Every finding on record at Ridge Valley Center for Nursing and Rehabilitation

Based on observations and staff interviews, the facility failed to remove 2 expired Bisacodyl suppositories, 10 expired omeprazole tablets in accordance with the manufacturer's expiration date, and 27 unidentifiable loose pills from the medication carts. The facility also failed to date 2 opened insulin pens per manufacturer's specification for 4 of 4 medication carts (A, B, C and D) reviewed for medication storage.The findings included: Review of the package inserts for insulin Glargine revealed it could be stored under refrigeration at 36 to 46 Fahrenheit (F) unopened until the expiration date. Once the insulin pen was opened and in use, it could be kept at room temperatures below 86 F for up to 28 days. Discarded the insulin after 28 days even if it still had insulin in it. a.During a medication storage audit conducted on 12/02/25 at 4:34 PM in the presence of Certified Medication Aide (CMA) #1, two (2) Bisacodyl rectal suppositories 10 milligrams (mg) that expired on 10/31/25 were found in the medication cart for A Hall and available for use. An interview was conducted with CMA #1 on 12/02/25 at 4:36 PM. He acknowledged that the 2 suppositories were expired and should be discarded. He did not notice the 2 expired suppositories in the medication cart and explained he typically checked the medication cart for expired medications at the end of the shift. During an interview conducted on 12/02/25 at 4:41 PM, Nurse #1 stated she was the supervising nurse for CMA #1. She confirmed the 2 Bisacodyl suppositories were expired and needed to be discarded. She expected the nurse who worked the previous shift to check the medication cart before shift transition to ensure the medication cart was free of expired medications. b. During a medication storage audit conducted on 12/02/25 at 5:00 PM in the present of Nurse #1, seventeen (17) unidentifiable loose tablets with different colors and shapes were found at the bottom of the drawer of medication cart for B Hall. Out of the 17 loose pills, 15 tablets were round shaped, and 2 tablets were oblong. An interview was conducted with Nurse #1 on 12/02/25 at 5:02 PM. She stated it was her first shift working with the medication cart for B Hall and added she was a visiting nurse from another facility. She explained she had just started the shift and did not have time to check the medication cart yet. Nurse #1 was unable to provide information related to the name of the loose pills and their expiration dates. She acknowledged that all the loose pills should be discarded. c. During a medication storage audit conducted on 12/02/25 at 5:17 PM in the presence of CMA #2, ten (10) unidentifiable loose tablets with different colors and shapes were found at the bottom of the drawer of medication cart for C Hall. Out of the 10 loose pills, 8 tablets were round shaped, and 2 tablets were oblong. In addition, 10 tablets of Omeprazole 20 mg that expired on 11/30/25 were also found in the medication cart and ready to be used. An interview was conducted with CMA #2 on 12/02/25 at 5:19 PM. He stated he had been instructed to check his medication cart each shift. He denied seeing any loose pills when he checked the medication cart for C Hall yesterday. CMA #2 indicated the expired Omeprazole that was found in the medication cart was his oversight. He acknowledged that all the loose pills and the expired Omeprazole should be discarded in a timely manner. d. During a medication storage audit conducted on 12/02/25 at 5:29 PM in the presence of CMA #3. Two (2) opened insulin Glargine pens that stored in room temperature were found in medication cart for D Hall without any opened date, and available for use. An interview was conducted with CMA #3 on 12/02/25 at 5:32 PM. She stated that as a CMA, she did not deal with insulin. The nurse was supposed to date the insulin once it was opened. During an interview conducted on 12/02/25 at 5:37 PM. Nurse #2 acknowledged that she was the supervisor nurse for CMA #3. She could not explain why both insulin pens in the medication cart for D Hall were not dated after they were opened and in use. It was her expectation for all the nurses to date the insulin pen or vial after it had been opened. A joint interview was conducted with the Director of Nursing (DON) and the Administrator on 12/02/25 at 5:48 PM. Both the DON and the Administrator stated it was their expectation for all the nursing staff to follow medication storage guidelines as specified by the manufacturer to ensure all insulin were dated after they were opened and discard all the expired and loose pills in a timely manner as indicated.

Based on observations, record reviews and staff interviews, the facility failed to identify the need for Enhanced Barrier Precautions (EBP) for Resident #2 with an unhealed surgical wound and failed to implement their infection control policy when Nurse #2 did not apply a gown when performing wound care for Resident #2. In addition, Nurse #2 failed to change gloves and perform hand hygiene after cleansing wounds and applying the ordered dressing on Resident #2 and Resident #3. This occurred for 1 of 1 staff member observed for infection control practices. The findings included:Review of the facility's Enhanced Barrier Precautions policy dated 2025 revealed: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. 2. Initiation of EBP: b. An order for enhanced barrier precautions will be obtained for residents for unhealed surgical wounds.Review of the facility's Hand Hygiene policy dated 2025 revealed: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. 1. Staff will perform hand hygiene when indicated using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in but not limited to the attached hand hygiene table. 6. The use of gloves does not replace hand hygiene. If your tasks require gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves.Review of the facility's policy for Clean Dressing Change dated 2024, revealed: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross contamination. 9. Loosen the tape and remove the existing dressing. 10. Remove gloves pulling inside out over the dressing and discard into appropriate receptacle. 11. Wash hands and put on clean gloves.1. An observation was made of Nurse #2 performing a surgical wound dressing change to Resident #2 on 07/16/25 at 2:50 PM. There was no EBP sign posted on or near the Resident's door. The Nurse sanitized her hands and donned gloves but did not don a gown, then proceeded to remove the existing dressing from the back of Resident #2's neck. Without removing her gloves and performing hand hygiene and applying new gloves, the Nurse proceeded to pick up the gauze soaked with wound cleanser and cleansed the wound. Nurse #2 then removed her gloves and performed hand hygiene and applied new gloves then applied the ordered dressing and secured it with a border dressing. The Nurse then removed her gloves and performed hand hygiene.An interview was conducted with Nurse #2 on 07/16/27 at 3:20 PM. The Nurse acknowledged there was no EBP sign posted on or around Resident #2's door. The Nurse was asked if a surgical wound constituted EBP and the Nurse stated she honestly did not know because it had been changed several times. The Nurse stated if Resident #2 should have been on EBP then she was aware that she should have applied a gown as well as gloves. Nurse #2 was asked to retrace the steps of the dressing change process and when the Nurse stated that she removed the old dressing she immediately stated she did not change her gloves and wash her hands, and she should have. The Nurse stated she just forgot the change her gloves. An interview was conducted with the Infection Preventionist (IP) on 07/16/25 at 3:35 PM. The IP explained that it was her responsibility to manage the infection control system in the facility, but she had not been doing it for long. The IP stated surgical wounds should have EBP posted, and it was an oversight on her part that Resident #2 did not have an EBP sign posted on her door. She stated Nurse #2 should have donned both gloves and gown for the dressing change procedure.During an interview with the Director of Nursing (DON) on 07/16/25 at 5:45 PM the DON acknowledged that there was no EBP sign posted on Resident #2's door and stated per the facility's policy on EBP there should have been a sign posted to inform the staff that the EBP should be followed. The DON indicated Nurse #2 should have changed her gloves and performed hand hygiene after she removed the old dressing.2. An observation was made of Nurse #2 performing a wound (skin tear) dressing change to Resident #3 on 07/16/25 at 3:10 PM. The Nurse sanitized her hands and donned gloves then proceeded to remove the existing dressing from the Residents left shin which was saturated with serosanguinous (bloody) drainage. Without removing her gloves and performing hand hygiene and applying new gloves, the Nurse proceeded to pick up the gauze soaked with wound cleanser and cleansed the wound. Nurse #2 then removed her gloves and performed hand hygiene and applied new gloves then applied the ordered dressing and secured it with a border dressing. The Nurse then removed her gloves and performed hand hygiene.An interview was conducted with Nurse #2 on 07/16/27 at 3:20 PM. Nurse #2 was asked to retrace the steps of the dressing change process and when the Nurse stated that she removed the old dressing she immediately stated she did not change her gloves and wash her hands just like she did not change them with the other dressing change, and she should have. The Nurse stated she just forgot to change her gloves.An interview was conducted with the Infection Preventionist (IP) on 07/16/25 at 3:35 PM. The IP explained that it was her responsibility to manage the infection control system in the facility, but she had not been doing it for long. The IP stated Nurse #2 should have changed her gloves and sanitized her hands after she removed the old dressing from Resident #3's shin.During an interview with the Director of Nursing (DON) on 07/16/25 at 5:45 PM the DON stated Nurse #2 should have changed her gloves and performed hand hygiene after she removed the old dressing from Resident #3's shin.

Based on record reviews and staff interviews, the facility failed to maintain an accurate Treatment Administration Record (TAR) for 1 of 3 residents (Resident #1) reviewed for wound care.The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus and bilateral below knee amputations (BKKA).Review of Resident #1's medical record revealed a physician order start date of 06/18/25 to cleanse the left below knee amputation (BKA) incision with wound cleanser then apply a petrolatum dressing (a wound dressing made of a fine mesh gauze infused with petrolatum and 3% bismuth and tribromophenate blend) then secure with gauze wrap and ACE bandage daily and as needed. The medical record also included a physician order for a start date of 06/19/25 for the right BKA to cleanse the incision with wound cleanser then apply a petrolatum dressing then secure with gauze wrap and ACE bandage daily and as needed.Review of Resident #1's 06/2025 TAR revealed there was no documentation on 06/21/25, 06/25/25, 06/27/25, 06/27/28, 06/28/25, 06/29/25 and 06/30/25 to indicate the treatment was completed as ordered.Review of Resident #1's medical record revealed a physician start date of 07/04/25 to cleanse the left BKA incision with wound cleanser then paint with betadine then apply a petrolatum dressing and secure with gauze wrap and ACE bandage daily and as needed. The medical record also included a physician order for a start date of 07/04/25 for the right BKA to cleanse the incision with wound cleanser then paint the incision with betadine then apply a petrolatum dressing then secure with gauze wrap and ACE bandage daily and as needed.Review of Resident #1's Treatment Administration Record (TAR) for 07/2025 revealed there was no documentation on 07/04/25 and 07/05/25 that the treatments had been completed as ordered.Attempts were made to interview Nurse #1 who worked on 06/21/25 but the attempts were unsuccessful.An interview was conducted on 07/16/25 with Nurse #2 who confirmed she worked on 06/25/25 for the day shift (7:00 AM - 7:00 PM). The Nurse explained that she normally signed off her treatments after she completed them, but she was really busy towards the end of June but ensured she completed the treatment as ordered.An interview was conducted on 07/16/25 at 9:30 AM with Nurse #3 who confirmed she worked the day shift on 06/27/25, 06/28/25, 06/29/25, 07/02/25 and 07/03/25. The Nurse explained that it took her several days to learn the facility's electronic medical record and that she had to go to the TAR to sign off for the treatments, but Nurse #3 assured that the treatments were completed as ordered.An interview was conducted with Nurse #4 on 07/17/25 at 10:20 AM who confirmed she worked 06/30/25, 07/04/25 and 07/05/25 on the day shift. The Nurse explained that she was aware of Resident #1's bilateral BKA (BBKA) stump dressings and assured the dressings were completed but she forgot to sign off on the TAR. During an interview with the Director of Nursing (DON) on 07/16/25 at 5:45 PM the DON reported that she educated nurses to sign off for the treatments as they completed them and that was her expectation. The DON stated that the treatments were being done.

Based on observation, record review, and staff interviews, the facility failed to secure an opened tube and an opened container of topical ointment for 1 of 1 Resident reviewed for medication storage. (Resident #3). The findings included: Resident #3 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS) assessment dated [DATE] coded Resident #3 with an intact cognition. During an observation conducted on 01/08/25 at 10:53 AM, an opened tube containing approximately 1.5 ounces of zinc oxide ointment 20 % (a topical ointment for treating or preventing skin irritation related to diaper rash) was found unattended on top of the over-bed table in Resident #3's room. A further observation revealed another opened container of zinc oxide ointment with the same strength with approximately 3 ounces remaining in the container left unattended on top of Resident #3's bedside table. An interview was conducted with Resident #3 on 01/08/25 at 10:55 AM. She stated the ointments were for her diaper rash and she was dependent on the staff to apply the ointment for her. She added these ointments had been left unattended in her room for at least 2 weeks. During an interview conducted on 01/08/25 at 11:00 AM, Nurse #1 confirmed the zinc oxide ointments were for Resident #3 and nurse aides (NAs) had been using it to apply to the buttock areas for treatment or prevention of diaper rash. She stated the ointments should be kept in the wound care medication cart instead of leaving them unattended in Resident #3's room. She did not notice the ointments were in Resident #3's room when she did medication pass on 01/08/25 in the morning. An interview was conducted with NA #1 on 01/08/25 at 11:03 AM. She recalled providing care for Resident #3 in her room on 01/08/25 in the morning around 9:00 - 9:30 AM. She noticed the container of zinc oxide was sitting on the bedside table next to Resident #3's bed. She stated she did not know that zinc oxide ointment was not supposed to be left unattended. Otherwise, she would have reported the findings to the hall nurse. During an interview conducted with the Director of Nursing (DON) on 01/08/25 at 11:09 AM, she confirmed Resident #3 was dependent on the staff to apply zinc oxide ointment to her buttock areas. She expected all the zinc oxide ointments to be kept in the wound care medication cart. It was her expectation for the facility to remain free of unattended medications. An interview was conducted with the Administrator on 01/08/25 at 4:08 PM. She expected all the medications to be stored in the wound care medication cart or medication storage room to ensure the facility was free of unattended medications.

Based on record review and staff and resident interviews, the facility failed to treat a resident with respect and dignity when Nurse #3 told a resident (Resident #48) that he would not be sent out to the hospital after he yelled that he was uncomfortable and felt that no one was helping him. The facility also failed to treat a resident with respect and dignity when the facility failed to address unwanted facial hair on a resident (Resident #20) This was for 2 of 6 residents reviewed for treating residents with respect and dignity. The findings included: 1. Resident #48 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, paraplegia, and chronic pain syndrome. A review of Resident #48's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #48 was cognitively intact with no delusions, behaviors, or rejection of care. During an interview with Resident #48 on 09/04/24 at 2:15 PM revealed he had been feeling bad on 08/21/24 with some pain in his upper back. Resident #48 reported he was seen by the Physician Assistant (PA) #1 earlier in the day who prescribed him some medication that she thought would help. He stated the day progressed and in the early evening he started to have worsening discomfort not just in his back but also in his chest accompanied by some shortness of breath. He reported he rang his call light, and Nurse Aide (NA) #5 came in his room and checked on him. He stated he told NA #5 about his worsening chest pain and shortness of breath, and she told him she would immediately go tell his nurse (Nurse #3). Resident #48 called 911. Resident #48 reported once he hung up with 911, Nurse #3 came to the room. He reported he was scared and hurting and yelled stating his chest was tight and that he was not ok. Resident #48 admitted he was loud in his communication with Nurse #3 but insisted it was due to him being scared. Resident #48 reported Nurse #3 responded by telling him he was not going to speak to her like that and that she would not send him out and he could just sit there. Resident #48 reported the interaction made him feel like he did not matter and was afraid that he would not get the help he felt he needed. Resident #48 reported after the interaction, Nurse #3 left his room, and he decided he would call 911 again. Resident #48 reported when he spoke with the 911 operator, he told them he was not ok and was having chest discomfort and shortness of breath. Resident #48 stated Emergency Medical Services (EMS) did arrive shortly after and took him to the hospital. An interview with NA #5 was conducted on 09/04/24 at 2:57 PM revealed she could not recall how she ended up in Resident #48's room on the evening of 08/21/24 but stated he reported to her that he was hurting badly in his back and chest. NA #5 reported Resident #48 appeared red-faced during this interaction, and she immediately left his room and went and reported Resident #48's condition and his request to go to the hospital to Nurse #3. NA #5 reported Nurse #3 was at the nurse's station at that time and told her that she would go down to Resident #48's room. NA #5 also stated she remembered hearing some conversation between Resident #48 and Nurse #3 while she was in a room across the hall but stated she could not make out what they were talking about. NA #5 reported EMS did arrive at the facility after she took Resident #48's vital signs and transported him to the hospital. An interview with Nurse #3 on 09/04/24 at 2:37 PM revealed she was the nurse assigned to Resident #48 on 08/21/24. She reported she was aware that Resident #48 had been seen by PA #1 earlier in the day for some pain in his back. She stated later in the day she was made aware by NA #5 that Resident #48 was complaining of pain. She stated she when she went down to the room to check on him, Resident #48 was agitated and was complaining of heaviness in his chest. She reported when she was trying to speak to Resident #48 about his complaints, he was very agitated and began beating on his chest and yelling no one here will help me! Nurse #3 reported at that point, she decided to remove herself from the room and asked NA #5 to get his vital signs. Nurse #3 insisted she never told Resident #48 that she would not send him out and that he was fine. She also indicated she felt her interactions with Resident #48 remained respectful throughout. Nurse #3 insisted that after she left Resident #48's room, she contacted the on-call provider and received an order to send Resident #48 to the hospital. She also reported she contacted EMS via telephone and requested them to come transfer Resident #48 to the hospital. An interview with the DON on 09/06/24 at 12:23 PM revealed she was not in the facility at the time of the incident but stated she was aware that Resident #48 had called EMS for assistance on the evening of 08/21/24. She reported Resident #48 did not have a history of behaviors and was cognitively intact. The DON reported Resident #48 had been seen earlier in the day by PA #1 for some mild upper back pain. The DON stated it did not matter if a resident was agitated, combative, or rude, he should have been treated with respect and understanding and that Nurse #3 should have never told him he was fine and he was not going to be sent out if Resident #48 was in pain or was requesting to be transferred. An interview with the Administrator on 09/06/24 at 2:55 PM revealed she was aware of the incident and that she was familiar with Resident #48. She reported Resident #48 did not have a history of behaviors and was cognitively intact. She reported she expected her staff to treat all residents with respect and dignity and she would have expected Nurse #3 to speak to Resident #48 in a respectful and dignified manner while trying to calm him down and reassure him that he would be taken care of. 37280 2. Resident #20 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact and required substantial to maximal assistance of one staff for personal hygiene which included shaving. On 09/03/24 at 12:48 PM an observation and interview were made of Resident #20 who was lying in her bed. The Resident was noted to have black and gray hairs approximately one eighth of an inch long that covered her chin and neck. Resident #20 was asked about the hairs and the Resident stated she got a bed bath on Sunday 09/01/24, (her choice) and if she did not request to be shaved, then she would not be shaved by staff. She stated she did not know why she was not shaved on Sunday 09/01/24. Resident #20 voiced the last time she was shaved was her last bed bath on 08/25/24. When the Resident was asked about her facial hair, she hid her face with her right hand and explained her facial hair grew fast and it was embarrassing to her. She stated she always shaved her facial hair to prevent the growth of a beard and while shielding her face with her hand she explained that it made her feel lesser of a woman. An observation was made on 09/04/24 at 9:15 AM of Resident #20 lying in bed sleeping. The facial hair remained unchanged. On 09/04/24 at 3:18 PM an interview was conducted with Nurse Aide (NA) #5 who explained that Resident #20 was alert and oriented and voiced her wants and needs. The NA continued to explain that he was assigned to Resident #20 on both Saturday 08/31/24 and Sunday 09/01/24 and received assistance of 2 other staff to provide the Resident's scheduled bed bath on Sunday. The NA stated that he first noticed the Resident's facial hair on Saturday (08/31/24), and he told Resident #20 on both Saturday and Sunday that he would shave her but there were no razors available to shave her with. The NA remarked that Resident #20 asked to be shaved on Sunday during her bed bath, but he knew there were no razors to shave her with. An interview was conducted with the Central Supply Clerk on 09/04/24 at 4:09 PM. The Central Supply Clerk explained that she was responsible for ordering medical supplies and she obtained the inventory and ordered the supplies once a week on Tuesday and the supplies arrived at the facility on Friday. She continued to explain that occasionally the delivery truck did not make the delivery on Friday and would usually come on the following Monday but the past Monday, 09/02/24 was a holiday and the delivery truck was delayed. The Central Supply Clerk confirmed there were no razors available to be used over the weekend and the Administrator obtained razors at a local store on Monday 09/02/24. An observation was made of Resident #20 on 09/05/24 at 11:00 AM. The Resident was noted to be clean shaven, and the Resident smiled and stated, thank you. On 09/06/24 at 2:39 PM an interview was conducted with the Administrator who confirmed she obtained razors from a local store on Monday 09/02/24 when she was notified that there were no razors in the facility. She indicated not being able to shave a resident because of running out of razors was unacceptable and they would have to review the system on how supplies were ordered to prevent that from happening again.

Based on record review, staff interview, and Nurse Practitioner (NP) interviews the facility failed to ensure a resident's code status election was accurate throughout the medical record (Resident #25) and failed to ensure an advanced directive form was signed by the Resident or Responsible Party (RP) (Resident #60) for 2 of 3 residents reviewed for advanced directives (Resident #25 and Resident #60). The findings included: 1) Resident #25 was admitted to the facility on [DATE]. A review of a physician's order dated [DATE] revealed Resident #25 was a Do Not Resuscitate (DNR). A review of a Medical Orders for Scope of Treatment form (MOST) dated [DATE] revealed Resident #25 wished to be a DNR with a limited scope of treatment. A review of a care plan dated [DATE] revealed Resident #25 had an advanced directive and chose to be a DNR with an intervention that included to honor Resident #25's choice to be a full code. A review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 was moderately cognitively impaired. An interview was conducted on [DATE] at 11:57 am with Nurse #1. Nurse #1 stated when a resident was admitted to the facility the hall nurse verified if the resident wanted to be a full code or a DNR and completed a MOST form. Nurse #1 stated that the MDS Nurse typically entered the code status and advanced directive information on the care plan. Nurse #1 stated the information on the MOST form, care plan, and physician orders should match. Nurse #1 stated she was unsure why Resident #25 was care planned as a full code and stated she should not have been. An interview was conducted on [DATE] at 8:40 am with the Nurse Practitioner (NP). The NP stated when a resident was admitted to the facility she discussed code status with the resident. The NP stated she also discussed code status annually, as changes in condition occurred, or if a resident expressed a desire to change their code status. The NP stated she documented code status in her notes and there was an order for code status in the chart. The NP stated that the code status on the MOST form, care plan, and physician's order should match, and she was not sure why Resident #25 had a care plan for a full code. An interview was conducted on [DATE] at 9:27 am with the MDS Nurse. The MDS Nurse stated the care plan was initially entered by the MDS Nurse and could be changed by the hall nurse if there was a change. The MDS Nurse stated that code status should be consistent throughout the record, and she was unsure why Resident #25 was care planned as a full code. An interview was conducted on [DATE] at 1:10 pm with the Director of Nursing (DON). The DON stated that on admission the nurse reviewed code status with the resident or Responsible Party (RP) and completed the MOST form. The DON stated the resident, or RP signed the MOST form after the form was completed. The DON stated if the provider was not in the building, nursing staff called and obtained a verbal order until the MOST form was signed. The DON stated the physician's order, MOST form, and the care plan should all match. The DON stated she assumed the care plan entry had been an oversight when Resident #25 changed from full code to DNR status and stated the care plan should have been changed to reflect the resident's wishes. 2) Resident #60 was admitted to the facility on [DATE]. A review of a MOST form dated [DATE] revealed Resident #60 wished to be a Do Not Resuscitate (DNR) with limited additional interventions, to determine the use or limitations of antibiotics when infection occurred, and to have intravenous (IV) fluids long-term if indicated. The MOST form was signed by the former Medical Doctor (MD) and did not have a resident or Responsible Party (RP) signature. A review of a quarterly MDS assessment dated [DATE] revealed Resident #60 was moderately cognitively impaired. A review of a care plan dated [DATE] revealed Resident #60 wished to be a Do Not Resuscitate (DNR) with interventions which included not initiating cardiopulmonary resuscitation (CPR) and only performing limited interventions according to the MOST form. An interview was conducted on [DATE] at 11:57 am with Nurse #1. Nurse #1 stated when a resident was admitted to the facility the hall nurse verified if the resident wanted to be a full code or a DNR and completed a MOST form. Nurse #1 stated the resident, or RP signed the MOST form after it was completed. Nurse #1 stated the nurse then had the provider sign the MOST form if they were in the building, or the nurse called the provider and obtained a verbal order for code status until the paper was signed. Nurse #1 stated the resident, or RP signed the MOST form after completion. Nurse #1 stated she was not aware that the resident or RP had not signed Resident #60's MOST form and stated they should have. Nurse #1 stated the MOST form was not valid without a signature from the resident or RP and Resident #60 was considered a full code until it was signed. An interview was conducted on [DATE] at 8:40 am with the NP. The NP stated when a resident was admitted to the facility she discussed code status with the resident. The NP stated she also discussed code status annually, as changes in condition occurred, or if a resident expressed a desire to change their code status. The NP stated she documented code status in her notes and there was an order for code status in the chart. The NP stated she was not aware Resident #60 or the RP had not signed the MOST form and stated the form was not valid without their signature and would be considered a full code. The NP stated she was not sure why it had not been signed. An interview was conducted on [DATE] at 1:10 pm with the DON. The DON stated that on admission the nurse reviewed code status with the resident or RP and completed the MOST form. The DON stated the resident, or RP signed the MOST form after the form was completed. The DON stated if the provider was not in the building, nursing staff called and obtained a verbal order until the MOST form was signed. The DON stated the MOST form should be signed by the resident or RP and was not aware that Resident #60's MOST form had not been signed and stated that it should have been.

Based on record review and staff interview the facility failed to protect Resident #125 from being physically restrained by Nurse Aide #2 when Resident #125 had terminal agitation and was attempting to sit up in bed for 1 of 3 residents reviewed for employee to resident abuse. Nurse Aide #2 used her hand to push Resident #125's head back into the pillow in an attempt to keep him in the bed. The findings included: Resident #125 was admitted to the facility on [DATE] and expired on [DATE]. Resident #125's diagnoses included malignant neoplasm of lung and skin, and anxiety. The admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #125 was cognitively intact and required supervision with transfers. There was no behaviors or rejection of care noted during the assessment reference period. The MDS also revealed that Resident #125 had a prognosis of less than 6 months to live and received hospice care. Review of an initial allegation report dated [DATE] at 4:25 AM read, staff reported that Nurse Aide (NA) #2 handled Resident #125 roughly during the provision of care. The initial allegation report was completed by Former Administrator #1. NA #2 was interviewed via phone on [DATE] at 11:40 AM. NA #2 confirmed that she was working the night shift on [DATE]. She stated she was walking past Resident #125's room and found him lying flat on the floor with urine all around him. NA #2 stated she requested assistance from the nurse but could not recall who that was, but no one came to the room for a while. NA #2 stated that while she was in Resident #125's room waiting for other staff to assist she went ahead and got Resident #125 off the floor and back into bed and was in the process of getting him cleaned up when NA #3 and NA #4 came in to assist. NA #2 stated that while she and NA #3 and NA #4 were cleaning up Resident #125 the Resident kept trying to sit up and get out of bed. She stated, I put my hand on his head and kinda of pushed him back and told him to stay in the bed. NA #2 added that after they had finished cleaning up Resident #125, she returned to his room a few times after that and each time Resident #125 was trying to sit up or get out of bed and she again stated, I put my hand on top of his head/forehead and pushed his head back to the pillow to keep him from getting up. NA #2 stated I had no intentions of hurting him and did not think her actions could have been perceived as rough. NA #2 also stated she tried rubbing Resident #125's head to help him settle down but it was not effective. NA #2 further stated that shortly after the incident Nurse #2 told her that she needed to leave the facility due to an allegation of abuse and not to return to the facility. NA #3 was interviewed via phone on [DATE] at 2:43 PM. NA #3 confirmed that she was working the night shift on [DATE] along with NA #2 and NA #4. NA #3 stated she recalled that she, NA #2 and NA #4 were in Resident #125's room and NA #2 had assisted Resident #125 from the floor to the bed after NA #3 and NA #4 had changed the sheets on the bed. NA #3 stated once Resident #125 was back in bed he continued to try and sit up and NA #2 kept putting her fingertips on Resident #125's forehead and pushing his head back onto the pillow. After a few times of that NA #3 stated that NA #2's actions seemed harsh and I left the room to get Nurse #2 because NA #2 was being too rough. NA #3 stated when she left the room to get Nurse #2, she was on the phone, so she went and alerted Nurse #3 of what had occurred. She added that after she reported the incident, she did not recall going back to Resident #125's room and stated NA #2 and NA #4 finished getting the room cleaned up before leaving. Very soon after she reported the incident NA #2 was asked to leave the facility and did not finish her shift. Attempts to speak to NA #4 were made on [DATE] and [DATE] and were unsuccessful. A handwritten statement from NA #4 dated [DATE] read in part, once the resident {Resident #125} was on the bed NA #3 began putting the clean linen on while I got a brief out of the closet. At this time the resident {Resident #125} tried to sit up and NA #2 held him down preventing him from raising up. We finished placing the brief on the resident and got him comfortable and I stayed with resident while {NA #2} went and got our nurse. We reported what we had witnessed. The statement was signed by NA #4. Nurse #2 was interviewed via phone on [DATE] at 12:10 PM who confirmed that she was working the night shift on [DATE]. She stated she was on the phone with hospice trying to get something for Resident #125 when NA #2 approached her about something. Because she was on the phone NA #2 went and got Nurse #3 but after the phone call was over Nurse #2 stated she went and got the rundown of what had occurred. It was reported that Resident #125 had fallen, and they got him back to the bed and NA #2 had grabbed him by his face and forcefully pushed his head back down repeatedly. Nurse #2 stated when she heard what had happened, she immediately reported the incident to Former Administrator #1 who instructed her to send NA #2 home. Nurse #2 stated that NA #3 reported the force that NA #2 used to push Resident #125's head back made her sick to her stomach and caught her off guard. Nurse #2 stated she sent NA #2 home and then she went to check on Resident #125. She stated she was concerned about a head injury due to the report, but his neurological assessment was negative, and she could not identify any other injuries. Nurse #3 was interviewed via phone on [DATE] at 3:17 PM who confirmed that she was working the night shift on [DATE]. Nurse #3 stated that one of the NA's, but she could not recall which one reported that NA #2 had pushed Resident #125's head down into the bed and was being very rough with him. Nurse #3 stated that she and Nurse #2 went to Resident #125's room and Nurse #2 assessed Resident #125 and she escorted NA #2 out of the building. Nurse #3 stated she had the staff members write statements and gave them to Former Administrator #1. Former Administrator #1 was interviewed via phone on [DATE] at 3:04 PM who stated he could not recall the events of the incident. He stated that he was relieved of his duties during this investigation and Former Administrator #2 took over for him and maybe could recall the incident better than he could. Former Administrator #2 was interviewed via phone on [DATE] at 3:17 PM who stated that she was notified of the incident by Former Administrator #1 on [DATE]. She stated that when she arrived at the facility on [DATE] she realized that Administrator #1 was not taking the incident seriously and she relieved him of his duties and then took over the investigation. Former Administrator #2 stated that she began interviewing the involved staff members and through the investigation no one truly felt that anything was done wrong, it was more vindictive between the employees. She stated she honestly could not recall the whole situation but recalled one of the NAs put her fingertips on the top of Resident #125's head never with any pressure but she was trying to calm him down. During the investigation it was never brought to light that the NA who she could not recall forced Resident #125's head down and she unsubstantiated the incident. Administrator #2 stated that she did not feel like the NA was restraining Resident #125 and felt like one employee was out to get the other employee. The Director of Nursing (DON) was interviewed on [DATE] at 11:56 AM who stated she did not find out about the incident until [DATE] and she was very upset that Former Administrator #1 had not called her. The DON stated that Former Administrator #2 conducted all the interviews with the staff and felt that NA #2 had put Resident #125 in bed, and she had slipped in the urine that was on the floor which made the transfer appear rough and then she had her fingers on his head to hold him down because he was agitated and trying to get up that night. The DON stated Administrator #2 made it seem like NA #2 was trying to do the best thing for the resident but you can not hold them down. She stated she did not understand the thought process because when you step back and look at the interviews and statements NA #2 should not have held or pushed Resident #125's head back to the pillow. The DON stated she shared her thoughts with Administrator #2, but she continue to insist NA #2 was doing what was in the best interest of the resident.

Based on observations, record reviews, and staff and Nurse Practitioner (NP) interviews, the facility failed to develop and implement a person-centered care plan for a resident on one-on-one supervision for 1 of 4 residents reviewed for development and implementation of a comprehensive care plan (Resident # 51). The findings included: Resident #51 was admitted to the facility on [DATE] with diagnoses which included dementia, disorientation (a state of confusion), and hallucinations (seeing/hearing something that is not there). A review of an admission Minimum Data Set (MDS) dated [DATE] revealed Resident #51 was severely cognitively impaired, had no behaviors, and no rejections of care. A review of the care plan dated 7/31/2024 revealed Resident #51 was at risk for elopement and wandering related to impaired safety awareness with interventions which included application of a wander guard and to address wandering behaviors. There was no care plan intervention related to one-on-one supervision. An observation was conducted on 9/3/2024 at 11:28 am of Resident #51. Resident #51 was sitting in a reclining chair beside of her bed holding a baby doll. There was a sitter at the resident's bedside. An interview was conducted on 9/4/2024 at 8:52 am with the NP. The NP stated Resident #51 had advanced dementia and behaviors. The NP stated the Regional Consultant instructed staff to place Resident #51 on one-on-one supervision. An interview was conducted on 9/4/2024 at 9:08 am with Nurse Aide (NA) #1. NA #1 stated she worked first shift (7:00 am to 7:00 pm) and was assigned to Resident #51. NA #1 stated Resident #51 had dementia and wandered around the facility. NA #1 stated Resident #51 was placed on one-on-one supervision because of behaviors. An interview was conducted on 9/4/2024 at 9:35 am with the Director of Nursing (DON). The DON stated Resident #51 was on hospice services and had behavioral issues. The DON stated Resident #51 was placed on one-on-one supervision to protect her dignity. An interview was conducted on 9/4/2024 at 9:56 am with the Regional Consultant. The Regional Consultant stated Resident #51 wandered the facility, however, was not exit seeking. The Regional Consultant stated she was initially placed on one-on-ones because she was giving her baby doll to other residents, then trying to take it back afterwards, and she was fearful another resident would take it the wrong way and try to hit Resident #51. The Regional Consultant stated after Resident #51 was initially placed on one-on-one supervision, she was treated for a urinary tract infection (UTI) and her behaviors subsided, and she was taken off one-on-one supervision. The Regional Consultant stated Resident #51 was placed back on one-on-one supervision after an incident to protect her dignity. The Regional Consultant stated Resident #51 was not care planned for one-on-one supervision because she was placed on it for dignity, not behaviors. An interview was conducted on 9/6/2024 at 9:27 am with the Minimum Data Set (MDS) Nurse. The MDS Nurse stated if a resident was on one-on-one supervision for an extended period that it should be care planned and stated if it needed to be care planned it should be documented under the interventions. The MDS Nurse was not sure why Resident #51 was not care planned for one-on-one supervision. The MDS Nurse stated the hall nurse should have updated the care plan to include one-on-one supervision after it was ordered. An interview was conducted on 9/6/2024 at 10:32 am with Nurse #1. Nurse #1 stated the care plan was placed and updated by the MDS Nurse. Nurse #1 stated if a resident was on one-on-one supervision, it should be care planned. Nurse #1 was unsure why Resident #51 was not care planned for one-on-one supervision and stated she should have been. An interview was conducted on 9/6/2024 at 1:04 pm with the DON. The DON stated the care plans were initiated and updated by the MDS Nurse. The DON stated one-on-one supervision should have been care planned for Resident #51 and stated she was not sure why the care plan had not been updated.

Based on observations, record reviews and resident and staff interviews, the facility failed to trim a dependent female resident's facial hair for 1 of 6 residents (Resident #20) reviewed for activities of daily living (ADL). The finding included: Resident #20 was admitted to the facility on [DATE] with diagnoses that included heart failure, diabetes mellitus, chronic obstructive pulmonary disease and respiratory failure. A review of Resident #20's care plan revised 06/19/23 revealed the Resident had a self-care ADL deficit related to decreased mobility and disease process. The goal to maintain her current level of function would be attained by utilizing interventions which included providing extensive assistance of one staff with personal hygiene (shaving). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was cognitively intact and required substantial to maximal assistance of one staff for personal hygiene which included shaving. There was no documentation on the MDS that indicated Resident #20 rejected care. On 09/03/24 at 12:48 PM an observation and interview were made of Resident #20 who was lying in her bed. The Resident was noted to have facial hair that covered her chin and neck. Resident #20 explained that she received a bed bath on Sunday (09/01/24) and did not get a shaved even after she requested to be shaved. The Resident indicated she had to request to be shaved when she was given a bed bath otherwise, she would not be given a shave. Resident #20 stated she did not know why she did not get a shave on Sunday. An observation was made on 09/04/24 at 9:15 AM of Resident #20 lying in bed sleeping. The facial hair remained unchanged. An interview and observation were made with Resident #20 on 09/04/24 at 3:11 PM. The Resident explained that she received a bed bath once a week on Sunday and usually got a shave on the same day. Resident #20 still had a facial hair during the interview. On 09/04/24 at 3:18 PM an interview was conducted with Nurse Aide (NA) #5 who explained that Resident #20 was alert and oriented and voiced her wants and needs. The NA continued to explain that he was assigned to Resident #20 on both Saturday 08/31/24 and Sunday 09/01/24 and received assistance of 2 other staff to provide the Resident's scheduled bed bath on Sunday 09/01/24. The NA stated that he noticed the Resident's facial hair on Saturday 08/31/24, and he told Resident #20 on both Saturday and Sunday that he would shave her but there were no razors available to shave her with. He indicated he looked in the shower room and the central supply room on both days and there were no razors available to use. NA #5 stated Resident #20 does not refuse her bed baths or her shaves. At 09/04/24 at 4:00 PM NA #5 was accompanied to the central supply room to locate razors and there were several packages of razors in a bag labeled with a local store brand. The NA explained that the bag of razors was not in the central supply room on Saturday or Sunday. An interview was conducted with the Central Supply Clerk on 09/04/24 at 4:09 PM. The Clerk explained that she was responsible for ordering medical supplies and she obtained the inventory and ordered the supplies once a week on Tuesday and the supplies arrived at the facility on Friday. She continued to explain that occasionally the delivery truck did not make the delivery on Friday and would usually come on the following Monday but the past Monday 09/02/24 was a holiday therefore, the delivery truck was delayed. The Clerk confirmed there were no razors available to be used over the weekend and stated she learned that they ran out of razors on Monday when the Administrator obtained razors at a local store. The Clerk indicated she should have thought to get razors when the delivery truck did not come Friday but she did not think of it. On 09/06/24 at 2:39 PM an interview was conducted with the Administrator who confirmed she obtained razors from a local store on Monday 09/02/24 when she was notified that there were no razors in the facility. She indicated it was unacceptable to run out of razors.

Based on record review, staff, and Nurse Practitioner interviews the facility failed to assess Resident #125 before transferring him back to bed after he was found on the floor for 1 of 2 residents reviewed for falls. The findings included: Resident #125 was admitted to the facility on [DATE] and expired on [DATE]. Resident #125's diagnoses included malignant neoplasm of lung and skin, and anxiety. The admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #125 was cognitively intact and required supervision with transfers. There was no behaviors or rejection of care noted during the assessment reference period. There was also no history of falls in the 6 months prior to admission or since admission to the facility. The MDS also revealed that Resident #125 had a prognosis of less than 6 months to live and received hospice care. Review of an initial allegation report dated [DATE] at 4:25 AM read, staff reported that Nurse Aide (NA) #2 handled Resident #125 roughly during the provision of care. The initial allegation report was completed by Former Administrator #1. NA #2 was interviewed via phone on [DATE] at 11:40 AM. NA #2 confirmed that she was working the night shift on [DATE]. She stated she was walking past Resident #125's room and found him lying flat on the floor with urine all around him. NA #2 stated she requested assistance from the nurse but could not recall who that was, but no one came to the room for a while. NA #2 stated that while she was in Resident #125's room waiting for other staff to assist she went ahead and got Resident #125 off the floor and back into bed and was in the process of getting him cleaned up when NA #3 and NA #4 came in to assist. NA #2 stated that she alerted the nurse and when she did not show up in the room, she assumed it was okay to get Resident #125 back into the bed because the nurse was aware that he was on the floor. Again NA #2 could not recall which nurse she reported to. NA #3 was interviewed via phone on [DATE] at 2:43 PM. NA #3 confirmed that she was working the night shift on [DATE] along with NA #2 and NA #4. NA #3 stated she recalled that she, NA #2 and NA #4 were in Resident #125's room and NA #2 had assisted Resident #125 from the floor to the bed after NA #3 and NA #4 had changed the sheets on the bed. NA #2 had reported to NA #3 and #4 that Nurse #3 was aware that Resident #125 was on the floor. NA #3 stated she did not recall Nurse #3 being in the room before NA #2 transferred him from the floor back to bed but stated but they were aware we moved him. Attempts to speak to NA #4 were made on [DATE] and [DATE] and were unsuccessful. A handwritten statement from NA #4 dated [DATE] read in part, I answered the call bell for {Resident #125} and when I entered the room, I noticed that he was half on and half off the bed in a praying stance. He was very confused and disoriented. I called for help and {NA #2 and NA #3} entered the room. {NA #2} began to try to assist the resident up out of the floor. In his given condition, he was unable to do so. {NA #2} ended up transferring the resident by herself without waiting for {NA #3} or myself to help. Once the resident was on the bed, I stayed with the resident while {NA #3} went and got our nurse. The statement was signed by NA #4. Nurse #2 was interviewed via phone on [DATE] at 12:10 PM who confirmed that she was working the night shift on [DATE]. She stated she was on the phone with hospice trying to get something for Resident #125 when NA #2 approached her about something. Because she was on the phone NA #2 went and got Nurse #3 but after the phone call was over Nurse #2 stated she went and got the rundown of what had occurred. It was reported that Resident #125 had fallen, and they got him back to the bed without being assessed. Nurse #2 stated that it was not reported to her that Resident #125 had fallen until after NA #2 had transferred him back to bed. She stated when she found out she did go and assess Resident #125 for injuries and range of motion but could not identify any injuries sustained from the fall. Nurse #3 was interviewed via phone on [DATE] at 3:17 PM who confirmed that she was working the night shift on [DATE]. Nurse #3 stated that she was unaware that Resident #125 had fallen, or that NA #2 had transferred him back to bed until after Resident #125 was back in the bed. Nurse #3 stated that she and Nurse #2 went to Resident #125's room and Nurse #2 assessed him to have no injuries from the fall. The Nurse Practitioner was interviewed on [DATE] at 8:35 AM who stated that any resident that had a fall should be assessed by a nurse for injury before being moved. The Director of Nursing was interviewed on [DATE] at 11:56 AM. The DON stated that she was unaware that Resident #125 had fall on the night of [DATE]. She stated when a resident had a fall they have to be assessed by a nurse before being moved. The NAs should never get anyone up including Resident #125 without an assessment from the nurse. Once the nurse assessed the resident and deemed it safe to move the resident then the resident can be assisted back to bed or chair.

