Every finding on record at Rich Square Health & Rehabilitation Center

Based on staff interview and review of the Facility Assessment the facility failed to ensure the required parties were involved in the development the Facility Assessment, failed to: have an accurate facility assessment that recorded the current administrative staff and Medical Director, ensure the staffing plan considered specific staffing needs for each unit and shift as required, provide information regarding the skills and competencies that were required for licensed nursing staff and Certified Nurse Aides (CNAs), and have an accurate staff type and position list. This deficient practice had the potential to affect 54 of 54 residents. The findings included: The Facility Assessment was reviewed and was noted to have been updated and reviewed with the facility's Quality Assurance Performance and Improvement (QAPI) committee on 1/28/25. The persons involved in completing the assessment were listed as the Administrator, the Director of Nursing (DON), the Medical Director, Social Service Director, Dietary Manager, Therapy Director, and a Governing Board Member. There was no indication that direct care staff were involved in completing the assessment or that the facility solicited and considered input from residents, resident representatives and family members. The Facility Assessment was noted to have the former Administrator, the former Medical Director, and the former Social Worker listed under the administrative personnel. Further review of the Facility Assessment revealed that the staffing plan listed the number of Nurses (Registered Nurse or Licensed Practical Nurse), and CNAs noted as the desired number FTE (full-time equivalent, the total number of full-time employees working in an organization) of staff and the professional requirement for those staff members. However, the staffing plan did not address staffing needs for each shift and weekends, or address staffing needs in these areas based on changes to the resident population as required. The staff type and position list recorded the facility had provided 1 FTE for a Staff Development Coordinator (SDC). The Facility Assessment did not provide information regarding the skills and competencies that were required for licensed nursing staff and CNAs. An interview was conducted with the Administrator on 7/02/25 at 11:59 am who revealed she was not employed by the facility when the current Facility Assessment was reviewed and updated. The Administrator confirmed the facility did not have an SDC and that the staff position list was inaccurate. The Administrator stated she had not yet reviewed or updated any information in the Facility Assessment since she started at the facility in March 2025. The Administrator was unable to provide any further documentation at the time of survey exit regarding the Facility Assessment.

Based on observations, record review, and staff interviews, the facility failed to implement their infection prevention program policies and procedures when Nurse #2 failed to perform hand hygiene between glove changes during the observation of medication administration for 1 of 4 staff observed for infection control practices (Nurse #2). The findings included: The facility's Infection Prevention and Control Program (IPCP) policy implemented 10/04/23 and reviewed annually indicated in part that the facility established and maintained an (IPCP) to prevent the development and transmission of communicable diseases and infections. The policy further noted that hand hygiene shall be performed in accordance with the facility's established hand hygiene procedures. Review of the facility's Hand Hygiene Policy, no date, indicated that all staff would perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. The policy further noted that the use of gloves did not replace hand hygiene and that staff were to perform hand hygiene prior to donning gloves, and immediately after removing gloves. A continuous observation was conducted on 7/01/25 from 8:54 am through 8:58 am of medication administration for Resident #260. At 8:54 am Nurse #2 donned clean gloves without performing hand hygiene and was observed to use her gloved hands to spread open Resident #260's eye lids to administer eye drops to both eyes. Nurse #2 then removed the gloves, donned clean gloves without performing hand hygiene, removed Resident #260's oxygen tubing from the nose and administered nasal spray to both nostrils. Nurse #2 removed the gloves and did not perform hand hygiene. Nurse #2 then adjusted Resident #260's oxygen tubing with her ungloved hands and handed the resident a medicine cup with pills. Nurse #2 donned clean gloves without performing hand hygiene and placed a pain patch on Resident #260's right shoulder. Nurse #2 removed the gloves and performed hand hygiene when she exited Resident #260's room. An immediate interview was conducted with Nurse #2 on 7/01/25 at 8:58 am who revealed she should have used hand sanitizer between the glove changes during the medication administration but she just forgot. During an interview with the Director of Nursing (DON) on 7/01/25 at 3:13 pm she revealed she was also the facility's Infection Preventionist and was responsible for the IPCP. The DON stated Nurse #2 should have performed hand hygiene before she put on clean gloves and immediately after she took the gloves off.

Based on observations, record review, and staff, Pharmacy Consultant and Nurse Practitioner (NP) interviews, the facility failed to clarify the physician orders for lidocaine 4% external pain patches that resulted in the pain patches remaining on the resident's skin over the manufacturer's recommended duration of 12 hours. This deficient practice was for 1 of 3 residents observed for medication administration (Resident #15). The findings included: Resident #15 was admitted to the facility on [DATE] with diagnoses which included pain unspecified and diabetes with neuropathy (nerve pain). Review of physician orders revealed an active physician order dated 2/18/24 for lidocaine 4% external pain patch. Apply to the left side topically one time a day for pain at 9:00 am; apply in the am and remove at bedtime and per schedule. The order noted the removal time as 8:59 am. In addition, there was an active physician order dated 4/30/25 for lidocaine external patch 4%. Apply to the right side topically one time a day for right side pain. The order did not specify a removal time. The manufacturer's instructions written on the Lidocaine 4% external pain patch package stated to use one patch for up to 12 hours and discard patch after single use. During a continuous medication administration observation on 7/01/25 at 8:14 am through 8:37 am, Nurse #1 was observed to prepare and date a lidocaine 4% external pain patch to apply to Resident #15's left side. Nurse #1 was then noted to remove a lidocaine external pain patch from Resident #15's left side dated 6/30/25 and throw the used patch in the trash can. Nurse #1 applied the new lidocaine 4% external pain patch to the same area of Resident #15's left side. Next, Nurse #1 was observed to prepare and date another lidocaine 4% external pain patch to apply to Resident #15's right side. Nurse #1 was then noted to remove a lidocaine external pain patch from Resident #15's right side dated 6/30/25 and throw the used patch in the trash can. Nurse #1 applied the new lidocaine 4% external pain patch to the same area of Resident #15's right side. Resident #15's skin was observed to be intact without redness or irritation. An immediate interview was conducted with Nurse #1 on 7/01/25 at 8:37 am who revealed she normally removed Resident #15's lidocaine 4% external pain patches from the previous day just before she applied the new one. She stated the time of removal for the left pain patch was listed for 8:59 am and the new patch was ordered to be administered at 9:00 am. Nurse #1 stated the right lidocaine external patch was not ordered to be removed at any certain time, so she removed it before she applied the new one. Nurse #1 stated she thought the lidocaine external patch was only supposed to be used for 12 hours but she did not clarify the orders with a physician to see if a removal time was needed. A telephone interview was conducted with the Pharmacy Consultant on 7/02/25 at 2:52 pm who revealed Resident #15's lidocaine 4% external pain patch was to be removed after 12 hours, and the next patch should not be placed for another 12 hours: 12 hours on 12 hours off. The Pharmacy Consultant stated that when a lidocaine 4% external pain patch remained in place continuously without the 12-hour time frame to remove the patch, the resident was at risk for skin rash or irritation at the site where the patch was applied. An interview was conducted with the Nurse Practitioner (NP) on 7/02/25 at 9:27 am who revealed Resident #15's lidocaine 4% external pain patch order should have included a removal time of 12 hours after application. The NP stated she did not realize the order did not have a removal time so that Resident #15 would have 12 hours with the lidocaine 4% external pain patch off the skin. During an interview on 7/01/25 at 3:15 pm with the Director of Nursing (DON) she revealed the orders for Resident #15's lidocaine 4% external pain patches to the left and right side were not accurate and should have included to remove the patches after 12 hours. She stated the order should have specified to apply the patch at 9:00 am and remove at 9:00 pm. The DON stated physician orders were reviewed during the clinical meetings but she did not recall seeing that Resident #15's orders for the lidocaine 4% external pain patches did not include to remove after 12 hours of use.

Based on record review, observations, and staff, Nurse Practitioner and Registered Dietitian (RD) interviews, the facility failed to provide nutritional supplements to prevent further weight loss as recommended by the RD and prescribed by physician (Resident #45) for 1 of 3 residents reviewed for nutrition. The findings included: Resident #45 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease and diabetes. An active physician order dated 6/22/24 to add ice cream to lunch tray every day to aid with prevention of further significant weight loss per RD recommendation. An active physician order dated 11/03/24 to add nutritional shake supplement to lunch tray daily to aid in the prevention of further weight loss per RD recommendation. An active physician order dated 4/28/25 for a consistent carbohydrate (CCD), no added salt (NAS) diet. Regular texture, thin (regular) liquid consistency. Review of Resident #45's electronic health record revealed the following weights were recorded: 6/20/25 185.6 pounds 5/10/25 186.4 pounds 4/13/25 185 pounds 3/20/25 188.8 pounds 2/13/25 190.2 pounds 1/17/25 189 pounds 12/16/24 192.6 pounds 11/11/24 207.4 pounds 10/12/24 212 pounds The RD visit note dated 3/25/25 revealed Resident #45's current base weight was 188.8 pounds and Resident #45 had a 10.9% weight loss for the last 159 days. Resident #45 was noted to have a CCD, NAS regular texture diet with ice cream and nutritional shake once daily. The RD visit note further recorded that Resident #45's diet order with additional supplements met requirements and the RD would continue to monitor Resident #45 per protocol. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #45 had severe cognitive impairment. Resident #45 was coded for a therapeutic diet, was not coded for any signs and symptoms of a swallowing disorder, was independent for eating. Resident #45 was coded for weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months, not on physician-prescribed weight-loss regimen. The care plan was last reviewed and updated on 5/08/25. Resident #45 had a nutritional problem related to diet restrictions with a goal to maintain adequate nutritional status. The interventions included explaining and reinforcing the importance of maintaining the diet ordered and encouraging compliance. An observation was conducted on 6/30/25 at 12:49 pm of Resident #45 during the lunch meal. The meal ticket on the lunch tray revealed Resident #45 was to receive ice cream and nutritional shake. No ice cream or nutritional shake were noted on the lunch tray. An attempt to conduct a telephone interview on 7/02/25 at 9:59 am with Dietary Aide #1 who worked on 6/30/25 during the lunch meal tray line was unsuccessful. An observation of Resident #45's lunch meal was conducted on 7/01/25 at 12:33 pm. No ice cream or nutritional shake were noted on the lunch tray. An interview was conducted on 7/02/25 at 11:07 am with Dietary Aide #2 who worked on 7/01/25 during the lunch meal tray line revealed the ice cream was normally added to Resident #45's lunch tray just before the meal tray cart goes to the unit and the nutritional shake would be put on the tray during the meal tray line. Dietary Aide #2 stated she must have forgotten to put the ice cream and nutritional shake on Resident #45's lunch tray. An interview was conducted on 7/01/25 at 2:51 pm with the Dietary Supervisor who revealed when a resident had supplements ordered on the diet ticket the dietary department was responsible to supply the supplements. The Dietary Supervisor stated when the meal tray line was in progress the Dietary Aides were responsible to review the meal tickets and ensure all supplements listed on the meal ticket were added to the meal tray. An interview was conducted on 7/01/25 at 12:38 pm with the Dietary Manager who revealed the Dietary Aides were responsible to place the ice cream and nutritional shake on Resident #45's lunch tray as ordered and noted on the meal ticket. A telephone interview with the facility's Registered Dietitian (RD) was conducted on 7/01/25 at 3:32 pm. The RD revealed she recommended the ice cream and nutritional shakes to be added to Resident #45's meal tray due to a recent significant weight loss. The RD stated Resident #45 was at risk for additional weight loss by not receiving the nutritional supplements as recommended and ordered. An interview was conducted on 7/02/25 at 9:05 am with the Nurse Practitioner (NP) who revealed Resident #45 was ordered the nutritional supplements due to weight loss and the supplements should have been provided as ordered. During an interview with the Administrator on 7/02/25 at 11:57 am she revealed the Dietary Department was responsible for ensuring that Resident #45 received the dietary supplements as ordered by the physician.

Based on record reviews and staff interviews, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) (form 10055) prior to discharge from Medicare Part A skilled services for 2 of 3 residents reviewed for beneficiary notification (Resident #19 and Resident #108). The findings included: 1. Resident #108 was admitted to the facility on [DATE]. Medicare Part A services began on 11/7/24. Review of a Notice of Medicare Non-Coverage (NOMNC) revealed the notice was discussed with Resident #108 on 1/28/25, which indicated Resident #108's Medicare Part A coverage for skilled services would end on 1/25/25. Resident #108 remained in the facility. Review of Resident #108's medical record revealed no evidence a SNF ABN was reviewed with or provided to Resident #108. An interview was conducted with the Business Office Manager 7/01/25 at 1:32 PM. He revealed that when Resident #108 was admitted from the hospital on [DATE], she was billed for the month of October 2024 and the first week of November 2024. However, the previous facility billing was not finalized yet, so they billed Resident #108 based on her recollection of admission history. The last day of coverage for Medicare Part A was 8/30/24, which needed a 60-day reset. Based on that history, she had cleared 60 days of reset for all 100 days to be available when she was admitted to the nursing facility. At the time, that was what the Business Office Manager thought was accurate. All services were provided and billed accordingly, and the last covered day was initially 1/25/25. When the claims for January and February were paid in March 2025, the Business Office Manager found out on 3/19/25 that she already had passed the 100 days 5 days earlier than they thought. The services from 9/1/24 through 9/6/24 were not included. Therefore, the last covered day had changed. The Business Office Manager stated that he then billed Medicare Part B instead of Medicare Part A. During a follow-up interview with the Business Office Manager on 7/01/25 at 11:00 AM, he stated the Social Worker (SW) was responsible for issuing the SNF ABN, and this was something the previous SW used to take care of it. The SW was interviewed on 7/01/25 at 11:02 AM. She stated that she was only responsible for the NOMNC document, and the Business Office Manager was responsible for issuing the SNF ABN. An interview was conducted with the Administrator on 7/01/25 at 11:06 AM. She stated that she began at the facility in March 2025, but it was her understanding that the SW was responsible for issuing all the Beneficiary Notices. During a follow-up interview with the Administrator on 7/02/25 at 10:04 AM, she revealed that she forgot to instruct the current SW to also provide the SNF ABN with the NOMNC when a resident remained in the facility. The previous SW must have included the SNF ABN in her workload, but that was not communicated to the current SW. 2. Resident #19 was admitted to the facility on [DATE]. Medicare Part A services began on 1/27/25. Review of a Notice of Medicare Non-Coverage (NOMNC) revealed the notice was discussed with Resident #19 on 3/3/25, which indicated Resident #19's Medicare Part A coverage for skilled services would end on 3/5/25. Resident #19 remained in the facility. Review of Resident #19's medical record revealed no evidence a SNF ABN was reviewed with or provided to Resident #19. An interview was conducted with the Business Office Manager on 7/01/25 at 11:00 AM, He stated the Social Worker (SW) was responsible for issuing the SNF ABN, and this was something the previous SW used to take care of it. The SW was interviewed on 7/01/25 at 11:02 AM. She stated that she was only responsible for the NOMNC document, and the Business Office Manager was responsible for issuing the SNF ABN. An interview was conducted with the Administrator on 7/01/25 at 11:06 AM. She stated that she began at the facility in March 2025, but it was her understanding that the SW was responsible for issuing all the Beneficiary Notices. During a follow-up interview with the Administrator on 7/02/25 at 10:04 AM, she revealed that she forgot to instruct the current SW to also provide the SNF ABN with the NOMNC when a resident remained in the facility. The previous SW must have included the SNF ABN in her workload, but that was not communicated to the current SW.

Based on record reviews, and staff and Nurse Practitioner interviews, the facility failed to provide written information to the resident and/or resident representative pertaining to their right to accept or refuse medical/surgical treatment and the opportunity to formulate an Advance Directive for 1 of 7 sampled residents (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included high blood pressure and a history of a stroke. A quarterly Minimum Data Set assessment dated [DATE] revealed Resident #1 was cognitively intact. Review of Resident #1's electronic medical record revealed a full code Physician order dated 4/22/2025. There was no documentation in the record for education regarding formulation of an advance directive and/or an opportunity to formulate an advance directive was offered to the resident or resident representative. An interview was completed on 7/1/2025 at 10:35 am with Resident #1. The Resident was unable to recall if she received education regarding the right to formulate an advance directive. An interview was completed on 7/2/2025 at 11:42 am with the Administrator. The Administrator revealed approximately 2 months ago the facility's Nurse Practitioner (NP) provided education regarding advance directives and treatment via phone call to Resident #1's Representative. The Administrator stated the NP revealed she had forgotten to document the conversation in Resident #1's medical record. The Administrator stated it was her expectation facility residents or resident representatives were educated on advance directives and those conversations documented in their medical record. An interview was completed on 7/2/2025 at 11:48 am with the facility's NP. The NP stated in May 2025 she had a telephone conversation with Resident #1's Representative and provided education on advance directives and treatment due to Resident #1's gradual decline in health. The NP stated she had forgotten to document the conversation in Resident #1's medical record. Attempts to contact Resident #1's Representative were unsuccessful.

Based on observations, record review, and resident and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of use of anticonvulsant medication (Resident #45), resident prescribed diet (Resident #6), and use of a hearing aid (Resident #25) for 3 of 21 residents whose MDS assessments were reviewed. The findings included: 1. Resident #45 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease and cerebrovascular disease. Resident #45 had a physician order dated 2/01/24 for gabapentin (an anticonvulsant medication also used to treat pain) capsule 300 milligrams (mg) give one capsule by mouth at bedtime for pain. Resident #45 had an active physician order dated 2/29/24 for divalproex sodium tablet delayed release (an anticonvulsant medication) 250 mg; give 2 tablets once time a day for mood disorder related to dementia. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #45 had severe cognitive impairment and was not coded for the use of anticonvulsant medication. Review of the April 2025 Medication Administration Record (MAR) revealed Resident #45 was administered the gabapentin and divalproex sodium medications as ordered. An interview was conducted on 7/02/25 at 10:44 am with the MDS Nurse who confirmed Resident #45 was administered the anticonvulsant medication during the look back period of the MDS assessment. The MDS Nurse stated she must have just missed the anticonvulsant medication when she completed Resident #45 medication section of the MDS assessment. During an interview on 7/02/25 at 11:55 am with the Administrator she revealed the MDS Nurse was responsible to ensure Resident #45's medications were coded accurately. 2. Resident #6 was admitted to the facility on [DATE]. Resident #6 had an active physician order dated 4/28/25 for a regular diet, regular texture, thin (regular) liquid consistency. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #6 was cognitively intact, had no swallowing issues, and was coded for a mechanically altered diet. During an observation of the lunch meal on 7/01/25 Resident #6 was observed to have a regular texture diet with thin liquids which was confirmed by the meal ticket. An interview was conducted with the MDS Nurse on 7/02/25 at 10:44 am who revealed the Dietary Manager completed the section regarding diet for Resident #6. The MDS Nurse stated she was not responsible for coding Resident #6's diet and she was not responsible for reviewing the section since it was completed by the Dietary Manager. During an interview on 7/02/25 at 11:22 am the Dietary Manager confirmed Resident #6 did not have a mechanically altered diet but was ordered a regular diet. The Dietary Manager stated she coded Resident #6's diet in error when she completed the MDS assessment. The Administrator was interviewed on 7/02/25 at 11:55 am and revealed the Dietary Manager was responsible to ensure Resident #6's diet was coded accurately on the MDS assessment. 3. Resident #25 was admitted to the facility on [DATE] with diagnoses which included cognitive communication deficit. Review of the Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #25 was cognitively intact and was not coded for use of a hearing aid. An observation and interview with Resident #25 was conducted on 6/30/25 at 10:48 am. Resident #25 was observed sitting in a wheelchair near the television with a hearing aid in the left ear and a hearing aid noted outside the right ear and attached to a clip. Resident #25 stated he normally took out the hearing aids when sleeping or he didn't want to hear all the noise, but he did use them throughout the day. An observation was conducted on 7/01/25 at 1:58 pm of Resident #25. Resident #25 was noted to be sleeping with his hearing aids in the charging station on the bedside table. An interview was conducted with the MDS Nurse on 7/02/25 at 10:35 am who revealed she did not recall Resident #25 with hearing aids when she completed the hearing section of the MDS assessment. The MDS Nurse stated she was not aware Resident #25 used hearing aids. An interview was conducted on 7/02/25 at 11:05 am with Nurse Aide (NA) #1 who revealed he was assigned to Resident #25 on the days he worked and knew the resident well. NA #1 stated Resident #25 had hearing aids that he used and was able to put them in and take them out as he liked. NA #1 stated Resident #25 was hard of hearing, and he had the hearing aids for as long as he could remember. During an interview on 7/02/25 at 11:55 am with the Administrator she revealed the MDS Nurse was responsible to ensure Resident #25's assessment was coded accurately.

Based on observations, record review, and resident and staff interviews, the facility failed to develop a person-centered care plan in the areas of use of side rails for positioning (Resident #45), and hearing loss with use of a hearing aid (Resident #25) for 2 of 21 residents whose care plans were reviewed. The findings included: 1. Resident #45 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease. The Side Rail Use assessment dated [DATE] revealed Resident #45 requested side rails related to weakness to assist with turning, repositioning, and transfers. Resident #45 was noted to have 1/4 side rails to the upper bed bilaterally (both sides) while in bed. Review of Resident #45's care plan reviewed and updated on 5/08/25 revealed no care plan for the use of side rails for positioning. Observations were conducted on 6/30/25 at 10:50 am, 7/01/25 at 12:35 pm, and 7/02/25 at 9:03 am and Resident #45 was observed to be in bed with side rails to the upper portion of the bed bilaterally. An interview was conducted with the MDS Nurse on 7/02/25 at 10:44 am who revealed she was responsible for the development of resident care plans. The MDS Nurse stated she was new to the facility and did not recall if she was notified of Resident #45's use of side rails. The MDS Nurse stated Resident #45's use of side rails should have had a care plan in place but she did not recall if there was a care plan in place in the past. During an interview on 7/02/25 at 11:13 am with the Director of Nursing (DON) who revealed the MDS Nurse was responsible for resident care plans. The DON stated resident care plans were reviewed during care plan meetings and Resident 45 should have had a care plan in place for the use of side rails. An interview was conducted with the Administrator on 7/02/25 at 11:55 am. The Administrator revealed the MDS Nurse was responsible to review and develop resident comprehensive care plans. The Administrator stated the MDS Nurse was responsible to develop Resident #45's care plan for the use of side rails. 2. Resident #25 was admitted to the facility on [DATE] with diagnoses which included dementia with other behavioral disturbances. The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #25 was cognitively intact, was coded for adequate hearing without the use of a hearing aid. Resident #25's care plan last reviewed on 6/22/25 revealed no care plan for hearing loss or use of hearing aids. An observation and interview with Resident #25 was conducted on 6/30/25 at 10:48 am. Resident #25 was observed sitting in a wheelchair near the television with a hearing aid in the left ear and a hearing aid noted outside the right ear and attached to a clip. Resident #25 stated he normally took out the hearing aids when sleeping or he didn't want to hear all the noise, but he did use them throughout the day. An observation was conducted on 7/01/25 at 1:58 pm of Resident #25. Resident #25 was noted to be sleeping with his hearing aids in the charging station on the bedside table. An observation was conducted on 7/02/25 at 11:30 am of Resident #25 who was observed sitting in his room with both hearing aids in place watching television. An interview was conducted with the MDS Nurse on 7/02/25 at 10:35 am who revealed she did not recall Resident #25 with hearing aids when she completed the hearing section of the MDS assessment. The MDS Nurse stated she was not aware Resident #25 used hearing aids and she did not develop a care plan for the use of hearing aids or hearing impairment. An interview was conducted with the Director of Nursing (DON) on 7/02/25 at 11:13 am with the Director of Nursing (DON) who revealed the MDS Nurse was responsible to ensure Resident #25's care plan was developed for hearing loss and use of hearing aids. During an interview on 7/02/25 at 11:55 am with the Administrator she revealed the MDS Nurse was responsible to ensure Resident #25 had a care plan in place for the use of hearing aids.

Based on observations, record review, and staff interviews, the facility failed to revise the care plan in the areas of pain management, hypertension management, and anticoagulant (blood thinner) medication use (Resident # 18) and the use of a wander/elopement alarm (Resident #45) for 2 of 21 residents whose care plans were reviewed. The findings include: 1. Resident #18 was readmitted to the facility on [DATE] with diagnoses which included end stage renal disease (ESRD) with dependence on hemodialysis (HD), hypertension (HTN), and diabetes. Resident #18's physician orders revealed the following: - 9/10/24 Roxicodone oral tablet 5 milligrams (mg), give 1 tablet by mouth every 4 hours as needed for pain - 1/10/25 Amlodipine Besylate tablet 10 mg, give 1 tablet by mouth at bedtime for HTN - 6/6/25 Eliquis oral tablet 2.5 mg, give 1 tablet by mouth two times a day for Pulmonary Embolism (blockage of a lung artery) Review of Resident #18's care plan reviewed and updated on 5/8/25 revealed no care plan for the use of pain, hypertensive, and anticoagulant medications. An interview was conducted with the Minimum Data Set (MDS) Nurse on 7/01/25 at 1:40 PM. She revealed that she began working at the facility in April 2025. She explained she was responsible for updating the nursing sections of resident care plans and gave examples of problems that would be added to the revised care plan: wounds, new pain, falls, HTN medication, anticoagulant medication, etc. The MDS Nurse stated that she received information for care plan updates from the daily clinical meetings. She confirmed that Resident #18's care plan was missing the topics for pain, HTN, and anticoagulant medications. These medications for Resident #18 should have been discussed in the daily clinical meeting. The pain and HTN medications were ordered prior to her start date in April of this year, so she was not involved when those medications were initiated. However, the anticoagulant medication was added on 6/6/25, but she could not recall if the new medication was discussed in the daily clinical meeting. During an interview with the Director of Nursing (DON) on 7/02/25 at 9:44 AM, she revealed that the MDS Nurse was responsible for updating the nursing section of the care plan, and updates were discussed in the daily morning meeting. She stated that the anticoagulant medication should have been entered into the care plan when it was ordered on 6/6/25. However, the HTN and pain medications should have been added when Resident #18 was readmitted . The Administrator was interviewed on 7/02/25 at 10:00 AM. She revealed that the care plan for Resident #18 should have included the pain, HTN, and anticoagulant medications ordered by the physician. She indicated that all new initiated medications were discussed in the daily clinical meeting. The Administrator stated that she could not speak to why the pain and HTN medications were an issue because she started with the company on 3/27/25. However, the MDS Nurse told her that she missed the anticoagulant medication ordered for Resident #18 on 6/6/25 by mistake. The Administrator stated that the staff turnover in the nursing department could have also influenced communication. 2. Resident #45 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease. Resident #45 had a physician order dated 3/05/24 for wander guard, check daily and ensure functioning properly every day, every shift for wandering. The wander guard order was discontinued on 4/16/25. The Minimum Data Set (MDS) quarterly assessment dated [DATE] completed by the MDS Nurse revealed Resident #45 had severe cognitive impairment and was not coded for the use of a wander/elopement alarm. The care plan last reviewed on 5/08/25 revealed Resident #45 was an elopement risk/wanderer related to exit seeking behavior with an intervention which included a wander guard to the left ankle. An observation of Resident #45 was conducted on 6/30/25 at 2:28 pm and no wander guard alarm was observed on Resident #45's ankles or wrists. An interview was conducted on 7/02/25 at 10:44 am with the MDS Nurse who revealed she completed the MDS assessment section related to the wander/elopement alarm and that Resident #45 did not have a wander guard in place when she completed the MDS assessment. The MDS Nurse stated she did review and revise Resident #45's care plan quarterly but she must have missed the care plan for the wander guard when the review was completed. The MDS Nurse stated she should have revised Resident #45's care plan to reflect the wander guard was no longer in use. During an interview on 7/02/25 at 11:13 am with the Director of Nursing (DON) she revealed Resident #45 no longer required a wander guard and the MDS Nurse was responsible to review and revise Resident #45's care plan to accurately reflect his care needs. An interview was conducted with the Administrator on 7/02/25 at 11:55 am who revealed the MDS Nurse should have revised Resident #45's care plan when last reviewed and the wander guard was no longer ordered.

