Every finding on record at Sunplex Sub-Acute Center

Based on staff interview, record review, and facility policy review, the facility failed to protect Resident #1 from misappropriation of property when a Certified Nurse Aide (CNA) removed the resident's debit card without permission and used it at multiple locations for unauthorized purchases for one (1) of four (4) residents sampled. Resident #1Findings include: A review of the facility's ABUSE AND NEGLECT POLICY AND PROCEDURE revised, 10/21/25, revealed, .Policy: To provide a safe environment for all residents free of abuse.Procedure.II. Types of Abuse.7. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent. A review of the facility's incident documentation, with an Incident Date of 11/6/25, revealed that on 11/9/25, the Administrator received a report that Resident #1's bank card was missing and that multiple unauthorized charges occurred between 11/6/25 and 11/9/25. The local police department was notified on 11/9/25, and the State Agency and Attorney General's Office were notified on 11/10/25. Resident #1 reported that her debit card was used at local liquor stores, gift shops, and a local hotel. She also reported concerns regarding CNA #1, who had been encouraging her to attend activities with him. The Administrator conducted interviews with staff who were involved in Resident #1's care. The Administrator contacted the local hotel, which confirmed that CNA #1 appeared on the hotel registry. The facility immediately suspended CNA #1 and notified local law enforcement. Through the facility's investigation, it was determined that CNA #1 removed Resident #1's debit card from her purse on 11/6/25 and used it repeatedly until the card was disabled by the bank on 11/9/25. The resident pressed charges. The facility initiated staff in-services related to abuse, neglect, and misappropriation of resident property.A record review of the local police department report dated 11/9/25 revealed a complaint involving a stolen debit card. Resident #1 informed police that her bank contacted her after identifying unauthorized transactions occurring from 11/7/25 to 11/9/25. On 11/11/25, the police received confirmation from the facility's Administrator that CNA #1 had used Resident #1's debit card to purchase a hotel room and had used his personal Mississippi identification card to make the reservation.A record of the admission Record revealed Resident #1 was admitted by the facility on 6/25/25 with diagnoses including Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/30/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. On 12/1/25 at 3:10 PM, an interview with Resident #1 confirmed that she received a phone call from her bank, informing her of the purchases. The resident revealed her card was used at local liquor stores, gift shops, and a local hotel. The resident revealed that CNA #1 was acting strange always asking her to go to activities. The bank reimbursed her for the charges and reimbursed the funds that were stollen. She confirmed that she had pressed charges against the CNA with local police department. On 12/2/25 at 11:20 AM, during a phone interview, CNA #1 provided conflicting information regarding who possessed or used the resident's debit card. CNA #1 alternated between claiming multiple staff used the card and claiming it had been handed to him by another employee. CNA #1 confirmed that he had used Resident #1's bank card multiple times. On 12/2/25 at 11:25 AM, during an interview with the Administrator, she confirmed that she was notified on 11/9/25 that Resident #1's bank card was missing and that there was $500.00 unauthorized charges. The Administrator began her investigation and reported the allegation to the local police on 11/9/25 and the SA/AGOs office on 11/10/25. During their investigation they came to the conclusion that CNA #1 was responsible for using Resident #1 bank card and using it for $500.00 in unauthorized charges. The facility interviewed all staff that was working in the resident's room area. The facility does not have video surveillance. The AGOs office revealed they contacted CNA #1 and he admitted to driving his car to multiple locations and using Resident #1's bank card to purchase, gas, liquor, food, and a hotel room. Based on the facility's implementation of corrective actions on 11/11/25, the State Agency (SA) determined the deficient to be Past Non-Compliance (PNC), and the deficiency was corrected as of 11/11/25, before the SA's entrance on 12/1/25. Validation: The SA validated on 12/2/25 through interview and record review, that all corrective actions had been implemented as of 11/11/25 and the facility was in compliance, prior to the SA's entrance on 12/1/25.

Based on staff interview and record review, the facility failed to ensure the facility assessment contained required details regarding staffing needs by shift and by unit and failed to maintain an actionable contingency plan for staffing emergencies for (59) of (59) residents in the facility during the influenza outbreak from 10/8/25 through 10/12/25.The facility's failure of not specifying in the facility assessment the number of licensed nurses and Certified Nurse Aides (CNAs) needed per shift and per unit to meet resident needs and the contingency plan not containing clear procedures for securing coverage during emergencies or staff call-offs, resulted in the facility being unprepared for staff absences during the influenza outbreak, which placed all residents at risk for serious illness, serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 10/12/25 when there was insufficient staffing during the influenza outbreak. The facility Administrator was notified of the IJ on 10/21/25 at 4:10 PM and was presented with the IJ Template. The facility provided an acceptable Removal Plan on 10/22/25, in which they alleged all corrective actions to remove the IJ were completed on 10/22/25, and the IJ removed on 10/23/25.The State Agency (SA) validated the Removal Plan on 10/28/25 and determined that the IJ was removed on 10/23/25, prior to exit. Therefore, the scope and severity for CFR(s) S483.71(c)(2)(3) and (5) - Facility Assessment (F838) was lowered from a L to a F while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements.Findings include:Record review of the Facility Assessment, dated 7/1/2025 and signed by the Administrator, revealed the Goal as The goal of this assessment is to identify the resources required to provide competent care for our residents during regular operations, including nights and weekends, as well as in emergency situations.Facility Assessment and Staffing Needs a. This facility assessment will be utilized to.d. Review staffing needs for each shift (day, evening, night).f. Aid in contingency planning for events that, while not necessitating activation of the facility's emergency plan, could impact resident care, such as the availability of direct care nurse staffing. Review of Staffing Needs as per Shift listed Ratio of Staff to Residents or #HPRD (hours per resident day) included the number of hours instead of the number of staff required per shift or per unit. Review of the Contingency Planning for Staffing revealed, In the case of an emergency event, the facility's emergency plan will be activated. IF the event does not rise to the level of activation of the facility's emergency plan the facility will utilize staff, accordingly, including utilizing Administrative staff .On 10/20/2025 at 5:00 PM, during a phone interview with Registered Nurse (RN) #3, she confirmed that the facility usually had two licensed nurses, including an RN and a Licensed Practical Nurse (LPN), that works on the 7 PM to 7 AM shift. On 10/21/25 at 1:30 PM, during an interview with the Administrator and Director of Nursing (DON), the Administrator explained she was notified on 10/11/25 at approximately 1:00 PM that the night nurse had called in sick during the influenza outbreak. She stated that additional attempts were made to contact all nurses, including those at sister facilities, but no coverage was found. The Administrator stated she arrived at the facility around midnight and remained at the [NAME] nursing station to assist the night nurse by answering call lights and notifying the nurse when residents requested medications. The Administrator reported that she notified the Regional Director of Operations of the staffing shortage and that administrative staff assisted as needed. She confirmed the facility's contingency plan allowed administrative staff to assist during emergencies but acknowledged no agency staff were used, and no updates were made to the contingency plan following the incident. The Administrator and DON both stated that only three (3) residents tested positive for influenza, and they did not consider the event an emergency requiring activation of the emergency plan. The Administrator stated the facility assessment used was carried over from the prior Administrator and did not contain a breakdown of the number of licensed nurses and Certified Nurse Aides (CNAs) required per shift or unit. She acknowledged she was unaware the assessment required this detail. She confirmed the assessment had not been revised following the outbreak and that staffing adjustments were made only as needed. Both the Administrator and DON described the incident as isolated and confirmed no changes had been made to the contingency plan or the facility assessment as a result.The facility submitted the following acceptable Removal Plan on 10/22/25:On 10/21/2025 at 4: 10 PM, the State Agency presented Immediate Jeopardy (IJ) Templates for five failures of the facility. The facility failed to provide the necessary care and services to protect residents from neglect. Residents did not receive prescribed medications; the physician was not notified of missed medications and supervision was inadequate on 10/12/25. The facility failed to provide sufficient licensed-nurse coverage to meet resident needs during an influenza outbreak resulting in one (1) nurse being assigned responsibility for 58 residents from approximately 12 AM until 7 AM on 10/12/25, resulting in missed medications and lack of monitoring for residents on one unit. The facility failed to identify an influenza (flu} outbreak when three residents tested positive for flu from 10/8/25 through 10/12/25. The facility did not initiate droplet precautions, notify health department, provide timely antiviral treatment, maintain outbreak surveillance or staff illness tracking during outbreak. The facility failed to ensure the facility assessment had required detail on staffing needs by shift and by unit, and the contingency plan for staffing emergencies had no actionable process which resulted in insufficient staffing during an influenza outbreak. The facility failed to use its Quality Assurance and Performance Improvement (QAPI) program to identify and correct system failures in infection control and staffing during an influenza outbreak. 1. On 10/21/2025 at 6:15 PM, the Administrator held an emergency Quality Assurance and Performance Improvement meeting with the Medical Director, Director of Nursing,Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse and others as part of the Interdisciplinary team to discuss findings from the State Agency, discuss immediate actions, and further interventions. Immediate actions were decided as in-servicing all staff on Abuse and Neglect, in-servicing nurses on medication administration and medication errors, in-servicing all staff on flu outbreak and isolation precautions. The Administrator would review policy for Quality Assurance and Performance Improvement for any changes needed and as re-education in policy. The Administrator would review and update facility assessment to identify updated needs to staff per unit and the contingency plan for emergencies. Administrative nurses would complete a 100 percent audit on all medication carts compared to medication orders to ensure all medications were accessible in the building. The Infection Preventionist would be in-serviced on the roles and responsibilities of an Infection Preventionist. Policies on Abuse and Neglect, medication administration, medication errors, QAPI, flu outbreak, isolation precautions, and the expectations of the Infection Preventionist were all reviewed and updated. Staff were in-serviced with new policies. 2. On 10/21/2025 at 6: 15 PM, the Administrator notified Medical Director of missed medications during QAPI meeting. All missed medications were reviewed with Medical Director during this meeting. No new orders were given. No adverse reactions were noted due to missed medications. 3. On 10/21/2025 at 8:00 PM, the Director of Nursing began an in-service for all staff on the policies and procedures of Abuse and Neglect. No employee was permitted to return to work until they completed the in-service. 4. On 10/21/2025 at 8:00 PM, the Director of Nursing began an in-service on medication administration and medication errors to educate all nursing staff. This in-service included procedures for when medication cannot be located anywhere in the facility. If medication is not available, staff should contact pharmacy and pull medication from emergency kit. Any missed medications are to be reported to the Director of Nursing and Medical Director immediately, an incident report is to be completed, the resident observed for any adverse reactions, and the family/resident representative is to be notified. Any tasks left undone are to be reported to relief during report for oncoming shift. No employee was permitted to return to work until they completed the in-service.5. On 10/21/2025 at 8:00 PM, Administrator and Director of Nursing reviewed Flu outbreak and Isolation precautions policy and procedures. The Director of Nursing began an in service for flu outbreak and isolation precautions to educate all staff. All staff a re to continue to monitor residents and staff for flu-like symptoms and report any findings to the immediate supervisor. No employee was permitted to return to work until they completed the in-service. 6. On 10/21/2025 at B: 15 PM, the Administrator reviewed policy on Quality Assurance and Performance Improvement plan and policy for re-education purposes and to review new policy. The Quality Assurance and Performance Improvement plan and policy was reviewed with the facility's Interdisciplinary Team including the Administrator, Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse and others in a follow up Quality Assurance and Performance Improvement meeting held on 10/22/2025 at 4:00 PM. 7. On 10/21/2025 at 8:30 PM, the facility Administrator began reviewing and updating the facility assessment to reflect correct staffing and supervision by shift and by unit related to the facility's acuity level. The Facility Administrator began updating the contingency plan for staffing emergencies within the facility assessment. The facility assessment was updated on 10/22/2025 at 12:00 PM. The contingency plan will be initiated effective 10/22/2025 at 12:00 PM and is as follows: Facility will utilize On-call for staffing needs and call ins. On-call will notify Director of Nursing if not able to cover. Facility will utilize Consultants and/or transfer staff from other nursing facilities within partnership to assist and cover staffing needs. The new facility assessment was reviewed with the interdisciplinary team during follow up QAPI held on 10/22/2025 at 4:00 PM. 8. On 10/22/2025 at 7:00 AM, the Infection Preventionist (IP) was included in an in-service held by the Director of Nursing for policy and procedures of outbreak surveillance and staff-illness tracking during an outbreak to be completed before beginning of their next shift. Due to this outbreak being finished, IP nurse was instructed to continue to monitor residents and staff for flu-like symptoms and to report to Director of Nursing any findings.9.On 10/22/2025 at 3:00 PM, the Director of Nursing, Medical Records nurse, and Wound Care nurse completed a 100 percent audit to compare the current medication orders to the medication on the carts and in medication rooms to verify all medications ordered were readily available in the facility. No negative findings during audit.10.On 10/22/2025 at 3:50 PM, the Administrator notified the Mississippi Department of Health of the flu outbreak beginning 10/8/2025. 11. On 10/22/2025 at 4:00 PM, the Administrator held a follow-up QAPI meeting to discuss all immediate actions that were in place. All in-services and audits were completed. All staff would continue to monitor any residents or staff for flu-like symptoms, staffing would be reviewed daily to ensure all areas were covered according to the facility assessment, and daily reviews of missed medications would be reviewed each morning in clinical meeting. The facility alleges all corrective actions to remove the IJ was completed on 10/22/25 and IJ would be removed on 10/23/2025.Validation:The SA validated the removal plan on 10/28/25 and the immediacy was removed on 10/23/25 prior to exit.

Based on staff interview, record review, and facility policy review, the facility failed to use its Quality Assurance and Performance Improvement (QAPI) program to identify, analyze, and correct systemic failures in infection prevention and control and staffing during an influenza (flu) outbreak for 59 of 59 residents residing in the facility from 10/8/25 through 10/12/25.The facility's failure to use its QAPI program to evaluate and address the lack of outbreak recognition including failure to initiate droplet precautions, failure to notify the local health department, failure to ensure antiviral medications were administered as prescribed, and failure to monitor staff illness and infection control compliance resulted in continued exposure and spread of influenza within the facility. Additionally, the facility failed to use its QAPI process to identify and correct deficiencies in staffing coverage and the absence of an actionable staffing contingency plan within the facility assessment. These failures demonstrated the facility's lack of an effective, ongoing, data-driven QAPI program and placed all residents in the facility at risk for serious illness, serious harm, serious impairment, or death.The situation was determined to be an Immediate Jeopardy (IJ) that began on 10/12/25 when there was insufficient staffing during the influenza outbreak. The facility Administrator was notified of the IJ on 10/21/25 at 4:10 PM and was presented with the IJ Template. The facility provided an acceptable Removal Plan on 10/22/25, in which they alleged all corrective actions to remove the IJ were completed on 10/22/25, and the IJ removed on 10/23/25.The State Agency (SA) validated the Removal Plan on 10/28/25 and determined that the IJ was removed on 10/23/25, prior to exit. Therefore, the scope and severity for CFR(s) S483.75(f)(4) - Quality Assurance and Performance Improvement Program (F865) was lowered from a L to a F while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements.Findings include:A review of the facility's policy, Quality Assurance and Performance Improvement (QAPI) Program, dated 10/2022, revealed, .This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focuses on indicators of the outcomes of care and quality of life for our residents. Policy Interpretation and Implementation The objectives of the QAPI program are to.2. Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators.Implementation.2. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include.c. identifying and prioritizing quality deficiencies; d. systematically analyzing underlying causes of systemic quality deficiencies; e. developing and implementing corrective action.A record review of the QAPI Committee Meeting Attendance Record provided by the Administrator revealed the most recent meeting was held on 9/26/25. There were no additional QAPI meeting records prior to the State Agency's (SA) entrance on 10/19/25, indicating there were no meetings during or after the influenza outbreak that occurred from 10/8/25 through 10/12/25. During a phone interview on 10/21/2025 at 12:30 PM, the facility's Medical Director/Physician explained he was notified that three (3) residents had tested positive for influenza but was unsure how many residents had signs and symptoms. He explained that when influenza is suspected or confirmed, he depends on the facility staff to follow protocols and notify him as needed. The physician stated that he was unaware whether Enhanced Barrier or Droplet Precautions were implemented during the outbreak and explained that he expects staff to follow infection control policies and procedures. He reported that he had not reviewed or been provided feedback on the facility's outbreak response plan and had not been informed of any challenges in obtaining antivirals or other medications. When asked about staffing, the physician reported he was not aware that only one (1) nurse was on duty overnight during the outbreak but stated that additional staff should have been provided, especially during an increase in resident acuity. He stated that staffing adequacy and infection control are discussed in QAPI meetings and that he relies on facility leadership to ensure appropriate staffing coverage. The physician stated that he was notified of residents' symptoms by phone and was not aware of any meetings with the Administrator, Director of Nursing, or Infection Preventionist regarding the outbreak. He stated that while infection prevention and the facility assessment are discussed during QAPI meetings, the Administrator typically completes the facility assessment. He could not recall whether the outbreak response was reviewed during the last QAPI meeting.During a phone interview with the facility Infection Preventionist (IP) nurse, on 10/21/2025 at 10:00 AM, she explained she was notified on 10/8/2025 that a resident sent to the hospital had tested positive for influenza. She stated that, following the first case, two additional residents tested positive on 10/10/2025 and 10/12/2025. She stated that she did not know what infection-control measures were implemented immediately but believed the two residents who were hospitalized were placed in isolation upon return. The IP stated that contact isolation was implemented rather than droplet precautions and that she was not on-site when the residents returned. She stated that she did not verify that orders were entered or that appropriate signage was placed on the doors. She reported that no line list or illness log was maintained and that she did not track or trend new cases or staff illness. The IP confirmed that the outbreak had not been discussed in a QAPI or Infection Control Committee meeting. The IP stated that she was not aware of staffing levels being affected by illness or call-outs and that she did not maintain any log or tracking system for staff illness. The IP stated that she was unsure if the facility's infection control policy included droplet precautions for influenza and could not recall when the policy was last reviewed or updated. She reported that she had only been in the IP role for a few weeks and was not familiar with who oversaw infection prevention program performance or policy updates.During an interview on 10/21/25 at 1:30 PM, the Administrator and Director of Nursing (DON), the Administrator explained she was notified on 10/11/25 at approximately 1:00 PM that the night nurse had called in sick during the influenza outbreak. The Administrator stated she arrived at the facility around midnight and remained at the [NAME] nursing station to assist the night nurse by answering call lights and notifying the nurse when residents requested medications. The Administrator reported that she notified the Regional Director of Operations of the staffing shortage and that administrative staff assisted as needed. She confirmed the facility's contingency plan allowed administrative staff to assist during emergencies but acknowledged no agency staff were used, and no updates were made to the contingency plan following the incident. The Administrator and DON both stated that only three (3) residents tested positive for influenza, and they did not consider the event an emergency requiring activation of the emergency plan. The Administrator stated the facility assessment used was carried over from the prior Administrator and did not contain a breakdown of the number of licensed nurses and Certified Nurse Aides (CNAs) required per shift or unit. She acknowledged she was unaware the assessment required this detail. She confirmed the assessment had not been revised following the outbreak and that staffing adjustments were made only as needed. Both the Administrator and DON stated that Enhanced Barrier Precautions were used rather than Droplet Precautions and that they did not verify the signage or physician orders for isolation. They confirmed the local health department was not notified of the outbreak and that no signage was posted for families. Staff were verbally educated on mask use, but no documentation of education was maintained. Both confirmed the facility did not initiate an internal investigation into missed medications, did not notify pharmacy, and did not submit a self-report to the State Agency. The DON reported she was out of town during the outbreak and expected all nurses to follow infection control procedures. She stated she became aware of the outbreak when residents were hospitalized and tested positive for influenza between 10/8/25 and 10/12/25. Both the Administrator and DON described the incident as isolated and confirmed no changes had been made to the contingency plan, facility assessment, or infection control processes as a result. There were no meetings with the IP, DON or medical director during or after the outbreak because it was not necessary. They also confirmed that the situation was not reviewed through QAPI or any other quality review process. When asked what lessons were learned from this outbreak and staffing shortage, both staff indicated that it was an isolated incident that occurred, and there were no concerns noted. The facility submitted the following acceptable Removal Plan on 10/22/25:On 10/21/2025 at 4:10 PM, the State Agency presented Immediate Jeopardy (IJ) Templates for five failures of the facility. The facility failed to provide the necessary care and services to protect residents from neglect. Residents did not receive prescribed medications; the physician was not notified of missed medications and supervision was inadequate on 10/12/25. The facility failed to provide sufficient licensed-nurse coverage to meet resident needs during an influenza outbreak resulting in one (1) nurse being assigned responsibility for 58 residents from approximately 12 AM until 7 AM on 10/12/25, resulting in missed medications and lack of monitoring for residents on one unit. The facility failed to identify an influenza (flu} outbreak when three residents tested positive for flu from 10/8/25 through 10/12/25. The facility did not initiate droplet precautions, notify health department, provide timely antiviral treatment, maintain outbreak surveillance or staff illness tracking during outbreak. The facility failed to ensure the facility assessment had required detail on staffing needs by shift and by unit, and the contingency plan for staffing emergencies had no actionable process which resulted in insufficient staffing during an influenza outbreak. The facility failed to use its Quality Assurance and Performance Improvement (QAPI) program to identify and correct system failures in infection control and staffing during an influenza outbreak. 1. On 10/21/2025 at 6:15 PM, the Administrator held an emergency Quality Assurance and Performance Improvement meeting with the Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse and others as part of the Interdisciplinary team to discuss findings from the State Agency, discuss immediate actions, and further interventions. Immediate actions were decided as in-servicing all staff on Abuse and Neglect, in-servicing nurses on medication administration and medication errors, in-servicing all staff on flu outbreak and isolation precautions. The Administrator would review policy for Quality Assurance and Performance Improvement for any changes needed and as re-education in policy. The Administrator would review and update facility assessment to identify updated needs to staff per unit and the contingency plan for emergencies. Administrative nurses would complete a 100 percent audit on all medication carts compared to medication orders to ensure all medications were accessible in the building. The Infection Preventionist would be in-serviced on the roles and responsibilities of an Infection Preventionist. Policies on Abuse and Neglect, medication administration, medication errors, QAPI, flu outbreak, isolation precautions, and the expectations of the Infection Preventionist were all reviewed and updated. Staff were in-serviced with new policies. 2. On 10/21/2025 at 6: 15 PM, the Administrator notified Medical Director of missed medications during QAPI meeting. All missed medications were reviewed with Medical Director during this meeting. No new orders were given. No adverse reactions were noted due to missed medications. 3. On 10/21/2025 at 8:00 PM, the Director of Nursing began an in-service for all staff on the policies and procedures of Abuse and Neglect. No employee was permitted to return to work until they completed the in-service. 4. On 10/21/2025 at 8:00 PM, the Director of Nursing began an in-service on medication administration and medication errors to educate all nursing staff. This in-service included procedures for when medication cannot be located anywhere in the facility. If medication is not available, staff should contact pharmacy and pull medication from emergency kit. Any missed medications are to be reported to the Director of Nursing and Medical Director immediately, an incident report is to be completed, the resident observed for any adverse reactions, and the family/resident representative is to be notified. Any tasks left undone are to be reported to relief during report for oncoming shift. No employee was permitted to return to work until they completed the in-service.5. On 10/21/2025 at 8:00 PM, Administrator and Director of Nursing reviewed Flu outbreak and Isolation precautions policy and procedures. The Director of Nursing began an in service for flu outbreak and isolation precautions to educate all staff. All staff are to continue to monitor residents and staff for flu-like symptoms and report any findings to the immediate supervisor. No employee was permitted to return to work until they completed the in-service. 6. On 10/21/2025 at B: 15 PM, the Administrator reviewed policy on Quality Assurance and Performance Improvement plan and policy for re-education purposes and to review new policy. The Quality Assurance and Performance Improvement plan and policy was reviewed with the facility's Interdisciplinary Team including the Administrator, Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse and others in a follow up Quality Assurance and Performance Improvement meeting held on 10/22/2025 at 4:00 PM. 7. On 10/21/2025 at 8:30 PM, the facility Administrator began reviewing and updating the facility assessment to reflect correct staffing and supervision by shift and by unit related to the facility's acuity level. The Facility Administrator began updating the contingency plan for staffing emergencies within the facility assessment. The facility assessment was updated on 10/22/2025 at 12:00 PM. The contingency plan will be initiated effective 10/22/2025 at 12:00 PM and is as follows: Facility will utilize On-call for staffing needs and call ins. On-call will notify Director of Nursing if not able to cover. Facility will utilize Consultants and/or transfer staff from other nursing facilities within partnership to assist and cover staffing needs. The new facility assessment was reviewed with the interdisciplinary team during follow up QAPI held on 10/22/2025 at 4:00 PM. 8. On 10/22/2025 at 7:00 AM, the Infection Preventionist (IP) was included in an in-service held by the Director of Nursing for policy and procedures of outbreak surveillance and staff-illness tracking during an outbreak to be completed before beginning of their next shift. Due to this outbreak being finished, IP nurse was instructed to continue to monitor residents and staff for flu-like symptoms and to report to Director of Nursing any findings.9.On 10/22/2025 at 3:00 PM, the Director of Nursing, Medical Records nurse, and Wound Care nurse completed a 100 percent audit to compare the current medication orders to the medication on the carts and in medication rooms to verify all medications ordered were readily available in the facility. No negative findings during audit.10. On 10/22/2025 at 3:50 PM, the Administrator notified the Mississippi Department of Health of the flu outbreak beginning 10/8/2025. 11. On 10/22/2025 at 4:00 PM, the Administrator held a follow-up QAPI meeting to discuss all immediate actions that were in place. All in-services and audits were completed. All staff would continue to monitor any residents or staff for flu-like symptoms, staffing would be reviewed daily to ensure all areas were covered according to the facility assessment, and daily reviews of missed medications would be reviewed each morning in clinical meeting. The facility alleges all corrective actions to remove the IJ was completed on 10/22/25 and IJ would be removed on 10/23/2025.Validation: The SA validated the removal plan on 10/28/25 and the immediacy was removed on 10/23/25 prior to exit.