Based on observations, record review, and staff, Registered Dietitian (RD), Nurse Practitioner (NP), and Medical Director (MD) interviews the facility failed to meet the recommended fluid needs for 1 of 2 residents (Resident #42) reviewed for nutrition. The findings included: Resident #42 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing), required the use of a gastrostomy tube (artificial opening in the stomach used for tube feeding) and tracheostomy. A physician order dated 07/21/24 read; flush tube with 30-60 milliliters (ml) of water before/after meds twice a day (120-240 ml). Review of the Registered Dietician (RD) nutritional assessment dated [DATE] revealed that Resident #42 required 1982-2379 ml of fluid per day. A review of the RD recommendations dated 7/25/2024 revealed Resident #42 was recommended to have free water at 30 ml per hour which totaled 720 ml (additionally 1094 ml of water were noted from the tube feeding formula). A review of the physician's orders dated 7/25/2024 revealed Resident #42 was to receive 30 ml every 4 hours of free water (180 ml of per day). A review of a care plan dated 7/30/2024 revealed Resident #42 had dehydration and potential fluid deficit related to tube feeding with interventions which included monitoring for signs and symptoms of dehydration which included decreased/no urinary output, concentrated urine and/or strong odor, tenting skin, cracked lips, furrowed tongue, new onset of confusion, dizziness on sitting/standing, increased heart rate, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, and/or dry/sunken eyes. A review of the labratory results revealed a blood urea nitrogen (BUN, helps diagnose kidney issues) was not obtained in July or August of 2024. A review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 was moderately cognitively impaired, had no weight loss or weight gain, and received 501 mls or greater fluid per day via tube feeding. A review of the September 2024 Medication Administration Record (MAR) revealed Residnet #42 was documented as having received 30 ml water flushes every 4 hours as ordered. An observation was conducted on 9/3/2024 at 11:15 am of Resident #42. Resident #42's lips were dry, cracked, and had dried tan crust-like substance on his upper and lower lip. Resident #42's free water flushes were infusing at 30 ml every 4 hours (180 ml per day). An observation was conducted on 9/3/2024 at 5:10 pm of Resident #42. Resident #42's lips were dry, cracked, and had dried tan crust-like substance on his upper and lower lip. Resident #42's free water flushes were infusing at 30 ml every 4 hours (180 ml per day). An interview was conducted on 9/5/2024 at 8:53 am with the Nurse Practitioner (NP). The NP stated Resident #42 received tube feeding and had a history of having high residuals and at one time was not tolerating his tube feedings or flushes. The NP stated Resident #42's urine output was measured by counting briefs and that he always had dry lips, mouth, and tongue regardless of how many times his mouth was cleaned per day. The NP stated dry mouth could be a sign of dehydration, but stated his lips and mouth were dry because he was a mouth-breather (breathed through his mouth). The NP stated she had lowered the rate of his free water flushes when he had high residuals and was experiencing an intolerance to the feedings and flushes. An interview was conducted on 9/5/2024 at 10:49 am with the RD. The RD stated she reviewed Resident #42's weights and tube feeding/free water every month, anytime there was a concern, or whenever a resident returned from the hospital. The RD stated he was placed on an elemental feeding (feeding that is broken down to simplest form for easier digestion) around July 2024 due to an intolerance. The RD stated Resident #42 received 1774 ml of free water from flushes, tube feeding, and medication administration and had a requirement of 1982 ml/day and could not explain the deficit of free water. The RD stated she was not aware that Resident #42's free water flushes were running at 30 ml every 4 hours instead of 30 ml every hour and stated she must have overlooked that and reported he should have been on 30 ml every hour of free water. The RD stated dry, cracked lips/mouth could be an indicator of dehydration and stated she was not aware Resident #42 had dry/cracked lips. An interview was conducted on 9/6/2024 at 10:36 am with Nurse #1. Nurse #1 stated Resident #42 was incontinent or urine and wore a brief. Nurse #1 stated Nurse Aides (NAs) reported brief counts and there had been no concerns with Resident #42's urinary output and no foul odors. An interview was conducted on 9/6/2024 at 10:55 am with the Medical Director (MD). The MD stated she was not familiar with Resident #42 and had only been employed at the facility for approximately one month. The MD stated she ideally checked tube feeding residents' lab every 2 weeks or month to assess their hydration status and monitored their intake and output via brief count. The MD stated an elevated BUN creatinine ratio and dry/cracked lips could be an indicator of dehydration and reported she was going to order laboratory testing to assess Resident #42's hydration status. An interview was conducted on 9/6/2024 at 1:07 pm with the Director of Nursing (DON). The DON stated when a resident was on tube feeding and free water flushes, the provider would look at laboratory results and RD recommendations to adjust the feeds and water intake as needed. The DON stated Resident #42 had not tolerated his tube feeding at one time and his orders were changed. The DON stated the most up to date recommendation had not been followed for Resident #42 and could not explain why Resident #42 was not getting the required amount of free water he needed. A review of laboratory results dated [DATE] revealed resident #42 had an elevated blood urea nitrogen (BUN) to creatinine ratio of 31.3 mg/dl normal levels were 10-20 (high levels can be indicative of dehydration). A follow-up telephone interview was conducted on 9/11/2024 at 1:18 pm with the NP. The NP stated that she initially lowered the amount of free water flushes at the end of May/beginning of June 2024 due to Resident #42 having high residuals and intolerance. The NP stated that she was not at the facility for a majority of June, all of July, and returned 8/5/2024 due to a change in physicians. The NP stated that her plan before she left was to slowly increase the free water flushes and stated she was unsure why the fill-in provider had not done so. The NP stated she increased Resident #42's free water flushes to 30 ml per hour on 9/5/2024 and reported Resident #42 had tolerated them well with no high residuals.

Based on record review, Resident, and staff interviews, the facility failed to assess a resident for pain on admission and when there was a change in condition for 1 of 3 residents reviewed for pain management (Resident # 88). The findings included: Resident #88 was admitted to the facility on [DATE] with diagnoses which included a left femur (long bone in the upper leg) fracture (break), sternal body (breastbone) fracture, liver laceration (trauma to the liver that causes bleeding), L1 vertebral body (spinal bone in the lower portion of the back) fracture, right forehead laceration (tear), and metacarpal (hand bone) fractures. A review of an admission nurse's note, authored by Nurse # 3, dated 6/14/2024 revealed Resident #88 had arrived at the facility via Emergency Medical Services (EMS), was pleasant, and alert and oriented. Resident #88 had extensive bruising and staples in his left leg and had a femur fracture. Resident #88 had staples on his right forehead and had a cast on his right arm. Resident #88 reported he had been in a motorcycle crash and sustained injuries. Resident #88 was wearing a two piece back brace. An interview was conducted on 9/4/2024 at 3:11 pm with Nurse #3. Nurse #3 stated she admitted Resident #88 to the facility on [DATE]. Nurse #3 stated Resident #88 was pleasant when he arrived at the facility and was placed in a room on one side of the building, but had requested a room change shortly after he arrived. Nurse #3 stated she moved Resident #88 to his new room and was unsure if she assessed his pain on admission. A review of Resident #88's Electronic Health Record (EHR) revealed there was no pain assessments documented on 6/14/2024. A review of the physician's orders dated 6/14/2024 revealed orders for Resident #88 to receive Hydrocodone-Acetaminophen (pain medication) 5-325 milligrams (mg) by mouth every 6 hours as needed for moderate (4-6 out of 10 on the numerical pain scale) pain or severe (7-10 out of 10 on the numerical pain scale) pain for 7 days, Tramadol (pain medication) 50 mg by mouth every 6 hours as needed for back pain for 5 days, and Acetaminophen 325 mg by mouth every 6 hours as needed for mild (1-3 out of 10 on the numerical pain scale) pain for 10 days. A review of Resident #88's Medication Administration revealed Resident #88 had not received any medications on 6/14/2024. A review of the medication count from the medication dispensing machine dated 6/14/2024 revealed the facility had a total of 6 tablets of Tramadol 50 mg tablets on hand. An interview was conducted on 9/6/2024 with Nurse Aide (NA) #6. NA #6 stated she worked first shift (7:00 am to 7:00 pm) and stated she was assigned Resident #88 on 6/14/2024. NA #6 stated Resident #88 was initially placed in a room on another hall and transferred to her hall soon after his arrival due to an issue with the air conditioning. NA #6 stated he was frustrated and upset because he was in pain and requested pain medication. NA #6 stated she told Nurse #5 that Resident #88 was in pain wanted pain medication. NA #6 stated Nurse #5 told her Resident #88's pain medication had not arrived. NA #6 stated he was upset the remainder of her shift and had not received any pain medication. An interview was conducted on 9/6/2024 at 11:53 am with Nurse #5. Nurse #5 stated she worked first shift (7:00 am to 7:00 pm) and was assigned Resident #88 on 6/14/2024. Nurse #5 stated Resident #88 was originally placed in a room on another hall and then transferred to her hall. Nurse #5 stated Nurse #3 told her Resident #88's admission had been completed. Nurse #5 stated she did not assess Resident #88 for pain because she was under the impression given by Nurse #3 that there were no needs/issues. Nurse #5 stated she did not recall NA #6 reporting Resident #88 being in pain to her during her shift. A review of a late entry nursing progress note dated 6/15/2024, authored by Nurse #4, revealed Resident #88 approached Nurse #4 in the hallway and requested to be sent to the hospital at which time he stated, I'm having chest pains. Resident #88's blood pressure was 206/135, heart rate was 87 beats per minute, respiration rate was 18 breaths per minute, and oxygen saturation level was 94% on room air (not on oxygen). Nurse #4 contacted the on-call provider and Director of Nursing (DON) and Resident #88 was sent to the Emergency Department. A review of the Emergency Medical Services (EMS) report dated 6/14/2024 revealed EMS was dispatched to the facility at 9:42 pm in reference to chest pain (non-cardiac) and hypertension. Upon arrival Resident #88 was found in bed, alert and oriented. Resident #88 had an initial blood pressure of 186/111, a heart rate of 82 beats per minute (normal is 60-100 beats per minute), a respiration rate of 18 breaths per minute (normal is 12-20 breaths per minute), and an oxygen saturation level of 97% (normal is greater than 92%) on room air. Resident #88 rated his pain as a 2 out of 10 (mild) on the numerical pain scale and did not receive any medications from EMS. Resident #88 was transported to the hospital and remained pleasant and talkative throughout the transport. A review of the Emergency Department documentation dated 6/14/2024 revealed Resident #88 arrived in the Emergency Department with chest pain and reported the facility wanted him to stay in bed all day until he was evaluated and not given him any pain medication since he had arrived at the facility. Resident #88 reported he did not want to return to the facility. Resident #88 received Morphine (pain medication) 4 milligrams (mg) intravenously and was admitted to the hospital for malignant hypertension (an elevated blood pressure accompanied by multiple complications). Resident #88 was discharged home from the hospital on 6/19/2024. A telephone interview was conducted on 9/6/2024 at 11:22 am with Resident #88. Resident #88 stated he arrived at the facility on a Friday afternoon after he was discharged from the hospital following a motorcycle accident. Resident #88 stated he was in pain when he arrived at the facility, and reported his pain was a 9-10 out of 10 on the numerical pain scale. Resident #88 stated he had back and leg pain. Resident #88 stated he had told a NA (unable to remember who), that he was in pain and requested pain medication. Resident #88 stated he was told the facility did not have his medication. Resident #88 stated the pain continued into the night, at which point he started to develop chest pains. Resident #88 stated he told the nurse he was having chest pain and wanted his vital signs checked. Resident #88 stated after he saw how high his blood pressure was, he demanded to go to the hospital. Resident #88 stated when he arrived at the hospital, he was given pain medication and later admitted . An interview was conducted on 9/6/2024 at 11:36 am with the Medical Director (MD). The MD stated she was not employed by the facility on 6/14/2024. The MD stated when a resident was admitted to the facility, the staff should assess for pain at that time and whenever the resident expressed that they were experiencing pain. An interview was conducted on 9/6/2024 at 1:16 pm with the DON. The DON stated she was on leave at the time Resident #88 was admitted to the facility. The DON stated a pain assessment should have been performed on admission. An interview was conducted with the former Interim DON. The former Interim DON stated she was present at the facility on 6/14/2024 when Resident #88 arrived. The former Interim DON stated he was initially on one hall and had to be moved to another hall. The former Interim DON stated when Resident #88 arrived at the facility he was smiling and conversating with other residents. The former Interim DON stated after he switched rooms, his mood changed, and he became aggravated and wanted to leave. The former Interim DON stated Resident #88 never mentioned being in pain and did not appear to be in pain while she was at the facility. The former Interim DON stated a pain assessment should be performed on admission and when changes occurred and was not sure why there was no pain assessment documented for Resident #88.

Based on record reviews, and staff, Nurse Practitioner and Pharmacist interviews, the facility failed to identify the lack of documentation of monitoring for side effects (Resident #35) for psychotropic medications for 1 of 5 residents reviewed for unnecessary medications. The findings included: Resident #35 was admitted to the facility on [DATE] with diagnoses that included Parkinson Disease, unspecific dementia without behavioral disturbance, psychosis, mood disorder and neurogenic disturbance with Lewy body dementia. A review of Resident #35's physician orders revealed orders for: Seroquel (an antipsychotic) 25 milligrams (mg) by mouth once a day for dementia dated 07/12/24, Nuplazid (an antipsychotic) 34 mg by mouth once a day for psychosis related to Parkinson Disease dated 07/13/24, and Seroquel 12.5 mg by mouth once a day for dementia dated 07/13/24. A review of Resident #35's Medication Administration Record (MAR) for 07/2024, 08/2024 and 09/2024 revealed the antipsychotic medications were intialed as administered as ordered. A review of Resident #35's MAR for 07/2024 revealed there were no side effect monitoring for the antipsychotic medications after 07/11/24, 08/2024 and 09/2024. During an interview with Nurse Aide (NA) #5 on 09/04/24 at 3:48 PM the NA stated he was often assigned to care for Resident #35 and explained that the Resident was alert, but his cognition was jaded like he talked about working on old cars. The NA stated the Resident could be physically aggressive and instantly angered but he had not displayed those behaviors with him. An interview was conducted with Nurse Aide (NA) #7 on 09/05/24 at 11:33 AM. The NA stated she was often assigned to care for Resident #35 and explained that the Resident had periods of physical aggression toward the staff and his behaviors had become more frequent. The NA continued to explain that Resident #35 had behaviors of hollering and had visual hallucinations of old cars coming after him. On 09/06/24 at 10:34 AM an interview was conducted with Nurse #1 who stated that Resident #35 was physical with the staff and had periods of continuous hollering especially during the night. She stated the Resident was not as bad as he used to be and that his medications seemed to control the behaviors better. The Nurse explained that the nurses documented the side effects of the psychoactive medications on the MARs along with the medications every shift. The Nurse looked at Resident #35's 09/2024 MAR and acknowledged there was no side effect monitoring on the MAR and stated it should be on there to watch for side effects. During an interview with the Director of Nursing (DON) on 09/06/24 at 11:14 AM the DON explained that it was an oversight that the side effects monitoring was left off the MARs when Resident #35 came back from the hospital. She stated the Unit Manager, or the Assistant Director of Nursing were responsible for reviewing the medical records after admissions to ensure accuracy but currently the facility did not have an active Unit Manager or Assistant Director of Nursing.

Based on observations, record reviews, and resident and staff interviews, the facility staff failed to don appropriate Personal Protective Equipment (PPE) before entering residents' room under transmission-based precautions. The facility also failed to utilize hand hygiene after removing gloves for 2 of 4 residents reviewed for infection control (Resident #40 and Resident #74). The findings included: 1. Review of the facility's policy for Enhanced Barrier Precautions (EBP) dated 12/2023 revealed the EBP will be implemented for the prevention of transmission of multidrug-resistant organisms. EBP employs gown and glove use during high resident care activities such as: Dressing Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, Changing briefs or assisting wit toileting, Device Care or use: central line, urinary catheter, feeding tube and tracheostomy, Wound Care: any skin opening requiring a dressing. Review of the facility's Hand Hygiene policy dated 12/2023 revealed staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. This applies to all staff working in all locations within the facility. #6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your talk requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. On 09/05/24 at 4:00 PM an observation was made of Nurse Aide (NA) #5 and NA #7 transferring Resident #40 from the bed to the chair using a total lift. Resident #40 was under EBP for multiple stage 3 and 4 pressure ulcers and a suprapubic urinary catheter and the signage for EBP was posted on the Resident's door. The two NAs sanitized their hands and applied gloves then proceeded to enter Resident #40's room and announced why they were there. NA #5 emptied the Resident's colostomy and handed the container to NA #7 to empty in the restroom. NA #7 then removed her gloves and went to the hallway to obtain pack of briefs and brought the briefs back into the room then donned new gloves without sanitizing her hands. NA #5 removed his gloves then washed his hands before he donned new gloves. Both NAs changed the Resident's brief then NA #7 removed her gloves and donned new gloves without sanitizing her hands. NA #5 removed his gloves and washed his hands before he donned new gloves. NA #7 obtained the Resident's urinal and handed it to NA #5 to empty the catheter bag. NA #5 took the urinal to the restroom to empty then removed his gloves and washed his hands before he donned new gloves. NA #7 then removed her gloves and proceeded to change the Resident's bed linens without wearing gloves. NA #5 assisted with the linen change while wearing gloves. NA #7 then brushed and braided Resident #40's hair without wearing gloves. An interview was conducted with both NA #5 and NA #7 simultaneously on 09/05/24 at 4:49 PM. The NAs were asked if Resident #40 was under any kind of precautions and both replied yes, Enhanced Barrier Precautions which meant they needed to don gloves and gown before entering the Resident's room. NA #5 explained he only wore the gloves because he did not intend on letting his uniform get against the Resident or his bed. NA #7 stated she always wore gloves and gown when working with Resident #40 and she knew to wash or sanitize her hands between glove changes but today she was nervous and forgot the procedure. On 09/06/24 at 11:46 AM during an interview with the Director of Nursing (DON) the DON explained that her former Assistant Director of Nursing oversaw infection control infection control education, but she left employment about 2-3 weeks prior. The DON stated regardless all the staff knew to abide by the different types of precautions posted on the residents' door and to follow the assigned PPE. 35789 2. Review of a facility policy revised on 12/2023 read in part, Personal Protective Equipment Considerations: Health Care Personnel should follow standard precautions if SARS-CoV-2 infection is not suspected in a resident presenting for care or transmission-based precautions if required based on suspected diagnosis. The facility may consider implementing broader use of respirators and eye protection by Heath Care Personnel during care encounters if SARS-CoV-2 transmission in the community increases as follows: eye protection (i.e. goggles or a face shield that covers the front and sides of the face) worn during all resident care encounters. Resident #74 was admitted to the facility on [DATE] with diagnosis of COVID-19. A Brief Interview for Mental Status was completed on 09/04/24 and revealed that Resident #74 was cognitively intact. An observation and interview were conducted with Resident #74 on 09/03/24 at 11:52 AM. There was a sign on the door of Resident #74's room that stated, Special Droplet Contact Precautions and instructed all healthcare personnel to clean hands before entering and when leaving room, wear a gown when entering room and remove before leaving, wear N95 or higher-level respirator before entering the room and remove after exiting, protective eyewear (face shield or googles), wear gloves when entering room and remove before leaving, and place in private room. Keep door closed. Resident #74 was up and dressed appropriately watching television sitting in a straight back chair in his room. He stated he was feeling much better and did not think he would have to stay at the facility for an extended period of time. Resident #74 explained that he was a retired respiratory therapist and was well aware of the COVID-19 precautions in place, when asked if all the staff that came in to assist him dressed appropriately in the recommend personal protective equipment he replied not as much as you have on indicating that the staff always had on gown, gloves, and mask but he did not see them wear a face shield or eye protection like the surveyor had on. An observation and interview were conducted on 09/03/24 at 1:09 PM of Nurse Aide (NA) #9. NA #9 was observed entering Resident #74's room to deliver his meal tray and was noted to be dressed in a gown, gloves, and N95 respirator but had no eye protection on. NA #9 knocked on the door and entered the room and sat the lunch tray down on Resident #74's table and proceeded to ensure the tray was set up for the resident to eat and make sure he had all needed items. Before exiting Resident #74's room NA #9 removed his N95 respirator, gown, and gloves and used hand sanitizer. NA #9 was asked about Resident #74, and he stated that the resident had COVID-19 and that when he went into his room, he applied personal protective equipment that included N95 respirator, gown and gloves. When asked if he wore eye protection, NA #9 stated no and when asked if he should wear eye protection NA #9 stated yes. NA #9 was then asked why he did not wear eye protection when he entered Resident #74's room and he stated that there was none in the personal protective equipment cart outside the room. The surveyor opened the second drawer of the personal protective equipment cart and there were two face shields in the drawer and NA #9 stated oh I guess I should have looked. The Director of Nursing (DON) was interviewed on 09/06/24 at 11:45 AM who explained that Resident #74 had recently admitted to the facility from the hospital on 08/30/24 with COVID-19 and was placed on special droplet contact precautions that required all staff who entered his room to clean their hands, apply gown, gloves, N95 respirator, and eye protection. The DON stated that NA #9 should have applied eye protection as the sign on the door indicated and if there was none in the personal protective equipment cart outside of the room there were plenty of extra supplies in the break room.

Based on record review, resident, staff, and Medical Director interview the facility failed to prevent a significant medication error for 1 of 3 residents reviewed for medication errors (Resident #31). Nurse #1 administered 38 units of insulin glargine (a long-acting insulin that lasts for 24 hours and does not have a peak onset of action) in error to Resident #31, a resident who did not have a diagnosis of diabetes. Resident #31's blood sugar dropped throughout the night and the resident was sent to the hospital due to a blood sugar level of 50 (normal range 90-100) requiring an overnight hospitalization . A serious set of symptoms of hypoglycemia can occur in people without diabetes including tremors, palpitations, anxiety, sweating, dizziness, weakness, increased risk for falls and fractures, drowsiness, confusion, altered mental status, loss of consciousness, or seizures. The symptoms occur when the glucose level falls below 55 mg/dL, although this can be variable. There was high likelihood for serious harm. The findings included: Resident #31 was admitted into the facility on [DATE] with diagnosis which included hypertension and asthma. Resident #31 did not have a diagnosis of diabetes mellitus. Resident #31's admission Minimum Data Set (MDS) dated [DATE] revealed he was alert and oriented requiring limited assistance of one staff member for most activities of daily living (ADL). Resident #31 was coded as not receiving insulin. A nursing progress note dated 05/14/23 at 2:07 AM written by Nurse #1 revealed she had made a medication error by administering Resident #31 38 units of insulin glargine, a long-acting insulin. The note revealed Nurse #1 gave the resident peanut butter cookies, apple juice, ice cream and orange juice. The nurse monitored Resident #31's blood sugar every 15 minutes with the following results. - 11:00 PM: 111 - 11:15 PM: 82 - 11:30 PM: 78 - 11:45 PM: 80 - 12:00 AM: 90 The note revealed Nurse #1 notified the Director of Nursing (DON) by text message and placed a note in the Medical Director's communication book for when he came into the facility. Nurse #1 placed a call to the on-call provider and was awaiting a return phone call. A nursing progress note dated 05/14/23 at 4:38 AM written by Nurse #1 revealed Resident #31 was sent out to the hospital for an evaluation due to low blood sugar. The Director of Nursing, Medical Director was notified via communication book. The note revealed Nurse #1 would notify the resident's Responsible Party and primary Medical Director at 6:00 AM. Review of Resident #31's May 2023 Medication Administration Record (MAR) revealed no active orders for insulin glargine. Resident #31's physician orders dated May 2023 revealed no active orders for insulin. An interview conducted on 06/04/23 at 12:39 PM with Resident #31 revealed on 05/14/23 Nurse #1 came into his room during the night and asked him his name and date of birth. He stated the next thing he knew the nurse had popped him in the right arm with a shot. The resident stated he later learned what she had given him was insulin. Resident #31 stated he had never taken insulin nor had his blood sugar checked while in the facility. The interview revealed Nurse #1 then started monitoring Resident #31's blood sugar level and kept him up during the night. He stated he had to go to the hospital because his blood sugar levels kept dropping even after he ate crackers and drank juice. Resident #31 stated, the nurse didn't know what she was doing. An interview was conducted on 06/04/23 at 9:45 AM with Nurse #1. During the interview Nurse #1 stated she was agency staffing and not familiar with Resident #31. She stated she was responsible for two halls and had a medication aide. The interview revealed the medication aide had written down residents' blood sugars that had orders for insulin and gave Nurse #1 the list of residents. She stated around 11:00 PM she was told by the Medication Aide (MA) that she had to administer the insulin for the hall. Nurse #1 stated she did not go and log onto a computer, instead she took the paper sheet the MA had written and transferred onto another piece of paper the residents' blood sugars and insulin orders. She stated she did not look at a computer to know what the resident looked like or verify the nursing orders. The interview revealed she immediately felt like she had made a mistake because the resident was thin, and she felt like he didn't look like he would need that much insulin. She stated when she began to question Resident #31 about insulin the resident stated to her that his blood sugar had never been checked while in the facility. Nurse #1 stated she went and got the MA who went back into the room with her and verified that she had given insulin to the wrong resident. Nurse #1 stated she immediately took the resident's blood sugar with a reading of 111. Nurse #1 gave Resident #31 peanut butter cookies, orange juice and ice cream to try and keep his sugar maintained. The interview revealed that she continued to monitor his blood sugar every 15 minutes for the next hour up until it reached 90 and she felt like he was going to be okay. She stated she called the on-call provider but received no return phone call. She sent the DON a text message and placed a note in the Medical Director communication book. Nurse #31 stated she came back to Resident #31 around 4:00 AM to recheck his blood sugar with a result of 53. She then called the DON who told her the facility had glucagon (a medication used to increase a resident's blood sugar level) and to send the resident to the hospital for an evaluation. She stated she went to the cubex (facility medication dispensing machine) but there was no glucagon in the cubex. Nurse #1 then called Emergency Medical Services and they arrived shortly after. She stated Resident #31 remained without symptoms or change in color or sweating through the incident. On 06/04/23 at 11:43 AM an interview was conducted with Medication Aide (MA) #1. During the interview she stated she had given medication on Resident #31's hall however could not administer insulin to residents so she told Nurse #1 she would have to administer them. She stated she handed Nurse #1 a paper with the resident's blood sugar results on it with the correct resident's name. MA #1 stated she was sitting at the nurse's station when she overheard Resident #31 tell Nurse #1, he had never had his blood sugar checked since being in the facility and did not take insulin. She stated Nurse #1 administered the insulin anyway despite what Resident #31 told her. MA #1 stated she went into the room and stated to Nurse #1 that she had administered the insulin to the wrong resident. The interview revealed the incident happened quickly and MA #1 did not have a chance to stop Nurse #1 prior to administration. She stated Nurse #1 immediately said to start monitoring the resident's blood sugar every 15 minutes. MA #1 stated the resident's blood sugar reached 90 at midnight and he remained without symptoms. She stated Nurse #1 had attempted to call the on-call provider but hadn't received a return phone call or orders. The interview revealed when they rechecked his blood sugar at 3:30 AM they received a result of 53 and Nurse #1 called the Director of Nursing (DON) who stated to send the resident to the hospital for an evaluation. MA #1 stated it was shortly after that Emergency Medical Services (EMS) arrived and took Resident #31 to the hospital. On 06/05/23 at 2:30 PM an interview was conducted with the Director of Nursing (DON). During the interview she stated Nurse #1 had given Resident #31 his roommate's insulin by mistake on 05/14/23. She stated the nurse immediately realized she had made a mistake and notified the on-call provider. The DON stated Nurse #1 sent her a text message, but she did not receive it. She stated the nurse should have called her instead for a medication error. The DON stated she received a phone call from Nurse #1 around 3:45-4:00 AM to tell her what had happened. The DON stated she told the nurse to send the resident to the hospital since the insulin was long acting and his blood sugar could continue to drop. She stated Resident #31 needed closer monitoring than the facility could provide. The interview revealed Nurse #1 was able to get in touch with the on-call provider and Resident #31 was sent to the hospital for an evaluation. The DON stated following the incident she obtained statements from all staff involved and completed education on the 6 rights of medication administration. All nurses and medication aides were in-serviced, and the 6 rights of medication administration were placed on the front of all of the narcotic books on the medication carts. An incident report was completed, and she believed the issue arose when Nurse #1 did not use the electronic charting system while administering the insulin. She stated Nurse #1 never looked in the computer system and had written the insulin order under Resident #31's name by mistake. The DON stated Nurse #1 had not been back into the facility since the incident. She believed Nurse #1 was in a hurry and that was when the error occurred. On 06/06/23 at 2:32 PM an interview was conducted with the Medical Director (MD). He stated he was not working in the building at the time of the incident but after review thought the nurses had acted appropriately after realizing the medication error. The MD stated he felt like the mistake had a potential for harm but there was no harm to Resident #31. However, the MD stated that a low blood sugar was more dangerous than a high blood sugar and could lead to death. Emergency Medical Service (EMS) records dated 05/14/23 revealed EMS was dispatched to the facility at 3:48 AM and arrived on scene at 4:02 AM due to resident with a diabetic issue. EMS services found the resident sitting upright at the edge of the bed eating crackers with peanut butter. The resident stated, Nobody here knows what they're doing. The resident denied any complaints of pain and stated his blood sugar had been low. The resident also stated he did not have diabetes. Nurse #1 informed EMS that she was new to the hall and was not familiar with the residents. She told EMS that the resident's roommate was supposed to receive the insulin, but she had mixed up the residents and gave it to the wrong one. The note revealed due to the circumstances the resident was transported for observation to the emergency department. Resident #31's blood sugar level was recorded as 50. On 06/06/23 at 11:32 AM an interview was attempted with Emergency Medical Services (EMS). The surveyor left their phone number for a return phone call. Hospital records dated 05/14/23 revealed Resident #31 presented to the emergency department after accidentally being administered insulin. Resident #31 received 38 units of long-acting insulin and he did not have diabetes. Upon evaluation Resident #31 showed no signs of low blood sugar and his blood sugar was 91 then decreased to 69. The resident was placed on a D5 drip (infusion used to provide the body with extra water and carbohydrates (calories from sugar), and the ED Medical Director contacted poison control who recommended to monitor his blood sugar every 2 hours for at least 24 hours. Resident #31 was admitted into the hospital for observation. At around 2:00 PM Resident #31's blood sugar was ranging 121-257. Resident #31 returned to the nursing facility on 05/15/23. Facility administration was notified of immediate jeopardy on 06/16/23 at 9:02 PM. The facility provided the following the following corrective action plan with completion date of 05/15/23: Date: 5/14/2023 PROCESSES THAT LEAD TO THE ALLEDGED DEFICIENCY CITED: Resident #1 was sent to the hospital on 5/13/2023 regarding a medication error. Resident was given 38 units of Insulin Glargine during the night shift. During the night shift Nurse #1 reviewed the 24-hour report and noted the blood sugar of written under the Resident #2 name. Nurse #1 retrieved the medication Insulin Glargine for resident #2. Nurse #1 entered the room and asked the resident in bed A if he was the name on the insulin pen. The resident #1 stated yes. The nurse dialed the pen to 38 units and proceeded to administer the medication. The nurse walked out of the room and had a conversation with the medication aide #1. She informed she just gave the insulin to bed A. The medication aide #1 stated that is not the right resident. It was to be given to Bed B. The nurse immediately checked the resident #1 blood sugar and gave the resident a bag of peanut butter cookies, apple juice 120 milliliter (ml), ice cream 120ml, orange juice 120ml. Nurse #1 called the medical doctor. Nurse #1 checked the blood sugar every (Q) 15min. Blood sugar 111 at 11pm, 96 at 1115pm, 82 at 11:30pm, 78 at 11:45pm, 80 at 12am, 90 at 12:30, and 88 at 1:30. Resident #2 was administered his 38 units of insulin. During this time the nurse practitioner called back and gave an order to send the resident to the emergency room . The resident was sent to the emergency room . Upon arrival the residents blood sugar was 91. Resident #1 was admitted to the hospital. The nurse was immediately removed from the building pending the investigation. Root cause analysis: Based on medical record review and interviews Nurse #1 did not follow the 6 medication rights. Right RESIDENT - identify resident to assure you are giving the medication to the resident who is supposed to receive the medication and using procedure required by the facility, such as photo on the MAR, asking a resident his/her name, etc. THE PROCEDURES FOR IMPLEMENTING THE ACCEPTABLE CREDIBLE ALLEGATION FOR THE ALLEGED IMMEDIATE JEOPARDY: Timeline of Event: On 5/13/2023 Director of Nursing reviewed Resident #1 medical record and determined that resident #1 did receive 38 units of insulin. The administrator was notified immediately. On 5/13/2023 the Director of Nursing and designee assessed confused residents for signs and symptoms of hypoglycemia. No concerns were noted. On 5/13/2023 the Director of Nursing and designee interviewed alert and oriented residents to ensure if the residents were on insulin, they were receiving it and if the residents were not on insulin, they had not received it. No concerns were noted. On 5/13/2023 the Director of Nursing initiated educated the License Nurses and Medication Aides on the 6 medication rights. Right RESIDENT - identify resident to assure you are giving the medication to the resident who is supposed to receive the medication and using procedure required by the facility, such as photo on the MAR, asking a resident his/her name, etc. Right MEDICATION - the name of the medication ordered by the physician; always use the three checks. Right DOSE - the amount of medication ordered. Right ROUTE - the method of medication administration Right TIME - when the resident is ordered to receive the medication. Right DOCUMENTATION - the process of writing down that a medication was administered to the resident on the MAR OR if a medication was not administered and the reason it was omitted. On 5/14/2023, 1:1 Education was provided by the Director of Nursing with Nurse #1 that was involved in medication error. THE MONITORING PROCEDURE TO ENSURE THAT THE CREDIBLE ALLEGATION IS EFFECTIVE AND REMOVE THE ALLEGED IMMEDIATE JEOPARDY: On 5/14/2023, the Director of Nursing or designee will monitor 5 medication passes a week for 4 weeks, 3 medication passes a week for 4 weeks, 2 medication passes a week for 4 weeks to ensure the 6 medication rights are being followed during the medication passes. Results of all audits will be reviewed in the facility Quality Assurance and Performance Improvement Committee meeting monthly for three months (3) months. The Quality Assurance and Performance Improvement Committee will review the audits to make recommendations to ensure compliance is sustained ongoing; and determine the need for further auditing beyond the three (3) months. The title of the person implementing this acceptable plan of correction: Effective 5/13/2023, the facility Administrator and Director of Nursing will be responsible for the implementation of this plan of correction. The Administrator will ensure the facility attains and maintains substantial compliance. Date of Immediate Jeopardy removal: 5/15/2023 On 06/07/23, the facility's corrective action plan effective 05/15/23 was validated by the following: Nursing staff interviews revealed they had received education on the 6 rights of medication administration. The 6 rights of medication administration document were placed on every medication cart in the facility as a reminder to nurses. Administrative staff interviews revealed they had completed audits of nurses and medication aides during medication pass. Documents were reviewed from the facility Quality Assurance and Performance Improvement (QAPI) committee meeting minutes of the audit results. The facilities medication error rate was 0% during the medication pass facility task completed by the survey team. The facility's action plan was validated to be completed as of 05/15/23.

Based on observation, record review and staff interviews, the facility failed to follow the manufacturer's guidelines for cleaning and disinfection of a blood glucose meter which was stored in the medication cart after use for 2 of 2 residents observed (Resident #3 and Resident #105) during a medication pass on 06/06/23 at 9:05 AM. The blood glucose meter was stored in the medication cart and was not designated as an individual resident meter. The facility had three residents in the building with a diagnosis of a bloodborne pathogen (microorganisms that cause disease and are present in human blood) (Resident #104, Resident #64 and Resident #76). This deficient practice had a high likelihood for transmitting bloodborne pathogens within the facility. Immediate Jeopardy began on 06/06/23 when Nurse #6 was observed during medication pass removing two glucometers from the medication cart and use them without disinfecting per manufacturer's guidelines. The immediate jeopardy is present and ongoing. Findings included: Review of the facility policy Glucometer Disinfection revised in October 2020 read, in part, to clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current infection control standards of practice. The blood glucose meter manufacturer's instructions for cleaning and disinfecting dated 9/2019 indicated the blood glucose monitoring system may only be used for testing multiple patients when standard precautions and the manufacturer's disinfecting procedures are followed. The meter should be cleaned and disinfected after use on each patient. A list of Environmental Protection Agency (EPA) wipes were recommended on the cleaning instructions. Additional instructions were to read the manufacturer's instructions for the use of the wipes. The wipes container which was located on top of the medication cart read in part to disinfect nonfood contact surfaces to thoroughly wet surface, allow treated surface to remain wet for two minutes and let air dry. These wipes were an EPA-registered germicidal wipe and approved for bloodborne pathogen use. An observation on 06/06/23 at 9:07 AM of Nurse #6 revealed she gathered necessary supplies, removed the glucometer from the top right drawer of the medication cart and went into Resident #3's room and obtained her blood sugar with a result of 84. She exited the room and returned to the medication cart in the hall. Nurse #6 was observed placing the glucometer immediately back into the top right drawer on the medication cart. An observation on 06/06/23 at 9:16 AM of Nurse #6 revealed she gathered necessary supplies, removed a second glucometer from the top right drawer of the medication cart and went into Resident #105's room and obtained his blood sugar with a result of 184. She exited the room and returned to the medication cart in the hall. Nurse #6 was observed placing the glucometer immediately back into the top right drawer on the medication cart. An interview conducted on 06/06/23 at 11:13 AM with Nurse #6 revealed she was an agency nurse. She stated she knew she was supposed to disinfect the glucometers after each use. Nurse #6 stated she had gotten nervous and just forgotten. An interview on 6/07/23 at 11:44 AM with the Director of Nursing (DON). She stated that the disinfecting contact time for the blood glucose meter should be two minutes. She stated the staff have been trained and she did not know why the nurse didn't follow policy. The DON stated that she did not know why each resident did not have their own personal glucometer. The interview revealed as far as she knew that's how it had always been in the facility with the residents not having individual glucometers. An interview on 06/07/23 at 6:47 PM with the Administrator revealed that blood glucose meters should be disinfected according to the manufacturer's instructions. An interview was conducted on 06/14/23 at 10:30 AM with the Administrator. The Administrator provided information regarding the number of residents in the facility with a diagnosis of a bloodborne pathogen. The document provided revealed the facility had three residents in the facility with a bloodborne pathogen, one with Hepatitis B and C (a severe form of viral hepatitis transmitted in infected blood), and two with Hepatitis C. Facility administration was notified of immediate jeopardy on 06/14/23 at 2:30 PM.