Based on record review and staff interviews, the facility failed to notify the Ombudsman in writing of a resident transfer to the hospital for 2 of 2 residents reviewed for hospitalization (Resident #25 and Resident #57). The findings included: 1.a. Resident #25 was admitted to the facility on [DATE]. The nursing progress note dated 8/19/24 revealed Resident #25 was transferred to the hospital for further evaluation of chest pain and difficulty breathing. The medical record indicated Resident #25 was discharged from the facility on 8/19/24 and returned to the facility on 9/06/24. The facility was unable to provide documentation regarding notification to the Ombudsman of Resident #25's transfer to the hospital. b. The nursing progress note dated 9/13/24 revealed Resident #25 was transferred to the hospital for further evaluation of altered mental status and low blood pressure. The medical record indicated Resident #25 was discharged from the facility on 9/13/24 and returned to the facility on 9/18/24. The facility was unable to provide documentation regarding notification to the Ombudsman of Resident #25's transfer to the hospital. c. The nursing progress note dated 11/22/24 revealed Resident #25 was transferred to the hospital for further evaluation of shortness of breath. The medical record indicated Resident #25 was discharged from the facility on 11/22/24 and returned to the facility on [DATE]. The facility was unable to provide documentation regarding notification to the Ombudsman of Resident #25's transfer to the hospital. Attempts to conduct a telephone interview with the previous Social Worker on 7/01/25 at 12:25 pm and 7/02/25 at 11:34 am were unsuccessful. An attempt to conduct a telephone interview with the Ombudsman on 7/01/25 at 1:10 pm was unsuccessful. An interview was conducted with the Administrator on 7/01/25 at 11:40 am who revealed she was unable to locate the previous Social Worker's documentation regarding notification to the Ombudsman for Resident #25's hospitalizations because she believed the previous Social Worker took items when she left the facility. 2. Resident #57 was admitted to the facility on [DATE]. The nursing progress note dated 5/21/25 revealed Resident #57 was transferred to the hospital for further evaluation of abnormal laboratory results. The medical record indicated Resident #57 was discharged from the facility on 5/21/25 and returned to the facility on 6/02/25. An interview was conducted with the Social Worker on 7/01/25 at 1:00 pm who revealed she was unable to locate the Ombudsman notification for Resident #57's transfer to the hospital on 5/21/25. The Social Worker stated she normally emailed the list to the Ombudsman but she was unable to find any record that information was sent to the Ombudsman for the May 2025 discharges and transfers. The Social Worker stated she must have just let it slip by without sending it to the Ombudsman. An attempt to conduct a telephone interview with the Ombudsman on 7/01/25 at 1:10 pm was unsuccessful. During an interview with the Administrator on 7/01/25 at 11:40 am she stated the facility was unable to locate any documentation that the Social Worker notified the Ombudsman of Resident #57's transfer to the hospital. The Administrator stated the Social Worker was responsible to submit the information to the Ombudsman as required.

Based on staff interviews and record review the facility failed to perform a Significant Change in Status Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed for hospice care (Resident #38). Findings included: Resident #38 was admitted to the facility on [DATE] with diagnoses that included hypertension and dementia. Review of Resident #38's medical records revealed she was receiving hospice services prior to admission to the facility and continued to receive services upon admission. Review of a Centers for Medicare and Medicaid Services (CMS) Notice of Medicare Non-Coverage (NOMNC, form 10123) dated 12/21/23 revealed Resident #38's hospice services were ending on 12/23/23. Review of Resident #38's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she received hospice services during the lookback period. Resident #38's quarterly MDS assessment dated [DATE] revealed she did not receive hospice services during the lookback period. Review of Resident 38's MDS assessments revealed a significant change assessment had not been completed when Resident #38 had been discharged from hospice services. During an interview conducted with the MDS Coordinator on 6/5/24 at 2:40 PM she stated during December she had just begun working in the facility and was not aware Resident #38's significant change assessment was not done during the transition. An interview was conducted with the Administrator on 6/6/24 at 11:10 AM who stated MDS assessments should be done within the required time frames. He further stated the MDS Coordinator was transitioning to the facility during December, and the failure to complete a significant change assessment when Resident #38 stopped receiving hospice services was an oversight.

Based on record review, observations and staff interviews, the facility failed to obtain a physician order for the use of supplemental oxygen and apply signage indicating the use of oxygen outside the resident's room for 1 of 3 residents reviewed for oxygen use (Resident #152). The findings included: Resident #152 was readmitted to the facility on [DATE] with diagnoses including congestive heart failure, and chronic respiratory failure. The care plan dated 3/27/24 indicated Resident #152 was using oxygen as indicated. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #152 was severely cognitively impaired and the use of oxygen. Nursing documentation dated 5/30/24 recorded Resident #152 on return to the facility 10:25 pm was on oxygen at 2 liters per minute via nasal cannula. Further nursing documentation dated 5/31/24 at 11:00 pm revealed Resident #152 receiving oxygen via nasal cannula at 2 liters per minute. There was no physician's order for the use of oxygen in Resident #152's medical record. On 6/4/24 at 3:13 pm, there was no signage outside Resident #152's room indicating the use of oxygen. Resident #152 was observed wearing oxygen via nasal cannula at 3 liters per minute. On 6/5/24 at 3:28 pm in an interview with Nurse #1, she explained she did not recognize there was no Oxygen in use, no smoking signage outside his door. She stated an Oxygen in use, no smoking signage should have been placed outside Resident #152's door when he was admitted or when nursing staff recognized signage was not outside the door. On 6/4/24 at 3:34 pm in an interview with Nurse Unit Manager, she explained she did not recognize there was not a Oxygen in use, no smoking signage out Resident #152's door. She stated an Oxygen in use, no smoking signage should have been placed outside Resident #152's door when he was admitted or when nursing staff recognized signage was not outside the door. After reviewing Resident#152's orders, Nurse Unit Manager stated there was no order for the use of 2 liters per minute of oxygen for Resident #152 in the physician's orders. She explained any nurse could enter a physician order for the use of oxygen and stated she did not know why there was not an order in Resident #262's electronic medical record (EMR) for the use of oxygen. On 6/5/24 at 8:35 a.m. in an interview with the Director of Nursing, she stated nursing should have called the physician for Resident #152 when he returned from the hospital for an order for the use of oxygen. The nursing staff should have entered an order for the use of oxygen into the EMR for Resident #152. She indicated the nursing staff could administer up to 2 liters per minute of oxygen when residents were in distress but usually called the physician for an order when oxygen was needed. She explained the nursing staff was responsible to ensure an Oxygen in use, no smoking sign was outside Resident #152's door due to oxygen in use.

Based on record review and staff interviews, the facility failed to document providing education of the influenza vaccine (2023-2024 season) and pneumococcal vaccine and the resident's or resident representative's refusal to receive the influenza vaccine (2023-2024 season) and pneumococcal vaccine for 2 of 6 residents reviewed for immunizations (Resident #41 and Resident #152). Findings included: 1. a. Resident #41 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #41 was severely impaired cognitively. There was no documentation in the electronic medical record (EMR) Resident #41 had received the influenza vaccine (2023-2024 season). The EMR for Resident #41 reported no past history of Resident #41 receiving a pneumococcal vaccine. The facility was unable to provide written documentation Resident #41 or Resident #41's Representative had received education for the influenza vaccine (2023-2024 season) and pneumococcal vaccine to consent for administration or refusal of administration of the influenza vaccine (2023-2024 season) and the pneumococcal vaccine. b. Resident #152 was admitted to the facility on [DATE]. A review of Resident #152's electronic medical record (EMR) reported on 5/20/2021refusal for the influenza and pneumococcal vaccines. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #152 was severely impaired cognitively. There was no documentation in the EMR Resident #152 had received the influenza vaccine (2023-2024 season). The EMR for Resident #152 reported no past history of Resident #152 receiving a pneumococcal vaccine. The facility was unable to provide written documentation Resident #152 or Resident #152's Representative had received education for the influenza vaccine (2023-2024 season) and pneumococcal vaccine to consent for administration or refusal of administration of the influenza vaccine (2023-2024 season) and pneumococcal vaccine. On 6/6/2024 at 1:01 p.m. in an interview with the Director of Nursing (who was also acting as the Infection Preventionist), she stated she started at the facility on 11/30/2023. She explained the annual influenza vaccine (2023-2024 season) was offered and administered to all residents or resident representatives prior to her employment at the facility. She stated in May 2024 she offered the pneumococcal vaccine to the all residents or resident representatives. She stated the facility obtained a written consent for a vaccine when a vaccine was to be administered and if Resident #41 and Resident #152 or their Representatives refused the vaccines, she did not have documentation. She explained when the residents or resident representatives were asked if they wanted to receive the influenza vaccine (2023-2024 season) and pneumococcal vaccine, the facility was not obtaining a written consent that stated education was provided on the vaccines, and the resident or resident representative refused the administration of the influenza vaccine (2023-2024 season) and pneumococcal vaccine.

Based on record review and staff interviews, the facility failed to document providing education of the COVID (2023-2024 season) vaccine and the resident's or resident representative's refusal to receive the COVID (2023-2024 formula) vaccine for 2 of 6 residents reviewed for immunizations (Resident #41 and Resident #152). Findings included: 1. a. Resident #41 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #41 was severely impaired cognitively. There was no documentation in the electronic medical record (EMR) Resident #41 had received education for the COVID (2023-2024 formula) vaccine. The facility was unable to provide written documentation Resident #41 or Resident #41's Representative had received education for the COVID (2023-2024 formula) vaccine to consent for administration or refusal of administration of the COVID (2023-2024 formula) vaccine. b. Resident #152 was admitted to the facility on [DATE]. A review of Resident #152's electronic medical record (EMR) reported on 1/4/2023 refusal for the COVID vaccine. There was no documentation that Resident #152 or Resident #152's Representative was provided education to consent or refuse the COVID (2023-2024 formula) vaccine. There was no documentation in the EMR Resident #152 had received the COVID vaccine (2023-2024 formula). The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #152 was severely impaired cognitively. The facility was unable to provide written documentation Resident #152 or Resident #152's Representative had received education for the COVID (2023-2024 formula) vaccine to consent for administration or refusal of administration of the COVID (2023-2024 formula) vaccine. On 6/6/2024 at 1:01 p.m. in an interview with the Director of Nursing (who was also acting as the Infection Preventionist), she stated she started at the facility on 11/30/2023. She explained the COVID (2023-2024 formula) vaccine was offered and administered to all residents or resident representatives prior to her employment at the facility. She explained when the residents or resident representatives were asked if they wanted to receive the COVID (2023-2024 formula) vaccine, the facility was not obtaining a written consent that stated education was provided on the vaccines, and the resident or resident representative refused the administration of the COVID (2023-2024 formula) vaccine.

Based on record review, resident interview and staff interviews, the facility failed to provide written notice of transfer/discharge to the resident and to the ombudsman for the resident who was transferred from the facility to the hospital for 1 of 2 residents reviewed for hospitalization (Resident #29). Findings included: Resident #29 was admitted to the facility on [DATE]. Resident #29 was discharged from the facility and admitted to the hospital on 12/14/2023. Resident #29 returned to the facility on [DATE]. A review of Resident #29's electronic medical record (EMR) revealed no written notice of transfer/discharge for Resident #29 related to the hospitalization on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #29 was cognitively intact. On 6/6/2024 at 7:12 a.m. in an interview with Resident #29, she stated she had not received a written letter notifying her of the reason she was discharged from the facility to the hospital on 12/14/2023. On 6/6/2024 at 9:43 a.m. in an interview with the Clinical Nurse Consultant, she stated she was unable to locate a written notice of transfer/discharge for Resident #29 in the EMR related to Resident #29's transfer from the facility to the hospital on 12/14/2023. She explained in February 2024 she identified the facility was not issuing a written notice of transfer/discharge to the resident or resident representatives when residents were transferred/discharged from the facility. On 6/6/2024 at 10:00 a.m. in an interview with the Social Worker, she explained she had not worked in long term care prior to July 2023 when she began employment with the facility. She stated in December 2023 she had not notified the ombudsman of residents' transfers and discharges from the facility, and the ombudsman was not notified of Resident #29's transfer/discharge on 12/14/2023. She explained she started sending monthly notifications, except for 30-day discharge notifications, to the ombudsman of all resident transfers and discharges in February 2024 upon learning of the required notification process. On 6/6/2024 at 10:23 a.m. in an interview with the Director of Nursing (who started at the facility on 11/29/2023), she stated in December 2023 the facility had not provided residents or resident representatives a written notice of transfer/discharge and was not able to explain why the facility had not provided the notification. She explained upon learning in February 2024 the facility needed to provide residents or resident representatives and the ombudsman with a written notice of transfer/discharge when residents transferred or discharged from the facility, the nursing staff were educated on the process. On 6/6/2024 at 10:10 a.m. in an interview with the Administrator, he said Resident #29 and the ombudsman did not receive written notification for the reason of Resident #29's transfer/discharge on 12/14/2023 because an issue with residents or resident representatives and the ombudsman not receiving the written notice of transfer/discharge was not identified until February 2024.

Based on record review, resident interview and staff interviews, the facility failed to provide the bed hold policy in writing at the time of transfer to 1 of 2 residents reviewed for discharged to the hospital (Resident #29). This practice had the potential to impact other residents. Findings included: Resident #29 was admitted to the facility on [DATE]. Resident #29 was discharged from the facility and admitted to the hospital on 12/14/2023. Nursing documentation on 12/14/2023 at 4:28 a.m. recorded Resident #29 requested to go to the hospital due to feeling weak. The physician and Resident #29's Representative were notified, and Resident #29 was sent to the hospital for an evaluation. There was no documentation in Resident #29's electronic medical record (EMR) that the bed hold policy was provided to Resident #29 on 12/14/2023 when she was transferred and admitted to the hospital. Resident #29 returned to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #29 was cognitively intact. On 6/6/2024 at 7:12 a.m. in an interview with Resident #29, she stated she did not recall receiving a bed hold policy from the facility on 12/14/2023 when she was transferred to the hospital. On 6/6/2024 at 9:43 a.m. in an interview with the Clinical Nurse Consultant, she stated she was unable to locate in Resident #29's EMR documentation Resident #29 was issued the bed hold policy on 12/14/2023 when transferred from the facility to the hospital. She explained in February 2024 it was identified the facility was not issuing the bed hold policy to residents or resident representatives when residents were transferred from the facility. On 6/6/2024 at 10:23 a.m. in an interview with the Director of Nursing (who started at the facility on 11/29/2023), she stated in December 2023 the facility was not issuing residents or resident representatives the bed hold policy when transferred from the facility. She stated she was not able to explain why the facility was not issuing the bed hold policy. She explained when the facility was informed in February 2024 of the need to provide residents or resident representatives with the bed hold policy when transferred from the facility, the nursing staff were educated on issuing the bed hold policy when transferring residents out of the facility. On 6/6/2024 at 10:10 a.m. in an interview with the Administrator, he said Resident #29 was not issued the bed hold policy when transferred from the facility on 12/14/2024. He explained the facility was not aware there was an issue with residents or resident representatives not receiving the bed hold policy when transferring from the facility until February 2024.

Based on observation, record reviews and interviews with residents, staff, dialysis center nurse, and Emergency Medical Services staff, the facility failed to ensure Transportation Assistant #1, who was also a facility Nurse Aide, was trained by staff who was aware of the facility's transportation van's manufacturer's instructions for safe securement when Nurse Aide #1 provided her with training. Nurse Aide #1 was not aware that transporting a resident in a geriatric chair (a padded chair with a wheeled based) was not in accordance with the transportation van's manufacturer's instructions. In addition, the facility failed to verify Transportation Assistant #1's competency to ensure resident safety during transportation for 1 of 1 staff who transported residents in the facility's transportation van. On 11/1/23 Transportation Assistant #1 utilized a geriatric wheelchair (geri chair) to transport Resident #1 and during transportation the resident slid out of the chair onto the floor of the van. Resident #1 was not injured. On 11/27/23 Transportation Assistant #1 did not buckle Resident #2's seatbelt and during transportation the resident fell out of the wheelchair and onto the floor of the van. Resident #2 reported pain in her right shoulder the following day. This deficient practice had a high likelihood of resulting in serious harm, injury, or death to residents who were transported in the facility's transportation van. Immediate jeopardy began on 11/1/23 when Transportation Assistant #1 failed to demonstrate competency when she transported Resident #1 in a geriatric chair that was not in accordance with the manufacturer's instructions and the resident fell out of the chair. The immediate jeopardy was removed on 12/22/23 when the facility provided an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to supervision to prevent accidents. The findings included: This tag is cross-referenced to: F689: Based on observation, record review, interviews with residents, staff, dialysis center nurse, and Emergency Medical Services staff, the facility failed to provide safe transportation in the facility's transportation van and to ensure wheelchairs were utilized during transportation in accordance with manufacturer's instructions for 2 of 4 residents reviewed for accidents (Resident #1 and Resident #2). On 11/1/23 Transportation Assistant #1 utilized a geriatric chair (a padded chair with a wheeled base) to transport Resident #1 and during transportation the resident slid out of the chair onto the floor of the van. Resident #1 was not injured. On 11/27/23 Transportation Assistant #1 did not buckle Resident #2's seatbelt and during transportation the resident fell out of the wheelchair and onto the floor of the van. Resident #2 reported pain in her right shoulder the following day. These incidents had the high likelihood of serious harm, injury or death. Review of a form dated 9/8/23 entitled Transportation Aide Major Duties and Responsibilities Checklist revealed one of the major duties was operating the facility's transport van in a safe manner and securing residents prior to operating. This form further indicated Transportation Assistant #1 had completed training and demonstrated competence in all areas. The form was signed by NA #1. An interview was conducted with NA #1 on 12/19/23 at 11:55 AM who reported she trained Transportation Assistant #1 on how to operate the lift and restraint system on the facility's transportation van prior to Transportation Assistant #1 providing transportation to residents. She explained she had worked for the facility for [AGE] years and had driven the van in the past prior to becoming a medication aide. NA #1 further explained that the former transportation assistant quit suddenly. She indicated Transportation Assistant #1 was an NA at the facility and she was asked to move to the position of transportation driver. She stated that the Maintenance Director was on leave at the time of these changes. She reported that because she (NA #1) was most familiar with the van she trained Transportation Assistant #1. She stated she had Transportation Assistant #1 demonstrate how to operate the lift and restraint system prior to Transportation Assistant #1's first assigned transport. Review of an Emergency Medical Services report dated 11/1/23 revealed Transportation Aide #1 informed the Emergency Medical Services staff when they arrived that she was just a [nurse aide] and did not know how anything about how this transport van works, indicating that she has never received proper training for the job that she is performing. During an interview with Emergency Medical Services staff #1 (EMS #1) on 12/19/23 at 1:10 PM he stated he reported to the scene of the accident on 11/1/23 and observed that Resident #1 was being transported in a geri chair (geri chair #2). He stated Transportation Aide #1 informed him that she had not been trained or oriented to use the facility's transportation van. During an interview with NA #1 on 12/19/23 at 11:55 AM she revealed she had not known that transporting a resident in a geri chair was not in accordance with the facility's transportation van's manufacturer's instructions. An interview was conducted with Transportation Assistant #1 on 12/19/23 at 1:18 PM who indicated she was an NA and had worked in that role at the facility prior to providing transportation. She explained that the previous transportation assistant quit suddenly and she was asked to provide transportation. Transportation Assistant #1 stated Nurse Aide #1 showed her how to secure a wheelchair on the transportation van. She indicated that was the extent of her training. She reported she began providing transportation for the facility on 9/8/23. She stated she was unaware geri chair #1 was not allowed to be used for transporting residents in the facility's transportation van until she was told by Emergency Services staff #1 after Resident #1 fell from geri chair #1. She stated she thought it was acceptable to use geri chair #2. She reported her retraining on 11/3/23 consisted of reading the policy and initialing each page. The policy did not mention geri chairs. Transportation Assistant #1 stated she forgot to secure Resident #2's seat belt on 11/27/23 which resulted in her falling out of her wheelchair on 11/27/23. An interview was conducted with the Maintenance Director on 12/19/23 at 11:40 AM. He indicated he supervised the transportation staff. He stated when Transportation Assistant #1 began work in September 2023 he was out of the office and she was trained by NA #1. The Maintenance Director explained NA #1 was responsible for training in his absence because she provided transportation prior to becoming a medication aide in the facility. The Maintenance Director reported that he was on leave on 11/1/23 when Resident #1 fell out of his geri chair in the facility's transportation van. He wasn't involved with any investigation and was not involved with retraining Transportation Assistant #1. He stated the only strategy the facility used to train transportation assistants was verbal instruction with hands-on demonstration. A form entitled Resident Transportation Policy dated 11/3/23 revealed Transportation Assistant #1's initials on each page with her dated signature. The form provided no indication if Transportation Aide #1 was provided with re-training on the facility's transportation van's manufacturer's instructions for safe securement or if her competencies were verified. During an interview with the Administrator on 12/19/23 at 3:00 PM he stated Transportation Assistant #1 was trained by NA #1 prior to transporting residents. He further stated he retrained Transportation Assistant #1 on 11/3/23 after the van incident in which Resident #1 fell out of his wheelchair. The retraining included a review of the facility policy which Transportation Assistant signed. There was no demonstration of competencies by Transportation Assistant #1. The Administrator revealed that when he was informed by EMS staff that geri chair #1 was not supposed to be used for transportation that he had not realized this meant all geri chairs. He explained that he thought this instruction was specific to geri chair #1. He indicated that when he provided retraining to Transportation Assistant #1 he did not inform her that geri chairs were not to be used for transporting residents in the facility's transportation van. The Administrator stated that after the 2nd van incident occurred on 11/27/23, where Resident #2 fell out of her wheelchair because she was not secured, Transportation Assistant #1 was terminated. On 12/19/23 at 4:15 PM, the facility's Administrator was informed of the immediate jeopardy. The facility provided the following corrective action plan with a completion date of 12/22/23. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. When transporting Residents #1 and #2 to appointments outside the facility, Transportation Assistant (TA) #1 failed to safely secure their wheelchairs in the facility transportation vehicle. On 11/1/23, TA #1 applied the brakes on the transport van as a car came out in front of it, causing Resident #1 to slide out of his geri- chair which was not a standard wheelchair and onto the van's floor. On 11/27/2023, while being transported to a doctor's visit, Resident #2 fell out of her wheelchair onto the van's floor. Resident #2 seatbelt was not fastened by TA #1. The facility failed to ensure TA #1 was properly train and competent in transportation safety prior to providing transportation to residents. Residents #1 and #2 were identified to be affected by the deficient practice. All residents who are transported in the facility van were identified to potentially be affected by the deficient practice. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 11/27/23 TA #1 was suspended pending investigation for violating the safety policy. She was terminated on 12/4/23. The current transportation aide has reviewed the facility's policy on transportation and completed an in-service on 12/21/23 regarding the safety and securement of all residents being transported in the facility transportation van, with a return demonstration observed by the Maintenance Director. The facility will utilize wheelchairs in place of geri-chairs when transporting residents or use a medical transportation company when needed. The transportation aide will be responsible for ensuring residents are transferred to a proper chair prior to transporting in the facility van. The transportation aide was educated on ensuring residents are transferred to proper chairs for transportation and that geri-chairs are not proper chairs on 12/21/2023 by the Maintenance Director. Beginning 12/21/23 all transport aides will receive safety training upon hire and annually. The training will be conducted by the Maintenance Director and will include a return demonstration of competency. This training will involve a review of the transportation policy, an in-service regarding the safety and security of residents being transported in the facility transportation van, and supervision as needed. Date of immediate jeopardy removal: 12/22/23 Onsite validation of the immediate jeopardy removal plan was completed on 12/28/23. Interviews verified on 11/27/23 TA #1 was suspended pending investigation, and she was terminated on 12/4/23. The facility has 1 current transportation aide, TA #2. Inservice records and interview confirmed TA #2 reviewed the facility's policy on transportation and completed an in-service regarding the safety and securement of all residents being transported in the facility transportation van, with a return demonstration observed by the Maintenance Director. An observation verified the current transportation assistant secured a wheelchair according to manufacturer's instructions. TA #2 reported she was educated on ensuring residents are transferred to proper chairs for transportation, that geri-chairs are not proper chairs, and that she is responsible for ensuring residents were transferred to proper chairs in accordance with the manufacturer's instructions prior to transporting a resident. The Maintenance Director stated he is responsible for safety training with verification of competency on hire and annually for any transportation aide. The immediate jeopardy removal date of 12/22/23 was validated.