Based on observation, interviews, record review, and facility policy review, the facility failed to implement appropriate infection prevention and control practices to prevent and contain the spread of influenza (flu) when three (3) residents (Residents #1, #53, and #63) tested positive between 10/8/25 and 10/12/25 for (59) of (59) residents in the facility. Additionally, the facility failed to implement Enhanced Barrier Precautions (EBP) during catheter care (a high contact care activity) for Resident #49.The facility's failure to identify the presence of an outbreak, initiate droplet precautions, post appropriate signage, notify the local health department, provide staff and family education regarding the outbreak, ensure the Infection Preventionist and clinical leadership verified isolation orders and monitored staff illness and infection-control compliance, and ensure antiviral medications were administered as prescribed resulted in the continued exposure of residents and the potential for transmission of flu throughout the facility, placing all residents at risk for serious illness, serious harm, serious impairment, or death The situation was determined to be an Immediate Jeopardy (IJ) that began on 10/8/25 when the facility had its first laboratory-confirmed case of flu. The facility Administrator was notified of the IJ on 10/21/25 at 4:10 PM and was presented with the IJ Template. The facility provided an acceptable Removal Plan on 10/22/25, in which they alleged all corrective actions to remove the IJ were completed on 10/22/25, and the IJ removed on 10/23/25.The State Agency (SA) validated the Removal Plan on 10/28/25 and determined that the IJ was removed on 10/23/25, prior to exit. Therefore, the scope and severity for CFR(s) S483.80(a)(1) - Infection Control (F880) was lowered from a L to a F while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements.Findings include:A record review of the facility's policy Influenza, Prevention and Control of Seasonal, revised 01/12/2024 revealed . This facility follows current CDC (Center for Disease Control and Prevention) and State and Federal guidelines and recommendations for the prevention and control of seasonal influenza. Policy Interpretation and Implementation.Surveillance 1. When there is influenza activity in the local community, or one laboratory-confirmed influenza case is identified in the facility, active daily surveillance for influenza illness is conducted among all new and current residents, healthcare personnel, and visitors . Influenza Control Symptomatic Residents and Visitors 1. Residents and visitors are asked to inform staff if they have symptoms of any respiratory infections (. cough, runny nose, fever) . 3. Residents and visitors are reminded to report signs and symptoms of respiratory infection through the posting of signs at the entrance to and in public areas of the facility. 4. Staff are trained in recognizing and reporting signs of respiratory illness observed in residents. 7. Visual alerts (. signs, posters) are posted at the entrance to and in common areas of the facility to provide residents, visitors, and staff with instructions about respiratory hygiene and cough etiquette. 12. Wear a facemask upon entering room of influenza positive or suspected resident. Remove and dispose of facemask when leaving the room. Symptomatic Healthcare Workers 1. The infection preventionist and/or designee monitors and manages ill healthcare personnel. Laboratory Testing for Influenza 1. Laboratory testing for influenza is considered for residents (whether or not it is influenza season): a. with signs and symptoms of influenza; OR b. for high-risk residents who have atypical signs and symptoms, AND c. for residents in which test results will influence clinical management. 2. Confirmation of influenza by laboratory testing is not required in order to prescribe antiviral medication, and antiviral treatment is not delayed while awaiting test results.Infection Precautions 1. Contact and droplet precautions are implemented for residents with suspected or confirmed influenza for seven (7) days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer. Precautions may be applied for longer periods based on clinical judgement.6. Report influenza outbreak to local health department. Two cases is considered an outbreak. 7. Follow CDC guidance for influenza outbreak management. 8. Notify medical director for guidance on administering antiviral treatment during an outbreak.A review of the facility's policy, Enhanced Barrier Precautions, undated, revealed, .Enhanced barrier precautions (EBP)s are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. Policy Interpretation and Implementation.2. EBPs employ targeted gown and glove use during high contact resident care . 3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBP's include: . g. device care or use . urinary catheter .A record review of the CDC Interim Guidance for Influenza Outbreak Management in Long-Term Care and Post-Acute Care Facilities, dated 9/17/2024, revealed, .Residents of long-term care facilities can experience severe and fatal illness during influenza outbreaks.When there is a confirmed or suspected influenza outbreak (2 or more ill residents).When 2 cases of laboratory-confirmed influenza are identified within 72 hours of each other in resident on the same unit, outbreak control measures should be implemented as soon as possible.Even if it's not influenza season, influenza testing should occur when any resident has signs and symptoms that could be due to influenza.Determine if influenza virus is the causative agent by performing influenza testing on upper respiratory tract specimens.Implement daily active surveillance for acute respiratory illness among residents, healthcare personnel and visitor so the facility.Conduct daily active surveillance until at least 1 week after the last laboratory-confirmed influenza case was identified.Test for influenza with.in the following: Ill person who are in the affected unit(s) as well as previously unaffected units in the facility.The local public health and state health departments should be notified of every suspected or confirmed influenza outbreak in a long-term care facility.Implement Standard and Droplet Precautions for all residents with suspected or confirmed influenza.Droplet Precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Droplet Precautions should be implemented for residents with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolutions of fever and respiratory symptoms, whichever is longer, while a resident is in a healthcare facility.These Precautions are part of the overall infection control strategy to protect against influenza in healthcare settings and should be used along with other infection control measures, such as isolation or cohorting of ill residents, screening employees and visitors for illness, furloughing ill healthcare personnel, and discouraging ill visitors from entering the facility.All long-term care facility residents who have confirmed or suspected influenza should receive antiviral treatment immediately.Initiation of antiviral treatment should not wait for laboratory confirmation of influenza.Antiviral treatment works best when started within the first 2 days of symptoms.If exposed, residents on units or wards with influenza cases in the long-term care facility (currently impacted wards) should receive antiviral chemoprophylaxis as soon as an influenza outbreak is determined.Antiviral chemoprophylaxis is meant for residents who are not exhibiting influenza-like illness but may be exposed or who may have been exposed to an ill person with influenza, to prevent transmission.Consider the following additional measures to reduce transmission among residents and healthcare personnel.Have symptomatic residents stay in their own rooms as much as possible, including restricting them from common activities, and have their meals served in their rooms when possible. Limit the number of large group activities in the facility and consider serving all meals in resident rooms if possible when the outbreak is widespread (involving multiple units of the facility.Limit visitation and exclude ill persons from visiting the facility via posted notices.Monitor healthcare personnel absenteeism due to respiratory symptoms and exclude those influenza-like symptoms from work until at least 24 hours after they no longer have a fever.Resident #1A record review of Resident #1's admission Record revealed the facility admitted her initially on 06/16/2022 and re-entry on 03/05/2025 with diagnoses including Chronic Respiratory Failure with Hypoxia and Chronic Obstructive Pulmonary Disease (COPD).A record review from of the History and Physical Notes , from an acute care hospital, dated 10/08/2024 revealed Resident #1 had a . Chief Complaint . temp (temperature) of 101.8 this morning. Diagnosed with pneumonia 1-2 weeks ago. New onset fatigue and tremors. Fever Temp of 103. Further review revealed, Workup in the emergency rooms finds a patient . influenza. Patient is being admitted on broad-spectrum antibiotics and Tamiflu.Problem List/Diagnosis . Active Problems: Influenza A. Assessment/Plan . 2. Influenza A continue Tamiflu.A record review of the Progress Notes revealed Resident #1 had a Health Status Note, dated 10/8/25 at 11:35 AM, indicating that Resident #1 felt as if her pneumonia had returned, reported chills, and wanted to go to the hospital. A record review of a Health Status Note, dated 10/15/25 at 12:40 AM revealed Resident #1 returned from the hospital and another note on 10/15/25 at 10:23 AM indicated Resident tested positive for influenza on 10/8/25.A record review of the Significant Change Minimum Data Set with an Assessment Reference Date (ARD) of 8/26/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) Summary Score of 15, which indicated she was cognitively intact.Resident #53A record review of the admission Record revealed the facility admitted Resident #53 on 06/07/2024 with diagnoses including Unspecified Intracranial Injury with Loss of Consciousness Status Unknown, Subsequent Encounter.A record review of the Physician Emergency Medicine notes, dated 10/12/2025, for Resident #53 revealed . ED (Emergency Department) Diagnosis Influenza A . Chief Complaint . pt (patient) had fever of 105.1 and gave 650 mg (milligram) of Tylenol. Prior to EMS (Emergency Medical Services) arrival, pt fever dropped to 100.4 . Results: Labs: . Influenza A and B . Abnormal for the following components: Result Influenza A Value POSITIVE .Medical Decision Making: . His workup is notable for positive Influenza . Treated with Tamiflu . Provided prescription for Tamiflu . Return Precautions given. A record review of a written medication prescription, dated 10/12/2025, revealed Resident #53 was prescribed Tamiflu 6 mg/ml(milliliters) Suspension and had specific instructions including . take 12.5 mls (75 mg total) by mouth in the morning and take 12.5 mls (75 mg total) before bedtime. Do all this for 9 doses.A record review of the Order Summary Report revealed Resident #53 had Physician Orders to transfer to the hospital for evaluation and treatment to rule out sepsis and influenza, dated 10/12/2025. No droplet or contact isolation orders noted. He had an order dated 10/12/25 for Oseltamivir Phosphate Oral Suspension (Tamiflu), with a Start Date of 10/12/25 and an End Date of 10/16/25. There were no physician orders for isolation or droplet precautions.A record review of the Medication Administration Record (MAR) for October 2025 revealed Resident #53 was administered five (5) doses instead of nine (9). On 10/12/25 and 10/13/25, there was a Chart Code documented as (9) which indicated Other/See Nurse Notes.A record review of the Progress Notes for Resident #53, effective date 10/12/2025 10:58 AM, revealed . Note text: Reports of resident not feeling well. Resident presents with temp of 105.1 . MD (medical doctor) notified of change, instructed to transfer resident to hospital to rule out influenza/sepsis . The Progress Notes with an effective date 10/12/2025 4:10 PM revealed . Note text: resident returned from hospital with influenza A, resident rec'd (received) first dose Tamiflu . resident to be on enhanced precautions for duration of medication and s/s (signs and symptoms) . will check in ekit (emergency kit) for dose for tonight, until pharmacy deliver medications. There were no progress notes explaining the reason for the medication not being administered and instead a Code number nine (9) on the MAR for 10/12/2025 and 10/13/2025.A record review of the RX (prescription) Profiles-Detailed from (Proper Name) Pharmacy revealed Resident #53's Tamiflu medication was not received by the facility until 10/14/2025, which was two (2) days after the medication was prescribed.A record review of Resident #53's Quarterly MDS with an ARD of 09/10/2025 revealed a BIMS score of 3, which indicated severely cognitively impaired.Resident #63A record review of the admission Record revealed the facility admitted Resident #63 on 01/24/2023 with diagnoses including Chronic Systolic (Congestive) Heart Failure. A record review of Resident #63's Lab Results collected on 10/10/2025 revealed a positive result for Influenza A.A record review of Resident #63's Discharge Summary Notes dated 10/14/2025 revealed .admit date : [DATE] . Problem List/Discharge Diagnosis: . Acute on chronic respiratory failure with hypoxia. Active Problems: . Influenza A . Hospital Course: . male who presented . with hypoxia with saturations in high 80s. He was positive for influenza . Patient was admitted to the hospital for acute hypoxic respiratory failure secondary to COPD exacerbation as well as influenza A. Was started on steroids nebulizers BiPAP placed in ICU (Intensive Care Unit) and also placed on Tamiflu .A record review of Resident #63's Order Summary Report revealed there were no Physician's Order for droplet or contact isolation orders. Resident #63 had a Physician's Order, dated 10/14/25 for Tamiflu Oral Capsule 75 mg Give one (1) capsule by mouth two times a day for flu related to Influenza . for 4 (four) days. The Start Date was 10/14/25 and the End Date was 10/18/25. A record review of Resident #63's MAR for October 2025 revealed the Tamiflu medication was not administered on 10/14/24 and a Chart Code of 9 was entered. A record review of Resident #63's Progress Notes with effective date 10/10/2025 5:46 PM revealed . Note text: reports of sob (shortness of breath, resident 100.0 temp . nasal swab collected for influenza culture, covid rapid test completed. Covid rapid presents negative. There was also a noted dated 10/11/2025 1:49 AM revealed . Note text: res (resident) lying in bed. Observed with labored breathing. Res with noted seizure like activity. Temp 105.2 . A progress noted dated 10/15/25 at 6:01 PM revealed . Note text: resident remains on enhance barrier precautions for pneumonia and flu . There were no progress notes indicating why the resident was not administered his prescribed Tamiflu medication on 10/14/25.A record review of the Quarterly MDS with an ARD of 09/24/2025 revealed Resident #63 had a BIMS score of 10, which indicated his cognition was moderately impaired.Resident #49A record review of the admission Record revealed the facility admitted Resident #49 on 9/11/25 with diagnoses including Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms.A record review of the Order Summary Report revealed Resident #49 had a physician's order, dated 9/13/25, for .Catheter care using soap and warm water every shift and as needed.A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/23/25 revealed Resident #49 had a Brief Interview for Mental Status (BIMS) Summary Score of 15, which indicated he was cognitively intact. Section H revealed he had an indwelling catheter.On 10/1/25 at 2:50 PM, during an observation of catheter care for Resident #49, Certified Nurse Aide (CNA) #1 provided incontinence and catheter care without donning a gown as required for Enhanced Barrier Precautions.On 10/1/25 at 3:05 PM, during an interview, CNA #1 confirmed there was no EBP signage on the resident's door and acknowledged she did not wear a gown while providing catheter care.On 10/2/25 at 3:00 PM, during an interview, the Director of Nursing (DON) stated that all staff had been educated on Enhanced Barrier Precautions and she expected staff to comply with EBP requirements for residents at risk. She stated staff had been in-serviced on infection control and EBP the prior week. She further explained that EBP signage should be placed when a resident is admitted or when a change in condition requires EBP. She confirmed Resident #49 had a catheter and required EBP.On 10/2/25 at 4:00 PM, during an interview, Registered Nurse (RN) #1 explained the facility used signs on residents' doors for staff to know who was on EBP and confirmed that she was responsible for placing EBP signage. She stated that she missed placing the sign for Resident #49 and reported that her expectation was for all staff to follow EBP requirements for residents requiring precautions.A record review of the facility's Order Listing Report with order date range from 10/01/2025 through 10/31/2025 revealed a total of five (5) residents received Tamiflu. Four (4) residents on the west unit and one (1) on the TCU unit. A record review of the facility's Infection Control Map for October 2025 revealed three (3) rooms on the west unit with respiratory infections and no residents on the TCU unit were coded for respiratory infections. A record review of the facility's Infection Control Log for October 2025 revealed one (1) resident on TCU treated for URI (Upper Respiratory Infection), one (1) resident on TCU for preventative Flu treatment, one (1) resident on the west unit for preventative Flu, and three (3) residents on the west unit treated for the Flu. A record review of the facility's On Call Log revealed one (1) staff member called in for four (4) shifts related to Flulike symptoms, one (1) staff member called in for two (2) shifts, and one (1) called in for one (1) shift from 10/09/2025 through 10/13/2025 and no further call-in logs were provided. On 10/19/25 at 2:40 PM, during an interview and observation with Licensed Practical Nurse (LPN) #2, she explained that Resident #53 had been moved to a private room after testing positive for influenza (flu). LPN #2 stated that today (10/19/25) was the last day the resident remained on precautions. During the observation, Enhanced Barrier Precaution signage was noted on Resident #53's door, with no indication of droplet or contact precautions. LPN #2 confirmed that the current signage had been in place throughout the weekend and did not include mask requirements. At the time of the observation, no staff were observed wearing masks.On 10/19/25 at 2:50 PM, during an interview with Registered Nurse (RN) #1, who identified herself as the Infection Preventionist (IP) Nurse, she stated that she was new to the position. RN #1 explained that several residents had tested positive for influenza (flu) the previous week. She stated she had been off work during that time but reviewed progress notes during the interview. After reviewing the progress notes for Resident #63, RN #1 stated the resident developed signs and symptoms, including a fever, on 10/10/25 at 5:46 PM, and specimens were obtained for influenza and COVID-19 testing. RN #1 stated the COVID-19 result was negative, and there was no documentation of the influenza result, although the resident was transferred to the hospital later that night at 1:50 AM. She stated that one resident remained hospitalized , others were no longer on isolation precautions, and no residents were currently on contact isolation. RN #1 stated she was unsure which residents had been tested for influenza.On 10/19/25 at 3:15 PM, during an interview with Certified Nurse Aide (CNA) #7, she stated that Resident #53 had been moved to a private room and was informed that isolation precautions were discontinued that day. CNA #7 confirmed that Enhanced Barrier Precaution signage was posted on the door, with no indication of contact or droplet precautions. She stated that Personal Protective Equipment (PPE) was available outside the resident's room and that staff had been wearing masks the previous week when providing care to the resident.On 10/19/25 at 3:50 PM, during an interview with CNA #4, she stated she had just arrived for the 2:00 PM to 10:00 PM shift. CNA #4 reported that several residents had experienced flu-like signs and symptoms since the previous week. She stated that only (1) resident, Resident #53, had been placed on precautions, was moved to a private room, and was no longer on isolation precautions. CNA #4 stated the only Personal Protective Equipment (PPE) she used when entering the resident's room was a mask.On 10/19/25 at 4:10 PM, during an interview with CNA #1, she stated she was working the 2:00 PM to 10:00 PM shift. CNA #1 reported that several residents had complained of flu-like signs and symptoms but confirmed that no residents were on precautions for influenza (flu) at that time.On 10/19/25 at 4:35 PM, during an interview with CNA #8, she stated that several residents on the [NAME] Unit had complained of flu-like symptoms the previous week and that the nurses were informed. CNA #8 reported that multiple residents in the facility had influenza (flu), but the only resident she recalled being on precautions was Resident #53, who had been moved to a private room. She stated that all staff were encouraged to wear masks; however, some staff did and some did not. CNA #8 stated that residents were not as ill as they had been the previous week, although some continued to complain of coughing and requested cough syrup.On 10/19/25 at 4:45 PM, during an interview with Resident #49, he stated that he experienced flu-like signs and symptoms the previous week and was prescribed Tamiflu but was not tested for influenza (flu). Resident #49 stated he wore a mask for a few days while he felt ill but not consistently and was not confined to his room. He stated that group activities continued as usual. Resident #49 reported observing some staff wearing masks and others not and stated he never observed any other residents wearing masks.On 10/19/25 at 4:55 PM, during an interview with Resident #36, she stated that several residents in the facility had been sick with influenza (flu), but she had only experienced coughing and had not developed a fever. Resident #36 stated she had felt unwell for approximately two weeks and was not offered Tamiflu or tested for influenza. She stated she became aware of other residents being ill because some of them were smokers. Resident #36 reported that she knew Resident #1 and other residents had flu-like symptoms. She stated that during smoke breaks and other times, she had not worn a mask and had not observed any other residents wearing masks.On 10/20/25 at 8:45 AM, during an interview with the Administrator, she stated the facility had three (3) residents who tested positive for influenza (flu). The Administrator reported she completed the weekly National Healthcare Safety Network (NHSN) report on 10/18/25 for the week of 10/4/25 through 10/11/25 and planned to complete the report for the following week on 10/25/25. She stated the flu outbreak was reported through the NHSN system but was not reported to the local health department. The Administrator stated she consulted with corporate leadership and was informed that she was not required to notify the local health department. She stated the facility had not yet started administering influenza vaccines; vaccination was scheduled for the week of the outbreak, and the plan was to begin vaccinations the following week. The Administrator confirmed she had not reviewed Centers for Disease Control and Prevention (CDC) guidance related to influenza outbreaks or reporting requirements.On 10/20/25 at 9:00 AM, during a phone interview with the facility's Ombudsman, he stated that he visited the facility on 10/13/25 and observed some staff wearing masks. He stated there was no signage posted at the entrance or on resident room doors to inform visitors of an influenza (flu) outbreak, and no visitor screening was conducted upon entry. The Ombudsman stated that after asking staff about the use of masks, he was informed there was a flu outbreak and was provided a mask to wear. He reported he did not observe the residents who were ill and confirmed that not all residents in the facility were wearing masks.On 10/20/25 at 10:00 AM, during an interview and observation, Resident #12 was observed sitting upright in a recliner. Resident #12 stated he was not aware of any influenza (flu) outbreak in the facility but reported experiencing signs and symptoms, including a sore throat and cough. He stated he had not been offered testing for influenza and had not been prescribed any flu medication.On 10/20/25 at 10:30 AM, during an interview and observation, Resident #63 was observed lying in bed. Resident #63 stated he had been very ill the previous week and was sent to the hospital. He stated the facility tested him for influenza (flu), and hospital staff informed him that he was positive for influenza. Resident #63 reported that upon his return to the facility, he was placed in a room with another resident. On 10/20/25 at 10:45 AM, during an interview with Licensed Practical Nurse (LPN) #5, she stated she worked on the days Residents #53 and #63 were ill. LPN #5 reported that Resident #63 remained hospitalized , and Resident #53 was sent to the hospital and returned to the facility on [DATE]. She stated she moved Resident #53 to a private room and placed Enhanced Barrier Precaution signage on the door instead of Droplet Precaution signage. LPN #5 reported that no one questioned the signage, but masks were placed with the Personal Protective Equipment (PPE) outside the resident's room. She stated she was not aware of any in-service training related to the influenza (flu) outbreak or flu precautions. LPN #5 reported that several residents had flu-like signs and symptoms, but not all were tested or offered Tamiflu. She stated that when Resident #53 returned to the facility, his medications were ordered and later received from the backup pharmacy because Tamiflu was not available in the facility's emergency kit. LPN #5 stated she wore a mask when passing medications but did not always change the mask between residents who were positive and those who were not. On 10/20/25 at 11:30 AM, during an interview with the Director of Nursing (DON), she stated she had been on vacation during the weekend of 10/11/25 and 10/12/25. The DON confirmed she was aware that the first resident tested positive for influenza (flu) on 10/8/25 at the hospital but stated the facility did not implement additional precautions at that time because, to her knowledge, no other residents were exhibiting signs or symptoms. She stated that when Residents #1 and #63 returned from the hospital, she was unsure why they required isolation precautions since both had been hospitalized for approximately five (5) days. The DON confirmed that after Resident #63 returned to the facility on [DATE], he was placed in the same room with Resident #53, who remained on precautions for influenza.On 10/21/2025 at 10:00 AM, during a phone interview with the Infection Preventionist (IP) Nurse, she explained she was notified on 10/8/2025 that a resident sent to the hospital had tested positive for influenza. She stated that, following the first case, two additional residents tested positive on 10/10/2025 and 10/12/2025. The IP reported that she was aware of three residents testing positive for influenza but was not aware of any staff members with flu-like symptoms. She stated that more than two positive cases were considered an outbreak. The IP explained that the Administrator, Director of Nursing (DON), and Medical Director were notified once she became aware of the outbreak. She stated that she did not know what infection-control measures were implemented immediately but believed the two residents who were hospitalized were placed in isolation upon return. She further explained that Resident #1's roommate was moved to another room, and Residents #53 and #63 were cohorted in the same room. The IP stated that contact isolation was implemented rather than droplet precautions and that she was not on-site when the residents returned. She stated that she did not verify that orders were entered or that appropriate signage was placed on the doors. She reported that staff and residents were verbally encouraged to wear masks if desired and that staff were educated on the proper use of personal protective equipment (PPE). She confirmed that no group activities or communal dining were restricted during the outbreak. The IP explained that there were no flu test kits available in the facility initially, and only one resident was tested in-house before being sent to the hospital. She stated that nurses were responsible for documenting resident symptoms and test results in progress notes and that she only recorded positive results on the infection control map. She reported that no line list or illness log was maintained and that she did not track or trend new cases or staff illness. She stated that some residents received Tamiflu if they had symptoms, but she was unsure which residents were treated. She further explained that prophylactic antivirals were not offered to exposed asymptomatic residents and that she was unaware of any delays in obtaining or administering antivirals. The IP stated that the local or state health department was not notified of the outbreak and that the Administrator reported the outbreak to the CDC through the website. She reported that only families of residents who tested positive were notified and that no outbreak notice was posted at the facility entrance. She stated that communication with staff was conducted verbally during shift meetings. The IP confirmed that the outbreak had not been discussed in a Quality Assurance Performance Improvement (QAPI) or in an Infection Control Committee meeting. The IP stated that she was not aware of staffing levels being affected by illness or call-outs and that she did not maintain any log or tracking system for staff illness. She explained that staff who became ill were instructed to see their physician and report back to the facility. She stated that no agency staff were brought in during the outbreak and that she relied on existing staff to clean and disinfect as needed. She reported that she verbally reminded staff to perform hand hygiene and proper cleaning. When asked about staff education, the IP stated that no in-service training specific to influenza precautions had been provided, and staff had only been spoken to verbally. She reported that competency checks for PPE donning and doffing were completed on hire and annually, but not during the outbreak. She stated that cleaning frequencies had been increased and that she believed Environmental Protective Agency (EPA) approved disinfectants were used, but she was not certain. The IP stated that she was unsure if the facility's infection control policy included droplet precautions for influenza and could not recall when the policy was last reviewed or updated. She explained that droplet precautions should be used for influenza

Based on observation, interviews, record review, and facility policy review, the facility failed to protect the resident's right to be free from neglect when licensed nursing staff failed to administer prescribed medications, failed to notify physicians of missed medications, and failed to ensure residents received appropriate supervision and monitoring during a period of increased resident illness and high acuity related to an influenza outbreak for five (5) of (5) residents reviewed for medication administration, Residents #12, #28, #36, #53, and #100. This had the potential to affect all 29 residents on the [NAME] Unit.The facility's failure to provide clear direction regarding nursing coverage responsibilities, ensure appropriate oversight, and timely physician notification for missed medications, placed all 29 residents on the [NAME] Unit at risk for serious illness, serious harm, serious impairment, or death.The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 10/12/25 when one (1) Registered Nurse (RN) was assigned responsibility for all 58 residents in the facility, including 29 residents on the [NAME] Unit and 29 residents on the Transitional Care Unit (TCU), from approximately 12 AM until 7:00 AM. The facility Administrator was notified of the IJ on 10/21/25 at 4:10 PM and was presented with the IJ Template. The facility provided an acceptable Removal Plan on 10/22/25, in which they alleged all corrective actions to remove the IJ were completed on 10/22/25, and the IJ removed on 10/23/25.The State Agency (SA) validated the Removal Plan on 10/28/25 and determined that the IJ was removed on 10/23/25, prior to exit. Therefore, the scope and severity for CFR(s) S483.12(a)(1) Freedom from Abuse, Neglect, and Exploitation (F600) was lowered from a K to an E while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements.Findings include:A record review of the facility's policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program , dated 10/2022 revealed .Residents have the right to be free from abuse, neglect . Policy Interpretation and Implementation. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect . by anyone including: a. facility staff . 3. Ensure adequate staffing and oversight/support to prevent burnout, stressful working situations and high turnover rates . 7. Implement measure to address factors that may lead to abusive situations, for example: a. adequately prepare staff for caregiving responsibilities . 8. Identify . all possible incidents of . neglect.A record review of the facility's policy Administering Medications, dated 8/2023 revealed . Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 4. Medications are administered in accordance with prescriber orders, including any required time frame .A record review of the facility's Nurse Schedule for October 2025 revealed on 10/11/2025 and 10/12/2025, two (2) nurses were scheduled for 7P-7A with one (1) nurse call-in for both days. Further review revealed the facility consistently scheduled two (2) licensed nurses for the 7P to 7A shift and the only RN scheduled for the facility was the RN that worked the night shift (7P to 7A shift.)A record review of the facility's Daily PPD (Per Patient Day) for 10/11/2025 revealed . Census 58 . Day Shift Actual RN (Registered Nurse) :0, LPN (Licensed Practical Nurse): 3, CNA (Certified Nurse Aide): 5 . Evening Shift Actual: RN: 0.5, LPN: 1.5, CNA: 5 . Night Shift Actual RN:1, LPN: 0, and CNA:4 . For 10/12/2025, the Daily PPD revealed . Census 58 . Day Shift Actual RN:0, LPN: 3, CNA:5 . Evening Shift Actual: RN: 0.5, LPN: 1.5, CNA: 5 . Night Shift Actual RN:1, LPN: 1, and CNA:4 .A record review of the facility's daily assignment sheet for 10/11/2025 for 10P-6:30A revealed RN #3 was listed as the TCU Nurse and there was no nurse assigned as [NAME] Nurse.A record review of the facility's Employee Time-Cards for 10/11/2025 revealed RN #3 was the only licensed nurse at the facility from approximately 11:00 PM until 7:00 AM. A record review of the facility's On-Call Log revealed the nurse scheduled for the 7:00 PM to 7:00 AM shift reported illness and called out at 12:00 PM on 10/11/25, providing the facility with approximately seven (7) hours to secure replacement coverage before the shift began. The facility was unable to provide written documentation that leadership attempted to find replacement coverage. A record review of the facility's Daily Census for 10/11/2025 and 10/12/2025 revealed there were 58 active residents at the facility.Resident #12A record review of the admission Record revealed the facility admitted Resident #12 on 07/21/2023 with current diagnoses including Other Intervertebral Disc Degeneration, Lumbar Region with Discogenic Back Pain Only.A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/23/25 revealed Resident #12 had a Brief Interview for Mental Status (BIMS) Summary Score of 14, which indicated he was cognitively intact.A record review of the Order Summary Report with active orders as of 10/22/2025, revealed Resident #12 had Physician's Orders for Gabapentin Tablet 600 mg (milligram) Give 1 table by mouth every eight (8) hours for neuropathy (dated 7/21/23), Hydrocodone-Acetaminophen Oral Tablet 7.5-325 mg (Hydrocodone-Acetaminophen) Give 1 tablet by mouth four times a day for pain (dated 8/8/24), Lasix Oral Tablet (Furosemide) Give 20 mg by mouth one time a day for edema (dated 10/16/23).A record review of the Medication Administration Record (MAR) for October 2025 revealed there was no documentation indicating Resident #12 received the 5:00 AM dose of Hydrocodone or the 6:00 AM doses of Lasix or Gabapentin on 10/12/25.A record review of Resident #12's Controlled Drug Receipt/Record/Disposition Form revealed there was no documentation that Hydrocodone was signed out by the nurse for 10/12/2025 for 5:00 AM administration.On 10/20/25 at 10:00 AM, during an interview and observation, Resident #12 resided on the [NAME] Unit and was observed sitting upright in a recliner. Resident #12 stated he did not receive his morning medications, including his prescribed pain medications, on 10/12/25. He stated he informed the daytime nurse when she arrived for her shift, but by that time, it was too late for the missed medications to be administered.Resident #28A record review of the admission Record revealed the facility admitted Resident #28 on 10/12/2023 with current diagnoses including Unspecified Injury At Unspecified Level of Cervical Spinal Cord, Sequela. A record review of the Quarterly MDS with an ARD of 8/6/25, revealed Resident #28 had a BIMS Summary Score of 15, which indicated he was cognitively intact.A record review of the Order Summary Report with active orders as of 10/22/2025 revealed Resident #28 had Physician's Orders for Cymbalta Oral Capsule Delayed Release Particles 30 mg (Duloxetine HCL) Give 2 capsules by mouth one time a day for depression (dated 1/24/25), Lyrica Capsule 150 mg (Pregabalin) Give 1 capsule by mouth three times a day for Neuropathy (dated 4/5/24), Methocarbamol Oral Tablet 750 mg (Methocarbamol) Give 2 tablets by mouth every eight (8) hours for spasms (dated 5/28/25), Multiple Vitamins-Minerals tablet give 1 tablet by mouth one time a day for supplement (dated 7/18/24), Omega-3 Fish Oil Capsule (Omega-3 Fatty Acids) Give 2 capsule by mouth one time a day for heart health (dated 10/13/23), Percocet Oral Tablet 10-325 mg (Oxycodone w/ (with) Acetaminophen) Give 1 tablet by mouth three times a day for pain (dated 6/3/25), Sennosides Tablet 8.6 mg Give 2 tablets by mouth two times a day for constipation (dated 10/13/23), Sertraline HCL Tablet 100 mg Give 1 tablet by mouth one time a day for depression (dated 1/3/25), and Sodium Chloride Tablet Give 1 tablet by mouth three times a day for hyponatremia (dated 10/13/23).A record review of Resident #28's MAR for October 2025 revealed there was no documentation indicating that the prescribed Pregabalin (Lyrica) and Sodium Chloride were administered at 9:00 PM on 10/11/25. There was no documentation indicating that Omega-3 Fish Oil Capsule, Pregabalin, Percocet, and Sodium Chloride were administered at 5:00 AM on 10/12/25 and there was no documentation indicating that Multiple Vitamins, Sertraline, Sennoside Tablet, Methocarbamol, and Cymbalta were administered at 6:00 AM on 10/12/25. A record review of Resident #28's Controlled Drug Receipt/Record/Disposition Form revealed there was no documentation indicating that Pregabalin was signed out by the nurse for 10/11/2025 at 9:00 PM and 10/12/2025 for 6:00 AM administrations.On 10/20/25 at 9:40 AM, during an interview and observation, Resident #28, who resides on the [NAME] Unit, was lying in bed. He stated he did not receive his morning medications, including his prescribed pain medication, on Sunday morning, 10/12/25. He stated he informed the nurse when she later brought his medications, but she told him it was too late to administer the missed doses. Resident #36A record review of the admission Record revealed the facility admitted Resident #36 initially on 05/20/2022 and reentry on 06/09/2022 with current diagnoses including Hemiplegia. A record review of the Quarterly MDS with an ARD of 9/30/25 revealed Resident #36 had a BIMS Summary Score of 14, which indicated she was cognitively intact.A record review of Resident the Order Summary Report revealed Resident #36 had Physician's Orders for Buspirone HCL Tablet 5 mg Give 2 tablets by mouth every 8 hours for anxiety (dated 8/16/23) , Lorazepam Oral Tablet 1 mg Give 0.5 mg tablet by mouth two times a day for Anxiety (dated 4/28/25), and Novolog Solution 100 unit/ml (milliliter)Inject 5 units subcutaneously with meals for diabetes and Inject per sliding scale subcutaneously before meals and at bedtime for diabetes (dated 11/3/24).A record review of Resident #36's MAR for October 2025 revealed there was no documentation indicating she received Lorazepam, Buspirone, or Novolog at 6:00 AM on 10/12/25. A record review of the Controlled Drug Receipt/Record/Disposition Form revealed Lorazepam for Resident #36 was not signed out on 10/12/25 at 6:00 AM as given by the nurse. Resident #53A record review of the admission Record revealed the facility admitted Resident #53 on 06/07/2024 with the diagnoses including Unspecified Intracranial Injury with Loss of Consciousness Status Unknown, Subsequent Encounter.A record review of the Quarterly MDS with an ARD of 09/10/2025 revealed Resident #53 had a BIMS score of 3, which indicated his cognition was severely impaired.A record review of the Order Summary Report revealed Resident #53 had a Physician's order for Levothyroxine Sodium Tablet 100 mcg (microgram) Give 1 tablet by mouth one time a day related to Hypothyroidism, Unspecified (dated 6/7/24)A record review of the MAR for October 2025 revealed there was no documentation indicating Levothyroxine Sodium was administered at 6:00 AM on 10/12/2025.Resident #100 A record review of the admission Record revealed the facility admitted Resident #100 on 10/08/2025 with the diagnoses of Encounter for Other Orthopedic Aftercare and Gram-Negative Sepsis, Unspecified. A record review of the Order Recap Report revealed Resident #100 had a Physician's Order, dated 10/8/25, for . Cefepime HCL Intravenous Solution 1gm (gram)/50ml Use 1 gram intravenously every 12 hours for infection for 4 days.A record review of the admission MDS with an ARD of 10/15/25, revealed Resident #100 had a BIMS score of 10, which indicated her cognition was moderately impaired. A record review of the MAR for October 2025 revealed there was no documentation indicating Resident #100 received the 8:00 AM doses of IV antibiotics on 10/11/2025 and 10/12/2025. On 10/19/2025 at 3:05 PM, during an interview and observation with Resident #100, resident lying in bed. She explained she was on IV antibiotics but was unable to recall if she had missed any doses. On 10/20/25 at 8:45 AM, during an interview with the Administrator, she explained that on 10/11/25, the nurse scheduled for the 7:00 PM to 7:00 AM shift called in sick around 1:00 PM, reporting a fever. She reported the on-call nurse was also ill and unable to find coverage or report to work. She explained she attempted to obtain coverage from the facility's sister facilities, but no nurses were available. She stated the day-shift nurses agreed to remain until approximately 11:00 PM, leaving one (1) Registered Nurse (RN) in the facility from 11:00 PM until 7:00 AM. She reported the day-shift nurses actually left around 12:00 AM, and because no additional nurse was found to provide care for the [NAME] Unit, she sat at the nurses' station to monitor the unit and notify the RN if assistance was needed. She stated she is not a nurse and was unaware of which medications were administered or missed. She reported that the RN came to the [NAME] Unit only twice to administer a PRN (as needed) pain medication and once to perform a PRN blood glucose check. She explained she did not observe the RN complete the scheduled 5:00 AM or 6:00 AM medication pass. She reported reviewing the Medication Administration Records (MARs) but did not review the 5:00 AM and 6:00 AM medications. On 10/20/25 at 1:00 PM, during an interview with Licensed Practical Nurse (LPN) #1, she reported she worked on 10/11/25 and 10/12/25 and confirmed there was no Registered Nurse (RN) in the facility on the day shift that weekend. She explained Resident #100 was receiving IV medications and, to her knowledge, no IV medications were administered on those dates at 8:00 AM. She stated the night-shift RN arrived on 10/11/25, but there was no nurse assigned to the [NAME] Unit at 7:00 PM. She explained that a number 9 on the Medication Administration Record (MAR) indicates other-see nurse note. She reported she entered 9s on the MAR during the day shift her shifts because she did not administer the IV medications, which were completed by the Director of Nursing (DON) during the week. She stated she was unaware of whether IV medications were administered over the weekend.On 10/20/25 at 1:30 PM, during an interview with LPN #6, she explained she was called in to work on 10/12/25 for the [NAME] Unit after the scheduled nurse called in. She reported she arrived a little after 8:00 AM. She stated TCU nurse, RN #3, completed the medication count for the cart, but no report was given, and there was no mention of any medications not being administered. She confirmed there was no Registered Nurse (RN) in the facility during the 7:00 AM to 7:00 PM shift on 10/12/25.On 10/20/25 at 1:50 PM, during an interview with LPN #7, she explained she was the nurse on call for the weekend of 10/11/25 and 10/12/25. She reported that when the scheduled night nurse called in on 10/11/25, she notified the Administrator, and both attempted to find coverage, but no nurse was available. She stated the day-shift nurses wanted to be relieved, but no coverage could be found, and to her knowledge, they were asked to remain until 11:00 PM. She explained she was unaware if the night-shift nurse had been informed she would be responsible for both units. She stated she knew the Administrator came in and sat at the nurses' station on the [NAME] Unit that night.On 10/20/25 at 2:45 PM, during an interview with the DON, she explained she was out of town at the time of the call-in for the weekend of 10/11/25. She reported receiving multiple phone calls and text messages regarding the staffing shortage but stated she was unable to assist because she was not in town. She explained that she is responsible for the on-call coverage Monday through Friday until 4:00 PM, after which other nurses rotate weekend on-call duty and are expected to work the shift if coverage cannot be found. She reported that during the weekend of 10/11/25 and 10/12/25, the on-call nurse was also sick, and the Administrator stayed in the facility overnight. She stated the nurse working that night should have been able to cover the entire building and complete the medication passes but confirmed she did not speak directly with the nurse to clarify those responsibilities or to ensure the scheduled 8:00 AM IV medication was administered.On 10/20/25 at 5:00 PM, during a phone interview with RN #3, she confirmed she worked the night shift from 7:00 PM to 7:00 AM on 10/11/25 and 10/12/25. She reported she was informed at the start of her shift that the nurse scheduled for the [NAME] Unit had called in sick. She explained she counted off with the nurses on the [NAME] Unit and was told the Administrator would remain at the nurses' station and notify her if any residents on that unit needed medications. She stated she was not told she would be responsible for administering medications for both units and explained it was understood she could not cover the entire building because she had residents on her assigned unit who were sick and required care. She reported she went to the [NAME] Unit a couple of times during the night to administer PRN pain medication and to perform a PRN blood glucose check for a resident requesting a nighttime snack. She stated she administered the 8:00 PM dose of IV antibiotic medication for Resident #100 but did not give the 8:00 AM IV dose because she believed the day-shift RN would complete it. She stated she left the facility at the end of her scheduled shift around 7:00 AM on 10/12/25.On 10/20/25 at 5:30 PM, during a phone interview with Certified Nurse Aide (CNA) #10, she confirmed she worked on 10/11/25 from 10:00 PM to 6:30 AM on the [NAME] Unit. She reported there was no nurse present on the unit after midnight. She explained several residents were complaining of flu-like symptoms during that weekend.On 10/20/25 at 5:45 PM, during a phone interview with Certified Nurse Aide (CNA) #11, she confirmed she worked on 10/11/25 from 10:00 PM to 6:30 AM on the TCU. She reported the facility had only one nurse, an RN, providing care for the entire building after midnight.On 10/21/25 at 9:00 AM, an interview with LPN #4 confirmed she worked on 10/11/25 when the scheduled night-shift nurse called in sick around 1:00 PM. She reported she was not relieved from her medication cart and explained no one specifically asked her to stay until 11:00 PM, but she remained because she knew she could not leave her residents unattended. She stated she left around 11:00 PM after counting the medication cart with RN #3. She confirmed there was no RN in the facility during the 7:00 AM to 7:00 PM shift on 10/11/25 and that many residents were ill with flu-like symptoms. She stated she and the other nurse did the best they could to complete their duties until 11:00 PM but acknowledged some tasks were missed, though she could not recall specific details.On 10/21/2025 at 10:30 AM, during an interview, the Administrator confirmed there was no RN scheduled for the day shift (7 AM to 7PM) on 10/11/2025 and 10/12/2025. She also confirmed that with the flu outbreak, the staffing numbers were low and the acuity of the residents was high. On 10/21/25 at 12:30 PM, during a phone interview with the facility's Medical Director, he reported he had not been informed of any residents who failed to receive medications as ordered and was unaware of any missed or delayed doses during the influenza (flu) outbreak. He stated he was not aware that only one (1) nurse was on duty overnight during the outbreak and explained that additional staff should have been provided given the increased resident acuity. On 10/21/25 at 1:30 PM, during an interview with the Administrator and Director of Nursing (DON), the Administrator explained she reviewed the MAR for evening medications but did not review or address the morning (5:00 AM & 6 AM) medication pass. She stated she did not direct the night nurse to complete the morning medication pass on the [NAME] Unit and was unaware that residents had missed scheduled medications. The DON confirmed she was aware that only one nurse was on duty overnight for approximately sixty (60) residents but stated one nurse should have been able to complete all medication passes. She reported she was not aware medications were missed until notified by the State Agency. The DON explained the facility reviews the MARs daily during Interdisciplinary Team (IDT) meetings but acknowledged the missed doses were not identified because the incident occurred over the weekend. Both the Administrator and the DON described the incident as isolated and confirmed no changes had been made to the contingency plan in the facility assessment.The facility submitted the following acceptable Removal Plan on 10/22/25:On 10/21/2025 at 4: 10 PM, the State Agency presented Immediate Jeopardy (IJ) Templates for five failures of the facility. The facility failed to provide the necessary care and services to protect residents from neglect. Residents did not receive prescribed medications; the physician was not notified of missed medications and supervision was inadequate on 10/12/25. The facility failed to provide sufficient licensed-nurse coverage to meet resident needs during an influenza outbreak resulting in one (1) nurse being assigned responsibility for 58 residents from approximately 12 AM until 7 AM on 10/12/25, resulting in missed medications and lack of monitoring for residents on one unit. The facility failed to identify an influenza (flu} outbreak when three residents tested positive for flu from 10/8/25 through 10/12/25. The facility did not initiate droplet precautions, notify health department, provide timely antiviral treatment, maintain outbreak surveillance or staff illness tracking during outbreak. The facility failed to ensure the facility assessment had required detail on staffing needs by shift and by unit, and the contingency plan for staffing emergencies had no actionable process which resulted in insufficient staffing during an influenza outbreak. The facility failed to use its Quality Assurance and Performance Improvement (QAPI) program to identify and correct system failures in infection control and staffing during an influenza outbreak. 1. On 10/21/2025 at 6:15 PM, the Administrator held an emergency Quality Assurance and Performance Improvement meeting with the Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse and others as part of the Interdisciplinary team to discuss findings from the State Agency, discuss immediate actions, and further interventions. Immediate actions were decided as in-servicing all staff on Abuse and Neglect, in-servicing nurses on medication administration and medication errors, in-servicing all staff on flu outbreak and isolation precautions. The Administrator would review policy for Quality Assurance and Performance Improvement for any changes needed and as re-education in policy. The Administrator would review and update facility assessment to identify updated needs to staff per unit and the contingency plan for emergencies. Administrative nurses would complete a 100 percent audit on all medication carts compared to medication orders to ensure all medications were accessible in the building. The Infection Preventionist would be in-serviced on the roles and responsibilities of an Infection Preventionist. Policies on Abuse and Neglect, medication administration, medication errors, QAPI, flu outbreak, isolation precautions, and the expectations of the Infection Preventionist were all reviewed and updated. Staff were in-serviced with new policies. 2. On 10/21/2025 at 6: 15 PM, the Administrator notified Medical Director of missed medications during QAPI meeting. All missed medications were reviewed with Medical Director during this meeting. No new orders were given. No adverse reactions were noted due to missed medications. 3. On 10/21/2025 at 8:00 PM, the Director of Nursing began an in-service for all staff on the policies and procedures of Abuse and Neglect. No employee was permitted to return to work until they completed the in-service. 4. On 10/21/2025 at 8:00 PM, the Director of Nursing began an in-service on medication administration and medication errors to educate all nursing staff. This in-service included procedures for when medication cannot be located anywhere in the facility. If medication is not available, staff should contact pharmacy and pull medication from emergency kit. Any missed medications are to be reported to the Director of Nursing and Medical Director immediately, an incident report is to be completed, the resident observed for any adverse reactions, and the family/resident representative is to be notified. Any tasks left undone are to be reported to relief during report for oncoming shift. No employee was permitted to return to work until they completed the in-service.5. On 10/21/2025 at 8:00 PM, Administrator and Director of Nursing reviewed Flu outbreak and Isolation precautions policy and procedures. The Director of Nursing began an in service for flu outbreak and isolation precautions to educate all staff. All staff are to continue to monitor residents and staff for flu-like symptoms and report any findings to the immediate supervisor. No employee was permitted to return to work until they completed the in-service. 6. On 10/21/2025 at B: 15 PM, the Administrator reviewed policy on Quality Assurance and Performance Improvement plan and policy for re-education purposes and to review new policy. The Quality Assurance and Performance Improvement plan and policy was reviewed with the facility's Interdisciplinary Team including the Administrator, Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse and others in a follow up Quality Assurance and Performance Improvement meeting held on 10/22/2025 at 4:00 PM. 7. On 10/21/2025 at 8:30 PM, the facility Administrator began reviewing and updating the facility assessment to reflect correct staffing and supervision by shift and by unit related to the facility's acuity level. The Facility Administrator began updating the contingency plan for staffing emergencies within the facility assessment. The facility assessment was updated on 10/22/2025 at 12:00 PM. The contingency plan will be initiated effective 10/22/2025 at 12:00 PM and is as follows: Facility will utilize On-call for staffing needs and call ins. On-call will notify Director of Nursing if not able to cover. Facility will utilize Consultants and/or transfer staff from other nursing facilities within partnership to assist and cover staffing needs. The new facility assessment was reviewed with the interdisciplinary team during follow up QAPI held on 10/22/2025 at 4:00 PM. 8. On 10/22/2025 at 7:00 AM, the Infection Preventionist (IP) was included in an in-service held by the Director of Nursing for policy and procedures of outbreak surveillance and staff-illness tracking during an outbreak to be completed before beginning of their next shift. Due to this outbreak being finished, IP nurse was instructed to continue to monitor residents and staff for flu-like symptoms and to report to Director of Nursing any findings.9.On 10/22/2025 at 3:00 PM, the Director of Nursing, Medical Records nurse, and Wound Care nurse completed a 100 percent audit to compare the current medication orders to the medication on the carts and in medication rooms to verify all medications ordered were readily available in the facility. No negative findings during audit.10.On 10/22/2025 at 3:50 PM, the Administrator notified the Mississippi Department of Health of the flu outbreak beginning 10/8/2025. 11. On 10/22/2025 at 4:00 PM, the Administrator held a follow-up QAPI meeting to discuss all immediate actions that were in place. All in-services and audits were completed. All staff would continue to monitor any residents or staff for flu-like symptoms, staffing would be reviewed daily to ensure all areas were covered according to the facility assessment, and daily reviews of missed medications would be reviewed each morning in clinical meeting. The facility alleges all corrective actions to remove the IJ was completed on 10/22/25 and IJ would be removed on 10/23/2025.Validation:The SA validated the removal plan on 10/28/25 and the immediacy was removed on 10/23/25 prior to exit.

