resident #1 returned from her dialysis appointment at approximately 5:30 pm and it was reported by the Contracted Transport Driver that Resident #1 had reported back pain and wanted to go to bed. Nurse #2 further noted that Resident #1 began moaning and crying out that her back hurt and Resident #1 explained that her wheelchair had flipped backwards while being transported back to the facility from dialysis. Resident #1 reported the Contracted Transport Driver forgot to lock the wheelchair down. Resident #1 reported a pain score of 10 out of 10 for her back from top of neck all the way down the back, neck on both sides, and both shoulders. Resident #1 was administered as needed pain medication. Nurse #2 further noted that Resident #1 continued to yell out in pain and was transferred to the hospital for further evaluation by EMS (emergency medical services). Review of the Controlled Drug Record revealed Resident #1 was administered 2 tramadol 50 mg tablets for pain on 4/25/25 at 5:45 pm and the medication was signed out by Nurse #2. A telephone interview was conducted on 5/05/25 at 1:05 pm with Nurse #2 who was assigned to Resident #1 on 4/25/25 when the Resident returned from the dialysis appointment. Nurse #2 stated she was sitting at the nursing station when the Contracted Transport Driver approached the desk with Resident #1 and he reported that Resident #1's back hurt and she wanted to go to bed. Nurse #2 stated the Contracted Transport Driver left the dialysis communication book at the desk and left the facility. Nurse #2 stated she was notified by Nurse Aide (NA) #1 that Resident #1 had reported she had a fall in the transportation van and she immediately went to the room. She stated Resident #1 appeared to be panicked, like talking all over the place and rambling. She indicated the resident seemed hesitant to report what happened, almost nervous like not looking at her [Nurse #2] when she asked her about what happened on the ride back from dialysis. Resident #1 did tell her that the Contracted Transport Driver did not lock the wheelchair to the van floor and the wheelchair tipped back and she hit the floor. Nurse #2 stated Resident #1 reported pain from the neck down and described it as really bad, everything hurt. She stated she contacted the physician and Resident #1 was transferred to the hospital since she had such severe pain all over her body. She stated Resident #1 was medicated with pain medication but she was in such pain and continued to cry out while waiting for the ambulance to arrive. Nurse #2 stated that at no time did the Contracted Transport Driver report that Resident #1's wheelchair had tipped backwards during the return trip to the facility or that Resident #1 had hit the floor of the van. Nurse #2 stated she notified the Director of Nursing of the incident. Review of the hospital record dated 4/25/25 through 5/01/25 revealed the following information. Resident #1 was seen in the emergency roiagnom on [DATE] after sustaining a fall in the transportation van with reports of head, neck, chest, abdominal, and back pain. The resident was also noted to be hypoxic (low blood oxygen level) and was placed on 2 liters of oxygen via nasal canula. Resident #1 reported she had received pain medication at the facility and her pain scale was now 8 out of 10. A computed tomography (CT) scan of the head was completed on 4/26/25 at 4:41 am with no acute intracranial findings. A CT of the cervical spine without intravenous contrast was completed on 4/26/25 at 4:45 am with no acute findings. The hospital record further noted that Resident #1continued to report pain all over and on 4/29/25 a magnetic resonance imaging (MRI) was performed on 4/29/25 which showed a fracture at the superior endplate of L1 without height loss (a less severe fracture that is not fully compressed). Resident #1 did not require any surgical interventions and was stable for transfer back to the facility on [DATE]. Resident #1 had a discharge activity level noted as tolerated and was prescribed additional pain medication which included oxycodone (opioid pain medication) 5 mg tablet every 4 hours as needed for moderate or severe pain for 5 days and a lidocaine 4% pain patch daily. Review of the MAR for May 2025 revealed Resident #1 received the as needed oxycodone for moderated to severe pain 9 times and her pain level varied from 0 through 8 from 5/01/25 through 5/06/25. The as needed oxycodone was discontinued on 5/06/25. During an interview on 5/06/25 at 11:50 am with the Rehabiliation Manager she revealed that Resident #1 had been evaluated for occupation therapy on 5/02/25 and her pain was reported as significant across her shoulders and lumbar area. The Rehabiliation Manager stated Resident #1 was educated along with nursing staff on proper positioning and turning for safety and comfort. Resident #1 was interviewed on 5/08/25 at 9:01 am and revealed she had some difficulty talking about the incident because she was so upset by what happened. Resident #1 stated she recalled getting into the transportation van and recalled someone from the dialysis center came out to give her something and the Contracted Transport Driver was talking with them. She stated he then closed the doors and got in the van and began to drive away. Resident #1 stated at that time she did not realize that the Contracted Transport Driver had not hooked her wheelchair to the van floor. She stated he went to take a turn or something and she felt her chair tip backwards and then the only thing she could see was the ceiling of the van. Resident #1 stated the Contracted Transport Driver pulled the van over and came to check on her and she stated that he (the Contracted Transport Driver) kept saying to her that he was going to get fired and that he was going to lose his job for this. Resident #1 stated she could not even say anything at that time, she stated she felt confused and in shock. Resident #1 stated during the ride back to the facility her pain continued to get worse and when she got back to the facility her pain was at least a 10 out of 10. Resident #1 stated she initially felt bad for the Contracted Transport Driver because the entire ride back he just kept saying he was going to be fired and that I [Resident #1] would be okay but when she got back to the facility the pain was so bad that she had to tell the facility staff what happened. Resident #1 stated she still had pain from the incident and she stated it was hard to describe just that she felt pain all over her body. The Director of Nursing (DON) was interviewed on 5/05/25 at 2:08 pm. The DON stated she was present at the facility when the Contracted Transport Driver brought Resident #1 back from the dialysis appointment. She stated she was notified by Nurse #2 of the incident and when she went to find the Contracted Transport Driver he had already left the facility. The DON stated she asked the Health Information Management (HIM) Director to contact the Contracted Transportation Company and report Resident #1's incident. An interview was conducted with the HIM Director on 5/05/25 at 2:21 pm. She reported she contacted the Contracted Transportation Company as requested by the DON and reported the incident that involved Resident #1 on 4/25/25. The HIM Director stated the Contracted Transportation Company obtained the statement from the Contracted Transport Driver and the company provided the information to the facility. The Contracted Transportation Company provided the facility with a written statement from the company which included a statement from the Contracted Transport Driver dated 4/25/25 regarding the incident. The Contracted Transport Driver reported he was loading Resident #1 into the transportation van and was about to secure her for travel when he was distracted by a person from the dialysis center. He noted that he stopped what he was doing to get something from the person from the dialysis center, then he secured the lift, shut the doors, and took off without realizing he had not secured Resident #1's wheelchair to the floor. The Contracted Transport Driver reported that as he took off, the wheelchair tilted over backwards causing Resident #1 to fall hitting her head and back. The statement further noted that the Contracted Transport Driver immediately stopped, asked the resident if she was okay, set the wheelchair upright, secured it to the van floor, and returned Resident #1 to the facility. He further noted that he wanted to report the incident to the facility management but Resident #1 asked him not to tell anyone because she did not want to get anyone in trouble. The Contracted Transport Driver stated Resident #1 reported she was okay and he left Resident #1 at the facility. The statement concluded that the Contracted Transport Driver was terminated due to not reporting the incident, not securing Resident #1's wheelchair, and gross negligence. A telephone interview was conducted on 5/05/25 at 1:56 pm with the Contracted Transportation Company's Office Manager who revealed they had provided the facility with the information regarding the incident with Resident #1 and at this time they had no further information to provide. An attempt to interview the Contracted Transport Driver on 5/07/25 was unsuccessful. A telephone interview was conducted on 5/05/25 at 1:12 pm with Nurse Aide (NA) #2 who was assigned to Resident #1 on the 7:00 am through 3:00 pm shift on 4/25/25. NA #2 reported that Resident #1 had no pain or discomfort prior to leaving the facility for the dialysis appointment. A telephone interview was conducted with NA #3 on 5/05/25 at 1:18 pm who was normally assigned to Resident #1 on 4/25/25 during the 3:00 pm through 11:00 pm shift. NA #3 stated when she went to Resident #1's room after she returned from dialysis she noticed immediately something was wrong by the expression on Resident #1's face, just looked different. NA #3 stated Nurse #2 was already present in the room and Resident #1 reported that when she was in the van her wheelchair had flipped backwards and her whole body was hurting. NA #3 stated Resident #1 was crying out every time she was touched and she had never seen Resident #1 in pain like that. An interview was conducted on 5/05/25 at 1:49 pm with NA #4 who revealed she was not assigned to Resident #1 on 4/25/25 but she knew the resident well. NA #4 stated she did see the Contracted Transport Driver pushing Resident #1 down the hall in her wheelchair on 4/25/25 and she stated Resident #1 was sitting slumped down, unable to sit upright in the chair with her lower body close to the front edge of the wheelchair and her neck resting on the back of the chair. She reported Resident #1 appeared to be upset and in pain because of the way she was sitting in the wheelchair and the way Resident #1 looked at her when they went by. NA #4 stated she tried to speak to Resident #1 and ask what was wrong but the Contracted Transport Driver continued to push the wheelchair down the hall without stopping. During an interview on 5/05/25 at 1:50 pm with NA #1 she revealed that she was working on 4/25/25 when Resident #1 returned from dialysis. NA #1 stated the Contracted Transport Driver came to the nursing station desk and he reported that Resident #1 had been crying like this and was not feeling good. She stated Resident #1 was visibly upset and when she was back in her room Resident #1 reported that the Contracted Transport Driver did not put her wheelchair in the van right and that her wheelchair tipped back and she had hit her head and back. NA #1 stated Resident #1 was crying saying she was in so much pain so she immediately told Nurse #2 who came right down to Resident #1's room. An interview was conducted on 5/08/25 at 12:34 pm with the Physician who revealed he had been the medical provider for Resident #1 for over 3 years at the facility. He stated Resident #1 had some diffuse left hip pain prior to the 4/25/25 incident with occasional use of opioid pain medication. The Physician stated Resident #1 was very sharp and alert and he would see her 2-3 times per week at the facility to manage her chronic and acute illnesses. He stated Resident #1 was normally very clear in her cognition and speech and she was a reliable source of information. A follow-up interview was conducted with the DON on 5/08/25 at 1:15 pm who revealed the Contracted Transport Driver should have checked to make sure Resident #1's wheelchair was secured as required before he left the dialysis center. During an interview on 5/05/25 at 2:29 pm with the Administrator she revealed she had initiated an investigation into the incident for Resident #1 and confirmed that the incident did occur and that it was with the Contracted Transportation Company's van and driver. The Administrator stated the Contracted Transport Driver was responsible to ensure Resident #1's wheelchair was secured to the van floor prior to driving. On 5/05/25 at 4:51 pm the Administrator was notified of immediate jeopardy. The facility provided the following Immediate Jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The Contracted Transport Driver failed to safely secure Resident #1's wheelchair to the floor of the Contracted Transportation Van. On 4/25/25 at 5:30 pm Resident #1 reported to Nurse #2 that her back was hurting and stated that her wheelchair flipped back in the transportation van, the driver forgot to lock her wheelchair down, and she bumped her head. Nurse #2 went directly to evaluate Resident #1 and identified that the resident was tearful and reported pain. Nurse #2 completed a neurological assessment of Resident #1, which was normal. Resident #1 was given Tramadol for pain at 5:45 p.m. for pain. Nurse #2 contacted the primary Medical Doctor (MD) for Resident #1 to report the resident complained of pain in her back, neck, and shoulder. The MD provided an order to transport Resident #1 to the Emergency Department (ED) for evaluation. Nurse #2 called Emergency Medical Services (EMS) for transportation to the ED and Resident #1 left for the ED at 6:45 pm. Nurse #2 contacted the Responsible Party (RP) to report the incident that occurred in the contracted van, the resident report of pain and the MD order to transport the resident to the ED. Resident #1 remained in the hospital undergoing a CT Scan on 4/25/25 with negative results for acute diagnosis. Due to continued complaints of pain at the hospital, the hospital completed an MRI on 4/29/25 which identified a lumbar 1 fracture. The Health Information Management (HIM) Director contacted the Contracted Transportation Company Owner on 4/25/25 at approximately 5:45pm to report the Resident #1's allegation that the Contracted Transport Driver failed to secure the wheelchair and Resident #1 stated her wheelchair flipped back and she hit her head. On 4/25/25 the Contracted Transportation Company Owner provided a statement to the facility in an email from the Contracted Transportation Company Owner. The email from the Contracted Transportation Company Owner described an interview that the Contracted Transportation Company Owner had with the Contracted Transport Driver following the incident on 4/25/25 with Resident #1. The email stated that the Contracted Transport Driver confirmed he did not secure Resident #1's wheelchair to the floor. Per the Contracted Transportation Company Owner, the Contracted Transport Driver reported that Resident #1's wheelchair tilted backwards causing her to fall and hit her head and back. The Contracted Driver reported he immediately stopped, asked Resident #1 if she was OK, sat her chair upright, secured her properly and returned her to the facility. The Contracted Transport Driver stated Resident #1 reported to him that she was OK. Per the Contracted Transportation Company Owner, the Contracted Transport Driver did not follow the policy by not securing a passenger. The Contracted Transportation Company Owner reported that the Contracted Transport Driver was terminated due to gross negligence and is ineligible for rehire. On 5/6/2025 the HIM Director identified all residents who have been transported by all transportation providers within the last 30 days using the facility transportation calendar. The Social Worker will identify alert and oriented residents on this list using the Brief Interview for Mental Status (BIMS) score of 10 and above. Social Services will interview alert and oriented residents to identify any incident where the transport driver failed to safely secure the wheelchair in the transportation van. These interviews will be completed on 5/6/25 and the results will be reported to the facility Administrator and/or the facility Director of Nursing (DON). The facility will complete an investigation for any concerns that are identified and take appropriate follow-up action based upon the results of the investigation. The Administrator will assume responsibility to ensure the investigation and follow-up are completed. The facility licensed nurses will complete a Skin Note and Pain Assessment for all residents with a BIMS of less than 10 who have had transportation in the last 7 days to identify potential injury which may have occurred during transportation. Results of the Skin Note and Pain Assessment will be completed on 5/6/25 and the results will be reported to the Administrator and/or the DON. The facility will complete an investigation for any concerns that are identified and take appropriate follow-up action based upon the results of the investigation. The Administrator will assume responsibility to ensure the investigation and follow-up are completed. 