Based on observation, record review, interviews with residents, staff, dialysis center nurse, and Emergency Medical Services staff, pharmacist and physician, the facility failed to provide effective leadership and oversight to ensure systems and processes were in place as evidenced by numerous deficient practices in multiple regulatory groupings resulting in immediate jeopardy and substandard quality of care. These high severity deficiencies were in the areas of physician notification, management of change in condition, safe transportation of residents, competent nursing staff, routine and emergency medication availability, accessibility and administration. Residents #1 and #2 were not transported in the van safely using transport chairs and fastening seat belts. Resident #3 did not receive his seizure medication as ordered and experienced seizure activity. These incidents had the high likelihood of serious harm, injury, or death. These deficient practices affected three of 46 residents residing in the facility and had a high likelihood of affecting other facility residents. Immediate jeopardy began on 11/1/23 when a lack of leadership and oversight in the area of safe transportation of Resident #1 resulted in the resident falling out of the chair during transport. The immediate jeopardy was removed on 12/23/23 when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. The findings included: This tag is cross-referenced to: a) F580: Based on record review and interviews with staff and physician, the facility failed to notify the physician of a medical emergency when Resident # 3 had seizure activity. Resident #3 had four incidents of seizure activity between 12/4/23 and 12/5/23. Emergency Medical Services (EMS) was contacted and the resident was transported to the emergency room (ER) where Vimpat (anti-seizure medication) was administered. The resident had no further seizure activity after receiving Vimpat and was discharged back to the facility the same day. This occurred for 1 of 3 residents (Resident #3) reviewed for notification of change. b) F684: Based on record review and interviews with staff, Emergency Medical Services (EMS) personnel, pharmacist, and physician, the facility failed to identify the seriousness of seizure activity on 12/4/23 and the need for medical intervention for a resident with a history of seizures who had not been provided with his anti-seizure medication (Vimpat) since 11/25/23. Resident #3 had four incidents of seizure activity between 12/4/23 and 12/5/23. Following the fourth seizure (12/5/23) the physician ordered Ativan (an antianxiety medication commonly used as a rescue medication for seizures) via intramuscular (IM) injection and the facility staff were unable to access the emergency Ativan medication supply to treat the resident in the facility. Emergency Medical Services (EMS) was contacted, and the resident was transported to the emergency room (ER) and Resident #3 experienced a fifth seizure upon arrival in the emergency room (ER). Intravenous (IV) Vimpat was administered in the ER and the resident had no further seizure activity and was discharged back to the facility the same day. This occurred for 1 of 2 residents whose condition required Emergency Medical Services. c) F 689: Based on observation, record review, interviews with residents, staff, dialysis center nurse, and Emergency Medical Services staff, the facility failed to provide safe transportation in the facility's transportation van and to ensure wheelchairs were utilized during transportation in accordance with manufacturer's instructions for 2 of 4 residents reviewed for accidents (Resident #1 and Resident #2). On 11/1/23 Transportation Assistant #1 utilized a geriatric wheelchair (a reclining chair with wheels) to transport Resident #1 and during transportation the resident slid out of the chair onto the floor of the van. Resident #1 was not injured. On 11/27/23 Transportation Assistant #1 did not buckle Resident #2's seatbelt and during transportation the resident fell out of the wheelchair and onto the floor of the van. Resident #2 reported pain in her right shoulder the following day. These incidents had the high likelihood of serious harm, injury or death. d) F 726: Based on observation, record reviews and interviews with residents, staff, dialysis center nurse, and Emergency Medical Services staff, the facility failed to ensure Transportation Assistant #1, who was also a facility Nurse Aide, was trained by staff who was aware of the facility's transportation van's manufacturer's instructions for safe securement when Nurse Aide #1 provided her with training. Nurse Aide #1 was not aware that transporting a resident in a geriatric chair (a padded chair with a wheeled based) was not in accordance with the transportation van's manufacturer's instructions. In addition, the facility failed to verify Transportation Assistant #1's competency to ensure resident safety during transportation for 1 of 1 staff who transported residents in the facility's transportation van. On 11/1/23 Transportation Assistant #1 utilized a geriatric wheelchair (geri chair) to transport Resident #1 and during transportation the resident slid out of the chair onto the floor of the van. Resident #1 was not injured. On 11/27/23 Transportation Assistant #1 did not buckle Resident #2's seatbelt and during transportation the resident fell out of the wheelchair and onto the floor of the van. Resident #2 reported pain in her right shoulder the following day. This deficient practice had a high likelihood of resulting in serious harm, injury, or death to residents who were transported in the facility's transportation van. e) F755: Based on record review and interviews with staff, pharmacist, and physician, the facility failed to obtain an anti-seizure medication for a resident with a history of seizures resulting in 22 missed doses of the medication and to have staff capable of accessing the emergency medication supply to treat a medical emergency. Resident #3 was ordered Vimpat two times a day for seizures and from 11/25/23 through 12/5/23 the resident did not receive the medication as it was not obtained from the pharmacy. Resident #3 had four incidents of seizure activity between 12/4/23 and 12/5/23. Following the fourth seizure (12/5/23) the physician ordered Ativan (an antianxiety medication commonly used as a rescue medication for seizures) via intramuscular (IM) injection and the facility staff were unable to access the emergency medication supply. EMS was contacted and the resident was transported to the emergency room (ER) where Vimpat was administered. The resident had no further seizure activity after receiving Vimpat and was discharged back to the facility the same day. Upon return from the ER the resident was not administered Vimpat until the evening dose on 12/6/23 as the medication had still not been obtained from the pharmacy. This deficient practice was for 1 of 1 resident reviewed for pharmaceutical services. f) F760: Based on record review and interviews with staff, Emergency Medical Services (EMS) personnel, pharmacist, and physician interviews, the facility failed to administer an anticonvulsant medication to a resident for a period of 10 and half consecutive days and doses (11/25/23 through 12/5/23). Resident #3 had four incidents of seizure activity between 12/4/23 and 12/5/23. EMS was contacted on 12/5/23 and the resident was transported to the emergency room (ER) where Vimpat was administered. The resident had no further seizure activity after receiving Vimpat and was discharged back to the facility the same day. Upon return to the facility the resident missed one additional dose of the anticonvulsant on 12/6/23 for a total of 22 missed doses. This occurred for 1 of 1 resident (Resident #3) whose medications were reviewed. An interview was conducted on 12/20/23 at 12:55 pm with the Administrator. The Administrator reported that nurses should notify the facility pharmacist when they were out of medication and notify the physician so he could sign the prescription in a timely manner. The Administrator stated he was unaware that geri chairs were not to be used in facility transportation vans. He stated the Maintenance Director did not train Transportation Aide #1. He stated at the time of the issue with the availability of Resident #3's Vimpat they were in transition with a new pharmacy and the Director of Nursing (DON) was new. He stated most of the staff were from agencies and these agency staff failed to notify management the medication was not available. He indicated they had inconsistent communication with agency nurses. An interview was conducted with the Chief Operations Officer (COO) on 12/28/23 at 1:00 PM. She stated she was working with the Administrator and DON to ensure effective systems are put in place. The COO stated she was working with the pharmacy to correct the procedure to ensure medications were delivered on time. The Administrator was notified of immediate jeopardy on 12/20/23 at 1:40 PM. The facility provided the following immediate jeopardy removal plan with a removal date of 12/23/23. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The facility failed to provide effective leadership and oversight to ensure effective systems and processes were in place to manage change in condition, physician notification, to ensure routine and emergency medications were available, accessible, and administered as ordered, and ensure safe transportation of residents. Residents #1 and #2 were not properly secured while being transported in the van causing them to slide from their chairs onto the floor. Resident #3 did not receive his seizure medication as ordered and facility failed to immediately notify the physician or seek emergency care for the resident when he had seizure activity. Residents #1, #2, and #3 were identified as affected by the deficient practice. All residents have the potential to be affected by the deficient practice. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 12/21/23 The Chief Operations Officer reviewed policies and educated the Administrator on oversight of facility transportation including educating and monitoring drivers, safety procedures, and following manufacturers recommendation for transporting residents. On 12/21/23 The Chief Operations Officer reviewed policies and educated the Administrator and Director of Nursing (DON) on oversight of nursing staff administering medications, pharmacy processes for reordering and accessing emergency medications, identifying resident's emergency needs, reporting events through chain of command, and notifying physicians. On 12/21/23 The Chief Director of Operations reviewed policies and educated the Administrator on the requirements of F835. This education included the expectations of oversight and completion of all education and staff monitoring. This education also includes the Administrator's responsibility to maintain safe transportation and provide quality care based on the facility's quality of care policy and daily monitoring to ensure adherence to required supervision. On 12/21/23 The Chief Operations Officer reviewed policies and educated the Administrator and DON regarding reviewing the 24- hour report daily and discussing issues that need addressed through proper morning meeting communication. Ensuring all members of the facility administration team are following through with their job duties in reference to resident care and safety. The Chief Operations Officer will conduct daily calls as well as weekly on-site meetings with the facility Administrator and DON to ensure compliance with all practice standards discussed and that plan of correction is being followed. Alleged date of immediate jeopardy removal: 12/23/23 Onsite validation of the immediate jeopardy removal plan was conducted on 12/28/23. Inservice records and interviews confirmed education was completed as indicated and covered preventing medication errors including missed medications, the significant risks to residents and the consequences for not notifying the physician and DON of medications not administered so further instructions can be given to reduce the risk to residents' health per facility policy and procedure. An observation was conducted of Transportation Assistant #2 securing a resident in the facility's transportation van according to manufacturer's recommendations. The DON and Administrator were participating in weekly meetings and daily calls with the Chief Operations Office for general oversight and monitoring to ensure the plan of correction is being followed. The immediate jeopardy removal date of 12/23/23 was verified.

Based on record review and interviews with staff, pharmacist, and physician, the facility failed to obtain an anti-seizure medication for a resident with a history of seizures resulting in 22 missed doses of the medication and to have staff capable of accessing the emergency medication supply to treat a medical emergency. Resident #3 was ordered Vimpat two times a day for seizures and from 11/25/23 through 12/5/23 the resident did not receive the medication as it was not obtained from the pharmacy. Resident #3 had four incidents of seizure activity between 12/4/23 and 12/5/23. Following the fourth seizure (12/5/23) the physician ordered Ativan (an antianxiety medication commonly used as a rescue medication for seizures) via intramuscular (IM) injection and the facility staff were unable to access the emergency medication supply. EMS was contacted and the resident was transported to the emergency room (ER) where Vimpat was administered. The resident had no further seizure activity after receiving Vimpat and was discharged back to the facility the same day. Upon return from the ER the resident was not administered Vimpat until the evening dose on 12/6/23 as the medication had still not been obtained from the pharmacy. This deficient practice was for 1 of 3 residents reviewed for pharmaceutical services. Immediate Jeopardy began on 11/25/23 when the facility failed to have Vimpat available for administration for a resident with a history of seizures. The immediate jeopardy was removed on 12/22/23 when the facility provided an acceptable credible allegation for immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of a E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and that monitoring systems put into place are effective. The findings included: Resident #3 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included traumatic subdural hemorrhage, seizure disorder/epilepsy, traumatic brain injury, and gastrostomy status (a tube surgically placed into the stomach). A physician order for Resident #3 dated 9/25/23 indicated valproic acid (anticonvulsant) oral solution give 10 milliliters (ml) via G-tube three times a day related to epilepsy. A physician order for Resident #3 dated 10/15/23 indicated Vimpat oral solution 10/milligrams (mg)/ml give 25 ml via G-tube two times a day for seizures. Give 250 mg/25ml two times a day. Review of the significant change Minimum Data Set, dated dated dated [DATE] identified the resident as having moderately impaired cognition. The MDS coded the resident as having seizure disorder/epilepsy and for gastrostomy (G-tube) status. Resident #3's physician order summary for November 2023 indicated the orders for valproic acid and Vimpat remained as active orders. The Medication Administration Record (MAR) and progress notes revealed the following information for Resident #3: - 11/25/23: The MAR indicated no doses of Vimpat were administered and a nurse's note written by Nurse #6 revealed Vimpat was on order. - 11/26/23: The MAR indicated no doses of Vimpat were administered and a nurse's note written by Nurse #6 revealed Vimpat was on order. - 11/27/23: The MAR indicated no doses of Vimpat were administered and a nurse's note written by Nurse #1 revealed Vimpat was out of stock and a prescription had been signed by the provider. - 11/28/23: The MAR indicated no doses of Vimpat were administered and a nurse's note written by Nurse #2 stated, Waiting on pharmacy. - 11/29/23: The MAR indicated no doses of Vimpat were administered and a nurse's note written by Nurse #2 stated, Coming from pharmacy. - 11/30/23: The MAR indicated no doses of Vimpat were administered and a nurse's note written by Nurse #8 revealed the medication was not available. - 12/1/23: The MAR indicated no doses of Vimpat were administered and a nurse's note written by Nurse #3 indicated the medication was not available. - 12/2/23: The MAR indicated no doses of Vimpat were administered and a nurse's note written by Nurse #5 indicated the medication was not available. - 12/3/23: The MAR indicated no doses of Vimpat were administered and a nurse's note written by Nurse #5 indicated the medication was not available. - 12/4/23: The MAR indicated no doses of Vimpat were administered and a nurse's note written by Nurse #2 stated, On order. - 12/5/23: The MAR indicated the morning dose of Vimpat was not administered and a nurse's note written by Nurse #1 stated, Out of stock. [Director of Nursing] and provider notified. An interview was conducted on 12/20/23 at 10:12 am with staff Nurse #4 who stated she gave Resident #3 his last dose of Vimpat on 3rd shift 11/24/23. She stated she did not call the physician as the hard prescription had been faxed to the physician before the medication ran out. On 12/19/23 at 1:21 pm the DON stated she had copies of the Vimpat prescriptions that were sent to the pharmacy. As of the survey exit date on 12/28/23 the information had not been provided. A telephone interview was conducted on 12/20/23 at 4:47 pm with agency Nurse #6. She stated that Resident #3 ran out of his prescription on 11/25/23, she called and faxed the physician to request a reorder on Resident #3's Vimpat. She revealed 11/26/23 was the last day she worked, and she was not aware Resident #3's Vimpat was not available. When asked what the process was for ordering refills of medication Nurse #6 reported for a controlled substance such as Vimpat, the nurse on the medication cart, would call or fax the physician before the medication ran out to sign a prescription reorder and he sent it to the pharmacy. An interview was conducted on 12/19/23 at 2:30 pm with agency Nurse #2 who had not administered the medication on 11/28/23, 11/29/23, and 12/4/23. Nurse #2 indicated Vimpat was a controlled substance, and they would need a signed prescription to reorder. She stated when the medication was not available, she called the pharmacy and was told the medication was coming on 11/29/23. She indicated when she called the pharmacy 11/29/23, she was told the medication was on its way. Agency Nurse #2 stated when the seizure medication had not arrived on 12/04/23 when she returned to work she notified the current DON and gave her a prescription to fax to the physician. When asked about the process for ordering refills of medication Nurse #2 revealed when in the building the doctor would sign the prescription and staff faxed it to the pharmacy. When the physician was not in the building the nurse needed a refill of a medication that was a controlled substance, the nurse would fax a refill prescription to the physician to sign and he faxed it to the pharmacy. An interview was conducted on 12/20/23 at 2:42 pm with agency Nurse #3 who on 12/01/23 documented the Vimpat as not available. Nurse #3 stated if they needed a signed prescription their procedure was to call the physician for a prescription refill and he sent the order to the pharmacy. She indicated she could not remember if she had called the pharmacy to see where the Vimpat was. A telephone interview was conducted on 12/20/23 at 2:35 pm with agency Nurse #5. Nurse #5 stated she called and left a message for the physician on 12/3/23 to order the seizure medication. She indicated she was not aware if the physician responded to her message. Nurse #5 indicated she did not remember if she contacted the pharmacy to find the Vimpat. Nurse #5 spoke about the process for obtaining medication refills and she indicated the nurse on the medication cart, would call or fax the physician for a signed prescription, and he would send it to the pharmacy. A nurse's note written by Nurse #2 dated 12/04/23 at 2:30 pm revealed that Resident #3 was seen this morning having seizure activity by staff during this shift. Nurse #2 indicated when she arrived at his room the resident was not showing seizure activity but wasn't answering questions like he would normally do. The note stated Nurse #2 and staff stayed by his side until resident was completely alert and responding like normal. Resident #3 was in stable condition and hadn't shown anymore seizure activity as of yet. An interview was conducted with Nurse #2 on 12/19/23 at 11:33 am who worked with Resident #3 on 12/04/23. She stated staff reported Resident #3 was having seizure activity and when she arrived to his room, she did not observe seizure activity. Nurse #2 stated she stayed with Resident #3 and continued to monitor him, to make sure he was alert and at his baseline on 12/04/23. A nurses' notes written by Nurse #1 dated 12/05/23 at 10:14 am revealed an aide bathed and shaved Resident #3 at approximately 8:18 am and the resident displayed seizure like activity for approximately 2 minutes or less in duration. The note indicated seizure activity was displayed again at 10:10 am while working with therapy. An interview was conducted with Rehabilitation Aide #1 on 12/19/23 at 10:09 am. Rehabilitation Aide #1 revealed that while bathing Resident #3 on 12/05/23 his arms drew tight up against his body for 10 seconds then ended. She indicated she reported the incident to the nurse (Nurse #1) who was agency staff. A nurse's note written by Nurse #1 dated 12/5/23 at 3:50 pm revealed resident sent out to hospital due to seizure activity. The note indicated Resident #3 had 3 episodes of seizure activity with the last event at 1:47 pm. An interview was conducted on 12/19/23 at 12:02 PM with Nurse #1. Nurse #1 stated on Friday 11/27/23 she texted Resident #3's physician a prescription requesting the Vimpat, for the physician to sign and fax over to the pharmacy for refill. Nurse #1 stated when she returned to work on Tuesday 12/05/23, the Vimpat was not on the medication cart. She reported the physician had been in earlier doing rounds and was aware Resident #3 had previous seizure activity that day and told staff to administer the Vimpat or Ativan. Nurse #1 indicated the DON began to search and found no Vimpat was in the facility. She indicated the emergency medication supply was stored in a secure medication dispensing machine and none of the staff, including the DON, had access to pull the Ativan. She stated on 12/05/23 at 1:47 PM, she observed Resident #3's contracted arm became stiff, he got still, for a minute and then he said he was okay. Nurse #1 stated as there was no Vimpat available, staff could not access the emergency medication supply for Ativan, she called EMS and the physician said to send the resident out to the ER. A physician note completed by the Medical Director dated 12/05/23 revealed Resident #3 had recurrent seizure activity on 12/05/23 with known history of seizure disorder. The resident was noted to recover in between the seizure episodes. He was at high risk for status epilepticus (a recurrent seizure activity without recovery between seizures) impending. He was currently on valproic acid plus Vimpat. The Medical Director indicated due to clinical condition he made the decision to transfer Resident #3 to the local emergency department for further definitive work up secondary to recurrent seizures since this morning. The Medical Director was interviewed on 12/19/23 at 1:58 PM and 2:16 PM. He indicated he could not recall the exact date, but he was told by staff that Resident #3 had seizure activity. He stated that due to the seizure activity he wanted to give the resident IM Ativan. He stated the facility staff could not get ahold of the Ativan so he sent Resident #3 out to the ER for evaluation. He stated he could not comment on the availability of Resident #3's Vimpat. The EMS Report dated 12/05/23 indicated dispatch received the call at 2:50 PM and they arrived at the facility at 2:57 PM. The nurse informed EMS Resident #3 was being sent out to the hospital per physician request due to the facility not having the resident's medication (Vimpat). When asked about the resident having seizures the nurse indicated Resident #3 had 3 seizures on this date (12/5/23) at these times: 8:18 AM, 10:10 AM and 1:47 PM. EMS departed the facility at 3:25 PM and arrived at the hospital at 3:56 PM. No seizure activity was noted during transport. While giving report to the hospital nurse Resident #3 was noted to start having a seizure. The hospital record dated 12/05/23 revealed Resident #3 presented on 12/05/23 for prior history of seizures, had three seizures on this date and had been out of Vimpat since Friday (11/24/23). He was noted as alert, verbally responsive but confused. The hospital report indicated he was treated with Vimpat 200 mg in sodium chloride 0.9 percent 50 mL via IV (intravenous), and no further seizure activity was noted. The record stated, Spoke with facility, reports medication has not been picked up from the pharmacy emphasized importance of [Resident #3] getting his medications as prescribed . Resident #3's diagnoses were listed as seizures, seizure disorder, and noncompliance with medication regimen. A nurse's note dated 12/05/23 at 9:52 pm revealed the resident returned from ER with no new orders. A nurse's note dated 12/6/23 at 7:48 am written by Nurse #1 indicated Vimpat was not administered for the morning dose due to it being out of stock. An interview was conducted on 12/20/23 at 10:16 AM with the facility's current DON who took the position on 11/27/23. The DON reported she was first made aware on 12/04/23 by Nurse #2 that Resident #3's Vimpat had not been available for administration and called the pharmacy that day. She revealed the pharmacy told her the medication was in the facility. When the medication was not found in the facility, she called the pharmacy back on 12/05/23 and was told it was found bagged up at the pharmacy. She stated the medication was delivered by the pharmacy the following day and the resident received his first dose as ordered on 12/06/23 in the evening. The DON could not explain why staff had not gone to the pharmacy to pick up Resident #3's Vimpat. The DON stated Resident #3 would have had his medication on 12/01/23 if the delivery driver had not hit a deer, the second driver could not find the facility and returned the medication to the pharmacy and they were never notified the medication was returned to the pharmacy. She stated when the physician ordered IM Ativan on 12/05/23, no staff in the facility had access to the emergency medication supply and could not access the Ativan. The DON revealed the facility had changed their pharmacy in October, gotten an emergency medication supply system from the pharmacy and staff had not received training on its use or had access. The DON indicated Resident #3's medical record revealed prior to the evening dose of Vimpat administered at the facility on 12/06/23, he had last received the medication at the facility on 11/24/23. A phone interview was conducted on 12/28/23 at 1:20 pm with the facility Pharmacist #1. She indicated Resident #3's MAR documented the Vimpat ran out on 11/25/23 and on 12/05/23 he was sent to the ER for seizure activity. The Pharmacist stated that abruptly stopping the Vimpat for 10 days Resident #3 would have the potential for seizures. She stated the first attempted delivery the pharmacy driver hit a deer and could not deliver the Vimpat, the second attempt to deliver the driver could not find the facility and returned the Vimpat to the pharmacy. An interview was conducted on 12/20/23 at 12:55 pm with the Administrator. He stated at the time of the issue with the availability of Resident #3's Vimpat they were in transition with a new pharmacy, the DON was new, and staff called the pharmacy, and were told the Vimpat was coming. The Administrator reported that nurses should notify the facility pharmacist when they were out of medication and notify the physician so he could sign the prescription in a timely manner. He stated he was not aware Resident #3 was out of his medication, most of the staff were from agencies and these agency staff failed to notify management the medication was not available. The Administrator indicated if medication did not arrive, staff should call the pharmacy to find out the status of the medication or call their back up pharmacy. The Administrator indicated he did not know why the medication would run out or why no one went to the pharmacy for the Vimpat. An interview was conducted on 12/20/23 4:33 pm with the DON who indicated staff should always call the physician when any resident was observed with seizure activity and notify the physician when any residents medications were not available. The Administrator was notified of immediate jeopardy on 12/20/23 at 1:40 PM. The facility provided the following immediate jeopardy removal plan: 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident #3 was identified as being affected by the noncompliance. Resident #3 had 4 incidents of seizure activity on the following approximate dates and times 12/4/23 at 2:30 PM, 12/5/23 at 8:18 AM, 12/5/23 at 10:10 AM, and 12/5/23 at 1:47 PM. The resident's Vimpat was not available within the facility and the nurses did not have access to remove medication from the emergency supply system. The physician indicated when he was first notified of the seizure activity on 12/5/23 he assessed the resident and wanted Ativan to be administered. He indicated there was no Ativan accessible for the resident, so he sent the resident to the ER. Resident #3's Vimpat was ordered on 12/4/23 and received from pharmacy 12/6/23. All other medication orders were reviewed, and medications were confirmed to be available on 12/4/23 by the DON. All other residents' medication orders were reviewed on 12/21/23 to ensure all medications were available. Any residents who had a medication with less than a week's supply available were reordered. This action was completed by the DON and MDS nurse. 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 nurses, including agency staff, were educated by the DON on accessing medication from the emergency dispensing system per facility policy and procedure on 12/21/23 no nurse will be permitted to work the medication cart prior to completing education. The Administrator, DON and Staffing Coordinator will ensure compliance. Newly hired licensed nurses, including agency staff, will be educated on accessing medications from the emergency dispensing system per facility policy and procedure, accordingly in orientation by Human Resources Director beginning 12/21/23. The Human Resources Director was notified of the change by the Administrator. The nurse or medication aide administering medications will receive education beginning 12/21/23 from the DON and pharmacy consultant on reordering medications observed to have less than a week supply available via the EMAR system. The DON obtained charge nurse access from the pharmacy to the emergency medication system on 12/20/23. The charge nurse access allows the DON to grant access to nurses working at the facility. The DON is actively granting access to the nurses for the emergency medication system. The DON will be available as needed to obtain emergency medications until there is at least one nurse per shift with access to the emergency medication system. The Chief Operating Officer conducted a conference call on 12/21/23 to discuss medication refill and emergency medication availability and access with the pharmacy director. The pharmacy will ensure that the emergency medication supply system is available and stocked. Replacement medications are automatically ordered through the inventory control system when removed and will be received on the next service day after being removed from the cabinet. New and refill orders are sent within 24 hours of receiving order unless order is written for stat dispensing. Pharmacy will provide additional monthly in-service education beginning 12/21/23 for the nurses and medication aides regarding medication administration, ordering, accessing emergency supply and all other services available. Alleged date of immediate jeopardy removal: 12/22/23 Onsite validation of the immediate jeopardy removal plan was conducted on 12/28/23. The audit of medication orders was verified as completed and any medications with less than a week's supply were reordered. Inservice records and interviews confirmed educated was completed as indicated. The education included: accessing medication from the emergency dispensing system per facility policy and procedure and reordering medications observed to have less than a week supply available. The DON received access from the pharmacy to the emergency medication system, was in the process of granting access to facility nurses and the DON was available as needed to obtain emergency medications until there was at least one nurse per shift with access to the emergency medication system. The Chief Operating Officer conference call with the pharmacy was confirmed to be completed. The HR Director confirmed she is responsible for ensuring all new staff are educated in orientation on accessing medications from the emergency dispensing system per facility policy and procedure. It was verified that the pharmacy is to provide additional monthly in-service education for the nurses and medication aides regarding medication administration, ordering, accessing emergency supply and all other services available. The immediate jeopardy removal date of 12/22/23 was verified.