Based on observation, interviews, record review, and facility policy review, the facility failed to provide sufficient licensed-nurse and nurse aide coverage to meet resident needs. Specifically, the facility failed to ensure adequate licensed nurse coverage during an influenza (flu) outbreak for one (1) of two (2) resident care units (the [NAME] Unit) and failed to ensure sufficient nurse aide staffing to provide scheduled showers for three (3) of (17) sampled residents (Residents #24, #54, and #58).The facility's failure to ensure sufficient licensed-nurse coverage resulted in missed medications and lack of resident monitoring on the [NAME] Unit, which placed all 29 residents on the [NAME] Unit at risk for serious illness, serious harm, serious impairment, or death.The situation was determined to be an Immediate Jeopardy (IJ) that began on 10/12/25 when one (1) Registered Nurse (RN) was assigned responsibility for all 58 residents in the facility, including 29 residents on the [NAME] Unit and 29 residents on the Transitional Care Unit (TCU), from approximately 12 AM until 7:00 AM. The facility Administrator was notified of the IJ on 10/21/25 at 4:10 PM and was presented with the IJ Template. The facility provided an acceptable Removal Plan on 10/22/25, in which they alleged all corrective actions to remove the IJ were completed on 10/22/25, and the IJ removed on 10/23/25.The State Agency (SA) validated the Removal Plan on 10/28/25 and determined that the IJ was removed on 10/23/25, prior to exit. Therefore, the scope and severity for CFR(s) S483.35(a)(1)(2) Sufficient Staff (F725) was lowered from a K to an E while the facility develops a plan of correction to monitor the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements.Findings include: A review of the facility's policy, Staffing dated 10/2022, revealed, .Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment.Policy Interpretation and Implementation.2. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. 5. Inquires or concerns relative to our facility's staffing should be directed to the administrator or his/her designee. A record review of the Facility Assessment, dated 7/1/2025 and signed by the Administrator, revealed the Goal as The goal of this assessment is to identify the resources required to provide competent care for our residents during regular operations, including nights and weekends, as well as in emergency situations.Facility Assessment and Staffing Needs a. This facility assessment will be utilized to.d. Review staffing needs for each shift (day, evening, night) .f. Aid in contingency planning for events that, while not necessitating activation of the facility's emergency plan, could impact resident care, such as the availability of direct care nurse staffing. Review of Staffing Needs as per Shift listed Ratio of Staff to Residents or #HPRD (hours per resident day) included the number of hours instead of the number of staff required per shift or per unit. Review of the Contingency Planning for Staffing revealed, In the case of an emergency event, the facility's emergency plan will be activated. If the event does not rise to the level of activation of the facility's emergency plan the facility will utilize staff, accordingly, including utilizing Administrative staff. A review of the facility's [NAME] reporting data revealed the facility triggered excessively low weekend staffing for the third (3rd) quarter, April 2025 through June 2025. A record review of a statement, undated, provided via the Administrator revealed The facility does not have a current policy for Contingency Staffing Plan/Emergency Staffing. A record review of a statement, undated, provided via the Administrator revealed . The facility does not have a staffing policy specific to on-call procedures for call ins. A record review of the facility's Nurse Schedule for October 2025 revealed on 10/11/2025 and 10/12/2025, two (2) nurses were scheduled for 7P-7A with one (1) nurse call-in for both days. Further review revealed the facility consistently scheduled two (2) licensed nurses for the 7P to 7A shift. A record review of the facility's Daily PPD (Per Patient Day) for 10/11/2025 revealed . Census 58 . Day Shift Actual RN (Registered Nurse) :0, LPN (Licensed Practical Nurse): 3, CNA (Certified Nurse Aide): 4 . Evening Shift Actual: RN: 0.5, LPN: 1.5, CNA: 5 . Night Shift Actual RN:1, LPN: 0, and CNA:4 . For 10/12/2025, the Daily PPD revealed . Census 58 . Day Shift Actual RN:0, LPN: 3, CNA:5 . Evening Shift Actual: RN: 0.5, LPN: 2, CNA: 3.75 . Night Shift Actual RN:1, LPN: 1, and CNA:4 . A record review of the facility's daily assignment sheet for 10/11/2025 for 10P-6:30A revealed RN #3 was listed as the TCU Nurse and there was no nurse assigned as West Nurse. A record review of the facility's Employee Time-Cards for 10/11/2025 revealed RN #3 was the only licensed nurse at the facility from approximately 11:00 PM until 7:00 AM. A record review of the facility's On-Call Log revealed the nurse scheduled for the 7:00 PM to 7:00 AM shift reported illness and called out at 12:00 PM on 10/11/25, providing the facility with approximately seven (7) hours to secure replacement coverage before the shift began. The facility was unable to provide written documentation that leadership attempted to find replacement coverage. A record review of the facility's Daily Census for 10/11/2025 and 10/12/2025 revealed there were 58 active residents at the facility. On 10/19/25 at 3:25 PM, during an interview with RN #2, she stated she was assigned on-call duty for the weekend and was working the medication cart that evening for four (4) hours. She stated she heard there was no nurse on duty for the night shift on Saturday, 10/11/25, but confirmed she was not on call and did not work that weekend. She stated the facility's wound care nurse had the on-call phone that weekend, but she was not sure what occurred. She explained the Director of Nursing (DON) is responsible for on-call coverage Monday through Friday until 4:30 PM, and staff nurses rotate on-call duty during weekends. She stated the nurse assigned to on-call duty is required to answer the on-call phone, attempt to find coverage for any call-ins, and, if no coverage is available, report to the facility to work the shift. On 10/20/25 at 8:45 AM, during an interview with the Administrator, she stated that on Saturday, 10/11/25, the nurse scheduled for the 7:00 PM to 7:00 AM shift called in sick around 1:00 PM, reporting a fever. She stated the on-call nurse was also ill that day and was unable to find coverage or report to work. She stated she attempted to obtain coverage from the facility's sister facilities but was told no nurses were available. She stated the day-shift nurses agreed to remain until 11:00 PM, leaving one (1) Registered Nurse (RN) in the building from approximately 11:00 PM until 7:00 AM. She stated the day-shift nurses actually left around 12:00 AM, and because no additional nurse was found for the [NAME] Unit, she went to the nurses' station to monitor activity and notify the RN if assistance was needed. She stated she is not a nurse and was unaware of which medications or treatments were completed. She stated the RN came to the [NAME] Unit twice during the shift, once to administer an as needed (PRN) pain medication and once to perform a PRN blood glucose check. She stated she did not observe the nurse complete any medication pass around 5:00 AM or 6:00 AM. She stated she attempted to review the Medication Administration Records (MARs) to see which medications were scheduled but did not think about the 5:00 AM and 6:00 AM medication pass. She confirmed she did not maintain any written documentation of the efforts made to secure shift coverage. A record review of the admission Record revealed the facility admitted Resident #28 on 10/12/2023 with current diagnoses including Unspecified Injury at Unspecified Level of Cervical Spinal Cord, Sequela. A record review of the Quarterly MDS with an ARD of 8/6/25, revealed Resident #28 had a BIMS Summary Score of 15, which indicated he was cognitively intact. On 10/20/25 at 9:40 AM, during an interview and observation, Resident #28 resided on the [NAME] Unit and was observed lying in bed. Resident #28 stated he did not receive his morning medications, including his prescribed pain medication, on Sunday morning, 10/12/25. He stated he informed the nurse when she later brought his medications, but she told him it was too late to administer the missed doses. A record review of the admission Record revealed the facility admitted Resident #12 on 07/21/2023 with current diagnoses including Other Intervertebral Disc Degeneration, Lumbar Region with Discogenic Back Pain Only. A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/23/25 revealed Resident #12 had a Brief Interview for Mental Status (BIMS) Summary Score of 14, which indicated he was cognitively intact. On 10/20/25 at 10:00 AM, during an interview and observation, Resident #12 resided on the [NAME] Unit and was observed sitting upright in a recliner. Resident #12 stated he did not receive his morning medications, including his prescribed pain medications, on 10/12/25. He stated he informed the daytime nurse when she arrived for her shift, but by that time, it was too late for the missed medications to be administered. On 10/20/25 at 10:45 AM, during an interview with Licensed Practical Nurse (LPN) #5, she stated she worked the 7:00 AM to 7:00 PM shift on 10/11/25 and was assigned to the split medication cart for both the Transitional Care Unit (TCU) and the [NAME] Unit. She stated the nurse scheduled for the [NAME] Unit called in sick around 1:30 PM. She stated there was no supervisor or Registered Nurse (RN) in the facility during the day shift that weekend, and there were critical issues because multiple residents were ill with flu-like symptoms. She stated two (2) residents were transferred to the hospital that day. She stated the other LPN on duty attempted to contact multiple staff for coverage by text and phone but received no response until approximately 5:00 PM. She stated the on-call nurse arrived at the facility around 5:00 PM, handed her and the other LPN the on-call phone, stated she quit, and left the facility because she was sick and unable to work. She stated the Administrator was notified, but no replacement nurse arrived. She stated she and the other LPN remained on duty and were informed that the TCU nurse would count off with them at 11:00 PM. She stated no one specifically asked them to stay, but they stayed voluntarily because no relief arrived, and residents required care. She stated both nurses remained until 11:00 PM after working sixteen (16) consecutive hours and completed all scheduled medication passes through that time. She stated she arrived late on the morning of 10/12/25 after oversleeping and came in at approximately 8:30 AM. She stated the other day-shift nurse called out, and the medical records nurse came in to assist with coverage. She stated that when she arrived, she counted the medication cart with the TCU nurse, and no mention was made of the 5:00 AM medications not being given; however, when she passed her own medications later that morning, several residents told her they had not received their morning medications. On 10/20/25 at 11:30 AM, during an interview with the Director of Nursing (DON), she stated she was on vacation the weekend of 10/11/25 and 10/12/25 and was not available to provide coverage for the nurse who called in sick. On 10/20/25 at 1:50 PM, during an interview with Licensed Practical Nurse (LPN) #7, she stated she was the nurse assigned to on-call duty for the weekend of 10/11/25 and 10/12/25. She stated that around Wednesday, 10/08/25, she began feeling ill and went to the doctor, who ruled out COVID-19 and influenza, so she continued to work while wearing a mask. She stated that on 10/11/25, the scheduled night nurse called in sick, and she notified the Administrator, and both attempted to find coverage. She stated the on-call phone rang throughout the day, and at one point she brought the phone into the facility and told the Administrator she was quitting, but they discussed it, and she agreed to continue to work. She stated the day-shift nurses wanted to be relieved, but no replacement could be found, and to her knowledge, they were asked to stay until 11:00 PM so the night nurse could take over the building. She stated she was unsure if the night nurse was ever told she would be responsible for both units. She stated she knew the Administrator came in that night and sat at the nurses' station on the [NAME] Unit. On 10/20/25 at 5:00 PM, during a phone interview with RN #3, she stated she worked the night shift from 7:00 PM to 7:00 AM on 10/11/25 and 10/12/25. She stated that when she arrived, she was informed another nurse scheduled for the [NAME] Unit had called in sick. She stated she counted off with the nurses on the [NAME] Unit and was told the Administrator would be at the nurses' station and would notify her if any residents on that unit needed medication. She stated she was never informed that she would be responsible for administering medications to residents on both units or completing the morning medication pass for the entire facility. She stated all staff were aware that she could not manage both units because she had multiple residents on the TCU who were ill and required her attention. She stated she went to the [NAME] Unit twice during her shift to administer a PRN pain medication and to perform a PRN blood glucose check for a resident who requested to have her blood sugar checked. On 10/20/25 at 5:30 PM, during a phone interview with Certified Nurse Aide (CNA) #10, she stated she worked on 10/11/25 from 10:00 PM to 6:30 AM on the [NAME] Unit. She stated there was no nurse present on the unit after midnight. She stated several residents were complaining of flu-like signs and symptoms during that weekend. On 10/20/25 at 5:45 PM, during a phone interview with CNA #11, she stated she worked on 10/11/25 from 10:00 PM to 6:30 AM on the TCU. She stated there was only one nurse, a Registered Nurse (RN), in the facility after midnight. On 10/21/2025 at 12:30 PM, during a phone interview with the facility's Medical Director/Physician, he reported he was not aware that only one (1) nurse was on duty overnight during the outbreak but stated that additional staff should have been provided, especially during an increase in resident acuity. He stated that staffing adequacy and infection control are discussed in QAPI meetings and that he relies on facility leadership to ensure appropriate staffing coverage. He explained that he believes the facility should have adequate staff and resources to meet resident needs during an outbreak, but that staffing continues to be an ongoing concern. On 10/21/25 at 1:30 PM, during an interview with the Administrator and DON, the Administrator explained on 10/11/25 she was notified at approximately 1:00 PM that the night nurse had called in sick. She stated that additional attempts were made to contact all nurses, including those at sister facilities, but they were unable to find coverage. The Administrator stated she arrived at the facility around midnight and remained at the [NAME] nursing station to assist the night nurse by answering call lights and notifying the nurse when residents requested medications. She confirmed she reviewed the Medication Administration Record (MAR) for evening medications but did not address the 5:00 AM medication pass. She stated she did not direct the night nurse to complete the morning medication pass and was unaware that some residents did not receive scheduled medications. The Administrator reported that she notified the Regional Director of Operations of the staffing shortage and that administrative staff assisted as needed. She confirmed the facility's contingency plan allowed administrative staff to assist during emergencies but acknowledged no agency staff were used, and no updates were made to the contingency plan following the incident. The DON confirmed she was aware only one nurse was on duty overnight for approximately sixty (60) residents but stated that one nurse should have been able to complete all medication passes. She stated she was not aware medications were missed until notified by the State Agency. Both the Administrator and DON described the incident as isolated and confirmed no changes had been made to the contingency plan or facility assessment. Resident #24 A record review of the admission Record revealed the facility admitted Resident #24 on 8/11/25 with diagnoses including Encounter for Other Orthopedic Aftercare. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/18/25 revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Section F revealed bathing preference was coded as very important. A record review of the Documentation Survey Report for September 2025 revealed Resident #24 was documented as having received one (1) bath on 9/2/25, listed as PRN (as needed), requiring one-person physical assistance. There were no other documented baths for Resident #24 for the month of September 2025. This documentation represented (12) missed showers during the month of September 2025. Resident #54 A record review of the admission Record revealed the facility admitted Resident #54 on 1/2/24 with diagnoses including Cerebrovascular Disease affecting the Left Dominant Side. A record review of the Quarterly MDS with an ARD of 9/10/25 revealed Resident #54 had a BIMS score of 15, which indicated she was cognitively intact. A record review of the Documentation Survey Report for September 2025 revealed Resident #54 was documented as having received one (1) bath on 9/22/25, listed as Bathing/Showers M, W, F (Monday, Wednesday, Friday) X (times) 2 bed baths and X 1 shower, requiring two-person assistance. There were no other documented baths for Resident #54 for the month of September 2025. During an interview on 9/29/2025, Resident #54 stated she received a bath once weekly but wanted to be bathed more often. During a phone interview on 10/1/2025 at 8:35 AM, Resident #54's family member stated she was concerned about her mother's bathing care because the resident's feet were unclean during visits. Resident #58 A record review of the admission Record revealed the facility admitted Resident #58 on 2/10/22 with diagnoses including Type 2 Diabetes Mellitus. A record review of the Comprehensive MDS with an ARD of 9/17/25 revealed Resident #58 had a BIMS score of 15, which indicated she was cognitively intact. Section GG revealed impairment of range of motion in both lower extremities and that she required maximal assistance for bathing, showers, and personal hygiene. A record review of the Documentation Survey Report for September 2025 revealed no documentation indicating Resident #58 received a shower or bath as scheduled on 9/4, 9/9, 9/11, 9/13, 9/23, 9/25, or 9/30/25 for a total of seven (7) missed showers during the month of September 2025. During an interview on 10/1/2025 at 7:40 AM, Resident #58 stated she did not receive her shower the previous evening, despite requesting it several times. She reported the staff were always short and that there were not enough Certified Nurse Aides (CNAs) to complete all resident showers. During an interview on 10/1/2025 at 7:55 AM, CNA #5 confirmed hearing Resident #58 complain about not receiving a shower and stated the resident was truthful. She confirmed there was no documentation in the electronic Kardex indicating Resident #58 received a shower on 9/30/25. During an interview on 10/1/25 at 10:37 AM, CNA #2 stated she was scheduled for three (3) baths that day but had only completed one (1) due to workload. During an interview on 10/1/25 at 11:12 AM, CNA #3 reported there were more residents scheduled on shower days than staff could handle, and she did not feel the facility had enough CNAs to meet resident needs. During an interview on 10/1/2025 at 3:20 PM, CNA #1 stated that usually two (2) CNAs worked per hall on both day and evening shifts, and not all showers were completed. CNA #1 stated staffing levels did not allow all scheduled showers to be completed and that management was aware of the problem. During an interview on 10/1/25 at 5:46 PM, LPN #1 reported staffing levels did not allow staff to provide showers consistently and residents often received bed baths instead. During an interview on 10/2/25 at 3:50 PM, the Director of Nursing (DON) confirmed residents complained of not receiving showers as scheduled. She stated CNA staffing shortages were an ongoing issue. During an interview on 10/2/25 at 4:15 PM, RN #2 stated that staffing shortages were ongoing. During an interview on 10/2/25 at 4:30 PM, the Administrator confirmed the facility did not have sufficient staff to meet resident needs. She stated resident acuity was high, CNA turnover was significant, and staff call-offs were frequent on weekends. The facility submitted the following acceptable Removal Plan on 10/22/25: On 10/21/2025 at 4: 10 PM, the State Agency presented Immediate Jeopardy (IJ) Templates for five failures of the facility. The facility failed to provide the necessary care and services to protect residents from neglect. Residents did not receive prescribed medications; the physician was not notified of missed medications and supervision was inadequate on 10/12/25. The facility failed to provide sufficient licensed-nurse coverage to meet resident needs during an influenza outbreak resulting in one (1) nurse being assigned responsibility for 58 residents from approximately 12 AM until 7 AM on 10/12/25, resulting in missed medications and lack of monitoring for residents on one unit. The facility failed to identify an influenza (flu} outbreak when three residents tested positive for flu from 10/8/25 through 1 0/12/25. The facility did not initiate droplet precautions, notify health department, provide timely antiviral treatment, maintain outbreak surveillance or staff illness tracking during outbreak. The facility failed to ensure the facility assessment had required detail on staffing needs by shift and by unit, and the contingency plan for staffing emergencies had no actionable process which resulted in insufficient staffing during an influenza outbreak. The facility failed to use its Quality Assurance and Performance Improvement (QAPI) program to identify and correct system failures in infection control and staffing during an influenza outbreak. 1. On 10/21/2025 at 6:15 PM, the Administrator held an emergency Quality Assurance and Performance Improvement meeting with the Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse and others as part of the Interdisciplinary team to discuss findings from the State Agency, discuss immediate actions, and further interventions. Immediate actions were decided as in-servicing all staff on Abuse and Neglect, in-servicing nurses on medication administration and medication errors, in-servicing all staff on flu outbreak and isolation precautions. The Administrator would review policy for Quality Assurance and Performance Improvement for any changes needed and as re-education in policy. The Administrator would review and update facility assessment to identify updated needs to staff per unit and the contingency plan for emergencies. Administrative nurses would complete a 100 percent audit on all medication carts compared to medication orders to ensure all medications were accessible in the building. The Infection Preventionist would be in-serviced on the roles and responsibilities of an Infection Preventionist. Policies on Abuse and Neglect, medication administration, medication errors, QAPI, flu outbreak, isolation precautions, and the expectations of the Infection Preventionist were all reviewed and updated. Staff were in-serviced with new policies. 2. On 10/21/2025 at 6: 15 PM, the Administrator notified Medical Director of missed medications during QAPI meeting. All missed medications were reviewed with Medical Director during this meeting. No new orders were given. No adverse reactions were noted due to missed medications. 3. On 10/21/2025 at 8:00 PM, the Director of Nursing began an in-service for all staff on the policies and procedures of Abuse and Neglect. No employee was permitted to return to work until they completed the in-service. 4. On 10/21/2025 at 8:00 PM, the Director of Nursing began an in-service on medication administration and medication errors to educate all nursing staff. This in-service included procedures for when medication cannot be located anywhere in the facility. If medication is not available, staff should contact pharmacy and pull medication from emergency kit. Any missed medications are to be reported to the Director of Nursing and Medical Director immediately, an incident report is to be completed, the resident observed for any adverse reactions, and the family/resident representative is to be notified. Any tasks left undone are to be reported to relief during report for oncoming shift. No employee was permitted to return to work until they completed the in-service. 5. On 10/21/2025 at 8:00 PM, Administrator and Director of Nursing reviewed Flu outbreak and Isolation precautions policy and procedures. The Director of Nursing began an in­service for flu outbreak and isolation precautions to educate all staff. All staff are to continue to monitor residents and staff for flu-like symptoms and report any findings to the immediate supervisor. No employee was permitted to return to work until they completed the in-service. 6. On 10/21/2025 at B: 15 PM, the Administrator reviewed policy on Quality Assurance and Performance Improvement plan and policy for re-education purposes and to review new policy. The Quality Assurance and Performance Improvement plan and policy was reviewed with the facility's Interdisciplinary Team including the Administrator, Medical Director, Director of Nursing, Infection Preventionist, Medical Records nurse, Life Connections Coordinator, Wound Care nurse and others in a follow up Quality Assurance and Performance Improvement meeting held on 10/22/2025 at 4:00 PM. 7. On 10/21/2025 at 8:30 PM, the facility Administrator began reviewing and updating the facility assessment to reflect correct staffing and supervision by shift and by unit related to the facility's acuity level. The Facility Administrator began updating the contingency plan for staffing emergencies within the facility assessment. The facility assessment was updated on 10/22/2025 at 12:00 PM. The contingency plan will be initiated effective 10/22/2025 at 12:00 PM and is as follows: Facility will utilize On-call for staffing needs and call ins. On-call will notify Director of Nursing if not able to cover. Facility will utilize Consultants and/or transfer staff from other nursing facilities within partnership to assist and cover staffing needs. The new facility assessment was reviewed with the interdisciplinary team during follow up QAPI held on 10/22/2025 at 4:00 PM. 8. On 10/22/2025 at 7:00 AM, the Infection Preventionist (IP) was included in an in-service held by the Director of Nursing for policy and procedures of outbreak surveillance and staff-illness tracking during an outbreak to be completed before beginning of their next shift. Due to this outbreak being finished, IP nurse was instructed to continue to monitor residents and staff for flu-like symptoms and to report to Director of Nursing any findings. 9.On 10/22/2025 at 3:00 PM, the Director of Nursing, Medical Records nurse, and Wound Care nurse completed a 100 percent audit to compare the current medication orders to the medication on the carts and in medication rooms to verify all medications ordered were readily available in the facility. No negative findings during audit. 10.On 10/22/2025 at 3:50 PM, the Administrator notified the Mississippi Department of Health of the flu outbreak beginning 10/8/2025. 11. On 10/22/2025 at 4:00 PM, the Administrator held a follow-up QAPI meeting to discuss all immediate actions that were in place. All in-services and audits were completed. All staff would continue to monitor any residents or staff for flu-like symptoms, staffing would be reviewed daily to ensure all areas were covered according to the facility assessment, and daily reviews of missed medications would be reviewed each morning in clinical meeting. The facility alleges all corrective actions to remove the IJ was completed on 10/22/25 and IJ would be removed on 10/23/2025. Validation: The SA validated the removal plan on 10/28/25 and the immediacy was removed on 10/23/25 prior to exit.

Based on observation, staff interview, and facility policy review, the facility failed to ensure food items were stored and maintained in a safe and sanitary manner as evidenced by not discarding expired products and spoiled food and not refrigerating items according to manufacturer's instructions for one (1) of four (4) survey days.Findings include:A review of the facility's policy, Food Receiving and Storage, reviewed 7/24/23, revealed, .Foods shall be stored in a manner that complies with safe food handling practices .On 9/29/25, at 10:28 AM, during an observation and interview, there were (10) loaves of wheat bread that had an expiration date of 9/23/25. In the dry goods room, there were five (5) quarts of nectar-consistency Thick & Easy milk with a use-by date of 8/1/25, and five (5) quarts of moderately Thick & Easy with a use-by date of 5/31/25. Additionally, there was (1) gallon of opened Sweet Baby Ray's teriyaki sauce that was stored on a dry goods shelf despite manufacturer instructions requiring refrigeration after opening. In Refrigerator #1, there was peanut butter pudding with an expiration date of 9/2/25, as well as three (3) bell peppers that were deteriorating and macerated. The Head [NAME] acknowledged and confirmed the findings and stated that the dietary staff who stock the food items were responsible for ensuring they were not expired, refrigerated appropriately, and were not overly ripe.On 10/2/25, at 11:47 AM, during an interview with the Administrator, she stated her expectation is for dietary staff to receive regular in-service training, perform routine checks of dry goods and refrigerator areas, ensure food items are labeled and dated, and consistently follow established procedures. She explained that the dietary staff had been employed at the facility for an extended period and should know how to perform those tasks.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure medications were stored securely and in accordance with professional standards of practice by allowing a resident to have medications stored at the bedside without an assessment for safe self-administration for one (1) of (17) sampled residents (Resident #2).Findings include:A review of the facility's policy, Self-Administration of Medication, revised February 2021, revealed, .Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so.Policy Interpretation and Implementation.9. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge.On 9/29/2025 at 12:07 PM, during an observation and interview, Resident #2 was observed with an inhaler on the bedside table in plain view. Resident #2 explained she used the inhaler as needed.On 9/30/2025 at 2:00 PM, during an observation, Resident #2 was sitting up on the side of the bed. The inhaler remained on the bedside table in plain view, and an empty inhaler box was observed inside the water basin on a shelf in the room.On 10/1/2025 at 8:40 AM, during an observation and interview, Resident #2 was again observed sitting on the side of the bed. The inhaler remained on the bedside table in plain view, and the box was still located in a basin in the room. Resident #2 stated she knew the inhaler was to be used as needed every four (4) to six (6) hours. She explained that staff previously brought her the inhaler, but since she did not always need it when they offered, it was left in her room. She stated she uses it when she feels it is needed and does not notify staff.On 10/1/2025 at 3:30 PM, during an observation and interview with Licensed Practical Nurse (LPN) #4, she stated she was not aware that Resident #2 had an inhaler at the bedside and confirmed the resident had never requested one. LPN #4 observed and confirmed the inhaler was on the bedside table in plain view. She stated Resident #2 had an order for an inhaler, two (2) puffs every four (4) hours as needed for shortness of breath. LPN #4 stated the resident was cognitively intact and capable of self-administering medications but acknowledged she was not aware if an assessment had been completed.On 10/2/2025 at 3:15 PM, during an interview, the Director of Nursing (DON) acknowledged that the facility had not assessed Resident #2 for safe self-administration of medications and that there was not a physician's order authorizing the medication to be kept at the bedside. The DON stated it was her expectation that all medications be stored securely and that medications should not be kept at the bedside unless specifically authorized and assessed.A record review of the admission Record revealed the facility admitted Resident #2 on 12/1/2023 with diagnoses including Simple Chronic Bronchitis and Unspecified Asthma, Uncomplicated.A record review of the Order Summary Report revealed Resident #2 had a physician's order, dated 4/12/24 for .Proventil HFA Inhalation Aerosol Solution.2) puff inhale orally every 4 hours as needed for SOB (shortness of breath). There was no order authorizing the medication to be kept at the bedside.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/19/2025 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident's right to a safe, clean, and comfortable environment when a resident was left with soiled linens for multiple days for one (1) of 17 sampled residents, Resident #2. Findings include:A review of the facility's policy, Resident Rights, revised 11/28/2016, revealed, . (a) Resident Rights. The resident has a right to a dignified existence, self-determination . (i) Safe environment. The resident has a right to a safe, clean, comfortable, and homelike environment . The facility must provide . (3) Clean bed and bath linens that are in good condition.On 9/29/2025 at 12:07 PM, during an observation and interview, Resident #2 was lying in bed with blood noted on the bed sheet and incontinence pad. Resident #2 explained that her legs were weeping and bleeding and that was the reason for the blood. She stated her sheets are only changed on shower days.On 9/30/2025 at 2:00 PM, during an observation and interview, Resident #2 was sitting on the side of her bed. She reported that she had removed the bloody incontinence pad herself but had not had her sheets changed. [NAME] circular areas and other dirty areas were noted on the bed sheet.On 10/1/2025 at 8:40 AM, during an observation and interview, Resident #2 confirmed her bed linens had not been changed since the prior week. [NAME] circular areas and other soiled spots were again noted on the sheet at the foot of her bed.On 10/1/2025 at 2:00 PM, during an interview with Certified Nurse Aide (CNA) #5, she stated that Resident #2 had refused her shower that morning and that she had notified the nurse. CNA #5 confirmed she did not change the resident's bed linens and acknowledged that the linens were dirty. She stated she had left clean linens in the chair in the resident's room to be placed on the bed later.On 10/2/2025 at 9:40 AM, during an observation and interview, Resident #2 was sitting on the side of the bed and stated she did not refuse her shower the previous day, but that staff often said she did. The clean linens remained on the chair where CNA #5 had left them the previous day and the dirty linens remained on the bed.On 10/2/2025 at 10:10 AM, during an interview and observation, CNA #5 confirmed that Resident #2's bed linens were still soiled and that the clean linens remained in the bedside chair.On 10/2/2025 at 3:07 PM, during an interview, the Director of Nursing (DON) confirmed that residents should never be left lying on soiled linens. She stated that linens are expected to be changed at least every other day and as needed.On 10/2/2025 at 4:45 PM, during an interview, the Administrator reported she was made aware of the dirty bed sheets not being changed. She stated her expectation is for all residents to have a safe and clean environment at all times and for staff to change linens immediately when soiled.A record review of the admission Record revealed the facility admitted Resident #2 on 12/1/2023 with diagnoses including Type 2 Diabetes Mellitus.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/19/2025 revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact.