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 will have effective systems in place for safe transportation. The facility ceased use of the outside vendor who was responsible for transportation of Resident #1 as of 5/5/25. The facility has one additional outside vendor utilized for appointment transportation. The Administrator spoke with the Contracted Transportation Company Owner regarding the need for education and documentation on 5/6/25. The Transportation Vendor who will be utilized for appointment transportation will provide competency training for all contract transport drivers who transport residents from the facility starting on 5/6/25. Training will be provided by the Contract Transportation Vendor Supervisors using the manufacturer's instructional Training Video and will include a return demonstration of safely securing a wheelchair. Effective 5/6/25 all contracted transport drivers this Transportation Vendor sends to the facility will have this training completed prior to being assigned transportation trips for the facility residents. Training documentation will be provided to the Administrator by the Contracted Transportation Company Owner or Designee to be maintained at the facility. Newly hired contract transport drivers for this vendor will be provided this training by the Contracted Transportation Company Owner or Designee prior to being assigned transportation trips for the facility residents, including a return demonstration of safely securing a wheelchair. On 5/6/25 100% of the facility's transport drivers will receive competency training related to securing wheelchairs in the van. The facility's transport driver training was provided by the facility Maintenance Director on 5/6/25. Training uses the manufacturer's instructions and includes a return demonstration of safely securing a wheelchair. Newly hired facility transportation drivers will be provided this training and include a return demonstration of safely securing a wheelchair, prior to being scheduled to provide transportation trips, provided by the Maintenance Director. Alleged date of immediate jeopardy removal: 5/07/25. Onsite validation of the immediate jeopardy removal plan was completed as follows: Interviews were conducted on 5/06/25 and 5/08/25 with multiple residents who utilized transportation services with no reported problems or concerns regarding the safety of transportation services. Review of the facility audit documentation revealed interviews were conducted with those residents who had a BIMS of 10 and up and utilized transportation in the last 30 days and a skin/pain assessments was completed for residents with a BIMS of less than 10 for the last 7 days. No concerns were identified. The Administrator verified that effective 5/05/25 the facility ceased use of the vendor for the company that provided transportation for Resident #1 on 4/25/25. Review of the facility education materials and sign-in sheets were reviewed to confirm that education was provided to all facility staff who provided resident transportation. The facility transportation staff were educated by the Maintenance Director regarding manufacturer guidelines for securing a resident for transportation and included a return demonstration of securing a wheelchair. Newly hired facility transportation drivers will be provided the educational video which will include a return demonstration of safely securing a wheelchair, prior to being scheduled to provide transportation trips, and will be provided by the Maintenance Director. The facility provided the contracted transportation company's education documentation for review. The documentation revealed that all staff at both service locations had completed video and written education on safely securing a wheelchair when transporting residents on 5/06/25. The education included a manufacturer instructional video on how to properly secure a resident wheelchair to the van floor and a return demonstration. The education was verified by sign-in sheets. Newly hired contract transport drivers for this vendor will be provided this training by the Contracted Transportation Company Owner or Designee prior to being assigned transportation trips for the facility residents, including a return demonstration of safely securing a wheelchair. The Administrator confirmed this was the only contracted transportation company the facility currently used for transportation effective 5/05/25. Interviews were conducted on 5/08/25 with transportation drivers and the Maintenance Director to confirm the education was provided and the return demonstration was completed. The facility's immediate jeopardy removal date of 5/07/25 was validated.

Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) in the areas of Gradual Dose Reduction (Residents #74 and #15), Discharge Location (Resident #146), and Restraints (Resident #44) for 4 of 26 residents reviewed. Findings included: 1. Resident #74 was admitted on [DATE]. His diagnoses included tactile hallucination and delusion. A psychiatry progress note dated 7/30/24 recorded Resident #74 was to continue taking quetiapine (an antipsychotic medication used to treat mental health conditions) 25 milligrams (mg) for tactile hallucination and delusion. His medications were reviewed for possible Gradual Dose Reduction (GDR to reduce the dose or discontinue the medication) of psychotropics (includes several classifications of medications used to treat mental illness), and noted a GDR was not recommended at this time. Review of Resident #74's August 2024 Medication Administration Record revealed he had received quetiapine daily. A psychiatry progress note dated 8/15/24 recorded Resident #74 was receiving quetiapine 25 mg, his medications were reviewed for possible GDR of psychotropics, and noted a GDR was not recommended at this time. Resident #74's most recent quarterly MDS assessment dated [DATE] indicated he had received antipsychotic medication routinely and a GDR had not been documented by a physician as clinically contraindicated. On 11/14/24 at 3:30 PM an interview with the MDS Nurse was conducted. She stated when completing Resident #74's 8/19/24 MDS assessment she may have only looked at the scanned records and did not see the 8/15/24 psychiatry note as it had not been scanned into the medical record at that time. After further record review she stated she should have used the information from the 7/30/24 psychiatry note which indicated a GDR was contraindicated. She explained the assessment had been coded wrong. On 11/15/24 at 1:52 PM an interview with the Administrator and Corporate Nurse Consultant was conducted. The Administrator stated she expected MDS assessments to be accurate. 2. Resident #15 was admitted on [DATE]. Her diagnoses included major depressive disorder and unspecified convulsions. A psychiatry note dated 8/15/24 recorded Resident #15 was receiving risperidone (an antipsychotic medication used to treat mental health conditions) 1 milligram (mg). Her medications were reviewed for possible Gradual Dose Reduction (GDR to reduce the dose or discontinue the medication) of psychotropics (includes several classifications of medications used to treat mental illness), and noted a GDR was not recommended at this time. Resident #15's October 2024 Medication Administration Record revealed she had received risperidone 1 mg twice daily and divalproex (an anticonvulsant medication used for the treatment of seizures and can also be used to treat mood disorders) 125 mg three times a day until 10/26/24 when it was reduced to twice a day. Resident #15's most recent quarterly MDS assessment dated [DATE] indicated she had received antipsychotic medication routinely, did not indicate she had received anticonvulsant medication, and a GDR had been attempted on 10/23/24. On 11/14/24 at 3:30 PM an interview with the MDS Nurse was conducted. She stated another nurse had completed this assessment. She explained it appeared the nurse had considered the dose reduction of the divalproex a GDR, but this was not an antipsychotic medication. She stated the GDR had been coded incorrectly. On 11/15/24 at 1:52 PM an interview with the Administrator and Corporate Nurse Consultant was conducted. The Administrator stated she expected MDS assessments to be accurate. 49502 3. Resident #146 was admitted to the facility on [DATE]. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #146 was discharged to a short-term general hospital. Review of a nursing note dated 10/7/24 indicated Resident #146 was discharged home with family. An interview with the MDS Nurse on 11/14/24 at 9:45 a.m. was conducted. She stated the discharge MDS for Resident #146 dated 10/7/24 should have been coded as discharged home. She explained she had inaccurately miscoded the MDS in error. During an interview with the Administrator on 11/15/24 at 3:04 p.m. she indicated the MDS should be completed accurately. 50234 4. Resident # 44 was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia. Resident #44's quarterly Minimum Data Set (MDS) dated [DATE] indicated she had severe cognitive impairment, had no behaviors, and needed supervision for ambulating around the unit. The MDS also documented that Resident #44 required a trunk restraint (a restraint on the torso that prevents a resident from getting up out of a chair) once during the observation period. Review of Resident #44's physician's orders from 7/1/24-11/14/24 did not reveal an order for a restraint. Review of Resident #44's progress notes from 7/1/24-11/14/24 did not reveal notes that she had any behaviors or any indications of a need for a restraint. The notes did not document that a restraint was used. In an interview on 11/12/24 at 12:22 PM, Nurse #4, Resident #44's regular charge nurse, said Resident #44 never had a restraint. In an interview on 11/15/24 at 1:20 PM, Nurse #5 said she completed the MDS for Resident #44. She said she could not find any documentation that the resident had a restraint. Nurse #5 indicated that she made a coding error on Resident #44's MDS when she documented that a trunk restraint was used.

Based on record review, and resident, family and staff interviews, the facility failed to offer the resident the right to participate in the person-centered planning process for 2 of 5 residents reviewed for care plans (Residents #96 and Resident #21). Findings included: 1. Resident #96 was admitted to the facility on [DATE] with diagnoses including heart failure, diabetes, and depression. Resident #96's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated she was cognitively intact and required substantial to dependent assistance with most activities of daily living (ADL). Resident #96's care plans were noted as last reviewed or revised on 11/11/24. Review of Resident #96's record did not indicate care plan meetings had been conducted. On 11/12/24 at 10:32 AM an interview was conducted with Resident #96 who deferred all questions to her Family Member. Her Family Member stated early in Resident #96's admission he had participated in a care plan meeting, but it had been a while since he was last invited or participated in a care plan meeting. He explained he would like to participate with her care planning. On 11/14/24 at 3:30 PM an interview with the MDS Nurse was conducted. She stated the MDS department had been short staffed and have gotten behind on care plan meetings with residents and families. After record review, she explained that only a few care plan meetings had been held in July, August and September which had not included Resident #96. On 11/15/24 at 1:52 PM an interview with the Administrator and Corporate Nurse Consultant was conducted. The Administrator explained the MDS department had gotten behind with conducting care plan meetings and were currently working to get caught up. 2. Resident #21 was admitted to the facility on [DATE] with diagnoses including cerebrovascular accident (stroke), heart failure, diabetes, and depression. Resident #21's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated he was cognitively intact and required varying levels of assistance with his activities of daily living (ADL). Resident #21's care plans were noted as last reviewed or revised on 11/12/24. Review of Resident #21's record did not indicate care plan meetings had been conducted. An interview with Resident #21 was conducted on 11/12/24 at 2:09 PM. He stated he did not recall being invited to participate in his care planning. On 11/14/24 at 3:30 PM an interview with the MDS Nurse was conducted. She stated the MDS department had been short staffed and have gotten behind on care plan meetings with residents and families. After record review, she explained that only a few care plan meetings had been held in July, August and September which had not included Resident #21. On 11/15/24 at 1:52 PM an interview with the Administrator and Corporate Nurse Consultant was conducted. The Administrator explained the MDS department had gotten behind with conducting care plan meetings and were currently working to get caught up.