Based on record review and interviews with staff, Emergency Medical Services (EMS) personnel, pharmacist, and physician interviews, the facility failed to administer an anticonvulsant medication to a resident for a period of 10 and half consecutive days and doses (11/25/23 through 12/5/23). Resident #3 had four incidents of seizure activity between 12/4/23 and 12/5/23. EMS was contacted on 12/5/23 and the resident was transported to the emergency room (ER) where Vimpat was administered. The resident had no further seizure activity after receiving Vimpat in the ER and was discharged back to the facility the same day. Upon return to the facility the resident was not administered one dose of the anticonvulsant on 12/6/23 for a total of 22 missed doses. This occurred for 1 of 3 residents (Resident #3) whose medications were reviewed. Immediate Jeopardy began on 11/25/23, when the facility failed to administer Resident #3's antiseizure medication. The immediate jeopardy was removed on 12/22/23 when the facility provided an acceptable credible allegation for immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of a E (a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and that monitoring systems put into place are effective. The findings included: Resident #3 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included traumatic subdural hemorrhage, seizure disorder/epilepsy, traumatic brain injury, gastrostomy status (a tube surgically placed into the stomach). Review of the significant change Minimum Data Set, dated dated dated [DATE] identified the resident as having moderately impaired cognition. The MDS coded the resident as having seizure disorder/epilepsy and for gastrostomy (G-tube) status. Resident #3's physician orders for November 2023 indicated an order initiated on 10/15/23 for Vimpat oral solution 10/milligrams (mg)/milliliters (ml) - give 25 ml via G-tube two times a day for seizures. Give 250 mg/25ml two times a day. A physician order dated 9/25/23 revealed an order for Valproic Acid oral solution give 10 ml via G-tube three times a day related to epilepsy. Resident #3's November 2023 electronic Medication Administration Record EMAR indicated the resident's last dose of Vimpat was administered on 11/24/23 at 8:00 pm. The EMAR also documented no doses of Vimpat were administered to Resident #3 from 11/25/23 through 11/30/23. Resident #3's December EMAR documented no doses of Vimpat were administered to Resident #3 from 12/01/23 through 12/06/23 with the first dose administered during 3rd shift on 12/06/23 at 8:00 pm. The Medication Administration Record (MAR) and progress notes revealed the following information for Resident #3: - 11/25/23: The MAR indicated no doses of Vimpat were administered and a nurse's note written by Nurse #6 revealed Vimpat was on order. - 11/26/23: The MAR indicated no doses of Vimpat were administered and a nurse's note written by Nurse #6 revealed Vimpat was on order. - 11/27/23: The MAR indicated no doses of Vimpat were administered and a nurse's note written by Nurse #1 revealed Vimpat was out of stock and a prescription had been signed by the provider. - 11/28/23: The MAR indicated no doses of Vimpat were administered and a nurse's note written by Nurse #2 stated, Waiting on pharmacy. - 11/29/23: The MAR indicated no doses of Vimpat were administered and a nurse's note written by Nurse #2 stated, Coming from pharmacy. - 11/30/23: The MAR indicated no doses of Vimpat were administered and a nurse's note written by Nurse #8 revealed the medication was not available. - 12/1/23: The MAR indicated no doses of Vimpat were administered and a nurse's note written by Nurse #3 indicated the medication was not available. - 12/2/23: The MAR indicated no doses of Vimpat were administered and a nurse's note written by Nurse #5 indicated the medication was not available. - 12/3/23: The MAR indicated no doses of Vimpat were administered and a nurse's note written by Nurse #5 indicated the medication was not available. - 12/4/23: The MAR indicated no doses of Vimpat were administered and a nurse's note written by Nurse #2 stated, On order. - 12/5/23: The MAR indicated the morning dose of Vimpat was not administered and a nurse's note written by Nurse #1 stated, Out of stock. [Director of Nursing] and provider notified. An interview was conducted on 12/20/23 at 10:12 am with staff Nurse #4 who stated she gave Resident #3 his last dose of Vimpat on 3rd shift 11/24/23. She stated she did not call the physician as the hard prescription had been faxed to the physician before the medication ran out. A telephone interview was conducted on 12/20/23 at 4:47 pm with agency Nurse #6. She stated that Resident #3 ran out of his prescription on 11/25/23, she called and faxed the physician to request a reorder on Resident #3's Vimpat. She revealed 11/26/23 was the last day she worked, and she was not aware Resident #3's Vimpat was not available. A nurse's note written by agency Nurse #2 dated 12/04/23 at 2:30 pm revealed that Resident #3 was seen this morning having seizure activity by staff during this shift. Nurse #2 indicated when she arrived at his room the resident was not showing seizure activity but wasn't answering questions like he would normally do. The note stated Nurse #2 and staff stayed by his side until resident was completely alert and responding like normal. Resident #3 was in stable condition and no further seizure activity was observed. An interview was conducted on 12/19/23 at 2:30 pm with agency Nurse #2 who had not administered the medication on 11/28/23, 11/29/23, and 12/4/23. Nurse #2 indicated Vimpat was a controlled substance, and they would need a signed prescription to reorder. She stated when the medication was not available, she called the pharmacy and was told the medication was coming on 11/29/23. She indicated when she called the pharmacy 11/29/23, she was told the medication was on its way. Agency Nurse #2 stated when the seizure medication had not arrived on 12/04/23 when she returned to work she notified the current Director of Nursing (DON) and gave her a prescription to fax to the physician. A nurse's note written by Nurse #1 on 12/05/23 at 10:14 am revealed resident resting in bed no signs or symptoms of pain, distress, or discomfort. Alert to person. Rehabilitation Aide #3 bathed and shaved resident at approximately 8:18 am. Resident displayed seizure like activity approximately 2 minutes or less in duration. And again at 10:10 am while working with therapy. DON notified. Will notify provider and family contact. An interview was conducted on 12/20/23 at 10:16 AM with the facility's current DON who took the position on 11/27/23. The DON reported she was first made aware on 12/04/23 by Nurse #2 that Resident #3's Vimpat had not been available for administration and called the pharmacy that day. She revealed the pharmacy told her the medication was in the facility. When the medication was not found in the facility, she called the pharmacy back on 12/05/23 and was told it was found bagged up at the pharmacy. She stated the medication was delivered by the pharmacy the following day and the resident received his first dose as ordered on 12/06/23 in the evening. The DON could not explain why staff had not gone to the pharmacy to pick up Resident #3's Vimpat. The DON indicated Resident #3's medical record revealed prior to the evening dose of Vimpat administered at the facility on 12/06/23, he had last received the medication at the facility on 11/24/23. An interview was conducted on 12/20/23 at 12:55 pm with the Administrator. He stated at the time of the issue with the availability of Resident #3's Vimpat they were in transition with a new pharmacy, the DON was new, and staff called the pharmacy, and were told the Vimpat was coming. The Administrator reported that nurses should notify the facility pharmacist when they were out of medication and notify the physician so he could sign the prescription in a timely manner. He stated he was not aware Resident #3 was out of his medication, most of the staff were from agencies and these agency staff failed to notify management the medication was not available. The Administrator indicated if medication did not arrive, staff should call the pharmacy to find out the status of the medication or call their back up pharmacy. The Administrator indicated he did not know why the medication would run out or why no one went to the pharmacy for the Vimpat. The Medical Director was interviewed on 12/19/23 at 1:58 PM and 2:16 PM. He indicated he could not recall the exact date, but he was told by staff that Resident #3 had seizure activity. He stated he could not comment on the availability of Resident #3's Vimpat. The EMS Report dated 12/05/23 indicated dispatch received the call at 2:50 pm for a resident with seizures and the EMS crew arrived at the facility at 2:57 pm and advised of Resident #3's room number. Resident #3 was found sitting up in bed and there was no nurse or medical staff available to give a report. The EMS crew had to request nursing staff to give them a report. The nurse informed EMS Resident #3 was being sent out to the hospital per physician request due to the facility not having the resident's medication (Vimpat). When asked about the resident having seizures the nurse indicated Resident #3 had 3 seizures on this date (12/5/23) at these times: 8:18 am, 10:10 am and 1:47 pm. EMS departed the facility at 3:25 pm and arrived at the hospital at 3:56 pm. No seizure activity was noted during transport. While giving a report to the hospital nurse, Resident #3 was noted to start having a seizure. A telephone interview was conducted on 12/19/23 at 12:48 pm with EMS #1. He indicated when he arrived to the resident's room there were no staff available to give report and he had to request nursing staff to give them a report. EMS #1 reported that Resident #3 was being sent out to the hospital per physician request due to the facility not having the resident's medication (Vimpat). EMS #1 stated he asked the nurse why Resident #3 went 4-5 days without his Vimpat and she could not answer, just said they did not have his Vimpat. The hospital record dated 12/05/23 revealed Resident #3 presented on 12/05/23 for prior history of seizures, had three seizures on this date and had been out of Vimpat since Friday (11/24/23). He was noted as alert, verbally responsive but confused. The hospital report indicated he was treated with Vimpat 200 mg via IV (intravenous), and no further seizure activity was noted. The record stated, Spoke with facility, reports medication has not been picked up from the pharmacy emphasized importance of [Resident #3] getting his medications as prescribed . Resident #3's diagnoses were listed as seizures, and seizure disorder. A phone interview was conducted on 12/28/23 at 1:20 pm with the facility Pharmacist #1. She indicated Resident #3's MAR documented the Vimpat ran out on 11/25/23 and on 12/05/23 he was sent to the ER for seizure activity. Pharmacist #1 stated that abruptly stopping the Vimpat for 10 days Resident #3 would have the potential for seizures. She stated the first attempted delivery the pharmacy driver hit a deer and could not deliver the Vimpat, the second attempt to deliver the driver could not find the facility and returned the Vimpat to the pharmacy. The Administrator was notified of immediate jeopardy on 12/20/23 at 1:40 PM. The facility provided the following immediate jeopardy removal plan: 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; Resident #3 was identified as being affected by the noncompliance. The facility failed to provide anti-seizure medication (Vimpat) ordered twice daily to Resident #3 from 11/25/23 through 12/5/23 resulting in 19 missed doses of the medication. Resident #3 experienced seizure activity on 12/4/23 and again on 12/5/23 the resident was transferred to the hospital and administered Vimpat in theER on [DATE] and no further seizure activity was noted. Upon return to facility, he did not receive his morning dose and was not administered Vimpat again until 12/6/23 in the evening. Resident #3's Vimpat was reordered on 12/4/23 and received on 12/6/23. All other medication orders were reviewed, and medications were available on 12/04/23 by the DON. All other residents' medication orders were reviewed on 12/21/23 to ensure all medications were available and being administered as ordered. Any residents who had a medication with less than a week's supply available were reordered. This action was completed by the DON and MDS nurse. 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 full-time, part-time, prn, and agency licensed nurses and medication aides were educated by the DON on preventing medication errors included missed medications, the significant risks to residents and the consequences for not notifying the physician and DON of medications not administered so further instructions can be given to reduce the risk to residents' health per facility policy and procedure beginning 12/21/23. No licensed nurse or medication aide will work until education has been completed. Nurses are to contact the DON and physician via phone immediately when resident medication errors occur or are anticipated to occur for further instructions. All newly hired and agency staff (licensed nurses and medication aides) will be educated on preventing medication errors including missed medications, the significant risks to residents and the consequences for not notifying the physician of medications not administered so further instructions can be given to reduce the risk to residents' health per facility policy and procedure, accordingly in orientation prior to working the floor. The DON and Human resources will ensure education is complete prior to allowing staff to work the medication cart. The regional nurse will conduct weekly meetings with the DON and Administrator to provide general oversight and monitoring of corrective actions. Alleged date of immediate jeopardy removal: 12/22/23 Onsite validation of the immediate jeopardy removal plan was conducted on 12/28/23. The audit of medication orders and medication administration was verified as completed and any medications with less than a week's supply were reordered. Inservice records and interviews confirmed educated was completed as indicated and covered preventing medication errors included missed medications, the significant risks to residents and the consequences for not notifying the physician and DON of medications not administered so further instructions can be given to reduce the risk to residents' health per facility policy and procedure. The DON and the Human Resources Director verified this education is now included in orientation and they are responsible for ensuring the education is completed prior to working on the floor. The DON and Administrator are participating in weekly meetings with the regional nurse for general oversight and monitoring. The immediate jeopardy removal date of 12/22/23 was verified.

Based on record review and interviews with staff, Emergency Medical Services (EMS) personnel, pharmacist, and physician, the facility failed to identify the seriousness of seizure activity on 12/4/23 and the need for medical intervention for a resident with a history of seizures who had not been provided with his anti-seizure medication (Vimpat) since 11/25/23. Resident #3 had four incidents of seizure activity between 12/4/23 and 12/5/23. Following the fourth seizure (12/5/23) the physician ordered Ativan (an antianxiety medication commonly used as a rescue medication for seizures) via intramuscular (IM) injection and the facility staff were unable to access the emergency Ativan medication supply to treat the resident in the facility. Emergency Medical Services (EMS) was contacted, and the resident was transported to the emergency room (ER) and Resident #3 experienced a fifth seizure upon arrival in the emergency room (ER). Intravenous (IV) Vimpat was administered in the ER and the resident had no further seizure activity and was discharged back to the facility the same day. This occurred for 1 of 2 residents whose condition required Emergency Medical Services. Immediate Jeopardy began on 12/04/23 when the facility failed to identify the seriousness of seizure activity for a resident with a history of seizures. The immediate jeopardy was removed on 12/22/23 when the facility provided an acceptable credible allegation for immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of a E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and that monitoring systems put into place are effective. The findings included: Resident #3 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included, traumatic subdural hemorrhage, seizure disorder/epilepsy, traumatic brain injury, gastrostomy status (a tube surgically placed into the stomach). Review of the significant change Minimum Data Set (MDS) dated [DATE] identified the resident as having moderately impaired cognition. The MDS coded the resident as having seizure disorder/epilepsy and for gastrostomy (G-tube) status. A nurse's note written by agency Nurse #2 dated 12/04/23 at 2:30 pm revealed that Resident #3 was seen this morning having seizure activity by staff during this shift. Nurse #2 indicated when she arrived at his room the resident was not showing seizure activity but wasn't answering questions like he would normally do. The note stated Nurse #2 and staff stayed by his side until the resident was completely alert and responding like normal. Resident #3 was in stable condition and no further seizure activity was observed. An interview was conducted with agency Nurse #2 on 12/19/23 at 11:33 am who worked with Resident #3 on 12/04/23 from 7:00 am to 3:00 pm. Nurse #2 stated she did not recall which nurse aide reported Resident #3 was having seizure activity and when she arrived in his room, she did not observe seizure activity. Nurse #2 stated she stayed with Resident #3 and continued to monitor him, to make sure he was alert and at his baseline on 12/04/23. An interview was conducted with Rehabilitation Aide #1 on 12/19/23 at 10:09 am. Rehabilitation Aide #1 revealed that while bathing Resident #3 on 12/05/23 his arms drew tight up against his body for 10 seconds then ended. She indicated she reported the incident to the nurse (Nurse #1) who was agency staff. A nurse's note written by Nurse #1 on 12/05/23 at 10:14 am revealed resident resting in bed no signs or symptoms of pain, distress, or discomfort. Alert to person. Rehabilitation Aide #1 bathed and shaved resident at approximately 8:18 am. Resident displayed seizure like activity approximately 2 minutes or less in duration. And again at 10:10 am while working with therapy. DON notified. Will notify provider and family contact. An interview was conducted on 12/19/23 at 12:02 pm with Nurse #1. Nurse #1 stated on Friday 11/27/23 she texted Resident #3's physician a prescription requesting the Vimpat, for the physician to sign and fax over to the pharmacy for refill. Nurse #1 stated when she returned to work on Tuesday 12/05/23, the Vimpat was not on the medication cart. She stated the physician was in the facility in the morning on 12/05/23 making his rounds and as she passed him in hall notified him of Resident #3's seizure activity. Nurse #3 indicated the physician then ordered Ativan be given to Resident #3. Nurse #1 indicated the DON began to search and found no Vimpat was in the facility. She indicated the emergency medication supply was stored in a secure medication dispensing machine and none of the staff, including the DON, had access to pull the Ativan. She stated on 12/05/23 at 1:47 pm, she observed Resident #3's contracted arm became stiff, he got still, for a minute and then he said he was okay. Nurse #1 stated as there was no Vimpat available, staff could not access the emergency medication supply for Ativan, she called EMS and the physician said to send the resident out to the ER. A progress noted entered by the Medical Director note dated 12/05/23 revealed Resident #3 had recurrent seizure activity on 12/05/23 with known history of seizure disorder. The resident was noted to recover in between the seizure episodes. He was at high risk for status epilepticus (a recurrent seizure activity without recovery between seizures) impending. He was currently on valproic acid (anticonvulsant used in the treatment of epilepsy) plus Vimpat. The Medical Director indicated due to clinical condition he made the decision to transfer Resident #3 to the local emergency department for further definitive work up secondary to recurrent seizures since this morning. Resident #3's Medical Director was interviewed on 12/19/23 at 1:58 pm and 2:16 pm. He indicated he could not recall the exact date, but he was told by staff that Resident #3 had seizure activity. He stated that due to the seizure activity he wanted to give the resident IM Ativan. He stated the facility staff could not get access to Ativan, so he sent Resident #3 out to the ER for evaluation. He stated he could not comment on the availability of Resident #3's Vimpat. The EMS Report dated 12/05/23 indicated dispatch received the call at 2:50 pm for a resident with seizures and the EMS crew arrived at the facility at 2:57 pm and advised of Resident #3's room number. Resident #3 was found sitting up in bed and there was no nurse or medical staff available to give a report. The EMS crew had to request nursing staff to give them a report. The nurse informed EMS Resident #3 was being sent out to the hospital per physician request due to the facility not having the resident's medication (Vimpat). When asked about the resident having seizures the nurse indicated Resident #3 had 3 seizures on this date (12/5/23) at these times: 8:18 am, 10:10 am, and 1:47 pm. EMS departed the facility at 3:25 pm and arrived at the hospital at 3:56 pm. No seizure activity was noted during transport. While giving a report to the hospital nurse, Resident #3 was noted to start having a seizure. A telephone interview was conducted on 12/19/23 at 12:48 pm with EMS Personnel #1. He indicated when he arrived in the resident's room there were no staff available to give report and he had to request nursing staff to give them a report. EMS #1 reported that Resident #3 was being sent out to the hospital per physician request due to the facility not having the resident's medication (Vimpat). EMS #1 stated he asked the nurse why Resident #3 went 4 to 5 days without his Vimpat, and she could not answer, just said they did not have his Vimpat. The hospital record dated 12/05/23 revealed Resident #3 presented on 12/05/23 for prior history of seizures, had three seizures on this date and had been out of Vimpat since Friday (11/24/23). He was noted as alert, verbally responsive but confused. The hospital report indicated he was treated with Vimpat 200 mg via IV (intravenous), and no further seizure activity was noted. The record stated, Spoke with facility, reports medication (Vimpat) has not been picked up from the pharmacy emphasized importance of [Resident #3] getting his medications as prescribed . Resident #3's diagnoses were listed as seizures, and seizure disorder. Review of the nurse's note dated 12/05/23 at 9:52 pm revealed Resident #3 returned from the hospital with no new orders. A phone interview was conducted on 12/28/23 at 1:20 pm with the facility Pharmacist #1. She indicated Resident #3's MAR documented the Vimpat ran out on 11/25/23 and on 12/05/23 he was sent to the ER for seizure activity. The Pharmacist stated that abruptly stopping the Vimpat for 10 days Resident #3 would have the potential for seizures. An interview was conducted on 12/20/23 at 10:16 am with the facility's current DON who took the position on 11/27/23. The DON reported she was first made aware on 12/04/23 by Nurse #2 that Resident #3's Vimpat had not been available for administration and called the pharmacy that day. She stated it was after lunch when the physician ordered IM Ativan on 12/05/23, no staff in the facility had access to the emergency medication supply and could not access the Ativan. The DON stated the physician saw Resident #3 on 12/05/23 and told staff if the resident continued to have seizures to send him out. An interview was conducted on 12/20/23 4:33 pm with the DON who indicated staff should always call the physician when any resident was observed with seizure activity and notify the physician when any residents medications were not available. The DON stated the nurses needed to make sure they have enough resident medication to last through the weekend. She indicated she was not aware if the nursing staff had called the physician to notify him the Vimpat was not available or if the physician had told the nurses to monitor Resident #3 and send out if any further seizure activity occurred. The Administrator was notified of immediate jeopardy on 12/20/23 at 1:47 pm. The facility provided the following immediate jeopardy removal plan: 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The facility failed to identify the seriousness of seizure activity on 12/4/23 and the need for medical intervention for a resident with a history of seizures who had not been provided with his anti-seizure medication (Vimpat) since 11/25/23. The facility did not have Vimpat available in the facility and did not have access to their emergency medication supply to treat the resident in the facility. EMS was not contacted until Resident #3 had his fourth incident of seizure activity. Resident #3 was identified as affected by the deficient practice. All residents were at risk from the deficient practice. Upon evaluation by the floor nurses and DON no other residents were identified as needing medical interventions on 12/20/23. 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. The DON removed the licensed nurses who were aware of the resident's seizure but did not seek further treatment interventions, from returning to the facility. Nurse #1 was removed 12/8/2023 and Nurse #2 was removed 12/20/23. All licensed nurses including agency staff were educated by the DON on identifying what is a medical emergency and the need to provide the necessary care and services for residents who require emergency medical services. Beginning 12/21/23 the Administrator, DON, and Staffing Coordinator will ensure no nurse is permitted to work prior to completing education. Education includes identifying changes in resident condition that indicate a medical emergency such as difficulty breathing, loss of consciousness, onset of seizures, injuries and other examples. Beginning 12/21/23 all newly hired licensed nurses, including agency staff, will be educated on what is a medical emergency and the need to provide the necessary care and services for residents who require emergency medical services as part of their orientation prior to working the floor. The Human Resources Director will ensure each nurse has completed and was informed of the task by the Administrator on 12/21/23. Alleged date of immediate jeopardy removal :12/22/23 Onsite validation of the immediate jeopardy removal plan was conducted on 12/28/23. The evaluations of all residents by the floor nurses and DON were verified and revealed no concerns. Nurse #1 and Nurse #2 were removed from the facility as indicated. In service records and interviews confirmed education was provided on: identifying what is a medical emergency and the need to provide the necessary care and services for residents who require emergency medical services. This education was added to orientation and the Human Resources Director is responsible for ensuring each nurse receives the education prior to working on the floor. The immediate jeopardy removal date of 12/22/23 was validated.

Based on observation, record review, interviews with residents, staff, dialysis center nurse, and Emergency Medical Services staff, the facility failed to provide safe transportation in the facility's transportation van and to ensure wheelchairs were utilized during transportation in accordance with manufacturer's instructions for 2 of 4 residents reviewed for accidents (Resident #1 and Resident #2). On 11/1/23 Transportation Assistant #1 utilized a geriatric chair (a padded chair with a wheeled base) to transport Resident #1 and during transportation the resident slid out of the chair onto the floor of the van. Resident #1 was not injured. On 11/27/23 Transportation Assistant #1 did not buckle Resident #2's seatbelt and during transportation the resident fell out of the wheelchair and onto the floor of the van. Resident #2 reported pain in her right shoulder the following day. These incidents had the high likelihood of serious harm, injury or death. Immediate jeopardy began on 11/1/23 when Transportation Assistant #1 transported Resident #1 in a geriatric chair (geri chair #1) that was not in accordance with the manufacturer's instructions and the resident fell out of the chair. The immediate jeopardy was removed on 12/22/23 when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. The findings included: 1. Review of the 4-point securement system's use and care manual (undated) found on the facility's transportation van's manufacturer's website included the following information: the system should only be used on front-facing wheelchair. Resident #1 was admitted to the facility on [DATE] with a diagnosis that included end stage renal disease. Resident #1's quarterly Minimum Data Set assessment dated [DATE] revealed he was cognitively intact. He was unable to walk and was assessed as dependent for transfers. Resident #1 utilized a wheelchair for mobility and received dialysis. A progress note dated 11/1/23 written by Nurse #14 revealed Transportation Assistant #1 called and reported a vehicle turned in front of the transport van and the transport aide had to press on the brakes. Resident #1 slid out of the geri chair. Emergency Medical Services were contacted. Resident #1 refused to be seen in the local emergency department. Attempts to interview Nurse #14 were not successful. Review of an Emergency Medical Services (EMS) report dated 11/1/23 revealed Resident #1 was found sitting on the floor of the facility's van. The resident had no complaints and requested assistance off the floor back into his chair. Resident #1 was being transported in a dialysis treatment chair (geri chair #1) that was not secured properly. The resident was sitting on top of three pillows and a mechanical lift pad during transport. According to the driver (Transportation Assistant #1) the resident was being transported in a reclined position. When this chair was in a reclined position there was no locking device to maintain that position. When the driver applied the van brakes the chair rocked forward from the reclined position to an upright position which caused the resident to be ejected from his chair onto the floor. The resident refused to be transported to the hospital by EMS. The EMS crew lifted the resident back into the chair and supplied extra retention straps to secure the chair into a reclined position and ensured the resident was secured with a lap belt. During an interview with Transportation Assistant #1 on 12/19/23 at 12:30 PM she reported on 11/1/23 she was transporting Resident #1 to a doctor's appointment with no other residents in the facility's transportation van. Transportation Assistant #1 reported Resident #1 was in a chair (geri chair #1) provided by the dialysis center. (Geri chair #1 was a clinical care recliner and had the capability to go into the Trendelenburg position [a position in which the resident's shoulder and legs can be reclined so his legs are above his head]). She indicated that when she secured Resident #1 into the van the seat belt was tight and the seat back of geri chair #1 was reclined. She stated that during transportation (11/1/23) another driver pulled out in front of her and she had to come to an abrupt stop and Resident #1 slid under his seat belt and slipped out of geri chair #1 onto the floor of the van seated on his butt. Transportation Assistant #1 explained the seat back of geri chair #1 did not stay in place when she hit the brakes of the van. She indicated it reclined further back than when she buckled him in. She pulled over and contacted 911. Transportation Assistant #1 stated she was unable to get him back in his chair. She stated she was informed at the scene by EMS staff that the chair used was not appropriate to use in the transportation van because it could not be secured in the van. She further stated the resident refused to go to the hospital and requested to proceed to his doctor's appointment. Transportation Assistant #1 stated EMS staff assisted in getting him back in the van and provided some additional straps to better secure the chair. She indicated after the incident the facility no longer transported Resident #1 in geri chair #1 and began to use one of the facility chairs (geri-chair #2). Geri chair #2 did not have the capability to go into the Trendelenburg position. An interview was conducted with Resident #1 on 12/19/23 at 1:00 PM who stated he recalled the accident on 11/1/23. He stated when Transportation Assistant #1 hit the brakes on the facility's transportation van he suddenly flew out from under the seat belt to the floor of the van. Resident #1 stated he refused to be transported to the hospital emergency department because he was not injured. He reported he was in a reclined dialysis treatment chair (geri chair #1) when the incident occurred. Resident #1 stated after the incident he no longer utilized the dialysis treatment chair for transportation, and was instead transported in a facility owned geriatric chair (geri chair #2). He stated he was transported to dialysis on 12/19/23 in a geriatric chair (geri chair #2). During a phone interview with Emergency Medical Services (EMS) Staff #1 on 12/19/23 at 1:10 PM he stated he reported to the scene of the accident on 11/1/23 and Resident #1 was sitting on the floor of the van. He indicated Resident #1 was transported in a dialysis treatment chair (geri chair #1). He stated the hooks of the van's restraint system were fastened on the side of the chair. EMS Staff #1 stated there was no restraint system in the van to prevent the chair from reclining. EMS Staff #1 stated Resident #1 was assessed and had no visible injuries. He stated Resident #1 was encouraged to go to the hospital, but the resident refused. EMS Staff #1 stated the Administrator came to the scene of the accident. He reported he informed Transport Aide #1 and the Administrator chairs other than wheelchairs were not compliant with the restraint system of the van. During an interview with the Administrator on 12/19/23 at 12:22 PM he reported on 11/1/23 Resident #1 slid out from under the seat belt when Transportation Assistant #1 hit the brakes on the van because the belt was not secure. He reported he responded to the scene of the accident and recalled being told by EMS Staff #1 that the geri chair #1 should not be used for transportation in the facility's van. He stated after the incident the facility began to utilize a facility geri chair (geri chair #2) rather than the dialysis treatment chair (geri chair #1). A phone interview was conducted with a Dialysis Center Nurse from Resident #1's dialysis center on 12/19/23 at 1:30 PM. The Dialysis Center Nurse indicated staff at the dialysis center had sent a dialysis treatment chair (geri chair #1) approximately one month prior to 11/1/23 with Resident #1 to minimize the number of transfers he needed while he was at dialysis. She reported to receive dialysis Resident #1 needed to be in a chair that would be able to be placed in the Trendelenburg position and a mechanical lift had to be used to transfer him from the facility's geri chair (geri chair #2) to the dialysis treatment chair (geri chair #1) as the facility's geri chair did not have the capability to be placed in the Trendelenburg position. Dialysis Center Nuse stated the resident had an open wound on his sacrum and Resident #1 complained about the discomfort associated with use of the mechanical lift. She reported that after the van accident (11/1/23) the facility began to send Resident #1 to dialysis in geri chair #2. The Dialysis Center Nurse stated she was told by the Administrator the dialysis treatment chair (geri chair #1) could not be utilized for transportation. An interview with Nurse Aide (NA) #1 was conducted on 12/19/23 at 11:55 AM who reported she received a phone call on 11/1/23 at approximately 1:30 PM from Transportation Assistant #1 who stated Resident #1 had fallen out of geri chair #1 in the van. She stated she was informed that Resident #1 slid out of his chair. NA #1 stated Resident #1 had been transported to dialysis for approximately one month prior to 11/1/23 in a dialysis treatment chair (geri chair #1). She indicated she was unsure of the difference between a dialysis treatment chair (geri chair #1) and the facility's geri chair (geri chair #2). A demonstration was observed on 12/19/23 at 2:15 PM of NA #1 attempting to secure a facility geri chair (geri chair #2) in the facility's transportation van. NA #1 provided back-up transportation for the facility. The primary transporter, Transportation Assistant #2, was unavailable. The Maintenance Director was present. She (NA #1) placed the hooks of the restraint system on the side of geri chair #2. The observation revealed there was no restraint system in the van to prevent the chair from reclining or to prevent the resident from slipping out if reclined. During a follow up interview with the Administrator on 12/19/23 at 3:00 PM he indicated he was aware the manufacturer's instruction stated the van should not be used with chairs other than wheelchairs. He indicated he believed transitioning from geri chair #1 to geri chair #2 after the 11/1/23 incident was sufficient. 2. Resident #2 was admitted to the facility on [DATE] for aftercare following joint replacement surgery. Resident #2's admission Minimum Data Set assessment dated [DATE] revealed she was cognitively intact. She was coded for using a wheelchair. A facility concern/comment report dated 11/27/23 revealed a family member expressed concern about an incident in the facility van. The findings of the investigation revealed the employee (Transportation Assistant #1) did not follow the policy in reporting the incident. The investigation was conducted by nursing, social services and the Administrator. The actions taken indicated to properly report an incident according to facility policy. The Administrator signed the form as complete. Review of progress notes from 11/27/23 through 12/8/23 revealed no mention of an incident involving Resident #2. Resident #2 was discharged from the facility on 12/8/23. During a phone interview with Transportation Assistant #1 on 12/19/23 at 12:30 PM she reported she was transporting Resident #2 and Resident #4 on 11/27/23. She reported someone pulled out in front of her and she came to an abrupt stop. Transportation Assistant #1 stated she may have not buckled Resident #2's seat belt. She stated the resident slid forward out of her wheelchair onto the floor of the van onto her buttocks. Transportation Assistant #1 stated she assisted Resident #2 back into her wheelchair, buckled the seat belt and continued to her (the resident's) doctor's appointment. She reported she contacted Nurse Aide #1 who instructed her to not report it to administrative staff if the residents didn't mention it. Transportation Assistant #1 stated the resident indicated she was fine and did not have any pain. An interview was conducted with Nurse Aide #1 (NA #1) on 12/19/23 at 11:55 AM who reported she received the phone call on 11/27/23 from Transport Assistant #1 who stated Resident #2 had slid out of her wheelchair. She stated she did not tell Transportation Assistant #1 not to report the incident. She indicated she did went to the Administrator to report the incident but he was already aware. She explained the family met the resident at the doctor's office, the resident informed them, and then the family notified the Administrator. A progress note by the Director of Nursing dated 11/28/23 revealed Resident #2's family member reported some concerns about shoulder pain. An x-ray was done, and the results were negative for fracture, separation and dislocation. Review of Resident #2's medical record found no pain medication was administered for her shoulder. An interview was conducted with the Director of Nursing on 12/19/23 at 12:20 PM who stated she was made aware of Resident #2's pain by a family member on 11/28/23 and contacted the Medical Director. A phone interview was conducted with Resident #2 on 12/19/23 at 10:29 AM. She reported on 11/28/23 Transportation Assistant #1 slammed on the brakes of the van and she slid under another resident's wheelchair [Resident #4]. She reported the wheelchair was fastened in the van, but her seat belt securing her into the wheelchair was not buckled. Resident #2 stated Transportation Assistant #1 assisted her back into her chair, buckled her in and they went to her doctor's appointment. Resident #2 reported she advised her family of the incident when she got to the doctor's office. She stated the next day she complained of shoulder pain. She stated she did not recall falling on her shoulder but the pain was new and she thought it was from the fall in the van. Resident #2 indicated pain medication was not necessary. She stated the pain resolved a few days later. Resident #2 stated x-rays were done and they did not find anything. During an interview with Resident #4, who appeared alert to person, place, time and situation, on 12/19/23 at 12:58 PM she stated she did not recall any incidents where someone fell out of their wheelchair while being transported. She added she did not have concerns about van transportation. Review of the investigation with an initiated date of 11/27/23 and completion date of 12/3/23 revealed Transportation Assistant #1 failed to properly secure the resident and did not contact the facility according to policy. She was terminated from employment. The investigation was completed by the Administrator. An interview was conducted with the Administrator on 12/19/23 at 12:22 PM who stated he was made aware of Resident #2 fell from her wheelchair when the concern came in from Resident #2's family member on 11/27/23. He stated the incident was investigated and Transportation Assistant #1 was terminated from employment for not reporting the incident and failing to properly secure the resident. On 12/19/23 at 4:15 PM, the Administrator was informed of the immediate jeopardy. The facility provided the following immediate jeopardy removal plan with a removal date of 12/22/23. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. When transporting Residents #1 and #2 to appointments outside the facility, Transportation Assistant (TA) #1 failed to safely secure their wheelchairs in the facility transportation vehicle. On 11/1/23, TA #1 applied the brakes on the transport van as a car came out in front of it, causing Resident #1 to slide out of his geri- chair which was not a standard wheelchair and onto the van's floor. On 11/27/2023, while being transported to a doctor's visit, Resident #2 fell out of her wheelchair onto the van's floor. Resident #2 seatbelt was not fastened by TA #1. Residents #1 and #2 were identified to be affected by the deficient practice. All residents who are transported in the facility van were identified to potentially be affected by the deficient practice. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 11/27/23 TA #1 was suspended pending investigation for violating the safety policy. She was terminated on 12/4/23. The current transportation aide has reviewed the facility's policy on transportation and completed an in-service on 12/21/23 regarding the safety and securement of all residents being transported in the facility transportation van, with a return demonstration observed by the Maintenance Director. The facility will utilize wheelchairs in place of geri-chairs when transporting residents or use a medical transportation company when needed. The transportation aide will be responsible for ensuring residents are transferred to a proper chair prior to transporting in the facility van. The transportation aide was educated on ensuring residents are transferred to proper chairs for transportation and that geri-chairs are not proper chairs on 12/21/2023 by the Maintenance Director. Beginning 12/21/23 all transport aides will receive safety training upon hire and annually. Training will be conducted by the Maintenance Director and will include a return demonstration of competency. This training will involve a review of the transportation policy, an in-service regarding the safety and securement of residents being transported in the facility transportation van, and supervision as needed. Date of immediate jeopardy removal: 12/22/23 Onsite validation of the immediate jeopardy removal plan was completed on 12/28/23. Interviews verified on 11/27/23 Transportation Assistant #1 was suspended pending investigation, and she was terminated on 12/4/23. Inservice records and interview confirmed Transportation Assistant #2 reviewed the facility's policy on transportation and completed an in-service regarding the safety and securement of all residents being transported in the facility transportation van, with a return demonstration observed by the Maintenance Director. In addition, Nurse Aide #1 who was a backup driver if needed for Transportation Assistant #2, received the same education and performed a return demonstration for the Maintenance Director. An observation verified the current transportation assistant (Transportation Assistant #2) secured a wheelchair according to manufacturer's instructions. Transportation Assistant #2 reported she was educated on ensuring residents are transferred to proper chairs for transportation, that geri-chairs are not proper chairs, and that she is responsible for ensuring residents were transferred to proper chairs in accordance with the manufacturer's instructions prior to transporting a resident. The Maintenance Director stated he is responsible for safety training with verification of competency on hire and annually for any transportation aide. The immediate jeopardy removal date of 12/22/23 was validated.