Based on interviews, record review, and facility policy review, the facility failed to develop a comprehensive care plan for a resident with an indwelling catheter (Resident #49) and failed to implement care plan interventions related to baths/showers as scheduled (Resident #54 and #58) for three (3) of 17 sampled residents. Findings include: A record review of the facility's policy Care Plans, Comprehensive Person-Centered dated 10/2022 revealed . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Policy Interpretation and Implementation . 2. The comprehensive, person-centered care plan is developed within seven (7) days of completion of the required MDS (Minimum Data Set) assessment . and no more than 21 days after admission . 7. The comprehensive, person-centered care plan . b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Resident #49 A record review of Resident #49's clinical medical record revealed there was no comprehensive care plan developed for the use and care of an indwelling catheter. A record review of Resident #49's admission Record revealed the facility admitted the resident on 09/11/2025 with the diagnoses including mechanical complication of other urinary catheter. A record review of the Comprehensive MDS with an Assessment Reference Date (ARD) of 09/23/2025 revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively impaired. A review of Section H revealed he had an indwelling catheter. A record review of the Order Summary Report revealed Resident #49 had a Physician's Order, dated 9/13/25 for catheter care. Resident #54 Record review of the Care Plan Report revealed, Focus: I have an Activities of Daily Living (ADL) self -care performance deficit .Interventions/Tasks .Bathing/Showers M, W, F x 2 with bed bath, x 1 with showers . A record review of the admission Record revealed the facility admitted Resident #54 on 1/2/24 with diagnoses including Cerebrovascular Disease affecting the Left Dominant Side. A record review of the Quarterly MDS with an ARD of 9/10/25 revealed Resident #54 had a BIMS score of 15, which indicated she was cognitively intact. A record review of the Documentation Survey Report for September 2025 revealed Resident #54 was documented as having received one (1) bath on 9/22/25, listed as Bathing/Showers M, W, F (Monday, Wednesday, Friday) X 2 (2 person assist) bed baths and X 1 (1 person assist) shower, requiring two-person assistance. There were no other documented baths for Resident #54 for the month of September 2025. This documentation represented (12) missed showers during the month of September 2025. During an interview on 9/29/2025 at 12:54 PM, Resident #54 stated she received a bath once weekly, but wanted baths more than once a week. Resident #58 A record review of the Care Plan Report revealed, Focus: I am at risk for altered ADL function .Interventions/Tasks .Bathing (TTS) (Tuesday, Thursday, Saturday) x 2 bed bath x 1 with shower . A record review of the admission Record revealed the facility admitted Resident #58 on 2/10/22 with diagnoses including Type 2 Diabetes Mellitus. A record review of the Comprehensive MDS with an ARD of 9/17/25 revealed Resident #58 had a BIMS score of 15, which indicated she was cognitively intact. A record review of the Documentation Survey Report for September 2025 revealed no documentation indicating Resident #58 received a shower or bath as scheduled on 9/4, 9/9, 9/11, 9/13, 9/23, 9/25, or 9/30/25 for a total of seven (7) missed showers during the month of September 2025. During an interview on 10/1/2025 at 7:40 AM, Resident #58 stated she did not receive her shower the previous evening, despite requesting it several times. She stated this happens often and that she was lucky to get a shower once a week. During an interview on 10/02/2025 at 3:50 PM, the Director of Nursing (DON) reported she was aware of residents complaining about not getting showers and baths as they are scheduled. This has been an ongoing problem especially with the staffing of Certified Nurse Aides (CNAs). She expects staff to honor each resident's preference of shower and to ask for assistance as needed and follow care plans. The DON confirmed that Resident #49 does have a catheter and reviewed the care plan and confirmed no care plan was implemented for a catheter. During an interview and record review on 10/02/2025 at 4:30 PM, Registered Nurse (RN)#2, she reported the purpose of the care plan is to provide the staff information on how to care for the residents and care plans are to be completed within 21 days after admission and should include all care areas. She reviewed and confirmed Resident #49 did not have a care plan developed for a catheter and reported the resident did have the catheter at the time the comprehensive care plans were completed. She explained she expects all staff to follow each individual resident's care plan to provide quality care for each resident including showers. During an interview on 10/02/2025 at 04:45 PM, the Administrator explained she was aware of staffing and residents not getting showers as scheduled. She does not expect any resident to miss a shower, and she expects showers and baths to be carried out as care planned. She reported she expects all residents to have a completed comprehensive care plan within 21 days after admission and to include all care areas.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure medications were administered in accordance with professional standards of practice, as evidenced by nursing staff did not notify the physician or attempt to obtain medications from an alternate pharmacy source when ordered medications were unavailable for one (1) of five (5) residents observed for medication administration, Resident #9.Findings Include:A review of the facility's policy, Medication Administration - General Guidelines, dated 8/25/14, revealed, .Medications are administered as prescribed in accordance with good nursing principles and practices.On 10/1/25 at 8:37 AM, during a medication administration observation, Licensed Practical Nurse (LPN) #1 failed to administer Resident #9's Icar-C Oral Tablet 100-250 milligrams (mg), one (1) tablet by mouth daily, and Cyanocobalamin Oral Tablet, one (1) tablet by mouth daily. LPN #1 stated the medications were not in the medication cart and were on order. LPN #1 documented a 9 on the MAR, indicating the medications were on order, but failed to notify the physician or the Resident Representative that the resident had not received the ordered medications and did not attempt to obtain the medication from another pharmacy source.On 10/1/25 at 4:10 PM, during an interview, LPN #1 confirmed she did not administer Resident #9's Icar-C or Cyanocobalamin. She explained she was trained to mark 9 on the MAR for medications on order and believed the medication would eventually come in. LPN #1 stated she did not realize she was required to notify the physician when medications were not administered or attempt to obtain unavailable medications from other pharmacy sources.On 10/1/25 at 4:20 PM, during an interview, Registered Nurse (RN) #1 stated LPN #1 should have notified the physician when medications were unavailable. RN #1 stated LPN #1 could have obtained the medications from the local pharmacy as per policy.On 10/1/25 at 4:25 PM, during an interview with the Director of Nursing (DON), she stated LPN #1 should have notified her or a supervisor when the medications were not in the cart so arrangements could have been made to obtain them from the local pharmacy. The DON stated LPN #1 should have notified the physician that Resident #9 did not receive her morning medications.On 10/2/25 at 2:54 PM, during an interview with the Administrator, she stated she expected staff to follow the facility's policy. She explained that if medication was not available, the nurse should notify the DON or the Administrator so arrangements could be made to obtain it from the local pharmacy.A record review of the admission Record revealed the facility admitted Resident #9 on 3/7/25 with diagnoses including Chronic Kidney Disease.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/12/25 revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated her cognition was moderately impaired.A record review of Resident #9's electronic Medication Administration Record (eMAR) for October 2025 revealed scheduled daily medications between 7:00 AM and 10:00 AM included: Cyanocobalamin one (1) tablet by mouth daily and Icar-C 100-250 mg one (1) tablet by mouth daily had a code of 9 and was electronically initialed by LPN #1

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure that residents who were dependent upon staff for activities of daily living (ADL) care received assistance with bathing and personal hygiene as scheduled and in accordance with their needs and preferences for three (3) of (17) sampled residents (Residents #24, #54, and #58).Findings include: A review of the facility's policy, Bath, Shower/Tub, dated 8/25/2014, revealed, .The purposes of this procedure are to promote cleanliness, provide comfort to the resident.Documentation.The following information should be recorded on the resident's ADL record and/or in the resident's medical record: 1. The date and time the shower/tub bath was performed.5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. Reporting.1. Notify the supervisor if the resident refuses the shower/tub bath. Resident #24A record review of the admission Record revealed the facility admitted Resident #24 on 8/11/25 with diagnoses including Encounter for Other Orthopedic Aftercare. A record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/18/25 revealed Resident #24 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Section F revealed bathing preference was coded as very important. A record review of the Documentation Survey Report for September 2025 revealed Resident #24 was documented as having received one (1) bath on 9/2/25, listed as PRN (as needed), requiring one-person physical assistance. There were no other documented baths for Resident #24 for the month of September 2025. This documentation represented (12) missed showers during the month of September 2025. On 10/1/2025 at 2:27 PM, during an interview, Resident #24 stated she preferred to receive her bath after lunch but reported that she typically only received one (1) bath per week. She explained that she wanted to receive a bath more than once a week. Resident #54A record review of the admission Record revealed the facility admitted Resident #54 on 1/2/24 with diagnoses including Cerebrovascular Disease affecting the Left Dominant Side. A record review of the Quarterly MDS with an ARD of 9/10/25 revealed Resident #54 had a BIMS score of 15, which indicated she was cognitively intact. A record review of the Documentation Survey Report for September 2025 revealed Resident #54 was documented as having received one (1) bath on 9/22/25, listed as Bathing/Showers M, W, F (Monday, Wednesday, Friday) X 2 bed baths and X 1 shower, requiring two-person assistance. There were no other documented baths for Resident #54 for the month of September 2025. On 9/29/2025 at 12:54 PM, during an interview, Resident #54 stated she received a bath once weekly, but wanted to receive them more often. On 10/1/2025 at 8:35 AM, during a phone interview, Resident #54's family member stated she was concerned about her mother's bathing care, explaining that she often found her mother's feet unclean during visits, leading her to believe the resident had not been bathed for several days. Resident #58A record review of the admission Record revealed the facility admitted Resident #58 on 2/10/22 with diagnoses including Type 2 Diabetes Mellitus. A record review of the Comprehensive MDS with an ARD of 9/17/25 revealed Resident #58 had a BIMS score of 15, which indicated she was cognitively intact. Section GG revealed impairment of range of motion in both lower extremities and that she required maximal assistance for bathing, showers, and personal hygiene. A record review of a handwritten Certified Nurse Aide (CNA) assignment sheet for the 2:00 PM to 10:00 PM shift dated 9/30/25 revealed Resident #58's name was written in for a shower. A record review of the Tuesday, Thursday, Saturday (TTS) shower schedule dated 9/30/25 revealed Resident #58 was not listed on the schedule. A record review of the Documentation Survey Report for September 2025 revealed no documentation indicating Resident #58 received a shower or bath as scheduled on 9/4, 9/9, 9/11, 9/13, 9/23, 9/25, or 9/30/25 for a total of seven (7) missed showers during the month of September. On 10/1/2025 at 7:40 AM, during an observation and interview, Resident #58 was observed ambulating down the hallway. She stated she did not receive her shower the previous evening, despite requesting it several times. She stated this happens often and that she was lucky to get a shower once a week. She reported the staff were always short and that there were not enough Certified Nurse Aides (CNAs) to complete all resident showers. On 10/1/2025 at 7:55 AM, during an interview, CNA #5 confirmed hearing Resident #58 complain about not receiving a shower. She stated the resident was truthful and preferred showers over bed baths. CNA #5 explained that if a resident refused a shower, the nurse should be notified, and several attempts should be made before documenting a refusal. She reviewed the resident's electronic Kardex and confirmed there was no documentation indicating Resident #58 received a shower on 9/30/25. On 10/1/2025 at 3:20 PM, during an interview, CNA #1 stated CNA #6, who typically worked part-time, had worked the prior evening but was unsure when she would return. CNA #1 stated that usually two (2) CNAs worked per hall on both day and evening shifts, and not all showers were completed. She reported that the number of showers listed on assignment sheets did not match the residents' Kardex documentation. CNA #1 stated this had been an ongoing problem. On 10/1/2025 at 3:30 PM, during an interview, CNA #4 stated she worked the evening shift on 9/30/25 on the 100 Hall and did not see Resident #58 go to the shower. She stated the resident required two-person assistance for transfers. On 10/1/2025 at 5:46 PM, during an interview, LPN #1 confirmed that the facility typically had two (2) CNAs per hall on each shift and stated, They don't have enough staff to give the residents showers like they should, and if they get a bed bath, they're doing good. On 10/2/2025 at 12:21 PM, during an interview, Licensed Practical Nurse (LPN) #5 stated the facility typically had two (2) CNAs assigned per hall, especially on weekends, making it difficult for residents to receive scheduled showers. On 10/2/2025 at 3:50 PM, during an interview, the Director of Nursing (DON) stated she was aware of ongoing resident complaints about missed baths and showers. She confirmed the issue was primarily related to CNA staffing shortages. The DON stated she expected staff to honor residents' bathing preferences and to request assistance when needed. She acknowledged that Resident #58 occasionally refused showers but stated staff should attempt to accommodate her preferred time rather than skip bathing entirely. On 10/1/2025 at 3:53 PM, during an interview with both the DON and the MDS Consultant, a review of documentation for Residents #24 and #54 revealed multiple days in September 2025 without recorded bathing. The MDS Consultant commented, There is something wrong with the documentation. On 10/2/2025 at 4:45 PM, during an interview, the Administrator stated she was aware of the staffing challenges and resident complaints regarding missed showers. She reported that management had discussed revising the shower schedule to better accommodate residents' needs. The Administrator stated she did not expect any resident to miss a shower and expected staff to honor resident preferences, including those who preferred showers to bed baths.

Based on staff interview and record review, the facility failed to accurately document a resident's weight in the medical record for one (1) of 17 sampled residents. Resident #10 Findings include:A record review of the Weights and Vitals Summary for Resident #10 revealed that on 9/5/25 a weight of 76.7 pounds was recorded in the clinical record. However, two (2) days earlier, on 9/3/25, his weight was recorded as 167.2 pounds. Also, on 6/6/25, Resident #10's weight was recorded as 159.5 pounds and five (5) days later, on 6/11/25, the resident's weight was documented as 189 lbs.On 10/1/25 at 3:30 PM, during an interview, the Director of Nursing (DON) identified that weights dated 9/5/25 and 6/11/25 for Resident #10 were entered incorrectly in the electronic medical record.On 10/1/25 at 4:44 PM, during an interview with Registered Nurse (RN) #1 (Nurse Supervisor), she confirmed that the weights documented on 9/5/25 and 6/11/25 were inaccurate and caused the resident's record to incorrectly trigger weight alerts. RN #1 explained that Licensed Practical Nurse (LPN) #2 entered the resident's weight as 76 pounds rather than 76.7 kilograms on 9/5/25, which resulted in the system calculating and triggering a 5% weight loss over a 180-day period. She further stated that LPN #3 entered the weights documented on 6/11/25, which were also inaccurate. RN #1 acknowledged these errors created inconsistencies between the resident's actual clinical status and the weights recorded in the medical record. On 10/2/25 at 11:50 AM, during an interview, the Administrator stated that resident weights are reviewed monthly during quality meetings to identify and correct potential errors. The Administrator stated her expectation is that when more than one staff member inputs weight, there should be a monitoring and follow-up review process to ensure accuracy of documented weights.A record review of the admission Record revealed the facility admitted Resident #10 on 9/16/24 has current diagnoses including Heart Failure.A record Review of Quarterly Minimum Data (MDS) with the Assessment Review Date (ARD) date of 6/18/25, Section K, revealed Resident #10 had a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months.

Based on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of a previously cited deficiency, specifically, the facility was cited for failing to ensure food items were stored and maintained in a safe and sanitary manner by not discarding expired products and spoiled food, and not refrigerating items according to manufacturer's instructions and was cited again for the same deficiency during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of (13) deficiencies cited. F812.Findings Include:Record review of the facility's policy, Quality Assessment and Performance Improvement QAPI Program, dated 10/2022, revealed, .This facility shall.maintain an ongoing, facility-wide, data-drive QAPI program.Policy Interpretation and Implementation The objectives of the QAPI program are to.4. Establish system through which to monitor and evaluate corrective actions.Implementation.2. The QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include.f. monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed.Record review of the Provider History Profile revealed the facility received a citation for F812 - Food Procurement, Store/Prepare/Serve-Sanitary for the annual survey dated 7/17/24. Record review of the CMS-2567 (a record that identifies the federal regulation in violation and describes the findings of noncompliance and the facility's plan of correction), with a survey date of 7/17/2024, revealed the facility received a citation for F812, .Based on observation, staff interviews, and facility policy review, the facility failed to ensure spoiled food items were discarded, food items such as seasonings and spices were not open and exposed, and the food prep area was free from contamination for two (2) of (2) kitchen observations. During the current recertification survey, the facility failed to ensure food items were stored and maintained in a safe and sanitary manner as evidenced by not discarding expired products and spoiled food and not refrigerating items according to manufacturer's instructions for one (1) of four (4) survey days. On 10/02/2025 at 4:45 PM, during an interview, the Administrator stated the facility conducts monthly QAPI meetings addressing high-risk concerns. The Administrator stated she was not the active Administrator during the July 2024 survey but was aware of the previous deficiencies.

Based on observation, interviews, record review, and facility policy review, the facility failed to provide adequate supervision to prevent an elopement for one (1) of four (4) sampled residents, Resident #1. On 9/17/25, Resident #1, who had a Brief Interview for Mental Status (BIMS) score of six (6), and was identified by the facility as an elopement risk, was assisted out of the front door by a Dietary Aide (DA) who thought she was a visitor. She remained outside the facility for approximately 35 minutes, during which the DA left the facility parking lot at approximately 8:50 PM. Resident #1 was found at 9:05 PM knocking on the front entrance door. The facility's failure to provide supervision placed Resident #1 and other vulnerable residents at risk for serious injury, serious harm, serious impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 9/17/25, when Resident #1 exited the facility. The State Agency (SA) notified the Administrator of the IJ on 9/23/25 at 2:00 PM and provided an IJ Template. Based on the facility's implementation of corrective actions on 9/18/25, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed as of 9/19/25 prior to the SA's entrance on 9/22/25. Findings include:A review of the facility's policy, Elopement/Unsafe Wandering Plan, dated February 7, 2012, revealed, .It is the policy of this facility to protect the resident from harm while providing care in a manner that helps promote quality of life in a safe environment.Definitions.3. Elopement-Elopement occurs when a resident leaves the premises or a safe area without authorization. A record review of the facility's investigation revealed on 9/17/2025, at 9:00 PM, Certified Nurse Assistant (CNA) #1, identified that Resident #1 was not in the common area or in her room when she returned from her lunch break. The Registered Nurse/Minimum Data Nurse (RN/MDS) was in the facility and was notified that Resident #1 was not on her side of the building. The RN/MDS nurse immediately called a Code W (elopement) and initiated a search of the building and perimeter. CNA #2 found Resident #1 who was knocking on the front door at 9:05 PM while searching in her assigned area; Resident #1 was dressed appropriately for the weather and had her purse on her shoulder. Resident #1 was escorted back into the building with no issues of distress noted. The Administrator and the Director of Nurses (DON) were notified of the incident. The RN/MDS completed a body audit with no signs or symptoms of injury. The RN/MDS completed a head count of all current residents in the facility, and all residents were accounted for. She also notified the medical provider and Resident Representative (RR). The Administrator arrived at the facility and checked that all doors were functioning properly. The root cause analysis determined by the Administrator and DON found that Resident #1 followed a dietary employee while he was leaving at the end of his shift. It was determined through interviews that the dietary employee was unaware that Resident #1, was a resident and was under the impression that she was a visitor. A record review of the admission Record revealed the facility admitted Resident #1 on 9/16/25 with current diagnoses including Wernicke's encephalopathy and vascular dementia. A record review of the BIMS (Brief Interview for Mental Status) Interview MDS, dated 9/16/25, revealed Resident #1 had a BIMS score of 6, which indicated her cognition was severely impaired. A record review of the local weather report revealed on 9/17/25 from 7:55 PM to 8:55 PM, the temperature was 83 degrees and clear.On 9/22/25 at 8:30 PM, during an observation of the facility and surrounding area, the facility is located approximately 925 feet from a four-lane highway and is situated within an industrial complex with multiple surrounding commercial buildings. A wooded area borders the south side of the property. The facility grounds include a paved parking lot with designated spaces for staff and visitors, and sidewalks providing access to the front entrance. Multiple exterior lights were observed around the building perimeter, including at the front entrance and doorways. There are no fencing or restricted barriers observed between the facility grounds and the surrounding industrial area.On 9/22/25 at 9:15 PM, during an interview with CNA #1, she confirmed that she was assigned to Resident #1 on 9/17/25. She reported that she last observed the resident sitting in the main lobby prior to leaving for her scheduled lunch break at approximately 8:30 PM. CNA #1 stated that when she returned from break around 9:00 PM, Resident #1 was not in her room or in the lobby. She immediately notified the RN/MDS nurse and other staff that the resident was missing, and a facility-wide search was initiated. At approximately 9:05 PM, CNA #2 located Resident #1 knocking on the facility's front door. CNA #1 confirmed that she was aware the resident was care-planned as an elopement risk, with 15-minute checks in place and identification in the wander book. She stated the facility followed its elopement policy, secured exits, and ensured all residents were accounted for. She further reported that after the incident, she was included in an in-service on elopement prevention and policies.On 9/22/25 at 9:25 PM, during an interview with CNA #2, she stated that on 9/17/25 while working on her unit, staff realized Resident #1 was not accounted for. CNA #2 explained that at approximately 9:00 PM, CNA #1 asked if she had seen Resident #1. When she confirmed she had not, the facility immediately implemented its elopement policy and all staff began searching the building and grounds. CNA #2 reported that she was aware Resident #1 was identified as an elopement risk in the wander book and wore a yellow bracelet. She began her search in the main lobby and near the front entrance of the facility. While checking that area at approximately 9:05 PM, she heard knocking at the front door. Upon opening the door, she identified Resident #1 outside the facility. She confirmed that the resident was appropriately dressed for the weather, carrying her purse, did not appear injured or distressed, and was safely escorted back inside. CNA #2 revealed that following the event, she observed the RN/MDS nurse complete a body audit and headcount of all residents. She further reported that she later participated in a staff in-service regarding the facility's elopement policy and procedures.On 9/23/25 at 11:20 AM, during an interview with Dietary Aide #1, he revealed that on 9/17/25, after completing his dietary shift, he clocked out and went to leave the building. He explained that he did not know the exit code, so he went to a nurses' station to obtain it. After entering the code at the front door, he exited the facility. At that time, an individual followed closely behind him and opened the door as he exited. Dietary Aide #1 reported that he did not recognize the person as a resident, as she was dressed in street clothes appropriate for the weather and was carrying a purse. He assumed she was a visitor leaving at the same time. The employee revealed that once he entered his father's car, both he and his father observed the woman attempt to get into a parked vehicle in the lot. When she discovered the car was locked, she returned to the facility's front entrance. He confirmed that later he learned that the individual was Resident #1. He stated he had previously received annual training on elopement prevention and resident identification but admitted he did not initially recognize Resident #1 as a resident due to her appearance and belongings. Following the incident, the employee confirmed he received re-education on the elopement policy, door security procedures, and how to identify and respond if a resident attempts to exit with staff or visitors.A record review of the Employee Time Cards revealed on 9/17/25 Dietary Employee #1 clocked out of the facility at 8:27 PM.On 9/23/25 at 1:32 PM, during an interview, the RN/MDS confirmed that on 9/17/25, at approximately 9:00 PM, she was informed that Resident #1 was missing from her unit. She immediately called a Code W (elopement). All staff secured the doors, conducted a head count of all residents, and began a facility-wide search. At approximately 9:05 PM, Resident #1 was located at the front door, knocking to be let back inside. The RN/MDS stated that following the event, she notified the Administrator and Director of Nursing (DON). Once all residents were accounted for, the resident's physician and RR were also notified. Resident #1 was assessed and had no injuries. She was observed to be dressed in a gray short-sleeved shirt, brown shorts, and sandals, with her purse on her shoulder and sunglasses on top of her head. The RN/MDS further explained that Resident #1 had previously been assessed as an elopement risk, and her name and information had been placed in the elopement books located at each nurses' station, the kitchen, and therapy department. She also wore a yellow elopement-risk bracelet. Following the incident, the resident's care plan was updated with new interventions.On 9/23/25 at 1:50 PM, during an interview with the Administrator, she confirmed that on 9/17/25 at approximately 9:00 PM, staff identified that Resident #1 was missing, and the MDS nurse immediately initiated a Code W (elopement). Staff secured all doors, conducted a head count, and began searching the building and perimeter. At approximately 9:05 PM, the resident was found knocking at the front door, appropriately dressed and without distress. A body audit revealed no injuries, and the medical provider and responsible representative were notified. The Administrator stated she verified the doors were functioning, interviewed involved staff and residents, and initiated in-services for all employees on elopement procedures before their next shift. The incident was reported to State Agency (SA) and the Attorney General's office, and an emergency Quality Assurance Performance Improvement (QAPI) meeting was held to implement corrective actions. These included door quality checks, alarms on exits, elopement drills on all shifts, wander assessments on all residents, and audits of care plans and elopement books. She further explained that the root cause analysis determined the resident had followed Dietary Aide#1 out of the building, as the employee mistakenly assumed the resident was a visitor.On 9/23/25 at 1:50 PM, during an interview, the Director of Nursing (DON) confirmed that on 9/17/25 she was notified by the Administrator and RN/MDS that Resident #1 had been found outside the facility, knocking on the front door. The DON stated that the RN/MDS verified all residents were accounted for and notified the resident's physician and RR. Resident #1 was assessed with no injuries noted and was observed to be appropriately dressed in a gray short-sleeve shirt, brown shorts, sandals, with her purse on her shoulder and sunglasses on top of her head. The DON further confirmed that Resident #1 had previously been assessed as an elopement risk, with her name and information placed in the elopement books located at each nurses' station, the kitchen, and therapy department. The resident also wore a yellow elopement-risk bracelet. Following the incident, the resident's care plan was updated with additional interventions.The facility submitted a corrective action plan as follows:9/17/25 at 9:00 PM, CNA#1 noted that Resident #1 was not in the common area or in her room when CNA #1 returned from her lunch break. CNA #1 reported to MDS Nurse #1 that Resident#1 was not in the common area or in her room. MDS Nurse called Code W (elopement), and all staff began a search of the facility and perimeter.9/17 /25 at 9:05 PM, CNA#2 was searching in the front of the building where the conference room and business office are located and heard Resident #1 knocking on the front door. Resident#1 was brought in with no signs of distress, only stating she was lost. Resident#1 was clothed appropriately with her purse on her shoulder. The weather was clear skies and around 75 degrees.9/17/25 at 9:10 PM, Administrator was notified by MDS Nurse about the incident. The Administrator notified the Director of Nursing (DON) of incident.9/17/25 at 9:18 PM, MDS Nurse completed body audit with no signs or symptoms of injury.9/17125 at 9:30 PM, MDS Nurse completed a head count of all current residents in the facility, and all residents were accounted for.9/17 /25 at 9:40 PM, MDS Nurse notified Resident #1 's representative of the incident.9/17/25 at9:45 PM, Medical Director (MD) was notified of Resident#1's incident and no new orders were given.9/17/25 at 10:15 PM, the Administrator arrived at the facility and checked that all doors were functioning properly. The Administrator interviewed all employees and any residents that had interactions with Resident #1 prior to the incident.9/17/25 at 10:30 PM, Administrator began in-service for all employees on elopement policy and procedures. All staff would be in-serviced before returning to their next shift.9/17/25 at 10:46 PM, Administrator reported incident to State Agency.9/18/25 at 9:00 AM, an emergency Quality Assurance & Performance Improvement (QAPI) committee meeting was held to discuss incident, actions taken, and further interventions.9/18/25 at 9:15 AM, Social Services Director spoke with Resident #1 and noted no psychosocial harm due to incident.9/18/25 at 10:30 AM, Maintenance Director conducted a quality check of all doors to make sure they were operating as expected and door alarms were added to all of the doors. 9/18/25 at 11:00 AM, Regional Director of Operations interviewed Resident#1 and Resident #2 for any details they remember about the incident.9/18/25 at 12:25 PM, during education of elopement policy and procedures with dietary staff, Dietary Aide #1 stated that Resident #1 had followed him out of the building on 9/17/25. Dietary Aide #1 clocked out at 8:27 PM and went to the front door to exit. Dietary Aide #1 did not know the new front door code and went to nurse's station to get code. When Dietary Aide #1 came back through the facility, the resident followed him to the front door and went out behind him after 8:30 PM. Dietary Aide #1 stated that he sat in the parking lot until 8:50 PM with eyes on Resident #1 trying to determine if Resident #1 was a visitor.9/18/25 at 2:00 PM, wander assessments were completed on all active residents in the facility by DON, Registered Nurse (RN) #1, Licensed Practical Nurse (LPN) #1, and Medical Records LPN. One out of sixty-one residents was identified at risk for elopement.9/18/25 at 2:00 PM, Maintenance Director began elopement drills for all shifts and completed on 9/19/2025 at 5:30 AM.9/18/25 at 3:30 PM, a follow up QAPI committee meeting was held by Administrator to discuss that all interventions were in place. These interventions are as follows: Maintenance will conduct a quality check of all doors, an elopement drill on each shift within the next 24 hours and put alarms on each of the doors. Completed on 9/18/2025 at 2:00 PM: Administrative nurses completed wander assessments on all current residents, update care plans and wander books accordingly; completed a 100 percent audit of care plans; completed 100 percent audit of wander books located at both nurse's stations. Social services would interview Resident #1 for any psychosocial harm. Administrative staff would in-service all employees on elopement policy and procedures before their next shift. The root cause analysis determined by Administrator and DON found that the resident followed out a dietary employee while he was leaving at the end of his shift. It was determined through interviews with Dietary Aide #1 that he was unaware that Resident #1 was a resident, under the impression that she was a visitor. The QAPI committee meeting determined at this time to prevent further adverse events the interventions would include elopement drills on all shifts and one elopement drill per week for four weeks on alternating shifts and one per month for six months on alternating shifts. Person-centered in-services will be completed with all staff for any new residents identified as an elopement risk or any current residents who are newly identified as an elopement risk.9/22/25 at 4:40 PM, incident was reported to Attorney General's office by Administrator.Facility alleges that all corrective actions were complete on 9/18/2025 and Immediate Jeopardy removed on 9/19/2025.Validation:The SA validated through interview and record review view, that all corrective actions had been implemented as of 9/18/25, and the facility was in compliance as of 9/19/25, prior to the SA's entrance on 9/22/25.

Based on staff interview, record review, and facility policy review, the facility failed to ensure a resident's safety during a bed bath, in which Resident #2 fell from the bed to the floor, sustaining fractures to her bilateral lower extremities for one (1) of four (4) residents reviewed for falls. Findings Include: A review of the facility's policy titled Accidents and Incidents, undated, revealed It is the policy of this facility that the resident environment remains as free of accidents and hazards as possible and those residents receive supervision and assistance devices to prevent accidents whenever possible . A record review of the facility's investigation of Resident #2's fall with fractures revealed that on 12/21/24 at approximately 10:45 AM, Certified Nurse Assistant (CNA)# 1 provided care and a bath to Resident #2 while turning her in the bed on her left side. CNA#1 attempted to reach to hold onto the resident, but due to her being slippery, she rolled out of bed. A record review of the Hospitalist Discharge Note, dated 12/22/24, indicated in the Hospital Course that Resident #2 was receiving a bath when she fell from the bed onto her knees, suffering bilateral femoral fractures . During a phone interview with CNA #1 on 1/22/25 at 3:30 PM, she confirmed that she was assisting Resident #2 with her bed bath. CNA #1 stated that Resident #2 helped during her bath because she could roll in the bed on each side, using the side rail. On that day, since she was slippery due to her bath, she could not catch her while turning. She accidentally fell to the floor on her knees while holding on to the siderail and I could not catch her before she slipped off the bed. CNA #1 immediately notified the nursing supervisor and called for assistance for Resident #2. During a phone interview with Registered Nurse #1 on 1/27/25 at 10:00 AM, she revealed on 12/21/24 that CNA #1 summoned her to Resident #2, finding the resident on the floor next to her bed. CNA #1 stated that when she gave her a bed bath, the resident was slippery and fell to the floor, and she could not catch her from falling. Resident #2 complained of bilateral knee pain and the nurse immediately phoned the local emergency medical response. Then she notified the medical provider, Resident Representative (RR), Director of Nursing (DON), and the Administrator. On 1/27/25 at 10:30 AM, during an interview with the DON, she confirmed that she was aware of the fall that occurred with Resident #2 on 12/21/24. The DON stated she immediately began an investigation, and all notifications were made. The DON confirmed that Resident #2 was able to assist with bed mobility for turning and repositioning in her bed for bed baths. The DON stated the fall was an accident due to Resident #2 being wet and slippery during the bed bath. On 1/27/25 at 10:45 AM, an interview with the Administrator confirmed that she was notified of the fall that occurred on 12/21/24 with Resident #2. She stated the facility investigated the allegation and ruled the fall as accidental. A record review of the Admission Record revealed the facility admitted Resident #2 on 3/27/24 and she had diagnoses including Atrial Fibrillation. A record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/25/2024 revealed Resident #2 had no impairment to her upper extremities, was not dependent for showering and bathing self, and was able to roll left and right with partial/moderate assistance.

Based on staff interview, record review, and facility policy review, the facility failed to ensure its Quality Assurance Performance Improvement (QAPI) program effectively addressed and prevented the recurrence of resident accidents. This failure resulted in a resident sustaining bilateral fractures, despite a prior citation for F689 on 10/3/24, which indicates the facility did not sustain systemic corrective actions to prevent the recurrence for one (1) of four (4) sampled residents. Resident #2. Findings Include: A review of the facility's Quality Assurance and Performance Improvement (QAPI) Program dated 10/22, revealed, .The facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents . A record review of the Centers for Medicare and Medicaid Services (CMS) Form 2567 (a record that identifies the federal regulation in violation and describes the findings of noncompliance and the facility's plan of correction), dated 10/3/24, revealed the facility was cited F689 (Accident Hazards) when two Certified Nurse Aides (CNAs) improperly positioned a resident in bed, resulting in a fall with an injury. A record review of the facility's investigation of Resident #2's fall with fractures revealed that on 12/21/24 at approximately 10:45 AM, Certified Nurse Assistant (CNA)# 1 provided care and a bath to Resident #2 while turning her in the bed on her left side. CNA#1 attempted to reach to hold onto the resident, but due to her being slippery, she rolled out of bed. During an interview with the Director of Nurses (DON) on 1/27/25 at 11:00 AM, she confirmed she reviewed the CMS-2567 from the survey on 10/3/24. She stated the facility continued to conduct audits to monitor compliance of residents having a safe environment and to prevent accidents as per the plan of correction. During an interview with the Administrator on 1/27/25 at 11:20 AM, the facility performed audits to monitor the residents for safety and accident prevention. She commented that she was going to take the concerns regarding accident/hazards back to the (QAPI) committee to again develop action plans and audits.