Based on record review, resident and staff interviews, and observations the facility failed to develop a comprehensive care plan after the admission assessment and failed to ensure individualized care plans were updated and accurate for 5 of 10 residents (Resident #20, Resident #37, Resident # 60, Resident #64, and Resident #355). The findings include: 1. Resident #355 was admitted to the facility on [DATE] with the following diagnosis: respiratory failure, atrial fibrillation, diabetes mellitus, and anxiety disorder. Review of physician orders for Resident #35 revealed: - 3/30/23 for Insulin 20 units at bedtime due to type 2 diabetes mellitus - 3/30/23 for anticoagulation to be administered twice daily for atrial fibrillation - continuous oxygen at 3 L/minute via nasal cannula dated 3/30/23 - Quetiapine Fumarate an antipsychotic medication dated 3/30/23 to be administered twice daily. Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #355 was cognitively intact. She required extensive assistance with most of her activities of daily living (ADLs). Resident 355's MDS was also marked for oxygen use while a resident along with anticoagulation, insulin, and psychotropic medication use. Review of the Care Area Assessment (CAA) summary dated 4/7/23 showed the areas of psychotropic medication and ADL's were triggered to be care planned. A review of Resident #355's care plan dated 4/6/23 showed the only care plan in place was one for discharge to community. Observation and interview with Resident #355 on 6/4/23 at 4:13 PM revealed she was receiving oxygen via nasal cannula. The setting on the oxygen concentrator was 3 liters (L) per minute. The resident reported she had been on oxygen for about [AGE] years due to a history of respiratory failure and possible congestive heart failure. Resident #355 also reported she received insulin daily. Interview with the MDS Coordinator on 6/7/23 at 3:32 PM revealed medications such as anticoagulants, oxygen, psychotropics, and insulin were usually care planned. The MDS Coordinator went on to say a care plan needed to be completed by day 21 following admission. She reported the care plans for Resident #355 were missed because she had fallen behind and was trying to get everything caught up. During an interview conducted on 6/7/23 at 5:31 PM with the Administrator, she expected to see comprehensive care plans completed in a timely manner with problems and medications care planned. 2. Resident #64 was admitted to the facility on [DATE] with the diagnoses of paraplegia, neurogenic bladder, poor dental health, pain, edema, anxiety disorder, pressure ulcers to right calf, right heel, left lateral skin, and history of constipation. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 was cognitively intact. His MDS was marked for neurogenic bladder and paraplegia with range of motion impairment to both legs. He needed extensive assistance with his activities of daily living (ADLs) including toilet use. Resident #64 was also coded as having an indwelling foley/suprapubic catheter with bladder continence not rated due to having the catheter in place. Diuretic, psychotropic, and pain medication were marked on the assessment along with pressure ulcers present upon admission. Review of Resident #64's current comprehensive care plan initiated on 11/15/22 revealed the care plan had not been reviewed and/or revised after a quarterly MDS assessment dated [DATE] was completed, or up until the date of the review on 6/7/23. During an interview on 6/7/23 at 3:32 PM with the MDS Coordinator she reported she was responsible for updating the care plans and they should be reviewed and revised at least quarterly and with any changes. She went on to say she had gotten behind and was trying to get the care plans up to date. An interview on 6/7/23 at 5:31 PM with the Administrator revealed she expected care plans to be updated and revised with changes and upon completion of quarterly assessments. 3.Resident #20 was originally admitted to the facility on [DATE] with diagnoses which included acute respiratory failure and hypertension. Review of Resident #20's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #20 was cognitively intact and required extensive assistance for majority of activities of daily living (ADL). The MDS further revealed Resident #20 was coded for oxygen. Review of Resident #20's comprehensive care plan dated revealed no interventions for the use of oxygen. Review of Resident #20's physician order dated 05/29/23 revealed Resident #20's oxygen to run at 2 L per minute continuously. An observation conducted on 06/06/23 at 10:10 AM revealed Resident #20 laying on bed with oxygen running at 2 L via nasal cannula. An interview conducted with the MDS Coordinator on 06/07/23 at 4:00 PM revealed Resident #20 had been coded on the most recent MDS assessment for oxygen use and Resident #20's care plan should have reflected that. The MDS Coordinator further stated when MDS are completed resident care plans were expected to be revised and updated. An interview conducted with the Director of Nursing (DON) on 06/07/23 at 5:20 PM revealed she was unaware Resident #20's care plan did not address her oxygen use. The DON further revealed Resident #20 had been ordered oxygen for several months and Resident #20's care plan should have reflected that. An interview conducted with the Administrator on 06/07/23 at 5:40 PM revealed Resident #20's care plan should have been revised and reflected her MDS for oxygen use. 4. Resident #37 was admitted to the facility on [DATE] with diagnoses which included respiratory failure. Review of Resident #37's admission MDS dated [DATE] revealed Resident #37 required extensive assistance with majority of ADL care. The MDS further revealed Resident #37 was coded for oxygen. Review of Resident #37's comprehensive care plan dated revealed no interventions for the use of oxygen. Review of Resident #37's physician order dated 04/30/23 revealed Resident #20's oxygen to run at 5 L per minute continuously. An observation conducted on 06/06/23 at 10:00 AM revealed Resident #37 laying on bed with oxygen running at 5 L via nasal cannula. An interview conducted with the MDS Coordinator on 06/07/23 at 4:00 PM revealed Resident #37 had been coded on the MDS assessment for oxygen use and Resident #37's care plan should have reflected that. The MDS Coordinator further stated when MDS were completed resident care plans were expected to be revised and updated. An interview conducted with the Director of Nursing (DON) on 06/07/23 at 5:20 PM revealed she was unaware Resident #37's care plan did not address her oxygen use. The DON further revealed Resident #37 had been ordered oxygen for several months and Resident #37's care plan should have reflected that. An interview conducted with the Administrator on 06/07/23 at 5:40 PM revealed Resident #37's care plan should have been revised and reflected her MDS for oxygen use. 37019 5. Resident #60 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and cerebral vascular accident. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #60 was cognitively intact and independent with decisions. His MDS was marked for impairment on one side of the body for upper and lower extremity. Resident #60 required extensive assistance of one staff member with bed mobility, transfers, dressing, toilet use, and bathing. Review of Resident #60's care plan dated 02/11/23 revealed a focus for the resident having an activities of daily living (ADL) self-care deficit related to limited mobility, bilateral lower extremity weakness, left lower extremity mild contracture and limited mobility of his left hand. The interventions included resident has preference to always wear a gown initiated 02/01/22 and bathing/showering resident prefers bed bath initiated 11/11/2021 with no update. Observation and interview on 06/04/23 at 3:49 PM with Resident #60 revealed he preferred showers over bed baths and preferred to wear clothes during the day since he attends therapy. The resident was observed dressed in pants, shirt, socks, and shoes. Observation of Resident #60 on 06/05/23 at 9:02 AM revealed him up in his wheelchair and dressed in pants, shirt, socks, and shoes and going to the gym for therapy. An interview on 06/07/23 at 3:32 PM with the MDS Coordinator revealed she was responsible for updating the care plans and said they should be reviewed and revised at least quarterly and with any changes. The MDS Coordinator stated she had overlooked the changes in Resident #60's preferences and should have made the changes to the care plan to reflect them. An interview on 06/07/23 at 5:31 PM with the Administrator revealed she expected care plans to be updated and reviewed with changes and upon completion of quarterly assessments.

Based on observations, record review and staff interviews, the facility failed to ensure leftover food items stored ready for use were labeled and dated and failed to remove expired food items in 1 of 1 walk-in freezer, 1 of 1 reach-in refrigerators and 1 of 2 nourishment rooms (the Intermediate Care Facility nourishment room). These practices had the potential to affect food served to residents. Findings included: An initial tour of the kitchen was conducted on [DATE] at 10:45 AM with Dietary Aide #1. The walk-in freezer was observed to contain an unlabeled and undated bag of frozen riblettes which had been opened and tied back and two bags of opened frozen fried squash that were not labeled and dated. Observation further revealed in the walk-in cooler a container of diced ham that was labeled and had the discard date of [DATE]. The observation of the reach-in refrigerator revealed a bag of lettuce in a plastic bag not labeled and dated, with a hole in the bag, and appeared to be brown. During this observation, Dietary Aide #1 was interviewed and revealed foods in the walk-in freezer and reach-in refrigerator should have been labeled and dated. An observation was conducted on [DATE] at 11:30 AM with Dietary Aide #1 revealed the nourishment room located on the Intermediate Care Facility (ICF) had a plastic bag of an estimated 23 slices of cheese that had a discard date of [DATE] and a sandwich in a plastic bag that was hard when touched and was not labeled or dated in the refrigerator. The Dietary Aide #1 revealed both items were old and should have been discarded. An interview conducted with Dietary Manager (DM) on [DATE] at 8:00 AM revealed all food items found during observations of the walk-in freezer, reach-in refrigerator and ICF nourishment room refrigerator should have been labeled, dated and/or discarded if stored past the date labeled. The DM revealed it was the dietary staff's responsibility to check the kitchen and nourishment rooms daily and the items should not have been missed. An interview conducted with the Administrator on [DATE] at 5:40 PM revealed food stored for residents should always be labeled and dated. The Administrator further revealed food items past the discard date should have been discarded.

Based on observations, record reviews, and staff interviews, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the complaint investigations that occurred on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], a focused infection control survey of [DATE] and the recertification and compliant investigation survey that occurred on [DATE]. This failure was for six deficiencies that were originally cited in the areas of Notification of Change (F580), Resident Assessment (F641), Tube Feeding Management (F693), and Infection Prevention and Control (F880) and were subsequently recited on the current recertification, revisit, and complaint investigation survey of [DATE]. The repeat deficiencies during multiple surveys of record show a pattern of the facility's inability to sustain an effective QA program. The findings included: This tag is cross referred to: F580: Based on record review, staff and Medical Director interview the facility failed to notify the physician after a non-diabetic resident was administered 38 units of insulin glargine (a long-acting insulin) in error by Nurse #1. This was for 1 of 1 resident reviewed for notification (Resident #31). During the complaint investigation survey conducted [DATE], the facility failed to notify the Infectious Disease Provider that was managing a resident's intravenous (IV) antibiotic which was being used to treat a right subdural empyema (collection of pus between the layers of the brain) and Cerebritis (inflammation of cerebrum of the brain) that the resident's peripherally inserted central catheter (PICC) (an IV used to administer medications) had become dislodged and his antibiotics were not administered as ordered for 1 of 1 resident. There was a high likelihood for bacterial regrowth, resistance to antibiotic, sepsis, or return to hospital due to the missed medications. During the complaint and focused infection control investigation conducted on [DATE] the facility failed to notify the physician of medication unavailability for 3 of 3 residents (Resident #2, Resident #3 and Resident #4) reviewed for medications. During the complaint investigation conducted on [DATE] the facility failed to notify a physician of an acute change in status immediately following an acute burn sustained by Resident #1 when he was involved in an accident involving smoking while wearing oxygen for 1 of 1 resident reviewed for notification of the medical provider (Resident #1). F641: Based on record review, observation, and resident and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) for discharge status (Resident #102), range of motion limitations (Resident #211), and accumulative diagnoses (Resident #210) for 3 of 28 residents whose MDS were reviewed. During the complaint investigation survey conducted on [DATE], the facility failed to complete an admission assessment for 1 of 4 residents within 14 days of admission. During the complaint survey conducted on [DATE] the facility failed to accurately code the Minimum Data Set assessments to reflect Resident #7 and Resident #5 received dialysis therapy. This was evident for 2 of 2 residents reviewed for dialysis. F693: Based on observation, record review, staff, and resident interviews the facility failed to ensure an opened bag of tube feed that was running through a feeding pump, had a date, time, and resident name on them for 1 of 3 residents (Resident #89) reviewed for tube feeding. During the recertification and complaint investigation survey conducted on [DATE], the facility failed to administer the correct tube feed formula at the correct rate per the physician's order for 1 of 2 residents with a gastrostomy tube (GT). F880: Based on observation, record review and staff interviews, the facility failed to follow the manufacturer's guidelines for cleaning and disinfection of a blood glucose meter which was stored in the medication cart after use for 2 of 2 residents observed (Resident #3 and Resident #105) during a medication pass on [DATE] at 9:05 AM. The blood glucose meter was stored in the medication cart and was not designated as an individual resident meter. The facility had three residents in the building with a diagnosis of a bloodborne pathogen (microorganisms that cause disease and are present in human blood) (Resident #104, Resident #64, and Resident #76). This deficient practice had a high likelihood for transmitting bloodborne pathogens within the facility. During the complaint and focused infection control survey conducted on [DATE] the facility failed to follow the CDC guidance regarding appropriate Personal Protective Equipment (PPE) for counties of high county transmission rates when 1 of 1 wound care personnel (Wound Care Nurse) failed to wear eye protection while performing wound care for 1 of 3 residents who required wound care (Resident #1). The facility also failed to change their PPE when exiting 2 of 10 residents room located on the quarantine unit (Resident #9 and Resident #10) who were under enhanced contact droplet precautions. This deficient practice occurred while the facility was in outbreak status with one staff member testing positive for COVID-19 on [DATE] and another testing positive on [DATE]. During the complaint survey conducted on [DATE] the facility failed to follow guidance produced by the Centers for Disease Control and Prevention by socially distancing 8 residents observed smoking in the courtyard adjacent to the facility for 8 of 8 residents reviewed for infection control (Resident #1, #2, #3, #4, #5, #6, #8, #9). During the complaint investigation survey conducted on [DATE], the facility failed to follow infection control policies when a personal care aide entered and exited resident rooms labeled Enhanced Droplet Contact Precautions (EDCP) without removing her personal protective equipment (PPE) or performing hand hygiene after providing nailcare. The facility failed to ensure required PPE was donned when two nurse aides performed a shower for a resident who was under EDCP and a medication aide administered medication to a resident on EDCP. During the complaint investigation survey conducted on [DATE], during a high level of transmission for COVID-19 in the county, the facility failed to implement their infection control policies and the Centers for Disease Control and Prevention (CDC) guidelines for the use of Personal Protective Equipment (PPE) when 2 of 3 staff members failed to wear eye protection while providing care to 1 of 1 resident who was on enhanced droplet contact precautions and when 5 of 8 staff members failed to wear eye protection while providing care to 7 of 7 residents in the general halls. These practices affected 8 of 8 residents reviewed for infection control. These failures occurred during a COVID-19 pandemic. During an interview on [DATE] at 5:34 PM with the Administrator, she reported her quality assurance (QA) team met monthly and included the medical director, department heads, administrative staff, the Nurse Practitioner, and the Registered Dietician and Pharmacist by phone. She reported they currently had Process Improvement Plans (PIPs) addressing the deficiencies of the previous 2 complaint investigation surveys and had made some significant changes but still had work to be done. She further reported they were currently working on PIPs on recruitment and retention to hire their own staff instead of relying heavily on agency staff, PIP on med errors, Cardiopulmonary Resuscitation (CPR), Insulin, family/community engagement with fire, police, Emergency Medical Services (EMS) and hospitals to improve relationships with them. She also reported the Minimum Data Set (MDS) assessment PIP was ongoing and have seen improvements in certain areas, but care plans were going to need a more significant focus. The Administrator stated the PIPs in place would be ongoing and monitored extensively to ensure ongoing and future compliance. During the complaint and focused infection control survey conducted on [DATE] the facility failed to implement infection control policies and Centers for Disease Control and Prevention (CDC) guidelines when two nursing assistants (NAs) failed to don and doff PPE (Personal Protective Equipment) and failed to perform hand hygiene before entering or after contact with a resident or objects in a resident's room for 4 of 4 sampled residents who resided on the COVID-19 care units and were on Enhanced Droplet Isolation Precautions (Residents #1, #2, #3, #4).These failures in infection control practices occurred during a global COVID-19 pandemic. During the focused infection control survey conducted on [DATE] the facility failed to ensure residents did not access the smoking area by going through the quarantine unit for 3 of 3 residents reviewed for infection control practices (Resident #1, Resident #2 and Resident #3). These infection control failures occurred during a global COVID-19 pandemic.

Based on record review, staff and Medical Director interview the facility failed to notify the physician after a non-diabetic resident was administered 38 units of insulin glargine (a long-acting insulin) in error by Nurse #1. This was for 1 of 1 resident reviewed for notification (Resident #31). Findings included: Resident #31 was admitted into the facility on [DATE] with diagnoses which included hypertension and asthma. Resident #31 did not have a diagnosis of diabetes mellitus. Resident #31's admission Minimum Data Set (MDS) dated [DATE] revealed he was alert and oriented requiring limited assistance of one staff member for most activities of daily living (ADL). Resident #31 was coded as not receiving insulin. A nursing progress note dated 05/14/23 at 2:07 AM written by Nurse #1 revealed she had made a medication error by administering Resident #31 38 units of insulin glargine a long-acting insulin. The note revealed Nurse #1 gave the resident peanut butter cookies, apple juice, ice cream and orange juice. The note further revealed Nurse #1 placed a call to the on-call provider and was awaiting a return phone call. Nurse #1 notified the Director of Nursing (DON) by text message and placed a note in the Medical Director's communication book for when he came into the facility. A nursing progress note dated 05/14/23 at 4:38 AM written by Nurse #1 revealed Resident #31 was sent out to the hospital for an evaluation due to low blood sugar. The Director of Nursing, Medical Director was notified via communication book. An interview was conducted on 06/04/23 at 9:45 AM with Nurse #1. During the interview Nurse #1 stated she was agency staffing and not familiar with Resident #31. She stated around 11:00 PM she was told by the Medication Aide that she had to administer the insulin for the hall. Nurse #1 stated she did not go and log onto a computer, instead she took the paper sheet the MA had written and transferred onto another piece of paper the residents blood sugars and insulin orders. She stated she did not look at a computer to know what the resident looked like or verify the nursing orders. The interview revealed she immediately felt like she had made a mistake because the resident was thin, and she felt like he didn't look like he would need that much insulin. She stated when she began to question Resident #31 about insulin the resident stated to her that his blood sugar had never been checked while in the facility. Nurse #1 stated she went and got the MA who went back into the room with her and verified that she had given insulin to the wrong resident. Nurse #1 stated she immediately took the residents blood sugar with a reading of 111. Nurse #1 gave Resident #31 peanut butter cookies, orange juice and ice cream to try and keep his sugar maintained. She stated she called the on-call provider but received no return phone call, she sent the DON a text message and placed a note in the Medical Director communication book. Nurse #31 stated she came back to Resident #31 around 4:00 AM to recheck his blood sugar with a result of 53. She then called the DON who told her the facility had glucagon (a medication used to increase a resident's blood sugar level) and to send the resident to the hospital for an evaluation. On 06/05/23 at 2:30 PM an interview was conducted with the Director of Nursing (DON). During the interview she stated Nurse #1 had given Resident #31 his roommates insulin by mistake on 05/14/23. She stated the nurse immediately realized she had made a mistake and notified the on-call provider. The DON stated Nurse #1 sent her a text message, but she did not receive it. She stated the nurse should have called her instead for a medication error. The DON stated she received a phone call from Nurse #1 around 3:45-4:00 AM to tell her what had happened. The DON stated she told the nurse to send the resident to the hospital since the insulin was long acting and his blood sugar could continue to drop. The interview revealed Nurse #1 should have immediately notified her via phone call of the incident and got in touch with the on-call provider when she didn't hear back from them initially. On 06/06/23 at 2:32 PM an interview was conducted with the Medical Director (MD). He stated he was not working in the building at the time of the incident. The MD stated that he felt the nurse should have been able to speak to an on-call provider when the mistake initially occurred. The MD stated the on-call providers are available throughout the night and placing a note in the communication book would not have been sufficient.

Based on record review, resident, staff, and Medical Director interviews the facility failed to assess a resident who had no reported bowel movement for eight days and failed to initiate their bowel protocol for 1 of 4 residents (Resident #1) reviewed. Resident #1 was transferred to the local emergency room and was found to have a large fecal impaction in the distal colon and required multiple enemas, laxatives, and stool softeners to resolve the impaction. The findings included: Review of a document titled Standing Orders revealed the following: 11. If no Bowel Movement in 72 hours, Milk of Magnesia 30 milliliters (ml) by mouth or Dulcolax Suppository everyday as needed unless (dialysis or Stage 2 renal disease present.) Not to exceed 2 times weekly. Resident #1 was admitted to the facility on [DATE] with diagnoses that included drug induced constipation, chronic pain syndrome, and incomplete lesion of cervical spinal cord. Review of a physician order dated 11/10/22 read; Sennosides-Docusate sodium (stool softener) 8.6/50 milligrams (mg) give two tablets by mouth two times a day for constipation. Review of a physician order dated 11/14/22 read: Lactulose (used to treat constipation) 10 gram (gm)/15 ml give 30 ml three times a day for constipation for forty-five days. Review of a Brief Interview for Mental Status (BIMS) dated 12/08/22 revealed that Resident #1 was cognitively intact. Review of a consultation report dated 01/16/23 read: start Movantik 25 mg daily for opiate induced constipation. The consult indicated that a prescription was sent. Review of a physician order dated 01/17/23 read: Movantik 25 mg by mouth daily for constipation for thirty days. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1's cognition was not assessed. The MDS further revealed that Resident #1 required extensive assistance of two staff members for toileting and personal hygiene and was always incontinent of bowel. Review of Resident #1's medical record revealed no care plan addressing his diagnosis of chronic constipation. Review of Resident #1's bowel record dated March 2023 revealed that Resident #1 had no documented bowel movements from 03/01/23 through 03/09/23. Review of a physician's order dated 03/08/23 read; Fleet enema rectally one time for no bowel movement in three days. Review of the Medication Administration Record (MAR) dated March 2023 revealed the following: Fleet enema insert one rectally one time for no bowel movement in three days. There was no initials on 03/08/23 indicating the enema had been given and on 03/09/23 the order was coded as the resident was on leave of absence. Review of nurses note dated 03/09/23 read in part; Resident #1 requested to be sent to the hospital for evaluation and treatment due to resident stating he thought he was septic (serious infection) due to his wounds. Medical Doctor (MD) notified, and order placed to send per resident request. Resident #1 left the facility via stretcher at 2:30 PM. The note was electronically signed by Nurse #1. Resident #1 was discharged to the local hospital on 03/09/23. Review of a discharge summary from the local hospital dated 03/14/23 read in part; diagnoses: fecal impaction. Scan of the abdomen read; large fecal burden with impaction of the distal colon up to 7.5 centimeters (cm). No small bowel obstruction. The discharge summary further read; large fecal impaction in the distal colon that required multiple enemas, stool softeners, and laxatives but did resolve. Nurse #1 (agency) was interviewed via phone on 05/16/23 at 9:02 AM. Nurse #1 stated she routinely cared for and was familiar with Resident #1 and recalled in March 2023 when Resident #1 went to the hospital. She stated that either on 03/08/23 or 03/09/23 Resident #1 had requested an enema but she could not recall if she actually administered the enema or not. She stated that at the same time he was also requesting to go to hospital because Resident #1 thought that he was septic from his wounds. Nurse #1 stated she called the MD and got an order to send him to the hospital per Resident #1's request. Nurse #1 explained that Resident #1 often times had trouble with his bowel movements because he was a paraplegic and did not have sensation or feeling below his under-arm area down to his feet. Nurse #1 stated that during the time in March 2023 when Resident #1 went to the hospital the Unit Managers (UMs) were responsible for reviewing the report in the electronic health record to determine which residents had not had a bowel movement in three days and would initiate our standing orders and administer something. She stated that if the UMs were not able to check the report she tried to do so as well but there were times when she did not have the time especially if she was working the medication cart. An interview was conducted with Resident #1 on 05/15/23 at 10:06 AM. Resident #1 stated that in March 2023 he went for eight days without having a bowel movement. He stated that he was a paraplegic and had no feeling or sensation from his under-arm area down to his feet. He added that he had no control of his bowels, and he was dependent on the staff to assist him with cleaning him after a bowel movement because he was not aware of when he went. Resident #1 stated that before he went to the hospital in March 2023, he knew he was impacted, he stated he had told several staff members and they kept telling him that he was on stool softeners every day. He stated that his stomach was distended, and it was very uncomfortable for him to sit in his chair. Resident #1 stated that he would have spams in his stomach but the muscles that were used to push out fecal matter were paralyzed so it was very difficult for him to have a bowel movement and as the stool built up over the days leading up to the hospitalization , he got more and more uncomfortable. Resident #1 stated that in the past he had received enemas in the facility but confirmed that he did not receive an enema by Nurse #1 in the facility prior to being discharged to the hospital on 03/09/23 nor did he refuse to have the enema but did request to go to the hospital. An interview was conducted with UM #1 on 05/15/23 at 10:48 AM who stated that she was the UM up until a few weeks ago. She stated that in March 2023 Director of Nursing (DON) #2 would check the clinical alerts in the electronic health record and see which residents flagged as not having a bowel movement in three days. Then during the clinical meeting each morning, we would make note of those resident on our units and after the meeting the UMs would go and have the hall nurse determine if the resident had a bowel movement or not and if not then they were to initiate the bowel protocol. UM #1 stated that when DON #2 left the facility she began reviewing the clinical alerts but there were days that she did not have time to. She added that the facility currently did not have any UMs and DON #1 was the only one that had access to the clinical report about bowel movements. She stated a lot of times she was pulled to work the medication cart or do other tasks and she did not have to time to review that report on a consistent basis. UM #1 stated that she was aware Resident #1 took several medications that would cause constipation but was unaware that he had gone to the hospital in March 2023 and was diagnosed with a fecal impaction. An interview was conducted with UM #2 on 05/15/23 at 3:52 PM who confirmed that she was a UM up until a few weeks ago. She stated that in March 2023 DON #2 checked the clinical alerts in the electronic medical record to see which residents flagged as not having a bowel movement in three days. Then during the clinical meeting each morning, we would make note of those residents on our units and after the meeting have the hall nurse initiate the bowel protocol. UM #2 stated that when DON #2 left the facility she began reviewing the clinical alerts. UM #2 stated that a lot of times she was pulled to the medication cart and did not review the clinical alerts and did not attend the morning meeting, so she was not aware of the residents that were triggered on the alert. UM #2 stated Resident #1 was discussed a lot in morning meeting, but she never recalled him flagging on the report for not having a bowel movement in three days. UM #2 stated she was aware Resident #1 went to the hospital on 03/09/23 and stated Nurse #1 was going to give him an enema but he demanded to go the hospital. Attempts to speak to Nurse #2 were made on 05/15/23 and were unsuccessful. Nurse #2 cared for Resident #1 on 03/01/23. Nurse Aide (NA) #1 was interviewed on 05/15/23 at 11:44 AM. NA #1 confirmed that she cared for Resident #1 on 03/01/23 and stated that he reported his bowel needed to move and his belly was hurting. She stated that she reported Resident #1's concerns to Nurse #1. NA #1 explained that Resident #1 could not push the fecal material out because his muscles were paralyzed. She stated that recently she had Resident #1 in the shower, and he asked her to push on his belly and when she pushed on his belly, he was able to pass quite a bit of of stool. NA #1 also stated that she documented in the electronic record that Resident #1 did not have a bowel movement on the shift that she was assigned to care for him on 03/01/23. NA #2 was interviewed on 05/15/23 at 6:03 PM. She stated that rarely cared for Resident #1 but confirmed that she had cared for him on 03/01/23 and he did not have a bowel movement during the time she was assigned to care for him. She stated if he would have had a bowel movement, she would have documented that in the electronic record. She did not recall Resident #1 complaining of being constipated or his abdomen hurting at that time. NA #3 was interviewed via phone on 05/16/23 at 10:28 AM and confirmed that he had cared for Resident #1 on 03/02/23 but stated to his recollection Resident #1 did not have bowel movement or he would have documented it in the medical record. NA #3 stated Resident #1 told him Quite often that he was constipated and if it had been several days that he had not had a bowel movement we would let the nurse know. NA #3 stated that if Resident #1 was really uncomfortable due to his constipation he would request an enema. NA #4 (agency) was interviewed via phone on 05/15/23 at 4:45 PM. NA #4 stated she had not worked at the facility in awhile but confirmed that she had cared for Resident #1 on 03/02/23. She stated that during that time Resident #1 did not have a bowel movement and if he had she would have documented that in the electronic medical record. An attempt to speak to Medication Aide (MA) #1 was made on 05/16/23 at 10:26 AM was unsuccessful. MA #1 provided care to Resident #1 on 03/03/23 and 03/06/23. Contact information was unavailable for Nurse #4 who provided care to Resident #1 on 03/03/23 from 7:00 AM to 7:00 PM. MA #3 was interviewed via phone on 05/16/23 at 4:10 PM and confirmed that she cared for Resident #1 on 03/03/23 from 7:00 PM to 7:00 AM, 03/04/23 from 7:00 PM to 7:00 AM, and 03/08/23 from 7:00 PM to 7:00 AM. She stated she could not recall if he had a bowel movement during those shifts but if he did, she would have documented it in the electronic record. She stated that Resident #1 had mentioned to her before that he had not used the bathroom in a few days, and she stated she had given him his ordered stool softener. NA #5 (agency) was interviewed via phone on 05/15/23 at 3:30 PM. NA #5 stated that she had not worked at the facility in a couple of months but confirmed that she cared for Resident #1 on 03/03/23 and 03/07/23. She stated that Resident #1 did not have a bowel movement during those shifts, and she charted that. She stated that Resident #1 did say that he was constipated, and he was going to have to go to the hospital if what they gave him did not work. NA #5 stated she did not report that to anyone because Resident #1 had indicated that the nurse had given him something. MA #2 was interviewed via phone on 05/16/23 at 10:33 AM. MA #2 stated confirmed that he cared for Resident #1 on 03/04/23 and 03/05/23. MA #2 could not recall if Resident #1 had a bowel movement on those days but stated if he did, he would have documented that in the electronic medical record. He did say that Resident #1 had told him a few times that he was constipated and needed something. MA #2 stated he would consult with the nurse and then administer what the nurse instructed him to give. NA #6 (agency) was interviewed via phone on 05/15/23 at 4:40 PM who confirmed that she had cared for Resident #1 on 03/04/23 but could not recall specifically if he had a bowel movement during that shift. She stated that if he had a bowel movement, she would have documented it in the medical record. NA #6 further stated she did not recall Resident #1 complaining of any constipation or issues with his bowels. An attempt to speak to NA #7 was made on 05/16/23 at 4:29 PM and was unsuccessful. NA #7 cared for Resident #1 on 03/04/23. An attempt to speak to NA #8 was made on 05/15/23 at 3:35 PM was unsuccessful. NA #8 cared for Resident #1 on 03/05/23 and 03/08/23. Nurse #5 (agency) was interviewed via phone on 05/16/23 at 5:08 PM. Nurse #5 confirmed that she worked the night shift on 03/06/23 and cared for Resident #1. She stated that during that shift he did not report any issues with constipation or indicated he had bowel issues. An attempt to speak to NA #9 was made on 05/17/23 at 10:31 AM and was unsuccessful. NA #9 cared for Resident #1 on 03/06/23. NA #10 (agency) was interviewed via phone on 05/15/23 at 3:41 PM who confirmed that she cared for Resident #1 on 03/06/23. She stated that she did not recall if Resident #1 had a bowel movement during that shift but stated if he had a bowel movement, she would have documented that in the electronic medical record. MA #4 was interviewed via phone on 05/16/23 at 10:37 AM who confirmed that she cared for Resident #1 on 03/07/23. She stated that Resident #1's bowel movements were infrequent, and he would often times request something to make his bowel move. She stated she would consult with the nurse and administer whatever was ordered. Nurse #6 (agency) was interviewed via phone on 05/15/23 at 4:13 PM who confirmed that she was covering the MA that was responsible for Resident #1 on 03/07/23. Nurse #6 stated that Resident #1 was alert and oriented and was able to tell if he had not had bowel movement or if he was having trouble. She stated he never reported to her issues with his bowels or requested something for constipation. She stated that she rarely interacted with Resident #1 and that most of the time she was supervising the MA on the unit and not providing direct care. Nurse #6 also stated that if she had the time, she would review the clinic alerts to determine which resident on her unit had not had a bowel movement in three days and would follow up. She would ask the resident and/or staff and if the resident had indeed not had a bowel movement in three days, she would initiate the bowel protocol. Nurse #7 (agency) was interviewed via phone on 05/16/23 at 5:22 PM. Nurse #7 confirmed that she cared for Resident #1 on 03/07/23 and during that shift she did not recall any issues with constipation or Resident #1 requesting something for his bowels. She stated if Resident #1 had complained of being constipated she would have contacted the medical provider and written a note about it. She further explained that she relied on the NAs to tell her which residents had not had a bowel movement or any resident complaint about being constipated. NA #11 was interviewed on 05/15/23 at 12:28 PM and confirmed that he cared for Resident #1 on 03/07/23 but could not recall if he had a bowel movement during that shift. He stated if Resident #1 had a bowel movement, then he would have documented it in the medical record. NA #11 stated that in the past Resident #1 had complained of having trouble with bowel movements and that at times he requested and received an enema. DON #2 was interviewed via phone on 05/15/23 at 11:16 AM. She stated she was the DON at the facility until mid-March 2023. During her time in the facility, she would review the electronic medical record for residents that flagged as not having a bowel movement in three days or seventy-two hours under the clinical alerts. She stated the UMs monitored them daily and if the resident had not had bowel movement in three days, they would initiate the bowel protocol. She recalled Resident #1 flagged a couple of times on the report but was not a constant issue. DON #2 stated she was unaware of why Resident #1 went to the hospital in March, but she was certain it was not related to constipation issues. DON #1 was interviewed on 05/15/23 at 4:49 PM who confirmed that she had been the DON at the facility since April 7, 2023. She stated that was not aware of any bowel protocol or clinical alerts that she needed to monitor until today when she was educated by a corporate staff member. DON #1 stated that she was educated to check the clinic alerts each day for residents that had not had a bowel movement in three days and then discuss in the morning clinical meeting to ensure that the bowel protocol was initiated if needed. The MD was interviewed via phone on 05/15/23 at 1:33 PM. The MD explained that he was not currently the MD but was the MD in March 2023. He confirmed that Resident #1 was a paraplegic and his bowels were being managed with stool softeners. The MD stated that the Gastrointestinal (GI) doctor had started Movantik in January for opioid induced constipation, and he stated he would have started MiraLAX after Movanik was stopped if he would have known about Resident #1's ongoing bowel issues. The MD stated that the hand that writes for the opioids is also the hand that has to write for something for the bowel and confirmed that he had prescribed Resident #1's opioids. The MD stated that he had overlooked the issue and somehow it fell through the cracks.