Based on record review and interviews with staff and physician, the facility failed to notify the physician of a medical emergency when Resident # 3 had seizure activity. Resident #3 had four incidents of seizure activity between 12/4/23 and 12/5/23. Emergency Medical Services (EMS) was contacted and the resident was transported to the emergency room (ER) where Vimpat (anti-seizure medication) was administered. The resident had no further seizure activity after receiving Vimpat and was discharged back to the facility the same day. This occurred for 1 of 3 residents (Resident #3) reviewed for notification of change. Immediate Jeopardy began on, 12/04/23, when the facility failed to notify the physician when Resident #3 had seizure activity. The immediate jeopardy was removed on 12/23/23 when the facility provided an acceptable credible allegation for immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of a D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and that monitoring systems put into place are effective. The findings included: Resident #3 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included traumatic subdural hemorrhage, seizure disorder/epilepsy, traumatic brain injury, and gastrostomy status (a tube surgically placed into the stomach). A nurse's note written by Nurse #2 dated 12/04/23 at 2:30 pm revealed that Resident #3 was seen this morning having seizure activity by staff during this shift. Nurse #2 indicated when she arrived to his room the resident was not showing seizure activity but wasn't answering questions like he would normally do. The note stated Nurse #2 and staff stayed by his side until resident was completely alert and responding like normal. Resident #3 was in stable condition and hadn't shown anymore seizure activity as of yet. There was no documentation in Resident'#3's medical record that the physician was notified of his seizure activity on 12/4/23. An interview was conducted with agency Nurse #2 on 12/19/23 at 11:33 am who worked with Resident #3 on 12/04/23. She stated staff reported Resident #3 was having seizure activity and when she arrived to his room, she did not observe seizure activity. Nurse #2 stated she and the Director of Nursing (DON) stayed with Resident #3 and continued to monitor him, to make sure he was alert and at his baseline on 12/04/23. A nurse's note written by Nurse #1 on 12/05/23 at 10:14 am revealed resident resting in bed no signs or symptoms of pain, distress, or discomfort. Alert to person. Rehabilitation Aide bathed and shaved resident at approximately 8:18 am. Resident displayed seizure like activity approximately 2 minutes or less in duration. And again at 10:10 am while working with therapy. DON notified. Will notify provider and family contact. An interview was conducted on 12/19/23 at 12:02 pm with Nurse #1. Nurse #1 stated the physician was in the facility making his rounds on 12/5/23 and as she passed him in hall notified him of Resident #3's seizure activity. She indicated he told staff to administer the Vimpat or Ativan. She stated on 12/05/23 at 1:47 pm, she observed Resident #3's contracted arm became stiff, he got still, for a minute and then he said he was okay. Nurse #1 indicated she first notified the DON on 12/05/23 Resident #3 had seizure activity and his Vimpat was not available. Nurse #1 indicated the physician ordered Ativan be given to Resident #3. She stated they could not administer Ativan as no staff had access to the emergency medication storage. Nurse #1 stated she called EMS and the physician said to send the resident out to the ER. A nurse's note written by Nurse #1 dated 12/5/23 at 3:50 pm revealed resident sent out to hospital due to seizure activity. The note indicated Resident #3 had 3 episodes of seizure activity with the last event at 1:47 pm. The Medical Director was interviewed on 12/19/23 at 1:58 pm and 2:16 pm. He indicated he could not recall the exact date, but he was told by staff that Resident #3 had seizure activity. He stated that due to the seizure activity he wanted to give the resident IM Ativan. He stated the facility staff could not get ahold of the Ativan so he sent Resident #3 out to the ER for evaluation. He stated he could not comment on the availability of Resident #3's Vimpat. The EMS Report dated 12/05/23 indicated dispatch received the call at 2:50 pm and they arrived at the facility at 2:57 pm. The nurse informed EMS Resident #3 was being sent out to the hospital per physician request due to the facility not having the resident's medication (Vimpat). When asked about the resident having seizures the nurse indicated Resident #3 had 3 seizures on this date (12/5/23) at these times: 8:18 am, 10:10 am, and 1:47 pm. EMS departed the facility at 3:25 pm and arrived at the hospital at 3:56 pm. No seizure activity was noted during transport. While giving report to the hospital nurse Resident #3 was noted to start having a seizure. The hospital record dated 12/05/23 revealed Resident #3 presented on 12/05/23 for prior history of seizures, had three seizures on this date and had been out of Vimpat since Friday (11/24/23). He was noted as alert, verbally responsive but confused. The hospital report indicated he was treated with Vimpat 200 mg in sodium chloride 0.9 percent 50 mL via IV (intravenous), and no further seizure activity was noted. The record stated, Spoke with facility, reports medication has not been picked up from the pharmacy emphasized importance of [Resident #3] getting his medications as prescribed . Resident #3's diagnoses were listed as seizures, seizure disorder, and noncompliance with medication regimen. An interview was conducted on 12/20/23 4:33 pm with the DON who indicated staff should always call the physician when any resident was observed with seizure activity and notify the physician. The Administrator was notified of immediate jeopardy on 12/20/23 at 5:21 pm. The facility provided the following immediate jeopardy removal plan: 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; Resident #3 was identified as being affected by the noncompliance. The facility failed to notify the physician when Resident #3 had seizure activity on 12/4/23 at approximately 2:30 PM and on 12/5/23 at approximately 8:18 AM. Resident #3 had 4 incidents of seizure activity on the following approximate dates and times -12/4/23 at 2:30 PM, 12/5/23 at 8:18 AM, 12/5/23 at 10:10 AM, and 12/5/23 at 1:47 PM. The physician indicated he was first notified of the seizure activity on 12/5/23. The DON notified the facility Medical Director of the incident on 12/5/23. The DON and Minimum Data Set (MDS) nurse evaluated all residents to identify any changes in condition. No additional residents were identified with a significant change in status on 12/21/23. The DON removed the licensed nurses who were aware of significant change, but did not report it to the physician, from returning to the facility. Nurse #1 was removed on 12/8/23 and Nurse #2 was removed on 12/20/23. 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 full-time, part-time, prn, and agency licensed nurses and medication aides were educated by the DON on change of condition and physician notification regulations per facility policy and procedure beginning 12/21/23. No licensed nurse or medication aide will work until education has been completed. Nurses are to contact physician via phone immediately when resident physical or mental condition is changed from baseline and additional interventions may be required. This includes abnormal behavior, vital signs, physical changes in movement or body function or consciousness such as lethargy or seizures. All full-time, part-time, prn, and agency nurse aides and medication aides were educated by the DON on reporting observed changes in residents' condition to licensed nurses beginning 12/22/23. No nurse aide will work until education has been received. All newly hired and agency staff (licensed nurses, nurse aides, and medication aides) will be educated on change of condition and physician notification regulations per facility policy and procedure, accordingly in orientation prior to working the floor. Human resources will ensure packet is complete. Alleged date of immediate jeopardy removal: 12/23/23 Onsite validation of the immediate jeopardy removal plan was conducted on 12/28/23. The physician was notified of the incident as indicated and the evaluations of all residents by the MDS Nurse and DON were verified and revealed no concerns. Nurse #1 and Nurse #2 were removed from the facility as indicated. In service records and interviews with licensed nurses and medication aides confirmed education was provided on changes of condition and physician notification regulations per facility policy and procedure. The procedure is for nurses to contact physician via phone immediately when resident physical or mental condition is changed from baseline and additional interventions may be required. Education was also confirmed for nurse aides and medication aides on reporting observed changes in residents' condition to licensed nurses. Education as noted was added to orientation and the Human Resources Director is responsible for ensuring the education is provided prior to working on the floor. The immediate jeopardy removal date of 12/23/23 was verified.

Based on observation, record review, resident interview and staff interview the facility Administration failed to provide oversight and leadership to ensure the facility was free from abuse and to prevent and protect 5 of 5 residents (Resident #26, #100, #43, #55 and #24) from being physically abused by Resident #2. Immediate jeopardy began on 8/2/21 when facility leadership did not implement effective interventions to maintain a safe abuse free environment for the residents resulting in Resident #2 punching Resident #26 in the face. Immediate Jeopardy was removed on 1/8/22 when the facility provided and implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level E (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to ensure that the education and monitoring of systems put in place to remove the Immediate Jeopardy are effective. The findings included: This tag is cross referenced to: F600: Based on observation, record review, resident interview, and staff interviews the facility neglected to protect the residents' right to be free from abuse when Resident #2 physically abused Residents #26, #100, #43, #55 and #24. The facility also failed to implement care plan intervention for one to one (1:1) supervision effectively for Resident #2. This was for 1 of 1 residents reviewed for resident to resident abuse. The Administrator was notified of Immediate Jeopardy on 1/5/22 at 1:46 PM. On 1/7/22 at 2:17 PM the facility provided the following credible allegation of Immediate Jeopardy removal. The credible allegation of immediate jeopardy removal indicated: Credible Allegation of Compliance for Immediate Jeopardy for F tag 835 for removal of Immediate Jeopardy completed on 1/8/22. 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The center's leadership/management team failed to provide continuous 1:1 supervision for Resident #2. The centers' leadership/management team failed to give clear concise direction to staff assigned to Resident #2 for providing 1:1 continuous supervision. All residents have the potential to be affected by the deficient practice. 2. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. The Staff Development Coordinator (SDC) in-serviced the License Nurses (LN) on 1/6/2022 to notify the MD for orders to send Resident #2 to the hospital for evaluation when resident aggressive behaviors cannot be managed. The Social Services Director and or Director of Nursing visited the alert and oriented residents on 1/7/22 to reassure them that Resident #2 has a one-to-one caregiver to always provide direct supervision. The direct care staff were in-serviced by the Staff Development Coordinator on 1/6/22 on how to properly conduct one-to-one monitoring of residents with an emphasis on never leaving the resident unattended and providing supervision during staff breaks. The Staff Development Coordinator and the Director of Nurses were in-service by the Administrator on 1/6/22 regarding the abuse policy with an emphasis on the different types of abuse, when to report the abuse, and who to report the suspected abuse. The Staff Development Coordinator in-serviced the direct caregivers on 1/6/22 and 1/7/22 regarding the abuse policy with an emphasis on steps to take to prevent resident to resident altercations, monitoring residents for aggressive/inappropriate behavior towards other residents, and strategies to take to deescalate the residents' aggressive behavior. A one-to-one time tracking tool was implemented on 1/7/22 that requires the staff to sign in and out documenting the assumption of resident observation and supervision for Resident #2. The direct caregivers will receive this education provided by the SDC or DON prior to their next scheduled shift. The direct care staff was in-serviced on 1/6/22 and 1/7/22 by the DON and/or SDC regarding how to properly conduct one-to-one monitoring of residents and completing the time tracking tool that will require the staff to sign in and out, to document and track the assumption of resident observation and supervision at all times. The licensed nurses were instructed/in-serviced on 1/6/22 and 1/7/22 by the SDC that the physician will be notified immediately for any resident that exhibits combative behavior. The management team, including the physician, met on 01/05/2022 to discuss the immediate jeopardies and the removal plan. The administrative staff has implemented the plan above. Leadership is enforcing compliance by ensuring that the one-to-one staff is supervising Resident #2 by having the licensed nurses provide oversight. The management team will also follow up with the residents to ensure that they feel safe. The facility alleges the removal of Immediate Jeopardy on 1/08/2022. The credible allegation of Immediate Jeopardy Removal was validated by onsite verification on 1/11/2022 as evidenced by interviews with licensed nurses, direct care and administrative staff, interviews with residents, and record review. An interview with licensed nurses was conducted on 1/11/2022 at 11:48 AM. They stated they had recently been to multiple in-services regarding abuse, managing behaviors, notifying the physician, law enforcement and family, and 1:1 monitoring in regard to Resident #2. The nurse responsible for Resident #2 stated he had not required hospitalization and had been visited by the psychologist earlier today. Resident rosters were observed with notations from either the Director of Nursing or the Social Worker indicating residents had been visited and reassured of the situation. On 1/11/2022 at 12:58 PM an interview with Residents #45, #21 and #63 was conducted. These residents were sitting together talking and watching the activity in the hall. They all stated the Director of Nursing and/or the Social Worker had been to visit with them recently to make sure everything was okay and if they had any concerns. Interviews with direct care staff revealed they had attended training regarding types of abuse, reporting, prevention of altercations, monitoring resident behaviors, 1:1 tracking tool, and notifications. In-service forms were reviewed and indicated the dates, topics discussed, and the trainer, and included attending staff signatures. No concerns were identified with these forms. The 1:1 tracking tool had been implemented on 1/7/2022. The tool was reviewed from implementation to the current day with no gaps in monitoring documentation observed. An interview with the Director of Nursing (DON) and the Administrator was conducted on 1/11/2022 at 2:00 PM. The DON sated she was the primary responsible person for monitoring the 1:1 tracking tool. The Administrator verified the management team including the physician had met on 1/05/2022 to discuss the Immediate Jeopardy removal plan. The facility's Immediate Jeopardy removal date of 1/08/2022 was validated.