Based on interviews, record review, and facility policy review, the facility failed to protect a vulnerable resident when Certified Nursing Aide (CNA) #1 and CNA #2 did not safely position Resident #1 in the bed allowing the resident to fall to the floor for one (1) of four (4) residents reviewed for falls. (Resident #1) Findings Include: A review of the facility's undated policy titled Accidents and Incidents revealed: It is the policy of this facility that the resident environment remains as free of accidents and hazards as possible and that residents receive supervision and assistive devices to prevent accidents whenever possible . A record review of the facility's investigation revealed on 9/19/24, around 8:05 AM, the Director of Nursing (DON) notified the Administrator of an allegation of abuse between Resident #1 and CNA #1. Resident #1 alleged that CNA #1 pushed her out of bed during care. An investigation was initiated by the DON and the Administrator. CNA #1 was suspended pending investigation, and the incident was reported to the State Agency (SA) Attorney General's Office (AGO), and the local Police Department. The family and the medical director were also notified. The investigation concluded that the allegation of abuse was not substantiated, and the incident was ruled accidental. During an interview on 10/01/24 at 9:15 AM, Resident #1 stated that she was sleepy on 9/19/24 while CNA #1 and CNA #2 provided care and she was unaware that CNA #2 had left the room. She explained that CNA #1 was standing behind her and that CNA #1 pulled the draw sheet to turn her over and it felt like CNA #1 had pushed her out of bed and she fell face down onto the floor. Resident #1 explained that she was unable to grab the bed rails because she did not realize she was that close to the edge of the bed. During an interview on 10/01/24 at 9:30 AM, CNA #1 stated that she was providing care with the help of CNA #2 for Resident #1 on 9/19/24. They were going to transfer her to her wheelchair, but noticed her brief needed to be changed. CNA #2 left the room and CNA #1 stayed in the room with the resident. Resident #1 was positioned on her side and after CNA #2 left the room, the resident began to slide out of bed. CNA #1 stated she was unable to catch the resident, and she fell to the floor. CNA #1 said she went to the door to tell the nurse. During an interview on 10/01/24 at 10:00 AM, CNA #2 stated that on 9/19/24, CNA #1 had asked for her help with getting the resident up and that she needed a new brief. CNA #2 said she left the room and confirmed the resident was lying on her left side facing the wall. During an interview on 10/03/24 at 9:30 AM, Licensed Practical Nurse (LPN) #2 confirmed that on 9/19/24, she heard a loud thump and saw the resident on the floor after CNA #1 came out of the room. She notified the resident's nurse and prepared the resident for transfer to the emergency room . During an interview on 10/3/24 at 9:46 AM, with LPN #3 she confirmed she was the nurse that was responsible for taking care of Resident #1 on 9/19/24. LPN #3 explained that LPN #2 called for her to come out of the medication room and go to Resident #1's room because she had fallen. LPN #3 stated that when she entered the room CNA#1, was standing in the room in a daze. She asked CNA #1 where the resident was because there was no one in the bed and CNA #1 stated that the resident was on the floor. The nurse stated she observed Resident #1 on the other side of the bed lying on her right side between the bed and the wall. Resident #1 was lying face down on her right side. The nurse stated that the bed was elevated to the waist level and Resident #1 had an opened brief between her legs on the floor that was saturated in urine. LPN #3 said the resident's bed had a draw sheet and an incontinent pad that was saturated in urine. LPN#3 also explained she assessed Resident #1 because she was bleeding from her right elbow, had a bruise on her right side, a bruise on the right side of her head, and her right knee had begun to swell. Resident #1 told her that CNA #1 pushed her out of the bed, and she did not want her back in her room ever again. Resident #1 was then sent to the emergency room for an evaluation. During an interview on 10/03/24 at 11:30 AM, the DON confirmed that she was aware of the fall that occurred with Resident #1 on 9/19/24. The DON stated she immediately began an investigation and made notifications. The DON confirmed the CNA did not ensure Resident #1 was positioned safely in the bed and should have had two people with bed mobility. During an interview on 10/03/24 at 11:45 AM, the Administrator confirmed he had been notified of the fall that occurred on 9/19/24 with Resident #1. He stated the facility investigated the allegation and ruled the fall as accidental. A record review of the Admission Record revealed the facility admitted Resident #1 was admitted to the facility on [DATE] with diagnoses including Paraplegia. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/07/24 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of fifteen (15), indicating the resident was cognitively intact. Section GG revealed Resident #1 required substantial assistance with rolling left to right while in bed.

Based on observation, staff interviews, and facility policy review, the facility failed to ensure spoiled food items were discarded, food items such as seasonings and spices were not open and exposed, and the food prep area was free from contamination for two (2) of two (2) kitchen observations. This has the potential to affect all residents receiving meals from the facility's dietary department. Findings included: A review of the facility's policy Food Storage, revised 07/11/2024, revealed, Fresh vegetables should be checked and sorted for ripeness .should be inspected for decay .dry products should be kept in tightly sealed containers . A review of the facility's policy Infection Prevention and Control, dated 10/6/2017, revealed, The goals of the infection prevention and control program are to: A. Decrease the risk of infection to residents and personnel .C. Identify and correct problems relating to infection prevention and control practices .D. Maintain compliance with state and federal regulations related to infection and prevention . On 07/14/24 at 9:07 AM, during an interview and observation of the kitchen with the Cook, there were three (3) green bell peppers that had soft, pliable spots and areas of white biological growth. There were 15 containers of seasonings that were not closed, and the seasonings were exposed. The [NAME] acknowledged the overly ripe bell peppers and the exposed seasonings. The [NAME] reported she was unaware the produce was over-ripe and reported she and the Dietary Manager (DM) were responsible for maintaining food quality in the kitchen. On 07/15/24 at 11:14 AM, during an observation, the [NAME] picked up a glove from the floor and placed it on a food prep table where pureed tomatoes and sandwiches were being prepared. On 07/15/24 at 11:16 AM, in an interview with the Cook, she acknowledged that she had picked up a glove off the floor and placed it on the food prep table. The cook stated she knew food was being prepared on the table, but she did not want to place the glove back into the container with clean gloves. She confirmed the floor was considered dirty and the glove should have been discarded appropriately. On 07/15/24 at 1:24 PM, an interview with the DM revealed she was aware of the issues regarding spoiled peppers, exposed seasonings, and the [NAME] placing a glove on the food prep table from the floor. The DM stated it was the responsibility of the cook and herself to make sure spoiled foods were discarded. The DM reported whoever opened an item should make sure it was not left open, with the contents exposed. The DM stated she expected spoiled foods to be discarded and the seasonings to be closed. She also stated she expected items that were picked up off of the floor are discarded appropriately. On 07/17/24 at 9:24 AM, an interview with the Administrator stated the issues in the kitchen should not have occurred. It was her expectation that items be stored and discarded appropriately.

Based on observations, interviews, record reviews, test tray evaluation, and facility policy review, the facility failed to ensure the resident's food was at an appetizing temperature for one (1) of 16 sampled residents. (Resident #53). This has the potential to affect all residents receiving meals prepared by the facility's dietary department. Findings include: This tag is cross-referenced to tag F565: Based on observations, interviews, and record reviews, the facility failed to ensure a grievance of cold food by Resident Council members was resolved four (4) of six (6) months of Resident Council meetings reviewed. A review of the facility's policy titled Food Temperatures, dated 03/19/20 revealed, Food should be served at the proper temperature to ensure food safety and palatability. Procedure: . 8. Palatability of foods determines appropriate temperatures at bedside or tableside food. Generally, hot food is palatable between 110 degrees Fahrenheit (F) and 120 degrees Fahrenheit (F) . On 07/14/24 at 11:24 AM, during an interview, Resident #53 complained the food had been served cold at times. On 07/14/24 at 11:25 AM, during an interview with Certified Nurse Aide (CNA) #7, she explained she had been at the facility since April 2024, and residents had complained about the food being cold. On 07/14/24 at 11:45 AM, during an interview with Dietary Department Cook/Staff #4, she revealed two (2) of the four (4) compartments on the steam table did not work. The cook reported she poured boiling water into one of the inoperable compartments to use it. The cook revealed the Maintenance Department had been informed that the steam table could not be repaired. The cook stated she was informed that the steam table would have to be replaced. On 07/15/24 at 11:35 AM, during an observation of the kitchen staff as they prepared trays, the staff were not covering plates as they prepared them. There were up to six (6) racks of trays on a cart with no lids on the plates. At 11:39 AM on 07/15/24, during an observation of the steam table food temperatures, the scalloped corn was 170 degrees, garlic pepper pork loin was 160 degrees, and zucchini, tomatoes, and mushrooms were 170 degrees. At 12:05 PM on 07/15/24, the first tray cart left the kitchen to go to the dining room. None of the dining room trays had a plate cover. At 1:14 PM on 07/15/24, the last open tray cart containing four (4) trays left the kitchen to go to the hall. On 07/15/24 at 1:18 PM, the test tray reached the State Agency (SA) in the conference room. The food temperatures revealed garlic pepper pork loin with gravy at 110 degrees, zucchini and tomatoes at 100 degrees, and corn at 110 degrees. The food was lukewarm to taste. The Dietary Manager confirmed the food was lukewarm and not at an appetizing temperature. At 2:05 PM on 07/15/24, during an interview, CNA #5 explained Resident #53 and other residents had complained about the food being cold for several months. On 07/17/24 at 10:50 AM, during a phone interview with the facility's Registered Dietitian, she explained she was not aware residents were complaining about the cold food. On 07/17/24 at 2:15 PM, during an interview, the Administrator explained she was made aware recently that the residents had been complaining about cold food and that the steam table was not working properly. She expected all food to be delivered to the residents at an appetizing temperature. A record review of the Admission Record of Resident #53 revealed the facility admitted the resident on 01/24/24, with diagnoses that included Bilateral Primary Osteoarthritis of Knee and Essential Hypertension. The significant change Minimum Data Set (MDS) for Resident #53, with an Assessment Reference Date (ARD) of 06/18/24, revealed a Brief Interview for Mental Status (MDS) score of 15, which indicated the resident was cognitively intact.

Based on facility policy review, record review and interviews, the facility failed to ensure a resident was free from neglect for one (1) of four (4) sampled residents, Resident #1, as evidenced by on 9/15/23 at approximately 3:45 PM, after returning to the facility from a dialysis appointment the facility abandoned Resident #1 on the facility's transport van. Resident #1 was left alone and unattended on the facility transport van for approximately 16 hours and 15 minutes. At approximately 7:50 AM on 9/16/2023, the facility staff located Resident #1 still strapped in the facility transport van. This resulted in Resident #1 missing medications, meals, hydration, and care and assessments, and expressing that she was anxious, hurting, and afraid and, I thought I was doomed. The State Agency (SA) conducted an onsite investigation from 9/20/23 through 9/28/23. The situation was determined to be Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 9/15/23 when the facility abandoned Resident #1 on the facility transport van. The facility's neglect to provide ordered care and services placed Resident #1 and other residents who use the facility transport van for transfers in a situation that could likely lead to serious injury, impairment or death. The IJ and SQC existed at: 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation - F600, Scope and Severity J. The SA notified the facility's Administrator of the IJ and SQC on 9/26/23 and provided the Administrator with the IJ template. The facility submitted an acceptable Removal Plan on 9/28/23, in which they alleged all corrective actions to remove the IJ and SQC were completed on 9/27/23 and the IJ was removed on 9/28/23. The SA validated the Removal Plan on 9/28/23 and determined the IJ and SQC was removed on 9/28/23, prior to exit. Therefore, the scope and severity of 42 CFR 483.12-F600- Freedom from Abuse, Neglect and Exploitation was lowered from a Scope and Severity of J to a D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, update 10/2022, revealed, Policy Statement: Residents have the right to be free from abuse, neglect . Policy Interpretation and Implementation .1. Protect residents from .neglect by anyone including .a. facility staff . Record review of the Admission Record revealed the facility admitted Resident #1 on 12/20/22 with diagnoses including Type 2 Diabetes Mellitus without complications, Hypertensive, Insulin-Dependent, Dependence on Renal Dialysis, chronic diastolic (congestive) heart failure, Type 2 Diabetes Mellitus, and Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic kidney disease. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/7/23 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 07 indicating Resident #1 had moderate cognitive impairment. Section G revealed for resident transfer, that the resident was an extensive assist with two people. Section H revealed the resident was always incontinent of bowel and bladder. Section J revealed Resident #1 experienced pain frequently. Section M revealed the resident was at risk for pressure ulcers/injuries. A record review of the facility-reported investigation, dated 9/19/2023, revealed, Incident: During shift report on 9/16/2023 at approximately 7:00 am (AM), the night shift informed the oncoming shift that the resident did not return from dialysis on 9/15/2023. At approximately 7:50 AM on 9/16/2023, the facility staff located Resident #1 still strapped in the facility transport van. On 9/20/23 at 9:30 AM, the State Agency (SA) observed Resident #1 sitting hunched over in the wheelchair with poor posture. The shunt/graft was covered by clothing. Resident was unable to stand. The SA observed a lift sling beneath the resident. The resident was soft-spoken and became short of breath during a conversation. During the interview, Resident #1 stated she was in bad shape. The Resident stated that she is always hungry, thirsty, and in pain. On 9/20/23 at 9:48 AM, an interview with Resident #1's daughter revealed her mother was left in her wheelchair overnight in the facility van because the Transportation Aide (TA) forgot to remove her. Resident #1's daughter also stated she was aware that her mother did not receive her nighttime medications, dinner, or any type of care for bedtime. During the interview, Resident #1's daughter confirmed the facility did not realize her mother was missing until the next day. Resident #1's daughter stated her mother always complains of being hungry, thirsty, and hurting. A record review of the Transportation Aide (TA)'s written statement revealed, on 9/16/23, .Arrived at (Proper Name of Facility) I noticed a elderly women falling so I jumped out of van to assist her the lady told me she was too weak then then pulled off. I went back inside (Proper Name of Facility) to finish up normal routine and left for the day. Around 7:15 AM I got a call asking about Resident #1 and I asked the nurse to check the bus .I would like to add that I arrived at (Proper Name of Facility) at or about 3:30 PM with Resident #1 . On 9/20/23 at 4:05 PM, an interview with the TA revealed on 9/15/23 at approximately 3:30 PM, she arrived from dialysis back to the facility with Resident #1 secured in the transport van. She parked and noticed a visitor who was in distress in the parking lot. She stated that she immediately jumped out of the parked van, closed the door, and assisted the visitor. Following the incident with the visitor, she stated that she clocked out and left the facility. The following day, 9/16/23, at approximately 7:20 AM, she received a phone call from the facility questioning where Resident #1 was. She realized that she had not removed Resident #1 from the van, and the resident remained unattended for approximately 16 hours. On 9/20/23 at 3:40 PM, an interview with Certified Nurse Assistant (CNA) #3 revealed that she worked on 9/15/23 until 7:00 PM. She was assigned to Resident #1. CNA #3 stated that Resident #1 usually returned to the facility around 4:30 PM. CNA #3 stated she informed Licensed Practical Nurse (LPN) #1, who was coming on 9/15/23 at 7:00 PM, that the resident wasn't back yet. A record review of the License Practical Nurse (LPN) #1's written statement revealed, . 9/15/23 I received report that patient had not returned from dialysis. After completed pm (PM) med (medication) pass resident had still not returned. At around 10 or so I tried to call (Professional Name Dialysis) with no answer. Reported told day nurse that she had not returned from dialysis . On 9/20/23 at 5:15 PM, an interview with LPN #1 revealed that she worked 9/15/23 from 7:00 PM until 9/16/23 at 7:00 AM. She said that at approximately 10:00 PM, she had one resident who had not received their medications, Resident #1. She stated, I realized (Resident #1) was the only resident that did not receive her hours' sleep medications. She stated, I called (the) dialysis unit and got no answer on 9/15/23 at 10:00 PM. LPN #1 revealed she received an admission on 9/15/23 at 10:00 PM and performed no further searches for Resident #1. The LPN confirmed on 9/16/23, she informed the day shift nurse and Registered Nurse (RN) #1 of the missing resident. LPN #1 confirmed that on 9/15/23 and 9/16/23 in the AM, Resident #1's shunt/ access site dressing was not observed for bleeding following dialysis. She also stated she did not give her medications, accucheck, or insulin. On 9/22/23 at 4:42 PM, an interview with the Administrator revealed that he was made aware on 9/16/23 at approximately 7:50 AM of the incident in which Resident #1 was last observed by facility staff strapped in her wheelchair on the facility van on 9/15/23 at approximately 3:30 PM and was located by facility staff strapped in her wheelchair on the facility van on 9/16/23 at approximately 7:45 AM. The Administrator confirmed that Resident #1 was left on the facility van following her dialysis treatment and did not receive any medications, food or fluids, care or services, or monitoring for sixteen (16) hours and fifteen (15) minutes. During an interview on 9/21/23 at 2:28 PM, an interview with CNA #2 revealed that she had worked on 9/15/23 and 9/16/23 and was assigned to the unit on the 7:00 AM to 7:00 PM (7A-7P shift). She assisted RN #1 and other staff finding Resident #1 and removing her from the van. We observed Resident #1 seated in her wheelchair on the van, sweaty with throw-up and drool on her mouth and clothes and that her skin was hot, hot. Then we were instructed by RN #1 to bring her to her room, give her a bath, and assist with a meal. During an interview on 9/26/23 at 10:20 AM, with the Medical Director (MD) revealed that there was potential for serious complications for Resident #1, , especially with her comorbidities. On 9/26/23 at 1:35 PM, an interview with the Director of Nursing (DON) revealed that on 9/15/23 at approximately 3:30 PM, the TA left Resident #1 in the facility van and was found on 9/16/23 at approximately 7:45 AM. The DON stated that the resident not receiving medications, supervision, or monitoring for over sixteen (16) hours could have resulted in serious injury or impairment. She stated that the failure of the facility to ensure the resident received the morning dose of insulin and monitoring of the blood glucose for Resident #1 on the morning of 9/16/23 could have resulted in the resident experiencing signs and symptoms of hyperglycemia. She said that failure to ensure the administration of respiratory medications on the evening of 9/15/23 for Resident #1 could have resulted in signs and symptoms of Chronic Obstructive Pulmonary Disease (COPD), which could have hurt the resident's breathing or exacerbated the resident's disease process. The DON stated that the failure of the facility to provide the scheduled dose of blood pressure medication on the evening of 9/15/23 could have resulted in serious negative cardiac results. During the interview with the DON, she stated that the facility's failure to provide adequate and appropriate monitoring for Resident #1 from approximately 3:30 PM on 9/15/23 until 7:45 AM on 9/16/23 could have resulted in the serious injury or impairment of Resident #1. The DON confirmed that failure to monitor the resident dialysis graph/shunt site could have resulted in bleeding at the site, which could have resulted in the resident losing blood or hemorrhaging. She stated that monitoring the site following a dialysis appointment was very important for the resident's safety. The DON stated that failure to appropriately monitor Resident #1 for signs/symptoms of hyperglycemia (high blood glucose levels) for over sixteen (16) hours could cause negative results for Resident #1 and cause serious injury or impairment. The DON confirmed that the Resident did not receive supervision, appropriate monitoring, or any Activities of Daily Living (ADL) care during the sixteen (16) plus hours when she was not in the facility. A record review of the Order Summary Report as of 9/25/23 revealed Resident #1 missed the following physician orders for blood pressure at 7-10 P: Amlodipine, Metoprolol Tartrate Tablet, Clonidine HCL and Hydralazine HCL Tablet. A record review of the Order Summary Report as of 9/25/23 revealed Resident #1 missed the following physician orders to monitor access site Right Upper Arm for thrill & bruit, two times a day and observe dressing to right arm two times a day. A record review of the Order Summary Report as of 9/25/23 revealed Resident #1 missed her diabetic medication and accucheck on 9/16/23 of Insulin Detemir Solution 100 UNIT/ML (milliliter) and accucheck is less than 60 mg/dl (deciliter) or greater than 400 mg/dl. A record review of the Order Summary Report as of 9/25/23 revealed an order for Proventil HFA (bronchitis). Record review of Resident #1's Medication Administration Record (MAR) for 9/1/23 - 9/30/23 revealed on 9/15/23, the following medications were coded as 3 (resident absent from home) and not administered for blood pressure Amlodipine, Metoprolol Tartrate Tablet, Clonidine HCL and Hydralazine HCL Tablet. Record review of Resident #1's Medication Administration Record (MAR) for 9/1/23 - 9/30/23 revealed on 9/16/23, the following medications were coded as 3 (resident absent from home) and not administered: Insulin Detemir Solution, Accu check, and Proventil for bronchitis. In a record review Documentation Survey revealed, the facility failed to perform ADL (Activities of Daily Living) on Resident #1 for 16 hours and 15 minutes, on 9/15/23 through 9/16/23. Record review revealed Resident #1 had no progress reports from 9/7/23 till 9/16/23 at 9:40 AM. Record review of Resident #1's Progress Notes revealed, 9/16/23 09:40 (9:40 AM) Note Text, Arrived to facility at approx. (approximately) 8:40 AM in regards to resident being left on facility transport van overnight . MD (Medical Doctor) notified of incident and findings .Orders received to send to ER (emergency room ). At approx. (approximately) 0920 (9:20 AM) Report was called to (Formal Name/local hospital) ER, Admin (Administrator) aware of incident and also at facility at this time. RP (Responsible Party) arrived to facility at approx. 0930 (9:30 AM) and Admin informed RP of incident and status of resident. Resident left facility at via stretcher at this time. The Emergency Department Nurse Practitioner (EDNP) from the local hospital confirmed in an interview on 9/27/23 at 4:15 PM, that she assessed and treated Resident #1 at the local hospital ED on 9/16/23 and that she had diagnosed Resident #1 with Heat Exposure, Neglect, and Abandonment. The EDNP confirmed her blood pressure was elevated and considered hospitalization . However, while blood tests revealed Creatine Phosphokinase (CPK) levels elevated to approximately ten (10) times the normal levels, this finding did not reach the threshold for hospitalization . The EDNP explained that Resident #1's elevated CPK levels were indicative of the resident being in one position for an extended period of time which led to the breakdown of muscle tissue due to muscle damage. The EDNP stated that while Resident #1 did not have devastating results, her health was compromised. The EDNP stated that Resident #1 was in an extremely dangerous situation and noted conditions that contributed to this situation included having missed routinely scheduled doses of hypertension medications, food, and fluids for twenty-four (24) hours and exposure to hot, humid conditions for over sixteen (16) hours. The EDNP stated that Resident #1 had not received any psychosocial assessment during her time at the emergency department (ED). She stated that the ED's dedicated Case Worker was not on duty on 9/16/23 and that the Case Worker on duty had communicated with the facility related to giving a report to the staff and communication with the family of Resident #1 to confirm their approval to return Resident #1 to the facility. She stated that psychosocial assessments were normally under the canopy of a certified psychiatric provider. She stated that she had not completed a thorough psychosocial assessment. She said that she had only documented observations on the ED Progress/Discharge notes. Record review of the hospital emergency department (ED) report signed by Acute Care-NP; Emergency Medicine (EDNP) revealed that on 9/16/23. The PHYSICIAN ATTESTATION NOTE signed by the EDNP stated that Resident #1 was assessed and received treatment at the ED after being left in the transport vehicle overnight. Record review of the local hospital Emergency Department (ED) notes dated 9/16/23 revealed that Resident #1 was assessed and treated by ED Nurse Practitioner (EDNP) on 9/16/23 for Heat Exposure .Rhabdomyolysis .Adult Neglect or Abandonment .Elevated Blood Pressure Reading. Record review of the Progress Note dated 9/27/23, revealed Resident #1 was seen for counseling by a contracted Licensed Certified Social Worker (LCSW) on 9/27/23 with Chief complaint listed as A recent Incident. Resident was left overnight in the facility transport LCSW asked to assess resident 2* (secondary) to this event. The progress note review revealed Resident Quote; I thought I was doomed .Resident reports current emotional status or behavior as: Tired and concerned that the incident (being left in the transport van overnight) not be repeated and another resident suffer as she had. Today resident discussed: The Incident of being left in the transport van. Resident shared that she was anxious, hurting, and afraid. She explained that she got through the night by crying and being worried and didn't sleep at all. When asked if it was the most frightened, she had ever been in her life, resident stated it was not but close .she feels she was denied the help I was supposed to get and added she is resentful and angry about the incident . On 9/28/23 at 11:10 AM, a telephone interview with the facility's contracted Licensed Certified Social Worker (LCSW) revealed that regarding the cognitive level of Resident #1, the resident was able to express her feelings and needs verbally. She was sure Resident #1 remembered being in the facility van overnight on 9/15/23 because Resident #1 was able to describe being in the wheelchair and the van, and the pain and fear she felt. The LCSW stated that the incident was definitely detrimental in the way she was frightened and talked about not being provided with care. The LCSW reported that Resident #1 stated, I was denied the care I needed during their conversation on 9/27/23. The LCSW reported that effects from the incident may appear over time and said, That will be found out in days to come. The facility provided the following removal plan on 9/28/23. On 9/26/2023 1:15 pm the State Agency notified the Administrator that the facility neglected to provide care and services for Resident #1 from approximately 3:45 pm on 9/15/2023 until approximately 7:45 am on 9/16/2023, failed to notify the Physician timely of a change in condition after resident was left in the transport van, alone and unattended by a staff member which resulted in Resident #1 missing medications, meals, hydration and post dialysis site care/assessments. On 9/15/2023 the Transportation Assistant (TA) left Resident #1 in the facility vehicle after returning to the facility from dialysis at approximately 3:45 pm. The facility staff located Resident #1 and removed her from the facility vehicle at approximately 7:50 am on 9/16/2023, assisted Resident #1 back in the facility, transferred Resident #1 to bed, Registered Nurse (RN) #1 completed an assessment revealing a temperature 100.3, blood pressure 175/79, pulse 97, Oxygen Saturation 100%. The nurse did not obtain blood sugar at this time. The physician was notified of the incident at approximately 8:40 am on 9/16/2023 by the Director of Nursing. The Resident Representative was notified of the incident at approximately 9:15 am on 9/16/2023 by the Administrator. 1. 9/16/2023 8:40 am the DON (Director of Nurses) arrived at the facility, assessed Resident #1 and noted that resident was at baseline. 2. On 9/16/2023 the Medical Director was notified at 8:40 am and received an order to send to the emergency room for evaluation. 3. 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. 4. 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. 5. 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. 6. On 9/16/2023 at 10:10 am the investigation revealed that when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. LPN #1 received in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis and did not follow up to determine where the resident was located. 7. On 9/16/2023 at 10:45 am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. QAPI minutes included: Review of the incident, investigation and missing resident policy. Review of immediate actions taken. Recommendations to prevent reoccurrence were to complete in-service for all staff regarding missing residents prior to working, in-service for nurses to include if the reason why a resident is not in the facility is not documented in the record to notify the supervisor immediately, initiate a log for 2 people to document that the facility vehicle is checked at the end of each day and after each transport, conduct a missing person drill on each shift, initiate 2 staff members to ride on the facility vehicle for all resident transports and educate all transportation drivers of new procedures. 8. On 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. 9. 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. 10. 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. 11. 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The missing resident drill consisted of a resident being hidden in the Administrator's office and was identified by a staff member who did a sweep of the office areas and the staff member immediately reported to the Administrator that the resident was found. No changes to policy and procedure needed. 12. On 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. 13. 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. 14. 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. 15. On 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. 16. 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. -The Committee reviewed the incident, the Immediate Jeopardies cited by the state agency on 9/26/2023, and the policies regarding abuse and neglect, supervision of residents, dialysis care, diabetic care, timely notification of the physician, accidents, staffing and care plans. The following recommendations were discussed. The root cause analysis revealed that the TA was distracted and as a result left Resident #1 on the facility vehicle. It also revealed that the nurse failed to follow proper procedure to investigate why Resident #1 did not return from dialysis that resulted in the resident not being located in a timely manner which resulted in the resident not receiving proper dialysis care, diabetic care and medications. There were no recommendations to make changes to any policies by the QAPI Team and all interventions that were put into place were effective. The MDS Nurse will conduct another audit of the care plans for 100% of residents receiving dialysis and diabetic care. The MDS Nurse will conduct an audit of the care plans for 100% of residents receiving routine transportation services. The Social Service Director will evaluate Resident #1 for signs of psychosocial harm due to the incident that occurred on 9/15/2023. The facility assessment was reviewed and updated regarding staffing according to the acuity of the residents. The Committee determined at this time the staffing required for the night shift is 4 Certified Nursing Assistants and 2 Nurses. If these requirements are not met the nurse will contact the DON and Administrator and they will make arrangements to cover staffing needs by contacting all employees, department heads and sister facilities as needed to fill gaps. DON will provide in-service for all staff regarding abuse/neglect, accidents, and supervision of residents. DON will provide in-service for all nursing staff regarding staffing, care plans, diabetic care, dialysis care and timely notification of the physician. All staff will receive in-service prior to returning to work. 17. 9/26/2023 3:00 pm the Social Service Director spoke with Resident #1 concerning her psychosocial needs and noted no signs of psychosocial harm related to the incident that occurred on 9/15/2023. 18. 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. 19. 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. 20. On 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident. The facility alleges removal of the immediacy on 9/28/2023. The SA validated the Removal Plan on 9/28/23 and determined the IJ was removed on 9/28/23 prior to exit. The SA validated through interview and record review that the DON stated she arrived on 9/16/2023 8:40 am and assessed Resident #1. The SA validated through interviews and record reviews that on 9/16/2023 the Medical Director was notified at 8:40 am and gave an order to send to the emergency room for evaluation. The SA validated through interviews and record reviews that on 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. The SA validated through interviews and record reviews that on 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. The SA validated through interviews and documentation reviews that on 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. The SA validated through interviews and record reviews that on 9/16/2023 at 10:10 am the facility initiated an investigation that revealed when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. The SA validated that the facility investigation also revealed LPN #1 did not follow up to determine where the resident was located when told in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis. The SA validated through interviews, observations, and record reviews that on 9/16/2023 at 10:45 am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. The SA validated through staff interviews and record reviews that on 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. The SA validated through observation, interviews, and record reviews that on 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. The SA validated through interviews and documentation reviews that on 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. The SA validated through interviews and documentation reviews that on 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The SA validated through interview that on 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. The SA validated through interviews and staff sign in sheets that on 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. The SA validated through interview and record review that on 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. The SA validated through interview that on 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. The SA validated through interviews and record reviews that on 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. The SA validated through interview and record review that on 9/26/2023 3:00 pm the Social Service Director spoke with resident #1 concerning her psychosocial needs. The SA validated through interviews and staff sign in sheets that on 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. The SA validated through interviews and record reviews that on 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. The SA validated through interview and documentation review that on 9/27/2023 at 5:00 pm[TRUNCATED]

Based on interviews, record review, and facility policy review, the facility failed to implement care plan approaches or interventions to ensure Resident #1 received care and services for monitoring after hemodialysis, significant medications, accu check and activities of daily living, for one (1) of four (4) resident care plans. Resident #1. The State Agency (SA) conducted an onsite investigation from 9/20/23 through 9/28/23. The situation was determined to be an Immediate Jeopardy (IJ) which began on 9/15/23 when Resident #1 was abandoned on the facility transport van. The facility failed to implement the plan of care for Resident #1 when Resident #1 was left unattended, unsupervised without care or monitoring following transportation from hemodialysis treatment. Resident #1 was abandoned and restrained by seat belts in a wheelchair in the facility transport van. The staff was unaware of Resident #1's absence from the facility from approximately 3:30 PM on 9/15/23 through 7:45 AM on 9/16/23 for over sixteen (16) hours without care as listed on the care plan, placed this resident, and other residents at risk, in a situation that was likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 9/15/23, when the facility abandoned Resident #1 on the facility van for approximately sixteen (16) hours and fifteen (15) minutes following hemodialysis. The resident received no treatment, supervision, monitoring or care as designated per the care plan during this time. The IJ existed at: 42 CFR 483.21(b)(1) Comprehensive Care Plans - F656 - Scope and Severity J; The State Agency (SA) notified the facility Administrator of the IJ on 9/26/23 at 1:15 PM and provided the IJ template. The facility submitted an acceptable Removal Plan on 9/28/23, in which they alleged all corrective actions to remove the IJ were completed on 9/27/23 and the IJ was removed on 9/28/23. The SA validated the Removal Plan on 9/28/23 and determined the IJ was removed on 9/28/23, prior to exit. Therefore, the scope and severity for 42 CFR 483.21(b)(1) Comprehensive Care Plans - F656 - Scope and Severity J; was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility's policy Using the Care Plan with a revision date of 9/25/23, revealed, Policy statement: It is the policy of this facility that the care plan be used in developing the resident's daily care routines Record review of the Care Plans, undated, for Resident #1 revealed the following care plans were not implemented: Activities of Daily Living: Focus: I have an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) .Dementia .Interventions/Task, Eating, Toilet Use, Transfer . Hypertension: Focus: I have hypertension .Interventions/Task .Give anti-hypertensive medications as ordered. Monitor for side effects . Impaired cognitive function: Focus: I have impaired cognitive function/dementia .Interventions/Task .Administer medications as ordered. Observe/document for side effects and effectiveness .Keep my routine consistent . Diabetes: Focus: I have Diabetes Mellitus .Interventions/ Task .Diabetes medication as ordered by doctor. Monitor for side effects and effectiveness . Pain: Focus: I have acute/chronic pain .Interventions/Task .Administer analgesia as per orders .Evaluate effectiveness of pain interventions . Hemodialysis: Focus: I am on hemodialysis r/t renal failure .Interventions/Task .Check dressing daily at access site, monitor vital signs q (every) shift Skin integrity: Focus: I have potential for impairment to my skin integrity .Interventions/Task .Keep body parts from excessive moisture .Encourage .good nutrition and hydration . Chronic Obstructive Pulmonary Disease (COPD) Focus: I have COPD .Interventions/Task Give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness .Monitor for s/sx (signs or symptoms) of .Anxiety, Confusion, Restlessness, SOB (Shortness of Breath) at rest . A record review of the facility-reported investigation, dated 9/19/2023, revealed, Incident: During shift report on 9/16/2023 at approximately 7:00 am (AM), the night shift informed the oncoming shift that the resident did not return from dialysis on 9/15/2023. At approximately 7:50 AM on 9/16/2023, the facility staff located Resident #1 still strapped in the facility transport van. Record review of the Documentation Survey Report .Tasks Only for Resident #1 for 9/15/23 and 9/16/23 revealed that there was no documentation of the resident receiving assistance in accordance with the Minimum Data Set (MDS) assessment or the resident's care plan or physician orders for Bed Mobility, Hygiene, or Toilet Use on 9/15/23 through 6:59 PM on 9/16/23. There was no documentation for Eating and Drinking or percent of meals or nourishments/snacks eaten or fluid intake for 9/15/23 through 8:00 AM on 9/16/23. There was no documentation for Bladder continence or Bowel Movements and no observations of skin or behaviors recorded on 9/15/23 through 6:59 PM on 9/16/23. Record review of Resident #1's Medication Administration Record (MAR) for 9/1/23 - 9/30/23 revealed on 9/15/23, the following medications were coded as 3 (three) (absent from home) and not administered for blood pressure Amlodipine, Metoprolol Tartrate Tablet, Clonidine HCL and Hydralazine HCL Tablet. Record review of Resident #1's Medication Administration Record (MAR) for 9/1/23 - 9/30/23 revealed on 9/16/23, the following medications were coded as 3 (absent from home) and not administered: Insulin Detemir Solution, Accu check, and Proventil for bronchitis. On 9/20/23 at 3:10 PM, an interview with Licensed Practical Nurse (LPN) #1 revealed that she worked as the medication nurse on 9/15/23 7 PM-7 AM shift and confirmed she did not follow the care plan of giving Resident #1 her medications or checking her accu check. During the interview, she stated if the resident was available, she should have followed the care plan to provide her with medication because it is the process for staff to take care of the residents. On 9/20/23 at 3:20 PM, an interview with Certified Nursing Assistant (CNA) #3 confirmed that Resident #1 had not received any supervision, monitoring, care, food or fluids after the resident left for dialysis on 9/15/23 at approximately 10:00 AM through 7:00 PM when the CNA completed her shift. On 9/26/23 at 1:35 PM, an interview with the Director of Nurses (DON) revealed it is my expectation that the nursing staff follow the care plans of all residents. The care plans provide a detailed and effective personalized outline of care for our residents. On 9/26/23 at 10:20 AM an interview with the Medical Director who is the primary physician confirmed that Resident #1 could have potentially suffered serious complications with her comorbidities; potentially serious injury or impairment, including but not limited to signs/symptoms (s/s) hyperglycemia or hypoglycemia, s/s of Chronic Obstructive Pulmonary Disease, negative effects of hypertension due to lack of monitoring while on the facility van for over sixteen (16) hours. The MD confirmed that he expected the facility nursing staff to follow the residents' care plans to ensure appropriate care for each resident. On 9/26/23 at 3:00 PM, an interview with LPN #2 reported that care plans were developed for individualized care and to ensure consistency in the nursing care of the resident, which helps improve services. LPN #2 added that she expects all nursing staff in the facility to follow care plans for the residents. Record review of the Admission Record revealed the facility admitted Resident #1 on 12/20/22 with diagnoses including Type 2 Diabetes Mellitus without complications, Hypertensive, Insulin-Dependent, Dependence on Renal Dialysis, Chronic Diastolic (congestive) Heart Failure, Type 2 Diabetes Mellitus, and Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic Kidney Disease. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/7/23 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 07 indicating Resident #1 had severe cognitive impairment. Section G revealed for resident transfer, that the resident was an extensive assist with two people. Section H revealed the resident was always incontinent of bowel and bladder. Section J revealed Resident #1 experienced pain frequently. Section M revealed the resident was at risk for pressure ulcers/injuries. The facility provided the following removal plan on 9/28/23. On 9/26/2023 1:15 PM the State Agency notified the Administrator that the facility neglected to provide care and services for Resident #1 from approximately 3:45 pm on 9/15/2023 until approximately 7:45 am on 9/16/2023, failed to notify the Physician timely of a change in condition after resident was left in the transport van, alone and unattended by a staff member which resulted in Resident #1 missing medications, meals, hydration and post dialysis site care/assessments. On 9/15/2023 the Transportation Assistant (TA) left Resident #1 in the facility vehicle after returning to the facility from dialysis at approximately 3:45 pm. The facility staff located Resident #1 and removed her from the facility vehicle at approximately 7:50 am on 9/16/2023, assisted Resident #1 back in the facility, transferred Resident #1 to bed, Registered Nurse (RN) #1 completed an assessment revealing a temperature 100.3, blood pressure 175/79, pulse 97, Oxygen Saturation 100%. The nurse did not obtain blood sugar at this time. The physician was notified of the incident at approximately 8:40 am on 9/16/2023 by the Director of Nursing. The Resident Representative was notified of the incident at approximately 9:15 am on 9/16/2023 by the Administrator. 1. 9/16/2023 8:40 am the DON (Director of Nurses) arrived at the facility, assessed resident #1 and noted that resident was at baseline. 2. On 9/16/2023 the Medical Director was notified at 8:40 am and received an order to send to the emergency room for evaluation. 3. 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. 4. 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. 5. 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. 6. On 9/16/2023 at 10:10 am the investigation revealed that when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. LPN #1 received in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis and did not follow up to determine where the resident was located. 7. On 9/16/2023 at 10:45 am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. QAPI minutes included: Review of the incident, investigation and missing resident policy. Review of immediate actions taken. Recommendations to prevent reoccurrence were to complete in-service for all staff regarding missing residents prior to working, in-service for nurses to include if the reason why a resident is not in the facility is not documented in the record to notify the supervisor immediately, initiate a log for 2 people to document that the facility vehicle is checked at the end of each day and after each transport, conduct a missing person drill on each shift, initiate 2 staff members to ride on the facility vehicle for all resident transports and educate all transportation drivers of new procedures. 8. On 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. 9. 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. 10. 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. 11. 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The missing resident drill consisted of a resident being hidden in the Administrator's office and was identified by a staff member who did a sweep of the office areas and the staff member immediately reported to the Administrator that the resident was found. No changes to policy and procedure needed. 12. On 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. 13. 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. 14. 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. 15. On 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. 16. 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. -The Committee reviewed the incident, the Immediate Jeopardies cited by the state agency on 9/26/2023, and the policies regarding abuse and neglect, supervision of residents, dialysis care, diabetic care, timely notification of the physician, accidents, staffing and care plans. The following recommendations were discussed. The root cause analysis revealed that the TA was distracted and as a result left Resident #1 on the facility vehicle. It also revealed that the nurse failed to follow proper procedure to investigate why Resident #1 did not return from dialysis that resulted in the resident not being located in a timely manner which resulted in the resident not receiving proper dialysis care, diabetic care and medications. There were no recommendations to make changes to any policies by the QAPI Team and all interventions that were put into place were effective. The MDS Nurse will conduct another audit of the care plans for 100% of residents receiving dialysis and diabetic care. The MDS Nurse will conduct an audit of the care plans for 100% of residents receiving routine transportation services. The Social Service Director will evaluate Resident #1 for signs of psychosocial harm due to the incident that occurred on 9/15/2023. The facility assessment was reviewed and updated regarding staffing according to the acuity of the residents. The Committee determined at this time the staffing required for the night shift is 4 Certified Nursing Assistants and 2 Nurses. If these requirements are not met the nurse will contact the DON and Administrator and they will make arrangements to cover staffing needs by contacting all employees, department heads and sister facilities as needed to fill gaps. DON will provide in-service for all staff regarding abuse/neglect, accidents, and supervision of residents. DON will provide in-service for all nursing staff regarding staffing, care plans, diabetic care, dialysis care and timely notification of the physician. All staff will receive in-service prior to returning to work. 17. 9/26/2023 3:00 pm the Social Service Director spoke with resident #1 concerning her psychosocial needs and noted no signs of psychosocial harm related to the incident that occurred on 9/15/2023. 18. 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. 19. 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. 20. On 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident. The facility alleges removal of the immediacy on 9/28/2023. The SA validated the Removal Plan on 9/28/23 and determined the IJ was removed on 9/28/23 prior to exit. The SA validated through interview and record review that the DON stated she arrived on 9/16/2023 8:40 am and assessed Resident #1. The SA validated through interviews and record reviews that on 9/16/2023 the Medical Director was notified at 8:40 am and gave an order to send to the emergency room for evaluation. The SA validated through interviews and record reviews that on 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. The SA validated through interviews and record reviews that on 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. The SA validated through interviews and documentation reviews that on 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. The SA validated through interviews and record reviews that on 9/16/2023 at 10:10 am the facility initiated an investigation that revealed when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. The SA validated that the facility investigation also revealed LPN #1 did not follow up to determine where the resident was located when told in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis. The SA validated through interviews, observations, and record reviews that on 9/16/2023 at 10:45 am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. The SA validated through staff interviews and record reviews that on 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. The SA validated through observation, interviews, and record reviews that on 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. The SA validated through interviews and documentation reviews that on 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. The SA validated through interviews and documentation reviews that on 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The SA validated through interview that on 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. The SA validated through interviews and staff sign in sheets that on 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. The SA validated through interview and record review that on 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. The SA validated through interview that on 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. The SA validated through interviews and record reviews that on 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. The SA validated through interview and record review that on 9/26/2023 3:00 pm the Social Service Director spoke with resident #1 concerning her psychosocial needs. The SA validated through interviews and staff sign in sheets that on 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. The SA validated through interviews and record reviews that on 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. The SA validated through interview and documentation review that on 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident.