Based on observations, staff interviews, and record reviews, the facility failed to keep a urinary catheter bag from touching the floor to reduce the risk of infection for 1 of 2 residents (Resident #5) reviewed with urinary catheters. The findings included: Resident #5 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (the final, permanent stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own), obstructive and reflux uropathy (when urine cannot drain through the urinary tract and urine backs up into the kidneys), artificial openings of urinary tract (a medical condition where a surgical procedure has created an opening in the urinary system to allow urine to exit the body when the normal pathway is blocked or damaged), and urinary tract infection (UTI). Resident #5's care plan dated 10/3/2024 revealed focus areas for catheter care and at risk for infection. Interventions included not allowing urinary catheter bag tubing or any part of the drainage system to touch the floor, positioning the urinary catheter bag below the level of the bladder, and reporting signs/symptoms of a UTI. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was moderately cognitively impaired. The assessment indicated Resident #5 was dependent upon staff for all his activities of daily living (ADL). Resident #5 was coded for an indwelling catheter. An initial observation was conducted on 11/12/2024 at 12:17 PM of Resident #5. He was observed lying in his bed. His urinary catheter bag was hanging off the bedframe on the resident's right side of the bed, resting on the floor. An interview was conducted on 11/12/2024 at 12:21 PM with Nurse #1 assigned to care for Resident #5. When asked about the position of Resident #5's urine catheter bag, he stated the CNA (certified nursing assistant) may have put the bed too low because of fall precautions. A subsequent observation was conducted on 11/13/2024 at 8:09 AM. Resident #5's urinary catheter bag was observed hanging off the bedframe on the resident's right side of the bed, resting on the floor. An interview was conducted with the Infection Preventionist on 11/13/2024 at 3:19 PM regarding Resident #5's urinary catheter bag observations. She stated that a urinary catheter bag resting on the floor is a concern and she would initiate re-education with staff. She further stated she would discuss this with the Clinical Competency Coordinator (Nurse Educator) so she may assist in staff re-education. An interview was conducted on 11/14/2024 2:19 PM with Nurse Aide #1 who was assigned to care for Resident #5. She stated urinary catheter bags should be kept below the bladder on the bed and off the floor. Attempts to interview the resident were unsuccessful. During an interview with the Director of Nursing (DON) on 11/14/2024 at 1:33 PM, she stated urinary catheter bags should be kept below the bladder, on side of bed, and should be placed off floor. She further stated all nursing staff received training regarding the care of urinary catheters in a web-based clinical competency education training system, as well as during skills fairs offered throughout the year.

Based on observations and interviews with staff, the facility failed to complete the daily staff posting sheet for 4 of 4 days observed (11/12 through 11/15/24). The daily staff posting sheet did not include the resident census of the facility. The findings included: Observation on 11/12/24 at 2:00 p.m. revealed the daily staffing posting at the front desk did not include the census. Observation on 11/13/24 at 9:15 a.m. revealed the daily staffing posting at the front desk did not include the census. Observation on 11/14/24 at 8:15 a.m. revealed the daily staffing posting at the front desk did not include the census. Observation on 11/15/24 at 8:15 a.m. revealed the daily staffing posting at the front desk did not include the census. In an interview on 11/15/24 at 3:27 p.m., the Staffing Coordinator said she did not know how to access the census for that day, so when she came in at 5 a.m., she would make rounds and fill out the accurate information and then wait for after the meeting to put in the census on the daily staffing posting. She would sometimes get busy helping residents and would forget to go back to enter the census. In an interview on 11/15/24 at 3:20 p.m., the Administrator said she was not aware the census hadn't been posted on the daily staffing posting but it should have been included.

Based on record reviews and staff interviews, the facility failed to have a complete and accurate medication and treatment administration record for 1 of 7 residents (Resident #399) reviewed for medical record accuracy. The findings included: Resident #399 was admitted to the facility on [DATE] with diagnoses including chronic pain syndrome, high cholesterol, yeast infection of skin and nails, and non-pressure chronic ulcer of the right lower leg. Resident #399's physician orders revealed the following: - An order dated 11/02/23 for a pain evaluation every shift - An order dated 11/02/23 for atorvastatin (a statin medication used for high cholesterol) 80 milligrams (mg) one tablet at bedtime. - An order dated 11/02/23 for behavior monitoring. - An order dated 11/02/23 for miconazole nitrate (an antifungal) 2 % powder to apply twice a day to skin folds. - An order dated 11/03/23 for COVID-19 Monitoring twice a day. - An order dated 11/30/23 for oxycodone (used for pain) 5 mg one tablet twice a day. - An order dated 12/04/23 to place plastic eye shield over left eye each night at bedtime until seen by surgeon. - An order dated 12/09/23 for acetaminophen (used for pain) 325 mg two tablets twice a day. Resident #399's January 2024 Medication and Treatment Administration Record (MAR and TAR) revealed the right leg wound care, the miconazole nitrate 2% powder, the COVID-19 monitoring, the pain evaluation, and the behavior monitoring evaluation had not been documented as completed or refused by Resident #399 for the day shift on 1/18/24. In an interview on 11/15/24 at 2:41 PM, Nurse #6 stated she worked with Resident #399 on the day shift but did not remember why she did not document on the MAR and TAR on 1/18/24. The January 2024 MAR revealed placement of the plastic eye shield, the acetaminophen, the atorvastatin, and the oxycodone had not been documented as completed or refused by Resident #399 for the night shift on 1/18/24. Attempts to interview Nurse #7, who worked with Resident #399 on the night shift on 1/18/24, were unsuccessful. The Director of Nursing (DON) and Administrator were interviewed on 11/15/24 at 3:00 PM. They were not aware there were blanks in the MARs and TARs, but said they expected documentation to be complete and accurate.

Based on record review and resident, staff, and Responsible Party (RP) interviews the facility failed to obtain the resident's consent before depositing and withdrawing the resident's personal funds into and from his non-transferring personal funds account. This was for 1 of 1 resident (Resident #52) reviewed for personal funds. Findings included: Resident #52 was admitted to the facility on [DATE] with a diagnosis of quadriplegia (paralysis of all four limbs). A review of Resident #52's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. A review of Resident #52's current Resident Fund Management Service authorization and agreement to handle resident funds dated 6/29/21 revealed Resident #52 provided his written consent for a non-transferring account (no-automatic transfer of deposits to pay for care costs). This consent was witnessed by the facility Regional Financial Counselor. A review of Resident #52's personal check #480 dated 10/10/22 revealed it was made out to the facility in the amount of $1502.00. A review of Resident #52's personal check #482 dated 11/12/22 revealed it was made out to the facility in the amount of $1502.00. A review of Resident #52's Resident Landscape Statement from 10/3/22 to 9/25/23 for his facility personal funds account revealed in part the deposit of a personal check dated 10/14/23 in the amount of $1502.00 and a withdrawal on 10/18/22 of a care cost payment of $1498.00. It further revealed a deposit on 11/16/22 of a personal check in the amount of $1502.00 and a withdrawal on 1/24/23 of a care cost payment of $1470.90. A review of Resident #52's Resident Landscape Statement from 10/3/22 to 9/25/23 for his facility personal funds account revealed in part the deposit on 5/30/23 of a Social Security Administration (SSA) insurance check in the amount of $709.20 and a deposit on 7/11/23 of a SSA insurance refund in the amount of $664.97. These were tax refund checks issued to the resident. On 9/25/23 at 3:09 PM in interview Resident #52 stated he was still able to take care of his finances including his tax refunds himself and it was important for him to continue doing this. He went on to say he used the facility address as his mailing address because he was residing in the facility when he completed his tax refund forms. Resident #52 stated he was expecting 2 tax refund checks for the tax forms he completed, and he never received them. He went on to say this had worried him. He stated he had contacted the Internal Revenue Service (IRS) to report the missing checks and they put a trace on them. He went on to say he found out that the facility had opened his mail and cashed these checks without ever telling him and he filed a police report. He further indicated he had not given the facility permission to deposit these checks into his account. On 9/26/23 at 8:21 AM a telephone interview with Resident #52's RP indicated Resident #52 did his own tax returns. She stated about a month ago the facility received Resident #52's tax refund checks, opened them, and never told him. She went on to say Resident #52 contacted the IRS and was told the checks had been sent to the facility and cashed. She further indicated she contacted Business Office Manager #1 and was told that the facility could re-issue Resident #52 a check from his facility account where these had been deposited. Resident #52's RP stated neither she nor Resident #52 had ever given the facility permission to deposit these checks or his care cost payment checks into his facility account or make any withdrawals from his facility account to pay for his care costs. She went on to say she had been aware of an account where she deposited small amounts of funds that Resident #52 used to pay for snacks and incidentals, but she paid Resident #52's care costs from Resident #52's outside personal checking account directly to the facility. On 9/27/23 at 10:12 AM an interview with Business Office Manager #1 indicated she was aware of a recent incident where Resident #52 mentioned to her that he had been expecting some checks. She went on to say she received the mail that came to the facility from the postal carrier. She stated she told Resident #52 she possibly had opened these checks and deposited them into his facility account. She went on to say he told her she should not have done this. Business Office Manager #1 stated for residents who have accounts with the facility she would be on the look-out for federal checks which come in a very noticeable envelope. She went on to say even if these had a resident's name on them, she would open them and deposit them into their facility account. Business Office Manager #1 stated she had stopped doing this after Resident #52 complained to her. She further indicated this was just how she had always done things at facility's where she worked. She stated a non-transferring account like Resident #52 had meant that his facility account was not used to pay for his care costs. She went on to say Resident #52's RP had been bringing in his personal checks made out to the facility for this, and these would be deposited into a separate facility Operational Account that had nothing to do with the Resident #52's personal funds account. She further indicated the previous Business Office Manager #2 had deposited the checks made out to the facility for his care costs into his personal funds account and them withdrew the funds from there to pay for Resident #52's care costs. On 9/27/23 at 3:21 PM a telephone interview with BOM #2 indicated a non-transferring account like Resident #52 had meant that the resident did not agree to have their SS or other things like retirement pensions direct deposited into their account and then automatically debited to pay for care costs. She stated when Resident #52's RP brought in the checks made out to the facility these were slightly over the amount needed to pay for his care costs, so she manually deposited them into his personal funds account and then manually debited the amount needed to pay his care costs leaving the extra in his personal funds account to pay for incidentals or snacks. She stated she had not wanted the facility to receive the extra or send the checks back to the RP to be redone. In a follow-up telephone interview on 9/27/23 at 4:21 PM BOM #2 stated she had not obtained a deposit or withdrawal slip for these transactions from Resident #52 or his RP or notified Resident #52 or his RP of these transactions other than what they would have seen on the quarterly statements. On 9/27/23 at 4:05 PM a telephone interview with the Regional Financial Counselor indicated a non-transferring resident funds account like Resident #52 had agreed to meant that this account was basically a personal savings account for Resident #52. She stated this type of account would require a deposit or withdrawal slip signed by Resident #52 or his RP in order for the facility to make deposits or withdrawals. On 9/28/23 at 9:53 AM in an interview the Administrator stated she did not really know the details of the types of accounts for resident fund management services the facility provided. She stated she would have to reach out to the Regional Financial Counselor and see what the facility policies were. In a follow-up interview on 9/28/23 at 3:19 PM the Administrator stated the facility did not have any specific policy for resident funds accounts.

Based on record review and resident, staff, and Responsible Party (RP) interviews the facility failed to deliver a residents personal mail unopened. This was for 1 of 1 residents (Resident #52) reviewed for privacy of communication. Findings included: Resident #52 was admitted to the facility on [DATE] with a diagnosis of quadriplegia (paralysis of all four limbs). A review of Resident #52's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact. On 9/25/23 at 3:09 PM in interview Resident #52 stated he was still able to take care of his finances including his tax refunds himself and it was important for him to continue doing this. He went on to say he used the facility address as his mailing address because he was residing in the facility when he completed his tax refund forms. Resident #52 stated he was expecting 2 tax refund checks for the tax forms he completed, and he never received them. He went on to say this worried him. He stated he had contacted the Internal Revenue Service (IRS) to report the missing checks and they put a trace on them. He went on to say he found out that the facility had opened his mail and cashed these checks without ever telling him and he filed a police report. On 9/26/23 at 8:21 AM a telephone interview with Resident #52's RP indicated Resident #52 did his own tax returns. She stated about a month ago the facility received Resident #52's tax refund checks, opened them, and never told him. She went on to say Resident #52 contacted the IRS and was told the checks had been sent to the facility and cashed. Resident #52's RP stated neither she nor Resident #52 had ever given the facility permission to open his mail. On 9/27/23 at 10:12 AM an interview with Business Office Manager #1 indicated she was aware of a recent incident where Resident #52 mentioned to her that he had been expecting some checks. She went on to say she received the mail that came to the facility from the postal carrier. She stated she told Resident #52 she possibly had opened these checks and deposited them into his facility account. She went on to say he told her she should not have done this. Business Office Manager #1 stated for residents who have accounts with the facility she would be on the look-out for federal checks which come in a very noticeable envelope. She went on to say even if these had a resident's name on them, she would open them and deposit them into their facility account. Business Office Manager #1 stated she had stopped doing this after Resident #52 complained to her. She further indicated this was just how she had always done things at facility's where she worked. On 9/28/23 at 9:53 AM in an interview the Administrator stated resident's mail should be delivered to them or their RP unopened.