Based on record review and staff, Nurse Practitioner and Medical Director interviews the facility failed to have basic lifesaving equipment readily available for use to immediately begin cardiopulmonary resuscitation (CPR) when Resident #3 experienced sudden cardiac arrest on [DATE] and staff were unable to immediately begin CPR that included chest compressions and rescue breathing because the first crash cart (cart of emergency supplies) that was brought to the bed side did not have a ambu bag or manual resuscitator (device to administer rescue breathing) on it, staff began chest compressions and it took the staff approximately three minutes to get the second crash cart that did have a ambu bag to begin rescue breathing. Resident #1 experienced sudden cardiac arrest on [DATE] and staff were unable to immediately begin CPR that included chest compressions and rescue breathing because the staff could not locate an ambu bag or manual resuscitator to begin rescue breaths and could not locate a backboard (hard surface to do chest compressions on while in bed). It took the staff approximately five minutes to locate the needed items to begin CPR. On [DATE] Resident #2 experienced sudden cardiac arrest and staff were unable to immediately begin CPR that included chest compressions and rescue breathing because they could not locate an ambu bag or manual resuscitator and had to borrow one from another resident's room. The staff also could not locate the paddles for the Automatic External Defibrillator (AED) (device used to deliver a shock to the heart). It took staff several minutes to locate the ambu bag and paddles for the AED to begin CPR. This affected 3 of 4 residents reviewed who experienced sudden cardiac arrest. Resident #1, #2, and #3 expired in the facility or in the hospital. Immediate Jeopardy began on [DATE] when Resident #3 experienced sudden cardiac arrest and staff were unable to immediately begin CPR that included chest compressions and rescue breathing because they could not locate an ambu bag to begin rescue breathing. Immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity E (no actual harm with more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place and the completion of staff education. The finding included: Review of the facility's policy titled CPR Procedures, last revised on ,d+[DATE] read in part: 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing a. Verify or direct a staff member to verify the DNR (Do Not Resuscitate) or code status of an individual b. Instruct a staff member to activate the emergency response system (code) and call 911 c. Instruct a staff member to retrieve the crash cart d. Initiate the basic life support (BLS) sequence of events. 1. Resident #3 was admitted to the facility on [DATE] with diagnoses that included acute and chronic respiratory failure with hypoxia and congestive heart failure. Review of a physician order dated [DATE] indicated Resident #3 was a full code. Review of a care plan dated [DATE] read; Resident #3 has an established advanced directive; Full Code. The goal read: Resident #3 wishes as expressed in Advanced Directive will be followed. Review of Resident #3's progress notes revealed a note by Nurse #13 dated [DATE] at 7:28 AM that read in part: Resident reported on floor at 6:15 AM by Med Aide #3 (MA) following ambulation by resident from smoking area. Resident assessed for pulse and respiration. Resident #3 was placed in a supine position and chest compressions were initiated immediately. EMS (Emergency Medical Services) notified by staff while this Nurse #13 and additional Nurse #7 performed CPR in (cardiopulmonary resuscitation] in residents' room. EMS arrived at 6:25 AM and began working with resident. Resident pronounced expired by EMS at 6:46 AM. An interview with Nurse #13 (agency nurse) was conducted on [DATE] at 3:44 PM via telephone and revealed he was an agency nurse and the first nurse to respond to calls for help from MA #3 on [DATE] when Resident #3 was found unresponsive but still warm. He reported he requested the crash cart and assistance from Nurse #7. He stated he immediately began chest compressions until Nurse #7 arrived at the room and began assisting with rescue breaths via an ambu bag. He reported he did not know if a second crash cart had to be retrieved as his main concern was trying to save Resident #3's life. Review of the facility's staffing schedule from [DATE], the morning Resident #3 passed away, revealed Nurse Aide (NA) #11, NA #12, Nurse #7, Nurse #12, Nurse #13, and Medication Aide (MA) #3 were working. An interview with MA #3 on [DATE] at 3:14 PM revealed when she found Resident #3 in the floor of his room unresponsive around 5:30 AM on [DATE] she immediately called for help and Nurse #13 arrived at the room. She reported she was told by Nurse #13 to go gather the necessary paperwork for transport, so she left the room. She did not know if there were issues with items not being on the crash carts. An interview with NA #13 (agency) was conducted on [DATE] via telephone, at 2:42 PM and revealed she was working in the facility on [DATE] as a nurse aide the morning Resident #3 had passed away. She stated around 5:30 AM, MA #3 entered Resident #3's room and found him unresponsive. She reported the first crash cart was brought to the room and she ran to get Nurse #7 who was working on the other unit. She stated when she returned from notifying Nurse #7, she found out the crash cart did not have an ambu bag on it and she ran back down the hall to get the other crash cart. She reported there was an approximate 5-minute delay in getting the supplies gathered to begin CPR. During an interview with NA #11 on [DATE] at 12:05 PM she reported she and NA #12 were assigned to Resident #3 on [DATE], the morning he passed away. She reported he had gone out to smoke around 4:00 AM and seemed his normal self. She reported when MA #3 went into his room around 5:00 AM, she found him on the floor and screamed for help. NA #11, NA #12, NA #13 and Nurse #13, responded to Resident #3's room. She reported NA #13 ran to get the crash cart while Nurse #13 began Cardiopulmonary Resuscitation (CPR). She reported she remembered the second crash cart had to be retrieved because the first crash cart did not have an ambu bag. An interview with NA #12 was conducted on [DATE] at 12:35 PM and revealed she was working on [DATE] the morning Resident #3 died . She reported that when the staff were made aware Resident #3 was in cardiac arrest, Nurse #13 sent NA #13 to go get the crash cart while she started CPR. NA #12 reported when NA #13 returned with the crash cart she had to go get a second crash cart because the first one did not have a backboard or an ambu bag. She reported it took ,d+[DATE] minutes before all the supplies were at Resident #3's room to begin CPR. An interview was attempted with Nurse #7 and was unsuccessful. A joint interview with Unit Manager (UM) #1 and UM #2 on [DATE] at 1:15 PM revealed they were responsible for ensuring crash carts were stocked and that the crash carts were checked daily and completed a log of inventory that was kept on the crash carts. They reported they checked the crash carts to ensure they contained ambu bags, oxygen, a suction machine, and other needed materials in the event of a cardiac arrest event. They also reported the logs from [DATE] had been long removed and were unable to locate them. UM #1 and UM #2 insisted both of the facility's crash carts had an ambu bag and that backboards were kept next to the crash carts. A telephone interview with the Medical Director on [DATE] at 5:13 PM revealed he expected the facility to have the supplies they needed on the crash carts to immediately start CPR in the case of a sudden onset of cardiac arrest. An observation of the facility's crash carts was made on [DATE] at 1:09 PM. Both crash carts were observed to have ambu bags on the bottom of the cart and a backboard was next to each crash cart. The crash carts were also stocked with a suction machine, tubing, nasal cannulas, stethoscope, blood pressure cuff, and other supplies that may be needed during a cardiac arrest emergency. An interview was attempted with the Director of Nursing #3 and was unsuccessful. An interview was attempted with Administrator #3 and was unsuccessful. 35789 2. Resident #1 was admitted to the facility on [DATE] with diagnoses that included diabetes, hypertension, peripheral vascular disease, atrial fibrillation, and others. Review of a physician order dated [DATE] read: Full Code. Review of a care plan dated [DATE] read; Resident #1 will have Full Code Advance Directives. The goal read: Resident #1 will have his Advance Directives followed. Review of a nurses note written on [DATE] as a late entry by Nurse #1 read, Resident was found to be unresponsive by the NA who was in the process of making rounds. CPR was started immediately. EMS was called and they arrived in 10 minutes. EMS took over CPR compressions and proceeded to continue to perform full code on resident. Resident continue to be none responsive. The ER doctor on call pronounced resident deceased at 2:26 AM. Resident #1 expired on [DATE]. Nurse #1 (agency nurse) was interviewed via phone on [DATE] at 12:14 PM who confirmed she was working third shift on [DATE]. She stated she was passing medications and had passed Resident #1's room and he was in bed and was his usual self. Nurse #1 stated that a short time later one of the NAs who she did not know came to her and stated that Resident #1 was not breathing. Nurse #1 stated that she was not aware how to page overhead, so she began yelling loudly to alert other staff that she needed some help. She stated that she sent the NAs to get the crash cart while she began chest compressions. Nurse #1 stated I was getting mad because they could not find anything that was needed, it took them over five minutes to find what we needed (backboard and ambu bag) and she was not aware of where they located the items. Nurse #1 stated she was the only nurse in the room and had to teach the nurse aides how to use the ambu bag really quick. Nurse #1 stated that she worked at the facility through an agency, and she did not get any orientation to the facility regarding emergency procedures or protocols. She stated she knew where the crash carts were from just observing during her times in the facility, she stated, I was very upset, I felt like that when you have crash carts it should be supplied even with the basics and that night it did not have an ambu bag and the back board could not be located. Nurse #1 confirmed that when the NA told her that Resident #1 was not breathing, she had gone to the electronic medical record and verified his code status as Full Code and when she began chest compression Resident #1's body was still warm to touch, and she confirmed that she checked all his pulse points and could not find one so chest compression were initiated while she waited for the appropriate equipment. NA #1 (agency NA) was interviewed via phone on [DATE] at 11:06 AM who confirmed that she worked at the facility through an agency and was working third shift on [DATE] when Resident #1 went into cardiac arrest. NA #1 stated that she was very familiar with Resident #1 and each night that she worked she would always go and check on him, she stated he particularly loved milk and shortly after the start of her shift on [DATE] she had gone and got Resident #1 a carton of milk to drink. She stated she had passed by his room several times during the shift and Resident #1 was in his bed in his usual state. She stated then she heard the staff verbally hollering that they had Code Blue (code for sudden cardiac arrest), and she went running towards Resident #1's room. NA #1 stated that someone had grabbed the crash cart but there was no ambu bag on it and no backboard was available. She stated that Nurse #1 began chest compressions, but he was on the soft bed not on a hard surface. NA #1 stated she suggested to Nurse #1 that they lower him to the floor to begin compressions, but she continued to do compressions while the staff frantically tried to locate an ambu bag to do rescue breathing. NA #1 stated that it took a few minutes for someone to find an ambu bag, but she could not recall who found it and she did not know where they found it. NA #1 stated that she believed the crash carts were to be checked daily to ensure all the supplies were available but stated that when they needed to do CPR on Resident #1 the crash cart did not have an ambu bag and no back board was available. She added that the crash cart they used stayed in disarray for about three weeks after the event until someone returned it to the correct place and restocked it. NA #2 was interviewed via phone on [DATE] at 11:23 AM and confirmed that she worked third shift on [DATE] and was responsible for Resident #1. NA #2 stated that she had answered a call light for another room and had walked past Resident #1's room on her way to the nurse's station to tell the nurse what that resident needed. She stated that as she passed by Resident #1's room he was in bed and was kicking the covers off of him, she proceeded to the nurse's station and as she walked back by Resident #1's room she noticed that his color was gone, and he was very pale. She stated that Resident #1 was warm to touch but was not breathing so she yelled Code Blue to the other staff on the unit. NA #2 stated she did not know how to overhead page, so she ran to the other side to alert the staff and on her way back grabbed the crash cart. She stated that there was no ambu bag on the crash cart and she could not find a backboard. NA #2 stated that she rushed around trying to find all the stuff that was needed for him. NA #2 recalled that eventually they found the backboard but finding the ambu bag was little more difficult because she was not sure what she was looking for. NA #2 stated that eventually another staff member who she did not know returned to the room with an ambu bag and they began rescue breathing around the same time that EMS arrived on scene. NA #2 stated that it took approximately five minutes to gather all the needed supplies to do CPR on Resident #1. Medication Aide (MA) #1 (facility staff) was interviewed via phone on [DATE] at 12:33 PM who confirmed that she was working third shift on [DATE]. She stated that she recalled hearing the Code Blue for Resident #1 and she went to assist as needed. She stated that Nurse #1 was a agency Nurse and really did not know what to do so she was telling her the procedure. She stated that Nurse #1 began CPR, but she could not recall anything regarding the supplies. MA #1 stated it had been a while since the event and she really could only recall that Resident #1 had passed away. NA #3 was interviewed via phone on [DATE] at 4:41 PM who confirmed that she was working third shift on [DATE]. She stated what she recalled about that evening was that Resident #1 coded and the crash cart was not fully stocked because it did not have an ambu bag and they could not find the backboard. She could not recall if they ever found the ambu bag but stated EMS was there quickly and they began working on Resident #1, but he passed away. NA #3 stated she was aware of where the crash cart was located but stated that when the staff brought it to the room it did not have what they needed. Unit Manager (UM) #1 and #2 were interviewed together on [DATE] at 1:15 PM. UM #2 stated that she was aware that Resident #1 had coded during the night when she was not in the building and had passed away. UM #1 stated that she and UM #2 were responsible for checking and stocking the crash carts daily and they logged those checks in a binder kept on the crash cart. UM #1 and UM #2 stated that they were not aware that the staff could not locate an ambu bag or backboard when Resident #1 went into cardiac arrest. Both stated that they checked the crash carts daily and both had an ambu bag and the backboard was always kept next to the crash cart. Both UM confirmed that they checked and restocked the crash carts daily on the days that they were working in the facility. Director of Nursing (DON) #2 was interviewed via phone on [DATE] at 11:18 AM. DON #2 stated that there were two crash carts in the building, one on each unit and the UMs were responsible for checking them and stocking them daily and as needed. DON #2 stated she recalled during one emergency the staff could not locate an ambu bag, but they found one and then she had the UMs check and restock the crash carts. She stated she could not recall if that emergency was with Resident #1 or not. DON #2 stated she believed that during the emergency the staff eventually found an ambu bag to use. Following the emergency when the ambu bag could not be immediately located they discussed the issue in morning meeting, and she had stressed the importance of checking the crash carts daily and ensuring that it contained all the supplies that would be needed during an emergency. Administrator #1 was interviewed on [DATE] at 5:03 PM who stated that she was not aware of issues with Resident #1 and could not say for sure how or when he passed away. Administrator #1 stated that she does not recall any staff member expressing concerns that the crash carts were not stocked appropriately and that they did not have the supplies they needed during an emergency. The Medical Director (MD) was interviewed via phone on [DATE] at 5:13 PM. The MD explained that Resident #1's diagnoses placed him at high risk for sudden cardiac arrest. The immediate start of CPR had a high likelihood of changing Resident #1's outcome and the MD stated he fully expected the facility to have the supplies they needed to immediately start CPR in the case of sudden cardiac arrest. An observation of the facility's crash carts was made on [DATE] at 1:09 PM. Both crash carts were observed to have ambu bags on the bottom of the cart and a back board was next to each crash cart. The crash carts were also stocked with a suction machine and tubing, nasal cannulas, stethoscope, blood pressure cuff and other supplies that may be needed during an emergency. 3. Resident #2 was admitted to the facility on [DATE] with diagnoses that included history heart attack, diabetes, atrioventricular heart block, chronic kidney disease, and others. Review of a physician order dated [DATE] read: Full Code. Review of a nurse's note dated [DATE] written by Nurse #2 read; Resident seen upon morning care in dire [NAME], resident seen in bed foaming at the mouth; this nurse checked resident for responsiveness. When patient did not respond this nurse called a code-initiated others to get a crash cart and call 911. CPR was initiated after patient was placed on back board. Necessary staff was present, and EMS arrived shortly after. Resident #2 was transferred to the local hospital where he died on [DATE]. Attempts to speak to Nurse #2 (agency nurse) were unsuccessful. Nurse #3 (agency nurse) was interviewed on [DATE] at 3:09 PM who confirmed that she was working on [DATE] when Resident #2 went into cardiac arrest. She stated that the staff brought the crash cart to the room and there was no ambu bag on it. She stated the staff were doing chest compressions, and someone went and got a non-rebreather mask (mask used to deliver oxygen with a bag on end), and we began pushing oxygen through the mask. Nurse #3 stated that initially Nurse #2 was doing chest compressions and when the crash cart arrived at the room with no ambu bag she took over chest compressions and Nurse #2 went to find an ambu bag. Nurse #3 stated that when she began chest compressions Resident #2 was still warm and it took the staff several minutes to find the ambu bag and she believed that they went to another resident's room in the facility that had a tracheostomy and got the one in his room. The ambu bag was found as Emergency Medical Services (EMS) was coming on scene and they took over and transported Resident #2 to the hospital, but he passed away shortly thereafter. Nurse #4 (agency nurse) was interviewed on [DATE] at 3:25 PM who confirmed that she was working on [DATE] when Resident #2 went into cardiac arrest. She stated when she heard the Code Blue called, she immediately responded to the room. Nurse #2 was in the room, and she was beginning to do compressions without a backboard. She stated she hollered at the staff to get the backboard and once it was found and brought to the room chest compressions were started again. Nurse #4 stated she instructed Nurse #3 to turn the oxygen all the way up and then realized that there was no ambu bag on the crash cart. When the staff finally found the ambu bag and brought it to the room she began administering rescue breaths. At some point during the time, they could not find an ambu bag, Nurse #4 instructed the staff to go into another resident's room that had an ambu bag and get it so they could start rescue breaths on Resident #2. Nurse #4 stated that prior to Resident #2's cardiac arrest she had informed Unit Manager (UM) #2 that the crash cart needed an ambu bag because she had worked a night shift back in [DATE] and while doing a routine check of the crash cart, she discovered it did not have an ambu bag, so she reported to UM #2 that it needed one. Nurse #4 stated that she followed up and asked UM #2 about the ambu bag a of couple days later and she stated that she had told the former Director of Nursing #2 (DON) about the need for the ambu bag. Nurse Aide (NA) #4 was interviewed on [DATE] at 10:02 AM who confirmed that he was working when Resident #2 coded and went into cardiac arrest. He stated that when he arrived at Resident #2's room it was very disorganized, and staff were running around trying to locate equipment that was not on the crash cart. NA #4 stated he was on standby to do compressions if needed so he did not leave the room and was not sure where they located the ambu bag or backboard. He added that they located all the equipment around the same time EMS arrived and they took over CPR until Resident #2 was transferred to the local hospital. NA #5 was interviewed on [DATE] at 12:11 PM who confirmed that she was working on [DATE] when Resident #2 coded. NA #5 stated that when she got to Resident #2's room they did not have a backboard and the first crash cart was in the room and did not have an ambu bag on it. She stated that she recalled seeing a backboard in the break room, so she left to go and get it. NA #5 stated that as she was returning to Resident #2's room with the backboard she saw NA #6 coming down the hallway with the other crash cart, but it did not have an ambu bag either. When she got to Resident #2's room with the backboard another staff member had yelled to go and get the ambu bag from another resident's room and someone ran to get it, but she could not recall who that was. Once they had the supplies to do CPR, they staff began performing CPR until EMS came and took over and Resident #2 was transferred to the hospital. NA #7 was interviewed on [DATE] at 12:14 PM and confirmed that she was working on [DATE] when Resident #2 coded. She stated when she heard the Code Blue, she grabbed the other crash cart. NA #6 had grabbed the one from the other side of the building. NA #7 stated when the crash carts arrived in Resident #2's room there was no ambu bag on either crash art. NA #7 stated she ran to the resident's room in the facility that had an ambu bag in his room and grabbed it and ran to the supply closet and got a suction canister and tubing so that the Nurse Practitioner could suction Resident #2 because the crash cart did not have the right equipment to suction him. NA #6 was interviewed on [DATE] at 3:00 PM who confirmed she was working on [DATE] when Resident #2 coded. She stated that when she heard the page for Code Blue, she grabbed the crash cart and ran to Resident #2's room. NA #6 stated that once she arrived in the room, she broke the seal on the crash cart but could not find the ambu bag. She stated she looked over the crash cart several times and there was no ambu bag, she stated she heard that they found one in another's resident room. NA #6 stated both crash carts were supposed to have an ambu bag on them, but she could not say whether the other crash cart had one or not. Nurse Practitioner (NP) #1 was interviewed via phone on [DATE] at 3:52 PM who confirmed she was in her office charting on [DATE] when she heard the Code Blue page. She stated she when she got to the room the staff were doing chest compressions on the bed with no backboard, I instructed the staff to go and get the backboard. Then the NP said, where is the ambu bag so we can do rescue breaths? The crash cart was in the room with no ambu bag on it, so she again instructed the staff to go and find an ambu bag. The NP stated Resident #2 had fluids running out of his mouth and he needed to be suctioned but there was no suction machine on the crash cart, so instructed staff to go and find a suction machine. The NP stated she was aware that the facility had an Automatic External Defibrillator (AED) she questioned that staff where the AED was. She stated that another staff member ran to get the AED and when they brought it to the room there was no paddles to use it. The NP stated, we did the best we could with what we had until EMS arrived. She stated that she questioned UM #1 about why the crash cart was not stocked but the check list indicated that everything was there. The NP stated UM #1 stated that she had checked the crash cart, and everything was there. The situation was awful and should not have happened that way, the NP added that she expected the crash carts to be stocked to run codes and perform CPR when needed. The NP also stated she had met with Administrator #1 and Director of Nursing (DON) #2 and expressed her dissatisfaction with the situation but really did not get any answers as to why it had happened the way it did. Unit Manager (UM) #1 and #2 were interviewed together on [DATE] at 1:15 PM. UM #1 stated that she and UM #2 were responsible for checking and stocking the crash carts daily and they logged those checks in a binder kept on the crash cart. UM #1 and UM #2 stated that they were not aware that the staff could not locate an ambu bag, backboard, and other equipment when Resident #2 went into cardiac arrest. Both stated that they checked the crash carts daily and both had an ambu bag and the back board was always kept next to the crash cart. Both UM confirmed that they checked and restocked the crash carts daily on the days that they were working in the facility. DON #2 was interviewed via phone on [DATE] at 11:18 AM. DON #2 stated that there were two crash carts in the building one on each unit and the UMs were responsible for checking them and stocking them daily and as needed. DON #2 stated she recalled during one emergency the staff could not locate an ambu bag, but they found one and then she had the UMs check and restock the crash carts. She stated she could not recall if that emergency was with Resident #2 or not. DON #2 stated she believed that during the emergency the staff eventually found an ambu bag to use. Following the emergency when the ambu bag could not be immediately located they discussed the issue in morning meeting, and she had stressed the importance of checking the crash carts daily and ensuring that it contained all the supplies that would be needed during an emergency. Administrator #1 was interviewed on [DATE] at 5:03 PM who stated that she was not aware of issues with Resident #2 and could not say for sure how or when he passed away. The Administrator stated that she did not recall any staff member expressing concerns that the crash carts were not stocked appropriately and that they did not have the supplies they needed during an emergency. The Medical Director (MD) was interviewed via phone on [DATE] at 5:13 PM. The MD explained that Resident #2's diagnoses placed him at high risk for sudden cardiac arrest. The immediate start of CPR had a high likelihood of changing Resident #2's outcome and the MD stated he fully expected the facility to have the supplies they needed to immediately start CPR in the case of sudden cardiac arrest. An observation of the facility's crash carts was made on [DATE] at 1:09 PM. Both crash carts were observed to have ambu bags on the bottom of the cart and a back board was next to each crash cart. The crash carts were also stocked with a suction machine and tubing, nasal cannulas, stethoscope, blood pressure cuff and other supplies that may be needed during an emergency. Administrator #1 and the DON #1 were notified of the Immediate Jeopardy on [DATE] 11:03 AM. The facility provide the following IJ removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On [DATE] at approximately 1:00 AM Resident #1 experienced sudden cardiac arrest. The staff were unable to locate an Ambu bag or manual resuscitator used to deliver ventilation to residents not breathing. The staff were also unable to locate a back board (hard surface) to correctly deliver chest compressions to the correct depth for delivery of CPR. It took the staff approximately 5 minutes of time to locate the required items to deliver CPR when Resident #1 was pulseless. Resident #1 expired on [DATE] in the facility. On [DATE] at approximately 10:30 AM Resident #2 experienced sudden cardiac arrest. The staff were unable to locate an Ambu bag or manual resuscitator used to deliver ventilation to residents not breathing. The staff were also unable to locate a back board (hard surface) to correctly deliver chest compressions to the correct depth for delivery of CPR. The Nurse Practitioner (NP) responded to the code and requested the basic lifesaving equipment and indicated that it took several minutes before a manual resuscitator was taken from another residents' rooms to use, the NP requested the facilities Automatic External Defibrillator (AED) and when staff retrieved the AED failed to have the paddles used to deliver the shock readily available for use by the NP. The NP also requested a suction machine that was not readily available for use. Resident #2 was transported to the emergency room (ER) and expired in the hospital. On [DATE] Resident #3 who had an extensive history of drug and opioid abuse was found on the floor with a white powdery substance on his bedside table. Resident #3 was warm to touch but was pulseless and was in cardiac arrest. Staff responded with the crash cart and there was no ambu bag on the crash cart. Another staff member had to obtain the other crash cart to get an ambu bag. It took approximately two to three minutes to obtain the other crash cart with the ambu bag and begin rescue breathing and compressions. Resident #1 expired on [DATE] at 2:26 AM in the facility. Resident #2 expired on [DATE] in the hospital. Resident #3 expired in the facility on [DATE]. All current residents that have a Full Code status have the potential to be affected by current practice deficiency. On [DATE], the Regional Nurse Consultant completed record review of residents that expired in a medical facility, expired in the facility, and/or discharged to another hospital for the following dates, [DATE] - [DATE] to ensure procedures for CPR were followed with no issues. Staff interviews completed with nurse involved. This was completed on [DATE]. 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

Based on record review, observation, and interviews with resident, Nurse Practitioner, and staff, the facility failed to implement measures to mitigate the risk of an accidental drug overdose for a resident who had a known history of substance abuse that included crushing and snorting pills/medications. On [DATE] Resident #3 was found unresponsive in his room as a result of sudden onset cardiac arrest and he was unable to be revived. Nursing Assistant (NA) #11, NA #12, and Housekeeper #1 had observed a white, powdery substance on the tray table in his room. The facility also failed to provide the necessary supervision to prevent accidents for a cognitively impaired resident (Resident #4) who was assessed as a high fall risk due to a history of multiple falls and tendency to overestimate or forget his limits. On the morning of [DATE], Resident #4 was left unsupervised in his room in his wheelchair after a therapy session. He was found by staff that afternoon after suffering an unwitnessed fall that resulted in right 9th through 11th rib fractures, facial fractures, right frontal bone fracture extending into the superior orbit roof and lateral orbit wall (fracture that extended to the top and to the side of right eye socket), right hemothorax (blood collecting between chest wall and lungs which can collapse the lung), and intraparenchymal hemorrhage of the brain (bleeding in the tissue of the brain). He was transferred from the emergency room to the local trauma center for a higher level of care. This deficient practice was for 2 of 3 residents (Residents #3 and #4) reviewed for supervision to prevent accidents. Immediate jeopardy began for example #1 on [DATE] when Nurse Practitioner #2 was informed by staff that Resident #3 was seen cutting a white powdery substance on his tray table, she ordered Narcan (a reversal agent used in case of an overdose) to treat an accidental overdose, but no measures were implemented by the facility to mitigate the risk of an overdose. Immediate jeopardy began for example #2 on [DATE] when the facility failed to provide the necessary supervision to prevent an accident for Resident #4. Immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity D (no actual harm with more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place and the completion of staff education. The findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses that included cocaine dependence, congestive heart failure, and chronic respiratory failure. A physician's order for Resident #3 dated [DATE] indicated Oxycodone HCl (narcotic pain medication) tablet 20 milligrams (mg) every 6 hours as needed for pain. The order indicated to crush the tablet and for the resident to take the medication in front of the nurse. Resident #3's quarterly Minimum Data Set assessment dated [DATE] revealed he was cognitively intact with no psychosis, behaviors, or rejection of care. Resident #3 was coded with having frequent pain and he received opioids on 7 of 7 days during the lookback period. The MDS revealed Resident #3 was born in 1960 indicating he was [AGE] years old. A physician's order for Resident #3 dated [DATE] indicated Narcan liquid 4 mg/0.1 milliliter (ml), provide 4 mg in nostril every 6 hours as needed for overdose. Resident #3's care plan last updated on [DATE] revealed the following information: - Resident #3 exhibits or has the potential to exhibit verbal/physical behaviors related to opioid dependence and anxiety; history of snorting pills/medications, misuse of oxygen. Interventions included monitoring medication administration to ensure medications are taken and swallowed prior to leaving resident. - Resident #3 does complain of pain at times due to impaired mobility. Resident #3 has a diagnosis of chronic pain and opioid dependence. Resident has pain medication in place and is followed by pain clinic. Interventions included Per MD order Narcan 1 milliliter by nasal route as needed for opioid overdose. Repeat every 2 minutes until emergency medical services arrive. A progress note written by Nurse Practitioner (NP) #2 dated [DATE] for Resident #3 indicated the following: Behavioral concerns - this NP recommends that the patient be discharged from this facility for numerous documented reports from the staff of overdose, abuse, and noncompliance. I believe that the patient puts the facility at risk for liability if he were to overdose. I have added Narcan 4mg nasal every 6 hours as needed for overdose. I have expressed my concerns with the [Former] Director of Nursing, Administration, and Medical Director. During an interview via telephone on [DATE] at 9:01 AM with Nurse Practitioner (NP) #2 she stated she was no longer working at the facility. She reported Resident #3 had a history of taking his narcotic pain medication and then turning his oxygen up on his portable tanks and concentrator until he passed out. She stated she was concerned about Resident #3 abusing his narcotics because she heard from staff (unable to recall their names) that he pocketed the medications and then crushed and snorted them. She reported several months before August of 2022 she refused to prescribe him narcotic pain medications and referred him to a pain clinic for monitoring. The pain clinic ordered the oxycodone. She reported Resident #3's narcotic pain medication was to be crushed and Resident #3 observed until it was fully taken in applesauce or another medium. She revealed she received information from an NA (unable to recall the NA's name) who informed her a picture was turned into facility administration that showed Resident #3 cutting a white powdery substance on his tray table in the facility. She explained this was when she prescribed Resident #3 Narcan ([DATE]) to be given in the event of an accidental overdose. During a follow up interview with the NP #2 via phone on [DATE] at 4:00 PM she revealed she prescribed Narcan on [DATE] to be administered not if but when Resident #3 overdosed. The Medication Administration Record (MAR) for [DATE] revealed oxycodone was administered to Resident #3 on [DATE] at 2:16 AM by Medication Aide (MA) #3. During an interview with NA #7 on [DATE] at 3:28 PM she reported she believed Resident #3 died from an overdose due to her experience of seeing him snort an unidentified powdery substance on more than one occasion. NA #7 stated each time she observed Resident #3 snorting a white substance, she stopped him and got the nurse on the hall. She reported by the time she and the nurse returned to the room, the white, powdery substance was gone, and Resident #3 stated it was baby powder and denied snorting it. She reported she also wrote two separate statements regarding what she observed and slid them under Administrator #3's door. NA #7 stated she could not remember the dates she completed the reports but was certain she slid them underneath Administrator #3's door. She reported to her knowledge, nothing was done to prevent Resident #3 from snorting a white, powdery substance. Administrator #1 was asked on [DATE] at 4:30 PM to provide the written statements from NA #7 regarding Resident #3's observed behaviors of crushing and snorting his medications. Administrator #1 reported on [DATE] at 10:00 AM she was unable to locate them. An interview with Resident #3's former roommate, Resident #13, was conducted via telephone on [DATE] at 1:16 PM. He revealed he had reported Resident #3's drug abuse to facility staff multiple times including to the Wound Nurse and to Former Social Worker #1. He stated he even sent pictures and a video he had taken on his cell phone to them on their cell phones. Resident #3's former roommate reported he felt that someone from the facility was bringing in either cocaine or opioids and providing them to Resident #3. He stated he watched Resident #3 numerous times pull out pills, chop them up on his tray table, and snort them. On [DATE] at 12:18 PM the photograph and video recorded by Resident #13 was observed. They showed Resident #3 sitting in his wheelchair, in his room, next to his bed with his back to the door. Resident #3 had a bank debit card in his hand pressing the edge down onto a white, powdery substance that was on his tray table beside his bed. An interview with the Wound Nurse on [DATE] at 12:01 PM via telephone revealed it was very well known that Resident #3 had a substance abuse problem and crushed his opioid medications and snorted them. She also reported she had received a photograph and a short video, unable to recall the date, from Resident #3's roommate, Resident #13, that showed Resident #3 using a credit card to cut a white, powdery substance on his tray table in his room at the facility. She reported she immediately sent them to Director of Nursing #3 at the time and also provided them to a Corporate Staff member who was a female. She was unable to remember the Corporate Staff member's name or her title. She stated she also wrote a statement, unable to recall the date, and provided it to the Corporate Staff member. The Wound Nurse reported she heard nothing back from Director of Nursing #3 or the Corporate Staff member about the situation. The Wound Nurse reported she felt that the situation was ignored. An interview with Social Worker #1 via telephone on [DATE] at 3:15 PM revealed she remembered Resident #3 and that he had a history of abusing his medications by crushing and snorting them. She reported Resident #3's former roommate, Resident #13, had approached her in her office some time, unable to recall the date, and told her Resident #3 was storing medications under his tongue then crushing and snorting them. She stated she brought it up to Director of Nursing #3 and Administrator #3 immediately after being informed, but it was blown off. She stated, everyone knew about it, and no one did anything. She reported there were no additional interventions put into place to increase supervision and despite his behaviors being discussed weekly at morning meeting it was always not taken seriously. A nurse progress note completed by Nurse #13 dated [DATE] at 7:28 AM read, in part, Resident #3 reported on floor at 6:15 AM by NA following ambulation by resident from smoking area .emergency medical services [EMS] notified by staff while this nurse and additional nurse performed cardiopulmonary resuscitation in resident room. EMS arrived at 6:25 AM .Resident #3 pronounced expired by EMS at 6:46 AM. An interview with Medication Aide #3 (MA) on [DATE] at 3:14 PM revealed she was assigned on the medication cart and was responsible for providing Resident #3 with his medication from 7:00 PM on [DATE] until 7:00 AM on [DATE]. She stated she last gave him his narcotic pain medication at 2:16 AM on [DATE] and found him unresponsive around 5:30 AM. She could not recall with certainty if she crushed his oxycodone when she last administered the medication. She went onto say that she would have administered them as it was ordered on the MAR. MA #3 stated she had worked with Resident #3 a few times previously and she remembered reading in his chart that he had some drug seeking behaviors. She revealed when she worked with him, he came up to her medication cart before he was due to receive his narcotic pain medication and waited there until it was time for it to be administered. Interview with NA #12 (agency) on [DATE] at 12:35 PM revealed she worked the night shift (7:00 PM to 7:00 AM) that ended on [DATE] on the date Resident #3 expired. She indicated she ran to the room when MA #3 called for help after finding him unresponsive. She stated Resident #3 was well known in the facility as a substance abuser and had a history of crushing and snorting his medications and she believed there was a crush order for his opioid medications that he was prescribed. She stated when she arrived at the room, she noticed a white, powdery substance on his tray table, and she immediately believed that he had crushed and snorted his medication due to her understanding of his history. NA #12 also reported that at some point during the emergency, Housekeeper #1 entered the room and wiped down Resident #3's tray table. During an interview with NA #17 (agency) on [DATE] at 2:42 PM via telephone, she reported she was present on [DATE] working as an NA at the time Resident #3 was found unresponsive in his room. She stated it was well known that Resident #3 had a history of substance abuse and had a history of crushing his opioid medications and snorting them. She reported around 6:20 AM to 6:30 AM on [DATE], while EMS was working on Resident #3, she noted Housekeeper #1 entered the room and wiped down Resident #3's tray table. An interview with Housekeeper #1 on [DATE] at 3:33 PM via telephone, revealed she went into Resident #3's room on [DATE] and wiped off a white, powdery substance from his tray table. She reported she did not know Resident #3's medical history or if he had a history of substance abuse. She reported she only wiped off the tray table after EMS requested her to do so. She could not provide any information on why EMS asked her to wipe off Resident #3's tray table. During an interview via telephone on [DATE] at 9:01 AM with NP #2 she verified she was the NP at the time Resident #3 expired. She indicated the death certificate indicated he died of natural causes. She revealed when she was asked to sign the death certificate, she refused because based on the information she received from the staff (unable to recall specific staff members) that were present at the time he went into cardiac arrest, she believed Resident #3 had died of an accidental overdose and not due to natural causes as was listed on the death certificate. During a follow-up interview with NP #2 via telephone on [DATE] at 4:00 PM she reported she felt an autopsy and toxicology report needed to be completed before signing off on the death certificate. She explained Resident #3 was one of the youngest residents at the facility and he was in relatively good health. She further explained that because of his history of drug abuse and the sudden onset of cardiac arrest she felt an autopsy and toxicology report had to be completed to confirm the cause of death. She reported the medical examiner was to conduct the autopsy and complete the toxicology testing, but the resident had already been embalmed prior to the medical examiner having access to the resident. She explained that due to the embalming the toxicology report was unable to determine any narcotic drug levels in Resident #3's system at the time of his death. She reported after she reviewed the autopsy and was told he had already been embalmed prior to getting a completed toxicology report, she signed off on the death certificate. The NP revealed it was her professional opinion, based on the circumstances of his death and what was observed by staff at the time of the sudden cardiac arrest, that Resident #3 had suffered cardiac arrest due to an overdose of some type of narcotic. She stated she believed that the administration did not take her concerns seriously leading to a lack of supervision by the floor staff which ultimately resulted in Resident #3's cardiac event. She stated the administration knew her concerns and did nothing to prevent the accidental overdose. An interview attempt with Director of Nursing #3 was unsuccessful. An interview attempt with Administrator #3 was unsuccessful. An interview with DON #1 was conducted on [DATE] at 10:26 AM revealed she was not working at the facility at the time Resident #3 was admitted . She also reported for a resident who had a history of pocketing medications, crushing, and snorting them, the facility should have had a crush order and provide them to the resident in applesauce or some other median and observed until the medication is fully given and swallowed. She also reported there should have been increased supervision of Resident #3 to curtail attempts to abuse medications or use illicit drugs at the facility. 43443 2. Resident #4 was initially admitted to the facility on [DATE] with diagnoses that included repeated falls, weakness, and a Thoracic-12 fracture (T-12 - lower back fracture), Alzheimer's, and Non-Alzheimer's dementia. Review of a fall risk assessment dated [DATE] revealed that Resident #4 was at high risk for falls due to his history of multiple falls and tendency to over-estimate or forget his limits. Resident #4 had a care plan initiated on [DATE] that read in part, The resident is at high risk for falls related to confusion. The interventions included: Anticipate and meet the resident's needs. Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, the resident needs prompt response to all requests for assistance, ensure that the resident is wearing appropriate footwear, non-skid socks when mobilizing in wheelchair. Review of Resident #4's medical record revealed a note written by Nurse #15 on [DATE] at 7:10 AM that read, this nurse and Nurse Aide (NA) were in front of resident's doorway and witnessed resident's fall. He rolled out of bed and fell . This nurse-initiated head to toe skin check and found no injuries related to this incident. Resident had no complaints of pain. Resident was placed back in his bed and on-call physician notified. Resident #4's care plan was updated on [DATE] to continue interventions on the at-risk plan and ensure bed is in lowest position prior to exiting resident's room. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #4 was moderately cognitively impaired and required extensive assistance of ,d+[DATE] staff members with activities of daily living (ADL). A fall within one month, prior to admission with a fracture was reported, and an additional fall since admission, with no injury, was reported on the MDS. Resident #4 was always incontinent of bowel and bladder, his balance was not steady and only able to stabilize with staff assistance, and ambulation with ,d+[DATE]-person assistance only occurred ,d+[DATE] times in the look back period. On [DATE] at 7:30 AM a progress note made by Nurse #16 read, Medication Aide (MA) called to writer and stated Resident #4 was on the floor of his own room. Writer entered room and observed Resident #4 on his hands and knees on floor and observed blood on floor. Writer assessed Resident, and a laceration to the right eyebrow was noted. Writer and medication aids assisted Resident off floor and onto bed at this time. Resident alert at this time and stated that area to eyebrow hurt. Writer applied pressure to eyebrow. Vital signs obtained and within normal limits. Physician notified and order received to send resident to emergency room (ER). Writer called for Emergency Medical Services (EMS) transportation. Resident #4's care plan was revised on [DATE] to add floor mats for injury prevention. On [DATE] at 11:07 AM an Occupational Therapy encounter note written by the Occupational Therapy Assistant (OTA) read in part, Patient was found up in the wheelchair and was seen to address self-feeding. The patient was returned to his room via wheelchair and left up seated to visit his Family Member (FM) #1. In a phone interview on [DATE] at 12:30 PM with the OTA, she stated she worked at the facility as needed (PRN). She recalled Resident #4 as a small frail man who tried to stand-up on his own sometimes from his wheelchair, but he was too weak to support himself. The OTA stated she writes her notes after therapy was finished. The OTA confirmed Family Member (FM) #1 was not in the room when she left Resident #4 alone in his room in a wheelchair. She stated she must have assumed FM #1 was in the building or on her way to visit. The OTA stated she likely told someone at the nurses' desk that Resident #4 was back in his room but could not recall. She stated Resident #4's room was right across from nursing station or at least very close. The OTA stated with Resident #4's history of falls and high risk for falls, she would not have left him alone in his room without notifying a staff member. A phone interview was conducted with MA #6 on [DATE] at 4:40 PM and MA #6 confirmed she was working on the unit where Resident #4 resided on [DATE]. MA #6 stated she recalled Resident #4 was in therapy that morning. She recalled FM #1 was usually with Resident #4 and cared for him all day through supper, but on [DATE] she was not present. MA #6 stated she was passing medications around lunchtime when an NA (can't remember the name) came to her and said Resident #4 was on the floor. MA #6 stated she went into Resident #4's room and found him on his face on the floor bleeding from a facial cut. She stated she told the NA to find a nurse. MA #6 stated UM #2 came into the room, and they kept Resident #4 on the floor to avoid additional injuries. She stated he had a cut above one of his eyes that was open. MA #6 stated Resident #4 was conscious but never said anything. The MA was unsure if Resident #4 was a fall risk and added she usually observed him in bed but had observed when the resident was in his wheelchair, he tended to lean forward. An interview was conducted with NA #14 on [DATE] at 4:39 PM and she stated she assumed care for Resident #4 on [DATE] at 11:00 AM from NA #15. The NA stated while she knew Resident #4 was high risk for falls, she was a restorative aide and only works on the floor when there are a lot of call-outs such as on [DATE]. She stated she was not very familiar with Resident #4's plan of care or fall interventions. NA #14 explained on [DATE] at 10:30 AM she saw therapy bring Resident #4 back to his room but was not the resident's nurse aide at that time. NA #14 further explained around 1:00 PM she saw Resident #4 sitting in a wheelchair alone in his room waiting for his lunch tray. She added she left him there sitting up in his wheelchair because therapy told her he ate better sitting up. NA #14 stated she left the hall to pass meal trays and as she was coming back to Resident #14's hall she saw Emergency Medical Services (EMS) entering Resident #4's room to take him to the emergency room (ER). She stated when she entered the room behind EMS, Unit Manager (UM) #1 and Unit Manager (UM) #2 were both attending Resident #4. She stated Resident #4 had fallen out of his wheelchair. NA #4 confirmed that Resident #4 was alone in his room, in his wheelchair, for approximately 3 hours and had not received his lunch tray prior to his fall. An interview with NA #15 was conducted on [DATE] at 3:16 PM she stated she was assigned to Resident #4 from 8:00 AM - 11:00 AM. She stated during this time, the resident was already dressed and out of his room with therapy. NA #15 explained at 11:00 AM NA #14 picked him up on her assignment. NA #15 did not recall the OTA or anyone telling her Resident #4 was back from therapy. She stated the first time she saw Resident #4 was when EMS was taking him out of his room on a stretcher. On [DATE] at 12:07 PM the Director of Therapy was interviewed and stated Resident #4 was admitted due to falls and high risk for falls. She stated she would have told someone Resident #4 was back or put him in the doorway, so he was visible. On [DATE] at 1:30 PM a progress note written by Unit Manager (UM) #2 read, Resident fell out of wheelchair to floor. Laceration noted above right eyebrow. Resident unable to answer questions due to Alzheimer's disease. Physician notified; EMS called for transport to the Emergency Department (ED) for evaluation. On [DATE] at 12:32 PM an interview was conducted with UM #2, and she shared Resident #4 was admitted to the facility due to falls at home. She stated when he was admitted he had several fractures in his neck and back, and stitches on the side of his head from falls he experienced at home. She stated she recalled on [DATE] she was working on the floor. She stated she knew OTA took Resident #4 to the therapy room at breakfast time because MA # 6 asked her where he was, so she called OTA to see if that had taken him to therapy and they confirmed they had picked him up for his therapy. She stated it was common practice for therapy to come get residents and bring them back without letting anyone know. She stated she did not know Resident #4 was back from therapy until she heard a loud thump that came from his room around 1:30 PM. She stated when she got to his room, she observed Resident #4 on his face on the floor. She added MA #6 was present in the room when she arrived. Review of the Emergency Medication Services (EMS) report dated [DATE] revealed the 911 call was received at 1:31 PM, EMS reached Resident #4 at 1:43 PM and Resident #4 was transported to the local hospital at 2:08 PM. The ER physician at the local hospital documented an admission note dated [DATE] that read, in part, Review of a computed tomography scan (CT scan) of the head and abdomen confirmed Resident #4 sustained right 9th through 11th rib fractures, and a sub-acute T-12 fracture (fracture in the spine that has already been present). Additionally Resident #4 sustained facial fractures, right frontal bone fracture extending into the superior orbit roof and lateral orbit wall (fracture that extended to the top and to the side of right eye socket), right hemothorax (blood collecting between chest wall and lungs which can collapse the lung), and intraparenchymal hemorrhage of the brain (bleeding in the tissue of the brain). A review of an ER physician notes from the local ER dated [DATE] at 6:42 PM, revealed Resident #4 was to be transferred to the local trauma center for definitive care (higher level of care). The noted further documented they had stabilized Resident #4 to the best of their ability. Review of a Trauma Center ED note dated [DATE], read in part, The patient presentation is most consistent with acute presentation with potential threat to life or bodily function. The trauma team managed Resident #4's care in the ED. Neurosurgery, Ophthalmology, Ear/Nose and Throat (ENT) consults ordered for evaluation of facial injuries. No surgical intervention was required. A trauma hospital physician discharge note dated [DATE], read in part, Palliative Care consulted for Goals of Care (GOC) due to patient injuries and history. After GOC meeting on [DATE] Resident #4 was transitioned to a Do No Resuscitate (DNR)/Comfort Care (CC) status. They will transfer Resident #4 back to a different skilled nursing facility (SNF) and will be followed by Hospice for end-of-life care. An interview was conducted on [DATE] at 12:00 PM with Director of Nursing (DON) #1 and Administrator #1. Administrator #1 stated it's their goal to keep all their residents safe. Residents who are at high risk for falls needed extra supervision and the staff were knowledgeable about preventing falls. The staff often kept residents at risk for falls visible in the hallway, by the desk, or even by the medication cart with the nurse for extra supervision. With Resident #4's fall history, he should have been monitored closely. She stated it sounded like miscommunication among departments and nursing staff. She stated he should not have been left alone in his room for 3 hours. Administrator #2 was notified of immediate jeopardy on [DATE] at 12:00 PM. The facility provided the following credible allegation of immediate jeopardy removal. F689: Identify those residents who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident #3 had a known history of substance abuse. Resident #3 was not supervised for illicit drug use. Resident #3 had an order for oxycodone to be crushed and the nurse to watch the resident take. On [DATE] the nurse failed to supervise Resident #3 after medication administration. On [DATE] Resident #3 was found unconscious. Resident #3 expired on [DATE] at the facility. All current residents that have a history of drug abuse have the potential to be affected. A list was made of the residents who had a history of polysubstance abuse. The list is located at each nurse's station. The Director of Nursing reviewed and is responsible for updating the list. Resident #4 who was a high fall risk was left alone and unattended in his room for approximately three hours after therapy session. Resident #4 was found on his floor and was sent to the local emergency room and then transferred to local trauma center for treatment of his injuries. Resident #4 sustained right 9 through 11 rib fractures, right frontal bone fracture extending into the superior orbit roof and lateral orbit wall. Current residents that were identified at High fall risk using the Morse fall scale have the potential to fall and obtained injuries. The review and collaboration was conducted by the Regional Nurse Consultant on [DATE]. The Director of Nursing is responsible for updating the list with new residents that are high fall risk. 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 [DATE], the Director of Nursing and Chief Nursing Officer educated staff on where to locate the list of residents with a history of polysubstance abuse. The Director of Nursing and Chief Nursing Officer educated staff on understanding of roles and responsibilities in identifying, reporting, and responding to residents who exhibit behaviors of seeking, acquiring and self-medicating with illegal drugs or medications not prescribed by the attending physician at the nursing home. Education included the following: dangers of self-medicating including serious adverse side effects and death, observing for medications/illegal substances in resident's room or in resident possession that are not prescribed by the nursing home MD/NP and responding by remaining with resident, calling out for nursing assistance for assessment and safe collection of substances and follow-up reporting by the licensed nurse to the MD/NP and to the Administrator or DON, intervening and asking to search resident with suspicious activity, ensuring resident safety by remaining with resident and calling for licensed nurse assistance, licensed nurse assessing resident for safety and s/s of potential self-medication such as changes in vital signs or altered mental status, visual observation of consumption, response in the event of resident self-medication to include; immediate removal of substance from resident to stop ingestion if possible, then providing emergency medical care as necessary and remaining with resident, calling MD/NP for new orders and calling 911 if indicated, then removing, counting and securing under double lock and key any medications/illegal substances with a second licensed nurse witness, then notification to the DON and Administrator for further investigation and follow-up, revising resident care plan to reduce risk of reoccurrence, education of the facility abuse and neglect policy and reporting immediately to the charge nurse if they hear or suspect a staff member is self-medicating or has an illegal substance in the facility. In the event illicit drug use is suspected the local police department will be contacted and a report made. The Director of Nursing will ensure no licensed nurses or medication aides will work without receiving this education. Any new hires including agency will receive education prior to the beginning of their next shift. On [DATE], the Director of Nursing and Chief Nursing Officer educated current staff members on fall protocol. Education to include the following: Identifying high fall risk residents upon admission using the Morse fall scale and putting in [TRUNCATED]