Based on observation, record review, resident interview, and staff interviews the facility neglected to protect the residents' right to be free from abuse when Resident #2 physically abused Residents #26, #100, #43, #55, and #24. The facility also failed to implement care plan intervention for one to one (1:1) supervision effectively for Resident #2. This was for 1 of 1 resident reviewed for resident-to-resident abuse (Resident #2). Immediate jeopardy began on 8/2/21 when staff failed to implement effective interventions to protect residents from the physical abuse of Resident #2 resulting in Resident #2 punching Resident #26 in the face. Immediate Jeopardy was removed on 1/8/22 when the facility provided and implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level E (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to ensure that the education and monitoring of systems put in place to remove the Immediate Jeopardy are effective. The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Admission Minimum Data Set (MDS) dated [DATE] indicated Resident #2's cognition was severely impaired. Resident #2 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . He required supervision for locomotion on and off unit. Resident #2 received an antipsychotic medication and an antidepressant medication 7 of 7 days during the look back period. A review of a psychiatric note dated 6/2/21 revealed an initial psych visit which indicated that Resident #2 was in an unfamiliar environment and had other health issues that could be precipitating factors. The psychiatric visit was for mood and behavior. Resident #2 exhibited aggression towards staff by yelling, balling up his fist, and striking at staff. A care plan initiated 6/9/21 noted a behavior problem related to having altercation with another resident. The goal was for fewer episodes of behavior by review date. The interventions included: -Administer medications as ordered. Monitor and document side effects and effectiveness. -Anticipate and meet resident's needs. -Assist the resident to develop more appropriate methods of coping and interacting. - Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. -If resident is agitated, leave resident in a safe area, and return when resident calms down -Staff advised to take 2 staff members to give care to resident each time. Resident #2 was seen again on 6/16/21 by psych. The psychiatric note revealed that staff were to redirect resident and document aggressive behaviors. A care plan intervention dated 7/26/21 revealed an intervention to redirect resident to lay down on bed for rest when he gets tired. Review of an incident report completed by Nurse #7 dated 8/2/21 revealed Resident #2 was observed to attack his roommate (Resident #26) by punching him in the face. The nurse (Nurse #7) caring for resident on 8/2/21 separated the residents and removed Resident #2 from room. (Resident #26's 7/3/21 MDS indicated he had severe cognitive impairment and exhibited no behaviors.) Nurse #7 was not available for interview. A care plan intervention dated 8/2/21 revealed Resident #2 was assigned to another room. An additional intervention dated 8/2/21 revealed Resident #2 was currently being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS dated [DATE] indicated Resident #2's cognition was severely impaired. Resident #2 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 required supervision for walking in room and corridor on/off unit. Resident # 2 was administered antipsychotic medication and antidepressant medication during the 7 day look back period. Review of an incident report completed by the Director of Nursing dated 9/30/21 revealed Resident #2 was found in Resident #100's room in his closet. When the Resident #100 asked Resident #2 to leave, he spun around and began punching the resident in the face. Residents were separated by the facility staff. Resident #100 was noted with a bruise over his right eye and his medical provider was notified. Directions were given to continue to monitor. Resident #100 reported the incident to the DON. Staff did not see Resident #2 hit Resident #100. Resident #100 was escorted to the courthouse to press charges. Resident #100 was told that he must appear at the court hearing to pursue case. (Resident #100's 9/29/21 MDS indicated he was cognitively intact and had no behaviors). A care plan intervention dated 9/30/21 revealed Resident #2 was removed from other resident's room (Resident #100) and redirected to his room. A care plan intervention dated 9/30/21 revealed the facility continued to search for more appropriate placement for resident long-term care (LTC). A review of Resident #2's medical record revealed that he was seen by psychiatry on 10/15/21. The psychiatry visit note indicated that Resident #2 was stable with the current dose of medication and a gradual dose reduction (GDR) attempt would likely impair this individual's function or cause psychological instability by exacerbating an underlying medical condition or psychiatric disorder. Resident #2 was on the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] (an antipsychotic medication)1.5 milligrams twice daily for behavioral disturbance. -[MEDICATION(S)] (an antianxiety medication) 1 milligram tablet every 24 hours as needed for agitation. -Trazadone (an antidepressant medication) 100 milligrams at bedtime for [CONDITION(S)]. Further documentation revealed that Resident #2 was stable during the visit and psychiatry would see him on an as needed basis. A review of a progress note completed by Nurse #8 dated 10/24/21 revealed Resident #2 was agitated and pushed open the emergency exit door despite staff attempting to redirect him. Resident #2 was assisted back inside by staff and was ambulating down the hallway when he approached another resident and began swinging. Staff intervened and Resident #2 was transferred to the hospital by a police officer and emergency services. An incident report completed by Nurse #8 dated 10/24/21 revealed that Resident #2 had pushed on the emergency exit door at the end of the 200 Hall and broke the magnetic lock (a lock that secures the door) to go outside. Staff immediately assisted resident back into the facility. Resident #2 was ambulating down the hall when he approached another resident and began swinging at the resident. Staff immediately intervened. Resident #2 was transported to the hospital by emergency medical services (EMS) for evaluation. A review of the interventions for the incident on 10/24/21 included: -Continue to monitor resident frequently to keep other residents safe. -Resident was sent to the ER for evaluation of behaviors. Multiple attempts to contact Nurse #8 were unsuccessful. Resident #2 went to the hospital on 10/24/21 and returned to the facility on [DATE]. A review of the hospital risk screening dated 10/27/21 indicated that Resident #2 did not meet admission criteria. Resident #2 did not present with an acute psychiatric problem and would not benefit from an inpatient psychiatric admission. The documentation further indicated Resident #2 had dementia that appeared to be progressing and needed placement in a long-term skilled nursing facility appropriate for a dementia patient. The care plan for Resident #2 with a focus area of a behavior problem related to having an altercation with another resident related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff were to constantly redirect resident and prevent any further altercations with other residents. A nursing note completed by Nurse #4 dated 11/17/21 at 4:42 AM revealed that Resident #43 reported that Resident #2 had cursed at her, hit her in the face with a closed fist and flipped the overbed table onto Resident #43. Review of the incident report dated 11/17/21 at 1:32 AM by Nurse #4 indicated Resident #2 was seen walking into his room then moments later, Resident #2 came back out of his room and walked into Resident #43's room and attacked her. Resident #43 began yelling out for help. NA #7 ran to the room and Resident #2 was exiting Resident #43's room. (Resident #43's 11/9/21 MDS indicated she had moderately impaired cognition and no behaviors.) The care plan was updated on 11/17/21 with an intervention to continue with one-to-one supervision to help prevent incident from occurring in the future. An interview was conducted with Resident #43 on 12/14/21 at 10:46 AM. Resident #43 stated she was unsure of the date but did recall that the incident happened. Resident #43 stated when Resident #2 came in her room she yelled at him to get out and Resident #2 hit her in the face. Resident #43 stated that staff came to check on her and got Resident #2 out of her room. Resident #43 stated she has not had any further issues with Resident #2. An interview was conducted with NA #7 on 12/16/21 at 12:19 PM. NA #7 stated that she heard yelling on 11/17/21 and saw Resident #2 leaving Resident #43's room. The NA stated Resident #43 told her Resident #2 had hit her. NA #7 stated the nurse (Nurse #6) walked into the room behind her. An interview was conducted with Nurse #4 on 12/16/21 at 12:16 PM. Nurse #4 stated she heard yelling and the call light sounding for Resident #43. Nurse #4 stated she saw Resident #2 leaving Resident #43's room. Resident #43 reported that Resident #2 had hit her. Nurse #4 assessed Resident #43 and found no injury. Resident #2 was taken to another area and the police were called. Resident #43 did not want to press charges. An interview was conducted with the DON on 12/15/21 at 10:34 AM. The DON stated Resident #2 was moved from that room the day before and forgot this was not his current room. Resident #2 entered the room and Resident #43 stated she yelled at him because he was standing there and she was afraid. The DON stated staff was educated on 11/18/21. The education included resident to resident abuse, the definition of abuse, who to report abuse to, and prevention of resident abuse. A review of the facility incident report for a 12/6/21 incident was completed on 12/7/21 by the DON. This revealed Resident #55 reported that Resident #2 had entered his room on 12/6/21 at 10:43 PM. Resident #55 stated he asked Resident #2 to leave his room and Resident #2 began hitting him on his right lower leg. Resident #2 then turned and left out of Resident #55's room. NA #4 met Resident #2 as he was walking out of Resident #55's room. NA #4 attempted to redirect Resident #2 by allowing him to ambulate with supervision. (Resident #55's 11/17/21 MDS indicated he was cognitively intact and had no behaviors). The care plan for Resident #2 with a focus area of a behavior problem related to having an altercation with another resident was updated on 12/6/21 with an intervention to continue with one-to-one supervision. A Psych consult was ordered. An interview was conducted with NA #4 on 12/16/21 at 10:01 AM. NA #4 stated that Resident #2 was very agitated and hard to redirect. The NA stated she had gone to assist another resident and left Resident #2 alone. NA #4 stated when she exited the other resident's room, she saw Resident #2 leaving out of Resident #55's room. NA #4 stated when she went to Resident # 55's door to assist with Resident #2 there was no mention of an altercation and she did not witness any aggressive behavior. NA #4 was assigned to 1:1 for Resident #2 at the time of the incident. NA #4 was not supposed to leave Resident #2 alone. An interview was conducted with Nurse #6 on 12/16/21 at 8:30 AM. Nurse #6 stated she worked the 100 Hall during the 3-11 PM shift on 12/6/21. Nurse #6 stated she was not notified of any incident between Resident #2 and Resident #55. An interview was conducted with the DON on 12/15/21 at 10:34 AM. The DON stated on 12/7/21 NA #4 was suspended from weekend shifts for not staying with Resident #2 and staff was educated on what it means to be 1:1 and expectations of 1:1 on 12/7/21. A review of the incident report completed by Nurse #6 dated 12/6/21 revealed that Resident #2 was ambulating in the hallway with 1:1 NA #4. Resident #2 entered Resident #24's room and started punching Resident #24 repeatedly in the left side of head. Staff intervened and Resident #2 was escorted out of Resident #24's room and returned back to his room. (Resident #24's 10/3/21 MDS indicated he had he was cognitively intact and had no behaviors). An interview was conducted with NA #4 on 12/16/21 at 10:01 AM. NA #4 stated she was with resident #2 on 12/6/21 as 1:1 NA. NA #4 stated she was walking with Resident #2 when he started walking towards Resident #24's room. NA #4 stated she yelled for help when Resident #2 could not be redirected. NA #4 stated that staff came in and assisted Resident #2 out of the room. NA #2 further stated the incident happened so fast and Resident #2 was hard to manage and scary. NA #4 stated she was unable to see if Resident #2 was hitting Resident #24 or the headboard. An interview was conducted with Nurse #6 on 12/16/21 at 8:30 AM. Nurse #6 stated she went to Resident #24's room on 12/6/21 when NA #4 was yelling for help and Resident #2 could not be redirected. Nurse #6 stated she was unable to see if Resident # 2 was hitting Resident #24 or hitting the headboard when she arrived at the room because staff was around trying to get Resident # 2 to stop. An interview was conducted with the Director of Nursing (DON) on 12/15/21 at 10:34 AM. The DON stated that she completed an assessment of Resident #24 on 12/7/21 and did not find any injury. The DON stated that all staff had been educated on de-escalating behaviors in residents with dementia on 11/30/21. The DON stated on 12/7/21 NA #4 was suspended from weekend shifts for not staying with Resident #2 and staff was educated on what it means to be 1:1 and expectations of 1:1 provider on 12/7/21. The DON provided education records for monthly staff meetings that included resident abuse. On 9/22/21 education was provided to all staff on approaching Resident #2 with 2 staff. On 10/16/21 education was provided on monitoring Resident #2 every hour and keeping him from other resident rooms. An in-service education was conducted on 11/20/21 on how to handle resident to resident aggression. An in-service education was conducted with all staff on 11/30/21 on Dementia Resident Training. An interview was conducted with the Administrator on 12/15/21 at 11:18 AM. The Administrator stated she had tried to send Resident #2 to theER on [DATE] for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator further stated she was told Resident #2 was not a candidate for inpatient psychiatric treatment. They adjusted the medications in the ER and sent Resident #2 back to the facility on [DATE]. The Administrator stated that she had worked with Department of Social Services (DSS) to try to find placement for Resident #2 and when DSS came into the facility to complete their evaluation of Resident #2, he seemed to be ok at the facility. The Administrator stated she was told by DSS they were closing out the case. The Administrator stated that the facility has been in contact with multiple facilities and has been unsuccessful at finding another facility to accept Resident #2. An observation of Resident #2 was conducted on 12/13/21 at 10:34 AM. Resident #2 was assisted up to wheelchair by 1:1 sitter. Resident #2 required multiple attempts at redirection. Resident #2 got up out the wheelchair and began ambulating in the hallway with 1:1 sitter. An observation was conducted of Resident #2 on 12/14/21 at 11:12 AM. Resident #2 was up at nurse's station standing by the cart with 1:1 sitter. Resident #2 was easily redirected and assisted to ambulate down the hall. An observation was conducted of Resident #2 on 12/15/21 8:31 AM. Resident #2 was observed getting up and sitting down in his chair at the bedside multiple times. The breakfast food tray in front of Resident #2 and the 1:1 sitter was trying to redirect him to eat. Resident got up and began wandering aimlessly around the room with 1:1 sitter in room. An observation was conducted of Resident #2 on 12/15/21 at 12:14 PM. The 1:1 sitter was assisting resident to ambulate down the hallway. The Administrator was notified of Immediate Jeopardy on 1/5/22 at 12:24 PM. On 1/7/22 at 2:18 PM the facility provided the following credible allegation of Immediate Jeopardy removal. The credible allegation of immediate jeopardy removal indicated: Credible Allegation of Compliance for Immediate Jeopardy identified for F-tag 600 for removal of Immediate Jeopardy completed on 1/8/22. 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Resident #55 reported that Resident #2 entered his room and Resident #2 began striking resident #55 on his right leg. Resident #2 was removed from the room by the nursing staff. No physical injuries were observed upon nursing assessment. A 24 hour and 5-day report were sent to the state. The attending physician was notified, and new orders were given to monitor resident #55 for bruising. The incident was reported by a family member to the social worker the following day, and the police were not notified. Resident #43 reported that Resident #2 cursed at her, struck her in the face with a closed fist, and flipped the over-bed table onto her hand. No physical injuries were observed upon nursing assessment. The Administrator moved resident #43 room closer to the nurse's station. 911 was called by staff and a law enforcement officer came to the facility. The officer refused to take the resident from the facility and stated that Resident #2 did not pose a threat to anyone at that time. The MD was notified, and orders were given to monitor resident #43 for bruising. A 24 hour and 5-day report were sent to the state. Resident #2 struck Resident #24 on the left side of the head; staff intervened and separated Resident #2 and escorted him out of Resident #24's room, and assisted resident #2 back to his room. Resident #24 was noted with redness to the left side of his face. A 24 hour and 5-day report were sent to the state. Resident #24 did not want the police called. Resident #2 was found in Resident #100's room in his closet. Resident #100 asked Resident #2 to leave. Resident #2 began to strike resident #100 in the face. The facility staff separated both residents. Resident #100 was noted with a bruise over his right eye. The attending physician was notified, licensed staff obtained new orders from MD to monitor for bruising. 911 was called, an officer came to the facility to complete the report but refused to remove resident #2 from the facility due to the resident not posing any danger at that time. Staff escorted resident #100 to the courthouse to press charges, and charges were filed. The case was dismissed, and no charges were filed based on resident #2 cognitive status. A 30-day discharge notice was issued for resident #2 and sent to the responsible party and ombudsman. Resident #100 met goals for rehabilitation and was discharged to the community. A 24 hour and 5-day report were sent to the state. Resident #2 was seen by psych services and was noted to be stable and indicate that no gradual dose reduction attempt will be made because it would likely impair this individual's function or cause psychological instability. Resident #26 was struck in the face by resident #2. No physical injuries were observed on Resident #26 upon assessment. The Director of Nursing changed resident #2 room to a different hall. Resident #2 was currently being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Due to resident #26 cognitive status and inability to be interviewed, police were not notified. The Family was notified but did not wish for police to be called. All residents are at risk for the current deficient practice. 2. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring and when the action will be complete. All staff to include nursing, housekeeping, dietary, therapy, medical records, were educated by Staff Development Coordinator on 1/5/22 -1/6/22 on the meaning of abuse and the different types of abuse. All disciplines have been educated to report abuse to the immediate supervisor, Director of Nursing, or Administrator. All direct care staff were educated on 1/5/22-1/6/22 by the Staff Development Coordinator on steps to prevent resident to resident altercations. The Staff Development Coordinator has educated all direct care staff to monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or staff. All direct care staff were educated on 1/5/22-/1/6/22 by the Staff Development Coordinator on Prevention and decreasing the occurrence with a resident-to-resident aggression. The Staff Development Coordinator educated all direct care staff on contributing factors and triggers of resident-to-resident aggression and strategies to decrease aggression. All direct care staff were educated on 1/5/22-1/6/22 by the Staff Development Coordinator on how to conduct 1:1 monitoring of residents properly and to never leave the resident unattended at any time. Staff Development Coordinator educated all direct care staff on the proper steps when a break is needed. The Administrator in-serviced the Staff Development Coordinator on 1/7/22 to educate all disciplines on the meaning of resident abuse, the different types of abuse, and who to report abuse to if suspected. Staff Development Coordinator in-serviced to educate direct care staff on steps to prevent resident to resident altercations, monitoring residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or staff. The Staff Development Coordinator was in-serviced by the Administrator in preventing and dealing with resident-to-resident aggression and strategies to decrease aggression. One agency staff member is employed and was educated by the Director of Nursing on 1/6/22 on the different types of abuse and who to report the abuse to. Resident #2 will remain with 1:1 supervision 24 hours a day, 7 days a week, until the resident is deemed no longer abusive to other residents/staff by the Interdisciplinary team to include the physician. The Director of Nursing will implement a 1:1 time tracking tool on 1/7/22 to require staff to sign in and out to document the assumption of resident observation and supervision at all times. The Director of Nursing or Staff Development Coordinator will educate all direct care staff on properly conducting 1:1 monitoring of residents. A 1:1 time tracking tool has been implemented that will require staff to sign in and out to document/track the assumption of resident observation and supervision at all times on 1/7/22. The Staff Development Coordinator will educate all licensed staff that any resident who displays combative behavior will notify the MD, licensed staff will obtain psych evaluation within 24 hours. If unable to get in-house facility psych services, the resident will be sent to the hospital for a psych evaluation on 1/7/22. The resident will continue to receive 1:1 supervision during this process. The Administrator in-serviced the Admission Coordinators that Resident #2 would remain in a room without a roommate to decrease occurrences of resident-to-resident abuse on 1/7/22. The Staff Development Coordinator will educate all licensed staff to notify law enforcement when Resident #2 exhibits any aggressive behaviors towards residents/staff on 1/7/22. The Staff Development Coordinator will educate all licensed staff to call the responsible party when Resident #2 displays any aggressive/combative behaviors regardless of the responsible party's refusal to be involved with the resident on 1/7/22. All direct staff will be educated by Staff Development Coordinator that any aggressive behavior that direct staff cannot redirect to call MD for orders to send to the hospital for evaluation on 1/7/22. The Director of Nursing and Administrator will be responsible for the overall implementation and compliance of this plan. The facility alleges the removal of Immediate Jeopardy on 1/08/2022. The credible allegation of Immediate Jeopardy Removal was validated by onsite verification on 1/11/2022 as evidenced by interviews with direct care, ancillary, and administrative staff, interviews with residents, record review and observations. Interviews conducted with nursing, housekeeping, dietary, therapy, medical record and other ancillary staff revealed they had attended training regarding types of abuse, reporting, prevention of altercations, monitoring resident behaviors, 1:1 tracking tool, and notifications. An interview with the Staff Development Coordinator was conducted on 1/11/2022 at 11:10 AM. She explained she ensured all staff had attended in-services by comparing the staff roster with the sign-in sheets. She further explained several employees who had been on leave were in-serviced the days they had returned to work. In-service forms were reviewed and indicated the dates, topics discussed, and the trainer, and included attending staff signatures. No concerns were identified with these forms. The 1:1 tracking tool had been implemented on 1/7/2022. The tool was reviewed from implementation to the current date with no gaps in monitoring documentation observed. Resident #2 was observed on 1/11/2022 at 11:54 AM in his room, reclined in a geri-chair and appeared asleep. A nurse aide was sitting inside the doorway of his room. There was no other resident residing in the room. Resident #2 was observed on 1/11/2022 at 1:20 PM. He appeared comfortable, sitting up in a geri-chair while being wheeled in the hallways by a nurse aide. An interview was attempted with Resident #2 with no response to questions, only eye contact. The nurse aide stated Resident #2 had foot pain and was most comfortable when his legs were elevated. She explained he enjoyed being out of his room at times to see other people and for a change in scenery. She further explained Resident #2 was receiving 1:1 monitoring and care, staff must sign in and out on a form for breaks, and he must not be left unattended at any time. On 1/11/2022 at 12:58 PM an interview with Residents #45, #21 and #63 was conducted. These residents were sitting together talking and watching the activity in the hall. They all stated the Director of Nursing and/or the Social Worker had been to visit with them recently to make sure everything was okay. These residents did not express any concerns. An interview with the Director of Nursing (DON) and the Administrator was conducted on 1/11/2022 at 2:00 PM. The DON sated she was the primary responsible person for monitoring the 1:1 tracking tool. The facility's Immediate Jeopardy removal date of 1/08/2022 was validated

Based on record reviews, observations, physician interview and staff interviews, the facility failed to maintain an environment as free from accident hazards as is possible by failing to discard a disposable razor safely after use. As a result, a disposable razor was found in the mouth of 1 of 5 sampled residents reviewed for accident hazards. Resident #1 was cognitively impaired. (Resident # 1) Immediate Jeopardy (IJ) began on 02/07/19 when a disposable razor was found in the mouth of Resident # 1 whose cognition was severely impaired. Review of the resident's medical record and facility in-servicing records, as well as staff interviews, revealed after the 02/07/19 incident the staff was not in-serviced about how to discard disposable razors safely and root cause analysis was not completed to try and determine where and how the disposable razor was left next to Resident # 1. The IJ was removed on 02/20/19 when the facility implemented an acceptable credible allegation of IJ removal. The facility remained out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not IJ) to ensure monitoring of systems were carried out and employee in-servicing was completed. Findings included: Resident # 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] indicated the resident's cognition was severely impaired and no behavioral symptoms were noted. The MDS also indicated Resident # 1 required extensive assistance of 2 persons with bed mobility, dressing, and transfer and was independent with her eating. Resident # 1 had care plans for the following areas of concerns: Resident # 1 required a mechanical soft diet; The resident required extensive assistance with most activities of daily living (ADLs) check mouth after meal for pocketed food debris; report to nurse to provide oral care to remove debris; Resident # 1 is in wheel chair when up out of bed; staff to assist with ADLs daily and encourage resident to participate in care as able. A nurse's note written by Nurse # 1 and dated 02/06/2019 documented, Per Nurse Aide ((NA) # 2), she came to this nurse at 3:30 PM and reported that she found resident in her room in her bed with a used (disposable) razor blade in her mouth. This nurse immediately assessed patient and found no injuries at this time. Vital signs obtained and resident was monitored throughout the shift. Director of Nursing (DON) is aware, Medical Director (MD) and Power of Attorney (POA) aware. Incident report completed. An incident report written by Nurse # 1 and dated 02/07/2019 documented Called to room per (NA # 2) who observed resident with dirty (disposable) razor blade in her mouth. Assessment completed per this nurse no injuries noted this time. Will monitor. Director of Nursing (DON) made aware. (Disposable) Razor blade was left at bed side table. Resident has dementia, she reached and picked (disposable) razor blade up and placed into her mouth. NA # 3 was interviewed on 02/19/2019 at 3:50 PM. NA # 3 reported she had an assignment at the facility as Restorative Aide (RA). NA # 3 reported she was not assigned to one particular resident at the facility but she visited residents and shaved them if she saw that they have chin hair or a long beard. NA # 3 indicated she recalled shaving Resident # 1 within the last 2 weeks but she did not recall the date when she shaved her. NA # 3 reported Resident # 1's family member had asked her to shave Resident # 1 on 02/01/2019. NA # 3 reported she did not recall leaving a disposable razor on Resident # 1's bed side table. She also reported the staff were trained to use a new disposable razor once and dispose them in the safety trash can where the sharp items were disposed in which was behind the bathroom door. She indicated they did not reuse the disposable razors. She further stated she usually kept the disposable razors in her pocket for easy access and also the disposable razors were kept in the medication room at the nurse's station. NA #1 (7-3 shift) who was assigned to Resident # 1 on 02/07/2019 was interviewed on 02/19/2019 at 3:40 PM. NA #1 reported she did not recall leaving or taking a disposable razor in Resident # 1's room. NA # 1 reported she did sometimes shave Resident # 1's chin hair, but she did not recall shaving Resident # 1 on 02/07/2019. NA # 2 (3-11 shift) who was assigned to Resident # 1 on 02/07/2019 was interviewed on 02/19/2019 at 3:45 PM. NA # 2 reported she just had reported to work at 3:00 PM on 02/07/2019 and while she was passing by Resident # 1's room she noticed a blue disposable razor in Resident # 1's mouth. NA # 2 reported that the part that was in the Resident 1's mouth was the sharp blades of the disposable razor. She also reported the disposable razor had been used because it did not have the safety cap on. NA # 2 stated she took the disposable razor out of Resident # 1's mouth and threw it in the sharp items container behind the resident's bathroom door. She then reported the incident to Nurse # 1. Nurse # 1 (3-11 shift) who was assigned to Resident # 1 on 02/07/2019 was interviewed via telephone on 02/19/2019 at 1:30 PM. Nurse # 1 reported she went to Resident # 1's room in the afternoon about 3:30 PM because NA # 2 found Resident # 1 with a disposable razor in her mouth. Nurse # 1 reported she was asked by Director of Nursing (DON) to write an incident report about the disposable blade that was found in Resident # 1's mouth. Observation of Resident # 1 on 02/19/2019 at 1:45 PM revealed the resident sitting in wheel chair beside her bed. The bedside table was next to the resident. The table had crackers and a white cup with a straw. The Resident was observed reaching for crackers and asking for help from a Nurse assistant to open up the cracker packages. The resident was observed putting the crackers in her mouth. No disposable razors were observed in Resident #1's drawer or on the bed side table. Nurse #2 (7-3 shift) who was assigned to Resident # 1 on 02/07/2019 was interviewed on 02/19/2019 at 2:00 PM. Nurse #2 reported Resident # 1 had no history of chewing items that are not food. She reported Resident #1 liked to snack on items like cookies and crackers all the time. Nurse # 2 reported she was not aware of Resident # 1 being found with a disposable razor in her mouth. Nurse #2 reported Resident # 1 was usually very organized with her bed side table and she was surprised 1st shift Nurse's Aide or Nurse did not see the disposable razor on Resident # 1's bed side table. She further reported the disposable razors were kept in the medication room by the nurse's station. The Director of Nursing (DON) was interviewed on 02/19/2019 at 4:00 PM. The DON reported she was aware of the disposable razor found in Resident # 1's mouth but she did not follow up to find out about the outcome of the investigation. She reported she was not aware the investigation had not been completed by the hall nurse. DON reported she was not aware of how the disposable razor got in Resident # 1's room since the resident could not get out of her bed independently. The DON reported disposable razors were always kept in the medication room by the nurse's station. The Administrator was interviewed on 02/19/2019 at 4:27 PM. The Administrator reported she was not aware how the disposable razor got on the table Resident # 1's bed side table and she did not recall completing the investigation to conclude how Resident # 1 got access to the disposable razor blade that she put in her mouth. She further reported her expectation was to complete an investigation within 48 hours but they failed to complete the investigation in reference to Resident # 1's incident on 02/7/2019. The Physician was interviewed on 02/20/2019 at 9:30 AM. The Physician reported his expectation was for the facility to safely discard the disposable razors after each use. He reported the facility always notified him with any change of Resident # 1's condition. The Physician also stated it had not been reported to him before 02/7/2019 that Resident # 1 was putting items in her mouth that were not edible. The Administrator was notified of the Immediate Jeopardy on 02 /20/19 at 10:30 AM. On 02/20/19 the facility provided an acceptable credible allegation for Immediate Jeopardy removal that included the following: The plan of correcting the specific deficiency including the processes that led to the deficient practice cited on 2/20/2019 at approximately 11:00 AM: Description of Incident: On 02/07/2019 at approximately 3:30pm, Resident #1 was observed in her room, in bed, with over bed table in front of her (resident in semi-private room) by NA #2. NA #2 observed Resident #1 with a disposable razor in her mouth with lips closed around the disposable razor. The aide asked Resident #1 to hand her the disposable razor and resident removed the disposable razor from her mouth and handed it to NA #2. The (Brief Interview for Mental status (BIMs) on Resident #1 on 02/20/19 is 6. Corrective action will be accomplished for the resident found to have been affected by the deficient practice: The resident's oral cavity was assessed for discoloration and open areas by Nurse #1. No injuries, redness or open areas noted on 2/7/2019 The resident RP (Responsible Party) and MD (Medical Doctor) were notified of the incident on 02/7/19, per information form incident report. Resident # 1 was not seen by MD on 02/7/19. On the a.m. (morning) of 02/19/19 the incident report was given to Executive Director, the information in reference to Resident # 1 being found with a disposable razor was reviewed and in-servicing of staff about safely disposing of disposable razors by RN (Registered) nurse manager the in-service was completed 2/20/2019. Investigation initiated at this time. A call was made by the Administrator to the family member regarding Resident #1 and razors. Administrator educated family on the facility providing the disposable razors so we ensure safely disposing of disposable razor after use. I asked her not to bring any in. Upon investigation, a late entry was made by Nurse # 1 on 02/12/19 in Resident 1's medical record stating on 02/6/19 incident occurred. Incident report submitted by same Nurse # 1, indicated incident as occurring on 02/7/19. NA #2 stated 02/7/19 as date of occurrence. Since Nurse #1 is no longer employed as of 02/15/19, cannot validate actual date of incident report completion or whom Nurse 1 gave report to. All residents have the potential to be affected. Upon notification on the incident, 02/19/19, the Executive Director instructed the RN supervisors to have the Licensed Nurses and NA's to check all resident rooms for disposable razors. This was completed on 02/19/19 on 7-3 shift. 3 Residents with disposable razors in their room were assessed for safety awareness and this was documented in their medical record. Those 3 residents were educated on keeping their razors secure in their bed side stand. They acknowledge and verbalized understanding. This was completed on 02/19/19. An audit was done on all residents BIMS assessment to validate current scores. Resident in question had new BIMs assessment done. Resident #1 BIMs score was 6. This was completed on 2/20/19 by Social Services. Care Plan was updated on 02/20/19 by the MDS RN regarding placing disposable razor in mouth. Measures put into place or systemic changes made to ensure that the deficient practice will not occur: 02/19/19 and 02/20/19 direct care givers were re-educated by the Nursing Supervisor and Executive Director on the timeliness of reporting incidents and accidents with emphasis on reporting and documenting the incidents in the medical record. The direct care givers were also educated regarding the use of disposable razors at the bed side with an emphasis on resident safety, impaired cognition and dementia diagnosis. This information will be included in the orientation program for direct care givers. Disposable razors are kept locked up in central supply and only nursing staff have access to them. Used disposable safety razors are placed in sharps containers in the resident's bathroom. The administrative nurses will inspect 5 resident rooms for disposable razors or other items placing resident at risk ( residents that have BIM score of less than 10) 2 times weekly times 4 weeks, then weekly times 4 weeks to ensure ongoing compliance. Facility plans to monitor it performance to make sure the solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained: The Director of Nursing will submit the PIP (Performance Improvement Plan) to the Quality Assurance Process Improvement committee on 02/22/19.The Director of Nursing will report the findings of the audit to the Quality Assurance and Process Improvement Committee monthly times 3 months or until a pattern of compliance is achieved. The title of the person responsible for implementing the acceptable plan of correction: The Administrator is responsible for implementing this acceptable credible allegation of compliance Immediate Jeopardy removal date: 02/20/19 Validation: Immediate Jeopardy (IJ) was removed on 02/20/19 at 6:30 PM. Validation of the credible allegation for IJ removal was completed as evidenced by interviews with nurses and nursing assistants related to in-servicing which was received as a result of the survey. Any staff members not receiving the in-servicing prior to IJ removal were not allowed to clock in for work again until receiving the in-servicing. Review of the facility's monitoring revealed no disposable razors were found in residents' rooms who were cognitively impaired.