Based on record review, resident, staff and physician interviews, the facility failed to supervise 1 of 1 resident (Resident #117) to prevent resident-resident altercations with other residents reviewed for supervision to prevent accidents and the non-smoking facility failed to complete smoking assessments for a resident that smoked, failed to provide supervision when a resident smoked and failed to ensure a resident did not possess smoking materials for 1 of 8 residents reviewed for accidents (Resident #12). The findings included: 1. Resident #117 was admitted to the facility on [DATE] with diagnoses that included dementia and schizophrenia. His quarterly Minimum Data Set assessment dated [DATE] revealed he was assessed as having a significant cognitive impairment with no behaviors. a. Resident #90 was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease and dementia. He passed away at the facility on 5/6/23. His quarterly Minimum Data Set assessment dated [DATE] revealed he had a significant cognitive impairment with no behaviors. Review of a facility incident report dated 11/7/22 written by the Administrator revealed on 10/31/22 Resident #117 had a verbal and physical altercation with Resident #90. Resident #117 was noted to self-propel his wheelchair up to Resident #90, point his finger in Resident #90's face resulting in a verbal argument and residents swinging arms at each other. An interview was conducted with the Administrator on 9/27/23 at 3:30 PM who stated the facility incident report was based upon the information provided by staff during the investigation. She indicated she did not witness the incident. Attempts to interview Resident #117 were not successful. An interview with Nurse #1 was conducted on 9/26/23 at 4:18 PM. She reported the incident occurred in the living area adjoining the nurse's station. Nurse #1 stated she witnessed the incident. Resident #90 was sitting in his wheelchair and Resident #117 passed by him in his wheelchair. She stated the wheelchairs locked. Nurse #1 stated she believed Resident #117 either kicked or punched Resident #90. She reported she was unsure of the details and could not remember the incident clearly. Nurse #1 stated it happened very quickly and she did not have time to react. She stated she reported the incident to Resident #117's nurse but was unable to recall the nurse's name. During an interview with Nurse #1 on 9/27/23 at 9:30 AM she stated Resident #90 had a scratch on his face after the incident. She stated he did not have it prior to the incident. Nurse #1 reported Resident #90 did not have any changes in behavior or express any concerns after the incident. An interview was conducted with Transporter #1 on 9/29/23 at 10:29 AM. She stated she witnessed Resident #117 rolled his wheelchair over to Resident #90 and struck Resident #90. Transporter #1 stated she could not remember any additional details. Attempts to contact NA #4 who witnessed the incident were unsuccessful. b. Resident #67 was admitted to the facility on [DATE] with diagnoses that included dementia and sepsis. His admission Minimum Data Set assessment dated [DATE] revealed he was assessed as having a moderate cognitive impairment with no behaviors. Review of a nursing progress note dated 11/5/22 written by Nurse #10 revealed Resident #117 was found in his roommate's legs, Resident #67, attempting to pull him from his bed. Resident #117 also threatened to kill Resident #67. After being reassured the incident would be handled Resident #117 released Resident #67. An interview was conducted with Nurse #10 on 9/26/23 at 3:43 PM. She reported she observed Resident #117's attempt to remove Resident #67 from his bed. Nurse #10 reported Resident #117 will react to changes in his normal routine by escalating his behavior and will strike other residents. Nurse #10 stated she has learned his triggers. She stated she can redirect him by offering a snack or removing him from the area. She reported Resident #67 had no change in behaviors or emotions after the incident. Nurse #10 further stated she is very familiar with Resident #117 and is his assigned nurse. Record review revealed Resident #67 was moved from the room on 11/5/22. Resident #117 was placed on one-to one supervision from 11/5/22-11/13/22. An interview was attempted with Resident #67 on 9/27/23 at 1:17 PM and he did not recall the incident. Attempts to contact Nurse Aide #5 who witnessed the incident were not successful. c. Resident #29 was admitted to the facility on [DATE] with diagnoses that included dementia and diabetes mellitus. Resident #29's quarterly MDS assessment dated [DATE] revealed she was assessed as having severe cognitive impairment with no behaviors. Review of a nursing progress note written by Nurse #15 dated 12/10/22 revealed Resident # 117 struck Resident #29 in the face. An interview was conducted with Nurse #15 on 9/29/23 at 10:30 AM who stated she based her note on what she was told by staff. She was unable to recall who gave her the information. Nurse #15 stated she did not observe any psychosocial changes in Resident #29, and she did not express any concerns related to the incident. Review of a facility interview of Nurse #12 revealed Resident #29 was calling out in the dayroom which appeared to frustrate Resident #117. She stated she attempted to separate the residents but Resident #117 struck Resident #29 before she could intervene. Attempts to contact Nurse #12 were not successful. d. Resident #11was admitted to the facility on [DATE] with diagnoses that included schizophrenia and epilepsy. Resident #11's quarterly MDS dated [DATE] revealed he was assessed as having moderate cognitive impairment with no behaviors. Review of a facility investigation dated 2/25/23 revealed Resident #11 reported to staff he was struck in the face by Resident #117. No staff witnessed the incident. The facility investigation revealed no changes in behavior or any expressions of concern after the incident. Attempts to interview Resident #11 were not successful. An interview was conducted with Resident #56 on 9/28/23 at 2:00 PM. He stated he witnessed the incident on 2/25/23 because it occurred outside his room door. Resident #56 stated the residents were arguing and he witnessed Resident #117 strike Resident #11 on the shoulder. He further reported he overheard Resident #117 tell Resident #11 he was going to hit him, and Resident #11 needed to go get him some coffee. Attempts to interview Nurse #8, the assigned nurse on the hall on 2/25/23 were not successful. An interview was conducted with Nurse #10 on 9/26/23 at 3:43 PM. She reported she is very familiar with Resident #117 and she is his assigned nurse. Nurse #10 reported Resident #117 will react to changes in his normal routine by escalating his behavior and will strike other residents. Nurse #10 stated she has learned his triggers such as loud noises and changes in his routine. She stated she can redirect him by offering a snack or removing him from the area. An interview was conducted with Physician #1 on 9/27/23 at 3:00 PM who stated Resident #117 is stable at this point because his current medication regimen is effective. An interview was conducted with the Administrator and Corporate Consultant on 9/28/23 at 9:00 AM. The Administrator stated Resident #117 had not had any incidents since February 2023 and staff have done a good job managing his behavior. She reported he was admitted in July 2022 and they worked to develop a behavior management plan for him. Review of an undated behavior management plan read in part, facility staff have learned to look at his face and monitor his mood. They have determined if he is staring and glaring, they know to redirect him and move him away from other residents, as well as keep him in a public area for staff to monitor him. 41387 2. The facility's Smoke Free Policy dated 2014 stated fire igniting materials and smoking materials should not be kept in a resident's possession. Resident's igniting smoking materials would be maintained at the nurse's station for safety of smokers. The policy also stated residents who were grandfathered-in would be assessed for risk and hazards prior to smoking in designated areas and shall be supervised as necessary based on the smoking observation form located in the electronic medical record. The smoking observation form was completed at least quarterly if questions indicated the resident smoked or had a history of smoking. Resident #12 was admitted to the facility on [DATE], and diagnoses included multiple sclerosis (an unpredictable disease of the central nervous system that disrupts the flow of information within the brain, and between the brain and body). Resident #12's care plan initiated on 03/17/2022 and reviewed on 9/26/2023 indicated Resident #12 was care planned as a smoker and was noncompliant with the facility's smoking policy. Interventions included re-education on the smoking policy. Nursing documentation in Resident #12's medical record recorded the following incidents related to Resident #12 smoking: -On 10/17/2022, a former Director of Nursing documented a vaporized smoking device (an electronic smoking device) was observed in Resident #12's room. Resident #12 was educated on the facility's smoking policy that included vaporized smoking devices and the vapor device was placed in a locked box on the 500-hall medication cart. -On 10/24/2022, Nurse #12 recorded Resident #12 was informed he could not receive his vapor smoking materials until he was ready to be escorted outside by family or visitors and staff were not to escort Resident #12 off the facility property to smoke. -On 11/26/2022, Nurse #12 recorded Resident #12 was reminded of the facility's non-smoking policy when an empty pack of cigarettes was observed on Resident #12's bedside table. Nurse #12 recorded Resident #12 denied having any other packs of cigarettes or a lighter. -On 4/19/2023, Nurse #3 documented the interdisciplinary team meet on that day, and Resident #12 remained a smoker and would continue with Resident #12's plan of care. -On 4/24/2023, Nurse #12 recorded Resident #12 had been outside to smoke and subsequently received a burn to right hand middle digit at the first knuckle area. Resident #12 reported the burn occurred about one week ago while trying to hold a cigarette in his hand and he did not report the incident to the staff. Nurse #12 documented observing healing blisters to the area with no redness or signs of infection. She recorded Resident #12 occasionally had difficulty with fine motor skills and manual dexterity due to multiple sclerosis disease process. She also recorded Resident #12 stated he required someone to place the cigarette to his lips and light his cigarette. Nurse #12 recorded Resident #12 was unable to extinguish a cigarette and could not swiftly swat away a lit cigarette if dropped on himself. She documented Resident #12 required someone to propel him off the property to smoke. Nurse #12 recorded a smoking assessment was completed. A smoking observation assessment dated [DATE] completed by Nurse #12 indicated Resident #12 was unable to hold, light and extinguish his own cigarette and was unable to independently move to and from designated smoking areas. The smoking observation further indicated Resident #12 had a medical diagnosis that make unsupervised smoking a danger for Resident #12 and was a supervised smoker. On 9/29/2023 at 12:20 p.m. in a phone interview with Nurse #12, she stated Resident #12 was a smoker, and facility's staff were aware Resident #12 went outside off the facility property to smoke. She explained smoking assessment were not conducted regularly because it was a non-smoking facility, and she conducted the smoke observation dated 4/24/2023 based on his disease process for multiple sclerosis and did not actually observe Resident #12 smoking for the assessment. She stated Resident #12 could safely smoke at times depending on how his multiple sclerosis was affecting him. She said nursing staff would assist Resident #12 to the front for coffee, but not the smoking area that was off the facility property. She explained visitors took him outside to smoke, and there was a plastic box in the medication room for residents who went off facility premises to smoke to lock up smoking materials. She stated she was unsure when Resident #12 obtained new smoking materials that were to be locked up when not in use. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #12 was cognitively intact, required one person assistance with transfers off the unit and required supervision of one person assistance with eating. Further review of nursing documentation in Resident #12's medical record regarding smoking included: -On 8/10/2023, Nurse #12 recorded Resident #12 continued to go outside the facility on the sidewalk off the facility's property to smoke and she was unable to secure smoking materials. -On 9/21/2023, Nursing #12 documented staff or other residents assisted Resident #12 outside to sit on sidewalk and smoke. On 9/25/2023 at 11:41 a.m. during an interview with Resident #12, Resident #12 was observed removing a blue lighter and a pack of cigarettes from a black pouch laying in Resident #12's lap. Resident #12 stated the facility knew he smoked, and he smoked off the facility's property on the sidewalk at the highway. He explained friends or other residents helped him to the sidewalk because he was not able to wheel himself in the wheelchair to the sidewalk. On 9/26/2023 at 2:30 p.m., a visitor was observed pushing Resident #12 up an elevated sidewalk from the facility's patio to the sidewalk alongside the highway, the visitor re-entered the facility leaving Resident #12 outside. On 9/26/2023 at 2:33 p.m., Resident #12 was observed sitting upright in his wheelchair and removing a cigarette and lighter from the black pouch in his lap. Resident #12 used his right hand to place the cigarette between his lips and used both hands to hold the lighter to ignite the cigarette. Holding the cigarette between the second and third right hand fingers, Resident #12 was observed moving the cigarette from his lips to outside the right side of his wheelchair and discarding ashes onto the concrete sidewalk. Resident #12 stated he discarded the cigarette butt into the highway, and old cigarette butts were observed along the edge of the highway, as well as, on a grass area between the sidewalk and highway. Resident #12's clothing was observed with no burnt areas. On 9/26/2023 at 2:40 p.m. in an interview with the Administration after requesting the smoking policy, she stated the facility was a smoke-free facility, and residents were not allowed to have smoking materials (lighters and cigarettes) in the rooms. The Administrator was informed Resident #12 was observed with a blue lighter and pack of cigarettes in a black pouch in his room. In a follow up interview with the Administrator on 9/28/2023 at 3:45 p.m., the Administrator stated there were no resident's grandfathered-in smokers at the facility. She stated residents' smoking materials should be locked up at the nurse's station, and Resident #12 was to obtain and return smoking materials to the nurse's station after going off the facility's property to smoke for safety concerns. On 9/28/2023 at 4:11p.m. in an interview with Nurse #13, Resident #12's assigned nurse on 9/28/2023, she stated she was not aware Resident #12 was a smoker and was not aware he had smoking materials in his room. She explained if smoking materials were in Resident #12's room, the smoking items needed to be obtained and given to the Director of Nursing. On 9/28/2023 at 4:22p.m. in an interview with Nurse #1, she stated she had observed Resident #12 date unknown smoking outside along the highway sidewalk when leaving the facility at the end of her shift. She explained when residents had smoking materials in their possession, she asked the resident for the smoking materials, and they were locked up in the medication cart until the resident was discharged . She stated she could not say Resident #12's smoking materials were locked in the medication cart. On 9/28/2023 at 4:26 p.m. in an interview with Nurse #14, he stated Resident #12 did not have any smoking materials locked inside the medication cart. He explained the facility was a smoke-free facility, Resident #12 was not to have smoking materials in his room, and there was no place to lock Resident #12's smoking materials. On 9/28/2023 at 6:26 p.m. in a phone interview with Nurse Aide #4, she explained she only assisted Resident #12 to the front of the facility, and Resident #12 got other residents or visitors to assist him to the sidewalk off the facility's property to smoke. She stated nursing staff stored resident's smoking materials and she had not seen any smoking materials in his room. On 9/29/2023 at 09:48 a.m. in an interview with Resident #12, he stated the Director of Nursing retrieved his smoking materials on the evening of 9/28/2023. He said the facility staff knew he went outside to smoke and how not asked him for his smoking materials. On 9/29/2023 at 11:00 a.m. in an interview with the Director of Nursing, she stated she was aware that Resident #12 was a smoker and was informed on 9/28/2023 of Resident #12 having smoking materials in his room. She said Resident #12 was cooperative in turning in his smoking materials when approached on 9/28/2023 and the smoking materials had been locked up on the medication cart labeled with his name. She explained Resident #12 will need to request the smoking materials prior to going outside off the property to smoke. She further stated Resident #12 had increased his ability to self-propel his wheelchair to the front of the facility to exit outside and was not dependent on the nursing staff. She explained the facility was a non-smoking facility and Resident #12 independently exited the facility or with family to smoke off the property. She stated the one smoking assessment conducted on 4/24/2023 was performed after obtaining vaporized smoking materials from Resident #12 and not conducted routinely because the facility was a non-smoking facility. On 9/29/2023 at 12:57p.m. in an interview with the Administrator, she explained Resident #12 was aware of the facility's smoking policy. She stated the facility did not know how Resident #12 was receiving his smoking materials, and Resident #12 continued to have smoking materials in his room without informing the facility. She explained Resident #12 had been re-educated on the smoking policy and smoking materials had been gathered at this time.