Based on record review, staff, Nurse Practitioner, and Medical Director interviews the facility's Administration failed to provide leadership and oversight to ensure the facility had supplies that were readily available and easily accessible to immediately start Cardiopulmonary Resuscitation (CPR) when 3 of 4 residents experienced sudden cardiac arrest (Resident #1, Resident #2, and Resident #3). This practice had the high likelihood of affecting other residents. Immediate Jeopardy began on [DATE] when Resident #3 experienced cardiac arrest and the facility did not have an ambu bag (used to deliver rescue breaths during CPR) readily available for use and it took the staff approximately three minute to locate the ambu bag and start rescue breathing. Immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity E (no actual harm with potential for more than minimal harm that is no immediate jeopardy) to ensure monitoring system are in place and the completion of employee education. The findings included: This tag is cross referenced to F678: F678: Based on record review, staff, Nurse Practitioner and Medical Director interviews the facility failed to have basic lifesaving equipment readily available for use to immediately begin cardiopulmonary resuscitation (CPR) when Resident #3 experienced sudden cardiac arrest on [DATE] and staff were unable to immediately begin CPR because the first crash cart (cart of emergency supplies) that was [NAME] to the bed side did not have a ambu bag or manual resuscitator (device to administer rescue breathing) on it, staff began chest compressions and it took the staff approximately three minutes to get the second crash cart that did have a ambu bag to begin rescue breathing. Resident #1 experienced sudden cardiac arrest on [DATE] and staff were unable to immediately begin CPR because the staff could not locate an ambu bag or manual resuscitator to begin rescue breaths and could not locate a backboard (hard surface to do chest compressions on while in bed). It took the staff approximately five minutes to locate the needed items to begin CPR. On [DATE] Resident #2 experienced sudden cardiac arrest and staff were unable to immediately begin CPR because they could not locate an ambu bag or manual resuscitator and had to borrow one from another resident's room. The staff also could not locate the paddles for the Automatic External Defibrillator (AED) (device used to deliver a shock to the heart). It took staff several minutes to locate the ambu bag to begin CPR and paddles for the AED. This affected 3 of 4 residents reviewed who experienced sudden cardiac arrest. Director of Nursing (DON) #1 was interviewed on [DATE] at 10:16 AM who explained that she began working in the facility as the Minimum Data Set (MDS) nurse at the beginning of [DATE] and had become the interim DON at the beginning of [DATE]. The DON stated she had no knowledge of Resident #1 as he was expired months prior to her arrival at the facility. She also stated she was not familiar at all with Resident #2 or any issues that arose during his sudden cardiac arrest and code situation. The DON further stated that she recalled hearing during the clinical morning meeting that when Resident #3 went into cardiac arrest and was coded by the staff that the facility did not have the appropriate equipment to immediately begin Cardiopulmonary Resuscitation (CPR). She added that she distinctly remembered the former Nurse Practitioner (NP) who was directly involved in the code situation voicing her dissatisfaction with how the code was handled and the lack of equipment that was available. The DON stated she recalled the former NP going around to the nurses talking to them about the situation and how it should have gone differently. The DON stated that she also recalled Administrator #1 asking the Unit Managers (UM) why the crash carts were not stocked, and they continued to insist that they had checked them, and they were stocked and believed that someone was taking the ambu bags off the crash carts. From what the DON could recall there was no resolution to that issue but stated after the event another staff member had gone to the hospital and borrowed a box of ambu bags. Administrator #2 was interviewed on [DATE] at 3:02 PM who confirmed that from [DATE] to [DATE] she was the Regional [NAME] President of Operations and provided oversight to the facility under the direction of Administrator #1. Administrator #2 stated that she had no knowledge of the situations that had occurred with Resident #1, Resident #2, and Resident #3, she stated that nothing had been communicated to her that there were issues that had arisen during the code situations that all three residents experienced. She contributed the failures of the facility on lack of effective leadership. Administrator #1 and DON #1 were notified of the Immediate Jeopardy on [DATE] at 11:03 AM. The facility provided the following IJ removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The facility's administration did not ensure that the crash carts (used in emergency situations) were stocked with the needed equipment that included Ambu bag or manual resuscitator, back board, suction machine, and automatic external defibrillator (AED) which are all required to perform CPR in the event of cardiac arrest. On [DATE] at approximately 1:00 AM Resident #1 experienced sudden cardiac arrest. The staff were unable to locate an Ambu bag or manual resuscitator used to deliver ventilation to residents not breathing. The staff were also unable to locate a back board (hard surface) to correctly deliver chest compressions to the correct depth for delivery of CPR. It took the staff approximately 5 minutes of time to locate the required items to deliver CPR when Resident #1 was pulseless. Resident #1 expired on [DATE] in the facility. On [DATE] at approximately 10:30 AM Resident #2 experienced sudden cardiac arrest. The staff were unable to locate an Ambu bag or manual resuscitator used to deliver ventilation to residents not breathing. The staff were also unable to locate a back board (hard surface) to correctly deliver chest compressions to the correct depth for delivery of CPR. The Nurse Practitioner (NP) responded to the code and requested the basic lifesaving equipment and indicated that it took several minutes before a manual resuscitator was taken from another residents' rooms to use, the NP requested the facilities Automatic External Defibrillator (AED) and when staff retrieved the AED failed to have the paddles used to deliver the shock readily available for use by the NP. The NP also requested a suction machine that was not readily available for use. Resident #2 was transported to the emergency room (ER) and expired in the hospital. On [DATE] Resident #3 who had an extensive history of drug and opioid abuse was found on the floor with a white powdery substance on his bedside table. Resident #3 was warm to touch but was pulseless and was in cardiac arrest. Staff responded with the crash cart and there was no ambu bag on the crash cart. Another staff member had to obtain the other crash cart to get an ambu bag. It took approximately two to three minutes to obtain the other crash cart with the ambu bag and begin rescue breathing and compressions. Resident #1 expired on [DATE] at 2:26 AM in the facility. Resident #2 expired on [DATE] in the hospital. Resident #3 expired in the facility on [DATE]. All current residents that have a full code status have the potential to be affected by current practice deficiency. On [DATE], the Regional Nurse Consultant completed record review of residents that expired in a medical facility, expired in the facility, and/or discharged to another hospital for the following dates, [DATE] - [DATE] to ensure procedures for CPR were followed with no issues. Staff interviews completed with nurse involved. This was completed on [DATE]. 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 [DATE] Regional Director of Nursing educated Administrator on the facility CPR policy and procedure and their role, emergency crash cart checklist, location of crash carts in facility, and location of additional BLS equipment. Education included the following: Procedure 1. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: Verify or instruct a staff member to verify the DNR or code status of the individual. Instruct a staff member to activate the emergency response system (code) and call 911. Instruct a staff member to retrieve the crash cart. Initiate the basic life support (BLS) sequence of events. The BLS sequence of events is referred to as C-A-B (chest compressions, airway, breathing). Chest compressions: a. Following initial assessment, begin CPR with chest compressions. Position flat hand over left chest and using heal of hand. b. Push hard to a depth of at least 2 inches (5 cm) at a rate of at least 100 compressions per minute; Allow full chest recoil after each compression; and Minimize interruptions in chest compressions. Airway: Tilt head back and lift chin to clear airway. Breathing: After 30 chest compressions provide 2 breaths via resuscitator or manually (with CPR shield). All rescuers should provide chest compressions to victims of cardiac arrest. Trained rescuers should also provide ventilations with a compression-ventilation ratio of 30:2. Continue with CPR/BLS until emergency medical personnel arrive. 2. Emergency Crash Cart Checklist 3. Location of crash carts 4. Location of backup BLS supplies On [DATE], Administrator was educated by Regional Director of Operations on Administrator's responsibility to thoroughly investigate cardiac events. Administrator must be notified by Director of Nursing or Designee of any cardiac events and must review code response to ensure CPR procedure was followed. Staff participating in cardiac event response must be interviewed by a member of nurse management team proceeding the incident and findings of cardiac event investigation must be shared with the Administrator for confirmation that CPR procedure was followed, basic life support supplies were readily available. If variation from CPR procedure is identified Administrator should immediately consult Regional Director of Nursing, initiate Ad Hoc QAPI meeting to include IDT and Medical Director, and modify plan of correction in order to achieve compliance. On [DATE], the Regional Nurse Consultant educated the nurse management team on interviewing the staff that participated in the CPR proceeding the incident to ensure CPR procedures were followed and basic lifesaving equipment was readily available. Effective [DATE], Administrator will receive on site visit from Regional Director of Operations or designated outside Administrator no less than once per week. Visit will include audit of the following: crash carts to ensure location, supply, and emergency crash cart checklist completed and accurate ensure adequate supply of BLS equipment is present on the crash cart and supply room and is housed in designated location review of cardiac event investigations since previous visit to ensure CPR procedure was followed interview staff to confirm knowledge of CPR procedure and role in cardiac event response. Review any new hires since last visit to ensure CPR procedure education was completed. Effective [DATE] the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: [DATE] On [DATE] and [DATE] the facility's credible allegation of immediate jeopardy removal was validated. Interviews with the DON and Administrator #2 revealed that they had been educated by the Regional Director of Nursing on the CPR policy and procedures, emergency crash cart check list, location of crash carts, and location of back up supplies. Administrator #2 is also the Regional Director of Operations (RDO) and was aware of her responsibility as the Administrator to thoroughly investigate cardiac events to ensure the facility's policy and procedures were followed. The investigation should include interviews with staff directly involved with the incident and should be reviewed by Administrator #2/RDO. Interviews with the management team confirmed that they had been educated on the importance of conducting thorough investigation after any cardiac event to ensure facility staff followed the proper procedures and that basic life saving equipment was readily available for use by the direct care staff. Administrator #2/RDO verbalized understanding of her responsibility to check crash carts and availability of supplies, review any cardiac events and review new hire orientation to ensure newly hired staff received the education during the orientation process. The facility's immediate jeopardy remove date of [DATE] was validated.

Based on record review, and interviews with staff and the Nurse Practitioner the facility failed to prevent a significant medication error when Narcan (reversal agent used in case of overdose) was not administered as prescribed for a resident who had a known history of substance abuse that included crushing and snorting pills/medications. The Nurse Practitioner ordered Narcan as needed for overdose on [DATE] for Resident #3. Resident #3 was found unresponsive in his room on [DATE], Cardiopulmonary Resuscitation (CPR) was initiated but Narcan was not administered as ordered and the resident was unable to be revived. Nursing Assistant (NA) #11, NA #12, and Housekeeper #1 had observed a white, powdery substance on the tray table in Resident #3's room. The facility also failed to notify Emergency Medical Services (EMS) that responded to Resident #3's cardiac arrest on [DATE] that he had a history of drug abuse nor that there was a white powdery substance found next to him. This affected 1 of 4 residents reviewed with sudden cardiac arrest (Resident #3) Resident #3 expired in the facility on [DATE]. Immediate Jeopardy began on [DATE] when Resident #3 was found unresponsive in his room with a white powdery substance on his bedside table and the facility staff failed to administer an ordered dose of Narcan for a suspected drug overdose. Immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity D (no actual harm with more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place and the completion of staff education. The findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses that included cocaine dependence, congestive heart failure, and chronic respiratory failure. Resident #3's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact with no psychosis, behaviors, or rejection of care. Resident #33 was coded with having frequent pain and he received opioids 7 of 7 days during the lookback period. The MDS revealed Resident #3 was born in 1960 indicating he was [AGE] years old. Review of Resident #3's physician orders revealed the following physician orders: - Oxycodone (opioid pain medication) HCl Tablet 20 milligrams (mg) - Give one table by mouth every 6 hours as needed for pain. Crush oxycodone and the patient is to take the medication in front of the nurse. The order's start date was [DATE] - Narcan [reversal agent used in case of overdose] liquid 4mg/0.1 milliliter (ml) - 4 mg in nostril every 6 hours as needed for overdose. The order's start date was [DATE]. Resident #3's care plan last updated on [DATE] revealed the following information: - Resident #3 exhibits or has the potential to exhibit verbal/physical behaviors related to opioid dependence and anxiety; history of snorting pills/medications, misuse of oxygen. Interventions included monitoring medication administration to ensure medications are taken and swallowed prior to leaving resident. - Resident #3 does complain of pain at times due to impaired mobility. Resident #3 has a diagnosis of chronic pain and opioid dependence. Resident has pain medication in place and is followed by pain clinic. Interventions included Per MD order Narcan 1 milliliter by nasal route as needed for opioid overdose. Repeat every 2 minutes until emergency medical services arrive. An interview with the Pharmacist on [DATE] at 12:12 PM revealed they received the physician order for Narcan on [DATE] and that the prescription was filled and delivered on [DATE]. She reported the Narcan they sent would have had Resident #3's name on it along with the dosing schedule. A review of Resident #3's medication administration record from [DATE] revealed the order for Narcan to be administered in the event of an overdose. No dose of Narcan was signed off on as having been given on [DATE]. A review of Resident #3's physician progress notes revealed a note from [DATE] that included the following: Behavioral concerns - this NP [Nurse Practitioner] recommends that the patient be discharged from this facility for numerous documented reports from the staff of overdose, abuse, and noncompliance. I believe that the patient puts the facility at risk for liability if he were to overdose. I have added Narcan 4mg [Milligrams] nasal every 6 hours as needed for overdose. I have expressed by concerns with the [Former] Director of Nursing, Administration, and Medical Director. The note was electronically signed by NP #2. During an interview via telephone on [DATE] at 9:01 AM with Nurse Practitioner (NP) #2 reported she was no longer working at the facility. She reported Resident #3 had a history of taking his narcotic pain medication and then turning his oxygen up on his portable tanks and concentrator until he would pass out. She stated she was concerned about Resident #3 abusing his narcotics because she heard from unknown staff members that he pocketed the medications and then crushed and snorted them. She reported several months before August of 2022 she refused to prescribe him narcotic pain medications and referred him to a pain clinic for monitoring. The pain clinic ordered oxycodone. She reported Resident #3's narcotic pain medication was to be crushed and Resident #3 observed until it was fully taken in applesauce or another medium. She reported she received information from a staff member whom she could no longer remember, who informed her there was a picture of Resident #3 cutting a white powdery substance on his tray table in the facility that was turned into administration. She explained this was when she prescribed Resident #3 Narcan ([DATE]) to be given in the event of an accidental overdose. The Medication Administration Record (MAR) for [DATE] revealed oxycodone was administered to Resident #33 on [DATE] at 2:16 AM by Medication Aide (MA) #3. An interview with Medication Aide #3 (MA) on [DATE] at 3:14 PM revealed she was assigned on the medication cart and was responsible for providing Resident #3 with his medication from 7:00 PM on [DATE] until 7:00 AM on [DATE]. She stated she last gave him his narcotic pain medication at 2:16 AM on [DATE] and found him unresponsive around 5:30 AM. She could not recall with certainty if she crushed his oxycodone when she last administered the medication. She went onto say that she would have administered them as it was ordered on the MAR. MA #3 stated she had worked with Resident #3 a few times previously and she remembered reading in his chart that he had some drug seeking behaviors. She revealed when she worked with him, he came up to her medication cart before he was due to receive his narcotic pain medication and waited there until it was time for it to be administered. She further stated Resident #3 did not have a physician order for Narcan because she would have made a note to herself. She also reported she did not have Narcan on her cart and that it would have been out of the ordinary for a resident to have a physician order for Narcan. She reported during the entirety of time she assisted with Resident #3's emergency, she never saw anyone administer Narcan or tell EMS personnel when they arrived that Resident #3 had a history of drug abuse. Med Aide #3 indicated she had not received any formal education on how to administer Narcan nor any education on how to identify a resident who had an overdose. A nurse progress note completed by Nurse #13 dated [DATE] at 7:28 AM read in part, Resident #3 reported on floor at 6:15 AM by [Med Aide #3] following ambulation by resident from smoking area .emergency medical services [EMS] notified by staff while this nurse and additional nurse performed cardiopulmonary resuscitation in resident room. EMS arrived at 6:25 AM .Resident #3 pronounced expired by EMS at 6:46 AM. During an interview with Nurse #13 via phone on [DATE] at 3:44 PM, he reported he responded to calls for help from MA #3. He stated he went to Resident #3's room and found him on the floor, still warm but with no pulse or respiration. He stated he immediately called a code blue and began chest compressions. Nurse #13 stated Resident #3 was not on his assignment, and he did not know anything about Resident #3's medical history including past drug abuse or overdoses. He stated he had no reason to suspect a drug overdose and stated that Narcan was not administered by him. He reported he was assigned to oversee the Medication Aide #3 on that hall but stated he had no knowledge of Resident #3's medical history or care needs. A review of the EMS run report from [DATE] at 6:25 AM revealed they arrived at the facility and began CPR on an unresponsive resident. Per the report, the responding EMS personnel were not informed of a potential overdose situation when they arrived or at any time while they provided emergency assistance to Resident #3. An interview with NA #11 (agency) on [DATE] at 12:05 PM via telephone, she reported she was assigned to Resident #3 on [DATE] on 3rd shift. She stated MA #3 went into Resident #3's room to give him his medications around 5:00 AM and found him unresponsive. She reported MA #3 screamed for assistance and she and NA #12 went running. She stated when she got to the room, she noticed a white, powdery substance on Resident #3's tray table. Interview with NA #12 (agency NA) on [DATE] at 12:35 PM revealed she worked the night of [DATE] Resident #3 and had run to the room when MA #3 called for help after finding him unresponsive. She stated when she arrived at the room, she noticed a white, powdery substance on his side table. An interview with Housekeeper #1 on [DATE] at 3:33 PM via telephone, revealed she went into Resident #3's room on [DATE] and wiped off a white, powdery substance from his tray table. She reported she did not know Resident #3's medical history or if he had a history of substance abuse. She reported she only wiped off the tray table after EMS requested her to do so. She could not provide any information on why EMS asked her to wipe off Resident #3's tray table. During an interview with NA #7 on [DATE] at 3:28 PM she reported she believed Resident #3 died due to an overdose due to her experience of seeing him snort an unidentified powdery substance on more than one occasion. NA #7 stated each time she observed Resident #3 snorting a white substance, she stopped him and got the nurse on the hall. She reported by the time she and the nurse returned to the room, the white, powdery substance was gone, and Resident #3 stated it was baby powder and denied snorting it. She reported she also wrote two separate reports regarding what she observed and slid them under Administrator #3's door. NA #7 stated she could not remember the dates she completed the reports but was certain she slid them underneath Administrator #3's door. She reported to her knowledge, nothing was done to prevent Resident #3 from snorting a white, powdery substance. Administrator #1 was asked on [DATE] at 4:30 PM to locate the written statements from NA #7 regarding Resident #3's observed behaviors of crushing and snorting his medications but she reported on [DATE] at 10:00 AM she was unable to locate them. An interview with Resident #3's former roommate, Resident 13, was conducted via telephone on [DATE] at 1:16 PM revealed he had reported Resident #3's drug abuse to facility staff multiple times including to the Wound Nurse and to former Social Worker #1. He stated he even sent pictures and video he had taken on his cell phone to them on their personal cell phones. Resident #3's former roommate reported he felt that someone from the facility was bringing in either cocaine or opioids and providing them to Resident #3. He stated he watched Resident #3 numerous times pull out pills, chop them up on his tray table, and snort them. On [DATE] at 12:18 PM the photograph and video recorded by Resident #13 was reviewed. They showed Resident #3 sitting in his wheelchair, in his room, next to his bed with his back to the door. Resident #3 was wearing a lime green t-shirt and had a bank debit card in his hand pressing the edge down onto a white, powdery substance that was on his tray table beside his bed. An interview with the Wound Nurse on [DATE] at 12:01 PM via telephone revealed it was very well known that Resident #3 had a substance abuse problem and crushed his opioid medications and snorted them. She also reported she had received a photograph and a short video, unable to recall the date, from Resident #3's roommate, Resident #13, that showed Resident #3 using a credit card to cut a white, powdery substance on his tray table in his room at the facility. She reported she immediately sent them to Director of Nursing #3 and provided them to a Corporate Staff member who was a female. She was unable to remember her name or her position. She stated she also wrote a statement, unable to recall the date, and provided it to the Corporate Staff member. The Wound Nurse reported she heard nothing back from Director of Nursing #3 or the Corporate Staff member about the situation. The Wound Nurse reported she felt that the situation was ignored. Interview with the former Social Worker #1 via telephone on [DATE] at 3:15 PM revealed she remembered Resident #3 and that he had a history of abusing his medications by crushing and snorting them. She reported Resident #3's former roommate, Resident #13, had approached her in her office some time, unable to recall the date, and told her Resident #3 was storing medications under his tongue then crushing and snorting them. She stated she brought it up to Director of Nursing #3 and Administrator #3 immediately after being informed, but it was blown off. She stated, everyone knew about it, and no one did anything. She reported there were no additional interventions put into place to increase supervision and despite his behaviors being discussed weekly at morning meeting; it was always not taken seriously. An interview was attempted with Director of Nursing #3 and was unsuccessful. An interview was attempted with Administrator #3 by telephone and was unsuccessful. An interview with Director of Nursing (DON) #1 on [DATE] at 10:26 AM, revealed although she was not working in the facility at the time of the incident, if there was a suspected overdose situation with a resident with a known substance abuse issue, who had a physician order for Narcan, she expected her staff to administer the Narcan as ordered. She also reported she expected the medication aides and the hall nurses to know which residents were at risk for overdose and administer Narcan as ordered. She reported she also expected her medication aides and hall nurses to be educated on how to administer Narcan and to notify responding EMS personnel on the drug abuse history of the resident in distress immediately upon their arrival. During a follow up interview with Nurse Practitioner (NP) #2 via phone on [DATE] at 4:00 PM, she stated due to Resident #3's history of drug abuse, along with continued observed abuses of his opioid medications while admitted to the facility she prescribed Narcan to be administered not if but when Resident #3 overdosed. She reported the Narcan was on the medication cart and should have been dedicated to Resident #3. She stated the failure of the facility to administer the ordered Narcan was a significant medication error and reported if it had been given, more than likely, could have saved Resident #3's life. She reported giving Resident #3 a dose of Narcan if he was having a genuine cardiac arrest of respiratory failure situation would have had no significant adverse effect. She reported when Narcan was ordered, it should have shown up directly under Resident #3's opioid prescription because that was the medication, she was worried he would overdose using. Administrator #2 was notified of the immediate jeopardy on [DATE] at 4:33 PM. The facility provided the following credible allegation of immediate jeopardy removal: Identify those residents who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident #3 was identified as having a significant medication error. Resident #3 was found unconscious on [DATE] with a white, powdery substance noted on the bedside and NARCAN was not administered. Resident #3 had a history of substance abuse. Resident #3 expired on [DATE] at the facility. All current residents that have a history of drug abuse have the potential to be affected. A list was made by the Chief Nursing Officer of the residents who had a history of polysubstance abuse. The list was placed on the nurse carts and placed in the narc book. The Director of Nursing will be responsible for updating the list with new admissions that have a history of polysubstance abuse. 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 [DATE], the Director of Nursing and Chief Nursing Officer educated licensed nurses and medication aides on the administration of NARCAN in the event a resident with known drug use history should be found unconscious and that residents with history of polysubstance abuse had physician order for NARCAN. Education also included signs and symptoms of overdose and nursing communication shift to shift on residents with history of polysubstance abuse and presence of list of residents with history of polysubstance abuse being located in the narc book on the cart for ease of access. Furthermore, education included notifying EMS upon their arrival of the substance abuse history and the administration of Narcan. The Director of Nursing will ensure no licensed nurses or medication aides will work without receiving this education. Any new hires including agency will receive education prior to the beginning of their next shift. Education will be completed on [DATE] by the Director of Nursing or Chief Nursing Officer. Effective [DATE], Administrator #2 will be responsible to ensure implementation of this IJ removal plan for this alleged non-compliance. The alleged date of IJ removal is [DATE]. On [DATE] and [DATE] the credible allegation of immediate jeopardy was validated. A full list of residents with histories of drug abuse was observed at the nurses' stations and on the medication carts. The interviewed medication aides and nurses were aware of the individuals identified by the facility as having histories of drug abuse and were also able to articulate what they needed to do in a suspected overdose situation and how to administer doses of Narcan. The facility's immediate jeopardy removal date of [DATE] was validated.

Based on interview, record review, staff, Medical Director, Telemedicine Physician, Regional Medical Director, and Infectious Disease Provider the facility failed to notify the Infectious Disease Provider that was managing Resident #1's intravenous (IV) antibiotic which was being used to treat a right subdural empyema (collection of pus between the layers of the brain) and Cerebritis (inflammation of cerebrum of the brain) that Resident #1's peripherally inserted central catheter (PICC) (an IV used to administer medications) had become dislodged and his antibiotics were not administered as ordered for 1 of 1 resident reviewed for significant medication errors. There was the high likelihood for bacterial regrowth, resistance to antibiotic, sepsis, or return to hospital due to the missed medications. Immediate jeopardy began on 12/22/22 when the facility failed to notify the Infectious Disease Provider Resident #1's PICC line became dislodged, and the IV antibiotics were not being administered as ordered. Immediate jeopardy was removed on 02/17/23 when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place and the completion of employee education. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included: brain metastasis (cancer that has spread to the brain), chronic subdural hematoma, and sepsis. The physician order dated 12/18/22 read, Oxacillin (antibiotic) 10 grams (gm) reconstituted. Use 12 gm IV one time a day for encephalitis/sepsis for 27 days. Infuse 12 gm over a 24-hour period. The Medication Administration Record (MAR) dated 12/2022 revealed that Nurse #3 was responsible for administering Resident #1's Oxacillin on 12/18/22, 12/19/22, 12/21/22, and 12/23/22. Nurse #2 was responsible for administering Resident #1's Oxacillin on 12/20/22, 12/22/22, and 12/24/22. Nurse #4 was responsible for administering Resident #1's Oxacillin on 12/25/22. A nurse's note dated 12/22/23 at 7:34 AM written by Nurse #1 read, made aware that resident's PICC line was out and at the foot of the bed. Writer noted PICC line of 45 centimeters on the floor and asked resident what happened. Per resident he got caught up turning in bed and must have pulled it out. On coming nurse made aware for replacement. Nurse #1 was interviewed via phone on 02/14/23 at 3:55 PM who confirmed that she was working on 12/22/22. She stated she was responsible for Resident #1 and another staff member who she could not recall notified her that Resident #1's PICC line was out. Nurse #1 stated she went to Resident #1's room and found his PICC line lying on the floor at the foot of Resident #1's bed. Nurse #1 stated she measured the PICC line to 45 centimeters and placed the line in a bag and gave to Nurse #2 and instructed her to call the MD to get the IV line replaced. Nurse #1 confirmed that she had not called the MD or the Infectious Disease Provider, she stated she left the PICC line with Nurse #2 and instructed her to notify the MD to get the IV line replaced. Review of a physician order dated 12/23/22 read, obtain peripheral line due to antibiotic use. The order was electronically signed by Nurse #3 and the Medical Director (MD). Nurse #3 was interviewed via phone on 02/15/23 at 4:56 PM. Nurse #3 stated that she recalled Resident #1 as he was on IV antibiotics that ran for twenty-four hours at a time. She stated she was not on shift when his PICC line got pulled out and could not recall if the IV line got reinserted or not. Nurse #3 could not recall why or how she obtained the order dated 12/23/22 to obtain a peripheral IV line for antibiotic use for Resident #1. She confirmed that she had not notified the MD or the Infectious Disease Provider that Resident #1's PICC was out or to obtain any new orders. The MD was interviewed on 02/15/23 at 10:03 AM who stated that he had been the MD at the facility since June 2022 and was at the facility once a week. The MD stated that he was not at all familiar with Resident #1 as he never evaluated him while he was in the facility. He indicated that the Telemed Physician (a physician who evaluates a resident via computer or electronic device) had evaluated Resident #1 and maybe she could answer questions regarding Resident #1. The MD stated that if he had a resident who was receiving IV antibiotic via a PICC line and was being followed by Infectious Disease he would prefer to consult with them regarding any issues with the IV antibiotic or PICC line. A follow up interview via phone was conducted with the MD on 02/15/23 at 8:42 PM. The MD stated that he recalled getting a call from a nurse on 12/22/22 but he could not recall which nurse regarding Resident #1's PICC line coming out. The MD stated he used his judgement to just observe Resident #1. The MD indicated he provided no further orders that night and he thought at that point it was a better option to just observe him and if he deteriorated then we would get some lab work. The MD stated, looking back I should have done things differently. He further confirmed that he did not refer the nursing staff to the Infection Disease provider as he previously stated he would do. The MD again stated he thought it was best to just observe Resident #1. The Regional Medical Director was interviewed on 02/15/23 at 11:50 AM via phone who stated he was not familiar with Resident #1 but stated if a resident was on IV antibiotic it was for good reason and would be important if the resident missed doses of the IV antibiotic. He further stated that he had reviewed Resident #1's medical record and it did not appear that any provider was made aware that Resident #1's PICC line was out. The Telemed Physician was interviewed via phone on 02/15/23 at 11:18 AM. The Telemed Physician stated she really could not recall Resident #1. She stated she did not take call for the facility and was not notified Resident #1's PICC line came out. She stated that generally if she was not the provider that initiated the antibiotic therapy, she was not going to alter it, that would need to go through the provider that ordered the medication and in this case was the Infectious Disease Provider. She further stated had someone called her she would have had the staff contact the Infectious Disease Provider and then try to figure out how to get the resident the next dose of scheduled antibiotic as quickly as possible. Nurse #4 was interviewed via phone on 02/15/23 at 2:43 PM. Nurse #4 stated that he recalled Resident #1 and recalled that he was on IV antibiotics. Nurse #4 stated he was told in report on 12/25/22 that Resident #1 had pulled his PICC line out and they were waiting for it to be replaced. Nurse #4 stated he could not confirm that the IV was ever replaced and stated he had not contacted the MD or the Infectious Disease Provider for any additional orders. Nurse #2 was interviewed via phone on 02/16/23 at 2:39 PM. Nurse #2 stated she vaguely recalled Resident #1 and him pulling his PICC line out. She stated she had not called the MD to get any alternate medication or antibiotics as she was not familiar with which antibiotics Resident #1 was on, why he was on it, or the duration of his treatment of those antibiotics. Nurse #2 stated if the PICC line came out on her shift she would assess the resident and notify the MD but Resident #1's PICC line came out on the shift before hers and she assumed that had all been taken care of. Nurse #2 confirmed that she had not had any communication with the Infectious Disease Provider at all. She stated if I called the IV company then I am sure that I texted the MD to let them know that he had pulled the PICC line out and I was getting it replaced but could not recall which provider. Nurse #2 again stated that Resident #1's PICC line came out on Nurse #1's shift and it would have been her responsibility to notify the MD that the line came out and obtain any new orders. The Director of Nursing (DON) was interviewed on 02/15/23 at 3:58 PM who stated she vaguely recalled Resident #1. She stated he was on IV antibiotics and his PICC line that was used for administration of those IV antibiotics got pulled out. The DON stated that when PICC's line became dislodged the provider was immediately notified but she did not know which provider was notified regarding Resident #1's PICC line. She stated sometimes they got a hold order to just hold the antibiotic until the IV line can be replaced but they could also get an order to give another antibiotic via a different route like intramuscularly until the IV line could be replaced. The DON was not aware of any additional orders that were obtained regarding the IV Oxacillin. The Infectious Disease Provider was interviewed via phone on 02/15/23 at 1:50 PM who stated she was very familiar with Resident #1 as she had followed him several days while he was in the hospital before coming to the facility. She indicated that Resident #1 was on IV Oxacillin for a specific organism that was detected on a culture that was obtained. The Infectious Disease Provider stated that her office had contacted Resident #1's nurse at the facility on 12/22/22 at 10:04 AM to confirm that the facility had the correct order for the IV antibiotic, the correct duration for the antibiotics, and that they had orders for the required weekly blood work that was needed. At no time during that conversation or other time was her office made aware that Resident #1's PICC line was out, and he was not receiving his IV Oxacillin. The Infectious Disease Provider also explained that Resident #1 was on day 19 (4 at the facility and 15 at the hospital) of his entire six-week course of antibiotic indicating he was not just starting his course of therapy, but he had not reached the halfway point in his therapy. The Infectious Disease Provider stated that if she would have been made aware she would have immediately intervened by bringing Resident #1 back to the emergency room , getting his IV access replaced while simultaneously administering a different antibiotic via a different route. The Administrator was notified of the immediate jeopardy on 02/15/23 at 5:20 PM. The facility provided the following IJ removal plan: F580: Identify those residents who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident #1 did not receive IV antibiotics on 12/22/22, 12/23/23, 12/24/23, and 12/25/23 secondary to IV access becoming dislodged. The infectious disease provider was not notified the access was dislodged and the antibiotics were not received. On 02/15/23, the Director of Nursing reviewed resident's medications for administration compliance and notification to the provider for any missed administrations. Any opportunities identified during this audit will be addressed by 02/16/23. 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 02/15/23, the Director of Nursing educated licensed nurses on requirements to notify the MD when medication cannot be administered as ordered. Education was also completed on notifying the provider in the event the IV access becomes dislodged. The MD will be notified by phone at the time medication is not given. The Director of Nursing will ensure no licensed nurses will work without receiving this education. Any new hires including agency will receive education prior to the beginning of their first shift. Education will be completed on 02/16/2023 by Director of Nursing or Unit Manager. The Chief Nursing Officer educated the Administrator and Director of Nursing on 02/15/23 regarding the clinical morning meeting process to include reviewing MD notification of missed medications and dislodged IV access. Effective 02/15/2023, the Administrator will be responsible to ensure implementation of this IJ removal plan for this alleged non-compliance. The alleged date of IJ removal is 02/17/2023. A credible allegation validation of notification was conducted in the facility on 02/20/23. The education provided to the licensed nurses in the facility including Nurse #1, Nurse #2, Nurse #3, and Nurse #4 was reviewed. The interviews revealed that the licensed nurses had been trained on the process of notification and immediately reporting to the medical provider when medications could not be given in the way they were ordered. The facility conducted a root cause analysis to help identify issues and was reviewed without concern. The facility's immediate jeopardy removal date of 02/17/23 was validated.

Based on record review, staff, Regional Medical Director, Medical Director, and Infectious Disease Provider interviews the facility failed to prevent a significant medication error when staff failed to administer ordered doses of an IV antibiotic on [DATE] and [DATE]. The Peripherally Inserted Central Catheter (PICC) (intravenous (IV) line used to administer IV antibiotics) line was replaced with a different type of IV access on [DATE] and the staff failed to administer the IV antibiotic on [DATE] and [DATE] for 1 of 1 resident (Resident #1) reviewed for significant medication errors. There was the high likelihood for bacterial regrowth, resistance to antibiotic, sepsis, or return to hospital due to the missed medications. Immediate jeopardy began on [DATE] when staff failed to administer 4 doses of Resident #1's IV antibiotics. Immediate jeopardy was removed on [DATE] when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place and the completion of employee education. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included: brain metastasis (cancer that has spread to the brain), chronic subdural hematoma, and sepsis. The physician order dated [DATE] read, Oxacillin (antibiotic) 10 grams (gm) reconstituted. Use 12 gm IV one time a day for encephalitis/sepsis for 27 days. Infuse 12 gm over a 24-hour period. The Medication Administration Record (MAR) dated ,d+[DATE] indicated that Oxacillin was given as ordered on [DATE], [DATE], [DATE], and [DATE]. The MAR indicated that Oxacillin was not administered on [DATE], [DATE], [DATE], and [DATE]. The nurse's note dated [DATE] at 7:34 AM written by Nurse #1 read, made aware that resident's PICC (IV line used to administer IV antibiotics) line was out and at the foot of the bed. Writer noted PICC line of 45 centimeters on the floor and asked resident what happened. Per resident he got caught up turning in bed and must have pulled it out. Oncoming nurse made aware for replacement. Nurse #1 was interviewed via phone on [DATE] at 3:55 PM who confirmed that she was working on [DATE]. She stated she was responsible for Resident #1 and another staff member who she could not recall notified her Resident #1's PICC line was out. Nurse #1 stated she was finishing her shift and was ready to clock out, but she went to Resident #1's room and found his PICC line lying on the floor at the foot of Resident #1's bed. Resident #1 was unable to conversate with Nurse #1 and could not recall what had occurred. Nurse #1 stated she measured the PICC line to 45 centimeters and placed the line in a bag and gave to Nurse #2 and instructed her to call the Medical Director (MD) to get the IV line replaced. She added Resident #1's arm was not bleeding and did not require any additional treatment and then she left the facility because her shift was over. A nurse's note dated [DATE] at 9:56 AM written by Nurse #2 read, IV company called, stated a central line (type of IV line) would be appropriate and a nurse would call shortly to establish when it could be done. Nurse #2 was interviewed via phone on [DATE] at 2:39 PM. Nurse #2 stated she vaguely recalled Resident #1 and him pulling his PICC line out. She stated if she documented that she called to have it replaced then she had done so but had not called the MD to get any alternate medication or antibiotic as she was not familiar with which antibiotics Resident #1 was on, why he was on it, or the duration of his treatment of those antibiotics. Nurse #2 stated if the PICC line came out on her shift she would assess the resident and notify the MD but Resident #1's PICC line came out on the shift before hers and she assumed that had all been taken care of. Nurse #2 could not recall if she attempted to reinsert the IV line or not. Nurse #2 confirmed that Resident #1's Oxacillin was not administered on [DATE] because his PICC line had been pulled out. The MAR administration note dated [DATE] at 1:15 PM and written by Nurse #3 read, Oxacillin, unable to give at this time due to resident pulling out PICC line and waiting on IV access to come and place peripheral line. Nurse #3 was interviewed via phone on [DATE] at 4:56 PM. Nurse #3 stated that she recalled Resident #1 as he was on IV antibiotic that ran for twenty-four hours at a time. She stated she was not on shift when his PICC line got pulled out and could not recall if the IV line got reinserted or not. Nurse #3 confirmed that on [DATE] she did not administer Resident #1's Oxacillin because his PICC line had been pulled out and he did not have IV access. Nurse #3 stated that she knew that someone had called for the IV line to be replaced could not recall if she had attempted to reinsert the IV or not. She also confirmed she had not contacted any provider for any additional orders regarding the Oxacillin. The MAR administration note dated [DATE] at 11:31 AM and written by Nurse #2 read, Oxacillin, no iv access, IV replacement to be done today. A document from an external IV company indicated that on [DATE] at 3:48 PM they arrived at the facility and inserted an IV access in Resident #1's right hand. The line was secured and flushed, and Resident #1 tolerated procedure well. The MAR administration note dated [DATE] at 9:59 AM and written by Nurse #4 read, Oxacillin, waiting for IV insertion. Nurse #4 was interviewed via phone on [DATE] at 2:43 PM. Nurse #4 stated that he recalled Resident #1 and recalled that he was on IV antibiotics. Nurse #4 stated that he was off for a few days and when he came back, he was told in report on [DATE] that Resident #1 had pulled his PICC line out and they were waiting for it to be replaced. Nurse #4 stated he could not confirm that the IV was ever replaced and stated he had not contacted the MD because someone had already done that, nor had he attempted to reinsert the IV because they were waiting on the IV company to come and reinsert the IV. Nurse #4 also stated that Resident #1 had not pulled his IV out during his shift and was certain that he did not administer the Oxacillin on [DATE] because he did not have an IV because as that was what he was told in report. Resident #1 died on [DATE] in the facility. Resident #1's death certificate indicated his cause of death to be encephalopathy (a broad term for any brain disease that alters brain function mostly commonly caused by infection). The MD was interviewed on [DATE] at 10:03 AM and stated he had been the MD at the facility since [DATE] and was at the facility once a week. The MD stated he was not at all familiar with Resident #1 as he never evaluated him while he was in the facility. He indicated that the Telemed Physician (a physician who evaluates a resident via computer or electronic device) had evaluated Resident #1 and maybe she could answer questions regarding Resident #1. The MD stated that if he had a resident who was receiving IV antibiotic via a PICC line and was being followed by Infectious Disease he would prefer to consult with them regarding any issues with the IV antibiotic or PICC line. A follow up interview via phone was conducted with the MD on [DATE] at 8:42 PM. The MD stated that he recalled getting a call from a nurse on [DATE] but he could not recall which nurse regarding Resident #1's PICC line coming out. The MD stated he used his judgement to just observe Resident #1. The MD indicated he provided no further orders that night and he thought at that point it was a better option to just observe him and if he deteriorated then we would get some lab work. The MD stated, looking back I should have done things differently. He further confirmed that he did not refer the nursing staff to the Infection Disease provider as he previously stated he would do. The MD again stated he thought it was best to just observe Resident #1. The Regional Medical Director was interviewed on [DATE] at 11:50 AM via phone who stated he was not familiar with Resident #1 but stated if a resident was on IV antibiotic it was for good reason and would be important if the resident missed doses of the IV antibiotic. The Director of Nursing (DON) was interviewed on [DATE] at 3:58 PM who stated she vaguely recalled Resident #1. She stated that he was on IV antibiotics and his PICC line that was used for administration of those IV antibiotics got pulled out. The DON stated it was replaced in the facility by an external IV company. The DON stated that the process for when a PICC line become dislodged was the provider was immediately notified and sometimes we get a hold order to just hold the antibiotic until the IV line can be replaced but we could also get an order to give another antibiotic via a different route like intramuscularly until the IV line could be replaced. The DON stated it was important to get the IV line reinserted as quickly as possible, so the resident did not miss scheduled doses of their medications. The Infectious Disease Provider was interviewed via phone on [DATE] at 1:50 PM who stated she was very familiar with Resident #1 as she had followed him several days while he was in the hospital before coming to the facility. She indicated that Resident #1 was on IV Oxacillin for a specific organism that was detected on a culture that was obtained. She further explained that Oxacillin's affects peaked at thirty minutes which was why in the hospital setting it was given very frequently but in the skilled nursing facility it was infused over a twenty-four-hour period. The Infectious Disease Provider also explained that Resident #1 was on day 19 (4 at the facility and 15 at the hospital) of his entire six week course of antibiotic indicating he was not just starting his course of therapy but he had not reached the halfway point in his therapy. The Infectious Disease Provider stated that from an infectious disease standpoint it was a very significant medication error when Resident #1 missed four doses of the IV Oxacillin. She further stated she would have intervened if she had been aware that his PICC line had become dislodged by assisting with getting IV access reinserted and using a different antibiotic that could have been administered intramuscularly until IV access could be obtained. The Administrator was notified of the immediate jeopardy on [DATE] at 5:20 PM. The facility provided the following IJ removal plan: F760: Identify those residents who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance: Resident #1 was identified as having a medication error. Resident #1's intravenous access line was dislodged on [DATE] and he was not administered his IV antibiotics (Oxacillin) as ordered on [DATE], [DATE]. [DATE], and [DATE]. Resident #1 was admitted to the facility on [DATE] with diagnoses included but not limited to viral encephalitis, nontraumatic chronic subdural hemorrhage, type II diabetes, malignant neoplasm of lung, and secondary malignant neoplasm of brain. On [DATE], the Director of Nursing reviewed resident medications for administration compliance. Any opportunities identified during this audit will be addressed by [DATE]. On [DATE], the Director of Nursing reviewed residents with intravenous access. Any opportunities identified during this audit will be corrected by the Director of Nursing by [DATE]. 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 [DATE], the Director of Nursing educated all licensed nurses on medication administration and the documentation to indicate completion of medication administration. Education also included requirements for notification to the MD for any missed administrations and in the event IV, access becomes dislodged/removed. The MD will be notified by phone at the time medication is not given. The Director of Nursing will ensure no licensed nurses will work without receiving this education. Any new hires including agency will receive education prior to the beginning of their next shift. Education will be completed on [DATE] by Director of Nursing or Unit Manager. The Chief Nursing Officer educated the Administrator and Director of Nursing on [DATE] regarding the clinical morning meeting process to include medication administration and the validation of documentation. Furthermore, education was provided on ensuring the provider is notified in the event the IV access is dislodged. Effective [DATE], the Administrator will be responsible to ensure implementation of this IJ removal plan for this alleged non-compliance. The alleged date of IJ removal is [DATE]. A credible allegation validation of significant medication errors was conducted in the facility on [DATE]. The education provided to the licensed nurses in the facility including Nurse #1, Nurse #2, Nurse #3, and Nurse #4 was reviewed. The interviews revealed that the licensed nurses had been trained on the process of preventing significant medication errors by immediately reporting to the medical providing and either requesting a hold order or additional orders for other medication that could be used. The facility conducted a root cause analysis to help identify issues and was reviewed without concern. The facility immediate jeopardy removal date of [DATE] was validated.