Based on observation, physician interview, staff interview, and record review the facility failed to document provision of basic care and treatment to prevent maggots from developing in the arterial/venous wounds of 1 of 1 sampled residents (Resident #43) reviewed for wound care. Resident #43 was observed to have maggots in his wound on 07/30/18. The facility also failed to conduct a root-cause analysis to determine where and how the resident's wound became contaminated. As a result there was a second observation of maggots in Resident #43's arterial/venous wounds one to two weeks after the initial sighting on 07/30/18. Immediate Jeopardy (IJ) began on 07/30/18 when basic wound care and treatment was not documented for Resident #43, and maggots were observed in his arterial/venous wound. One to two weeks after 07/30/18 maggots were again observed in the resident's arterial/venous wound beds and on his bedding. The IJ was removed on 09/28/18 when the facility implemented an acceptable credible allegation of IJ removal. The facility remained out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not IJ) to ensure monitoring of systems were carried out and employee in-servicing was completed. Findings included: Record review revealed Resident #43 was initially admitted to the facility on [DATE], and was readmitted to the facility on [DATE]. The resident's documented [DIAGNOSES REDACTED]. Resident #43's 06/22/18 Admit/Readmit Screener documented he had a suspected deep tissue injury (DTI) to his right heel measuring 3.2 x 3.5 centimeters (cm), an arterial/venous ulcer to his right lower inner leg measuring 13 x 3.2 x 0.2 cm, a suspected DTI to his left heel measuring 7.6 x 6.5 cm, and an arterial/venous ulcer to his left lower inner leg measuring 4.09 x 7.5 x 0.2 cm. Review of a care plan from a previous admitted d 04/03/18 revealed The resident has DTI and potential for pressure ulcer development r/t (related to) impaired bed mobility, bowel bladder incontinence was identified as a problem. Interventions to this problem included administering treatments as ordered and monitoring for effectiveness, assessing/recording/monitoring wound healing, and reporting improvements/declines to the primary physician/Medical Director. A 06/25/18 physician order [REDACTED]. Weekly wound assessments completed on 06/26/18, 07/03/18, and 07/10/18 documented the change in the measurements of Resident #43's four ulcers were minimal. There was no documentation about wound bed tissue, odor, and exudate in these assessments. The resident's 06/29/18 admission minimum data set (MDS) documented his cognition was severely impaired, he did not exhibit rejection of care, he required extensive assistance from staff to being dependent on staff for his activities of daily living (ADLs) except for requiring only supervision with eating, he had two unstageable deep tissue injury pressure ulcers, he had two arterial/venous ulcers, and he was receiving [MEDICAL TREATMENT] services. Review of the resident's (MONTH) (YEAR) TAR revealed the treatments/dressing changes to his bilateral lower extremity ulcers were not initialed off as being completed on 07/02/18, 07/03/18, 07/04/18, 07/06/18, 07/07/18, 07/08/18, 07/09/18, and 07/16/18 (the resident went to the wound clinic on this day). Consult notes documented Resident #43 was seen by the wound clinic on 07/16/18 with a return appointment scheduled for 07/23/18 at 9:30 AM. There was no documentation of infection or the presence of maggots in the 07/16/18 wound clinic treatment notes. On 07/17/18 the resident's care plan was updated to reflect that he had bilateral DTIs to his heels, an arterial/venous ulcer to his right lower lateral leg, and an arterial/venous ulcer to his left lower medial leg. A 07/17/18 progress note, written by Nurse #5, documented, Wound assessment completed, Vascular ulcer at right lower leg measures 10.4 cm x 5.1 cm, wound bed is beefy red, mild odor, pain to touch, minimal serosanguineous drainage, edges smooth, peri-wound tissue is dry. Vascular ulcer at left lower leg measures 0.7 cm x 0.9, wound bed is beefy red, no odor, pain to touch, minimal serosanguineous drainage, edges smooth, peri-wound tissue is dry. Current tx (treatment) for vascular wounds of foam dressings with dressing changes daily continue. DTI right heal measures 4.5 cm x 4.5 cm, DTI left heel measures 9.7 cm x 10.5 cm, both DTIs are hard/black eschar, peri-wound skin is intact/very dry. Current treatment of [REDACTED]. A 07/18/18 physician order [REDACTED]., and the dressing was to be secured with roll gauze daily. Review of the resident's (MONTH) (YEAR) TAR revealed the treatments/dressing changes to his bilateral lower extremity ulcers were not initialed off as being completed on 07/18/18, 07/19/18, 07/20/18, 07/21/18, 07/23/18 (the resident was sent out to the emergency room and returned back to the facility on this same day), 07/25/18, 07/27/18, 07/28/18, and 07/30/18 (Nurse #2 changed some of the dressings on this evening until she observed maggots in an arterial/venous wound). A 07/23/18 transfer form documented Resident #43 was sent to the emergency room (ER) due to a change in mental status. The resident was not admitted to the hospital, but missed his 07/23/18 wound clinic appointment. The resident's (MONTH) (YEAR) TAR documented that on 07/29/18 Nurse #1 did the treatments and dressing changes to the bilateral heels DTIs and the bilateral arterial/venous ulcers for Resident #43. On 09/26/18 at 4:12 PM, during a telephone interview, Nurse #1 stated she did dressing changes for Resident #43 on the weekends. She reported the resident's arterial/venous wounds were not in good shape. She commented these wounds always had odor which was not pleasant but not foul. She stated the tissue and drainage varied from weekend to weekend. Nurse #1 reported she could not remember for sure what the resident's wounds looked like on 07/29/18 when she did the dressing changes, but if they had been different from usual she would have made contact with the resident's primary physician. According to this nurse, on 07/29/18 she did not remember seeing maggots in the resident's wound beds. A 07/30/18 progress note, written at 11:06 PM by Nurse #2, documented, While changing resident's BLE (bilateral lower extremity) dressings, noted left lower extremity to have foul, foul odor with copious amounts of drainage noted coming from all sites, also noted large amount of larvae coming out of wounds on lower left leg, Administrative nurse .notified, resident sent to hospital to be evaluated and treated Dressing to RLE (right lower extremity) was changed without difficulty with copious amounts of foul purulent drainage noted On 09/26/18 at 4:20 PM Nurse #2 stated on 07/30/18 nursing assistant (NA) #1 came to her stating that when she provided incontinent care to Resident #43 the dressings to his bilateral lower legs rolled down and needed to be secured and/or changed. The nurse reported she decided to change the dressings, and there was a large amount of wet, yellow to slightly green drainage on the existing dressings. She also commented there was a strong odor coming from both arterial/venous wounds, but the odor coming from the left lower leg wound was extremely strong and foul. According to Nurse #2, when she unwrapped the old dressing on the left leg five or six very large and plump maggots fell from the wound onto the resident's bed. Nurse #2 reported one of the dressings to the lower legs had a date on it, but she could not remember which one, and she could not remember what the date was. She stated she had experience dealing with maggots and infected wounds, and using that knowledge base, she would estimate that it had taken a week for the maggots to reach the stage at which they presented on 07/30/18. Nurse #2 commented she could not remember if she obtained the order to send Resident #43 to the ER from the primary physician or the on-call physician. A 07/30/18 transfer form documented Resident #43 was sent to the emergency room (ER) due to ulcers to BLE (with) maggot infestation. A 07/30/18 ER report documented, .Wounds are not purulent and do not appear infected. There are no maggots seen in any of the wounds Patient certainly has chronic changes and chronic wounds to both feet. However, there is no evidence of acute infection to either foot though (it require antibiotics or hospitalization ). Discharge patient back to the nursing home and recommend that he resume treatments at his wound care center. Review of wound clinic consults revealed Resident #43's wounds were assessed and treated at the wound clinic on 07/31/18, 08/09/18, and 08/23/18. There was no documentation of maggots to the wounds on any of these consult notes. A 08/01/18 physician order [REDACTED]., and secured with roll gauze daily. Review of the resident's (MONTH) (YEAR) TAR revealed the treatments/dressing changes to his bilateral lower extremity ulcers were not initialed off as being completed on 08/01/18, 08/06/18, 08/08/18, 08/09/18 (the resident was seen at the wound clinic on this day), and 08/10/18. The resident's 08/07/18 significant change MDS documented his cognition was severely impaired, he did not exhibit rejection of care, he required extensive assistance from staff to being dependent on staff for his activities of daily living (ADLs) except for requiring only supervision with eating, he had two unstageable deep tissue injury pressure ulcers, he had two arterial/venous ulcers, and he was receiving [MEDICAL TREATMENT] services. On 09/26/18 at 8:15 AM Nurse #5 stated that observations of Resident #43's wounds/treatments would not be possible because the resident had been sent out to the emergency room the night before with a low grade temperature and mental status changes. This nurse reported the resident was admitted to the hospital. On 09/27/18 at 9:38 AM Nurse #5, the current Treatment Nurse, stated he took over as full time Treatment Nurse on 08/14/18. Prior to 8/14/18 he reported he was changing Resident #43's dressing two to three times weekly. He reported back in (MONTH) (YEAR) there was minimal drainage and no odor from the resident's arterial/venous wounds. According to Nurse #5, on the weekends Nurse #1 did the dressing changes/wound treatments for residents. He reported Nurse #1 dated her dressings, and he did not recall there being evidence that dressings were not being changed on the weekends. Nurse #5 commented that in general he thought the treatments/dressing changes were being done timely because of the consistent presentation of Resident #43's wounds. On 09/27/18 at 12:43 PM the Director of Nursing (DON) stated she assumed her current position on 08/01/18, but was not aware of any residents having maggots in their wounds until questions were asked during the survey. She commented when she talked with Nurse #8 (the Staff Development Coordinator-SDC), Nurse #8 reported no in-servicing or root cause analysis was done concerning maggot infestation because the facility felt it had handled the problem appropriately by sending Resident #43 to the ER and wound clinic. On 09/27/18 at 4:18 PM Nurse #5, the current Treatment Nurse, stated he did see a single maggot on Resident #43's bed after the resident's wound dressings were changed. He reported this sighting occurred a couple of weeks after the resident was sent out to theER on [DATE] due to maggot infestation and decline in wound status. He commented that he did not notify the resident's primary physician or document his observation of the maggot, but he did call the wound clinic to discuss his observation, and the resident was seen there the next day. On 09/27/18 at 5:05 PM NA #1 stated she sometimes helped the nurses position and hold Resident #43's legs when the nurses were changing the dressings on his arterial/venous wounds. She reported that sometimes the resident received dressing changes on first shift before he left for [MEDICAL TREATMENT], but on other days it was too hectic on first shift, and his dressings were supposed to be changed on second shift after the resident returned from [MEDICAL TREATMENT]. According to NA #1, she had observed maggots in Resident #43's lower leg wounds twice. She commented the first time was on 07/30/18 and the next time was one to two weeks later. NA #1 stated that both times very large maggots fell from the wound bed onto the floor and the resident's bed. She also remarked that there were at least five or six very plump maggots present both times and that the resident went out to the wound clinic the day after both observations. On 09/27/18 at 5:26 PM the DON stated she was not aware of any problems with staff not signing treatments off on the TARs. However, she commented that no staff had complained to her that they were unable to complete treatments/dressings changes. On 09/27/18 at 5:41 PM NA #2 stated he worked on third shift, and about one and a half to two months ago when he was rounding on residents who were in his assignment, Resident #43 seemed restless so he decided to check him to see if he was wet or soiled. The NA reported when he pulled the covers back the resident's bed was full of large maggots. He commented he alerted Nurse #3 who gathered them and placed them in a cup. On 09/27/18 at 6:02 PM Resident #43's primary physician and the facility's Medical Director stated if the maggots in the resident's arterial/venous wounds were as big as staff described them, it had probably taken a week for them to mature. He reported that obviously these maggots were not being used therapeutically, and they grew in the wound due to contamination. He commented that it would be important to determine where and how the contamination occurred since the resident resided in the facility but left the facility with family, and went to the [MEDICAL TREATMENT] center three times a week, to the wound clinic, and to the surgeon's office every two weeks. According to the Medical Director, if there were maggots, they had no negative effect since the resident was already on a bad vascular path which would eventually end in the bilateral amputation of Resident #43's legs. On 09/27/18 at 11:16 PM, during a telephone interview, Nurse #3 stated she worked on third shift. She reported on 07/30/18 she had maggots collected from Resident #43's bed, placed them in a sterile container, and refrigerated them. However, she commented she disposed of them at the end of her shift. According to Nurse #3, she thought six large maggots were probably collected on 07/30/18, but she commented about a week or a week and a half later eight to nine maggots were once again found in Resident #43's wound and bedding. She stated she did not notify Resident #43's primary physician either time she observed maggots because she thought Nurse #2 had already done so since she was the first staff member who observed them on the night of 07/30/18. Nurse #3 reported she forgot to document about her observation of maggots a week or two later. On 09/28/18 at 10:17 AM Nurse #8 (SDC and Infection Control) stated she remembered hearing mention of maggots in a resident's wound, and that from an infection control standpoint, you would want to figure out when and where the resident's wounds were contaminated by flies. She commented in-servicing about pest control, prompt removal of meal trays from resident rooms, frequent emptying of trash in resident rooms, and the importance of timely incontinent care would have been important topics to educate the staff about. However, she stated that root-cause analysis and infection and pest control in-servicing were not conducted after maggots were found either time in Resident #43's wound and/or room. On 09/28/18 at 11:50 AM the DON stated she had asked staff about the wound treatments that were not initialed off on the TAR for Resident #43. However, she reported that no staff member, other than Nurse #1 who stated she was sure she did all dressing changes for the resident on 07/28/18, could say without a shadow of a doubt that treatments were provided to Resident #43 on the days when they were not initialed off on the TAR. According to the DON, her expectation was that nurses initial treatments as being done on the TAR as soon as they were completed. She also commented that during report first shift nurses should have shared with second shift nurses if Resident #43 left for [MEDICAL TREATMENT] before his wound dressings could be changed on first shift, but she was not sure that this was happening based on the missing documentation on the TARs. On 09/28/18 at 3:55 PM, during a telephone interview, Nurse #4 stated she was assisting Nurse #2 with Resident #43's dressing changes on 07/30/18. She stated the arterial wounds had a very pungent odor, and when they got to the left leg arterial/venous wound she saw something drop on the bed. She commented she saw at least three large maggots fall from the wound bed before she had to leave the room. She reported she called 911 and started the paperwork for sending Resident #43 to the ER, but did not notify the resident's primary physician. Nurse #4 commented she was not sure how long it had been since the resident's dressings had been changed last, but she thought it could have been awhile since there was some confusion about whether first or second shift was responsible for the wound treatments. According to Nurse #4, she was prepared to make a statement about what she saw since it was such an infection control issue, but she reported she was never asked to do so by the facility. During the survey several flies were noted in resident rooms and commons areas, but the presence of flies was minimal. Review of pest control visits revealed that the contracted pest control company was in the facility on 04/30/18 (when no pest activity was noted), 05/30/18 (when a problem was noted with ants and treatment was provided for ants, mice, and roaches), 06/22/18 (when the presence of mice and roaches were noted and there was the creation of a perimeter for spiders), 07/31/18 (when treatment was provided for mice and ants), and 08/30/18 (when the dining room and kitchen were treated for [REDACTED]. The facility's maintenance manager was unavailable during the survey. The DON and Corporate Consultants were notified of the Immediate Jeopardy on 09/27/18 at 6:25 PM. On 09/28/18 the facility provided an acceptable credible allegation for Immediate Jeopardy removal that included the following: The plan of correcting the specific deficiency including the processes that led to the deficient practice cited on 9/27/2018 at approximately 6pm: 0n 7/30/18 the nurse working second shift noted larvae and maggots in wound. The nurse documented the assessment of larva in the wound of the resident and notified nursing administration. The nurse sent the resident to the emergency department for wound evaluation. The emergency department reports no record of larva present in the wound. The resident returned to the facility 7/30/18 with recommendations to resume treatment with the wound care clinic. 8/8/18 a nurse and certified nursing assistant again witnessed larvae and maggots to wound. The wound clinic was notified and the facility was instructed for the resident to keep scheduled appointment with wound clinic the following day. The interdisciplinary team (IDT) including the Director of Nursing (DON), Minimal Data Set Nurse (MDS) and Corporate Minimum Data Set Nursing Supervisor met on 9/27/2018. Root cause was determined that the facility failed to provide adequate pest control. Research has shown that for larvae and/or maggots to be noted there had to be a presence of flies. The resident frequently left the facility for [MEDICAL TREATMENT] treatment and wound clinic visits. These transfers out of the facility were during the summer months when flies can be prevalent. Additional root cause is failure of staff to report the presence of larvae/maggots in resident care area to administration. The interdisciplinary team (IDT) including the Director of Nursing (DON), Minimal data set Nurse (MDS) and Corporate Minimum data set Nursing supervisor met on 9/27/2018 and determined the root cause to be a breakdown in the wound care delivery process resulting in inconsistent documentation of treatment performed. An additional root cause was determined that there was inconsistent communication when the resident did not receive their wound treatment because the resident was out to [MEDICAL TREATMENT] during day shift hours and wound care needed to be completed on evening shift. An additional root cause was that the wound treatments could not be performed on day shift because resident was out of the facility for [MEDICAL TREATMENT]. Additional root cause for failure to document treatment completion on TAR is lack of education regarding the importance of documenting as soon as treatment is rendered and lack of communication. The procedure for implementing the acceptable plan of correction for the specific deficiency cited: 9/27/18 all resident care areas were inspected by IDT team to include MDS nurses, Staff Development Coordinator, Director of Nursing and Nursing Supervisor for larvae/maggots and flies with no observations of larvae/maggots or flies in any resident care area. 9/28/18 skin assessments completed for all residents in the facility by MDS nurses, Director of Nursing, Staff Development Coordinator and treatment nurse. Skin assessment includes inspection of any wounds and/or open areas for the presence of larvae/maggots. Skin assessments indicate no larvae/maggots noted in any wounds and/or open areas. 9/28/18 the Director of Nursing contacted the facility contracted pest control provider to visit the facility and complete a facility wide assessment for pest control. Visit scheduled for 9/28/18. On 9/27/2018 the nurse who documented the presence of larva in the wound on 7/30/18 was educated by the nursing supervisor on the need for physician notification if larva or maggots were noted in the wound and notification to administration related to the presence of larvae/maggots. On 9/28/18 the nurse who observed larvae/maggots in the wound on 8/8/18 was educated by the nursing supervisor on the need for physician notification if larva or maggots were noted in the wound and notification of administration related to the presence of larvae/maggots. On 9/27/18 in-service education by the nursing supervisor began for all staff regarding notification of administration if any maggot, larva or flies was found in the facility. Education includes notification of maintenance and/or environmental services if flies are observed in the residents' rooms. Out of 83 staff members 66 have been educated. Staff who have yet to receive the education will not be permitted to work until the education is received. On 9/28/18 in-service education by the nursing supervisor began for all staff regarding environmental services to include emptying of trash cans in a timely manner, removal of meal trays upon completion of meal and resident care promptly provided. Out of 83 staff members 10 have been educated. Staff who have yet to receive the education will not be permitted to work until the education is received. On 9/28/18 in-service education began by nursing supervisor for certified nursing assistants related to reporting to licensed nurse if resident wound dressing is heavily soiled and / or not in place. Out of 33 certified nursing assistants 6 have been educated. Staff who have yet to receive the education will not be permitted to work until the education is received. The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements: On 9/27/18 the Quality Assurance and Performance Improvement committee met. They were notified of the immediate jeopardy and reviewed pest control practices. The team participated in root cause analysis and development of acceptable plan of correction. Beginning on 9/28/2018 during twice daily ambassador rounds the staff will perform observation of resident care areas. If any pests including flies are identified the ambassador will attempt to eradicate as appropriate and notify administration immediately. Administration will contact pest control as indicated. Upon completion of ambassador rounds the completed ambassador rounds sheets will be submitted to the facility administrator for review. Beginning on 9/28/18 during twice daily ambassador rounds the staff will perform observation of resident care areas to include uncovered food / perishable items, meal trays removed from room and trash removed from the room. If uncovered food / perishable items, meal trays and /or excess trash observed they will be removed at time of rounds completion. Upon completion ambassador rounds the completed ambassador rounds sheets will be submitted to the facility administrator for review. Beginning on 9/28/18 during twice daily ambassador rounds the staff will perform observation to include evidence of completion of prompt resident care. Observations of residents requiring resident care will be reported to licensed nurse assigned to resident for care to be completed. Upon completion of ambassador rounds the completed ambassador rounds sheets will be submitted to the facility administrator for review. Beginning on 9/28/18 environmental services staff to round all areas of facility twice daily for monitoring of emptying of trash cans in a timely manner, removal of meal trays, and uncovered / perishable food items. During rounds any concerns related to emptying of trash cans, removal of meal trays and/or uncovered / perishable food items will be corrected at the time of rounds completion. Results of twice daily environmental rounds will be submitted to the facility administrator for review. Beginning on 9/28/18 the dietary manager and / or dietary supervisor will round food storage areas of the facility twice daily for monitoring of removal of meal trays, uncovered / perishable items. During rounds any concerns related to food storage including removal of meal trays and / or uncovered / perishable items will be corrected at the time of rounds completion. Results of twice daily food storage rounds will be submitted to the facility administrator for review. Beginning on 9/28/18 the Director of Nursing, Assistant Director of Nursing and / or Nursing Supervisor will complete wound observations weekly for all residents with wounds to monitor for the presence of larvae and/or maggots in wounds. Any observations of larvae and/or maggots in wounds will be reported to physician at time of observation. The facility Administrator will report the findings of ambassador care rounds and environmental services rounds to the Quality Assurance and Performance Improvement Committee monthly x 6 months for recommendations including new interventions to assure compliance is sustained ongoing. The Director of Nursing will report the findings of wound care observations and progress notes review for notification of the physician for change of condition to the Quality Assurance and Performance Improvement Committee monthly x 6 months for recommendations including new interventions to assure compliance is sustained ongoing. The title of the person responsible for implementing the acceptable plan of correction: The Director of Nursing is responsible for implementing this acceptable credible allegation of compliance. Immediate Jeopardy removal date: 09/28/18 Validation: Immediate Jeopardy (IJ) was removed on 09/28/18 at 4:00 PM. Validation of the credible allegation for IJ removal was completed as evidenced by interviews with nurses, nursing assistants, housekeeping, and dietary services related to in-servicing which was received as a result of the survey. Any staff members not receiving the in-servicing prior to IJ removal were not allowed to clock in for work again until receiving the in-servicing. Review of the facility-wide skin sweeps revealed no other residents in the facility had larvae/maggots in their wounds. Contracted pest control services made an on-site facility visit on 09/28/18 during which they reviewed the facility's current treatment regimen for flies and suggested ways in which to improve management of flying insects in all areas of the building.