Based on physician interview, nurse practitioner interview, staff interview, and record review the facility neglected 1 of 2 sampled residents (Resident #6) reviewed for pressure ulcers when the facility failed to assess excoriation to the sacrum for eight days after it was identified, failed to obtain treatment orders for ten days after the skin impairment was identified, and failed to enter and initiate the treatment orders provided by the Wound Nurse Practitioner (NP) for eleven days in response to deterioration of the sacral wound. These delays in wound assessment, initiation of wound treatment, and implementation of changes to the treatment process resulted in Resident #6's sacral pressure getting larger, deeper, and developing a foul odor, with the resident eventually [MEDICAL CONDITION]. After discharge from the nursing home, tunneling (channels that extended from the wound into and through tissue and/or muscle) was identified in the resident's sacral wound at the hospital, and Resident #6 passed away in hospice care with her death certificate [MEDICAL CONDITION] due to pressure ulcer as the immediate cause of death. Immediate Jeopardy began on 08/05/20 when the facility failed to complete a comprehensive assessment and treat Resident #6's sacral wound, and neglected to provide ongoing care and services necessary to prevent deterioration of the wound. The Immediate Jeopardy was removed on 02/05/21 when the facility implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of an E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. Findings included: Review of a hospital Discharge Summary revealed Resident #6 was hospitalized from [DATE] until 08/05/20. The report did not document any problems with the resident's skin integrity at discharge other than a surgical incision to the resident's left hip post left-hemiarthroplasty (surgical procedure to repair fracture). However, [MEDICATION NAME] Rapid Relief (zinc oxide), frequently used as a barrier to prevent skin irritation and excoriation, was documented as a medication to be discontinued. 08/03/20 lab work documented Resident #6's [MEDICATION NAME] (a protein which helps with skin repair) level was low at 3.0 milligrams per deciliter (mg/dL) with the normal range being 3.5 - 5.7 mg/dL. Resident # 6's medical record documented she was admitted to the facility on [DATE]. Her documented [DIAGNOSES REDACTED]. A 08/06/20 Braden Scale for Predicting Pressure Sore Risk documented Resident #6 was at high risk for pressure ulcers. The assessment identified the resident as having very limited sensory perception, having very moist skin, being chairfast, having very limited ability to change/control body position, having probable inadequate nutritional intake, and having a problem with friction and shearing. A 08/06/2020 12:53 PM Nursing Progress Note documented, (Resident #6) refused breakfast and lunch today. Alternatives encouraged- refused Refused to eat or drink this morning, multiple attempts made . On 08/06/20 (Resident #6) has impaired skin integrity related to incontinence of (bowel and bladder) incontinence, impaired mobility, admitted with surgical wound to left hip was identified as a problem in the resident's care plan. Approaches for the problem included, Monitor for (signs and symptoms) of infection daily. Refer to wound care team as needed. Report any changes to provider. Treatments as ordered. In her 08/06/20 1:54 PM Late Entry Admission Note the admitting nurse (Nurse #1) documented Resident #6 was suffering from debility associated with a left [MEDICAL CONDITION] and status [REDACTED]. Excoriations on sacrum with protective foam noted . In her 08/06/20 2:13 PM Admission Observation Nurse #1 documented Resident #6 had a sacral pressure ulcer which measured 0.1 x 0.1 centimeters (cm) with no depth and a pressure ulcer to the coccyx which also measured 0.1 x 0.1 cm with no depth. In his nursing home History and Physical, completed on 08/06/20 at 2:30 PM, Physician #1 documented Resident #6 was discharged to the nursing home for medical management as well as continued rehabilitation. Associated signs and symptoms included positive for pain, negative for skin breakdown, and positive for weakness. An incision to the left hip with staples and bruising to the left lower extremity was noted. Extremity: no ulceration was also documented. [MEDICAL CONDITION] to the bilateral lower extremities ranging form 1+ non-[MEDICAL CONDITION] to a trace of [MEDICAL CONDITION] was noted. During a telephone interview with Nurse #1 on 01/28/21 at 1:50 PM she stated in her Admission Observation 0.1 x 0.1 cm was not an actual measurement, but a place holder to let the Treatment Nurse know that Resident #6 had some type of skin impairment on the sacrum and coccyx which needed to be assessed. She explained she was not allowed to measure or stage wounds, and the Treatment Nurse set the treatments which were appropriate for the wounds. Nurse #1 stated it looked like to her that the first layer of skin had been pulled off areas on Resident #6's sacrum and coccyx. She commented she thought when the Treatment Nurse assessed the wounds later in the day or the next morning she would discover stage I or stage II pressure ulcers. According to Nurse #1, the Treatment Nurse would decide upon the appropriate treatment at that time. A 08/07/20 9:36 AM Physician Assistant (PA) Note documented, .Frail elderly with muscle wasting- concern for poor recovery/poor prognosis from .surgery. The PA documented she was working with the facility's Registered Dietitian (RD) to provide the resident with nutritional supplementation. A 08/09/20 12:59 PM Nursing Progress Note documented Resident #6 was refusing medications and spitting out her food, refusing to eat. In her 08/10/20 Weekly Skin Check Nurse #2 documented Resident #6's skin was warm and dry with normal color and skin turgor. No alterations in skin integrity. During a telephone interview with Nurse #2 on 01/28/21 at 12:12 PM she stated the weekly skin checks were head to toe assessments, and during those assessments the nurse was only looking for skin integrity issues which had newly emerged since the previous weekly wound assessment or the admission assessment. She reported her documentation on the 08/10/20 Weekly Skin Check meant there were no new wounds, bruises, abrasions, or skin tears found on Resident #6 other than what was identified during previous assessments. Nurse #2 commented she could not remember if there were still skin impairment issues on the resident's sacrum or if the area was covered by some type of dressing. According to Nurse #2, it was not the nurse's responsibility to assess pre-existing wounds during Weekly Skin Checks. Resident #6's 08/10/20 admission minimum data set (MDS) documented she had short and long term memory impairment, her decision making skills were severely impaired, she exhibited no behaviors including resistance to care, she required extensive assistance from the staff with bed mobility/eating, she was dependent on staff for transfers/dressing/toileting/hygiene/bathing, she was always incontinent of bowel and bladder, she was 66 inches tall and weighed 100 pounds, she had no skin ulcers, she had a surgical wound, and she had pressure-reducing devices for her bed. Review of wound documentation revealed Resident #6's sacral/coccyx wound was assessed by the facility's Treatment Nurse and Wound Care Nurse Practitioner (NP) on 08/13/20. In her 08/13/20 Wound Management Detail Report the Treatment Nurse documented Resident #6 had an unstageable pressure ulcer to her sacrum which measured 2.5 x 1.5 x 0.2 cm with a moderate amount of [MEDICAL CONDITION] (malodorous) drainage which was yellow or tan, cloudy, and thick. The Treatment Nurse documented the wound bed was comprised of slough, but there was no undermining or tunneling. She also noted, LAL (low air loss mattress) ordered and placed on bed. During a telephone interview with the facility's Treatment Nurse on 01/28/21 at 12 noon she stated she had a communication book in which a nurse had documented on 08/06/20 that Resident #6 had a wound to her sacrum which needed to be assessed. However, she reported she could not read the nurse's initials. She commented that the way the system was set up was the admitting nurse should have notified the hall nurse that the resident had a wound, and the hall nurse would have done a preliminary assessment, and a treatment would have been put in place and entered into the electronic medical record system until she (the Treatment Nurse) could have measured, staged, and assessed the wound, and decided if the treatment could remain the same or needed to be changed. According to the Treatment Nurse, it was important for her to assess wounds quickly, usually the day the wound was identified or the day after at the latest, because sometimes what might look like an excoriation to a nurse who did not have wound care training might actually be discolored tissue with more serious things going on underneath. The Treatment Nurse stated she was delayed in assessing Resident #6's sacral wound because she was pulled to work a hall medication cart for a week. She reported she had no wound care back-up when she was pulled to administer medications. In her 08/13/20 Evaluation and Management Report the Wound NP documented, .She was admitted with an unstageable pressure ulcer to the sacrum. There is black-yellow colored necrotic tissue present in the wound bed. There is a musky odor to the wound exudate. The wound will be cleaned with Dakin's 0.5% moistened gauze. The wound will be treated with Santyl ointment Review of Resident #6's August 2020 Treatment Administration Record (TAR) documented the first time the resident received a wound treatment to her sacrum via physician order [REDACTED]. During a telephone interview with the facility's Treatment Nurse on 01/28/21 at 2:02 PM she stated if Resident #6 had a true excoriation to her sacrum/coccyx on admission barrier cream could have been utilized, and a physician order [REDACTED]. She commented she could not explain why the treatment recommended by the Wound NP on 08/13/20 was not implemented until 08/15/20. After reviewing Resident #6's August 2020 TAR she stated it appeared there was some confusion about getting the correct order into the electronic medical record system. She stated facility staff entered physician orders [REDACTED]. In her 08/17/20 Weekly Skin Check Nurse #2 documented Resident #6's skin was warm and dry with normal color and skin turgor. She noted the resident now had blisters on her bilateral heels. A 08/20/20 10:52 AM PA Note documented Resident #6 was seen for ongoing poor intake of food and liquids. The resident refused to drink a supplemental shake for the PA, refusing to open her mouth. The resident reported she was not hungry. The PA documented she spoke with a family member who stated she had no problem consulting hospice since the resident continued to refuse to eat. In her 08/21/20 Wound Management Detail Report the Treatment Nurse documented Resident #6 had an unstageable pressure ulcer to her sacrum which measured 3.5 x 2.5 x 0.4 cm with a moderate amount of [MEDICAL CONDITION] (malodorous) drainage which was yellow or tan, cloudy, and thick. The Treatment Nurse documented the wound bed was comprised of slough/eschar. She also documented wound odor was present, and described this wound odor as foul. During a telephone interview with the facility's Treatment Nurse on 01/29/20 at 9:10 AM she stated she recollected the wound bed of Resident #6's sacral pressure remaining about 20 - 25% eschar and 75 - 80% slough during her entire nursing home stay. She reported the resident's wound did not receive physical debridement while in the facility. In her 08/21/20 Evaluation and Management Report the Wound NP documented, .The wound to the sacrum has increased in volume, and the base of the wound continues to be obscured by necrotic tissue. The wound exudate is malodorous. The treatment for [REDACTED]. There is moderate [DIAGNOSES REDACTED] to the peri-wound with accompanying warmth The NP also documented in her report that Resident #6's white blood count (WBC) was within normal limits per 08/18/20 lab results. During a telephone interview with the Wound NP on 01/28/21 at 11:40 AM she stated there was a difference between malodorous drainage on an old dressing which was being removed and a wound itself being malodorous after it was cleaned with normal saline or wound cleanser. She reported the latter scenario was more serious, and appeared to be what was captured in the Treatment Nurse's 08/21/20 Wound Management Detail Report. She commented she realized a change in treatment needed to be made, but decided to change the wound treatment on 08/21/20 rather than start an antibiotic then since Resident #6 was not running a temperature and had a recent white blood cell count which was within normal limits. According to the Wound NP, on 08/21/20 she recommended discontinuing use of the Santyl and applying Dakin's-soaked gauze to the wound bed daily instead. She commented that Resident #6 was elderly, frail, and not eating, and under those circumstances a wound could decline significantly in as little as twelve hours. She stated under those circumstances in was important to respond quickly to declining wounds. Review of Resident #6's August 2020 TAR revealed the resident continued to receive Santyl in her sacral wound bed through 08/30/20. During a telephone interview with the facility's Treatment Nurse on 01/28/21 at 2:02 PM she stated she could not explain why the change from Santyl to Dakin's-saturated