Based on interview, record review, and facility policy review, the facility failed to provide adequate staffing to ensure the safety and the necessary care and services for one (1) of four (4) residents reviewed, Resident #1. The facility failed to identify the location of a resident when the resident failed to return to the facility unit following transportation from her hemodialysis treatment. This resulted in the facility abandoning the resident restrained by seat belts in a wheelchair in the facility transport van, without supervision or monitoring. The staff was unaware of Resident #1's absence from the facility from approximately 3:30 PM on 9/15/23 through 7:45 AM on 9/16/23. The facility's failure to staff the facility sufficiently resulted in Resident #1 been left unattended in the facility van for over sixteen (16) hours. This placed Resident #1 in a situation that was likely to cause serious harm, injury, impairment, or death. The State Agency (SA) conducted an onsite investigation from 9/20/23 through 9/28/23. The situation was determined to be an Immediate Jeopardy (IJ) that began on 9/15/23, when the facility failed to locate Resident #1 on the facility van for approximately sixteen (16) hours and fifteen (15) minutes following hemodialysis. The resident received no treatment, supervision, monitoring or care during this time. The IJ existed at: 42 CFR 483.35(a) Sufficient Staff - F725 Scope and Severity J The State Agency (SA) notified the facility Administrator of the IJ on 9/26/23 at 1:15 PM and the IJ template was provided to the Administrator. The facility submitted an acceptable Removal Plan on 9/28/23, in which they alleged all corrective actions to remove the IJ were completed on 9/27/23 and the IJ was removed on 9/28/23. The SA validated the Removal Plan on 9/28/23 and determined the IJ was removed on 9/28/23, prior to exit. Therefore, the scope and severity for 42 CFR 483.35(a) Sufficient Staff F725 J was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility policy titled Staffing . revised October 2017 revealed Our facility provides sufficient staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment .Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care . During an interview with Registered Nurse (RN) #2 on 9/20/23 at 3:40 PM, RN #2 reported that she was 'usually' the RN Supervisor Monday through Friday of each week from 8:00 AM through 4:30 PM but had worked the cart as the medication/charge nurse on the Transitional Care Unit (TCU) on 9/15/23 due to a staff member scheduled to work had called off work. She confirmed that this left the unit without an RN Supervisor for the day shift on 9/15/23. She stated also that a new resident was admitted by the facility TCU shortly after 4:00 PM on 9/15/23. She confirmed that new admissions required additional time from staff for orientation to their surroundings, audits, monitoring for pain and overall condition and to establish a baseline to determine care needs. She reported that she was relieved by Licensed Practical Nurse (LPN) #3 at 4:30 PM. She stated that during the shift change report she had informed LPN #3 that Resident #1 had not returned from dialysis. RN #2 said she then went to the [NAME] unit to work until 7:00 PM due to staff calling off work. During an interview with LPN #3 on 9/20/23 at 4:52 PM, confirmed that she had been told by RN #2 during shift change report at 4:30 PM on 9/15/23 that Resident #1 had not returned from the dialysis unit. LPN #3 confirmed that she had not been concerned when Resident #1 had not returned by 6:30 PM when she gave shift change report to LPN #1. She stated that she left the facility without contacting the dialysis unit, the Responsible Party (RP) for Resident #1 or the Director of Nurses (DON). During an interview with LPN #1 on 9/20/23 at 5:15 PM, the LPN said that she was not concerned that Resident #1 had not returned from the dialysis unit when she initially assumed responsibility for the residents on TCU between 6:30 PM and 7:00 PM on 9/15/23. She said that on 9/15/23 at approximately 10:00 PM, after she had finished medication administration rounds, she 'realized' that Resident #1 had not returned. LPN #1 stated that she attempted to contact the dialysis unit by telephone without success. LPN #1 described the 7:00 PM - 7:00 AM shift on 9/15/23 as hectic and said she had one CNA assisting her to care for twenty-nine (29) to thirty (30) TCU residents. LPN #1 stated, that between 10:00 PM and 10:30 PM on 9/15/23 There was a new admit coming in and problems with another new resident. She said it was possible that if she had more staff present on the evening of 9/15/23 she would have had more time to give to locating Resident #1. LPN #1 stated, there was a lot going on and we were trying to make it work, She confirmed that after she called the dialysis unit, she did not make any further efforts to determine the whereabouts of Resident #1 or notify the DON or the resident's Responsible Party (RP) of the resident's absence. LPN #1 confirmed that because the resident was unsupervised in the facility van in the facility parking lot she had not received food, fluids, care, medications or monitoring following dialysis treatment, which LPN #1 described as very heartbreaking. On 9/21/23 at 9:48 AM, an interview with LPN #4 revealed that she became aware that Resident #1 was missing from the facility when she was making 'first rounds' shortly after 7:00 AM on 9/16/23 and directly observed that the resident was not in her room. She said she asked LPN #1 where Resident #1 was to which LPN #1 responded I didn't even know she wasn't here till after 10:00 (PM) last night. On 9/27/23 at 1:30 PM, an interview with the DON reported that there was one (1) LPN and one (1) CNA responsible for the care of the residents on each unit of the facility (TCU and West) from 7:00 PM on 9/15/23 through 7:00 AM on 9/16/23. She confirmed that it was possible that more staff on the shift may have led to staff locating Resident #1 sooner. She confirmed that prior to the incident the facility had not scheduled an additional staff member to accompany residents for medical appointments, with the driver being the sole staff member responsible for loading, transporting, unloading, and supervising residents during transportation. She confirmed that an additional staff accompanying Resident #1 for the return to the facility may have prevented the resident being left unsupervised on the facility van. The DON reported that there were two additional CNAs scheduled to work 9/15/23 at 7:00 PM through 7:00 AM on 9/16/23 that had called off work due to testing positive for COVID-19 and were not replaced on the schedule because there was no one available. On 9/27/23 at 5:05 PM, an interview with the Administrator confirmed he had completed a Facility Assessment, which was updated annually, was utilized in staffing decisions. The Administrator stated that staffing needs change often based on need determined by the number and acuity of residents. He reported that the facility did not employ agency staffing. The Administrator said that employees calling off work could sometimes be an issue. He stated that he had not been notified by the DON of a need for additional staff. He stated that if he were made aware of a need for additional staff he could reach out to sister facilities for additional staff to meet the care needs of residents. He confirmed that he had not done so for 9/15/23. He stated that on 9/15/23 the facility could have had more staff and that the staffing for 9/15/23 had not been by design. The Administrator clarified that by design there was supposed to be more staff but that had changed due to staff calling off work due to staff testing positive for COVID-19. Record review of the local hospital Emergency Department (ED) notes dated 9/16/23 revealed that Resident #1 was assessed and treated by ED Nurse Practitioner (EDNP) on 9/16/23 for Heat Exposure, Rhabdomyolysis, Adult Neglect or Abandonment, and Elevated Blood Pressure Reading. The ED notes included consideration of intravenous fluids avoided due to the resident's diagnosis of End Stage Renal Disease. The EDNP confirmed on 9/27/23 at 4:15 PM, during a telephone interview, that providing assessment and care for Resident #1 on 9/16/23 was important. She stated that the incident was extremely dangerous for Resident #1 and that the resident's health was absolutely compromised. During a telephone interview on 9/28/23 at 11:10 AM, the contracted Licensed Certified Social Worker (LCSW) revealed that she had counseled Resident #1 at or about 5:00 PM on 9/27/23. Following her assessment, she had diagnosed Resident #1 with Acute Reaction to Stress and had recommended monitoring for adverse effects for at least ninety days. The LCSW stated that Resident #1 had reported feeling doomed, anxious, fearful and worried. The LCSW stated, I definitely believe it was detrimental in the way she was frightened and talked about not being provided with the care she needed Record review of the Admission Record revealed the facility admitted Resident #1 on 12/20/22 with diagnoses including Type 2 Diabetes Mellitus without complications, Hypertensive Urgency, Long Term (current) use of Insulin, End Stage Renal Disease, Dependence on Renal Dialysis, Chronic diastolic (congestive) heart failure, Type 2 Diabetes Mellitus, long-term current use of insulin, Dependence on renal dialysis, and Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic Kidney Disease, or End Stage Renal. The facility provided the following Removal Plan on 9/28/23. On 9/26/2023 1:15 pm the State Agency notified the Administrator that the facility neglected to provide care and services for Resident #1 from approximately 3:45 pm on 9/15/2023 until approximately 7:45 am on 9/16/2023, failed to notify the Physician timely of a change in condition after resident was left in the transport van, alone and unattended by a staff member which resulted in Resident #1 missing medications, meals, hydration and post dialysis site care/assessments. On 9/15/2023 the Transportation Assistant (TA) left Resident #1 in the facility vehicle after returning to the facility from dialysis at approximately 3:45 pm. The facility staff located Resident #1 and removed her from the facility vehicle at approximately 7:50 am on 9/16/2023, assisted Resident #1 back in the facility, transferred Resident #1 to bed, Registered Nurse (RN) #1 completed an assessment revealing a temperature 100.3, blood pressure 175/79, pulse 97, Oxygen Saturation 100%. The nurse did not obtain blood sugar at this time. The physician was notified of the incident at approximately 8:40 am on 9/16/2023 by the Director of Nursing. The Resident Representative was notified of the incident at approximately 9:15 am on 9/16/2023 by the Administrator. 1. 9/16/2023 8:40 am the DON (Director of Nurses) arrived at the facility, assessed Resident #1 and noted that resident was at baseline. 2. On 9/16/2023 the Medical Director was notified at 8:40 am and received an order to send to the emergency room for evaluation. 3. 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. 4. 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. 5. 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. 6. On 9/16/2023 at 10:10 am the investigation revealed that when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. LPN #1 received in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis and did not follow up to determine where the resident was located. 7. On 9/16/2023 at 10:45 am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. QAPI minutes included: Review of the incident, investigation and missing resident policy. Review of immediate actions taken. Recommendations to prevent reoccurrence were to complete in-service for all staff regarding missing residents prior to working, in-service for nurses to include if the reason why a resident is not in the facility is not documented in the record to notify the supervisor immediately, initiate a log for 2 people to document that the facility vehicle is checked at the end of each day and after each transport, conduct a missing person drill on each shift, initiate 2 staff members to ride on the facility vehicle for all resident transports and educate all transportation drivers of new procedures. 8. On 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. 9. 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. 10. 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. 11. 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The missing resident drill consisted of a resident being hidden in the Administrator's office and was identified by a staff member who did a sweep of the office areas and the staff member immediately reported to the Administrator that the resident was found. No changes to policy and procedure needed. 12. On 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. 13. 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. 14. 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. 15. On 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. 16. 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. -The Committee reviewed the incident, the Immediate Jeopardies cited by the state agency on 9/26/2023, and the policies regarding abuse and neglect, supervision of residents, dialysis care, diabetic care, timely notification of the physician, accidents, staffing and care plans. The following recommendations were discussed. The root cause analysis revealed that the TA was distracted and as a result left Resident #1 on the facility vehicle. It also revealed that the nurse failed to follow proper procedure to investigate why Resident #1 did not return from dialysis that resulted in the resident not being located in a timely manner which resulted in the resident not receiving proper dialysis care, diabetic care and medications. There were no recommendations to make changes to any policies by the QAPI Team and all interventions that were put into place were effective. The MDS Nurse will conduct another audit of the care plans for 100% of residents receiving dialysis and diabetic care. The MDS Nurse will conduct an audit of the care plans for 100% of residents receiving routine transportation services. The Social Service Director will evaluate Resident #1 for signs of psychosocial harm due to the incident that occurred on 9/15/2023. The facility assessment was reviewed and updated regarding staffing according to the acuity of the residents. The Committee determined at this time the staffing required for the night shift is 4 Certified Nursing Assistants and 2 Nurses. If these requirements are not met the nurse will contact the DON and Administrator and they will make arrangements to cover staffing needs by contacting all employees, department heads and sister facilities as needed to fill gaps. DON will provide in-service for all staff regarding abuse/neglect, accidents, and supervision of residents. DON will provide in-service for all nursing staff regarding staffing, care plans, diabetic care, dialysis care and timely notification of the physician. All staff will receive in-service prior to returning to work. 17. 9/26/2023 3:00 pm the Social Service Director spoke with resident #1 concerning her psychosocial needs and noted no signs of psychosocial harm related to the incident that occurred on 9/15/2023. 18. 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. 19. 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. 20. On 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident. The facility alleges removal of the immediacy on 9/28/2023. The SA validated the Removal Plan on 9/28/23 and determined the IJ was removed on 9/28/23 prior to exit. The SA validated through interview and record review that the DON stated she arrived on 9/16/2023 8:40 am and assessed Resident #1. The SA validated through interviews and record reviews that on 9/16/2023 the Medical Director was notified at 8:40 am and gave an order to send to the emergency room for evaluation. The SA validated through interviews and record reviews that on 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. The SA validated through interviews and record reviews that on 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. The SA validated through interviews and documentation reviews that on 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. The SA validated through interviews and record reviews that on 9/16/2023 at 10:10 am the facility initiated an investigation that revealed when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. The SA validated that the facility investigation also revealed LPN #1 did not follow up to determine where the resident was located when told in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis. The SA validated through interviews, observations, and record reviews that on 9/16/2023 at 10:45 am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. The SA validated through staff interviews and record reviews that on 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. The SA validated through observation, interviews, and record reviews that on 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. The SA validated through interviews and documentation reviews that on 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. The SA validated through interviews and documentation reviews that on 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The SA validated through interview that on 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. The SA validated through interviews and staff sign in sheets that on 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. The SA validated through interview and record review that on 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. The SA validated through interview that on 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. The SA validated through interviews and record reviews that on 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. The SA validated through interview and record review that on 9/26/2023 3:00 pm the Social Service Director spoke with resident #1 concerning her psychosocial needs. The SA validated through interviews and staff sign in sheets that on 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. The SA validated through interviews and record reviews that on 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. The SA validated through interview and documentation review that on 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident.

Based on record review and interviews the facility failed to provide resident centered care and services in accordance with the resident's individualized care plan and professional standards of practice that met Resident #1's physical, mental, and psychosocial needs for one (1) of four (4) sampled residents, Resident #1, as evidenced by the facility abandoned Resident #1 on the facility's transport van after returning to the facility from a dialysis appointment on 9/15/23 at approximately 3:45 PM. Resident #1 was left alone and unattended on the transport van for approximately 16 hours and 15 minutes which resulted in Resident #1 missing medications, meals, hydration, care and assessments. At approximately 7:50 AM on 9/16/2023, the facility staff located Resident #1 still strapped in the facility transport van and transferred the resident to their room in the facility. Registered Nurse (RN) #1 completed an assessment revealing the resident's temperature 100.3 Fahrenheit, blood pressure 175/79, pulse 97, and Oxygen Saturation 100%. The facility did not obtain a blood glucose level at the time of assessment. The State Agency (SA) conducted an onsite investigation from 9/20/23 through 9/28/23. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 9/15/23 when the facility abandoned Resident #1 on the facility transport van. The facility's failure to provide care and services in accordance with professional standards to maintain a resident's highest practicable well-being placed Resident #1 and other residents who use the facility transport van in a situation with the likelihood of serious injury, harm, impairment or death. The IJ and SQC existed at: 42 CFR 483.25, Quality of Care - F684 Scope and Severity J The SA notified the facility's Administrator of the IJ and SQC on 9/26/23 at 1:15 PM and provided the Administrator with the IJ template. The facility submitted an acceptable Removal Plan on 9/28/23, in which they alleged all corrective actions to remove the IJ and SQC were completed on 9/27/23 and the IJ was removed on 9/28/23. The SA validated the Removal Plan on 9/28/23 and determined the IJ and SQC was removed on 9/28/23, prior to exit. Therefore, the scope and severity of 42 CFR 483.25, Quality of Care was lowered from a J to a Scope and Severity of D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: The facility did not provide a specific policy on Quality of Care. Record review of Resident #1's Medication Administration Record (MAR) for 9/1/23 - 9/30/23 revealed on 9/15/23, the facility coded the following medications and services as '3' (resident absent from home) and failed to administer: Lyrica, Pravastatin Sodium, Risperdal, Amlodipine Besylate, Hydrocortisone Acetate, Lidocaine-Prilocaine, Memantine HCL, Metoprolol Tartrate, Clonidine HCL, Hydralazine HCL, Nephro-Vite, Proventil HFA, and Calazime, monitoring of access site, application of Nystatin external powder, observation of dressing right arm, vital signs, rate level of pain, monitor behaviors exhibited, or check fluids, . Boost was coded 1 away from home with meds. Record review of Resident #1's Medication Administration Record (MAR) for 9/1/23 - 9/30/23 revealed on 9/16/23, the facility coded the following as 3 (resident absent from home) and failed to administer: Insulin Detemir Solution, Protonix, Synthroid, Boost, Clonidine, Hydralazine, Nephro-Vite, and Proventil. Record review of the Documentation Survey Report .Tasks Only for Resident #1 for 9/15/23 and 9/16/23 revealed that there was no documentation of the resident receiving assistance in accordance with the Minimum Data Set (MDS) assessment or the resident's care plan or physician orders for Bed Mobility, Hygiene, or Toilet Use from 9/15/23 through 9/16/23 at 6:59 PM. There was no documentation for Eating and Drinking or percent of meals or nourishments/snacks eaten or fluid intake from 9/15/23 through 8:00 AM on 9/16/23. There was no documentation for Bladder continence or Bowel Movements and no observations of skin or behaviors recorded on 9/15/23 through 6:59 PM on 9/16/23. Record review of the local hospital Emergency Department (ED) notes dated 9/16/23 revealed that Resident #1 was assessed and treated by ED Nurse Practitioner (EDNP) on 9/16/23 for Heat Exposure .Rhabdomyolysis .Adult Neglect or Abandonment .Elevated Blood Pressure Reading. On 9/20/23 at 3:10 PM, an interview with RN #2 revealed that she worked as the medication nurse for Transitional Care Unit (TCU) at the facility from 8:00 AM through 4:30 PM on 9/15/23. She said that Resident #1 was propelled to the facility van for transportation to a dialysis appointment on 9/15/23 between 9:45 (AM) and 10:00 (AM) as usual. RN #2 confirmed that she did not observe Resident #1 for the rest of the day. RN #2 stated that the facility did not send food, fluids or medications for residents to dialysis appointments. An interview with Certified Nursing Assistant (CNA) #3 on 9/20/23 at 3:20 PM, revealed she worked 7:00 AM through 7:00 PM on 9/15/23 on the TCU and that she had mentioned to Licensed Practical Nurse (LPN) #1 that Resident #1 was not in her room at approximately 7:00 PM, when the CNA had clocked out for the day and left the building. CNA #3 confirmed that Resident #1 had not received any supervision, monitoring, care, food or fluids after the resident left for dialysis at approximately 10:00 AM through 7:00 PM when the CNA left work on 9/15/23. In an interview with LPN #1 on 9/20/23 at 5:15 PM, she confirmed that she was assigned to provide care for Resident #1 for the 7:00 PM to 7:00 AM shift on 9/15/23. She reported that she had arrived and clocked in at approximately 6:30 on 9/15/23 and relieved LPN #3 on the TCU and during shift change report, was told by LPN #3 that Resident #1 had not returned from her dialysis appointment. LPN #1 stated that Resident #1 had not received any supervision, monitoring, care, food, fluids, pain management or medications from 6:30 PM on 9/15/23 through 9/16/23 at 7:00 AM when the LPN had clocked and left the facility. In an interview on 9/21/23 at 2:28 PM, CNA #2 confirmed that AM (morning) care for each resident should include monitoring for and provision of incontinence/toileting needs, hygiene (which she said would include oral care/toothbrushing, washing hands and face, and use of personal care products of preference, such as deodorant/antiperspirant) and getting ready. CNA stated, Normally when she (Resident #1) gets back from dialysis, we heat her lunch up and she eats it and then she lays down cause she's tired from dialysis. Normally the Transportation Aide drops the resident off at the common area at the nurse's station and that's where she (Resident #1) eats her lunch. CNA #2 stated that Resident #1's CNA would then assist Resident #1 with transfer into bed and provide care as needed including monitoring for and provision of incontinence/toileting needs and hygiene. She stated that Resident #1 normally ate her evening meal (supper) in bed. CNA #2 confirmed that Resident #1 did not receive any care, monitoring (including monitoring of skin or behaviors), supervision, food, or fluids from 7:00 PM on 9/15/23 to 7:00 AM on 9/16/23, because she was on the van. CNA #2 stated that on 9/16/23 she and CNA #3 arrived on TCU unit at approximately 7:00 AM and asked the 7 PM-7 AM shift nurse and they told us that (Resident #1) had not come back from dialysis. She reported that they went down hall to do rounds and then, during breakfast, she (Resident #1) was found on the van on 9/16/23 at approximately 7:45 AM. She stated that she had gone to the van and observed Resident #1 seated in her wheelchair on the van, sweaty with throw-up and drool on her mouth and clothes and that her skin was hot, hot. CNA #2 stated that Resident #1 required assistance with a bed bath, hygiene, eating, dressing and had her vital signs measured by staff upon return to her room at approximately 7:50 AM on 9/16/23. On 9/21/23 at 3:00 PM, an interview with the facility Medical Director (MD), who was the Resident #1's primary physician, confirmed he had been made aware of the incident by the Administrator and DON on the morning of 9/16/23 at or about 8:40 AM and was told that the Transportation Aide forgot to transfer Resident #1 from the van to the facility on the evening of 9/15/23 upon return from a dialysis appointment and Resident #1 had spent the night in the van and was found on the van at approximately 7:45 AM on 9/16/23. The MD confirmed that the resident would have required monitoring for signs and symptoms of dehydration and monitoring of the dialysis shunt site for bleeding, which the facility failed to provide for over sixteen (16) hours due to Resident #1 being in the van without awareness of the staff. The MD confirmed that the resident did not receive any care supervision, monitoring, food, physician ordered medications or hydration from approximately 3:30 PM on 9/15/23 through approximately 7:50 AM on 9/16/23. The Administrator revealed on 9/22/23 at 4:42 PM, during an interview that he was made aware on 9/16/23 at approximately 7:50 AM of the incident in which Resident #1 was left alone on the facility van following her dialysis treatment. The Administrator confirmed she was last observed by facility staff strapped in her wheelchair on the facility van on 9/15/23 at approximately 3:30 PM and was located by facility staff still strapped in her wheelchair on the facility van on 9/16/23 at approximately 7:45 AM. He confirmed that Resident #1 did not receive any medications, food or fluids, care or services or monitoring for approximately sixteen (16) hours and fifteen (15) minutes. On 9/26/23 at 10:20 AM, an additional interview with the Medical Director confirmed that Resident #1 could have potentially suffered serious complications with her comorbidities; potentially serious injury or impairment, including but not limited to signs/symptoms (s/s) hyperglycemia or hypoglycemia, s/s of Chronic Obstructive Pulmonary Disease, negative effects of hypertension due to lack of monitoring while on the facility van for over sixteen (16) hours. Record review of the Admission Record revealed the facility admitted Resident #1 on 12/20/22 with diagnoses including Type 2 Diabetes Mellitus without complications, Hypertensive Urgency, Long Term (current) use of Insulin, End Stage Renal Disease, Dependence on Renal Dialysis, Chronic Diastolic (congestive) Heart Failure, Type 2 Diabetes Mellitus, long-term current use of insulin, Dependence on renal dialysis, End stage renal disease, and Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic Kidney Disease, or End Stage Renal. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/7/23 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score is 07 indicating Resident #1 had severe cognitive impairment. Section G revealed for resident transfer, that the resident was extensive assist with two people. Section H revealed the resident was always incontinent of bowel and bladder. Section J revealed the resident had pain frequently. Section M revealed that the resident was at risk for pressure ulcers/injuries. The facility provided the following Removal Plan on 9/28/23. On 9/26/2023 1:15 pm the State Agency notified the Administrator that the facility neglected to provide care and services for Resident #1 from approximately 3:45 pm on 9/15/2023 until approximately 7:45 am on 9/16/2023, failed to notify the Physician timely of a change in condition after resident was left in the transport van, alone and unattended by a staff member which resulted in Resident #1 missing medications, meals, hydration and post dialysis site care/assessments. On 9/15/2023 the Transportation Assistant (TA) left Resident #1 in the facility vehicle after returning to the facility from dialysis at approximately 3:45 pm. The facility staff located Resident #1 and removed her from the facility vehicle at approximately 7:50 am on 9/16/2023, assisted Resident #1 back in the facility, transferred Resident #1 to bed, Registered Nurse (RN) #1 completed an assessment revealing a temperature 100.3, blood pressure 175/79, pulse 97, Oxygen Saturation 100%. The nurse did not obtain blood sugar at this time. The physician was notified of the incident at approximately 8:40 am on 9/16/2023 by the Director of Nursing. The Resident Representative was notified of the incident at approximately 9:15 am on 9/16/2023 by the Administrator. 1. 9/16/2023 8:40 am the DON (Director of Nurses) arrived at the facility, assessed resident #1 and noted that resident was at baseline. 2. On 9/16/2023 the Medical Director was notified at 8:40 am and received an order to send to the emergency room for evaluation. 3. 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. 4. 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. 5. 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. 6. On 9/16/2023 at 10:10 am the investigation revealed that when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. LPN #1 received in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis and did not follow up to determine where the resident was located. 7. On 9/16/2023 at 10:45 am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. QAPI minutes included: Review of the incident, investigation and missing resident policy. Review of immediate actions taken. Recommendations to prevent reoccurrence were to complete in-service for all staff regarding missing residents prior to working, in-service for nurses to include if the reason why a resident is not in the facility is not documented in the record to notify the supervisor immediately, initiate a log for 2 people to document that the facility vehicle is checked at the end of each day and after each transport, conduct a missing person drill on each shift, initiate 2 staff members to ride on the facility vehicle for all resident transports and educate all transportation drivers of new procedures. 8. On 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. 9. 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. 10. 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. 11. 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The missing resident drill consisted of a resident being hidden in the Administrator's office and was identified by a staff member who did a sweep of the office areas and the staff member immediately reported to the Administrator that the resident was found. No changes to policy and procedure needed. 12. On 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. 13. 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. 14. 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. 15. On 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. 16. 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. -The Committee reviewed the incident, the Immediate Jeopardies cited by the state agency on 9/26/2023, and the policies regarding abuse and neglect, supervision of residents, dialysis care, diabetic care, timely notification of the physician, accidents, staffing and care plans. The following recommendations were discussed. The root cause analysis revealed that the TA was distracted and as a result left Resident #1 on the facility vehicle. It also revealed that the nurse failed to follow proper procedure to investigate why Resident #1 did not return from dialysis that resulted in the resident not being located in a timely manner which resulted in the resident not receiving proper dialysis care, diabetic care and medications. There were no recommendations to make changes to any policies by the QAPI Team and all interventions that were put into place were effective. The MDS Nurse will conduct another audit of the care plans for 100% of residents receiving dialysis and diabetic care. The MDS Nurse will conduct an audit of the care plans for 100% of residents receiving routine transportation services. The Social Service Director will evaluate Resident #1 for signs of psychosocial harm due to the incident that occurred on 9/15/2023. The facility assessment was reviewed and updated regarding staffing according to the acuity of the residents. The Committee determined at this time the staffing required for the night shift is 4 Certified Nursing Assistants and 2 Nurses. If these requirements are not met the nurse will contact the DON and Administrator and they will make arrangements to cover staffing needs by contacting all employees, department heads and sister facilities as needed to fill gaps. DON will provide in-service for all staff regarding abuse/neglect, accidents, and supervision of residents. DON will provide in-service for all nursing staff regarding staffing, care plans, diabetic care, dialysis care and timely notification of the physician. All staff will receive in-service prior to returning to work. 17. 9/26/2023 3:00 pm the Social Service Director spoke with resident #1 concerning her psychosocial needs and noted no signs of psychosocial harm related to the incident that occurred on 9/15/2023. 18. 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. 19. 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. 20. On 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident. The facility alleges removal of the immediacy on 9/28/2023. The SA validated the Removal Plan on 9/28/23 and determined the IJ and SQC was removed on 9/28/23 prior to exit. The SA validated through interview and record review that the DON stated she arrived on 9/16/2023 8:40 am and assessed Resident #1. The SA validated through interviews and record reviews that on 9/16/2023 the Medical Director was notified at 8:40 am and gave an order to send to the emergency room for evaluation. The SA validated through interviews and record reviews that on 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. The SA validated through interviews and record reviews that on 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. The SA validated through interviews and documentation reviews that on 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. The SA validated through interviews and record reviews that on 9/16/2023 at 10:10 am the facility initiated an investigation that revealed when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. The SA validated that the facility investigation also revealed LPN #1 did not follow up to determine where the resident was located when told in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis. The SA validated through interviews, observations, and record reviews that on 9/16/2023 at 10:45am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. The SA validated through staff interviews and record reviews that on 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. The SA validated through observation, interviews, and record reviews that on 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. The SA validated through interviews and documentation reviews that on 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. The SA validated through interviews and documentation reviews that on 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The SA validated through interview that on 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. The SA validated through interviews and staff sign in sheets that on 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. The SA validated through interview and record review that on 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. The SA validated through interview that on 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. The SA validated through interviews and record reviews that on 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. The SA validated through interview and record review that on 9/26/2023 3:00 pm the Social Service Director spoke with resident #1 concerning her psychosocial needs. The SA validated through interviews and staff sign in sheets that on 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. The SA validated through interviews and record reviews that on 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. The SA validated through interview and documentation review that on 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident.