Based on record reviews, observations and resident and staff interviews, the facility failed to treat residents in a dignified manner when staff did not provide scheduled bed baths requested. The resident expressed feelings of being dirty, unhappy, itchy, and unclean. This affected 2 of 3 residents reviewed for dignity and respect (Resident #7 and Resident #6). The findings included: 1.Resident #7 was admitted to the facility on [DATE] with diagnoses of hypertension and muscle weakness. A review of the admission Minimum Data Set (MDS) dated [DATE] indicated Resident #7 was cognitively intact. The MDS revealed Resident #7 was total dependent and required two staff assist for bathing. The MDS also indicated it was very important to for Resident #6 to choose between a tub bath, shower, or bed bath. An interview and observation with Resident #7 on 2/14/23 at 10:15 AM revealed she had not received consistent showers as scheduled since admission. Resident #7 further revealed she preferred bed baths and had to ask nursing staff on weekends to receive one. Resident #7 stated she felt unclean, and her hair felt dirty and had expressed this to staff multiple times. Observation revealed Resident #7 to have greasy and tangled hair and have facial expressions of being unhappy. An interview with Nurse Aide (NA) #1 on 02/15/23 at 2:05 PM revealed she worked on the shower team for the facility but was often pulled to the floor to assist other NAs due to short staffing. NA #1 further revealed Resident #7 had missed preferred bath baths multiple days and had complained of feeling nasty. NA #1 stated multiple residents had complained showers and baths were not being given as scheduled as preferred. An interview with NA #5 on 02/15/23 at 2:15 PM revealed assisted NA #1 with showers and baths and Resident #7 had not refused. NA #5 indicated the facility sometimes did not have enough NAs so staff assisting with showers would get pulled to the floor. NA #5 stated Resident #7 had expressed she had felt dirty at time due to not receiving a scheduled bed bath. An interview with Unit Manager (UM) #1 on 02/15/23 at 12:05 PM revealed she did not recall Resident #7 had refused preferred bed baths before. UM #1 further revealed NA's completing showers and baths had been pulled to the floor to assist other NAs due to staff who had called out. UM #1 indicated she was not aware #7 had missed multiple bed baths as scheduled and expressed feelings of being unclean. An interview with the Director of Nursing (DON) on 02/15/23 at 12:30 PM revealed Resident #7 preferred a bad bath and was not aware that she had missed several scheduled days and complained of feeling dirty. The DON further revealed she expected for Resident #7 and other residents to receive their shower or bath on scheduled days and to feel clean and comfortable. 2. Resident #6 was admitted to the facility on [DATE] with diagnoses of hypertension, and arthritis. A review of the admission Minimum Data Set (MDS) dated [DATE] indicated Resident #6 was cognitively intact. The MDS further revealed Resident #6 was total dependent and required two staff assist for bathing. The MDS also indicated it was very important to for Resident #6 to choose between a tub bath, shower, or bed bath. An interview and observation with resident #6 on 2/14/23 at 1:00 PM revealed he had not received consistent showers as scheduled since admission. Resident #6 further revealed he preferred bed baths and had told nursing staff he had not received preferred bed baths. Resident #6 stated he felt dirty and itchy and wanted his bed baths as scheduled and had expressed this to nursing staff. Observation revealed Resident #6 to have an odor. An interview with NA #1 on 02/15/23 at 2:05 PM revealed she worked on the shower team consistently for the facility but was often pulled to the floor to assist other NAs due to short staffing. NA #1 further revealed Resident #6 had missed preferred bath baths multiple days and had complained of feeling dirty. NA #1 stated multiple residents had complained showers and baths were not being given as scheduled as preferred. An interview with NA #5 on 02/15/23 at 2:15 PM revealed assisted NA #1 with showers and baths and Resident #6 had not refused. NA #6 indicated the facility sometimes did not have enough NAs so staff assisting with showers would get pulled to the floor. NA #5 stated Resident #6 and other residents had complained they had not received showers or baths as scheduled. An interview with Unit Manager (UM) #1 on 02/15/23 at 12:05 PM revealed she did not recall Resident #6 had refused preferred bed baths and had expressed he had felt dirty. UM #1 further revealed NAs completing showers and baths had been pulled to the floor to assist other NA's due to staff who had called out. UM #1 indicated she was not aware #6 had missed multiple bed baths as scheduled. An interview with the Director of Nursing (DON) on 02/15/23 at 12:30 PM revealed Resident #6 preferred a bad bath and was not aware that he had missed several scheduled days and complained of feeling dirty. The DON further revealed she expected for Resident #6 and other residents to receive their shower or bath on scheduled days and to feel clean and comfortable.

Based on observations, record review and resident, family, staff, Nurse Practitioner and Wound Physician interviews the facility failed to complete thorough assessments or obtain measurements of a resident's pressure ulcer and implement interventions that would prevent the worsening of a pressure ulcer for 1 of 3 resident reviewed with pressure ulcers (Resident #1). Resident #1 admitted on [DATE] with a red area on her sacrum, on [DATE] the red area opened and on [DATE] the wound was an unstageable wound with 100% slough (dead tissue) that measured 3.5 centimeters (cm) x 3.5 cm x 0.4 cm. Resident #1 was hospitalized from [DATE] to [DATE] for acute [CONDITION(S)] (stroke) and returned to the facility with a wound vacuum (vacuum that sucks fluid out of wounds) in place. Resident #1 was evaluated by the Wound Physician on [DATE] and the Stage 4 pressure ulcer measured 4.3 cm x 4.5 cm x 1.6 cm and contained 30% slough 15 % granulation tissue and 15 % of bone and muscle was exposed. The Wound Physician evaluated Resident #1 on [DATE] and suspected [CONDITION(S)] that required rehospitalization and intravenous antibiotic therapy. Resident #1 expired on [DATE] due to severe [CONDITION(S)] and Stage 4 decubiti. Immediate jeopardy began on [DATE] when the facility identified an unstageable pressure ulcer on Resident #1 after lack of thorough assessments or interventions. The immediate jeopardy was removed on [DATE] when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of Level D (no actual harm with the protentional for more than minimal harm that is not immediate jeopardy). The findings included: Review of a Discharge Summary from the local hospital dated [DATE] read in part; Discharge Exam: Wounds: stage 2 pressure ulcer to bilateral buttock without signs or symptoms of infection. No measurements were noted. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Braden Scale for predicting pressure ulcers dated [DATE] indicated that Resident #1 was at moderate risk of developing a pressure ulcer. Review of an Admission Nursing Assessment signed by Nurse #1 and dated [DATE] indicated that Resident #1 had no skin issues. Nurse #1 was interviewed on [DATE] at 10:39 AM. Nurse #1 stated that she helped with admissions and confirmed that she had signed the Admission assessment dated [DATE] but stated she had not completed the skin assessment. She stated that the Director of Nursing (DON) completed the assessment did not enter a weight so it would not let her sign and complete the assessment so when Nurse #1 came to the facility a few days later she entered a weight then signed the assessment. Nurse #1 again stated she had not completed the skin assessment dated [DATE] she had only signed the assessment but stated the DON had opened the assessment and that was who would have done the assessments. Review of an admitting daily skin assessment dated [DATE] and signed by Nurse #2 on [DATE] indicated that Resident #1 had redness to her sacrum. No further description or measurements were noted on the assessment. Attempts to speak to Nurse #2 were made on [DATE], [DATE] and [DATE] and were unsuccessful. Review of a Resident Body Scan Tool dated [DATE] with no staff signature indicated that Resident #1 had a red sacrum and had handwritten on the form house barrier? (cream used for skin protection). Review of a baseline care plan dated [DATE] completed by Minimum Data Set (MDS) Nurse #1 on [DATE] indicated that Resident #1 had no pressure ulcers. Review of an admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #1 was cognitively intact, had no behaviors or rejection of care and required total assistance of two staff members for bed mobility. The MDS further indicated that Resident #1 was always incontinent of bowel and bladder, was at risk of developing a pressure ulcer but had no pressure ulcers during the assessment reference period. Review of Resident #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Treatment Administration Record (TAR) dated [DATE] revealed no treatment to Resident #1's sacrum prior to [DATE]. Review of weekly skin review dated [DATE] and signed by the Wound Care Nurse on [DATE] read that Resident #1 had skin tears to lower extremities and wrist upon admission and treatment was in place. No other skin issues were noted. Review of a Situation Background Assessment and Recommendation (SBAR) dated [DATE] and electronically signed by the Wound Care Nurse read in part; area to left buttock that measured 1.0-centimeter (cm) x 0.5 cm. [MEDICATION(S)] (moisture retentive dressing) dressing every Monday, Wednesday, Friday. The Nurse Practitioner (NP) was notified on [DATE] at 12:00 AM. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a weekly skin review dated [DATE] and signed by the Wound Care Nurse on [DATE] read in part; sacrum upper buttock deteriorated to unstageable (full thickness tissue loss in which actual depth is completely obscured by slough). Positioning wedge provided. Treatment changed and referred to Wound Physician. The review contained no measurements or further description of the wound. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply calcium alginate (dressing used on wound that have heavy drainage) to open area and cover with [MEDICATION(S)] dressing. Review of a SBAR dated [DATE] and completed by the Wound Care Nurse read in part; area was excoriated that has deteriorated. Area originally measured 1.0 cm x 0.5 cm. The NP was notified on [DATE] at 6:00 PM. Review of a weekly pressure wound observation tool dated [DATE] and completed by the Wound Care Nurse indicated that Resident #1 had a wound to her sacrum/buttock that was acquired in the facility on [DATE]. The stage of the pressure ulcer was unstageable with 100 percent of slough that measured 3.5 cm x 3.5 cm x 0.4 cm. Treatment order changed and indicated the wound had deteriorated. The provider was notified on [DATE]. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply calcium alginate with silver (dressing used to prevent bacterial penetration) to the open area and cover with [MEDICATION(S)] every Monday, Wednesday, and Friday. Review of a Significant Change MDS dated [DATE] indicated that Resident #1 was cognitively intact and had no behaviors or rejection of care. The MDS further indicated that Resident #1 required extensive assistance of two staff members for bed mobility, was always incontinent of bowel and bladder and had 1 unstageable pressure ulcer that was not present on admission. The MDS indicated that Resident #1 was on a pressure reducing device for bed. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a discharge summary from the local hospital dated [DATE] indicated Resident #1's discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The summary also read; patient had a wound vac (suction machine placed over wounds to pull fluid from the wound) placed and needs to be changed on [DATE]. A wound consult obtained while in the hospital read in part; sacral wound unstageable 3.5 cm x 4.0 cm x 1.0 cm with 1.5 tunnel (passageway under the skin) at 9:00 o ' clock extending vertical 1.5 cm. Undermining (erosion of underlying skin) noted 12:,d+[DATE]:00 1.0 cm. Wound bed with 75% coverage thin layer of yellow slough. Fascia (connective tissue) not intact. Awaiting surgical recommendations to develop treatment plan. The discharge summary further read; general surgery consulted, and no debridement was performed. Wound vacuum will be applied [DATE] and family is requesting patient to return to the nursing facility for further care. Resident #1 was readmitted to the facility on [DATE]. Review of admission assessment dated [DATE] that revealed that Resident #1 had a pressure ulcer to her sacrum that was a stage 4. No measurements were listed. The assessment also read; resident has wound vac to sacrum and multiple skin tears to bilateral arms and legs. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the August Treatment Administration Record (TAR) revealed that the wound vacuum was changed on [DATE] by the Wound Care Nurse at 5:12 PM. Review of an Initial Wound Evaluation and management Summary dated [DATE] read in part; Resident #1 had a pressure ulcer to the sacrum that was a stage 4 and measured 4.3 cm x 4.5 cm x 1.6 cm with moderate serous drainage. The wound contained 30% slough, 55% granulation tissue, and 15% of bone and muscle. The treatment plan included: pack wound with Dakin's (bleach type solution) and cover with a large gauze pad after prepping the wound edges with skin prep every day. The recommendations also indicated group 2 mattress (low air loss mattress). The evaluation was electronically signed by the Wound Physician. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation and interview were conducted with Resident #1 on [DATE] at 9:24 AM. Resident #1 was resting on a low air loss mattress and was positioned slightly on her right side. Resident #1 stated that she had just received her low air loss mattress on [DATE] and she was being seen by the Wound Physician who was trying to heal the wound that was on her sacrum. She stated that her wound was a Stage 4 and stated, it was very painful and added when I came to the facility, I had no wounds on my sacral area. Resident #1 explained that she had been at the facility for about 2 weeks when her sacrum started hurting and she asked the staff to look at it and they found a red spot and then it got worse and now is a hole. Resident #1 stated that at times she laid in urine for ,d+[DATE] hours and initially the staff were not turning her. Resident #1 explained that she was paralyzed from a previous stroke and could not turn herself. The staff were completing wound care as the Wound Physician ordered with Dakin's solution. Resident #1 stated that about three times a week it took between ,d+[DATE] hours for staff to come in and change her when she was wet but added that the call bell response time had improved a little bit. Resident #1 explained that she laid on her back all night (previous night) no one changed her until sometime around 4:30 AM and when staff came in to change her, she was soaked and so was her bed. Then the Nurse Aide (NA) that changed her forgot to put the positioning wedge behind her so when NA #4 got there she had fixed it. NA #4 was interviewed on [DATE] at 9:23 AM who confirmed that she worked at the facility through an agency. NA #4 confirmed that when she arrived for her shift yesterday ([DATE]) Resident #1 did not have her positioning wedge behind her back, so she placed the wedge behind Resident #1 and covered it with a towel as the resident requested her to do. An observation of wound care was completed on [DATE] at 10:32 AM along with the Wound Care Nurse and NA #2. The Wound Care Nurse was observed to perform hand hygiene and don clean gloves and then remove a dressing from Resident #1's sacral area. Once the dressing was removed there was large hole over the sacral area with bone and muscle exposed. There was a dark black area on the edge of the wound. The wound was clean with light pink tissue noted to the wound bed. Resident #1 asked the Wound Care Nurse to take a picture of the wound and the Wound Care Nurse did as asked. The Wound Care Nurse stated to NA #2 that the area started out as an excoriated area and began cleaning the wound with Dakin's solution. Once the wound was clean with the Dakin's solution the Wound Care Nurse removed her gloves and performed hand hygiene and donned clean gloves. She began packing the wound with gauze soaked in Dakin's solution and placed it in the wound and covered with a padded dressing as ordered. Once the treatment was completed Resident #1 was again placed slightly on her right side where she had been positioned at the start of the wound observation and during an earlier observation of Resident #1 on the same day. The Wound Care Nurse was interviewed on [DATE] at 3:30 PM who confirmed that she reviewed each new admission either the day of admission or the next day. The Wound Care Nurse stated admissions that came in on Friday or over the weekend were reviewed on Monday. She added that she rounded with the Wound Physician each week and once his reports were in the system, she would review them and carry out any new orders. The Wound Care Nurse stated that when Resident #1 came to the facility she had a [MEDICATION(S)] (dressing) to her sacral area and when it was removed there was nothing under it. The Wound Care Nurse confirmed that she had seen Resident #1 during her first week after admission and she had no sacral wound then started to get excoriated and [MEDICATION(S)] was ordered three times a week. The Wound Care Nurse stated that someone was taking my dressings off in between her three time a week changes and they were not replacing them. The Wound Care Nurse explained that frequently when she went to complete the wound dressing the wound would be uncovered and Resident #1 would be wet with urine. Initially the staff were just using barrier cream which the Wound Care Nurse indicated was standard protocol and after Resident #1 had been there about 2 weeks we found the excoriated area and [MEDICATION(S)] was initiated then a week later the wound was unstageable and covered in slough. At times the staff were turning her but at times they were not and if the staff had been changing her like they should have been it would not have progressed that quickly. The Wound Care Nurse added I think the lack of routine incontinent care and lack of consistent offloading contributed to the development of this wound. The Wound Care Nurse stated she did provide the staff with a positioning wedge but Resident #1 did prefer the use of pillows for turning and repositioning. An interview with Resident #1's family member was conducted on [DATE] at 10:12 AM. The family member stated that Resident #1 had a cell phone that she always kept close to her and several times on [DATE] and [DATE] Resident #1 had called and asked the family member to come over to the facility and change her because the staff had not answered her call light. The family member stated that when Resident #1 called him to come to the facility and change her, he would ask her if the call light was on, and she confirmed that it was. The family member stated that he drove over to the facility and when he got to the facility the call light was still on and he went ahead and changed Resident #1 and repositioned her. The family member reported on numerous occasions Resident #1 would call him and report no one would answer her call light and he would call the facility and have someone go and check on Resident #1. The family member confirmed that the air mattress was placed on [DATE]. NA # 3 was interviewed on [DATE] at 9:03 AM. NA #3 confirmed that she had cared for Resident #1 shortly after she admitted to the facility in [DATE]. She stated that Resident #1 would ring her call light and ask to be changed and when they changed her, they would try to turn her off her bottom, but she was in a lot of pain so a lot of times it was just slightly turning her from side to side. NA #3 also confirmed that Resident #1 required at a minimum of two people to turn and change her and at times three people due to her pain but could not recall if Resident #1 had any wounds or not. NA #6 was interviewed on [DATE] at 11:09 AM. NA #6 stated she had been coming to the facility the last 4 weeks through an agency and confirmed she was familiar with Resident #1. She stated that she was very difficult to turn due to her pain. She stated that initially Resident #1's wound was just some very mild redness then she was off a few days and when she came back it was much worse. NA #6 stated that she had found the wound several times with no dressing on it and she would always report it to the nurse. NA #6 confirmed that this morning around 4:00 AM to 5:00 AM she went into check on NA #7 who had Resident #1 and NA #7 was upset and stated she was not aware that she was assigned to care for Resident #1 when she arrived for her shift at 11:00 PM. NA #6 stated to NA #7 that she would take care of Resident #1 for her. She stated that Resident #1 was soaked with urine through to the mattress and her brief was soaked as was the bedding. NA #6 stated that she provided incontinent care to Resident #1 and got her situated in the bed and as comfortable as possible. NA #6 stated that on multiple occasions she would find Resident #1 soaked with urine and few times with feces and would immediately get her changed and cleaned up. She added that on [DATE] she had moved Resident #1 to her chair so the low air loss mattress could be applied to her bed. Attempts to speak to NA #7 were made on [DATE] and [DATE] were unsuccessful. NA #5 was interviewed on [DATE] at 11:13 AM. NA # stated that she worked at the facility through an agency and had been coming to the facility for about a month. NA #5 stated that she was working the day Resident #1 was admitted . NA #5 stated that Resident #1 was able to ring her call bell and let us know what she needed, she had a lot of pain from her fractures, so we really did not turn her it was just propping her on each side to relieve the pressure from her bottom. NA #5 stated she recalled Resident #1 had ,d+[DATE] nickel size areas that were light red on her buttock and that she applied barrier cream when she provided incontinent care and notified the nurse but could not recall which nurse and stated that the nurse was already aware of the areas. The DON was interviewed on [DATE] at 11:37 AM. The DON stated she did not assess Resident #1 upon admission, she stated she had opened the assessment then Nurse #1 completed the assessment and signed it. The DON explained that Nurse #1 who signed the Admission Assessment should have looked at Resident #1's skin and taken measurements of anything that was present even if was a red area. The DON stated that when she reviewed the Discharge Summary from the hospital dated [DATE], she read that Resident #1 had a stage 2 pressure ulcer and when she had reviewed Resident #1's admission to the facility and there were no skin issues noted. She asked the Wound Care Nurse to go and complete another assessment on [DATE] and no sacral area was noted. She explained that Resident #1 needed to be turned and repositioned with frequent incontinent care provided due to her limited mobility from a previous stroke. The DON stated that Resident #1 drank more than she ate but her family brought her lots of stuff from home, and she would always eat that food and was not losing weight. The DON stated that when she saw the SBAR completed by the Wound Care Nurse on [DATE] she was aggravated because she had asked the Wound Care Nurse to review Resident #1 shortly after admission when she saw the discrepancy (difference from the discharge summary to the admission assessment completed at the facility) from the discharge summary and the initial Admission Assessment. She expected the Wound Care Nurse to review all admission that had come in the previous 24 hours or over the weekend, assess any skin issues and ensure a treatment was in place. A follow up interview was conducted with the DON on [DATE] at 3:35 PM. The DON stated that the facility staff should have obtained an air mattress more quickly when Resident #1's wound first developed and provided consistent turning and repositioning along with frequent incontinent care to help promote good wound healing. The NP was interviewed on [DATE] at 4:31 PM who confirmed that she was made aware of the development of Resident #1's wound could not recall the exact date but had been made aware. She stated that shortly after being made aware of a wound, the wound deteriorated, and she had a large hole in her sacrum. She added that Resident #1 was referred at some point to the Wound Physician and the NP stated that she had observed the wound but could not recall the exact date but stated the wound had slough and was easily packed with gauze. The NP stated that she routinely read through the Wound Physician notes but generally the Wound Physician handled the significant wounds in the facility. The Wound Physician was interviewed on [DATE] at 2:35 PM and confirmed that this would be his second visit with Resident #1. He stated that Resident #1 had diabetes, RA and was immunocompromised along with her paralysis, immobility, and incontinence placed her at risk for skin breakdown. He explained that if the skin was exposed to urine and feces that would not help the skin at all. The Wound Physician stated if the staff were not cleaning Resident #1 well enough then, the wound could get worse. The Wound Physician was made aware of the dark black edges of the wound observed on [DATE] and he stated that indicated a need for further offloading. One thing he noticed his first visit on [DATE] was she was not on an air mattress which would encourage wound healing. The Wound Physician also explained that the rapid increase in size was from lack of offloading, poor nutrition, and acute health decline. He stated he questioned why she was on a group 1 mattress (not an air mattress) and why she would not have been on a low air loss mattress sooner. A follow up interview was conducted with the Wound Physician on [DATE] at 6:40 PM. The Wound Physician stated after examining Resident #1 he was very suspicious that she may have [CONDITION(S)] (infection of the bone) and was going to start working her up for that. The first step was to order some lab work and go from there. The Wound Physician stated that depending on her lab work Resident #1 may need to go back to the hospital for treatment. He stated that it was very hard to say if Resident #1's wounds were avoidable or unavoidable but stated they were always declining along with her overall health. A follow up interview was conducted with the Wound Physician on [DATE] at 5:18 PM. The Wound Physician indicated that the lab work he ordered on [DATE] had come back and indicated that Resident #1 was mounting a significant infection and needed to be worked up very quickly, like in the next hour. The Wound Physician indicated that Resident #1 could die from complications of [CONDITION(S)], and he must work quickly and was going to send her to the ER for evaluation and treatment. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A follow up interview with the Wound Physician was conducted on [DATE] at 10:24 AM and stated that Resident #1 was sent to the hospital on [DATE] and expired in the early hours of [DATE]. He indicated the cause was likely from the [CONDITION(S)] of the sacral wound but with her co-morbidities it would be hard to tell for sure. Review of Resident #1's death certificate indicated her cause of death was severe [CONDITION(S)] and Stage 4 decubiti (pressure sore that reaches muscle, tendon, and bone) left buttock. The Administrator was notified of the Immediate Jeopardy (IJ) on [DATE] at 11:22 AM. The facility provided the following IJ removal plan: F686: Identify those residents who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to fully assess including measuring a resident's wound and failed to implement interventions that would prevent the worsening of a pressure ulcer for 1 of 3 resident reviewed with pressure ulcers (Resident #1). Because all residents are at risk upon admission when a wound is not fully assessed and when preventative care is not provided to prevent the worsening of a pressure ulcer, the following plan has been devised: On [DATE], licensed nurses completed head-to-toe skin assessments on all facility residents to identify changes in skin integrity. Residents identified with new changes in skin condition documented on a skin assessment form and were reported to the physician and/or nurse practitioner via phone by the licensed nurse and follow-up orders obtained as appropriate. The Minimum Data Set (MDS) nurse or Licensed Nurse updated resident care plans to reflect skin changes for actual or potential pressure wounds and preventative interventions by [DATE]. 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 [DATE], the Administrator, Director of Nursing (DON), Regional Director of Operations (RDO), Regional Director of Clinical Services (RDCS), Wound Nurse, MDS Nurse, Wound Practitioner and Medical Director conducted an Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting to review the facility Pressure Injury Prevention and Management Policy and to determine root cause of deficient practice. By root cause analysis, the QAPI committee determined that the facility failed to follow the Pressure Injury Prevention and Management Policy by failing to ensure that upon admission the accurate completion of skin assessments to identify, address resident skin impairments and implement wound prevention strategies for high-risk residents by the Licensed Nurses and Nurse Aides. A plan was formulated by the QAPI committee to address the identified issue to include a review of education, audit/monitoring needs, and QAPI committee responsibilities in reviewing for compliance. On [DATE], the DON and RDCS completed education to current facility and agency Licensed Nurses and Nurse Aides on the facility Pressure Injury Prevention and Management Policy. Education included the following: a) the facility's wound care protocol and the expectation of each Licensed Nurse for wound care prevention including assessing all wounds when discovered, implementing interventions to mitigate risk of deterioration and ensure effective prevention and treatment occurs. b) the facility's protocol on completing skin assessments to include accurate description and measurements and role of Licensed Nurse. c) Skin Assessments to be completed upon admission/readmission and weekly thereafter by the licensed nurse. Weekly skin assessments will be ordered on the Treatment Administration Record. d) the facility's protocol on Nurse Aides inspecting skin during activities of daily living (ADL) care such as when performing incontinence care and bathing to identify any alteration in residents skin integrity and to report changes to licensed nurse on duty. Or reported pain to the licensed nurse supervisor e) interventions to reduce the risk of a pressure ulcer development or worsening (turning/reposition, hydration, routine incontinence care, pressure relieving cushions/wedges) and f) Licensed Nurses and Nurses' Aides educated on frequency of incontinence care, turning and repositioning and reporting to the nurse if wound dressings are soiled or comes off during care. Licensed nurse on duty to replace dressing. g) following resident physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Licensed Nurses and Nurse Aides not receiving education on [DATE] will not be allowed to work until completed. The DON will utilize a master employee list to track completion of education. This responsibility was communicated to the Director of Nursing by the RDCS on [DATE]. Education will also be included during orientation for newly hired facility and agency Licensed Nurses and Nurse Aides, to be completed by Director of Nursing or Nurse Manager. Effective [DATE], the facility has hired a full-time, wound-certified licensed nurse who began working in facility on [DATE]. Effective [DATE], the wound certified licensed nurse will review resident skin condition upon admission, weekly and with changes in condition. Nurse aides will complete body audits during ADL care and will report skin concerns, soiled, uncovered wounds, or reports of pain to the licensed nurse on duty for further assessment. New skin concerns will be reported to the physician and/or nurse practitioner upon findings by the licensed nurse for follow-up treatment via phone. MDS Nurse will ensure care plans for residents with actual/potential pressure wounds include pressure relieving interventions to prevent further breakdown. Pressure relieving devices and interventions will be added to the Kardex for Nurse Aide communication. The DON will review newly admitted /readmitted residents in daily clinical meeting to monitor for the accurate completion of skin assessments and treatment to prevent and heal pressure wounds and ensure that pressure relieving devices are put into place These expectations were communicated on [DATE] by the Administrator to the wound nurse and clinical team Effective [DATE], the Director of Nursing or Licensed Nurse will complete surveillance care rounds to validate incontinence care is being completed routinely, pressure relieving devices are in place per resident plan of care. Effective [DATE], the Administrator and Director of Nursing will be responsible to ensure implementation of this immediate jeopardy removal for this alleged noncompliance. Alleged Date of IJ Removal: [DATE] A credible allegation validation of pressure ulcers was conducted in the facility on [DATE]. All residents skin assessments were reviewed and ensured all areas were appropriately documented in the medical record that included description of wound and measurements if applicable. The root cause analysis was reviewed along with training materials used to reeducate the staff. The in-service training records indicated that all staff including agency nursing staff and facility nursing staff including Nurse Aides, Nurses, and Medication Aides had been educated on the facility ' s policy and procedure for preventing and treating pressure ulcers. Interview with both agency staff and facility nursing staff revealed that they had received the education on wound prevention that included frequent incontinence rounds, frequent turning, and repositioning, assessing residents' skin on admission and then weekly, reporting of skin changes, and addressing pain that interfered with frequent incontinence round or turning. The facility's Quality Assurance (QA) team met on [DATE] to discuss and implement the plan. The facility's IJ removal date of [DATE] was validated.

Based on observations, record review, staff, resident, Nurse Practitioner (NP) and Wound Physician interview the facility failed to stop a wound dressing change when a resident experienced pain on a pain scale of 12 and when reported to the NP the NP failed to assess the residents sudden change in pain for 1 of 3 residents reviewed for pressure ulcers (Resident #1). Resident #1 was visibly crying, moaning, hollering, and pulling away as the staff were packing her sacral wound and the Wound Care Nurse did not stop the treatment or ask the resident if she wanted her to continue. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #1 was cognitively intact, had no behaviors or rejection of care and required extensive to total assistance for activities of daily living. The MDS further indicated that Resident #1 received scheduled pain medication, endorsed pain almost constantly that made it hard to sleep and affected her to day-to-day activities and rated her pain at a 7 on pain scale. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Acetaminophen 325 mg give 2 tablets by mouth every 6 hours for mild pain, [MEDICATION(S)] (opioid pain reliever) 10 mg by mouth every 6 hours as needed for pain. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation and interview were conducted with Resident #1 on 08/17/22 at 9:24 AM. Resident #1 was resting on a low air loss mattress and was positioned slightly on her right side. Resident #1 stated she was being seen by the Wound Physician who was trying to heal the wound that was on her sacrum. Resident #1 proceeded to say that the wound on her bottom was a stage 4 and was very painful and currently her pain was a 7 on pain scale and at its worst was a 9 on a pain scale. She reported that the staff completed her wound care as directed by the Wound Physician but stated it is so painful sometimes they give me pain medication, but I never know when the nurse is coming to do my treatment, so it is hard to get pain medication before the treatment. An observation of wound care was made on 08/17/22 at 3:00 PM along with the Wound Care Nurse. Upon entering the room Resident #1 stated to the Wound Care Nurse, I know you are here to torture me again. The Wound Care Nurse was observed to perform hand hygiene and don clean gloves and then she removed the dressing from Resident #1's sacral area to expose a large hole with muscle and bone exposed. As the Wound Care Nurse began to clean the wound with Dakin's solution (bleach like solution) Resident #1 let out a scream. She continued to clean the wound and Resident #1 began to thrust her hips forward to pull away from the Wound Care Nurse. Resident #1 stated, the pain medication is not helping, and my pain is a 12 and I usually tolerate pain well. The Wound Care Nurse stated to Nurse Aide (NA) #2 that was assisting with the wound change, Resident #1 tolerated the pain from her recent fracture better then she was tolerating the pain from the wound. As the Wound Care Nurse began to pack the wound with gauze soaked with Dakin's solution Resident #1 started moaning and stated, this is awful and continued to pull away from the Wound Care Nurse and let out a scream to which the Wound Care Nurse replied, I am almost done honey. Resident #1 took a gasp of air and stated oh then asked the Wound Care Nurse are you done to which she replied almost. Resident #1 was noted to be crying with liquid falling from her eyes rolling down the air mattress to the floor. The Wound Care Nurse continued to pack the wound and then covered the wound with a dressing. The Wound Care Nurse and NA #2 proceeded to then place a dry brief on Resident #1 who continued to cry. The Wound Care Nurse stated to Resident #1 she was going to speak to the Nurse Practitioner (NP) to get her something stronger for pain. A follow up interview and observation were conducted with Resident #1 on 08/17/22 at 3:25 PM. Resident #1 was resting in bed on her right side. She continued to cry and stated, it hurts so bad, and I cannot take much more. The Wound Care Nurse was interviewed on 08/17/22 at 3:30 PM and stated that this was the first time that Resident #1 had ever reacted to a dressing change the way she did today (08/17/22). She stated that Resident #1 had received pain medication prior to the treatment and it shocked me the way she reacted. She stated Resident #1 does have pain but has never reacted the way she did today. Normal protocol would have been to stop the dressing change when Resident #1 stated she was hurting or began having nonverbal signs of pain but at the time I just wanted to get it done so the pain would be done. If I would have stopped, she would have never let me finish and I did not want to leave the wound uncovered. Again, she stated I probably should have stopped but I am leaving the wound open? A follow up interview with the Wound Care Nurse was conducted on 08/17/22 at 4:17 PM. The Wound Care Nurse stated that she spoke to the NP about Resident #1's pain and she replied that the NP stated, I will absolutely not increase her medication because she has a history of narcotic abuse. The Wound Care Nurse explained that when Resident #1 first admitted to the facility she was constantly on the call light for pain medication. The NP was interviewed on 08/17/22 at 4:31 PM. The NP stated that when Resident #1 first admitted to the facility she was on a lot of [MEDICATION(S)] and I said no way I am comfortable with that and referred her to pain management clinic. When told about Resident #1's pain during the wound care observation on 08/17/22 the NP replied, I think her pain was not real, I have never seen any signs of pain. She stated, I have been in the room during wound care, and she laid there peacefully and quietly. She stated that Resident #1 had poor kidney function and chronic opioid abuse and I think her pain was a show. The NP stated she was covering Resident #1 with [MEDICATION(S)] 10 mg 4 times a day and again stated that she had never seen Resident #1 with signs of pain. Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Wound Physician was interviewed on 08/18/22 2:35 PM. The Wound Physician was made aware of the wound observation from 08/17/22 and indicated that he had evaluated Resident #1 last week on 08/11/22 and she had some discomfort but nothing like the pain that was described from the 08/17/22 wound change. He stated that he was suspicious that Resident #1 has some early [CONDITION(S)] (infection of the bone) developing and that was causing her increase pain. The Wound Physician stated he was going to go and evaluate Resident #1 and determine the next course of action. A follow up interview was conducted with the NP on 08/18/22 at 4:23 PM. The NP stated that Resident #1 had pain medication on 08/18/22 at 12:00 PM but had instructed the staff to go ahead and give her extra pain medication so the Wound Physician could examine her on his rounds in the facility. NA #2 was interviewed on 08/18/22 at 4:33 PM and stated that he had never seen Resident #1 display pain like she did during the wound care observation on 08/17/22. He stated that was the first time he saw her crying, moaning, or pulling away during wound care. A follow up interview with the Wound Physician was made on 08/18/22 at 6:40 PM. He stated that he had evaluated Resident #1 and her pain was much more significant than on his last visit and he was going to immediately start a workup for [CONDITION(S)] that included lab work and a white blood cell count. A follow up interview with the Wound Physician was conducted on 08/19/22 at 5:18 PM. He stated that the lab work he ordered on 08/18/22 indicated that Resident #1's white blood cell count was 22.5 (high) and was very concerning for acute [CONDITION(S)] and would explain the increase in her pain. He stated that on 08/17/22 when Resident #1 had the sudden change in her pain it should have been reported to the provider and the resident should have been assessed and a workup including lab work that included a white blood cell count to try and figure out why the change in her pain. The Wound Physician explained that Resident #1 had RA and was immunosuppressed, and her pain tolerance was much different than a normal person without RA and the increase in pain was her first sign that something more severe was going on. The Director of Nursing (DON) was interviewed and stated that the Wound Care Nurse had told her about the wound observation with Resident #1 on 08/17/22. She stated she asked the Wound Care Nurse if she stopped the wound care and she stated no. The DON stated she educated the Wound Care Nurse that she should have stopped and immediately reported it to the provider for further assessment and appropriate pain management.

Based on observation, record review and staff interviews, the facility neglected to provide incontinence care to a resident who was soiled with urine and resulted in a small reddish open area on her buttocks for 1 of 4 (Resident #23) residents reviewed for activities of daily living. The resident stated that her bottom was burning like it was on fire and wished she could care for herself, so she did not have to sit in a soiled brief. The findings included: Resident #23 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #23 has a skin care plan revised 5/19/21 which indicated she was at risk for skin breakdown. An incontinence care plan revised 05/25/21 indicated Resident #23 was incontinent of bowel and bladder with a goal of no skin breakdown due to incontinence with interventions that included peri-care after each incontinent episode and total dependance from staff for incontinence care. Resident #23 had a self-care deficit care plan related to total incontinence revised on 07/01/21 with a goal to remain clean, dry and odor free and interventions to include the need for assistance by staff for personal hygiene and grooming and two personal physical assistance for bed mobility. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #23 to be require extensive assistance for her bed mobility and personal hygiene needs. The MDS further indicated Resident #23 was always incontinent of bowel and bladder. A Brief Interview of Mental Status (BIMS) dated 10/05/21 indicated Resident #23 was cognitively intact. An observation and interview made on 10/11/21 at 12:45 PM revealed Resident #23 laying on her back in bed yelling for assistance with incontinence care. Resident #23 was pulling at the blue incontinence brief she wore that was partially covered by a white sheet and she said, please change me, my bottom it is on fire. There was a strong urine odor in the room during the observation. Resident #23's call light was not on during the observations; however, she was heard requesting assistance from outside of the door by the surveyor who entered. An observation and interview made on 10/11/21 at 1:00 PM revealed Resident #23 continue to lay in her bed still on her back yelling for assistance with incontinence care while staff walked by the room. Resident #23 stated it is hurting worse; someone please get this off me before I have a hole in my butt. I wish I could just take care of myself, so I didn't need anyone to wipe my butt and sit wet. The surveyor told the resident she would make the nurse aware she needed assistance. The surveyor then told a nurse who was sitting behind the desk at the nurses' station and the nurse said she would have an Nurse Aide (NA) to take care of it. An observation and interview made on 10/11/21 at 3:45 PM revealed Resident #23 was again yelling for assistance requesting incontinence care and when approached became tearful saying her buttocks felt like it was burning like it was on fire and felt like she couldn't barely stand to sit on it any longer. Resident #23 indicated she thought she had a hole on her butt. Resident #23 verbalized staff did not help when she called out. The surveyor approached the nurses' station and notified the oncoming nurse that Resident #23 was requesting assistance with incontinence care and need for observation when it occurred. An observation on 10/11/21 at 3:47 PM of incontinence care provided by Nurse Aide (NA #12) and NA #19 revealed Resident #23 lying in bed with a blue brief heavily saturated with a dark ring of liquid that revealed the interior cotton lining separating and shedding from the brief linings. The bed pad under Resident #23 was visibly wet with a yellow liquid substance present. The brief was discarded and visualization of Resident #23's buttocks revealed a quarter sized red circular area to the left lower buttocks near Resident #23's peri-area. The area was open and non-blanchable approximately 1 inch from the center of her rectum. As NA #12 began to wipe Resident #23's bottom, Resident #23 continued to complain of burning and stinging throughout the procedure. Once the incontinence care was completed with a clean brief and bed pad, then NA #19 covered Resident #23 up with the sheet and the Resident #23 stated she felt better. An interview with NA #12 and NA #19 on 10/11/21 at 3:53 PM stated they had only been on duty approximately an hour and had not yet provided care to Resident #23 since they arrived for their shift. They stated the day shift should have provided incontinence care to Resident #23 before they left for the day. Both NAs indicated the state of which Resident #23 presented during the incontinence care was not acceptable to be this wet. They felt the open area observed was new to their knowledge as they had cared for Resident #23 before and stated they would let the nurse know. An interview with Wound Nurse on 10/12/21 at 10:15 AM revealed she was responsible for wounds in the facility; however, she had recently been working as a floor nurse more often than being able to assess resident wounds. Wound Nurse indicated she had not been made aware Resident #23 was observed to have a reddened open area visible during incontinence care on 10/11/21 but she would investigate this concern. An observation and interview with Wound Nurse on 10/12/21 at 11:30 AM revealed Wound Nurse's observation of Resident #23's buttocks. Wound nurse acknowledged a new reddened open area to Resident #23's buttocks. Wound Nurse was unable to determine what caused the area during the observation, stated it was a new area and indicated she would obtain a new order for ointment from the physician. An interview with NA #11 on 10/12/21 at 3:00 PM revealed she had been assigned to care for Resident #23 on 10/11/21 during day shift. NA #11 indicated she felt overwhelmed with the assignment she was given on 10/11/21 and had only changed Resident #23 before breakfast that morning. NA #11 indicated with all the lifts, feedings, and incontinence care it was more than she was able to get done in a shift and got sidetracked and did not make it back in to change Resident #23 before her shift ended on 10/11/21. NA #11 stated she wants to change residents every two hours, but often it may only be once or twice when the NAs are assigned up to 20 residents on day shift. NA #11 did not recall noticing the red open area noted to Resident #23's buttocks on 10/11/21 when she changed her early that morning. NA #11 also vocalized staff are aware that Resident #23 has a history of hollering out and doesn't always need care, but often just wants someone to come in the room. An order was obtained from the physician on 10/12/21 at 3:43 PM for [MEDICATION(S)] to Resident #23's buttocks twice daily on day and evening shifts for redness. An interview with the Director of Nursing (DON) on 10/12/21 at 4:45 PM revealed she expected all residents to be changed every two to three hours regardless of the facility's recent staffing shortages and increase workloads. The DON indicated she Resident #23 should not have went without being checked and incontinence rounds provided from before breakfast until 3:45 PM when second shift staff arrived on duty.