gauze which was recommended by the Wound NP on 08/21/20 was not placed in Resident #6's electronic medical record and implemented until 08/31/20. In her 08/24/20 Weekly Skin Assessment Nurse #2 documented Resident #6's skin was warm and dry with normal color and skin turgor. Existing skin issues still present. In his 08/25/20 5:07 PM Progress Note Nurse #3 documented Resident #6 was alert and oriented x 1, she had a poor appetite, and her sacral wound had foul smell and black tissue. Notified the Wound Treatment Nurse. Changed wound dressing as directed During a telephone interview with the facility's Treatment Nurse on 01/28/21 at 2:02 PM she stated Nurse #3 no longer worked in the facility. She reviewed her communication notebook and found no entry by Nurse #3 in regard to Resident #6's wounds, but she reported this nurse often relayed information to her verbally in passing. She commented she may have told Nurse #3 that Resident #6 had an upcoming wound assessment due soon, and she would look more closely at the sacral wound then. In her 08/28/20 Wound Management Detail Report the Treatment Nurse documented Resident #6 had an unstageable pressure ulcer to her sacrum which measured 5 x 3.5 x 1 cm with a moderate amount of [MEDICAL CONDITION] (malodorous) drainage which was yellow or tan, cloudy, and thick. The Treatment Nurse documented the wound bed was comprised of slough/eschar. In her 08/28/20 Evaluation and Management Report the NP documented, .The wound to the sacrum has increased in size. There is malodorous wound exudate, and there is [DIAGNOSES REDACTED] with accompanying warmth to the peri-wound. (Resident #6) will be started on a course of oral [MEDICATION NAME] (antibiotic) for [MEDICAL CONDITION]. Topical treatment for [REDACTED]. Review of Resident #6's August 2020 TAR revealed the first time her sacral wound bed was treated with Dakin's-soaked gauze at all was on 08/31/20. During a telephone interview with the facility's Treatment Nurse on 01/28/21 at 2:02 PM she stated she could not explain why the treatment recommended by the wound NP on 08/28/20 was not entered into the facility's electronic medical record and implemented until 08/31/20. A 08/28/20 physician's orders [REDACTED]. Review of Resident #6's August 2020 and September 2020 Medication Administration Records (MAR's) revealed the order was immediately implemented and administered as ordered until the resident's 09/03/20 discharge from the facility. 08/31/20 lab results documented Resident #6's [MEDICATION NAME] level was within normal range at 3.5 mg/dL with the normal range being 3.5 - 5.2 mg/dL. Review of Resident #6's August 2020 MAR indicated [REDACTED]. A 09/01/20 10/17 AM PA Note documented, . (Resident #6) seen for discharge plans. She is scheduled to discharge to (assisted living) with hospice on 09/03/20 During a telephone interview with Nurse #4 on 01/28/21 at 1:31 PM she stated she not only completed a skin check on Resident #6 on 08/31/20, but she changed the resident's dressings on the morning of 09/03/20 before the resident was transferred out of the nursing home back to the assisted living facility where she had resided prior to a fall and subsequent [MEDICAL CONDITION]. She reported she could recall the sacral wound was large, full of necrotic tissue, and produced a large amount of drainage. However, she commented she did not remember the sacral wound having foul odor. According to Nurse #4, Resident #6 was only alert and oriented x 1 on her best of days, was dependent on the staff for all of her activities of daily living, was totally incontinent of bowel and bladder, was bedbound for most of her stay, and would purse her lips and clench her mouth frequently when food and medications were offered. A 01/29/21 8:31 AM telephone interview was conducted with Physician #1 who cared for Resident #6 during her nursing home stay. He stated the Wound Care NP and facility's Treatment Nurse worked together to assess wounds and make recommendations. He reported he was available for consult if they needed him. He commented he expected the facility to implement the Wound Care NP's recommendations and immediately enter her orders into the facility's electronic medical record system. He stated foul wound odor and increasing size of the wound would cause him to raise an eyebrow. He explained interventions needed to be put in place quickly when caring for residents who were frail and not eating and drinking well. According to the physician, wounds in such individuals could deteriorate in as little as 24 hours. He stated wound-[MEDICAL CONDITION] needed to be avoided, and signs of such included fever, [MEDICAL CONDITION] elevated lactic acid, and elevated white blood cell count. He stated wounds not being treated with antibiotics which were malodorous, were deep and large in size, were presenting with increased necrotic tissue in the wound bed, and which developed tunneling were at an increased risk of becoming septic. During a telephone interview with the facility's Administrator on 01/29/21 at 11:13 AM he stated the Treatment Nurse was expected to assess new wounds within a couple of days of being identified. He also reported orders provided by the Wound NP were supposed to be entered into the electronic medical record and implemented immediately without delay. Review of 09/03/20 hospital Emergency Department (ED) notes revealed the receiving assisted living facility immediately sent Resident #6 out to the emergency room (ER) when her wounds were assessed on admission there. The assisted living facility was concerned about the necrotic pressure ulcer which presented with a strong, foul odor. She (Resident #6) has this large stage IV decubitus ulcer to the sacrum with foul-smelling purulent drainage with necrotic tissue. She also has some mild skin breakdown to bilateral heels .At this point will place an IV and give her fluids and [MEDICATION NAME] antibiotics for this open wound to her sacrum. Will obtain labs to look for any signs [MEDICAL CONDITION] The ED notes also documented XXX[AGE] year old female with past medical history of [REDACTED].Her vital signs here are stable except for her elevated heart rate at 146. Her physical exam findings were positive for her [MEDICAL CONDITION] she is going in and out of ([MEDICAL CONDITION]) (Family member) states that she is chronically in and out of ([MEDICAL CONDITION]) .(Family member) states that we can do whatever we feel is necessary but feels that (the resident) is giving up and is wanting to die Spoke to (assisted living facility) .states that when she left to go the (nursing home) after breaking her hip she did have this small little sore on her bottom, but it was nowhere near the size of what it is now .Patient labs are nonactionable with a normal white count and lactic acid. She does not appear to be severely dehydrated either Review of lab results from 09/03/20 ED lab draws revealed Resident #6's WBC and lactic acid were within normal limits, the blood culture was negative for growth after 6 days of incubation, and the wound culture gram stain documented, Few WBC's, moderate gram-positive cocci in singles and pairs, few gram-positive rods, and few gram-negative rods. The ER noted the resident was being admitted to the hospital for wound care and tachyarrhythmia of her heart. A 09/04/20 hospital wound consult documented Resident #6 had a stage IV sacral pressure ulcer which presented with a necrotic, painful, palpable bone appearance. The wound measured 5.5 x 4 x 2 cm with 3.5 cm of undermining. The wound presented with a moderate amount of purulent drainage. A 09/08/20 hospital Discharge Summary documented Resident #6's discharge [DIAGNOSES REDACTED]. Family does not want to continue antibiotic treatment Case manager notified regarding hospice and comfort care. Plan is to discharge patient to hospice house A 09/18/20 death certificate [MEDICAL CONDITION] due to pressure ulcer as the immediate cause of Resident #6's death. On 02/03/21 at 9:20 AM the Administrator was notified of the Immediate Jeopardy by phone. The facility's credible allegation of Immediate Jeopardy removal for F-600 Neglect included the following: 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the non-compliance. All residents have the potential to be affected. Unable to correct deficiency for the identified resident due to resident being discharged . It was identified that a comprehensive nurse assessment was not completed upon admission and no treatment order was obtained following identification. Orders were not initiated correctly upon being provided by Wound NP. New admissions and readmissions will be reviewed by Senior Nurse Consultant for the past 30 days by 2/4 to ensure the skin observation was completed on the day of admission to identify any necessary skin interventions. Interventions would include, but not limited to if wounds were present, facility will ensure that orders were written, treatments were initiated, and appropriate notification upon identification to MD/NP. All wound care orders provided by attending physician in the past 30 days will be audited by Senior Nurse Consultant by 2/4 for all current residents to ensure that all orders are being followed by verifying care provided matches order. 2.) Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. All licensed nursing staff will be educated that upon admission, readmission, and any newly identified wounds on how to conduct an appropriate skin assessment and the appropriate interventions that they are responsible for. Nurses will be educated on these appropriate interventions such as observation, writing orders, initiating orders for the wound care to be provided, and appropriate notification upon identification to MD/NP and notification of IDT team. Immediate education was conducted by Administrative Nurses and Senior Clinical Consultants on 2/3/2021 and ongoing- to be completed by 2/5. All licensed nursing staff will be educated on skin assessment schedule and schedules will be reviewed. All licensed nursing staff will be educated on abuse/neglect policy as it relates to patient care by Administrative Nurses and Senior Nurse Consultants on 2/3 and ongoing- to be completed by 2/5. All Nursing assistants will be educated on appropriate ADL care and the requirement to report any skin issues immediately to charge nurse by 2/5 via Administrative nurses and Senior Nurse Consultants. 100% skin audit has been completed on 2/3 by Administrative Nurses and Senior Nurse Consultants. All Licensed Nursing Staff have been educated on Skin Assessment Policy to address and timely communicate any identified skin concerns. IDT team was notified on 2/4 to meet weekly to review Wounds and interventions beginning 2/5. Nurse Manager will be notified of new admissions/readmissions by Admissions Director and new admissions/readmissions will be reviewed in morning clinical meeting by nurse manager to identify if skin observation was completed and if applicable to ensure wound care orders and necessary interventions were initiated by 2/4. Senior Nurse Consultant will educate and review 24-hour chart report process and responsibility with Nurse Managers by 2/4/21. Nurse Manager will review skin audits the following day to ensure proper identification, observation, notification, orders, orders initiated. Nurse Managers educated on 2/4 related to this process. IDT team will meet weekly w/ Wound NP to include, but not limited to by ensuring that wounds continue to be monitored for changes, treatments changed as needed, appropriate notifications and monitoring. The Treatment Nurse will be responsible for functioning with her respective role and should any need occur outside the scope of functioning as a Treatment Nurse the Treatment Nurse will notify the Director of Health Services immediately and a plan of coverage will be established by the DHS. DHS and Treatment nurse were educated on 2/4. PruittHealth Raleigh alleges the removal of Immediate Jeopardy on 02/05/21. On 02/10/21 at 1:45 PM, the facility's credible allegation for Immediate Jeopardy removal was validated by the following: *review of facility-wide audits including head-to-toe skin checks on 98 residents, skin observations completed for admits/re-admits on the day of admission/re-admission (for the past 30 days), implementation of wound care orders for 34 residents (for the past 30 days). *review of outlines/handouts/agendas/sign-in sheets for in-servicing regarding the facility wound policy/procedure, ADL care and reporting of new or worsening skin integrity issues, charting process and meetings related to interdisciplinary detection and treatment input on wounds, and neglect. *interviews with nurses who worked from 7:00 AM until 7:00 PM, nurses who worked from 7:00 PM until 7:00 AM, nursing assistants (NAs) who worked first shift, NAs who worked second shift, NAs who worked third shift, the nurse manager for week days, and the nurse manager for weekends about the key points that were emphasized during their in-servicing. *review of daily body check audits *review of minutes from the 02/04/21 Weekly Patients at Risk Meeting Wounds meeting which was attended by the Dietary Manager, Nurse Navigator, Registered Dietitian, Therapy Manager, Treatment Nurse, Wound NP, Social Workers, MDS Coordinator, and Director of Nursing. *review of minutes from the 02/05/21 QAPI meeting which focused on review of the citation at F600. *interview with Treatment Nurse about being pulled to complete other tasks without back-up to complete wound assessment tasks. The credible allegation of Immediate Jeopardy removal on 02/05/21 was confirmed on 02/10/21.