Based on policy review, record review, and interviews, the facility failed to provide supervision for a resident who was left alone, abandoned, strapped in her wheelchair without monitoring on the facility transport van following a dialysis treatment for approximately 16 hours and 15 minutes for one (1) of four (4) Residents reviewed. Resident #1. The facility failed to remove the resident from the facility van following transportation from her hemodialysis treatment, abandoning the resident restrained by seat belts in a wheelchair in the facility transport van, without supervision or monitoring. The staff was unaware of Resident #1's location from approximately 3:30 PM on 9/15/23 through 7:45 AM on 9/16/23. The State Agency (SA) conducted an onsite investigation from 9/20/23 through 9/28/23. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 9/15/23 when Resident #1 was abandoned on the facility transport van. The facility's failure to supervise Resident #1 placed this resident, and other resident, in a situation that was likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 9/15/23, when the facility abandoned Resident #1 on the facility van for approximately sixteen (16) hours and fifteen (15) minutes following hemodialysis. The resident received no treatment, supervision, monitoring or care during this time. The IJ and SQC existed at: CFR 483.25(d)(2) Accidents - F689 Scope and Severity J The State Agency (SA) notified the facility Administrator of the IJ and SQC on 9/26/23 at 1:15 PM. The facility provided an acceptable Removal Plan on 9/27/23, in which the facility alleged all corrective actions were completed on 9/27/23 to remove the IJ on 9/28/23. The facility submitted an acceptable Removal Plan on 9/28/23, in which they alleged all corrective actions to remove the IJ and SQC were completed on 9/27/23 and the IJ was removed on 9/28/23. The SA validated the Removal Plan on 9/28/23 and determined the IJ was removed on 9/28/23, prior to exit. Therefore, the scope and severity for F689 - 483.25(d)(2) Accidents scope and severity J was lowered to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's policy, Accidents and Incidents with a revision date of 9/25/23, revealed, Policy: It is the policy of this facility that the resident environment remains as free of accidents and hazards as possible, and those residents receive supervision and assistance devices to prevent accidents whenever possible . A record review of the Facility Investigation, dated 9/19/2023, revealed, during shift report on 9/16/2023 at approximately 7:00 am (AM), the night shift informed the oncoming shift that the resident did not return from dialysis on 9/15/2023. At approximately 7:50 AM on 9/16/2023, the facility staff located Resident #1 still strapped in the facility transport van. A record review of Resident #1's Incident Report revealed, 9/16/23 13:38 (1:38 PM), .writer notified of resident being left in facility transport van after dialysis yesterday evening. Resident was located in facility van the AM . A record review of the Transportation Aide (TA's) written statement revealed, on 9/16/23, .Arrived at (Proper Name/facility) I noticed a elderly women falling so I jumped out of van to assist her the lady told me she was to weak then pulled off. I went back inside (Proper Name of facility) to finish up normal routine and left for the day. Around 7:15 AM I got a call asking about Resident #1 and I asked the nurse to check the bus .I would like to add that I arrived at (Proper Name of facility) at or about 3:30 PM with Resident #1 . An interview with the TA on 9/20/23 at 4:05 PM, revealed that 9/15/23, After receiving Resident #1 from dialysis, I drove back to the facility and parked the van, with Resident #1 secured in the van. The TA noticed a visitor who was in distress in the parking lot and assisted the visitor. Following the incident with the visitor, she clocked out and left the facility. The following morning, she received a phone call from the facility questioning where Resident #1 was located. At that moment, she realized she had not transferred the resident from the van to the facility. The resident remained unattended for approximately 16 hours while in the facility van. A record review of Licensed Practical Nurse (LPN) #1's written statement revealed, . On 9/15/23, I received a report that patient had not returned from dialysis. After completed pm (PM) med (medication) pass resident had still not returned. At around 10 or so I tried to call (Professional Name/Dialysis) with no answer. Reported to the oncoming nurse that she had not returned from dialysis . On 9/20/23 at 5:15 PM, an interview with LPN #1 confirmed she was assigned to Resident #1 on 9/15/23 at 7:00 PM until 9/16/23 at 7:00 AM. LPN #1 stated that on 9/15/23 at 10:00 PM, Resident #1 did not receive her medications and was not in the building. She assumed she was at the hospital or still at dialysis. She attempted to contact dialysis unsuccessfully and passed on to the oncoming nurse on 9/16/23 at 7:00 AM that Resident #1 was not in the building. On 9/20/23 at 10:25 AM, an interview with the Director of Nurses (DON) confirmed that Resident #1 was left in the facility transport van, strapped in her wheelchair from 9/15/23 at approximately 3:30 PM until 9/16/23 at 7:45 AM, when she was located by the facility staff. The DON revealed the resident was unattended for approximately 16 hours and 15 minutes. During an interview on 9/20/23 at 3:40 PM, Certified Nurse Assistant (CNA) #3 revealed that she worked the day shift at the facility on Friday, 9/15/23, until 7:00 PM and confirmed Resident #1 was not in the facility. She reported to the night shift nurse (LPN #1) that Resident #1 was not in the facility. When she arrived at work on 9/16/23 at approximately 7:45 AM, Resident #1 was in the facility van strapped in her wheelchair. A record review Registered Nurse (RN) #1's written statement revealed, .At approximately 7:10, I was notified by night shift nurse and oncoming nurse and Certified Nurse Assistant (CNA) that resident did not return to facility from Dialysis on 9/15/23. Night shift nurse stated, I do not know where she is, I did not realize she was still gone around 10 pm (PM). Called TA, she stated, Oh my gosh, check the van. Resident was seen in the van, shoulders moving up and down indicating she was breathing. On 9/21/23 at 9:23 AM, an interview with Registered Nurse (RN) #1 confirmed on 9/16/23 that she was informed that Resident #1 was not in the building. She stated she started making phone calls to locate the resident. The TA advised her to look in the facility van, where she was located still strapped in her wheelchair. Resident #1 was strapped in her wheelchair and the facility van for approximately 16 hours and 15 minutes with no supervision. In an interview on 9/22/23 at 4:42 PM, with the Administrator, confirmed Resident #1 was last observed on the facility van when she was transported from dialysis on 9/15/23 at approximately 3:30 PM. The Administrator conveyed that he was informed on 9/16/23 at approximately 7:50 AM of the incident that Resident #1 was left unattended on the facility van following her dialysis treatment for approximately 16 hours and 15 minutes, with no supervision. In an interview on 9/26/23 at 10:20 AM, with the Medical Director (MD) revealed the potential for serious complications for Resident #1 for being unsupervised and left in the facility van for over 16 hours. In an interview on 9/26/23 at 1:35 PM, with the DON revealed that on 9/15/23 at approximately 3:30 PM, the TA left Resident #1 in the facility van and was found on 9/16/23 at approximately 7:45 AM. The DON stated that the resident not receiving medications, supervision, or monitoring for over sixteen (16) hours could have resulted in serious injury or impairment. The DON confirmed that the Resident did not receive supervision, appropriate monitoring or any Activities of Daily Living (ADL) care, during the sixteen (16) plus hours when she was not in the facility. On 9/27/23 at 3:13 PM, an interview with RN #4 from the dialysis clinic confirmed Resident #1's dialysis was completed, and she was transported from the dialysis clinic to the facility on [DATE] at approximately 3:15 PM, by a facility staff member. She was unsure of who performed the transport. Record review of the local weather temperature for 9/15/23 at approximately 3:45 pm through 9/16/23 at 8:40 AM, when the facility located Resident #1, ranged from 89 degrees Fahrenheit to 77 degrees Fahrenheit and was obtained at https://www.timeanddate.com. Record review of the Admission Record revealed the facility admitted Resident #1 on 12/20/22 with diagnoses including Type 2 Diabetes Mellitus without complications, Hypertension, Insulin-Dependent, Dependence on Renal Dialysis, Chronic Diastolic (congestive) Heart Failure, Type 2 Diabetes Mellitus, Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic kidney disease. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/7/23 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 07 indicating Resident #1 had severe cognitive impairment. Section G revealed for resident transfer that the resident was an extensive assist with two people. Section H revealed the resident was always incontinent of bowel and bladder. Section J revealed Resident #1 experienced pain frequently. Section M revealed that the resident was at risk for pressure ulcers/injuries. The facility provided the following Removal Plan on 9/28/23. On 9/26/2023 1:15 pm the State Agency notified the Administrator that the facility neglected to provide care and services for Resident #1 from approximately 3:45 pm on 9/15/2023 until approximately 7:45 am on 9/16/2023, failed to notify the Physician timely of a change in condition after resident was left in the transport van, alone and unattended by a staff member which resulted in Resident #1 missing medications, meals, hydration and post dialysis site care/assessments. On 9/15/2023 the Transportation Assistant (TA) left Resident #1 in the facility vehicle after returning to the facility from dialysis at approximately 3:45 pm. The facility staff located Resident #1 and removed her from the facility vehicle at approximately 7:50 am on 9/16/2023, assisted Resident #1 back in the facility, transferred Resident #1 to bed, Registered Nurse (RN) #1 completed an assessment revealing a temperature 100.3 Fahrenheit, blood pressure 175/79, pulse 97, Oxygen Saturation 100%. The nurse did not obtain blood sugar at this time. The physician was notified of the incident at approximately 8:40 am on 9/16/2023 by the Director of Nursing. The Resident Representative was notified of the incident at approximately 9:15 am on 9/16/2023 by the Administrator. 1. 9/16/2023 8:40 am the DON (Director of Nurses) arrived at the facility, assessed Resident #1 and noted that resident was at baseline. 2. On 9/16/2023 the Medical Director was notified at 8:40 am and received an order to send to the emergency room for evaluation. 3. 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. 4. 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. 5. 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. 6. On 9/16/2023 at 10:10 am the investigation revealed that when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. LPN #1 received in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis and did not follow up to determine where the resident was located. 7. On 9/16/2023 at 10:45 am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. QAPI minutes included: Review of the incident, investigation and missing resident policy. Review of immediate actions taken. Recommendations to prevent reoccurrence were to complete in-service for all staff regarding missing residents prior to working, in-service for nurses to include if the reason why a resident is not in the facility is not documented in the record to notify the supervisor immediately, initiate a log for 2 people to document that the facility vehicle is checked at the end of each day and after each transport, conduct a missing person drill on each shift, initiate 2 staff members to ride on the facility vehicle for all resident transports and educate all transportation drivers of new procedures. 8. On 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. 9. 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. 10. 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. 11. 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The missing resident drill consisted of a resident being hidden in the Administrator's office and was identified by a staff member who did a sweep of the office areas and the staff member immediately reported to the Administrator that the resident was found. No changes to policy and procedure needed. 12. On 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. 13. 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. 14. 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. 15. On 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. 16. 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. -The Committee reviewed the incident, the Immediate Jeopardies cited by the state agency on 9/26/2023, and the policies regarding abuse and neglect, supervision of residents, dialysis care, diabetic care, timely notification of the physician, accidents, staffing and care plans. The following recommendations were discussed. The root cause analysis revealed that the TA was distracted and as a result left Resident #1 on the facility vehicle. It also revealed that the nurse failed to follow proper procedure to investigate why Resident #1 did not return from dialysis that resulted in the resident not being located in a timely manner which resulted in the resident not receiving proper dialysis care, diabetic care and medications. There were no recommendations to make changes to any policies by the QAPI Team and all interventions that were put into place were effective. The MDS Nurse will conduct another audit of the care plans for 100% of residents receiving dialysis and diabetic care. The MDS Nurse will conduct an audit of the care plans for 100% of residents receiving routine transportation services. The Social Service Director will evaluate Resident #1 for signs of psychosocial harm due to the incident that occurred on 9/15/2023. The facility assessment was reviewed and updated regarding staffing according to the acuity of the residents. The Committee determined at this time the staffing required for the night shift is 4 Certified Nursing Assistants and 2 Nurses. If these requirements are not met the nurse will contact the DON and Administrator and they will make arrangements to cover staffing needs by contacting all employees, department heads and sister facilities as needed to fill gaps. DON will provide in-service for all staff regarding abuse/neglect, accidents, and supervision of residents. DON will provide in-service for all nursing staff regarding staffing, care plans, diabetic care, dialysis care and timely notification of the physician. All staff will receive in-service prior to returning to work. 17. 9/26/2023 3:00 pm the Social Service Director spoke with Resident #1 concerning her psychosocial needs and noted no signs of psychosocial harm related to the incident that occurred on 9/15/2023. 18. 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. 19. 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. 20. On 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident. The facility alleges removal of the immediacy on 9/28/2023. The SA validated the Removal Plan on 9/28/23 and determined the IJ was removed on 9/28/23 prior to exit. The SA validated through interview and record review that the DON stated she arrived on 9/16/2023 8:40 am and assessed Resident #1. The SA validated through interviews and record reviews that on 9/16/2023 the Medical Director was notified at 8:40 am and gave an order to send to the emergency room for evaluation. The SA validated through interviews and record reviews that on 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. The SA validated through interviews and record reviews that on 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. The SA validated through interviews and documentation reviews that on 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. The SA validated through interviews and record reviews that on 9/16/2023 at 10:10 am the facility initiated an investigation that revealed when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. The SA validated that the facility investigation also revealed LPN #1 did not follow up to determine where the resident was located when told in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis. The SA validated through interviews, observations, and record reviews that on 9/16/2023 at 10:45 am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. The SA validated through staff interviews and record reviews that on 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. The SA validated through observation, interviews, and record reviews that on 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. The SA validated through interviews and documentation reviews that on 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. The SA validated through interviews and documentation reviews that on 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The SA validated through interview that on 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. The SA validated through interviews and staff sign in sheets that on 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. The SA validated through interview and record review that on 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. The SA validated through interview that on 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. The SA validated through interviews and record reviews that on 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. The SA validated through interview and record review that on 9/26/2023 3:00 pm the Social Service Director spoke with resident #1 concerning her psychosocial needs. The SA validated through interviews and staff sign in sheets that on 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. The SA validated through interviews and record reviews that on 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. The SA validated through interview and documentation review that on 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident.

Based on interview, record review, and facility policy review, the facility failed to ensure Resident #1 received care and services following a hemodialysis treatment consistent with professional standards of practice including ongoing assessment of the resident's condition and monitoring for complications after dialysis treatments for one (1) of four (4) residents reviewed, Resident #1 as evidenced by the facility failed to remove the resident from the facility van on 9/15/23 following their transportation from the dialysis facility, leaving the resident strapped in a wheelchair restrained by the seatbelts in the facility van for sixteen (16) hours and fifteen (15) minutes without the staff's monitoring. The facility's failure to provide treatment, monitoring, care, food, or fluids after hemodialysis placed this resident and other residents in a situation that has caused and is likely to cause serious harm, injury, impairment, or death. The State Agency (SA) conducted an onsite investigation from 9/20/23 through 9/28/23. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) that began on 9/15/23, when the facility abandoned Resident #1 on the facility van. The IJ and SQC existed at: 42 CFR 483.25(l) Dialysis - F698 Scope and Severity J. The SA notified the facility's Administrator of the IJ and SQC on 9/26/23 and provided the Administrator with the IJ template. The facility submitted an acceptable Removal Plan on 9/28/23, in which they alleged all corrective actions to remove the IJ and SQC were completed on 9/27/23 and the IJ was removed on 9/28/23. The SA validated the Removal Plan on 9/28/23 and determined the IJ and SQC was removed on 9/28/23, prior to exit. Therefore, the scope and severity of 42 CFR 483.25(l) Dialysis - F698 was lowered from a J to D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility policy, Clinical Practice Guideline Dialysis-Hemodialysis dated March 24, 2010, revealed the Objectives .To ensure the resident is assessed and/or observed appropriately .to ensure adequate nutrition and hydration .The access device should be observed for complications at least every shift and more frequently if the resident has just been dialyzed. These observations should include the appearance of the device, and the presence or absence of sign/symptoms of infection, and the presence of bruit or thrill if applicable. Observations of the resident's mental status, dialysis access, respiratory status, body/skin condition, pain status, and urine output should be done pre and post dialysis .Ongoing observations/assessments of the resident's skin should be done. Ongoing observations/assessments of the resident's fluid balance, nutritional state, mental status, respiratory status, and cardiovascular status should be done. In an interview on 9/20/23 at 4:05 PM, the Transportation Aide (TA) revealed that on 9/15/23 she had transported Resident #1 from the dialysis facility following the resident's dialysis treatment to the facility at approximately 3:45 PM. She said she encountered a situation in the parking lot upon return to the facility, prior to unloading Resident #1, in which she had gone to the assistance of a visitor. She stated that she went inside the facility and forgot to unload Resident #1. The TA stated that after checking to see if she had any more transports for the day (and discovering that she did not) she clocked out and left the facility and left Resident #1 secured in her wheelchair in the van. She said she did not think any more about Resident #1 until she received a telephone call the following morning from Registered Nurse (RN) #2 who asked her if she had picked Resident #1 up from the dialysis facility. The TA stated she immediately told RN #2 to go check the van. Certified Nurse's Aide (CNA) #3 revealed on 9/20/23 at 3:20 PM, in an interview that she had worked 7:00 AM through 7:00 PM on 9/15/23 on TCU and that she had mentioned to Licensed Practical Nurse (LPN) #1 that Resident #1 was not in her room at approximately 7:00 PM, when the CNA clocked out for the day and left the building. CNA #3 confirmed that Resident #1 had not received any observation, monitoring, care, food, or fluids after the resident left for dialysis at approximately 10:00 AM through 7:00 PM when the CNA left work on 9/216/23. In an interview on 9/20/23 at 5:15 PM, Licensed Practical Nurse (LPN) #1 confirmed she was assigned to provide care for Resident #1 from 7:00 PM on 9/15/21 to 7:00 AM on 9/16/23. She reported that she had arrived and clocked in at approximately 6:30 PM on 9/15/23 and relieved LPN #3 on the Transitional Care Unit (TCU) and during shift change report was told by LPN #3 that Resident #1 had not returned from her dialysis appointment. LPN #1 stated that at approximately 10:00 PM on 9/15/23 she noted that the only resident she had not completed medication administration for was Resident #1 and she had attempted to contact the dialysis facility by telephone without success but did not attempt to contact anyone else. LPN #1 stated that Resident #1 had not received any observation, monitoring, care, food, or fluids from 6:30 PM on 9/15/23 through 9/16/23 at 7:00 AM when the LPN had left the facility with no knowledge of the location of the resident. CNA #2 revealed on 9/21/23 at 2:28 PM, during an interview that Resident #1 did not receive any care, monitoring, observation, or fluids from 7:00 PM on 9/15/23 to 7:00 AM on 9/15/23, because she was on the van. CNA #2 stated that on 9/16/23 she and CNA #3 arrived on the TCU at approximately 7:00 AM and asked the 7PM-7AM shift nurse and they told us that (Resident #1) had not come back from dialysis. She reported that they went down hall to do rounds and then, during breakfast, she (Resident #1) was found on the van at approximately 7:45 AM. She stated that she had gone to the van and observed Resident #1 secured in her wheelchair on the van, sweaty with throw-up and drool on her mouth and clothes and that her skin was hot, hot. On 9/21/23 at 3:00 PM, during an interview with the facility Medical Director (MD), who was Resident #1's primary physician, he confirmed that the resident would have required monitoring for signs and symptoms of dehydration and monitoring of the dialysis shunt site for bleeding, which the facility failed to provide for over sixteen (16) hours due to Resident #1 being in the van without awareness of the staff. The Administrator revealed on 9/22/23 at 4:42 PM, during an interview that he was made aware on 9/16/23 at approximately 7:50 AM of the incident in which Resident #1 was left alone on the facility van following her dialysis treatment. The Administrator confirmed she was last observed by facility staff strapped in her wheelchair on the facility van on 9/15/23 at approximately 3:30 PM and was located by facility staff still strapped in her wheelchair on the facility van on 9/16/23 at approximately 7:45 AM. He confirmed that Resident #1 did not receive any medications, food or fluids, care or services or monitoring for approximately sixteen (16) hours and fifteen (15) minutes. On 9/26/23 at 10:20 AM, in a later interview with the MD, he confirmed that Resident #1 could have potentially suffered serious complications with her comorbidities including potentially serious injury or impairment due to lack of monitoring and care while on the facility van for over sixteen (16) hours. The MD stated that there were additional risks related to no fluids provided to the resident for over 16 hours following hemodialysis. He stated that following dialysis monitoring of the resident's vital signs and monitoring for bleeding at the access site would have been important. Record review of the local hospital Emergency Department (ED) notes dated 9/16/23 revealed that Resident #1 was assessed and treated by ED Nurse Practitioner (EDNP) on 9/16/23 for Heat Exposure .Rhabdomyolysis .Adult Neglect or Abandonment .Elevated Blood Pressure Reading. The ED notes included consideration of intravenous fluids avoided due to the residents diagnosis of End Stage Renal Disease. On 9/27/23 at 4:15 PM, an interview with the EDNP revealed that she considered Resident to #1 to be a risk for several potential negative cardiac results of having sat up in a wheelchair without care or repositioning for over sixteen (16) hours which included Rhabdomyolysis, Heat Exposure and Elevated Blood Pressure. Record review of Resident #1's 9/2023 Medication Administration Record (MAR) revealed on 9/15/23 the following were coded as '3' for (resident absent from home) and not administered: prescribed fluids to be provided related to dialysis, monitoring dialysis access site, observation of dressing right arm, and vital signs. Record review of the interdisciplinary progress notes for Resident #1 for September 2023 revealed there were no entries that documented the resident leaving or returning to the facility for or following dialysis appointments/treatments. Record review of the Dialysis Transfer Forms for Resident #1 for September 2023 revealed that out of ten (10) forms, four (4) of the forms were completed in the section labeled Upon Return to Facility Following Dialysis; the section was not completed for the Dialysis Transfer Form dated 9/15/23. Record review of the Sign Out binder at the TCU nurses' station and the [NAME] Hall nurses stations for September 2023 revealed that there were no entries that documented any of the sampled residents, who relied on the facility for transportation for dialysis treatments at a dialysis unit outside of the facility, having been signed out or back in from dialysis appointments prior to 9/16/23. Record review of the Documentation Survey Report .Tasks Only for Resident #1 for 9/15/23 and 9/16/23 revealed that there was no documentation of the resident receiving assistance in accordance with the MDS assessment or the resident's care plan or physician orders for 'Eating and Drinking' or percent of meals or nourishments/snacks eaten or fluid intake for 9/15/23 through 8:00 AM on 9/16/23. There was no documentation for observations by Certified Nurse's Aides (CNAs) on 9/15/23 through 6:59 PM on 9/16/23. Record review of the Admission Record revealed the facility admitted Resident #1 on 12/20/22 with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure, Stage 5 Chronic Kidney Disease or End Stage Renal Disease, Dependence on Renal Dialysis, Diabetes, Hypertensive Urgency, and Long Term (current) use of Insulin. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/7/23 for Resident #1 revealed the resident had a Brief Interview for Mental Status (BIMS) score is 07, which indicated severe cognitive impairment and Section O indicated that the resident received renal dialysis. The facility provided the following Removal Plan on 9/28/23. On 9/26/2023 1:15 pm the State Agency notified the Administrator that the facility neglected to provide care and services for Resident #1 from approximately 3:45 pm on 9/15/2023 until approximately 7:45 am on 9/16/2023, failed to notify the Physician timely of a change in condition after resident was left in the transport van, alone and unattended by a staff member which resulted in Resident #1 missing medications, meals, hydration and post dialysis site care/assessments. On 9/15/2023 the Transportation Assistant (TA) left Resident #1 in the facility vehicle after returning to the facility from dialysis at approximately 3:45 pm. The facility staff located Resident #1 and removed her from the facility vehicle at approximately 7:50 am on 9/16/2023, assisted Resident #1 back in the facility, transferred Resident #1 to bed, Registered Nurse (RN) #1 completed an assessment revealing a temperature 100.3, blood pressure 175/79, pulse 97, Oxygen Saturation 100%. The nurse did not obtain blood sugar at this time. The physician was notified of the incident at approximately 8:40 am on 9/16/2023 by the Director of Nursing. The Resident Representative was notified of the incident at approximately 9:15 am on 9/16/2023 by the Administrator. 1. 9/16/2023 8:40 am the DON (Director of Nurses) arrived at the facility, assessed Resident #1 and noted that resident was at baseline. 2. On 9/16/2023 the Medical Director was notified at 8:40 am and received an order to send to the emergency room for evaluation. 3. 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. 4. 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. 5. 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. 6. On 9/16/2023 at 10:10 am the investigation revealed that when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. LPN #1 received in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis and did not follow up to determine where the resident was located. 7. On 9/16/2023 at 10:45am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. QAPI minutes included: Review of the incident, investigation and missing resident policy. Review of immediate actions taken. Recommendations to prevent reoccurrence were to complete in-service for all staff regarding missing residents prior to working, in-service for nurses to include if the reason why a resident is not in the facility is not documented in the record to notify the supervisor immediately, initiate a log for 2 people to document that the facility vehicle is checked at the end of each day and after each transport, conduct a missing person drill on each shift, initiate 2 staff members to ride on the facility vehicle for all resident transports and educate all transportation drivers of new procedures. 8. On 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. 9. 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. 10. 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. 11. 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The missing resident drill consisted of a resident being hidden in the Administrator's office and was identified by a staff member who did a sweep of the office areas and the staff member immediately reported to the Administrator that the resident was found. No changes to policy and procedure needed. 12. On 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. 13. 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. 14. 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. 15. On 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. 16. 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. -The Committee reviewed the incident, the Immediate Jeopardies cited by the state agency on 9/26/2023, and the policies regarding abuse and neglect, supervision of residents, dialysis care, diabetic care, timely notification of the physician, accidents, staffing and care plans. The following recommendations were discussed. The root cause analysis revealed that the TA was distracted and as a result left Resident #1 on the facility vehicle. It also revealed that the nurse failed to follow proper procedure to investigate why Resident #1 did not return from dialysis that resulted in the resident not being located in a timely manner which resulted in the resident not receiving proper dialysis care, diabetic care and medications. There were no recommendations to make changes to any policies by the QAPI Team and all interventions that were put into place were effective. The MDS Nurse will conduct another audit of the care plans for 100% of residents receiving dialysis and diabetic care. The MDS Nurse will conduct an audit of the care plans for 100% of residents receiving routine transportation services. The Social Service Director will evaluate Resident #1 for signs of psychosocial harm due to the incident that occurred on 9/15/2023. The facility assessment was reviewed and updated regarding staffing according to the acuity of the residents. The Committee determined at this time the staffing required for the night shift is 4 Certified Nursing Assistants and 2 Nurses. If these requirements are not met the nurse will contact the DON and Administrator and they will make arrangements to cover staffing needs by contacting all employees, department heads and sister facilities as needed to fill gaps. DON will provide in-service for all staff regarding abuse/neglect, accidents, and supervision of residents. DON will provide in-service for all nursing staff regarding staffing, care plans, diabetic care, dialysis care and timely notification of the physician. All staff will receive in-service prior to returning to work. 17. 9/26/2023 3:00 pm the Social Service Director spoke with resident #1 concerning her psychosocial needs and noted no signs of psychosocial harm related to the incident that occurred on 9/15/2023. 18. 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. 19. 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. 20. On 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident. The facility alleges removal of the immediacy on 9/28/2023. The SA validated the Removal Plan on 9/28/23 and immediacy removed it on 9/28/23 prior to exit. The SA validated through interview and record review that the DON stated she arrived on 9/16/2023 8:40 am and assessed Resident #1. The SA validated through interviews and record reviews that on 9/16/2023 the Medical Director was notified at 8:40 am and gave an order to send to the emergency room for evaluation. The SA validated through interviews and record reviews that on 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. The SA validated through interviews and record reviews that on 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. The SA validated through interviews and documentation reviews that on 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. The SA validated through interviews and record reviews that on 9/16/2023 at 10:10 am the facility initiated an investigation that revealed when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. The SA validated that the facility investigation also revealed LPN #1 did not follow up to determine where the resident was located when told in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis. The SA validated through interviews, observations, and record reviews that on 9/16/2023 at 10:45am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. The SA validated through staff interviews and record reviews that on 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. The SA validated through observation, interviews, and record reviews that on 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. The SA validated through interviews and documentation reviews that on 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. The SA validated through interviews and documentation reviews that on 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The SA validated through interview that on 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. The SA validated through interviews and staff sign in sheets that on 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. The SA validated through interview and record review that on 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. The SA validated through interview that on 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. The SA validated through interviews and record reviews that on 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. The SA validated through interview and record review that on 9/26/2023 3:00 pm the Social Service Director spoke with resident #1 concerning her psychosocial needs. The SA validated through interviews and staff sign in sheets that on 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. The SA validated through interviews and record reviews that on 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. The SA validated through interview and documentation review that on 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident.

Based on staff interviews, resident interviews, facility policy review, and record review the facility failed to ensure significant medication (anti-diabetic, anti-hypertension, bronchitis, and pain management medications) were administered to prevent discomfort or complications for one (1) of four (4) residents reviewed, Resident #1. The State Agency (SA) conducted an onsite investigation from 9/20/23 through 9/28/23. On 9/15/23 the facility failed to remove the resident from the facility van following their transportation from the dialysis facility, leaving the resident strapped in a wheelchair in the facility van, unsupervised and without significant medications including insulin, respiratory and hypertensive medications for sixteen (16) hours and fifteen (15) minutes without the staff awareness. The facility's failure to transfer Resident #1 inside the facility and administer medications as ordered by the physician after hemodialysis placed Resident #1 in a situation that was likely to cause serious harm, injury, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) that began on 9/15/23, when the facility abandoned Resident #1 on the facility van for approximately sixteen (16) hours and fifteen (15) minutes following hemodialysis and did not receive medications as ordered by the physician. The IJ and SQC existed at: 42 CFR 483.45(f)(2) Residents are free of any significant medication errors - F760, Scope and Severity J'. The SA notified the facility's Administrator of the IJ and SQC on 9/26/23 and provided the Administrator with the IJ template. The facility submitted an acceptable Removal Plan on 9/28/23, in which they alleged all corrective actions to remove the IJ and SQC were completed on 9/27/23 and the IJ was removed on 9/28/23. The SA validated the Removal Plan on 9/28/23 and determined the IJ and SQC was removed on 9/28/23, prior to exit. Therefore, the scope and severity of 42 CFR 483.45(f)(2) Residents are free of any significant medication errors - F760 was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility policy titled Medication Administration-General Guidelines with a current revision date, August 25, 2014, revealed, Medications are administered as prescribed in accordance with good nursing principles and practices .Medications are administered within 60 minutes of scheduled time, except before or after meals order, which are administered based on mealtimes. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration scheduled for the facility. A record review of the Facility Investigation, dated 9/19/2023, revealed, Incident: During shift report on 9/16/2023 at approximately 7:00 am (AM), the night shift informed the oncoming shift that the resident did not return from dialysis on 9/15/2023. A record review of a written statement by Licensed Practice Nurse (LPN) #1 revealed, on 9/15/23 she received report that patient (Resident #1) had not returned from dialysis. After completing pm (PM) med (medication) pass, the resident had still not returned. At around 10 (PM) or so I tried to call (Professional Name Dialysis Center) with no answer. Reported told day shift nurse that she had not returned from dialysis . A record review of the Order Summary Report as of 9/25/23 revealed Resident #1 missed the following physician orders for blood pressure medication that was scheduled from 7 PM until 10 PM: Amlodipine, Metoprolol Tartrate Tablet, Clonidine HCL and Hydralazine HCL Tablet. A record review of the Order Summary Report as of 9/25/23 revealed Resident #1 missed her diabetic medication (insulin) and accucheck on 9/16/23. She also missed accucheck parameter monitoring with orders to report to the physician if the blood glucose was less than 60 mg/dl (milligrams/deciliter) or greater than 400 mg/dl. A record review of the Order Summary Report also revealed Proventil HFA (bronchitis) was missed for Resident #1's breathing. In an interview on 9/20/23 at 5:15 PM, with LPN #1 revealed that she worked 9/15/23 from 7:00 PM until 9/16/23 at 7:00 AM. LPN #1 confirmed that Resident #1 did not receive her accucheck (blood sugar checks) on 9/15/23 in the evening and on 9/16/23 in the morning. Resident #1 did not receive her significant medications, such as blood pressure, bronchitis inhaler, and insulin. LPN #1 stated that since Resident #1 did not receive her blood pressure medications, a bronchitis inhaler or accucheck with insulin, this could have caused Resident #1's blood pressure to be elevated and caused a hypertensive crisis. Since the resident did not receive her inhaler, she could have been experiencing shortness of breath. Resident #1's accucheck was not checked nor was her insulin given, since neither was performed, she may have been hypo or hyperglycemic (high or low blood sugar levels), which would have been dangerous to her health. Record review of Resident #1's Medication Administration Record (MAR) for 9/1/23 - 9/30/23 confirmed on 9/15/23, the following medications were coded (documented) as 3 (resident absent from home) and not administered for blood pressure Amlodipine, Metoprolol Tartrate Tablet, Clonidine HCL and Hydralazine HCL Tablet. Record review of Resident #1's [DATE]/1/23 - 9/30/23 revealed on 9/16/23, the following medications were coded (documented) as 3 (resident absent from home) and not administered: Insulin Detemir Solution, Accu check, and Proventil for bronchitis. Record review of Resident #1's [DATE]/1/23 - 9/30/23 revealed the following medications were coded (documented) as a 3 (resident absent from home) on 9/15/23: Lidocaine-Prilocaine cream to left hand and Lyrica for Neuropathy. Ultram (Tramadol) was ordered every 12 hours as needed for pain. Resident #1 received Ultram daily from 9/1/23 - 9/14/23. Three of these 14 days, the resident received Ultram twice a day. The facility Medical Director reported during an interview on 9/26/23 at 10:20 AM, Missed medications are always a concern; that, among other things, is the reason I wanted her to go to the emergency room (ER), so they could look at her, check labs, etc. The Medical Director stated there was potential for serious complications for Resident #1, especially with her comorbidities. An interview with the Director of Nurses (DON) on 9/26/23 at 1:35 PM, revealed that on 9/15/23 at approximately 3:30 PM, the Transportation Aide (TA) left Resident #1 in the facility van and was found on 9/16/23 at approximately 7:45 AM. The DON stated that the resident not receiving her significant medication for blood pressure, diabetes, and an inhaler could have caused serious injury or impairment. She stated that the failure of the facility to ensure the resident received the morning dose of insulin and monitoring of the blood glucose for Resident #1 on the morning of 9/16/23 could have resulted in the resident experiencing signs and symptoms of hyperglycemia. The DON confirmed that failure to monitor the resident dialysis graph/shunt site could have resulted in bleeding at the site, which could have resulted in the resident losing blood or hemorrhaging. She stated that monitoring the site following a dialysis appointment was very important for the resident's safety. Record review of the Admission Record revealed the facility admitted Resident #1 on 12/20/22 with diagnoses including Type 2 Diabetes Mellitus without complications, Hypertensive, Insulin-Dependent, Dependence on Renal Dialysis, Chronic Diastolic (Congestive) Heart Failure, Type 2 Diabetes Mellitus, and Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic Kidney Disease. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/7/23 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score is 07 indicating Resident #1 had severe cognitive impairment. Section J revealed the resident had pain frequently. The facility provided the following Removal Plan on 9/28/23. On 9/26/2023 1:15 pm the State Agency notified the Administrator that the facility neglected to provide care and services for Resident #1 from approximately 3:45 pm on 9/15/2023 until approximately 7:45 am on 9/16/2023, failed to notify the Physician timely of a change in condition after resident was left in the transport van, alone and unattended by a staff member which resulted in Resident #1 missing medications, meals, hydration and post dialysis site care/assessments. On 9/15/2023 the Transportation Assistant (TA) left Resident #1 in the facility vehicle after returning to the facility from dialysis at approximately 3:45 pm. The facility staff located Resident #1 and removed her from the facility vehicle at approximately 7:50 am on 9/16/2023, assisted Resident #1 back in the facility, transferred Resident #1 to bed, Registered Nurse (RN) #1 completed an assessment revealing a temperature 100.3, blood pressure 175/79, pulse 97, Oxygen Saturation 100%. The nurse did not obtain blood sugar at this time. The physician was notified of the incident at approximately 8:40 am on 9/16/2023 by the Director of Nursing. The Resident Representative was notified of the incident at approximately 9:15 am on 9/16/2023 by the Administrator. 1. 9/16/2023 8:40 am the DON (Director of Nurses) arrived at the facility, assessed Resident #1 and noted that resident was at baseline. 2. On 9/16/2023 the Medical Director was notified at 8:40 am and received an order to send to the emergency room for evaluation. 3. 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. 4. 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. 5. 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. 6. On 9/16/2023 at 10:10 am the investigation revealed that when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. LPN #1 received in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis and did not follow up to determine where the resident was located. 7. On 9/16/2023 at 10:45 am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. QAPI minutes included: Review of the incident, investigation and missing resident policy. Review of immediate actions taken. Recommendations to prevent reoccurrence were to complete in-service for all staff regarding missing residents prior to working, in-service for nurses to include if the reason why a resident is not in the facility is not documented in the record to notify the supervisor immediately, initiate a log for 2 people to document that the facility vehicle is checked at the end of each day and after each transport, conduct a missing person drill on each shift, initiate 2 staff members to ride on the facility vehicle for all resident transports and educate all transportation drivers of new procedures. 8. On 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. 9. 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. 10. 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. 11. 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The missing resident drill consisted of a resident being hidden in the Administrator's office and was identified by a staff member who did a sweep of the office areas and the staff member immediately reported to the Administrator that the resident was found. No changes to policy and procedure needed. 12. On 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. 13. 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. 14. 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. 15. On 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. 16. 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. -The Committee reviewed the incident, the Immediate Jeopardies cited by the state agency on 9/26/2023, and the policies regarding abuse and neglect, supervision of residents, dialysis care, diabetic care, timely notification of the physician, accidents, staffing and care plans. The following recommendations were discussed. The root cause analysis revealed that the TA was distracted and as a result left Resident #1 on the facility vehicle. It also revealed that the nurse failed to follow proper procedure to investigate why Resident #1 did not return from dialysis that resulted in the resident not being located in a timely manner which resulted in the resident not receiving proper dialysis care, diabetic care and medications. There were no recommendations to make changes to any policies by the QAPI Team and all interventions that were put into place were effective. The MDS Nurse will conduct another audit of the care plans for 100% of residents receiving dialysis and diabetic care. The MDS Nurse will conduct an audit of the care plans for 100% of residents receiving routine transportation services. The Social Service Director will evaluate Resident #1 for signs of psychosocial harm due to the incident that occurred on 9/15/2023. The facility assessment was reviewed and updated regarding staffing according to the acuity of the residents. The Committee determined at this time the staffing required for the night shift is 4 Certified Nursing Assistants and 2 Nurses. If these requirements are not met the nurse will contact the DON and Administrator and they will make arrangements to cover staffing needs by contacting all employees, department heads and sister facilities as needed to fill gaps. DON will provide in-service for all staff regarding abuse/neglect, accidents, and supervision of residents. DON will provide in-service for all nursing staff regarding staffing, care plans, diabetic care, dialysis care and timely notification of the physician. All staff will receive in-service prior to returning to work. 17. 9/26/2023 3:00 pm the Social Service Director spoke with resident #1 concerning her psychosocial needs and noted no signs of psychosocial harm related to the incident that occurred on 9/15/2023. 18. 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. 19. 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. 20. On 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident. The facility alleges removal of the immediacy on 9/28/2023. The SA validated the removal plan on 9/28/23 and determined the IJ was removed on 9/28/23 prior to exit. The SA validated through interview and record review that the DON stated she arrived on 9/16/2023 8:40 am and assessed Resident #1. The SA validated through interviews and record reviews that on 9/16/2023 the Medical Director was notified at 8:40 am and gave an order to send to the emergency room for evaluation. The SA validated through interviews and record reviews that on 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. The SA validated through interviews and record reviews that on 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. The SA validated through interviews and documentation reviews that on 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. The SA validated through interviews and record reviews that on 9/16/2023 at 10:10 am the facility initiated an investigation that revealed when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. The SA validated that the facility investigation also revealed LPN #1 did not follow up to determine where the resident was located when told in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis. The SA validated through interviews, observations, and record reviews that on 9/16/2023 at 10:45 am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. The SA validated through staff interviews and record reviews that on 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. The SA validated through observation, interviews, and record reviews that on 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. The SA validated through interviews and documentation reviews that on 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. The SA validated through interviews and documentation reviews that on 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The SA validated through interview that on 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. The SA validated through interviews and staff sign in sheets that on 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. The SA validated through interview and record review that on 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. The SA validated through interview that on 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. The SA validated through interviews and record reviews that on 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. The SA validated through interview and record review that on 9/26/2023 3:00 pm the Social Service Director spoke with resident #1 concerning her psychosocial needs. The SA validated through interviews and staff sign in sheets that on 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. The SA validated through interviews and record reviews that on 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. The SA validated through interview and documentation review that on 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident.