Based on physician interview, staff interview, and record review the facility neglected to address missing documentation of treatment/dressing changes on the Treatment Administration Record (TAR), and neglected to determine where and how wound contamination occurred after maggots were found in arterial/venous wounds on 07/30/18 for 1 of 5 residents (Resident #43) reviewed for wounds. As a result maggots were found a second time in Resident #43's wound bed and bedding one to two weeks after the initial observation of maggots on 07/30/18. Immediate Jeopardy (IJ) began on 07/30/18 when maggots were observed in Resident #43's arterial/venous wound which had not been receiving documented daily dressing changes per the TAR. Review of the resident's medical record and facility in-servicing records, as well as staff interviews, revealed after the 07/30/18 incident the staff was not in-serviced about contamination of wounds resulting in maggot formation, and root-cause analysis was not completed to try and determine where and how the resident's arterial/venous wounds were contaminated. One to two weeks after 07/30/18 a nurse and nursing assistant (NA) observed more maggots in Resident #43's arterial/venous wound bed and in his bedding. The IJ was removed on 09/28/18 when the facility implemented an acceptable credible allegation of IJ removal. The facility remained out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not IJ) to ensure monitoring of systems were carried out and employee in-servicing was completed. Findings included: Record review revealed Resident #43 was initially admitted to the facility on [DATE], and was readmitted to the facility on [DATE]. The resident's documented [DIAGNOSES REDACTED]. Resident #43's 06/22/18 Admit/Readmit Screener documented he had suspected bilateral deep tissue injury (DTIs) to his heels, an arterial/venous ulcer to his right lower inner leg, and an arterial/venous ulcer to his left lower inner leg. Review of a care plan from a previous admitted d 04/03/18 revealed The resident has DTI and potential for pressure ulcer development r/t (related to) impaired bed mobility, bowel bladder incontinence was identified as a problem. Interventions to this problem included administering treatments as ordered and monitoring for effectiveness, assessing/recording/monitoring wound healing, and reporting improvements/declines to the primary physician/Medical Director. The resident's 06/29/18 admission minimum data set (MDS) documented his cognition was severely impaired, he did not exhibit rejection of care, he required extensive assistance from staff to being dependent on staff for his activities of daily living (ADLs) except for requiring only supervision with eating, he had two unstageable deep tissue injury pressure ulcers, he had two arterial/venous ulcers, and he was receiving [MEDICAL TREATMENT] services. Review of the resident's (MONTH) (YEAR) TAR revealed the treatments/dressing changes to his bilateral lower extremity ulcers were not initialed off as being completed on 07/02/18, 07/03/18, 07/04/18, 07/06/18, 07/07/18, 07/08/18, 07/09/18, 07/16/18 (the resident was seen at the wound clinic on this day), 07/18/18, 07/19/18, 07/20/18, 07/21/18, 07/23/18 (the resident was sent out to the emergency room and returned to the facility on this day), 07/25/18, 07/27/18, 07/28/18, and 07/30/18 (Nurse #2 changed some of the dressings on this evening until she observed maggots in an arterial/venous wound). Consult notes documented Resident #43 was seen by the wound clinic on 07/16/18, and there was no documentation of infection or the presence of maggots in the wound clinic treatment notes. On 07/17/18 the resident's care plan was updated to reflect that he had bilateral DTIs to his heels, an arterial/venous ulcer to his right lower lateral leg, and an arterial/venous ulcer to his left lower medial leg. A 07/30/18 progress note, written at 11:06 PM by Nurse #2, documented, While changing resident's BLE (bilateral lower extremity) dressings, noted left lower extremity to have foul, foul odor with copious amounts of drainage noted coming from all sites, also noted large amount of larvae coming out of wounds on lower left leg, Administrative nurse .notified, resident sent to hospital to be evaluated and treated Dressing to RLE (right lower extremity) was changed without difficulty with copious amounts of foul purulent drainage noted On 09/26/18 at 4:20 PM Nurse #2 stated on 07/30/18 nursing assistant (NA) #1 came to her stating that when she provided incontinent care to Resident #43 the dressings to his bilateral lower legs rolled down and needed to be secured and/or changed. The nurse reported she decided to change the dressings, and there was a large amount of wet, yellow to slightly green drainage on the existing dressings. She also commented there was a strong odor coming from both arterial/venous wounds, but the odor coming from the left lower leg wound was extremely strong and foul. According to Nurse #2, when she unwrapped the old dressing on the left leg five or six very large and plump maggots fell from the wound onto the resident's bed. Nurse #2 reported one of the dressings to the lower legs had a date on it, but she could not remember which one, and she could not remember what the date was. She stated she had experience dealing with maggots and infected wounds, and using that knowledge base, she would estimate that it had taken a week for the maggots to reach the stage at which they presented on 07/30/18. A 07/30/18 transfer form documented Resident #43 was sent to the emergency room (ER) due to ulcers to BLE (with) maggot infestation. A 07/30/18 ER report documented, .Wounds are not purulent and do not appear infected. There are no maggots seen in any of the wounds Patient certainly has chronic changes and chronic wounds to both feet. However, there is no evidence of acute infection to either foot though (it require antibiotics or hospitalization ). Discharge patient back to the nursing home and recommend that he resume treatments at his wound care center. Review of wound clinic consults revealed Resident #43's wounds were assessed and treated at the wound clinic on 07/31/18 and 08/09/18. There was no documentation of maggots to the wounds on any of these consult notes. Review of the resident's (MONTH) (YEAR) TAR revealed the treatments/dressing changes to his bilateral lower extremity ulcers were not initialed off as being completed on 08/01/18, 08/06/18, 08/08/18, 08/09/18 (the resident was seen at the wound clinic on this day), and 08/10/18. On 09/27/18 at 12:43 PM the Director of Nursing (DON) stated she assumed her current position on 08/01/18, but was not aware of any residents having maggots in their wounds until questions were asked during the survey. She commented when she talked with Nurse #8 (the Staff Development Coordinator-SDC), Nurse #8 reported no in-servicing or root cause analysis was done concerning maggot infestation because the facility felt it had handled the problem appropriately by sending Resident #43 to the ER and wound clinic. On 09/27/18 at 4:18 PM Nurse #5, the current Treatment Nurse, stated he did see a single maggot on Resident #43's bed after the resident's wound dressings were changed. He reported this sighting occurred a couple of weeks after the resident was sent out to theER on [DATE] due to maggot infestation and decline in wound status. He commented that he called the wound clinic to discuss his observation, and the resident was seen there the next day. On 09/27/18 at 5:05 PM NA #1 stated she sometimes helped the nurses position and hold Resident #43's legs when the nurses were changing the dressings on his arterial/venous wounds. She reported that sometimes the resident received dressing changes on first shift before he left for [MEDICAL TREATMENT], but on other days it was too hectic on first shift, and his dressings were supposed to be changed on second shift after the resident returned from [MEDICAL TREATMENT]. According to NA #1, she had observed maggots in Resident #43's lower leg wounds twice. She commented the first time was on 07/30/18 and the next time was one to two weeks later. NA #1 stated that both times very large maggots fell from the wound bed onto the floor and the resident's bed. She also remarked that there were at least five or six very plump maggots present both times and that the resident went out to the wound clinic the day after both observations. On 09/27/18 at 5:26 PM the DON stated she was not aware of any problems with staff not signing treatments off on the TARs. However, she commented that no staff had complained to her that they were unable to complete treatments/dressings changes. On 09/27/18 at 5:41 PM NA #2 stated he worked on third shift, and about one and a half to two months ago when he was rounding on residents who were in his assignment, Resident #43 seemed restless so he decided to check him to see if he was wet or soiled. The NA reported when he pulled the covers back the resident's bed was full of large maggots. On 09/27/18 at 6:02 PM Resident #43's primary physician and the facility's Medical Director stated if the maggots in the resident's arterial/venous wounds were as big as staff described them, it had probably taken a week for them to mature. He reported that obviously these maggots were not being used therapeutically, and they grew in the wound due to contamination. He commented that it would be important to determine where and how the contamination occurred since the resident resided in the facility but left the facility with family, and went to the [MEDICAL TREATMENT] center three times a week, to the wound clinic, and to the surgeon's office every two weeks. According to the Medical Director, if there were maggots, they had no negative effect since the resident was already on a bad vascular path which would eventually end in the bilateral amputation of Resident #43's legs. On 09/27/18 at 11:16 PM, during a telephone interview, Nurse #3 stated she worked on third shift. She reported on 07/30/18 she had maggots collected from Resident #43's bed, placed them in a sterile container, and refrigerated them. However, she commented she disposed of them at the end of her shift. According to Nurse #3, she thought six large maggots were probably collected on 07/30/18, but she commented about a week or a week and a half later eight to nine maggots were once again found in Resident #43's wound and bedding. On 09/28/18 at 10:17 AM Nurse #8 (SDC and Infection Control) stated she remembered hearing mention of maggots in a resident's wound, and that from an infection control standpoint, you would want to figure out when and where the resident's wounds were contaminated by flies. She commented in-servicing about pest control, prompt removal of meal trays from resident rooms, frequent emptying of trash in resident rooms, and the importance of timely incontinent care would have been important topics to educate the staff about. However, she stated that root-cause analysis and infection and pest control in-servicing were not conducted after maggots were found either time in Resident #43's wound and/or room. On 09/28/18 at 11:50 AM the DON stated she had asked staff about the wound treatments that were not initialed off on the TAR for Resident #43. However, she reported that no staff member, other than Nurse #1 who stated she was sure she did all dressing changes for the resident on 07/28/18, could say without a shadow of a doubt that treatments were provided to Resident #43 on the days when they were not initialed off on the TAR. According to the DON, her expectation was that nurses initial treatments as being done on the TAR as soon as they were completed. She also commented that during report first shift nurses should have shared with second shift nurses if Resident #43 left for [MEDICAL TREATMENT] before his wound dressings could be changed on first shift, but she was not sure that this was happening based on the missing TAR documentation. On 09/28/18 at 3:55 PM, during a telephone interview, Nurse #4 stated she was assisting Nurse #2 with Resident #43's dressing changes on 07/30/18. She stated the arterial wounds had a very pungent odor, and when they got to the left leg arterial/venous wound she saw something drop on the bed. She commented she saw at least three large maggots fall from the wound bed before she had to leave the room. She reported she called 911 and started the paperwork for sending Resident #43 to the ER. Nurse #4 commented she was not sure how long it had been since the resident's dressings had been changed last, but she thought it could have been awhile since there was some confusion about whether first or second shift was responsible for the wound treatments. According to Nurse #4, she was prepared to make a statement about what she saw since it was such an infection control issue, but she reported she was never asked to do so by the facility. The DON and Corporate Consultants were notified of the Immediate Jeopardy on 09/27/18 at 6:25 PM. On 09/28/18 the facility provided an acceptable credible allegation for Immediate Jeopardy removal that included the following: The plan of correcting the specific deficiency including the processes that led to the deficient practice cited on 9/27/2018 at approximately 6pm: 0n 7/30/18 the nurse working second shift noted larvae and maggots in wound. The nurse documented the assessment of larva in the wound of the resident and notified nursing administration. The nurse sent the resident to the emergency department for wound evaluation. The emergency department reports no record of larva present in the wound. The resident returned to the facility 7/30/18 with recommendations to resume treatment with the wound care clinic. 8/8/18 a nurse and certified nursing assistant again witnessed larvae and maggots to wound. The wound clinic was notified and the facility was instructed for the resident to keep scheduled appointment with wound clinic the following day. The interdisciplinary team (IDT) including the Director of Nursing (DON), Minimal data set Nurse (MDS) and Corporate Minimum data set Nursing supervisor met on 9/27/2018 and determined the root cause to be a breakdown in the wound care delivery process resulting in inconsistent documentation of treatment performed. An additional root cause was determined that there was inconsistent communication when the resident did not receive their wound treatment because the resident was out to [MEDICAL TREATMENT] during day shift hours and wound care needed to be completed on evening shift. An additional root cause was that the wound treatments could not be performed on day shift because resident was out of the facility for [MEDICAL TREATMENT]. On 9/28/18 24 hour initial allegation report for neglect related to failure to document wound care delivery completed and submitted to Health Care Personnel Registry. The procedure for implementing the acceptable plan of correction for the specific deficiency cited: On 9/27/18 the Quality Assurance and Performance Improvement committee met. They were notified of the Immediate Jeopardy and reviewed wound care documentation practices. The team participated in root cause analysis and development of acceptable plan of correction. On 9/27/18 administration time for residents that receive [MEDICAL TREATMENT] treatment during day shift hours wound care has been scheduled to be completed on evening shift. On 9/27/2018 education by nursing supervisor began for all licensed nurses that wound care to be documented on TAR upon completion of treatment. Out of 20 licensed nurses on staff 18 have been educated. Licensed nurses who have yet to receive the education will not be permitted to work until the education is received. On 9/27/2018 in-service education by nursing supervisor began for all licensed nurses that for any resident receiving [MEDICAL TREATMENT] treatment during day shift hours that wound care to be scheduled for completion on evening shift. Out of 20 licensed nurses on staff 18 have been educated. Licensed nurses who have yet to receive the education will not be permitted to work until the education is received. On 9/28/18 in-service education began by nursing supervisor for all staff for neglect. Out of 83 staff members 66 have been educated. Staff who have yet to receive the education will not be permitted to work until the education is received. On 9/28/18 in-service education began by nursing supervisor for certified nursing assistants related to reporting to licensed nurse if resident wound dressing is heavily soiled and / or not in place. Out of 33 certified nursing assistants 6 have been educated. Staff who have yet to receive the education will not be permitted to work until the education is received. On 9/27/2018 the treatment assessment record (TAR) for all residents were checked by the Director of Nursing to ensure wound care had been documented. Documentation was validated by observation of resident's dressings in place and noted to be clean, dry and intact. The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements: On 9/27/18 the Quality Assurance and Performance Committee met and decided that on 9/28/18 the Director of Nursing, Assistant Director of Nursing and/or Nursing supervisor began audits of TAR for completion of documentation of wound care completion daily. Documentation of wound care documentation will be validated by observation of resident's dressings in place and noted to be clean, dry and intact. If a licensed nurse is identified as not documenting wound care completion the nurse will be provided a one to one re-education. The Director of Nursing will report the findings of TAR wound care documentation audits to the Quality Assurance and Performance Improvement Committee monthly x 6 months for recommendations including new interventions to assure compliance is sustained ongoing. The title of the person responsible for implementing the acceptable plan of correction: The Director of Nursing is responsible for implementing this acceptable credible allegation of compliance Immediate Jeopardy removal date: 09/28/18 Validation: Immediate Jeopardy (IJ) was removed on 09/28/18 at 4:00 PM. Validation of the credible allegation for IJ removal was completed as evidenced by interviews with nurses, nursing assistants, housekeeping, and dietary services related to in-servicing which was received as a result of the survey. Any staff members not receiving the in-servicing prior to IJ removal were not allowed to clock in for work again until receiving the in-servicing. Review of the facility-wide skin sweeps revealed no other residents in the facility had larvae/maggots in their wounds. Contracted pest control services made an on-site facility visit on 09/28/18 during which they reviewed the facility's current treatment regimen for flies and suggested ways in which to improve management of flying insects in all areas of the building.

Based on staff interview and record review the facility failed to provide restorative nursing services to maintain the activity of daily living (ADL) progress made in therapy by 1 of 1 sampled residents (Resident #113) who was reviewed for therapy and restorative services. Findings included: Record review revealed Resident #113 was admitted to the facility on [DATE] and was discharged to another facility on 05/15/18. The resident's documented [DIAGNOSES REDACTED]. Review of therapy documentation revealed Resident #113 was on physical therapy caseload from 01/04/18 until 02/26/18, and was on occupational therapy caseload from 01/05/18 until 02/26/18. The resident's 01/10/18 admission minimum data set (MDS) documented her cognition was moderately impaired, she exhibited no behaviors including rejection of care, she required extensive assistance by two staff members with transfers/locomotion off the unit/toileting, she required extensive assistance by one staff member with bed mobility/locomotion on the unit/dressing/hygiene, she required limited assistance by a staff member with bathing, and she did not walk in the room or corridor during the look-back period. On 01/25/18 The resident requires limited to extensive assist with ADLs (activities of daily living) and is at fall risk due to need for assist with transfers and ambulation due to generalized weakness . was identified as a problem in the resident's care plan. Interventions to this problem included referral to therapy to reach the resident's goal of going home. Resident #113's 02/26/18 Physical Therapy Discharge Summary documented she met her long term goal for bed mobility by progressing from requiring maximum assist and 75% verbal cuing to being independent with no verbal cuing required. The summary also documented the resident met her maximum potential with the following long term goals as evidenced by: the resident went from requiring maximum assist and 75% cuing with transfers to requiring only supervised assistance and 5% cuing, and the resident went from ambulating 50 feet using a rolling walker with maximum assist to ambulating 350 feet using a rolling walker with stand-by assist. The summary documented, Maximum Potential Achieved, referred for RNP (restorative nursing program). A Physical Therapy Restorative Nursing Program plan documented Resident #113 was to receive restorative nursing services starting on 03/01/18 and ending on 04/12/18. The plan called for the resident to receive sitting quad strengthening in the form of leg kicks, two sets of ten for each leg one time a day, and to receive sit to stand exercise from the wheelchair, two sets of ten one time a day. The plan was signed off on by the Director of Nursing (DON), a physical therapist, and Nurse #9 (Restorative) on 03/01/18. The resident's 04/07/18 quarterly MDS documented her cognition was intact, she exhibited no behaviors including rejection of care, she required extensive assistance by two staff members with transfers, required extensive assistance by one staff member with bed mobility/locomotion on the unit/dressing/hygiene, was dependent on a staff member for toileting/bathing/locomotion off the unit, and she did not walk in the room or corridor during the look-back period. On 09/26/18 at 10:45 AM Physical Therapist (PT) #1 stated between 01/04/18 and 02/26/18 Resident #113 went from requiring a lot of staff assistance with bed mobility to being independent, went from requiring a lot of staff assistance with transfers from the bed to the chair to requiring only staff supervision, and went from walking 50 feet using a walker with a lot of staff assistance to walking 350 feet using a walker with less staff assistance. He reported the resident was discharged from physical therapy because she met her maximum potential. On 09/26/18 at 10:52 AM Occupational Therapist (OT) #1 stated between 01/05/18 and 02/26/18 Resident #113 cooperated and participated in therapy. She reported during the time the resident received occupational therapy she made the following improvements: the resident went from being barely able to move her arms to minimal resistance with full range of motion, went from requiring a lot of assistance to being independent with self-feeding, went from moderate assist to set-up only with grooming and hygiene, and went from requiring a lot of assistance to requiring a little bit of assistance with toileting. However, the OT commented Resident #113 seemed to give up on improving her toileting skills toward the end of her therapy. On 09/26/18 at 11:23 AM Nursing Assistant (NA) #5 stated Resident #113 was alert and oriented, and required extensive assistance with her ADLs except she was able to feed herself. She reported the resident received therapy services, but she did not remember there being much difference in the resident's ability to help out with her ADLs after she was discharged from therapy. She commented the resident used the call bell, and would ask for assistance. The NA stated she did not remember seeing the resident ambulate, and when out of bed, the resident was in a wheelchair. On 09/26/18 at 12:23 PM Nurse #5 stated Resident #113 was confused when admitted , but became more alert and oriented during her nursing home stay. He reported that the resident could use her hands, but had very little strength and mobility in her trunk and lower extremities. He commented the resident could not wheel herself in her wheelchair, and required extensive assistance from staff to being dependent on the staff for her ADLs. According to Nurse #5, Resident #113 could ring the call bell, but she did not use it very often because she did not want to bother the staff. He reported the resident's ADL status remained about the same during her stay. On 09/26/18 at 1:02 PM Nurse #9 (Restorative) stated she was the staff member responsible for implementing restorative plans of care. However, she reported there was no restorative documentation for Resident #113 because the resident never received restorative services since she was not aware that Resident #113 was supposed to receive them. She reported that the therapists usually provided her with a copy of the restorative plan they designed, and she commented this plan outlined the services to be provided, the frequency of the services, and the duration of the services. On 09/26/18 at 1:08 PM PT #1 stated he could only select two ADL areas to carry forward in Resident #113's restorative care plan. He reported he selected two types of exercises to keep the resident mobile, limber, and to maintain her strength. According to PT #1, the restorative program was important because it kept residents from losing the ADL progress they made while working with therapy. He commented when he designed a restorative plan he signed off on it, the DON signed off on it, and the Restorative Nurse signed off on it. On 09/26/18 at 3:46 PM NA #4 stated Resident #113 required extensive assistance with her ADLs during her entire nursing home stay. She reported the resident tried to do as much as possible for herself, but would use the call bell for staff assistance when she needed help. She commented the only difference she saw in the resident after therapy was that she could help turn and reposition herself more in the bed. On 09/28/18 at 11:50 AM the DON stated therapists designed restorative nursing plans when residents met their maximum potential and had shown significant ADL improvement which could be continued through the provision of restorative nursing services. She commented Nurse #9 (Restorative) was responsible for seeing that the plans were implemented. She reported if Resident #113 had a restorative nursing plan which had been signed off on by a therapist, the DON, and the Restorative Nurse, then the plan should have been implemented. She commented the lack of implementation had the potential of causing the resident to lose progress which had been made with physical and occupational therapy.

Based on record reviews and staff interviews the facility failed to provide interventions to prevent pressure ulcer development in 1 of 3 residents (Resident # 84). Findings Include: Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The fracture was sustained in a fall on 7/13/11 while living in an assistive living community. She was admitted to the facility for physical and occupational therapy. A review of the medical record revealed Resident #84 was assessed by Staff Nurse #1 upon her admission. The Admission Nursing Assessment was completed on 8/18/11 and revealed the resident had reddened areas on both elbows and sacrum. The resident scored 13 on the Braden Scale - for Predicting Pressure Sore Risk on 8/18/11. A number higher than 12 represented a high risk for the development of pressure sores Review of the Minimum Data Set ((MDS) dated [DATE] documented Resident #84 had a Brief Interview Mental Status (BIMS) score of 5 out of 12. The resident was severely impaired in cognitive skills and was a total care patient who required extensive assistance in all areas of daily care and was incontinent of bladder and bowel. The MDS indicated the resident had (3) stage 1 pressure sores. A stage 1 pressure sore is defined in the MDS as intact skin with nonblanchable redness of a localized area usually over a bony prominence. A review of the Care Area Assessment (CAA) Summary dated 8/31/11 indicated care areas which triggered to be addressed in care plans. Pressure ulcers triggered but were not checked to be addressed in care plans for the resident. A care plan for Resident #84 was initiated on 9/6/2011 which identified one of the resident ' s problems as at risk for skin breakdown related to decreased mobility. The care plan was updated on 9/7/11 from at risk to the presence of (2) pressure ulcers on the resident ' s heels. The care plan was never updated to include the sacral ulcer or to note the pressure wounds had healed. During the review of the resident ' s medical record no interim care plan was found for the time period of admission on 8/18/2011 until 9/6/2011. A review of Resident #84 ' s nursing notes revealed no change in skin assessment status, no treatments to the 3 documented Stage I pressure sores, and no interventions to prevent further skin breakdown until 9/6/2011. A comprehensive care plan initiated on 9/6/2011 addressed risk of skin breakdown due to decreased mobility. The care plan was updated on 9/7/2011 due to development of 1 Stage II pressure ulcer to the left heel and 1 Stage II pressure ulcer to the right heel. The care plan never addressed the Stage II sacral ulcer which developed on 9/14/2011. A review of the nursing notes in Resident #84 ' s medical chart on 9/7/2011 revealed the resident complained of bilateral heel pain after therapy. The presence of a stage II pressure ulcer measuring 0.5cm x 0.6cm (centimeters) was documented on the left heel. A Stage II pressure ulcer is defined as partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. A stage I unopened pressure wound was documented on the right heal. A note was faxed to the primary doctor and an order was obtained for Polymen 7 days and as needed to left heel Stage II pressure ulcer. Clean with Sea Clean with each dressing change. A Wound / Skin Healing Record dated 9/7/11 indicated a pressure ulcer to the left heel but did not document an original stage when discovered. On 9/14/11 the Wound /Skin Healing Record revealed the pressure ulcer measured 2cm x 2.5cm, had a small amount of drainage, and was identified as a Stage II. An [MEDICATION NAME] level of 3.4 (3.4-5.0) was obtained on 9/14/11. On 9/21/11 the Treatment Nurse documented the wound measured 0.5cm x 0.5 cm with no drainage. The Wound / Skin Healing Record dated 9/28/11 indicated the left heel area was closed and had healed. A separate Wound /Skin Healing Record was initiated on 9/10/11 for a sacral pressure wound. An original stage at time of discovery was not documented. On 9/14/11 the wound measured 5cm x 0.5cm and was documented as a Stage II. Review of the 9/21/11 Wound/Skin Healing Record sacral pressure ulcer had decreased to 0.4cm x 0.3cm. The Monthly Summary completed by Nurse #1 dated 10/5/11 indicated no open areas to skin and no pressure ulcers. Observation during incontinent care on 11/2/2011 at 11:55 AM revealed no open areas and wounds healed. During an interview with the MDS Nurse on 11/2/11 at 3:20 PM she revealed it was the facility policy to provide nursing with an interim care plan within 24 hours for each new admission. She indicated the interim care plan was based on the Nursing Admission Assessment and admitting diagnoses. She reported a comprehensive care plan was developed for each resident after the first full MDS assessment was completed. She stated the purpose of care plans was to provide nursing staff with guidance in the care of the facility residents. The MDS Nurse was unable to find an interim care plan for Resident #4. The MDS Nurse revealed she had just recently taken over the MDS position and was still learning how to complete all the care plans. She stated she did not know how Resident # 84 had been at the facility for 19 days with no care plan. She stated she had missed doing the interim for the resident. The nurse revealed she was not aware Resident #84 was not receiving treatments for the pressure ulcers documented on the MDS 8/31/2011 until 9/7/2011. An interview was conducted with Nurse # 2 on 11/3/11 at 9:40 AM. She revealed a new admission was given a head to toe assessment by nursing staff, medical orders were clarified, and MDS created an interim care plan in the first 24 hours. She reported the interim care plan was based on MD orders, diagnoses, and assessments. She stated the interim care plan told staff how to care for the new resident until a comprehensive care plan was completed. During an interview with the Nurse #3 on 11/3/11 at 9:55 AM she revealed she had recently become the facility Treatment Nurse. She indicated she initiated treatment on Resident #84 as soon as the pressure ulcers were reported to her. She stated she obtained a Dr. ' s order per facility protocol and initiated a Wound / Treat Healing Record. She indicated once treatment was begun the wounds healed in less than a month. During an interview with the Director of Nursing (DON) on 11/3/11 at 10:10 AM she revealed it was her expectation each resident would have an accurate assessment, an interim plan of care, and interventions in place to prevent pressure sores when a new admission was identified as high risk. She stated the interim care plan was based on the ICD9 ([DIAGNOSES REDACTED]. She indicated she was not aware a resident identified on admission as high risk with a reddened sacral area had gone 19 days without a care plan and had received no treatment for [REDACTED]. She stated the MDS Nurse and Treatment Nurse were new but nursing staff should have identified the pressure sores and notified the Treatment Nurse so she could provide care to areas of breakdown.

Based upon staff interviews and record reviews the facility failed to develop and revise comprehensive plans of care for 2 of 15 sampled Residents (Resident #84 and Resident #51). Findings Include: Resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The fracture was sustained in a fall on 7/13/11 while living in an assistive living community. She was admitted to the facility for physical and occupational therapy. A review of the medical record revealed Resident #84 was assessed by Staff Nurse#1 upon her admission. The Admission Nursing Assessment was completed on 8/18/11 and revealed the resident had reddened areas on both elbows and sacrum. The resident scored 13 on the Braden Scale - for Predicting Pressure Sore Risk on 8/18/11. Per scoring scale, any number higher than 12 represented a high risk for the development of pressure sores. A dietary assessment completed on 8/29/2011 indicated the resident had good skin tugor, no wounds, and no swelling. Review of the Minimum Data Set ((MDS) dated [DATE] documented Resident #84 had a Brief Interview Mental Status (BIMS) score of 5 out of 12. The resident was severely impaired in cognitive skills and was a total care patient who required extensive assistance in all areas of daily care and was incontinent of bladder and bowel. The MDS indicated the resident had (3) stage 1 pressure sores. A stage 1 pressure sore is defined in the MDS as intact skin with nonblanchable redness of a localized area usually over a bony prominence. A review of the Care Area Assessment (CAA) Summary dated 8/31/11 indicated care areas triggered to be addressed in care plans. Pressure ulcers triggered but were not checked to be addressed in care plans for the resident. A care plan for Resident #84 was initiated on 9/6/2011 which identified one of the residen's problems as at risk for skin breakdown related to decreased mobility. The care plan was updated on 9/7/11 from at risk to the presence of (2) pressure ulcers on the resident's heels. The care plan was never updated to include the sacral ulcer or to note the pressure wounds had healed. During the review of the resident's medical record no interim care plan was found for the time period of admission on 8/18/2011 until 9/6/2011. A review of the nursing notes in Resident #84 ' s medical chart on 9/7/2011 revealed the resident complained of bilateral heel pain after therapy. The presence of a stage II pressure ulcer measuring 0.5cm x 0.6cm (centimeters) was documented on the left heel. A Stage II pressure ulcer is defined as partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. A stage I unopened pressure wound was documented on the right heal. A note was faxed to the primary doctor and an order was obtained for Polymen 7 days and prn to left heel Stage II pressure ulcer. Clean with sea clean with each dressing change. A Wound / Skin Healing Record dated 9/7/11 indicated a pressure ulcer to the left heel but did not document an original stage when discovered. On 9/14/11 the Wound /Skin Healing Record revealed the pressure ulcer measured 2cm x 2.5cm, had a small amount of drainage, and was identified as a Stage II. An [MEDICATION NAME] level of 3.4 (3.4-5.0) was obtained on 9/14/11. On 9/21/11 the Treatment Nurse documented the wound measured 0.5cm x 0.5 cm with no drainage. The Wound / Skin Healing Record dated 9/28/11 indicated the left heel area was closed and had healed. A separate Wound /Skin Healing Record was initiated on 9/10/11 for a sacral pressure wound. An original stage at time of discovery was not documented. On 9/14/11 the wound measured 5cm x 0.5cm and was documented as a Stage II. Review of the 9/21/11 Wound/Skin Healing Record sacral pressure ulcer had decreased to 0.4cm x 0.3cm. The Monthly Summary completed by Nurse #1 dated 10/5/11 indicated no open areas to skin and no pressure ulcers. Observation of incontinence care on 11/2/2011 at 8:55 AM revealed no open areas and all pressure ulcers had healed. During an interview with the MDS Nurse on 11/2/11 at 3:20 PM she revealed it was the facility policy to initiate an interim care plan for all new admissions within 24 hours. She indicated the interim care plan was based on the Nursing Admission Assessment and admitting diagnoses. She stated if a resident was admitted during first shift or the beginning of second shift she initiated an interim care plan the day of admission. The MDS Nurse reported residents admitted after she went home had an interim care plan initiated the next morning. The MDS Nurse was not able to find an interim care plan for Resident #84 in the medical record. The MDS Nurse revealed she had just recently taken over the MDS position and was still learning how to complete all the care plans. She stated she did not know how Resident # 84 had been at the facility for 19 days with no care plan. She indicated she had missed doing an interim for the resident. The MDS Nurse revealed the Treatment Nurse sends out a weekly report to update staff on wounds and treatments. The update was given to nursing, MDS, and dietary. The MDS Nurse stated she had not received an update Resident #84 had developed a sacral wound or that the pressure ulcers had healed. An interview was conducted with Nurse # 2 on 11/3/11 at 9:40 AM. She revealed a new admission was given a head to toe assessment by nursing staff, medical orders were clarified, and MDS created an interim care plan the day of admission or the next day. She reported the interim care plan was based on MD orders, diagnoses, and assessments. She stated the interim care plan told staff how to care for the new resident until a comprehensive care plan was completed. During an interview with the Nurse #3 on 11/3/11 at 9:55 AM she revealed she had recently become the facility Treatment Nurse. She stated she was learning how to do the treatments and how to document the treatments given. She indicated she tried to update staff on which residents had new pressure ulcers and when pressure ulcers had healed. The Treatment Nurse could not remember reporting to MDS the sacral ulcer or the healing of the wounds. During an interview with the Director of Nursing (DON) on 11/3/11 at 10:10 AM she revealed it was her expectation each resident would have an interim care plan in place within 24 hours of admission to inform staff of the care the resident requires. She stated the interim care plan was based on the ICD9 ([DIAGNOSES REDACTED]. She indicated she was not aware a resident had gone 19 days without a care plan and had developed pressure ulcers until the MDS Nurse made her aware. She stated the MDS Nurse and Treatment Nurse were new but the interim care plan should have been initiated and the comprehensive care plan should have been updated as the status of the pressure ulcers changed. 2. Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] indicated Resident #51 was cognitively intact with a disease [DIAGNOSES REDACTED]. A record review of the physician orders revealed an order for [REDACTED]. A record review of Resident #51 medical record revealed there was no comprehensive care plan for [MEDICAL TREATMENT] treatment. An interview with the MDS Nurse Assistant on 11/2/11 at 10:55am revealed she did not recall doing a [MEDICAL TREATMENT] care plan for Resident #51. She indicated she would follow-up with this concern. An Interview with MDS Nurse Assistant on 11/2/11 at 11:19am revealed she did not know how she missed doing a care plan for her [MEDICAL TREATMENT] but she has now created a care plan. A record review of the facility policy and procedures for [MEDICAL TREATMENT] residents dated 3/13/11 was conducted. It indicated a care plan would be present to include other [MEDICAL TREATMENT] care measures and precautions as prescribed by the physician. An interview with the Director of Nursing (DON) on 11/3/11 at 9:37am revealed they had a care plan meeting for Resident #51 but did agree there needed to be formal care plan documentation for the staff.