Based on observation, record reviews, staff interviews, the facility failed to implement their COVID-19 Infection Prevention and Control policies and The Centers for Disease Control and Prevention Center (CDC) COVID-19 guidelines when a nurse exited a resident ' s room who was COVID positive and failed to remove her Personal Protective Equipment (PPE) and disinfect her face mask before immediately entering the room of a resident who was COVID negative, the facility failed to have enough PPE available for staff to ensure the CDC recommended maximum number of uses of five donnings/doffings of N95 and KN95 masks were being followed, staff failed to store N95 and KN95 masks in a paper bag at the end of the work shift and the facility failed to post required enhanced droplet isolation precaution signage on the doors to the rooms of 69 residents with new-onset or confirmed COVID-19 which specified hand hygiene, eye protection, gloves, gown and a N95 mask were required before entering the resident's room. From 12/17/20 to 12/28/2020, a total of 69 of the facility's 138 residents had tested positive for COVID-19 in the facility. This system failure occurred during the COVID-19 pandemic and had a high likelihood of affecting all residents by placing them at an increased risk of developing and transmitting COVID-19. Immediate Jeopardy began on 12/29/2020 when observations revealed the same staff were assigned to work with residents who were COVID-19 positive and residents who were COVID-19 negative and Nurse #1 was observed in a COVID-19 positive resident ' s room at bedside and exited the room without discarding her N95 face mask or disinfecting her face shield and immediately entered a COVID-19 negative resident ' s room and approached the resident at bedside. PPE supplies, including N95s, KN95s and face shields were not observed on the 400 and 600 halls for staff to use for resident care. The facility was posting Airborne Precaution signage throughout the facility for suspected or confirmed COVID-19 rather than Enhanced Droplet Contact Precautions. Staff were storing used facemasks in plastic bags instead of the CDC recommended paper bags between shifts for reuse the next day or their next assigned shift. The immediate jeopardy was removed on 01/05/2021 when the facility implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of an E (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put into place are effective. Findings included: The facility's COVID-19 Guidance on use of PPE to Conserve Supplies dated 04/24/2020 was responsible for ensuring appropriate PPE was readily available and accessible, implementing limited re-use of medical facemasks, and PPE medical facemasks should be removed and discarded before leaving a COVID-19 resident ' s room, extended use medical facemasks will be discarded at the end of the shift and respirators are to be stored in a paper bag in between encounters. A review of facility policy labeled Coronavirus (COVID-19) Infection Prevention and Control Practices Policy, Section coronavirus has been identified in the facility dated 03/06/2020 revealed the facility would implement contact and droplet precautions for all residents with suspected or confirmed flu-like symptoms and for suspected or confirmed COVID-19 and Healthcare Personnel (HCP) would wear an N95 mask upon entering the resident ' s room or when working within three feet of the resident, remove the mask when leaving the resident ' s room and dispose of the mask in a waste container. The CDC guideline entitled Crisis Capacity Strategies updated on November 23, 2020 indicated the following statement: *Limit the number of reuses to no more than five uses (five donnings) per device to ensure adequate respirator performance. The CDC guideline entitled Responding to Coronavirus (COVID-19) in Nursing Homes last reviewed and updated on 04/30/2020 indicated the following statements: *Place signage at the entrance to the COVID-19 unit that instructs (HCP) they must wear eye protection and an N95 or higher-level respirator (or facemask if respirator is not available) at all times while on the COVID-19 unit. Gown and gloves should be added when entering resident rooms. *All recommended COVID-19 PPE should be worn during the care of residents under observation which includes use of N95 or higher-level respirator (or facemask if respirator is not available), eye protection, (goggles or a disposable face shield that covers the front and sides of the face), gloves and gown. Observation during a facility tour on 12/29/2020 at 10:46AM to 12:23 PM revealed COVID-19 positive resident ' s rooms were among COVID-19 negative resident ' s rooms on the 400 and 600 halls outside of a COVID-19 designated area or unit located on the 300 and 500 hallways. Each COVID-19 positive resident ' s room within the 400 and 600 halls had an Airborne Infection Isolation Precautions sign on the door, 12 doors in total. The Airborne Infection Isolation Precautions signage instructed staff to perform hand hygiene before entering and before leaving the room, wear an N95 respirator when entering the room and keep the door closed. The 400 hall had five of 11 doors with signage that read Airborne Infection Isolation Precautions. The 400 hall had eight COVID-19 positive residents and 12 COVID-19 negative residents, and positive and negative rooms were scattered throughout the hall. The 600 hall had seven of 12 doors with signage that read Airborne Infection Isolation Precautions. The 600 hall had seven COVID-19 positive residents and eight COVID-19 negative residents, and positive and negative residents were scattered throughout the hall. The signage of Airborne Infection Isolation Precautions was observed throughout the facility, including on the COVID-19 unit. Resident #1's medical record revealed Resident #1 was admitted on [DATE] and tested positive for COVID-19 on 12/28/2020. The facility's census sheet revealed Resident #1 resided on the 600 hall and was in a semi-private room with a roommate, Resident #2. Resident #2 ' s medical record revealed Resident #2 was admitted [DATE] and tested positive for COVID-19 on 12/28/2020 The facility ' s census sheet revealed Resident #2 resided on the 600 hall in a semi-private room with Resident #1. Resident #3 ' s medical record revealed Resident #3 was admitted on [DATE] and tested negative for COVID-19 on 12/28/2020. The facility ' s census sheet revealed Resident #3 resided on the 600 hall. Observation on 12/29/20 at 10:53 AM revealed Resident #1 was in a semi-private room on the 600 hall with an Airborne Infection Isolation Precautions sign posted on the door, the door was open, and Nurse #1 was at bedside. Before exiting Resident #1 ' s room, Nurse #1 discarded a yellow gown and a pair of gloves in Resident #1 ' s waste basket, washed her hands inside the room and stepped outside of the room. There were no PPE supplies available outside of the door of Resident #1 ' s room or the hallway. Upon exiting Resident #1 ' s room, Nurse #1 did not disinfect her face shield or discard her facemask. After Nurse #1 exited Resident #1 ' s room into the hallway, she was observed using alcohol-based hand sanitizer and immediately entered Resident #3 ' s room and approached Resident #3 at bedside and began speaking with Resident #3 and reached to turn off the call light. Resident #3 did not have precaution signage posted on the door. A phone interview with Nurse #1 on 12/29/2020 at 3:39 PM revealed she was assigned to the 600 hall on 12/29/2020 from 7:00 am to 7:00 pm and her assignment included both COVID-19 positive and COVID-19 negative residents. She added she often cared for residents who were COVID positive and COVID negative during her shifts at the facility. Nurse #1 stated she did not remove her facemask or disinfect her face shield in between providing care for Resident #1 and Resident #3 on 12/29/20 because she was unaware that she was required to and supplies, specifically N95s and KN95s, were not readily available upon exiting a COVID-19 room to allow for donning a new facemask. Nurse #1 confirmed she typically wore the same N95 and face shield during her entire shifts and did not disinfect her face shield in-between caring for COVID positive and COVID negative residents. She stated she was aware the door for COVID-19 residents should be closed and was not sure why some of the doors for COVID-19 rooms on the 600 hall were open. She also stated she wore her facemask for five to seven shifts depending on if she wore an N95 (five days) or KN95 (seven days) unless it became soiled or damaged before that time. Nurse #1 stated N95s were given to her by the Administrator in a plastic bag every five days for N95s and every seven days for KN95s and she could ask the Administrator for a new facemask if hers became soiled or damaged. Nurse #1 stated if he was not available, she could ask the nurse supervisor on duty. Nurse #1 stated that, at the end of her shift, she either took her mask with her when she left the facility either in a plastic bag or she may not have put it in a bag at all. A phone interview with Nurse #2 on 12/29/2020 at 3:51 pm revealed she was assigned to the 400 hall from 7:00 am to 7:00 pm on 12/28/2020 and 12/29/2020. Nurse #2 stated her assignment included both COVID-19 positive and COVID-19 negative residents over the last several weeks. Nurse #2 stated gowns and gloves, but not N95s or KN95s, were stored at the door of some of the COVID-19 positive rooms. Nurse #2 confirmed she wore the same N95 and face shield her entire shift and did not sanitize the shield during her shift. Nurse #2 revealed she had not been changing her facemask after providing care to a COVID-19 positive resident and before providing care to a COVID-19 negative resident because she had not been given enough facemasks by the facility to do so. Nurse #2 stated she was only issued one facemask every week and it was very hard to ask for another one if she needed it because they are stored in the Administrator ' s office. Nurse #2 revealed she had been changing her gown and gloves and washing her hands after providing care for a COVID-19 positive resident and before providing care for a COVID-19 negative resident, but did not disinfect her face shield unless it became soiled or dirty during her shift. Nurse #2 stated she was aware the Airborne Precaution signs were not the correct ones and stated she reported it to the Infection Preventionist, but the signs remained on the doors until the afternoon of 12/29/2020. Nurse #2 stated she keeps her used facemask in a plastic bag provided by the facility and takes it with her upon leaving at the end of her shift and brings it back the next day or shift until it is time for her to receive a new one. A phone interview with Nurse #3 on 12/29/2020 at 4:08 pm revealed she was not working at the facility on 12/29/2020 but has previously worked on the 400 and 600 halls, and her past assignments have included both COVID-19 positive and COVID-19 negative residents during the same shift. Nurse #3 stated she was issued a KN95 facemask once every seven days and revealed she had looked for additional facemasks at times during her shifts after hers became damaged and had to contact the Administrator because there were no extra masks on the supply carts. Nurse #3 stated she did not change her facemask or disinfect her face shield in between taking care of COVID-19 positive and COVID-19 negative residents because she didn ' t know she was required to, and she wouldn ' t have had enough facemasks to do so. Nurse #3 stated she wore gloves and a gown when providing care to a COVID-19 positive resident, discarded them and washed her hands before leaving the resident ' s room. Nurse #3 stated she does not store her used facemask in any type of bag and takes it with her when she leaves the facility at the end of her shift. Nurse #3 revealed she would identify a COVID-19 positive resident ' s room at the facility because she had been told by the Infection Preventionist the doors of COVID-19 positive residents had an Airborne Infection Isolation Precaution signs posted on each door. A phone interview with NA #1 on 12/30/2020 at 2:20 pm revealed most of her assignments at the facility occur on the 400 and 600 halls and her past assignments have included caring for both COVID-19 positive and COVID-19 negative residents during the same shift. NA #1 stated she was not working at the facility on 12/29/2020. NA #1 revealed she was issued a facemask an N95 or a KN95 about every seven days by the facility Administrator. NA #1 stated when she provided care to a COVID-19 positive resident, she wore a gown, facemask, face shield and gloves. NA #1 stated she did not change her facemask or disinfect her face shield after providing care to a COVID-19 positive resident because she was unaware that she needed to and stated she wouldn ' t have had enough facemasks to do that. NA #1 revealed supplies such as gowns and gloves were available on the 400 and 600 halls, but N95s and KN95s were not readily available. NA #1 stated the COVID-19 positive rooms were identified on the 400 and 600 halls by the Airborne Infection Isolation Precautions signs posted on them. NA #1 revealed she asked the facility Infection Preventionist if the Airborne Precautions were the correct precautions for COVID-19 positive residents, but the Infection Preventionist did not provide an answer for her. NA #1 added her normal practice does not include disinfecting her face shield or exchanging her mask after providing care to a COVID-19 positive resident and before providing care to a COVID-19 negative resident. An interview with the Infection Preventionist on 12/29/2020 at 12:35 PM revealed Airborne Infection Isolation Precautions signage was used throughout the facility for COVID-19 positive residents and room doors were to be closed. She stated the facility was using Airborne Infection Isolation Precautions signage because the Enhanced Droplet/Contact Precaution signs stated staff must be fit tested for N95 masks to enter the COVID-19 rooms, and none of the facility staff had been fit tested . She added she had received the newest CDC Enhanced Droplet Precaution signage a month or so ago but had not posted them for this reason. In addition, she revealed staff should discard gown, gloves and facemasks, wash hands with soap and water and sanitize face shields when exiting a COVID-19 positive resident ' s room and before providing care to a COVID-19 negative resident. She also stated facility staff had been educated using an online module on the topic of generalized Infection Control-Coronavirus (COVID-19). Continued attempts were made to contact the Infection Preventionist by the facility Administrator and Surveyor for further interviews on 12/30/2020, 12/31/2020 and 01/01/2021 but were unsuccessful. An interview with the Director of Nursing (DON) on 12/29/2020 at 10:46 AM revealed as a result of the facility's number of COVID-19 positive residents and the designated COVID-19 unit being full, COVID-19 positive residents were housed on the 400 and 600 halls which also housed COVID-19 negative residents. She added the COVID-19 positive resident rooms could be identified throughout the two halls in no specific order and by the signage of Airborne Infection Isolation Precautions posted on the doors along with the doors to these resident's room would also be closed. She revealed the facility did not have a negative pressure room and she was not sure why signage of Airborne Infection Isolation Precaution had been posted by the Infection Preventionist. An additional phone interview with the DON on 12/30/2020 at 8:48 AM revealed staff should remove all PPE, including gowns, gloves, and face masks, wash hands with soap and water and sanitize face shields each time when exiting