Based on record review and staff, hospice, and physician interviews, the facility failed to administer pain medications as prescribed by the physician to a hospice resident to treat chronic pain for 1 of 1 resident reviewed for pain management (Resident #15). As a result, Resident #15 reported her pain level was 7 to 9 on a scale of 1 to 10 across all three shifts during her stay in the facility. Findings included: Resident #15's hospital discharge summary included the following order with a fill date of 08/27/21: ·Morphine Sulfate Immediate Release ([MEDICATION(S)]) 15 milligram (mg) tabs give 3 to equal 45mg every 4 hours for 15 days for pain. [MEDICATION(S)] is controlled substance in the opiate category used to treat moderate to severe pain. Resident #15 was admitted to the facility on [DATE] under hospice services following a hospitalization for narcotic medication withdrawal and chronic obstructive pulmonary disease ([CONDITION(S)]) and she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #15's August 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . to include: ·Morphine Sulfate Immediate Release ([MEDICATION(S)]) 15 milligram (mg) tabs give 3 to equal 45mg every 4 hours as needed for pain for 15 days A review of the August 2021 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . ·Resident #15 received no [MEDICATION(S)] on 08/27/21 after her admission to the facility. ·Resident #15 was administered [MEDICATION(S)] on 8/28 at the following time: 8:40 AM when her pain was documented to be a 9 on a scale of 1 to 10 and again at 10:15 PM with pain levels documented at an 8. Based on the original order prescribed Resident #15 missed 4 doses. ·Resident #15 was administered [MEDICATION(S)] on 08/29 at the following times: 4:58 AM when her pain was documented to be a 7, 10:57 AM with an unidentified pain level (NA was listed), and again at 11:48 PM with pain level documented to be a 8. Resident #15 missed 3 doses on 08/29/21. ·Resident #15 was administered [MEDICATION(S)] on 8/30 at the following times: 4:23 AM when pain was documented to be a 7 and 8:58 AM with pain levels documented at a 3. The discharge Minimum Data Set (MDS) dated [DATE] assessed Resident #15 with intact cognition and noted she received opiates and antianxiety medications on 3 of 7 days during the MDS assessment period. The MDS further indicated under a section titled pain assessment Resident #15 verbalizing a pain level of a 9 of 10 on the pain scale over the last 5 days. A review of the nursing progress notes dated 08/27/21 through 08/30/21 revealed no documentation related to Resident #15's pain management to include location of pain or notification of the provider. A facility social worker (SW) note dated 08/30/21 revealed a telephone conversation between the SW and Resident #15's family member about Resident #15's desire for discharge due to believing she will receive better care under hospice services at home and get her medications provided for pain and anxiety on time. A review of a hospice note dated 08/30/21 written by Hospice Nurse #1 indicated Resident #15 had expressed being very displeased with her stay at the facility due to not receiving pain medications as prescribed and having to wait 1-2 hours after she requested them before they were administered. An interview with Med Aide (MA) #1 on 10/13/21 at 3:20 PM revealed she was familiar with Resident #15 and had been responsible for administering her medications on 10/29/21 during the evening shift. MA #1 stated she recalled medicating Resident #15 with controlled substances to include an opiate. MA #1 explained Resident #15 had approached her on one occasion although she was unable to recall the time inquiring why her medications were not being administered routinely and why she had to ask and wait to receive them every time she wanted them. MA #1 elaborated that she told Resident #15 the medications were ordered as needed and she would have to ask for them to receive them. MA #1 indicated Resident #15 frequently complained of experiencing debilitating pain although she was unable to give an exact pain level and she made a nurse aware although she was unable to recall which nurse she notified. An interview with Nurse Aide (NA) #13 on 10/13/21 at 3:25 PM revealed she had not directly worked with Resident #15; however, did recall being in the room when Resident #15 called her family member who resided in the facility and was complaining of being in pain and not receiving her medications as prescribed. NA #13 stated she overheard Resident #15 tell her brother someone needed to do something to fix this, or she was leaving the facility and going home where she could get better care. NA #13 indicated she told Resident #15's nurse that day about what she had overheard; however, she was unable to recall which nurse was assigned to Resident #15 on that date. An interview with NA #3 on 10/13/21 at 3:29 PM revealed she worked with Resident #15 while in the facility and recalled her constantly complaining of pain in her back and overall generalized pain. At times, Resident #15 stated her pain was excruciating and NA #3 would make Nurse #4 aware, but she was unsure if Resident #15 received pain medications to treat her pain or how long it took to administer the medications requested. An interview with MA #2 on 10/13/21 at 4:11 PM revealed she was the familiar with Resident #15 and had been responsible for medicating Resident #15 on the date of her discharge of 08/30/21. MA #2 stated she recalled administering controlled substances for pain; however, Resident #15 complained of a lot of pain in her back and abdomen and she made Nurse #4 aware. MA #2 could not recall the names of the medications she administered that day; however, she did recall applying a pain patch that was ordered and was clarified to be [MEDICATION(S)]. An interview with Nurse #4 (an agency nurse) was attempted three times without success. An interview with the Hospice Social Worker (HSW) on 10/14/21 at 11:00 AM revealed she had visited Resident #15 in the facility and was familiar with Resident #15's concerns regarding her pain management. The HSW stated she had made the medicating staff on the cart on that day (although she could not recall the exact date, she believed it was the day after admission) aware of Resident #15's concerns with pain and her not receiving medications as requested without prolonged delays resulted in unmanaged pain and severe anxiety and had previously had negative effects on Resident #15 but she could not recall the staff member she told. An interview with Hospice Nurse #1 on 10/14/21 at 11:13 AM revealed she was familiar with Resident #15 and had overseen her hospice care for the last year prior to admission to the facility. Hospice Nurse #1 indicated her hospice records indicated Resident #15 was ordered [MEDICATION(S)] 75mcg/hr. patches, [MEDICATION(S)] 45mg every 4 hours, and Lorazepam 1mg every 4 hours. Hospice Nurse #1 stated she had been present at the hospital with Resident #15 on the day she was discharged to the facility and saw her in the facility shortly after her time of admission to the facility on [DATE]. Hospice Nurse #1 said she notified the nurse on the cart of the importance of Resident #15 receiving her medications as ordered and not missing or delaying doses due to her history of side effects when the medications are not taken as prescribed but did not recall what the nurses' name she spoke with on that date. Hospice Nurse #1 also revealed she visited Resident #15 at the facility on 08/30/21 when she was planned to discharge home under hospice services. Resident #15 expressed to her that she did not believe her medications had been administered as ordered but Hospice Nurse #1 did not have access to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospice Nurse #1 recalled Resident #15 having increase heart rate, decrease oxygen saturations, anxiety, and pain on the date of discharge and felt her to be experiencing some withdrawal symptoms from her medications. An interview with Nurse #5 on 10/14/21 at 3:12 PM revealed she was no longer employed with the facility however she was familiar with Resident #15. Nurse #5 stated she recalled one day during Resident #15's stay being approached by a staff member (although she was unable to recall the date or the staff member who approached her) about Resident #15's medications. Nurse #5 indicated she was very busy attempting to process an overwhelming number of admissions on that day, she had planned to phone the physician about Resident #15's pain management concerns, but after completing the other tasks that day, she did not remember and therefore she did not look into Resident #15's medication concerns. Nurse #5 mentioned new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with the Director of Nursing (DON) on 10/12/21 at 10:45 AM revealed she was unaware Resident #15's pain had not been managed while in the facility or that Resident #15 did not receive her pain medications as prescribed on the discharge summary. The DON acknowledged she was the nurse who transcribed the medications from the discharge summary and had transcribed them as PRN instead of scheduled doses of the opiates and antianxiety medications. The DON explained that the facility's typical procedure included herself and another administrative nurse (typically Nurse #5) although at times other administrative nurses were utilized where new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Although she is unsure how these orders were missed if these orders were reviewed the following day. An interview with the Medical Director on 10/12/21 at 3:39 PM revealed he was not aware Resident #15's pain had not been managed during her stay because it was limited in days and he did not see her while in the facility. The MD vocalized the medications should have been administered as ordered on the hospital discharge summary. The MD elaborated that a resident who had opiate dependance who was accustomed to [MEDICATION(S)] 6 times a day routine and then receiving less than the prescribed doses may result in adverse side effects.

Based on observations, record reviews, resident, family, and staff interviews, the facility failed to provide sufficient nursing staff for the provision of incontinence care to a resident (Resident #23) who was wet and yelling that it was burning and hurting her skin and as a result ended up with a reddened area on her skin, failed to provide incontinence care to a resident (Resident #17) who was wet through her brief and onto her draw sheet, failed to provide incontinence care to a resident (Resident #2) who had a bowel movement, failed to provide showers as scheduled for 3 residents (Resident #1, Resident #6 and Resident #9) and failed to provide nail care for 2 residents (Resident #18 and Resident #2) for 7 of 7 residents reviewed for sufficient nursing staff. The findings included: This tag is cross referred to: F600: Based on observation, record review and staff interviews, the facility neglected to provide incontinence care to a resident who was soiled with urine and resulted in a small reddish open area on her buttocks for 1 of 4 (Resident #23) residents reviewed for activities of daily living. The resident stated that her bottom was burning like it was on fire and wished she could care for herself, so she did not have to sit in a soiled brief. F684: Based on observation, record review, and staff interviews, the facility failed to prevent skin breakdown when incontinence care was delayed resulting in an open area of redness to the buttocks for 1 of 1 resident reviewed for neglect (Resident #23). F 561: Based on observations, record reviews, resident, family and staff interviews, the facility failed to honor the residents' preferences regarding number of showers or bed baths per week for 3 of 3 residents (Resident #1, Resident #6, and Resident #9) reviewed for choices. F677: Based on observations, record reviews, resident, family and staff interviews, the facility failed to provide incontinence care prior to a resident (Resident #17) wetting through her brief onto her draw sheet, failed to provide incontinence care to a resident (Resident #2) who had a bowel movement, failed to provide showers as scheduled for 1 resident (Resident #3), and failed to provide nail care for 2 residents (Resident #18 and Resident #2) for 4 of 4 residents reviewed for activities of daily living for dependent residents. Interview on 10/11/21 at 4:50 PM with the Treatment Nurse revealed last week she had been assigned to work on a medication cart every day. She further revealed she had worked all shifts as needed to cover the schedule instead of her normal job of wound care. The Treatment Nurse stated when she was assigned to work on a cart each nurse was responsible for the wound care of their assigned residents. Interview on 10/12/21 at 9:15 AM with Nurse Aide (NA) #13 revealed she was assigned 22 residents to care for the morning of 10/12/21. She stated she usually had that many residents for a portion of the day if not all day. NA #13 stated she was not able to get all her tasks done for 22 residents. She indicated the NAs did their best to keep the residents dried, turned, and fed and if no one was assigned to showers they did their best to wash their face, armpits, privates, and butt. NA #13 indicated the NAs didn't have time to wash the residents' hair and said they hadn't had shampoo caps in a long time. According to NA #13, on days they had 22 residents they were only able to do 2 rounds for incontinence care and maybe were able to get 1 shower per shift done. NA #13 explained she was frequently asked to stay late or come in early to cover schedules. She further explained that residents were frequently found in a mess when she came in for her shift. NA #13 said residents were probably found that way because the staff on the previous shift didn't have time to keep residents dry due to the workload. Interview on 10/12/21 at 11:13 AM with Nurse #2 revealed residents frequently complained about not getting showers and not receiving incontinence care. Nurse #2 further revealed the NAs were only able to complete 2 rounds of incontinence care per shift and with their workload it was impossible for them to do rounds every 2 hours. She stated they were not able to get showers done as scheduled and were lucky if they had time to do one shower per shift. Nurse #2 further stated the nurses did not have time during their shift to assist the NAs with resident care. Interview on 10/12/21 at 4:45 PM with the Director of Nursing (DON) revealed there were staffing challenges at the facility. The DON further revealed she only had 2 full time nurses working at the facility and the other nurses were either as needed (prn) or agency nurses. She stated corporate had recently increased the base salary for NAs and nurses to be more competitive with hiring but still had several positions open on all shifts. The DON stated she was not sure how many positions were still open, that would be a question for the Regional Director of Operations. Interview on 10/12/21 at 5:30 PM with the Regional Director of Operations (RDO)revealed there were 3 Licensed Practical Nurse (LPN) open positions, 5 Registered Nurse (RN) open positions, 2 NA open positions, and 3 Certified Medication Aide (CMA) open positions. She further revealed over the past 5 weeks they had hired 8 NAs, 2 CMAs and 1 RN. The RDO stated they had increased wages to allow for better recruitment of their open positions and were orienting staff as they were hired. She further stated they had not and were not planning to stop taking admissions to the facility.

Based on record review, staff, hospice, and physician interviews, the facility failed to prevent significant medication errors by not accurately transcribing and administering medication as ordered from the hospital discharge summary prescribed to treat chronic pain, shortness of breath, and anxiety for a hospice resident for 1 of 1 resident reviewed for medication errors (Resident #15). As a result, Resident #15 reported her pain level was 7 to 9 on a scale of 1 to 10 across all three shifts during her 4 days as resident in the facility. Findings included: A review of the hospital records dated 08/25/21-08/27/21 indicated in part Resident #15 was restarted on narcotic pain medications following withdrawal symptoms. Resident #15's discharge summary revealed she had been discharged to the facility with the following orders with fill dates of 08/27/21: - [MEDICATION(S)] Immediate Release 15 milligram (mg) tabs give 3 to equal 45mg every 4 hours for 15 days for pain or shortness of breath. - Lorazepam 1mg tabs every 4 hours for anxiety. A copy of the original hard script for controlled substances provided by the hospital written by the discharging physician's assistant indicated: - [MEDICATION(S)] Immediate Release 15 milligram (mg) tabs give 3 to equal 45mg every 4 hours for 15 days start 08/27/21. Dispense 270 tablets. - Lorazepam 1mg tabs every 4 hours for 15 days start 08/27/21. Dispense 90 tablets. Resident #15 was admitted to the facility on [DATE] under hospice services following a hospitalization for narcotic medication withdrawal and chronic obstructive pulmonary disease ([CONDITION(S)]) and she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She was subsequently discharged home on continued hospice services on 08/30/21. A review of the control substance sheets provided by pharmacy with the narcotic medications indicated in part controlled substances were dispensed as follows: - [MEDICATION(S)] 15mg tablets ([MEDICATION(S)]) three tablets by mouth every 4 hours for 15 days and was filled for 252 tablets with a quantity of 18 remaining to be dispensed later by Polaris pharmacy and indicated 9 doses had been administered. - Lorazepam 1mg tablets one tablet by mouth every 4 hours for 15 days and was filled for 88 tablets with 7 doses administered. Resident 15's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] Immediate Release ([MEDICATION(S)]) 15 milligram (mg) tabs give 3 to equal 45mg every 4 hours as needed for 15 days - Lorazepam 1mg tabs every 4 hours as needed for anxiety. A review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] - Resident #15 received no [MEDICATION(S)] on 08/27/21 while in the facility. Resident #15 was administered [MEDICATION(S)] on 8/28/21 at the following time: 8:40 AM when her pain was documented to be a #9 and again at 10:15 PM with pain levels documented at an #8. Based on the original order prescribed Resident #15 missed 4 doses which is over half of her doses ordered for 08/28/21. Resident #15 was administered [MEDICATION(S)] on 08/29/21 at the following times: 4:58 AM when her pain was documented to be a #7, 10:57 AM with an unidentified pain level- NA was listed, and again at 11:48 PM with pain level documented to be a #8. Resident #15 missed 3 doses on 08/29/21. Resident #15 was administered [MEDICATION(S)] on 8/30/21 at the following times: 4:23 AM when pain was documented to be a #7 and 8:58 AM with pain levels documented at a #3. Resident #15 missed an undetermined number of doses of pain medication on 08/30/21 secondary to the facility being unable to determine the exact time of discharge from the facility. It further revealed Lorazepam was administered on 6 occasions: Resident #15 was not administered any Lorazepam on 08/27/21 following her admission time of 5:20 PM. Once on 8/28 at 3:52 PM. Based on the original ordered prescribed Resident #15 missed 5 doses of Lorazepam on 08/28/21. Three times on 8/29 at 4:57 AM, 10:57 AM, and 11:47 PM; Missed 3 doses of Lorazepam on 08/29/21. Twice on 8/30 at 4:23 AM and 8:56 AM. The discharge Minimum Data Set (MDS) dated [DATE] assessed Resident #15 with intact cognition and noted she received opiates and antianxiety medications on 3 of 7 days during the MDS assessment period. The MDS further indicated Resident #15 had experienced pain on resulting in a level 9 of 10 on the pain scale over the last 5 days. A review of a hospice note dated 08/30/21 written by Hospice Nurse #1 indicated Resident #15 had expressed being very displeased with her stay at the facility due to not receiving medications as prescribed and having to wait 1-2 hours after she requested them before they were administered. An interview with Med Aide #1 (MA #1) on 10/13/21 at 3:20 PM revealed she was familiar with Resident #15 and had been responsible for administering her medications on 08/29/21 during the evening shift. MA #1 stated she recalled medicating Resident #15 with controlled substances to include an opiate and antianxiety medication. MA #1 explained Resident #15 had approached her on one occasion although she was unable to recall the time inquiring why her medications were not being administered routinely and why she had to ask and wait to receive them every time she wanted them. MA #1 elaborated that she told Resident #15 the medications were ordered as needed and she would have to ask for them to receive them. An interview with Med Aide #2 on 10/13/21 at 4:11 PM revealed she was the familiar with Resident #15 and had been responsible for medicating Resident #15 on the date of her discharge of 08/30/21. MA #2 stated she recalled administering controlled substances for pain and anxiety to include [MEDICATION(S)] and Lorazepam. MA #2 explained she had not thought to ensure the order in the electronic medical record matched the control substance log and card in which the medication was being dispensed, she only checked to ensure the dosage was equal to the ordered dosage. An interview with Hospice Nurse #1 on 10/14/21 at 11:13 AM revealed she was familiar with Resident #15 and had overseen her hospice care for the last year prior to admission to the facility. Hospice Nurse #1 indicated her records indicated Resident #15 was routinely ordered [MEDICATION(S)] 75mcg/hr. patches, [MEDICATION(S)] 45mg every 4 hours, and Lorazepam 1mg every 4 hours. Hospice Nurse #1 stated she had been present at the hospital with Resident #15 on the day she was discharged to the facility and saw her in the facility shortly after her time of admission to the facility on [DATE]. Hospice Nurse #1 also revealed she visited her on the date Resident #15 was discharged home under hospice services on 08/30/21 but despite Resident #15 expressing to her that she did not believe her medications had been administered as ordered, Hospice Nurse #1 did not have access to the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Hospice Nurse #1 recalled Resident #15 having increase heart rate, decrease oxygen saturations, anxiety, and pain on the date of discharge and felt her to be experiencing some withdrawal from her medications. An interview with Nurse #3 on 10/14/21 at 2:18 PM revealed she vaguely recalled Resident #15 being in the facility although verified that when any controlled substance is ordered the medication should be checked to verify the ordered medication and the card the medication is stored match both in name, strength, route, and frequency before administering the medication and she forgot to verify the match when administering the medications to Resident #15. An interview with the Interim Director of Nursing (DON) on 10/12/21 at 10:45 AM revealed she was the nurse who transcribed the medication orders from the discharge summary for Resident #15 on the date of admission and felt the medications should have been as needed (PRN) based on the dosage and therefore transcribed the [MEDICATION(S)] and Lorazepam as PRN medications instead of scheduled medications. The DON indicated the morning following a resident's admission, orders are verified in a clinical meeting, but she acknowledged these medications were transcribed incorrectly and were not verified the following morning although she could not provide an explanation as to what happen. An interview with the Medical Director (MD) on 10/12/21 at 3:39 PM revealed he was not aware Resident #15's medications were transcribed incorrectly as her stay was limited in days and he did not see her while in the facility. The MD indicated if Resident #15 was a patient who was on long term use of opiates and antianxiety medication there was a possibility for her to begin to experience withdrawal symptoms if her medications were not given as prescribed. The MD stated he expected all orders to be transcribed, verified, and clarified as quickly as possible following admission to the facility and classified these errors to be significant.

Based on record review, resident and staff interview, and facility documents titled Resident Smoking, the facility failed to provide a safe smoking environment for two smokers when staff failed to properly store oxygen at a safe distance from open flame and prevent a resident who utilized oxygen from smoking while his oxygen was in use for 2 of 2 residents reviewed for safe smoking (Resident #1 and Resident #2). Resident #1 lit a cigarette with his nasal cannula in his nares and his oxygen tank on while out in the designated smoking area which resulted [MEDICAL CONDITION] the resident's face and high likelihood of injury to the other resident who was in the smoking area. The findings included: A review of the facility document titled Resident Smoking reviewed/revised 10/22/20 indicated on page 1 of 2 the facility provides a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking. Safety protections apply to smoking and non-smoking residents. It further indicated safety measures for the designated smoking area will include, but not limited to: 2e: prohibition of oxygen use in the smoking area. 5. All residents and family members will be notified of this policy during the admission process, and as needed. 6. Residents will be asked about tobacco use during the admission process, and during each quarterly and comprehensive minimum data set (MDS) assessment process. 7. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to see if any residents are safe to smoke at all. 8. Any resident who is deemed safe to smoke, WILL BE SUPERVISED, will be allowed to smoke in designated smoking areas (weather permitting), at designated smoking times, and in accordance with his/her care plan. 9. If a resident who smokes experiences a decline in condition or cognition, he/she will be reassessed for ability to smoke independently and/or evaluate whether any additional safety measures are indicated. 10. All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan. 12. If a resident or family member does not abide by the smoking policy or care plan (e.g. smoking materials are provided directly to the resident, smoking in non-smoking areas, does not wear protective gear), the plan of care may be revised to include additional measures such as room searches, prohibited smoking, or even discharge. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].#1 was to have 4-5 liters (L) of continuous oxygen per nasal cannula to keep oxygen saturations above 90%. According to signed admission agreement dated 11/10/20, Resident #1 did not sign a copy of the smoking policy on admission as Exhibit B in the agreement. Resident #1's admission document titled Safe Smoking Screen dated 11/10/20 indicated the Resident was a current smoker, does not use supplemental oxygen and may smoke independently without supervision. Resident #1's admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #1 required supervision to two person staff assist for transfers, was cognitively intact, and used oxygen while a resident. A review of Resident #1's admission care plan dated 11/13/20 did not include a care area for smoking. A care plan conference note dated 11/25/20 revealed Resident #1 participated in self-directed activities of smoking. A physician's progress note written by the Medical Director (MD) dated 1/18/21 indicted Resident #1 was non-ambulatory, transfers to wheel chair, requires assistance with multiple activities of daily living (ADL), utilizes 5 liters (L) of oxygen via nasal cannula (NC), and smokes 1 pack of cigarettes per daily as current usage. A nurses' progress note documented by Nurse #1 dated 1/28/21 revealed Resident #1 was smoking with his oxygen tank on the back of his wheelchair and his nasal cannula intact to his nostrils bilaterally which ignited a flame and caused Resident #1 to be burned on his upper lip, nose, left side of cheek, left eyelid, and left eyebrow. Interview conducted on 2/25/21 at 5:55 PM with Resident #1 revealed he had [MEDICAL CONDITION] his face following a smoking incident he was involved in approximately a month ago. Resident #1 reported he had been assessed as a safe smoker when he was admitted to the facility and had always gone outside with his oxygen tank on the back of his wheelchair on many occasions; however, this was the first time he had failed to remember to remove his nasal cannula from his nose and turn off his oxygen tank before lighting a cigarette. Resident #1 explained on the night of the accident, he had arrived at the smoking area shortly before the time for designated smoking time to end, felt rushed as he hurried and self-propelled his wheelchair past NA #1 who was standing in the doorway to the smoking area and out the door entering the courtyard. Resident #1 explained he turned his wheelchair around, attempted to light a partially smoked cigarette and it caused the nasal cannula to spark a fire from the unused oxygen that remained in the tubing to light directly from the flame of the lighter which caused a flame and him to become burned. Resident #1 reported he immediately swatted at his nose causing his nasal cannula to fall to the ground. Resident #1 indicated as he knocked the nasal cannula from his nostrils, Resident #2 reached over and turned his oxygen tank to the off position. He stated he felt very rushed and singled out by NA #1 for being late that night to the smoking area and then when he finally arrived to the area, after already being winded from self-propulsion of his wheelchair down the hallway, he was rushing himself so much he strictly forgot to even remove the nasal cannula from his nostrils and turn off the oxygen. He indicated NA #1 didn't even say anything to him about being outside with the oxygen tank on his wheelchair before he lit the cigarette that night. Resident #1 expressed remorse for his actions and not thinking about the safety of himself and others and took partial blame for his injuries. Resident #1 indicated after the fire was extinguished, NA #1 left him and Resident #2 outside in the smoking area and went inside the building leaving the oxygen tank on the back of his wheelchair. Resident #1 smoked his other cigarette before returning to his room. Further interview with Resident #1 on 2/26/21 at 10:00 AM and 12:00 PM revealed Resident #1 was not able to self- propel himself down the hall without oxygen usage or place his oxygen tank in the tank holder located to the right of the door to the smoking area. Resident #1 further elaborated staff had seen him outside before with his tank on the back of the wheelchair and had made no attempts to remove it or check to see if it had been turned off prior to this incident. Resident #1 stated prior to this accident, he had gone outside anytime he wanted independently to smoke. Resident #1 acknowledged he was asked by Nurse #2 if he wanted to go to the emergency room and he declined due to his fear of not being allowed to smoke anymore; however, if he had realized how much discomfort the burn would cause he would have agreed immediately. Resident #2 was admitted to the facility on [DATE]. A review of the admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #2 to be cognitively intact. Interviews conducted on 2/25/21 at 5:00 PM with Resident #2 revealed Resident #1 had recently had an accident with smoking while wearing oxygen and it had caused him to [MEDICAL CONDITION] his face and all smoking residents to have their privileges altered. Resident #2 further reported he was in the smoking area on the night of Resident #1's smoking incident and had witnessed and assisted in extinguishing the fire. Resident #2 explained at around the time of the facility's last smoking time in the evening, between 8:00-8:30 PM, but could not recall the exact date but believed it to be about 3 weeks ago, he witnessed NA #1 shaking her keys at Resident #1 and telling him to hurry up and smoke or she wasn't going to let him have a smoke break that night because she was locking the doors. Resident #2 revealed he witnessed Resident #1 roll out the door towards him, turn around and park his wheelchair directly next to him, and start to light up a cigarette when all of a sudden he saw a big spark and saw the flame on Resident #1's face. Resident #2 accounts witnessing Resident #1 immediately reach up to remove the nasal cannula which remained in his nostrils and throw it down to the ground and try to reach around to turn off the oxygen tank. Resident #2 quickly reached over and turned it off before NA #1 could reach Resident #1. Resident #2 explained NA #1 checked to make sure the tank had been turned off and Resident #1 was no longer burning and then, turned and went inside the building leaving the oxygen tank on the back of the wheel chair of Resident #1. Further interview of Resident #2 on 2/26/21 at 10:20 AM revealed Resident #1 had proceeded to smoke his additional cigarette with no staff present before entering back into the building after he had already sustained a burn to his face. Resident #2 stated, I told him (Resident #1) her (NA #1) rushing you like she was dangling the keys at you and you not turning off your tank, you could have killed us all doing stuff like that. You really need to be more careful next time. Resident #2 revealed he did not get injured during this incident; however, his privileges had been altered along with the other smokers as a result of the incident with Resident #1. Resident #2 verbalized he had witnessed Resident #1 with the oxygen tank on the back of his wheelchair in the past, but Resident #1 had not previously been witnessed to have his nasal cannula intact prior to the accident. An interview with NA #1 on 2/25/21 at 7:30 PM revealed she was on light duty on the night of 1/28/21 and was assigned to lock the smoking area after the last smoke break. NA #1 explained she told Resident #1 and Resident #2 it was time to wrap it up and come back inside because she had to lock the door. NA #1 stated Resident #1 and Resident #2 were the only residents in the smoking area of the courtyard when the incident occurred. NA #1 confirmed she was present at the door when Resident #1 exited the building and had told him he must hurry, or he would not be allowed to smoke anymore that evening. She further revealed as Resident #1 propelled his wheelchair past her, there was a conflict of what time the door was to be locked and stated it was about 8:15 PM at the time and the residents had indicated the smoke time was to last until 8:30 PM according to the Administrator and didn't even notice the oxygen tank on the back of Resident #1's chair or that Resident #1 had the nasal cannula in place. NA #1 stated the next thing she knew, Resident #1 lit a cigarette. She heard it [MEDICATION NAME] and had seen the flash and about that time Resident #1 hit his face and extinguished the fire and put it out knocking the nasal cannula from his nose to the ground. NA #1 went over to him to make sure he was not on fire and checked his oxygen tank and it was on so, she turned it off and made sure Resident #1 and Resident #2 were okay and they were fine other than the charring that Resident #1 had to his face. The flame had charred Resident #1's nose and the left side of his face from his eyebrow down to the top of his beard. NA #1 revealed she went in the facility and told Nurse #1. NA #1 reported she did not think about removing the tank from the wheelchair after the accident nor securing his other cigarette and lighter and bringing him back in before alerting Nurse #1 of the accident. NA #1 explained Resident #1 should have removed his oxygen tank from the wheelchair before entering the smoking area and placed it in the canister holder in the day room. NA #1 admitted she had witnessed Resident #1 outside in the smoking area with his oxygen tank on the back of his wheelchair before and no one had ever said anything to Resident #1 but she had never noticed him having the nasal cannula still on his face when she had seen him in the past so most of the time she did not bother to go outside to remove the tank or ensure it was in the off position, but on the occasions she had checked the oxygen tank, it was in the off position. NA #1 elaborated prior to the accident, the routine for the smokers should be for them to remove their tanks from their wheelchair and place it in the oxygen holder inside the dayroom adjacent to the smoking area. An interview with Nurse #1 on 3/1/21 at 12:42 PM revealed she had been Resident #1's nurse during day shift on the date of his accident. She reported she had just come off duty and was in the nurses station charting at the time NA #1 approached her to make her aware Resident #1 had lit a cigarette with his oxygen in place and it had caught fire. Nurse #1 explained she instinctively got up and went to assess Resident #1 who had made it almost to his room when she arrived. Nurse #1 stated she noticed the black soot on his face and immediately went to the treatment cart and collected items to clean his face and some burn cream because she knew it worked well [MEDICAL CONDITION] calling the physician for orders. Nurse #1 said she returned to Resident #1's bedside and cleaned his face and applied the cream and then immediately went to notify the Administrator via telephone for further instructions. Nurse #1 did not ask the resident if he wanted to go to the hospital on the night of the accident as she had already turned over Resident #1's care to Nurse #2 and was only assisting with assessment because she was alerted by NA #1. She was instructed to complete an incident report and make a note and the Administrator would further handle it when she arrived in the morning. Nurse #1 revealed she did not contact any medical provider that night and assumed Nurse #2 would alert the provider of the accident since she had turned the care over to Nurse #2. An interview on 2/27/21 at 2:30 PM revealed Nurse #2 was assigned to Resident #1 at the time of the incident but had just come on shift and Nurse #1 had assessed and handled Resident #1's injuries and therefore she had not reassessed the injuries during her shift. Nurse #2 stated she was instructed to ask Resident #1 the following morning before ending her shift if he wished to go to the emergency room for evaluation and he had then declined but said it was still very uncomfortable. Nurse #2 explained Resident #1 frequently reported pain and therefore she had not clarified if Resident #1's discomfort was from his disease process or from the burn he sustained on 1/28/21. Nurse #2 indicated she had never gone to the smoking areas to assess Resident #1 herself but did not feel like he was capable of safely removing his oxygen tank from the bag on the back of his wheelchair before exiting the facility to the smoking area. Nurse #2 further stated she had never gone out to the smoking area and was unsure whether he had been outside in the smoking area with his oxygen tank in place prior to 1/28/21. An interview with the Administrator on 2/25/21 at 6:00 PM revealed she was aware that Resident #1 had lit himself on fire when he tried to light a cigarette while he had his oxygen tank. The Administrator stated she knew Resident #1 singed his nasal hair and under his eye but had refused to go to the hospital on the night the incident occurred so Wound Doctor (WD) was contacted via telehealth by her the next day and the WD ordered cream for under his eye and a nasal swab gel for his nose. The Administrator explained all residents were re-evaluated for safe smoking after that. The Administrator stated she interviewed the Nurse #1 and NA #1 assigned to Resident #1 following the incident and she asked, the why's. The Administrator explained she and the Interdisciplinary Team (IDT) met the following week on 2/4/21 and decided to remove all the keys used to access personal smoking materials from individual residents possession and secure all items in a locker, limit smoking to an assigned schedule, and make all smoking times supervised. The Administrator also indicated all smokers had been reassessed for smoking, each provided a smoking apron, and been required to sign a copy of the smoking policy following the meeting as a corrective action. The Administrator explained she had not made any official monitoring protocols other than just to have the smoking supervised by a schedule and with a staff member present. She indicated she had not yet had a quality assurance meeting as they are provided monthly but did call the medical director and let him know what plan she and the IDT had put into place. A follow-up interview with the Administrator revealed she had been made aware of the incident by Nurse #1 and had re-educated NA #1 on safe smoking practices. The Administrator revealed the following morning she contacted WD via telehealth visit who assessed Resident #1 and provided orders for the injury. In addition, the morning of 01/29/21 all staff were in-serviced, and an IDT meeting was conducted. The Administrator revealed the Root Cause Analysis (RCA) from the investigation was NA #1 was not being observant and had not noticed the resident had the oxygen on his wheelchair or the oxygen tubing in his nose. The Administrator revealed a combination of things caused the accident to include a small amount of oxygen that remained in the nasal cannula was ultimately what ignited the flame. However, she further elaborated when he lit a partially smoked cigarette, the remainder being too close to the nasal cannula, Resident #1 rushing because he wanted to quickly smoke his cigarette before the courtyard closed and the open flame from the lighter quickly flash sparked causing [MEDICAL CONDITION] Resident #1's face. The Administrator noted Resident #1, in his rush, didn't realize he still had his oxygen on. She revealed Resident #1 was alert and oriented and knew his oxygen tank wasn't supposed be outside in the smoking courtyard because he doesn't have a cognitive deficit. The Administrator revealed when she talked to him after it happened, he voiced understanding but she stated Resident #1 had not voiced concern that his room was too far away from the smoke area at that time, but complained he was late to the smoke time. The Administrator revealed she completed the investigation and RCA; her expectation was that the aide should have noticed that Resident #1 had his oxygen on. The Administrator indicated she was unsure if anyone had assessed his ability to independently remove his oxygen tank from his wheelchair but would think the nurse who completed his smoking assessment would have done so. The Administrator explained prior to the accident and in the few months she had been there, there had been an oxygen tank holder placed in the doorway immediately prior to exiting from the facility into the designated smoking area and staff were aware oxygen was to be placed in this location prior to entering the smoking area and she felt the staff should have been aware of the importance of oxygen tanks not being in the vicinity of open flames due to the potential for fire. An interview with Wound Doctor stated as best he could recall [MEDICAL CONDITION] by Resident #1 on the night of 1/28/21 were second degree in severity. There was not a documented note for this visit or the visit the following week. An interview with the Medical Director (MD) on 2/26/21 at 4:30 PM revealed he had been made aware of Resident #1's incident the following week when he arrived at the facility to make routine rounds for resident care needs. The MD indicated he thought Resident #1 had been non-weight bearing at one time and was not certain Resident #1 had the physical ability to safely remove his oxygen tank from his wheelchair independently before exiting the facility to smoke and felt he would need staff assistance for this task. The MD also explained he had been made aware of the changes the IDT had planned to ensure safety during smoking but could not recall a date he was notified. An interview with the Physician's Assistant (PA) on 3/1/21 at 3:30 PM revealed he was made aware of [MEDICAL CONDITION] by Resident #1 when he entered Resident #1's room on 2/4/21 at the residents' request to review his medication. The PA indicated Resident #1 told him he had [MEDICAL CONDITION] his face when he was smoking with his oxygen tank on his wheelchair and nasal cannula intact to his nostrils. The note written by the PA did not mention the current condition of Resident #1's skin on 2/4/21 but classified the burn to be superficial. The Administrator provided the following corrective action plan with a compliance date of 02/05/21. On 1/28/21, Resident #1 entered the smoking courtyard with his oxygen tank attached to his wheelchair wearing his nasal cannula and lit a cigarette. This caused a flash burn to nares/lips and facial areas. Resident immediately extinguished the flame by dropping his nasal cannula to the ground. There was a Nursing Assistant (NA #1) in the courtyard at this time and assured flame was out, oxygen off. NA #1 stated that she did not initially notice the oxygen in place due to the resident customarily removes his own oxygen and places it in the tank holder prior to going outside. NA #1 left Resident #1 out in the courtyard with his oxygen tank attached but the Nasal Cannula had been removed and Oxygen turned off. She did so as was in a hurry to notify a nurse. Resident #1 and Resident #2 continued to smoke as if nothing had happened. Nurse #1 was notified of incident by NA #1 and she went to assess for any injury and cleansed face and applied cream. Resident #1 did not indicate discomfort or any request for ER or further treatment. Nurse #1 reported off to Nurse #2. Nurse #2 checked on Resident #1 during her shift and he did not express any discomfort and declined her offer to go to ER or further treatment. On 1/29/21 the Administrator initiated a Telehealth visit with the Wound Doctor who prescribed Silver [MEDICATION NAME] Cream. On 2/4/21 the Physician Assistant assessed Resident #1 and agreed with current treatment and noted [MEDICAL CONDITION] face. The Physician Assistant discussed with Resident that he had removed oxygen for months prior to this incident and reinforced importance of removing prior to smoking. Resident #1 has demonstrated his ability to perform the act of removing oxygen tank/nasal cannula without difficulty multiple times in the last three months prior to this incident and has not had any concerns. On 1/29/21 the Administrator had Resident #1 demonstrate ability to remove oxygen tank and nasal cannula and he did so without difficulty and voiced he has had no issues with this in the past. Resident #1 has a Brief Interview of Mental Status (BIMS) of a 15 on a scale of 0-15 being the highest level of cognition function measurable on this scale and had repeatedly shown ability and awareness to remove his oxygen tank and place in holder as well as remove his nasal cannula. Administrator interviewed Resident #1 on 1/29/21 whom indicated he had been compliant with removing oxygen tank and nasal cannula in the past, but this time felt rushed by the nursing assistant. A Smoking Assessment of nine Residents was completed on 2/5/21 by the Assistant Director of Nursing. Eight of the nine were assessed at having the ability to smoke independently. Resident #1 was assessed for having the ability to smoke independently, however under the History part of his assessment it does indicate if any history of burning self then at minimum is a supervised smoker. Administrator interviewed Resident #2 on 1/29/21 and he reported that he was in the smoking area at the time of the incident and he was not harmed and felt the nursing assistant was rushing both Residents to finish smoking. Resident #2 has a Brief Interview of Mental Status (BIMS) of a 15 on a scale of 0-15 with 15 being the highest level of cognition function. Administrator was in contact immediately after the incident, assured safety of Resident #1 and Resident #2. Had all the smoking materials (lighters) gathered and locked up until she could meet with Smokers and assure a safe plan. Administrator will continue to honor Resident preferences and meet with Residents as needed. Administrator re- educated the nurse aide #1 on 1/28/21 on the safety factors around smoking and that at no time can an oxygen tank or cannula be present on a resident while smoking. She was also re-educated on validating that any oxygen tank that was removed from or by the resident was secured in the rack prior to going to the smoking area. In addition, she was educated on importance of customer service related to not rushing Residents. Resident #1 has a Brief interview mental status of a 15 and can articulate that he cannot have his oxygen or cannula in place while smoking. He can remove the cannula and tank prior to smoking and the person supervising smoking will now ensure that no resident has an oxygen tank or cannula in place while smoking. Resident #1 continues to show ability of removing tank/nasal cannula. On 1/29/21 the Administrator reviewed Smoking Policy and Procedure with Residents that smoke, and Residents signed policy. Residents were in agreement regarding safety and supervision and reviewed the procedure for location of oxygen tank in canister holder with nasal cannula and no oxygen in smoking area. On 1/29/21 the Administrator educated all Department Heads and Smoking Attendants (staff that assist with Residents that smoke), regarding smoking policy and location for oxygen tanks. The Administrator educated on importance of no oxygen in the smoking area, the location for oxygen tanks / cannulas and importance to assure Resident #1 can still safely remove his own tank and if not, then staff is to assist. This education will be part of orientation as well for new hires which the Administrator notified Human Resources and Assistant Director of Nursing on 1/29/21. On 1/29/21 the Administrator assured appropriate and very visible signage regarding smoking area and no Oxygen in the area. On 1/29/21 the Administrator implemented and educated on a monitoring tool for Smoking Attendants to assess all Residents during smoking regarding appropriate Protective Gear(Apron)/Smoking Materials and Oxygen secured in Canister. The Smoking Attendants are to initial each shift regarding assurance of appropriate Protective Gear (Apron)/Smoking Materials and Oxygen secured in canister. This tool will be utilized for 3 months with findings reported to Monthly QAPI and ongoing as needed. Administrator and Department Head Designee will assure continued compliance with random observations of smoking area and report during monthly QAPI. On 1/29/21 the Administrator held an AD HOC QAPI with Department Heads in attendance regarding Safety with Smoking and continuous monitoring. The facility will continue to monitor safety with smoking for three months with findings reported to Monthly QAPI for three months and ongoing as needed. On 03/05/21 the facility's corrective action plan with a correction date of 02/05/21 was validated by the following: A review of the facility's inservice attendance sheets and facility records indicated, NA #1 was re-educated on oxygen safety for the resident who smoked, the Administrator reviewed the Smoking Policy and Procedures with the residents who smoked and had the residents sign the policy and the Administrator educated all Department Managers and Smoking Attendants on the Smoking Policy and Procedure. Interviews were conducted with the residents identified as smokers both safe and unsafe. The smokers were able to explain the new smoking policy that included being allowed to smoke at will and when ever they desired if they were deemed a safe smoker but if a resident was deemed a supervised smoker, they had to abide by the allotted times to smoke. The residents explained the procedure of putting the oxygen tanks in the oxygen holder before they went out to smoke if they required oxygen and the need to social distance during their smoking session. All the residents accepted the new smoking policy. Observations were made of the No Oxygen sign posted at the smoking area entrance and an oxygen tank holder adjacent to the wall near the smoking entrance. The smoking area had spaces marked with an X that were spaced 6 feet apart to indicate the social distancing plan. The residents were observed to abide by the social distancing plan and there was a Smoking Attendant monitoring the residents. Interviews were conducted with Smoking Attendants who explained that they had to complete a monitoring tool during each smoking session to indicate if the residents wore a smoking apron and if a resident used oxygen the tank was stored in the canister inside the facility. Interviews were conducted with the Department Managers who explained they had to monitor the smoking area for compliance of the new smoking policy at designated and assigned times. The monitoring tools was reviewed and verified at the time of the interview. Review of the inservice training records included current staff from all the departments and the Department Managers were educated on the new Smoking Policy and Procedures. An interview was conducted with the Administrator who explained that she had a meeting with all the resident smokers and explained the new Smoking Policy and Procedures. She stated she had a general inservice with all the staff including the Department Managers on 01/29/21 and introduced the new Smoking Policy and Procedure and the monitoring tool which was initiated because of the smoking incident. The Administrator stated the monitoring tools will be reviewed in the monthly QA meetings for 3 months and longer if needed.