the COVID-19 positive resident ' s room and before providing care to a COVID-19 negative resident. She added all employees were educated on this process via online module between the dates of 10/11/2020 to 11/17/2020. An additional interview with the DON on 12/30/2020 at 4:07 PM revealed PPE such as gowns and gloves were available for COVID-19 positive residents inside the specific COVID-19 rooms and supply carts could be found on certain hallways. She stated staff, including herself, used plastic bags to store their used facemasks for the next assigned shift and stated she took her used facemask with her when she left the facility at the end of the work day and brought it back the next day. She stated the Administrator provided the instruction to her to place her facemask in a plastic bag at the end of her day/shift. She added the Administrator issues N95 masks every 5 days and KN95s every 7 days and supplies of these facemasks were stored in his office and if he was not available, staff could request additional facemasks through the nurse supervisor if needed. An additional phone interview on 01/02/2020 at 12:14 pm revealed that additional gowns and gloves, as well as facemasks, could be found up and down hallways on carts that resemble bedside tables and added she did not know the exact number of carts that were on hallways throughout the facility and a few additional masks could be found on a nurse ' s cart on the 400 & 600 halls. She added she was not sure why she or the staff were using plastic bags instead of paper bags as required per facility policy, but stated she preferred plastic bags as she felt they were a little bit safer. An interview with the Administrator on 12/29/2020 at 12:48 PM revealed all residents who were COVID-19 positive were to have doors closed and there were residents on the 400 and 600 halls who were COVID-19 positive and COVID-19 negative. A phone interview with the Administrator on 12/30/2020 at 9:10 AM revealed signage of Enhanced Droplet Contact Precautions should have been posted on the outside of all COVID-19 positive resident ' s rooms throughout the facility, including the COVID-19 unit. During an additional phone interview on 01/01/2021 at 11:07 AM, the Administrator confirmed the COVID-19 positive residents residing on the 400 and 600 halls on 12/29/2020 had tested positive on 12/28/2020 and were not immediately moved the same day away from COVID-19 negative residents because of not having enough staff to deep clean rooms and other residents needed to be moved around to make room for the COVID-19 positive residents. He added he felt it was not humanly possible to move the COVID-19 positive residents on 12/28/2020 on the day they tested positive. He continued and stated COVID-19 positive residents on the 400 and 600 halls were moved to the 100, 200, 300 and 500 halls of the facility during the late afternoon/evening of 12/29/2020 and Airborne Infection Isolation Precaution signage had been replaced with Enhanced Droplet Contact Precaution signage for COVID-19 positive residents throughout the facility. He stated the Airborne Precaution signs had been used throughout the facility for COVID-19 positive residents because the Infection Preventionist had informed him the Enhanced Droplet Contact Precaution signs used verbiage that staff must be fit tested to enter the COVID-19 positive rooms. He added the remaining residents on the 400 and 600 halls were COVID-19 negative with Enhanced Droplet Contact Precautions signage posted on the doors. He added the facility had not been low on PPE supplies, including N95s and KN95s, and he distributes KN95 facemasks to staff every seven shifts and N95 facemasks every five shifts and instructed staff to store their masks (KN95s or N95s) in a plastic bag until it is needed for the next shift -- and most staff take it with them when they leave the facility at the end of their shift and bring it back for their next assigned shift. An additional phone interview on 12/31/2020 at 11:17 AM revealed he was not aware of the CDC guideline of Crisis Capacity Strategies updated on November 23, 2020 that recommended limiting the number of facemask reuses to no more than five uses (five donnings) per device to ensure adequate respirator performance. An additional interview on 01/01/2021 at 11:07 AM revealed the reason the facility staff were using plastic bags instead of paper bags per facility policy was due to not having an abundance of paper bags. He stated the facility was using low-density, resealable plastic bags to store used N95s and KN95s. A phone interview on 12/31/2020 at 10:11 AM revealed staff should remove PPE, including facemasks, and sanitize face shields in between providing care for COVID-19 positive and COVID-19 negative residents. He stated facemasks had been made available through the nursing supervisor, at nursing stations and carts on hallways. A phone interview with the Nurse Navigator/Liaison on 01/05/2020 at 11:32 AM revealed her working schedule on 12/28/2020 was from 8am-5pm and was assigned to help with employee COVID-19 testing. She stated she assisted staff at times during the day shift hours if needed and added she did not remember receiving a call from staff asking for a replacement face mask during the hours she was at the facility on 12/29/2020. She stated if she had received a call from staff requesting a new facemask, she would have asked the Administrator to issue one for the requested staff member. She added facemask supplies, such as N95s and KN95s, as of 12/29/2020 were kept in the Administrator ' s office. An interview with the Environmental Maintenance Director on 01/05/2020 at 2:14 pm revealed there had not been any PPE shortages throughout the COVID-19 pandemic and shipments had arrived regularly. He added he was responsible for ordering and receiving PPE supplies. On 01/01/2021 at 6:11 PM, the Administrator was notified of the immediate jeopardy by phone. The facility's credible allegation of immediate jeopardy removal for F-880 Infection Prevention and Control included the following: 1.) Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the non-compliance. All residents have the potential to be affected by the infection control breaches. Observations on 12/29/20 on the 400 and 600 halls revealed the doors to all 12 rooms with COVID-19 positive residents were not closed and all rooms with COVID-19 positive residents throughout the facility had signage for Airborne Precautions, which does not include the verbiage to don gown and gloves prior to entering the room. Staff were not changing personal protective equipment (PPE) specifically facemasks (N95 and KN95 respirator masks) and disinfecting face shields/goggles per The Centers for Disease Control and Prevention (CDC) guidance between positive and negative residents. Staff were not storing respirator masks in paper bags per the facility policy and reported during interviews they wore the same facemask for five to seven days. Interviews with staff revealed they did not have access to additional N95 or KN95 respirator masks for changing between COVID-19 positive and COVID-19 negative residents. The Administrator and Director of Nursing were not aware of the CDC guideline of Crisis Capacity Strategies updated on November 23, 2020 recommended limiting the number of facemask reuses to no more than five uses (five donning ' s) per device to ensure adequate respirator performance. As of 12/29/20, 69 of 138 residents have tested positive for COVID-19 for the December outbreak. 2.) Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. All positive residents have been moved as of 01/01/2021 to COVID positive halls 100, 200, 300, 500, 600, and 700 hall. Rooms 710 & 709 are negative residents separated from the rest of 700 hall on the Memory Support Unit. All negative residents have been moved to the 400 hall and rooms [ROOM NUMBERS] on the Memory Support Unit. Residents that test positive will be moved to a COVID-19 positive hall. If there is not a room on a COVID-19 positive hall, they will be placed in a private room under enhanced droplet contact precautions. The Nurse Navigator, Consultants, Interim DON, Nurse Supervisors and Case Mix Director have been assigned to retest all staff and residents that tested negative every three days to seven days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive results. On 01/02/2021, The Nurse Navigator, Consultants, Interim DON, Nurse Supervisors, and Case Mix Director were educated on the CMS guidance on testing for Facilities with a new COVID-19 positive case. They were also assigned to testing and moving residents. The correct signage of Enhanced Droplet Isolation and Contact Precautions signage has been placed on all COVID-19 rooms on 100, 200, 300, 500, 600, 700 halls as of 01/01/2021, and will be placed on any new COVID-19 rooms as needed. The Clinical team (Interim DON, ADON, Infection Control Nurse, Unit Manager, Education Nurse, Nurse Consultants (SPICE trained and Clinical Supervisors) is responsible for placing the signage on each positive room. The Clinical Team including the Interim DON and Consultants (SPICE Trained) were notified of this assignment on 01/01/2021. The Area Vice President educated the Administrator and Director of Nursing on 12/29/2020, the use and storage of N95 and KN95 and reuse of mask per the CDC guidelines utilizing the PruittHealth COVID-19 Pandemic Isolation and Cohorting Process for Healthcare Centers. Corporate sent a revised policy on 01/05/2021 to provide the language directly in relation to CDC guideline of Crisis Capacity Strategies updated on November 23, 2020 recommending limiting the number of facemask reuses to no more than five uses (five donning's) per device to ensure adequate respirator. This change was made for quick reference on the policy related to the five donning's, but the policy did have the link to the Crisis Capacity Strategies referenced on original policy (effective 4/24/20). The Clinical Team (DHS, ADHS, Interim DHS, Consultants, Nurse Navigator, Nurse Supervisors) started education for all 180 staff in departments on 12/29/2020 regarding these areas: Enhanced Droplet Isolation and Contact Precautions, keeping doors closed for COVID-19 positive residents, donning and doffing of PPE per CDC guidance to include, appropriate donning and doffing of PPE between COVID-19 positive residents and non COVID-19 residents, donning ' s of KN95/N95 for 5 donning ' s only (taking the mask off to eat and/or drink fluids counts toward the total number of donning ' s), cohorting of positive residents with positive residents and negative residents with negative residents and face shield/goggle disinfecting process. Staff that has not been educated by 01/04/2021 will not be allowed to work until they have been in-serviced. The Interim Director of Nursing and her clinical team will ensure that the education is completed by staff. There is an Interim DON that has been appointed and a Nurse Consultant have been assigned to assist this facility that will provide Infection Control Monitoring and to assist the Interim DON. On 01/02/2021, education began for all staff on the process of keeping paper bags in the facility to store their KN95 & N95 after their shift. The masks are stored in the Ante Room at the top of 100 Hall. There is an Isolation Cart that will be used to store masks in paper bags that each staff member will leave after their shift. They will label their bag with their name and they are able to wear for five donning ' s. It was explained to staff each time they don their mask during a shift counts toward the five total donning ' s. This would include doffing and donning a N95 or KN95 for any reason, including eating and drinking. After a mask has been donned five times, staff are responsible to getting a new mask at the PPE stations. They will replace with a clean surgical mask to exit the building. When staff enter the building, they will receive a clean surgical mask and proceed to the ante room and retrieve their mask before their shift. Staff that have not been educated as of 01/04/2021 will not be allowed to work until they complete this education prior to their next shift. The Dietary Manager was notified he will supply the paper bags and be responsible for storing them in the ante room, on 01/02/2021. The Maintenance Director and his designee(s) is/are responsible for ensuring there are adequate masks and PPE available at the donning tables and nurses' station daily. The Maintenance Director and/or designee will utilize an inventory tracker to maintain par levels for each station. The Maintenance Director and his designees were educated on this process on 01/03/2021. The storage of the bulk of the PPE items are in the facility warehouse on property site. The Maintenance Director will order supplies based on needs weekly through our corporate vendor. Each hall has two donning/supply stations with PPE. The exception to this is the 400 hall, which is a non-COVID-19 hall. This area has one donning/supply station. On 01/02/2021, the Interdisciplinary (IDT) Team met and reviewed the Surveillance forms that were created to ensure the education below is being followed. Infection Control surveillance as it applies to PPE available at hall stations, signage appropriate for COVID-19 Rooms, and COVID-19 doors closed surveillance rounds. The second Surveillance Form identifies staff observed applying and removing PPE, KN95 and N95 Mask Storage, and Face Shield/Goggles disinfecting. Each audit tool will be conducted at least six times per day by members of the IDT to ensure these policies are being followed and implemented appropriately, per the credible allegation. This was assigned on 01/03/2021. On each Audit tool there is a comment section, as well. Additional education will be provided for not following policy and or disciplinary actions for staff members that have been educated and unable to or not willing to follow the policies. The Interdisciplinary Team includes, but is not limited to, Interim DON, ADON, Nurse Navigator, Administrator, Dietician, Clinical Consultants, Social Worker, and Activity Director. PruittHealth Corporation updates the policies and procedures from the CDC guidance and once the policy/procedure is updated the policy is released to the facilities. The Administrator will check daily for updates and pull the newly released policies and educate Department Managers who will educate their departments on newly released policies/procedures. The Corporate office is responsible for updating policies and procedures. PruittHealth Raleigh alleges the removal of Immediate Jeopardy on 01/05/2021. On 01/11/2021 at 9:27 AM, the facility ' s credible allegation for immediate jeopardy removal was validated by the following: -observation of the facility's COVID-19 residents to ensure doors were closed and Enhanced Droplet Isolation Contact signage was posted -observation of staff assigned to COVID-19 residents to verify use of PPE according to the CDC guidelines and facility 's policy -observation of staff wearing appropriate PPE, donning/doffing stations throughout each hall, -review of COVID-19 positive and COVID-19 negative residents to ensure room assignments in the facility were according to their COVID-19 test results and/or respiratory signs and symptoms. -review of testing schedule for new cases of COVID-19 staff or residents for a period of at least 14 days since the most recent positive results. -review of education logs for The Nurse Navigator, Consultants, Interim DON, Nurse Supervisors, and Case Mix Director on the CMS guidance on testing for Facilities with a new COVID-19 positive case. -review of education log for the Administrator and Director of Nursing on the use and storage of N95 and KN95 and reuse of mask per the CDC gui (TRUNCATED)