Based on record reviews, and resident, staff, psychiatric Nurse Practitioner and Medical Doctor interviews, the facility failed to protect a resident's right to be free of sexual abuse for 1 of 3 sampled residents (Resident #1) reviewed for abuse. Resident #2, was cognitively intact and observed to have his hand down the pants and incontinent brief of Resident #1 who was cognitively impaired. Resident #1 was assessed by facility staff and found to have no physical injuries. Immediate Jeopardy began on 01/03/19 when Resident #2, who was cognitively intact, placed his hand in the brief and pants of Resident #1 who was cognitively impaired. Immediate Jeopardy was removed on 02/01/19 when the facility provided and implemented a Credible Allegation of Immediate Jeopardy removal. The facility remains out of compliance at the lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to ensure monitoring systems put into place are effective. The findings included: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #2's admission minimum data set ((MDS) dated [DATE] revealed he was cognitively intact for daily decision making. The MDS also indicated he transferred self, requiring extensive assistance at times, was mobile in a wheelchair and had contracture of left hand and wrist. The most recent quarterly MDS dated [DATE] revealed the resident was cognitively intact for daily decision making, had physical behavioral symptoms 4-6 days, and was independent with transfers and wheelchair locomotion. A review of Resident #2's medical record beginning 07/13/18 revealed the resident had behaviors towards the staff. A nurse's note dated 07/13/18 described Resident #2 grabbed Nurse #2's breast, took his whole hand and grabbed her vaginal area and attempted to grab her breast again before she was able to get out of the room. This occurred while she was administering medications and checking Resident #2's blood sugar as ordered. An interview on 02/01/19 at 9:30 AM with Nurse #2 revealed she was the nurse who had been working with Resident #2 the evening of 07/13/18. Nurse #2 stated when she was giving Resident #2 his medication he grabbed her breast with his hand. Nurse #2 stated she told him that was inappropriate behavior and it would not be tolerated by the staff. She stated Resident #2 looked at her and smiled. The nurse stated she then obtained his blood sugar and he took his hand and grabbed her crotch and attempted to grab her breast a second time, but she was able to put her arm up and block him from grabbing her. Nurse #2 again told the resident his behavior was unacceptable and would not be tolerated and stated he again smiled at her. A review of Resident #2's record revealed he had been seen by the psychotherapist beginning 08/16/18 for irritability and inappropriate behaviors with staff. The note stated he appeared to be suspicious, was narcissistic and depressed. Stated he seemed to have disdain for professionals and their opinions. The plan was for follow up psychotherapy for 26 sessions. A review of Resident #2's care plan dated 12/17/18 revealed he had a care plan for behaviors of cursing, red face and history of throwing things. The goal was for Resident #2 to have less episodes of anger over the next quarter. The interventions included encourage resident to go to a quiet environment, promote safe, secure surroundings and reduce noise during behavior episodes to prevent escalation, psyche consult, and provide reorientation as needed. There was no indication on the care plan there had been sexually inappropriate behaviors towards staff. A review of Resident #2's record revealed he was seen on 12/21/18 by the Psychiatric Nurse Practitioner (NP). The NP documented the resident had a new roommate and seemed pleasant, cooperative and in no apparent distress. Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of Resident #1's annual MDS dated [DATE] revealed she was assessed as having short and long-term memory problems and was severely impaired for daily decision making. The MDS indicated Resident #1 required extensive assistance with all activities of daily living (ADL) except eating and locomotion. The MDS also indicated Resident #1 had no range of motion (ROM) impairments. A review of the medical record for Resident #1 revealed the following timeline on the evening of 01/03/19, as documented by Nurse #1, when Resident #1 was sexually assaulted by Resident #2: 7:10 PM Nurse Aide (NA) #1 was informed by the Community College Nurse Aide Instructor that Resident #2 was in the hallway outside his room and had his right hand down Resident #1's brief and pants. NA #1 instructed Resident #2 to remove his hand out of Resident #1's pants and he did not comply. NA #1 walked over and removed Resident #2's right hand out of Resident #1's pants and immediately separated the residents. NA #1 removed Resident #1 while another NA stayed with Resident #2. NA #1 informed Nurse #1 of the incident and Nurse #1 immediately notified the DON. Resident #1 was taken to her room and NA #1 returned to Resident #2's room and took him in the room where he remained with 1 on 1 supervision. 7:20 PM Nurse #1 notified the Director of Nursing (DON) and she in turn notified the Administrator of the sexual abuse. 8:06 PM - the DON came in to facility and a skin observation of Resident #1 was completed with no issues identified. It was documented that special time and attention was paid to the vaginal area of the resident. 8:30 PM - The DON and Administrator notified the local Police Department about the sexual abuse. 8:35 PM - The DON notified the Medical Director of the sexual abuse. 9:23 PM - The direct care nurse - Nurse #1 called Resident #1's family member and left a voicemail message for a return call. 9:26 PM - Two Police officers (one male and one female) from the local Police Department came in to talk with both residents and make a report and take statements from the staff. 9:35 PM - The female Police officer went into Resident #1's room to interview her and was not able to get any reliable answers from the resident. 9:40 PM - The male Police officer went in to interview Resident #2 and he told the police officer that Resident #1 had placed his hand on her abdomen and believed she placed his hand down her pants. The resident then became very angry, cursing and swearing at the officers and would not answer any further questions. 10:00 PM - Resident #1's family member called back to the facility and staff informed her of the sexual abuse that had occurred. An interview on 01/30/19 at 8:14 PM with Nurse #1 revealed she had both residents assigned to her the evening of 01/03/19 and stated NA #1 told her about the sexual abuse with Residents #1 and #2. Nurse #1 stated she immediately notified the DON about what had happened. Nurse #1 stated she had seen Resident #1 rolling around in the hallway prior to the incident and stated she had seen Resident #2 sitting in his wheelchair in the doorway of his room. The nurse stated she had not noticed anything unusual about either of the residents prior to the sexual abuse and stated the off going nurse had not reported anything unusual about either of the residents during report. An interview on 01/30/19 at 11:50 AM with Nurse Aide (NA) #1 revealed on the evening of 01/03/19 at approximately 7:10 PM she walked out of another resident's room and was summoned by the local Community College Nurse Aide (NA) Instructor that Resident #2 had his hand down inside the pants and brief of Resident #1. NA #1 immediately went over and asked Resident #2 to remove his hand out of Resident #1's pants and he did not comply. She stated she removed his hand from Resident #1's brief and pants. NA #1 asked another NA to stay with Resident #2 while she took Resident #1 to the nurse's station to tell the nurse. After NA #1 told Nurse #1 what had happened she took Resident #1 back to her room. NA #1 went back to Resident #2's room and asked him what he was doing and said Resident #2 stated to her am I in trouble? NA #1 stated she told the resident that she had to report the sexual abuse. NA #1 revealed Resident #2 was immediately placed on one to one supervision and was never left alone. An interview on 01/30/19 at 12:21 PM with the NA Instructor revealed she had students at the facility on the evening of 01/03/19. The Instructor stated she rounded the corner and saw Resident #2 with his right hand in the brief and pants of Resident #1. She stated both residents were right outside Resident #2's door and she found NA #1 and asked her to handle the situation. The Instructor stated after the residents were separated, Resident #2 was placed on one to one supervision. The Instructor stated Resident #2 was never left alone after the abuse. An interview on 01/30/19 at 4:06 PM with the Speech Therapist (ST) revealed she had been asked to do a cognitive screening on Resident #2 which was done on 01/17/19. The ST stated she had done two different tests on him and had determined from the test scores that he was cognitively intact, and his reasoning ability was good, and he had the ability to recall. The ST stated Resident #2 was mobile with his wheelchair and had been on psyche services since before the sexual abuse with Resident #1. An interview on 01/30/19 at 5:45 PM with the Director of Nursing (DON) revealed she had been notified of the sexual abuse and had immediately come to the facility. The DON stated at around 8:00 PM on the evening of 01/03/19 she had done a head to toe skin assessment on Resident #1 and paid special attention to her vaginal area to assure there was no redness, bleeding, tearing, or swelling. The DON stated Resident #1 was severely cognitively impaired for daily decision making and could not consent to sexual activity. The DON also stated Resident #2 was cognitively intact for daily decision making and could consent to sexual activity with another cognitively intact resident. An interview on 01/30/19 at 3:01 PM with Resident #1 revealed she was alert to name only and was unable to answer any questions related to the sexual abuse that occurred on 01/03/19. An interview on 01/30/19 at 3:16 PM with Resident #2 revealed he remembered a female resident whose name he doesn't recall and doesn't remember what she looked like came into his room. The resident stated he was legally blind and could only see someone right in front of him and objects far off were just like shadows. Resident #2 stated he had not ever done anything inappropriate to another resident as he knew of. The resident stated he didn't remember putting his hand down a woman's pants into her brief and said he didn't do it. Resident #2 also stated he didn't remember a staff member asking him to remove his hand from a woman's pants and didn't remember a staff member removing his hand. Resident #2 stated he had not been sexually abused while at the facility and had not sexually abused anyone that he knew of. Resident #2 stated 01/03/19 had been a while ago and he didn't remember anything. An interview on 01/30/19 at 4:35 PM with the Medical Doctor (MD) revealed he was the physician for both residents but his interaction following the sexual abuse was with Resident #2 as Resident #1 was not able to give any valuable information due to her cognition. The MD stated Resident #1 was not cognitively capable of consenting to sexual activity; however, Resident #2 was capable of consenting to sexual activity. The MD stated he had asked Resident #2 about the sexual abuse and Resident #2 told him Resident #1 had placed his hand down in her pants inside her brief. The MD stated Resident #2 knew what he was doing and knew it was wrong. An attempt was made on 01/30/19 at 4:47 PM to interview the Psychotherapist for Resident #2; however, he was out of the country and unable to be reached. An interview on 01/30/19 at 4:51 PM with the Psychiatric Nurse Practitioner revealed she had seen Resident #2 in follow up after the sexual abuse on Resident #1 and stated he was capable of intact thought and his insight and judgement were within normal limits. The NP also stated Resident #2 was capable of remembering what he did and knowing what he did and she stated he had no cognitive problems. An interview on 01/30/19 at 5:45 PM with the Director of Nursing (DON) and the Administrator revealed they both came to the facility immediately after they were notified of the sexual abuse. They both stated Resident #2 had been on one to one supervision since the abuse and would remain on supervision until they found placement for him. The Administrator stated they had done training on behaviors instead of abuse because their staff had appropriately handled the abuse situation and had done everything according to their policy and procedure. The DON and Administrator stated they chose behaviors because Resident #2 had not responded to the staffs request to remove his hand from Resident #1's pants. The Administrator and DON confirmed that training was not started for 5 days after the abuse and had not been completed with all the staff but stated they had not provided training on sexual abuse. The DON stated she had completed 3 mandatory in-services but had not reached all the nursing staff and had only done training with the nurses and nurse aides but not the rest of the staff. A review of the Police Report dated 01/04/19 revealed the Police Department and the District Attorney's office had obtained a criminal summons for Resident #2 for the sexual battery of Resident #1. The Administrator was informed of Immediate Jeopardy on 01/31/19 at 12:16 PM. The facility provided an Acceptable Allegation of Immediate Jeopardy removal on 02/01/19 at 10:40 AM as follows: This letter and the documentation constitute a credible allegation by Curis at Wilkesboro Transitional Care and Rehabilitation Center that the immediate jeopardy identified by the Department of Health and Human Services (DHHS) of North Carolina on (MONTH) 31, 2019 has been removed as of (MONTH) 31, 2019. While the Nursing Center does not agree that all the allegations set forth in the (MONTH) 31, 2019 Statement of Deficiencies are accurate, the Nursing Center recognizes that it must persuade your office that appropriate systems are in place to assure ongoing compliance with the Federal requirements for participation in the Medicare and Medicaid programs. As set forth in detail below, the Nursing Center believes that as of (MONTH) 31, 2019, the immediate jeopardy is removed. Credible Allegation of immediate jeopardy removal The following interventions have been initiated; to assure that as of (MONTH) 31, 2019, the Nursing Center has abated the immediate jeopardy that was called F600 Abuse. Curis at Wilkesboro Transitional Care and Rehabilitation Center Immediate Corrective plan to Remove Immediate Jeopardy January 31, 2019 Resident Affected: On 1/3/19 NA Instructor #1 witnessed resident #2 having their hand in Resident #1's brief. Called for assistance and NA #1 helped separate the two residents immediately. Resident #1 has no signs of mental anguish or physical injury from incident. Resident #2 was immediately placed on 1:1 care and continues to be on 1:1. A total body skin assessment was completed immediately by the facility nurse on that assignment on resident #1 to ensure no injury. There was a psychological visit set up for resident #1 to ensure there were no residual effects. Social well-being visits were completed for resident #1. Close observation by nursing staff for the resident #1 to include well-being, s/s of depression/anxiety, changes in appetite, changes in habits or behaviors. Police department, responsible party and other required agencies were contacted. Following investigation, the abuse was substantiated and criminal charges were filed. Medical director was at the facility when the incident happened and was informed and went to resident ' s room and she was resting in bed. How the facility will identify other residents with the potential to be affected: Safe surveys are corporate interview tools to assist in identifying any potential abuse. Safe surveys were completed by Administrator, Unit managers, activities director, business office manager, admissions director, and MDS coordinators on 1/31/19 on all residents with a BIMS score of 12 or higher. There were no issues identified that dealt with abuse, neglect or behaviors. Licensed nurses completed skin assessments on all residents with a BIMS less than 12. The Skin assessments were completed on 1/4/19. The Executive Director and Director of Nursing held a meeting with the department heads on 1/30/19 to discuss how to identify residents with behaviors and how to protect other residents from abuse. It was discussed that surveyors identified that there was a failure in the system to prevent abuse from happening due to a previous incident when resident #2 had become sexually inappropriate with staff, on 7/13/18. This was not addressed sufficiently by the previous administrator, Director of Nursing, and/or the Social Services Director. The facility will identify other residents by utilizing behavior management batch orders that were added to all residents in Point Click Care, effective on 1/31/19. This will be added to all new residents upon admission. Licensed nursing staff were in-serviced on adding resident behaviors management orders to all new residents, by the Director of Nursing, Unit Managers and/or Staff Development Coordinator on 2/1/19. The interdisciplinary team will develop an individualized plan of care that will take in account type of behavior, time of day and any underlying factors that might need to be addressed for the resident. The 24-hour clinical report will be reviewed in morning clinical startup and any identified behaviors will be added to the clinical follow-up tool to be addressed immediately by, director of nursing, unit managers, and/or staff development coordinator. Administrator and/or director of nursing will be notified during weekends if any residents exhibit challenging behaviors and/or sexually inappropriate behaviors. Systemic Changes: A. Additional in-services on abuse policy and procedures was started on at 7:00 pm on 1/30/19 in addition to continual in-service and post-test on challenging behaviors that were started on 1/8/19 for 100% of staff. All staff will be complete this in-service training on 1/31/19 or staff will be removed from schedule until training can be completed. All staff, including nursing, dietary, housekeeping, maintenance, therapy, and department heads, were in-serviced by Director of Nursing, Staff Development Coordinator, and Unit Managers on the following: 1. Residents exhibiting challenging behaviors/sexually inappropriate behaviors. 2. Monitoring changes in residents' behaviors. 3. Documentation in medical records regarding interventions surrounding resident challenging behaviors/sexually inappropriate behaviors. 4. Notifying family and Director of Nursing of any changes in residents' conditions. 5. Reporting to appropriate people when sexually inappropriate behaviors or abuse occurs. B. The Administrator and Director of Nursing will continue to review all 24 - hour reports (paper copies) and the 24 hour report on orders from Point Click Care Monday thru Friday during morning meeting to identify any Resident with behaviors/statements that could be a danger to themselves or other Residents. Behaviors identified on the 24-hour report will be added to the clinical follow-up log and addressed daily to ensure that all behaviors are identified, monitored and care planned. Once behaviors have been identified or any additional concerns identified, the interdisciplinary team will continue to use the PCC generated tool for monitoring and will develop an individualized care plan. Clinical follow-up log with corrective actions from interdisciplinary team meeting and/or clinical startup will be taken to monthly QAPI. Administrator and/or director of nursing will be notified during weekends if any residents exhibit challenging behaviors and/or sexually inappropriate behaviors. C. New hires for all departments will be educated by the Administrator, Director of Nursing, and/or Staff Development Coordinator on Abuse Policy/Procedures and Behaviors during orientation. Monitoring: A. An Adhoc QAPI meeting was held with interdisciplinary team and Medical Director (via phone) on 1/31/19 to discuss the problem, plan and interventions initiated (PCC behavior monitoring tool, staff in-services, and current care plans for both resident #1 and resident #2) and the Medical Director did not have any further recommendations. B. All staff will have annual abuse and behavior in-services with post-tests. The Staff Development Coordinator will audit annual in-service and post-test for continued compliance. C. The daily clinical follow-up sheet which contains identified behaviors from the 24 hour report, the Point Click Care behaviors generated 24 hour order report, and individualized interventions which were put into place will be presented at the monthly QAPI meeting x 3 months by the Director of Nursing for discussion and review by the interdisciplinary team which consist of the Executive Director, Director of Nursing, all department heads and the Medical Director, to assure continued compliance is maintained. Any concerns identified in the QAPI meeting will be discussed and an appropriate plan and interventions will be put into place. Upon completion of the initial 3 month process the QAPI team will discuss and determine if there is a need for continued monitoring. The Director of Nursing or nurse supervisor will audit systemic changes and be responsible for presenting information to the QAPI team. D. Administrator will be responsible for the ongoing compliance of F 600. The alleged compliance date is (MONTH) 31, 2019. Conclusion: Curis at Wilkesboro Transitional Care and Rehabilitation Center believes that the corrective action described above demonstrates that as of (MONTH) 31, 2019, the Nursing Center has removed the alleged immediate jeopardy identified during the (MONTH) 30, 2019 survey. Therefore; the Nursing Center requests that DHHS lift the immediate jeopardy. Executive Director Curis at Wilkesboro Transitional Care and Rehabilitation Alleged Compliance Date is 02/01/19 The Director of Nursing is responsible for ongoing compliance of F-600. The facility's Credible Allegation of Immediate Jeopardy removal was verified on 02/01/19 at 3:17 PM and based on verification that Resident #2 had been and would remain on 1 to 1 observation until placement in another facility. Interviews with alert and oriented residents were conducted and no one expressed they had been sexually abused or abused in any way and family members were interviewed and voiced no concerns. Administrative, management, nursing, housekeeping, dietary, maintenance, therapy and activities staff all verified that training had been provided regarding the abuse policy and the need to protect residents, report allegations, investigate allegations, and report to the state agency and authorities if needed. This training was verified as being provided to all departments.

Based on observations, record reviews, resident, family, staff, and Wound Doctor interviews the facility failed to eliminate sharp metal edges of a resident's wheelchair that would prevent a skin tear from occurring. The skin tear resulted in the resident requiring multiple wound debridement's (the removal of damaged tissue) for 1 of 2 residents sampled for non-pressure related wounds (Resident #67). The findings included: Resident #67 was admitted to the facility on [DATE] and most recently readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent comprehensive Minimum Data Set ((MDS) dated [DATE] revealed that Resident #67 was cognitively intact and required extensive assistance with activities of daily living. Skin tears were not checked on the MDS assessment. Review of an Investigation for skin tears or bruise dated 03/20/18 at 6:13 PM read in part, description of injury: Resident #67 was in the shower room and was standing beside her wheelchair and hit the side of her wheelchair and tore the skin on her right lower leg. The skin tear was dressed and wrapped with gauze. Leg protector was placed on right leg to prevent future occurrences. Skin condition was listed as fragile with previous skin tears noted. The form was signed by Nurse #1. The investigation results read, no further investigation needed. Skin tear occurred during transfer to wheelchair from shower chair. This was signed by the Director of Nursing (DON). Review of a care plan that was initiated on 04/16/18 read, Resident #67 has the potential for skin integrity impairment. The care plan indicated that Resident #67 had skin tears to her right superior lateral leg, right inferior lateral leg, left lateral leg, and right superior shin area. The goal of the care plan read, Resident #67 will be free from skin tears through the review period and her skin tear of the left leg would be healed by the review date. The interventions listed read in part, if a skin tear occurred treat per facility protocol and notify the medical doctor, keep skin clean and dry, use lotion on scaly skin, use caution during transfers and bed mobility to prevent striking arms, legs and hands against any sharp or hard surface. An interview and observation was conducted with Resident #67's family member on 04/30/18 at 11:18 AM. Resident #67's family member stated that she has had 4 incidents of getting her leg cut on her wheelchair. She stated that this past weekend the facility had started using the lift to transfer her family member and indicated that the lift was the only protective measure they have used since the injury to her right leg that occurred on 03/20/18. She added that the wound was not looking good and had to be seen by the Wound Doctor (WD). The family member stated she had spoken to several staff members but could not recall who they were. The family member further stated she had asked about what they were going to do to protect her family members legs and she has never gotten clear answers. Resident #67's wheelchair was observed to be sitting next to her bed and there were 2 small sharp pieces of metal on each side of the wheelchair where the leg rest were supposed to attach to the chair. The metal sides of the wheelchair and lower frame where visible. An observation was made of wound care on 05/02/18 at 4:12 PM with Nurse #3. Nurse #3 removed the old dressing to the right lateral lower leg and cleaned the wound. The wound was long with a beefy red wound bed. The skin tear was cleaned and calcium alginate applied and covered with a foam dressing and Nurse #3 exited the room. Resident #67's wheelchair was observed to be sitting next to her bed and there were 2 small sharp pieces of metal on each side of the wheelchair where the leg rest were supposed to attach to the chair. The metal sides of the wheelchair and lower frame where visible. An interview was conducted with the Wound Doctor (WD) on 05/04/18 at 3:17 PM. The WD stated that when he first began to see Resident #67 she had a large wound to her right lower leg and was also suffering from stasis [MEDICAL CONDITION] (skin inflammation in the lower legs caused by fluid buildup) and he started compression dressings to her lower legs. The WD stated that there was a divot or hole in the wound and initially he did not probe into the hole but on subsequent visits he did probe into the hole and was very certain this wound was related to trauma from the wheelchair. He added that on his first visit with Resident #67 he had to clean the wound up by surgically [MEDICATION NAME] the wound and removing the slough (dead) tissue so the wound could begin to heal. He added that he had also debrided the wound several more times since then. The wound to Resident #67's right lower leg was trauma related and the WD stated she gets trauma wounds a lot. The WD stated that the right lower leg had required several surgical debridement but was doing well and he expected it to heal in the next 2 weeks. An interview was conducted with Resident #67 on 05/04/18 at 4:13 PM. Resident #67 stated on 03/20/18 she was in the shower room with the staff and after they had completed the shower they pulled the wheelchair up beside the shower chair instead of up behind her and that caused her to bump her leg. Resident #67 stated that she had told numerous staff members that when they transfer her they must put the wheelchair directly behind her but indicated each time she received her shower it was someone different. She could not recall if she had told NA #3 about that before or after the skin tear occurred. She pointed at the wheelchair and stated it was the part of the wheelchair where the leg rest connected to the wheelchair. Resident #67 stated that they did not pay attention to what they were doing but now they were more careful and pull the chair up behind me so I all I have to do is sit down. Resident #67 stated that skin tear bled a lot but really did not cause her pain. She stated the staff was wrapping her bilateral lower legs with ace bandages to help with the swelling and indicated that she had not seen any padding to her wheelchair since the incident. An attempt to speak with Nurse #1 on 05/04/18 at 5:04 PM was unsuccessful. An interview was conducted with the Director of Nursing (DON) on 05/04/18 at 5:33 PM. The DON stated that Nurse #1 had completed the Investigation for skin tears or bruise dated 03/20/18 and then she entered them into the facility's electronic record system and provided any additional follow up that was needed. The DON stated that from her understanding NA #3 was giving Resident #67 a shower and had finished the shower and gotten her completely dressed and while transferring her back to her wheelchair Resident #67 stood up and went to sit down in her wheelchair and bumped her leg on the wheelchair. She added that Resident #67's legs were like a ripe melon and you can barely touch them. The DON stated that NA #3 went and reported it to Nurse #1 who clean and dressed the wound and notified the family and the medical provider. In this case the DON stated it was pretty clear cut and the root cause was she bumped her leg during a transfer and no further follow up was required. The DON stated that after the Wound Doctor (WD) visited with Resident #67 the facility added the shin guards but she was not currently wearing them because her legs were being wrapped with ace bandages. The DON stated that on 03/21/18 she went to look at the skin tear because it was a bad skin tear that had an indentation from the piece on the wheelchair. The DON stated that prior to this incident she could not recall any specific intervention that was in place to protect Resident #67's skin but since the incident they were wrapping her bilateral lower legs with ace bandages to help with the [MEDICAL CONDITION] and recently they had started using the mechanical lift for her transfers. She also believed that they had added some padding to the wheelchair brake handles for protection. The DON stated she expected the staff to be as careful as possible with Resident #67 because her skin was so fragile. An interview was conducted with the Director of Maintenance (DOM) on 05/04/18 at 5:43 PM. The DOM stated he had not received any request to make any modifications or padding to Resident #67's wheelchair An interview was conducted with Nursing Assistant (NA) #3 on 05/05/18 at 11:58 AM. NA #3 stated that on 03/20/18 she was responsible for giving Resident #67 a shower, she indicated this was not her first time showering Resident #67 and she was familiar with her and her needs. NA #3 stated that she had pushed Resident #67 into the shower room in her wheelchair and she had transferred her to the shower chair. She added she was able transfer by standing up using the grab bar and pivoting to the shower chair. NA #3 stated that Resident #67 did a good job of using the grab bar to pull herself up to the standing position. She added that she placed Resident #67 in the shower chair and proceeded to give her a shower. After the shower she had helped Resident #67 dry off and get dressed for bed. She indicated that she had pulled the wheelchair up beside Resident #67 and she pulled up on the grab bar and pivoted back to her wheelchair. NA #3 stated that somehow, she bumped her leg on the wheelchair and it caused a skin tear. She added that the part of the wheelchair that Resident #67 bumped her leg on was the 2 small sharp metal pieces where the leg rest connected to her wheelchair and to her recollection there was no padding to that part of the wheelchair. She indicated that there was quite a bit of blood and she immediately went and got Nurse #1 who came to the shower room and cleaned and dressed the skin tear. NA #3 stated that currently Resident #67 was not wearing any leg protector because her lower legs had bandages on them and she was very careful when she transferred Resident #67 now. NA #3 stated that Resident #67 requested that the staff place her wheelchair directly behind her so all she had to do was sit down, and that seems to be helping as well. NA #3 could not recall seeing any padding to Resident #67's wheelchair since the incident.

Based on observations, record review, staff and medical doctor (MD) interviews, the facility failed to manage the pain of 1 of 1 resident (Resident #6) reviewed for Hospice services. The findings included: Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of a note written by the Minimum Data Set (MDS) nurse on 02/01/18 revealed during a pain interview Resident #6 revealed she had pain frequently, mostly in her head and neck. Her pillow was repositioned and it helped some but Resident #6 stated her pain was at a level 8 out of 10. A review of the Significant Change Minimum Data Set ((MDS) dated [DATE] revealed Resident #6 had moderately impaired cognition for daily decision making but was able to make her needs known. The MDS also revealed Resident #6 required extensive assistance of 1 to 2 persons with most activities of daily living (ADL), had a catheter due to a sacral pressure ulcer and was incontinent of stool. The MDS revealed Resident #6 received scheduled and as needed (PRN) pain medication for frequent pain at a level 8 on a scale of 1 to 10. A review of the Care Area Assessment (CAA) summary dated 02/15/18 revealed Resident #6 was under Hospice care as of 01/19/18 for acute and chronic [MEDICAL CONDITION] with [MEDICAL CONDITION]. The resident has a history of chronic pain and received [MEDICATION NAME] and prn [MEDICATION NAME] sulfate (MS) was ordered every 2 hours prn pain. She had an air mattress on her bed and had pressure areas to her toes, heel sacrum and shins. A review of Resident #6's care plan dated 02/20/18 revealed she had a care plan for acute and chronic pain related to arthritis, chronic pai[DIAGNOSES REDACTED] and immobility. The goal was Resident #6 would verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the next review date. The orders included: administer [MEDICATION NAME] as per orders, anticipate need for pain relief and respond immediately to any complaints of pain, evaluate the effectiveness of pain interventions approximately 30 minutes to 1 hour post intervention and review for compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results, monitor/record pain characteristics, quality, severity, location, onset, duration, aggravating factors and relieving factors, monitor/record any signs or symptoms of non-verbal pain such as changes in breathing, vocalizations, mood/behavior changes, eyes, face, and body, monitor/report to nurse resident complaints of pain or requests for pain treatment, notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain, remind resident to call for assistance when in pain and needing repositioning or medication, and report to nurse any change in usual activity attendance patterns or refusal to attend activities related to pain or discomfort. A review of Resident #6's current physician orders [REDACTED]. 72 hour 100 micrograms (MCG) per hour - apply trans-dermally one time a day every 3 days for pain. An observation of Resident #6's dressing change to her pressure ulcers on 05/02/18 at 10:40 AM revealed Nurse #2 and Nurse #6 in to change dressings to right calf, right medial heel, and left medial heel. As Nurse #2 starting positioning Resident #6 for the dressing changes, the resident was crying and her eyes were clinched and face grimaced and she stated her head, neck, shoulders and both legs were hurting. Nurse #2 continued with the dressing change to the resident's right calf and right medial heel as the resident continued with grimaced face and crying in pain. There was a dressing on the resident's left medial heel which was new and Nurse #2 stated she did not have orders and would need to talk with the Director of Nursing about the dressing and left the room. Nurse #6 told Resident #6 she would check to see if she could have something for pain and left the room. Resident #6 stated her pain was a level 9 out of 10. Nurse #6 returned to the room with [MEDICATION NAME] sulfate (MS) 0.25 ml or 5 mg and gave the resident the medication via oral route in the side of her mouth at 10:50 AM. Nurse #2 came back into the room and changed the dressing on the resident's left medial heel. A review of Resident #6's Medication Administration Record [REDACTED]. An observation of Resident #6 on 05/03/18 at 2:30 PM being cleaned up by Nurse Aide (NA) #8 and NA #5 after her feeding tube had leaked all over her and her bed revealed the resident with grimaced face, clinched eyes, crying and stated oh please help me honey, it hurts so bad. Resident #6 stated her pain was at a level 10 out of 10 and continued crying in pain. The NAs placed Resident #6 on her back and were cleaning under her abdominal fold and under her breasts and the skin was red, shiny and irritated and the resident was red in the face, crying and stated oh that hurts. Resident #6 stated her skin was extremely irritated and when they rubbed on it to clean it, it really hurt badly. NA # 5 left the room to get the nurse to come and apply medicated powders to the resident's skin folds. Nurse #2 came into the room and applied medicated powder to her irritated skin folds and assessed the resident for pain and told her she would bring her back some medication for pain. Nurse #2 returned to the room and medicated the resident with MS 5 mg via oral route in the side of her mouth at 2:30 PM. A review of Resident #6's MAR indicated [REDACTED]. An observation of Resident #6 on 05/04/18 at 11:58 AM revealed her in bed with her oxygen on via nasal cannula and her feeding tube infusing via pump at 25 milliliters per hour and the resident had grimaced face and was moving in her bed and stated her pain was a level 10 out of 10. Resident #6 stated she had some pain medication earlier but it had not helped her pain and it was still a level 10. The resident's pain level was reported to her nurse. A review of Resident #6's MAR indicated [REDACTED]. A review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. On 05/02/18 the resident received MS 5 mg at 10:50 AM for pain level of 9 with effectiveness at level 1 and again at 11:50 AM for pain level of 8 with documented effectiveness. On 05/03/18 the resident received MS 5 mg at 8:39 AM for pain at level 4 with effectiveness and at 2:30 PM for pain level of 10 with documented effectiveness and on 05/04/18 the resident received MS 5 mg at 09:50 AM for pain level of 6 with documented effectiveness, at 2:27 PM for pain level of 3 with documented effectiveness and at 3:53 PM for pain level of 6 with documented effectiveness. The order was written for the resident to have 0.25 ml or 5 mg of MS every 1 hour as needed for pain; however, the resident only averaged getting the medication 2 to 3 times per day. An interview with NA #8 revealed she had been trained to notify the nurse immediately when a resident complained of pain during care. An interview with Nurse #2 on 05/03/18 at 2:44 PM revealed she had called Hospice on 05/02/18 about increasing Resident #6's pain medication and stated the Hospice nurse had been at the facility on 05/02/18 and talked about increasing her pain medication but had not changed the orders. Nurse #2 stated she would call again and ask about getting her pain medication increased by Hospice. A review of Resident #6's chart on 05/04/18 revealed an order had been written to increase the [MEDICATION NAME] Patch from 100 mcg to 150 mcg per hour every 72 hours. A phone interview on 05/04/18 at 5:19 PM was attempted with the Hospice nurse with no return call received. An interview on 05/04/18 at 6:24 PM with the Director of Nursing (DON) revealed her expectation was for the resident's pain to be controlled in collaboration with the facility and Hospice. An interview on 05/04/18 at 7:46 PM with the facility Medical Director revealed the resident commonly winced when examined but stated it was his hope since it was the premise of Hospice to keep residents comfortable they would be able to do that for Resident #6.

Based on record reviews and resident and staff interviews the facility failed to secure a side rail during incontinence care to prevent a resident who used side rails for turning and positioning from falling from bed and resulted in fractures of the femurs (thigh bones) on both legs for 1 of 3 sampled residents for supervision to prevent accidents (Resident #3). The findings included: Resident #3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of an annual Minimum Data Set ((MDS) dated [DATE] indicated Resident #3 was cognitively intact for daily decision making. The MDS also indicated Resident #3 required extensive assistance for bed mobility and was totally dependent on staff for toileting, hygiene and bathing and was always incontinent of bladder and bowel. A review of a care plan which was updated on 06/08/16 indicated Resident #3 was at risk for falls related to deconditioning and incontinence and a goal revealed Resident #3 would not have a fall with injury through next review date. The interventions were listed in part for padded half side rails on the bed to use for positioning, bed mobility and activities of daily living (ADL). The care plan revealed Resident #3 had a fall from bed on 06/08/16 which resulted in femur fractures on both legs. The care plan also revealed Resident #3 was sent to the emergency room and was ordered knee immobilizers for both legs and a consult with an Orthopedic Physician. A review of a nurse's note dated 06/08/16 at 8:02 AM revealed Resident #3 had a fall from bed in the high position. The note indicated Resident #3 complained of pain in both knees, left hip pain and there was a large abrasion to her left hip. The notes further indicated the physician was notified and orders were received to send Resident #3 to the emergency room . A review of a nurse's note dated 06/08/16 at 8:26 AM revealed Resident #3 was transferred to the emergency room by emergency medical services (EMS). A review of a facility document titled Unusual Occurrence Report & Investigation for Resident Fall dated 06/08/16 at 9:50 AM revealed factors observed at the time of the fall was bed height was not appropriate and an air mattress was on the bed. The report indicated Resident #3's bed in high position and a side rail was not engaged in the horizontal position and Resident #3 was in a puddle of urine and urine was on the floor. A review of a nurse's note dated 06/08/16 at 12:36 PM revealed Resident #3 arrived back to the facility by EMS transport and had knee immobilizers in place on both knees. A review of a therapy note dated 06/09/16 at 11:49 AM by the Director of Rehabilitation revealed Resident #3 had a fall from bed on 06/08/16 while being cleaned by staff and Resident #3 reported she was told to to roll and when she rolled her legs slid off the bed and hit the floor. The therapy notes indicated a review of xrays revealed Resident #3 had a displaced fracture of her right femur and had a non-displaced fracture of her left femur and had knee immobilizers in place on both legs. The notes further indicated Resident #3 had an appointment with an Orthopedic Physician on 06/10/16. A review of a care plan titled ADL self care deficit revised on 06/28/16 indicated Resident #3 required extensive to total assistance for incontinence care. During an interview on 08/17/16 at 5:08 PM with Resident #3 she confirmed she fell out of bed on 06/08/16 and it shouldn't have happened. She explained she was in bed and was wet and needed to be cleaned and NA #1 came in to clean her up. She stated the side rail on the left side of the bed was in the up position and was not engaged in it's normal horizontal position and when she turned to her left side she reached for the side rail like she usually did and nothing was there for her to grab onto and she fell out of bed. She explained usually the side rail was down in the horizontal position so she could reach for it and turn herself and hold onto it while staff cleaned her. She stated she felt the fall could have been prevented if the side rail had been engaged in the horizontal position like it usually was. She explained when she fell out of bed, she hit her knees on the floor and broke her legs. She stated she wanted the side rails on her bed because they gave her the ability to turn herself in bed and she felt safer when the side rails were engaged. During an interview on 08/18/16 at 10:15 AM with NA #1 she explained she was assigned to care for Resident #3 on 06/08/16 and when she made her first round around 7:30 AM Resident #3 was in bed and was in a mess and urine was puddled on the bed and was dripping off the side of the bed onto the floor. She stated she left the room to get clean linens and when she returned she asked Resident #3 roll to her right side and Resident #3 grabbed the right side rail which was engaged and was in the horizontal position for her to hold onto. She explained she cleaned Resident #3 and started to put clean linens on the bed and asked Resident to turn onto her back. She stated she then realized a tray table was too close at her left side and was in her way so she walked and pushed the tray table to the foot of the bed and turned her back to Resident #3. NA #1 stated when she turned around Resident #3 was turning to her left side and she saw the left side rail was pointed up in a vertical position and was not engaged in its usual horizontal position. She further stated Resident #3 kept rolling and slid out of bed and down the left side rail and onto her knees on the floor. She explained Resident #3 was stuck in a squatting position on her knees on the floor and she couldn't leave her in that position so she laid Resident #3 on the floor and went and got the nurse who came to the room and assessed her. She explained Resident #3 complained of pain in her legs and she had a long scrape on her left hip and complained it hurt too. She stated she did not know why the left side rail had been left up and was not engaged and she did not know who had left it in that position. She explained usually 1 NA provided incontinence care when Resident #3 was in bed because the resident could assist staff and turn herself with the help of side rails. She stated she realized now she should have put the left side rail in the horizontal positron so that it was engaged for Resident #3 to use it to turn herself. She stated it did not register with her when she first entered Resident #3's room that morning that the left rail was not engaged since it usually was because Resident #3 needed the side rails to turn herself in bed. She explained when Resident #3 had the immobilizers placed on her legs she needed more assistance with turning in bed but now that the immobilizers had been removed Resident #3 could assist with turning herself in bed. During an interview on 08/18/16 at 11:00 AM with Unit Manager #1 she stated she arrived at work at 8:00 AM on 06/08/16 and was told Resident #3 had fallen out of bed. She explained Resident #3 had an air mattress on her bed and she would have expected for both of the side rails to be engaged when Resident #3 turned for safety. She further explained the air fluctuated inside the air mattress and the side rails should have been engaged to provide Resident a rail to hold onto. She stated Nurse #1 who assessed Resident #3 after her fall was away on vacation and was not available for interview. During an interview on 08/18/16 at 1:54 PM with Unit Manager #2 she explained it was reported to her after Resident #3 fell out of bed on 06/08/16 that NA #1 was providing incontinence care to Resident #3 and NA #1 had turned her back and the resident fell out of bed. She stated NA #1 had reported the left side rail was not engaged. She explained when the side rails were engaged in a horizontal position they kept the resident from falling out of bed as the air in the air mattress shifted. She stated it was her expectation that residents who had air mattresses should have side rails so when the air in the mattress shifted the resident could hold onto the side rail to prevent a fall out of bed. During an interview on 08/18/16 at 2:48 PM with the Director of Nursing she stated it was her expectation for Nurse Aides (NAs) to make sure the side rails were engaged when the NAs provided care to Resident #3 when she was in bed. She confirmed Resident #3 had an air mattress on her bed and she expected the NA would ensure the side rails were engaged before they provided care to Resident #3.