Based on facility policy review, record review, and interviews the facility failed to notify Resident #1's primary physician following immediately of a change in status following an incident that required the resident to be transferred to the hospital for evaluation for one (1) of four (4) sampled residents. Resident #1. Resident #1 was left alone and unattended on the facility transport van for approximately 16 hours and 15 minutes which resulted in Resident #1 missing medications, meals, hydration, and care and assessments. At approximately 7:50 AM on 9/16/2023, the facility staff located Resident #1 still strapped in the facility transport van after being abandoned on the facility's transport van after returning to the facility from a dialysis appointment on 9/15/23 at approximately 3:45 PM. The facility failed to notify the primary physician for Resident #1 immediately when staff located the resident and determined that she had been left unattended in the facility van for over sixteen (16) hours following her return to the facility after her hemodialysis treatment. Resident #1 was abandoned and restrained in her wheelchair by seat belts in the facility transport van and did not receive supervision or monitoring from the facility from approximately 3:30 PM on 9/15/23 through 7:45 AM on 9/16/23. The facility's failure to notify the primary physician immediately placed this resident, and other residents, in a situation that was likely to cause serious harm, injury, impairment, or death. The State Agency (SA) conducted an onsite investigation from 9/20/23 through 9/28/23. The State Agency determined the situation to be an Immediate Jeopardy (IJ) which began on 9/15/23 when Resident #1 was abandoned on the facility transport van for approximately sixteen (16) hours and fifteen (15) minutes following hemodialysis. The resident received no treatment, supervision, monitoring or care during this time. The IJ existed at: 42 CFR 483.10(g)(14)(i)(B)(D) Notification of Changes; Scope and Severity J - F580 The State Agency (SA) notified the facility Administrator of the IJ on 9/26/23 at 1:15 PM and provided the IJ Template. The facility submitted an acceptable Removal Plan on 9/28/23, in which they alleged all corrective actions to remove the IJ were completed on 9/27/23 and the IJ was removed on 9/28/23. The SA validated the Removal Plan on 9/28/23 and determined the IJ was removed on 9/28/23, prior to exit. Therefore, the scope and severity for F580; 42 CFR 483.10(g)(14)(i)(B)(D) Notification of Changes was lowered from a J to a D, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility policy titled Change in a Resident's Condition or Status .reviewed 08/2023 revealed that it was the facility's policy that the resident's attending physician be notified promptly of changes in the resident's status, specifically when there has been an incident involving the resident or need to transfer the resident to a hospital. Record review of the Facility Investigation revealed the Transportation Aide (TA) transported Resident #1 back to the facility following her dialysis treatment at an outside dialysis facility at about 3:30 PM on 9/15/23 and the resident remained strapped in her wheelchair in the facility van in the facility parking lot until about 7:45 AM on 9/16/23 without supervision, monitoring, or care and without the knowledge of facility staff. According to the Facility Investigation on 9/16/23 facility staff began to attempt to locate Resident #1 at 7:00 AM, the resident was located on the van at 7:45 AM. The resident was removed from the van at 7:50 AM and the staff provided a bed bath and breakfast, and the Director of Nurses (DON) was notified. The DON notified Resident #1's primary physician at or about 8:40 AM, fifty (50) minutes after the resident was located on the van, one (1) hour and forty (40) minutes after the staff began to attempt to locate the resident and approximately sixteen (16) hours after the resident was left alone, without supervision in the facility van. On 9/21/23 at 2:28 PM, an interview with CNA #2 revealed that she had worked on 9/15/23 and 9/16/23 and was assigned to the unit on the 7:00 AM to 7:00 PM (7A-7P shift). She assisted Registered Nurse (RN)#1 and other staff locating Resident #1 and removing her from the van. We observed Resident #1 seated in her wheelchair on the van, sweaty with throw-up and drool on her mouth and clothes and that her skin was hot, hot. Then we were instructed by RN #1 to bring her to her room, give her a bath, and assist with a meal. On 9/26/23 at 10:20 AM, an interview with the facility Medical Director/Primary Physician (MD) for Resident #1 stated that Resident's missed medications and care were a concern. He stated that as soon as he was notified, he issued an order for Resident #1 to be transferred via ambulance to the hospital emergency department (ED) for assessment and lab tests to protect the resident. He confirmed that there was a period of at least fifty minutes between the resident's removal from the van and his notification and that he would not characterize his notification as immediate or prompt. He stated that if he had been notified sooner, he would have, and did, order assessment and treatment as needed at the Emergency Department (ED). The DON stated during an interview on 9/26/23 at 1:35 PM, that RN #1 notified her by telephone at home on 9/16/23 at approximately 7:45 AM that nursing staff had located Resident #1 on the facility van after she arrived back at the facility from dialysis at approximately 3:30 PM the previous afternoon. The DON confirmed that she reported to the facility at or about 8:40 AM and assessed Resident #1 and notified the MD. The DON stated that she was aware that the regulations and the facility policy required the resident's primary physician to be notified immediately upon change of condition or status and said that postponement of fifty (50) minutes did not qualify as immediate or prompt. The DON described monitoring of the dialysis access site as very important for the safety of the resident. The DON stated that the results of the resident having sat up and strapped in her wheelchair in the van for over sixteen (16) hours could have resulted in negative results including serious negative cardiac results and that the resident could have lost a lot of blood due to lack of monitoring of the dialysis access site following dialysis treatment. The DON confirmed that the resident was supposed to receive care and monitoring in accordance with current standards of practice and the resident's care plan. Physician care instructions that were missed or omitted for the sixteen (16) hours the resident spent in the facility van unsupervised without the knowledge of the facility staff. Record review of the local hospital ED notes dated 9/16/23 revealed that Resident #1 was assessed and treated by ED Nurse Practitioner (EDNP) on 9/16/23 for Heat Exposure .Rhabdomyolysis .Adult Neglect or Abandonment .Elevated Blood Pressure Reading. On 9/27/23 at 4:15 PM, an interview with the EDNP revealed that she considered Resident to #1 to be a risk for several potential negative cardiac results of having sat up in a wheelchair without care or repositioning for over sixteen (16) hours which included Rhabdomyolysis, Heat Exposure and Elevated Blood Pressure. Record review of the Admission Record revealed the facility admitted Resident #1 on 12/20/22 with diagnoses including Hypertensive Heart and Chronic Kidney Disease with Heart Failure with Stage 5 Chronic Kidney Disease, Dependence on Renal Dialysis, Diabetes, Hypertensive Urgency, Long Term (current) use of Insulin. The facility provided the following removal plan on 9/28/23. On 9/26/2023 1:15 pm the State Agency notified the Administrator that the facility neglected to provide care and services for Resident #1 from approximately 3:45 pm on 9/15/2023 until approximately 7:45 am on 9/16/2023, failed to notify the Physician timely of a change in condition after resident was left in the transport van, alone and unattended by a staff member which resulted in Resident #1 missing medications, meals, hydration and post dialysis site care/assessments. On 9/15/2023 the Transportation Assistant (TA) left Resident #1 in the facility vehicle after returning to the facility from dialysis at approximately 3:45 pm. The facility staff located Resident #1 and removed her from the facility vehicle at approximately 7:50 am on 9/16/2023, assisted Resident #1 back in the facility, transferred Resident #1 to bed, Registered Nurse (RN) #1 completed an assessment revealing a temperature 100.3, blood pressure 175/79, pulse 97, Oxygen Saturation 100%. The nurse did not obtain blood sugar at this time. The physician was notified of the incident at approximately 8:40 am on 9/16/2023 by the Director of Nursing. The Resident Representative was notified of the incident at approximately 9:15 am on 9/16/2023 by the Administrator. 1. 9/16/2023 8:40 am the DON (Director of Nurses) arrived at the facility, assessed resident #1 and noted that resident was at baseline. 2. On 9/16/2023 the Medical Director was notified at 8:40 am and received an order to send to the emergency room for evaluation. 3. 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. 4. 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. 5. 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. 6. On 9/16/2023 at 10:10 am the investigation revealed that when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. LPN #1 received in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis and did not follow up to determine where the resident was located. 7. On 9/16/2023 at 10:45 am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. QAPI minutes included: Review of the incident, investigation and missing resident policy. Review of immediate actions taken. Recommendations to prevent reoccurrence were to complete in-service for all staff regarding missing residents prior to working, in-service for nurses to include if the reason why a resident is not in the facility is not documented in the record to notify the supervisor immediately, initiate a log for 2 people to document that the facility vehicle is checked at the end of each day and after each transport, conduct a missing person drill on each shift, initiate 2 staff members to ride on the facility vehicle for all resident transports and educate all transportation drivers of new procedures. 8. On 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. 9. 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. 10. 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. 11. 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The missing resident drill consisted of a resident being hidden in the Administrator's office and was identified by a staff member who did a sweep of the office areas and the staff member immediately reported to the Administrator that the resident was found. No changes to policy and procedure needed. 12. On 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. 13. 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. 14. 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. 15. On 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. 16. 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. -The Committee reviewed the incident, the Immediate Jeopardies cited by the state agency on 9/26/2023, and the policies regarding abuse and neglect, supervision of residents, dialysis care, diabetic care, timely notification of the physician, accidents, staffing and care plans. The following recommendations were discussed. The root cause analysis revealed that the TA was distracted and as a result left Resident #1 on the facility vehicle. It also revealed that the nurse failed to follow proper procedure to investigate why Resident #1 did not return from dialysis that resulted in the resident not being located in a timely manner which resulted in the resident not receiving proper dialysis care, diabetic care and medications. There were no recommendations to make changes to any policies by the QAPI Team and all interventions that were put into place were effective. The MDS (Minimum Data Set) Nurse will conduct another audit of the care plans for 100% of residents receiving dialysis and diabetic care. The MDS Nurse will conduct an audit of the care plans for 100% of residents receiving routine transportation services. The Social Service Director will evaluate Resident #1 for signs of psychosocial harm due to the incident that occurred on 9/15/2023. The facility assessment was reviewed and updated regarding staffing according to the acuity of the residents. The Committee determined at this time the staffing required for the night shift is 4 Certified Nursing Assistants and 2 Nurses. If these requirements are not met the nurse will contact the DON and Administrator and they will make arrangements to cover staffing needs by contacting all employees, department heads and sister facilities as needed to fill gaps. DON will provide in-service for all staff regarding abuse/neglect, accidents, and supervision of residents. DON will provide in-service for all nursing staff regarding staffing, care plans, diabetic care, dialysis care and timely notification of the physician. All staff will receive in-service prior to returning to work. 17. 9/26/2023 3:00 pm the Social Service Director spoke with resident #1 concerning her psychosocial needs and noted no signs of psychosocial harm related to the incident that occurred on 9/15/2023. 18. 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. 19. 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. 20. On 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident. The facility alleges removal of the immediacy on 9/28/2023. The SA validated the Removal Plan on 9/28/23 and determined the IJ was removed on 9/28/23 prior to exit. The SA validated through interview and record review that the DON stated she arrived on 9/16/2023 8:40 am and assessed Resident #1. The SA validated through interviews and record reviews that on 9/16/2023 the Medical Director was notified at 8:40 am and gave an order to send to the emergency room for evaluation. The SA validated through interviews and record reviews that on 9/16/2023 9:15 am the Administrator notified the State Department of Health of the incident. The SA validated through interviews and record reviews that on 9/16/2023 9:40 am Resident #1 was transferred to the hospital and returned to the facility at 2:30 pm. The SA validated through interviews and documentation reviews that on 9/16/2023 10:00 am the DON conducted a 100% head count of all residents in the facility and audited records of all residents that were out of the facility to ensure adequate documentation with no negative findings. The SA validated through interviews and record reviews that on 9/16/2023 at 10:10 am the facility initiated an investigation that revealed when the TA arrived at the facility on 9/15/2023 with Resident #1 she noticed a visitor almost fall, got out of the vehicle to assist then went in the facility not realizing that the Resident #1 was still on the van. The SA validated that the facility investigation also revealed LPN #1 did not follow up to determine where the resident was located when told in report on 9/15/2023 at 7:00 pm that Resident #1 did not return from dialysis. The SA validated through interviews, observations, and record reviews that on 9/16/2023 at 10:45am an emergency Quality Assurance and Performance Improvement (QAPI) Committee meeting was held regarding the incident involving Resident #1 that occurred on 9/15/2023. In attendance were the Administrator, DON, Infection Preventionist (IP), Regional Director of Operations, Regional Nurse Consultant, Medical Records Nurse, Minimum Data Set (MDS) Nurse, RN Supervisor, Medical Director, and Dietary Manager. The SA validated through staff interviews and record reviews that on 9/16/2023 11:30 the DON began in-service for all staff regarding missing residents and all nurses to include if the reason a resident is not in the facility is not documented in the progress note to notify the supervisor immediately, no staff was allowed to work until receiving in-service. The SA validated through observation, interviews, and record reviews that on 9/18/2023 11:30 am the Director of Nursing created a log to be placed on the facility vehicle and in-serviced all transportation drivers regarding signing in and out with a witness after every transport and at the end of each day to verify that no residents are on the transport van. The SA validated through interviews and documentation reviews that on 9/16/2023 11:58 am the Administrator conducted a missing resident drill for all staff on day shift. The SA validated through interviews and documentation reviews that on 9/17/2023 6:30 am the Administrator conducted a missing resident drill for all staff on night shift. The SA validated through interview that on 9/18/2023 at 11 am the Administrator notified the Attorney General's office of the incident. The SA validated through interviews and staff sign in sheets that on 9/19/2023 at 10 am the DON in-serviced all staff on abuse and neglect policies. The SA validated through interview and record review that on 9/19/2023 at 6:30 pm the MDS Nurse audited 100 % of the records for all residents receiving dialysis to include care plans with no adverse findings. On 9/26/2023 at 8 pm the MDS nurse audit the care plans of 100% of residents receiving routine transportation services, dialysis, and diabetic care with no adverse findings. The SA validated through interview that on 9/20/2023 at 2:40 PM the Administrator notified the local police department of the incident involving Resident #1. The SA validated through interviews and record reviews that on 9/26/2023 2:34 pm an emergency QAPI meeting was held regarding the incident involving Resident #1 being left on the van on 9/15/2023. Those in attendance were Administrator, DON, IP, Social Service Director, Medical Records, Business Office Manager, Customer Relations Specialist, RN Supervisor, MDS Nurse and Medical Director. The SA validated through interview and record review that on 9/26/2023 3:00 pm the Social Service Director spoke with resident #1 concerning her psychosocial needs. The SA validated through interviews and staff sign in sheets that on 9/26/2023 5:00 pm the DON began in-servicing all staff regarding accidents, supervision of residents and abuse/neglect. All staff will receive in-service prior to returning to work. The SA validated through interviews and record reviews that on 9/26/2023 5:00 pm the DON began in-servicing all nursing staff regarding diabetic care, dialysis care, staffing, notifying the physician in a timely manner and care plans. All staff will receive in-service prior to returning to work. The SA validated through interview and documentation review that on 9/27/2023 at 5:00 pm the Licensed Clinical Social Worker (LCSW) assessed Resident #1 concerning her psychological needs and concerns regarding the incident on 9/15/2023 the LCSW concluded, bothered but not overly traumatized by the event as evidenced by her willingness to stay, having stated faith in caregivers/staff here, continue to monitor Resident.

Based on observation, interview, record review, and policy review, the facility failed to administer [MEDICATION NAME] (a diuretic medication) as ordered, and failed to obtain daily weights to adjust the dosage of the [MEDICATION NAME], as ordered, for one (1) of six (6) sampled residents and five (5) un-sampled residents reviewed, Resident #2. Resident #2 had a [DIAGNOSES REDACTED]. Resident #2 had a weight gain of approximately 27 pounds from [DATE] until [DATE]. This resulted in Resident #2's admission to the hospital with a [DIAGNOSES REDACTED]. The failure to administer the [MEDICATION NAME] as ordered, and failure to obtain daily weights, and give medication based on the results of those weights, placed Resident #2 and all other residents with medications, based on weights obtained, or with [DIAGNOSES REDACTED]. This situation was determined to be an Immediate Jeopardy (IJ), which began on [DATE], when Resident #2 was admitted to the hospital with [REDACTED]. The facility's Administrator and the Director of Nursing (DON) was notified on [DATE] at 10:30 AM, of the IJ. An acceptable Credible Allegation of Compliance (AoC) was received on [DATE], in which the facility alleged the removal of the IJ on [DATE]. The State Agency (SA) determined the IJ to be removed on [DATE], prior to exit. Therefore, the scope and severity for the IJ at CFR (s) 483.45 (f) (2), F760, Residents are Free from Significant Medications Errors, was lowered to a D while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: The facility's policy, titled, physician's orders [REDACTED]. Resident #2 The facility admitted Resident #2 on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of [DATE], revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 14, that indicated Resident #2 was cognitively intact. Review of the physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Review of the Weight and Vitals Summary form, documented Resident #2's weight on [DATE] at 235 pounds. Resident #2 was admitted to the hospital on [DATE], with a documented weight of 262 pounds, with a [DIAGNOSES REDACTED]. A review of a Cardiology note, dated [DATE], revealed Resident #2 was evaluated for shortness of breath and [MEDICAL CONDITION], with a documented a weight of 262 pounds. The previous weight documented by the Cardiology note on [DATE], was 238.9 pounds, which was approximately 23 pounds in difference. A review of the Hospitalist Admission Note on [DATE], revealed Resident #2 was seen by the Cardiologist that day and was sent to the emergency room (ER) to be evaluated for Dyspnea (Shortness of Breath). The Assessment/Plan included: Dyspnea- Consider multiple contributors. Possible GI (Gastrointestinal) Bleed and developing [MEDICAL CONDITION]. Consider cardiac cause given h/o (history of) AS ([DIAGNOSES REDACTED]) and CAD ([MEDICAL CONDITION]). A review of the Hospitalist Discharge Note on [DATE], revealed Resident #2 had a discharge [DIAGNOSES REDACTED]. The Hospital Course noted: Resident #2 was a direct admit from the Cardiologist office due to evidence of severe volume overload and Acute and Chronic Diastolic Heart Failure Exacerbation. On arrival she appeared to be an Active Diastolic Heart Failure Exacerbations and had gained approximately 20 pounds over the preceding several weeks and had evidence of [MEDICAL CONDITIONS] and severe lower extremity anti-[MEDICAL CONDITION]. A repeat echocardiogram did reveal evidence of significant Diastolic Failure with a least moderate [DIAGNOSES REDACTED] and severe bilateral dilation and elevated [MEDICAL CONDITION] pressures; which in essence is [MEDICAL CONDITION]. In a telephone interview with Resident #2's Responsible Party (RP), on [DATE] at 4:02 PM, the RP stated Resident #2's [MEDICATION NAME] was not increased or given based on the resident's weights, because they didn't weigh her daily to adjust her medication. The RP stated the staff did not weigh Resident #2 in the mornings as they should have and the resident was able to tell her that she had only been weighted a few times. The RP reported Resident #2 was taken immediately to the Cardiologist upon leaving the facility, because she was unable to speak a full sentence and was so short of breath and that she was admitted to the hospital for [MEDICAL CONDITIONS]. The RP stated the physician reported the resident had gained 35 pounds in fluid weight and was in [MEDICAL CONDITION]. The RP stated he thought Resident #2 was not given her [MEDICATION NAME] right and she almost died . He stated he brought her home because he didn't trust the facility. The RP stated Resident #2 wanted to get well and return home and had never refused to be weighed because she knew how important it was for her weights to be monitored. An interview on [DATE] at 10:00 AM, with the Nurse Practitioner (NP), confirmed that [MEDICATION NAME] 20 mg was ordered for Resident #2 and should have been increased to 40 mg if she had more than a three (3) pound weight gain overnight, and five (5) pounds in a week. The NP confirmed by not giving the [MEDICATION NAME] correctly, it could have resulted in [MEDICAL CONDITION] for Resident #2. The NP stated she had concerns that weights were sometimes not done and had spoken to the DON about it. The NP also stated, The residents would tell me that they have not been weighed. The NP stated she had even had the Cardiologist to complaint of weights not being obtained. The NP stated she had gone to the Nurses and stressed to them that weights are to be done before breakfast, daily. In an interview on [DATE] at 9:20 AM, the Director of Nursing (DON) acknowledged the physician's orders [REDACTED].#2. The DON stated the nurse administering the medication for Resident #2 should have ensured a weight was obtained, and reviewed the weight prior to administering the [MEDICATION NAME], to give the correct dose, but they didn't. She acknowledged the medication error. On [DATE] at 2:10 PM, in an interview, Licensed Practical Nurse (LPN) #1, a Minimum Data Set (MDS) Nurse, confirmed if the staff fails to follow the physician's orders [REDACTED]. An interview with LPN #2, on [DATE] at 2:20 PM, revealed if an order for [REDACTED]. In an interview, on [DATE] at 1:40 PM, the Medical Director stated if weights are ordered, they needed to be done. The Medical Director confirmed the [MEDICATION NAME] for Resident #2 had not been given as ordered since the weights weren't obtained to see what the dosage should be. The facility submitted an acceptable Allegation of Compliance (AoC) on [DATE], for the Immediate Jeopardy. Review of the facility's AoC revealed the facility took the following corrective actions to remove the IJ: Brief Summary of Event: At 10:32 AM, on Monday [DATE], the State Complaint Surveyor informed the Facility Administrator the facility was in Immediate Jeopardy (IJ) status concerning Resident #2 and Resident #3. Resident #2 attended a follow-up appointment related to post Aortic Valve Replacement at a local Cardiology Clinic on [DATE]. Resident #2 was noted to have shortness of breath and an increase in weight of 23 pounds (lbs) since the previous [DATE] Cardiology visit per Cardiology consult note. Resident #2 was transported to the local hospital emergency room (ER). Resident #2 was admitted to the hospital on [DATE], with an admitting [DIAGNOSES REDACTED]. Per hospital lab result sheet, less than (<)300 pg/ml effectively rules out Acute [MEDICAL CONDITIONS] and greater than (>) 300 pg/ml could be indicative of Acute [MEDICAL CONDITION]. The facility failed to obtain 20 daily weights since admission to the facility on [DATE]. The facility failed to assess the weight in order to provide the proper dose of [MEDICATION NAME] according to parameters set by the physician order. The order included [MEDICATION NAME] 20 milligrams (mg) per day, may increase to 40 mg if weight gain is greater than three (3) lbs over night or five (5) lbs in a week. The facility failed to develop and implement a care plan regarding obtaining daily weights. The facility failed to develop and implement a care plan regarding [MEDICATION NAME] therapy with weight changes. This resulted in the resident being hospitalized from [DATE] to [DATE], with the hospital discharge summary stating Resident #2 had a [DIAGNOSES REDACTED]. The Facility failed to obtain nine (9) daily weights for Resident #3. Resident #3's initial admission weight from [DATE] was 167.2 lbs and her discharge weight to the hospital on [DATE], was 172.6 lbs; a weight change of 5.4 lbs. The facility failed to implement a care plan for daily weights for Resident #3, who has a history of [MEDICAL CONDITION]. Resident #3 was sent to the local emergency room related to Altered Mental Status on [DATE], and was admitted to the hospital with [REDACTED]. Resident received treatment of [REDACTED]. Resident #3 was discharged from the hospital on [DATE] back to the facility with a [DIAGNOSES REDACTED]. Facility Actions: 1. On [DATE], a 100 percent (%) audit of a total of 20 residents, with [DIAGNOSES REDACTED]. The facility Nurse Practitioner (NP) reviewed all residents with a [DIAGNOSES REDACTED]. Six (6) residents with a determined unstable [MEDICAL CONDITION] condition remained on daily weights and 14 residents were added for weekly weights. The residents on [MEDICAL TREATMENT] are being monitored and treated by the local [MEDICAL TREATMENT] center and weights are being recorded weekly at the facility. 2. Care plans for all residents with [MEDICAL CONDITION] were reviewed by the Regional Minimum Data Set (MDS) Registered Nurse on [DATE], to ensure they reflected all the weight monitoring orders and that care plans were developed and implemented for each resident with [MEDICAL CONDITION], with no concerns found. 3. On [DATE] at 4:00 PM, an in-service was initiated for clinical staff members which included one (1) of one (1) Social Services Director (SSD), one (1) of one (1) Nursing Home Administrator, one (1) of one (1) Life Connections Coordinator, two (2) of 11 Registered Nurses, five (5) of 16 LPN, and three (3) of 33 Certified Nursing Assistants (CNAs) by the DON regarding the procedure for daily weights, documentation, and signs and symptoms of [MEDICAL CONDITION] including: Daily/weekly weights for residents with [MEDICAL CONDITION] are to be done on 11:00 PM-7:00 AM shift in the AM by the CNA, and documented by the Nurse in the Medication Administration Record [REDACTED]. Daily/weekly weights will be reviewed by the Clinical Team consisting of the DON, TCU RN, MDS #1, MDS #2, Medical Records LPN, Dietary Manager, and Social Services Director (SSD) in the clinical meeting every morning during the week. The Weekend RN Supervisor will review the daily/weekly weights on the weekends. The MD/NP will be notified by the TCU Manager during the week and the Weekend RN Supervisor during the weekend of a daily gain of three (3) lbs or a five (5) lb gain within a week. All [MEDICATION NAME] and weight orders will be care planned and updated as they are received by MDS #1 or MDS #2 Nurse. Signs and symptoms of [MEDICAL CONDITION] include: Shortness of breath especially when lying flat, tired, run-down feeling, swelling in feet, ankles, and legs, weight gain, and confusion. 4. On [DATE] at 4:30 PM, an emergency Quality Assurance Improvement Meeting (QAPI) was held with the Medical Director and QAPI team including the Medical Director, DON, Facility Administrator, Social Services Director, MDS #1, and MDS #2. In this meeting residents with [MEDICAL CONDITION] were discussed and the following procedure was adopted and implemented: All residents with [MEDICAL CONDITION] that have daily weights ordered will be discussed in the morning clinical meeting by the Clinical Team. The facility weight policy was reviewed with no changes made on [DATE]. 5. On [DATE] at 10:40 AM, the Medical Director was notified of the IJ concerning Resident #2 and Resident #3. 6. A QAPI meeting was held on [DATE] at 5:00 PM, with the following staff members present: Medical Director, Director of Nursing, Facility Administrator, Social Services Director, MDS Nurse #1, and MDS Nurse #2. Facility policies for medication administration, physician orders, and developing and implementing care plans, were reviewed with no changes made on [DATE]. The following procedures were reviewed and adopted by the Medical Director and QAPI team regarding obtaining daily weights, initiating and updating care plans to reflect correct plan of care regarding weights, and following [MEDICATION NAME] parameters: Daily/weekly weights will be monitored daily during morning clinical meeting by the Clinical Team including DON, TCU RN, MDS #1, MDS #2, Medical Records LPN, Dietary Manager, and Social Services Director on week days, and Weekend RN Supervisor on the weekends, to ensure that all daily weights are obtained and properly addressed. This monitor will be documented by the DON during the week, and the Weekend RN Supervisor on the weekends, by a Care Plan & Weight Audit check list tool. This monitor will be gathered from the Medication Administration Record [REDACTED] All new orders will be reviewed daily during morning clinical meeting by the Clinical Team consisting of the DON, MDS #1, MDS #2, Medical Records LPN, TCU RN, Social Services Director, and the Dietary Manager during week days, and the Weekend RN Supervisor on weekends, to ensure that parameters are being performed and documented properly as ordered. All new orders obtained for daily/weekly weights will be added to the care plan at the time of review during clinical meeting, by the clinical team on weekdays, and RN supervisor on weekends. All care plans initiated or revised regarding daily/weekly weights will be reviewed daily to ensure completeness and accuracy, by the Clinical Team on weekdays and Weekend RN Supervisor on weekends, to ensure completeness. This monitor will be documented by the DON during the week and the Weekend RN Supervisor on the weekends, by a Care Plan & Weight Audit check list tool. This monitor will be gathered from the care plan. 7. On [DATE], an in-service was initiated by the Director of Nursing and Facility Administrator for all staff members regarding daily weights are to be done on 11:00 PM-7:00 AM in the AM, unless otherwise specified by residents of alternate time. Daily/weekly weights will be reviewed by the Clinical Team consisting of the DON, TCU RN, MDS #1, MDS #2, Medical Records LPN, Dietary Manager, and Social Services Director (SSD) in the clinical meeting every morning during the week. The Weekend RN Supervisor will review the daily/weekly weights on the weekends. The MD/NP will be notified by the TCU Manager during the week and the Weekend RN Supervisor during the weekend, of a daily gain of three (3) lbs or a five (5) lb gain within a week. The following staff were present at the in-service: RNs-11 of 11, LPNs-14 of 14, CNAs-28 of 28, Administrator-one (1) of one (1), Therapy Department-34 of 34, Dietary-seven (7) of seven (7), Housekeeping/Laundry-seven (7) of seven (7), Maintenance Director-one (1) of one (1), Business Office Manager-one (1) of one (1), Marketing Director-one (1) of one (1), Social Service Director-one (1) of one (1), and Life Connections-one (1) of one (1). No staff will be allowed to work at the facility until in-serviced, which includes new hires; this will be monitored by the Facility Administrator. -On [DATE] at 11:30 AM, an in-service was initiated by the Regional Minimum Data Set (MDS) Registered Nurse regarding ensuring residents with [MEDICAL CONDITION] and residents receiving [MEDICAL TREATMENT], should all have weights as ordered included in the plan of care for MDS #1, MDS #2, Medical Records LPN, and the DON. 8. The facility alleges that all corrective actions have been completed as of [DATE], and the Jeopardy was removed as of [DATE]. The SA validated through interview, record review, observation and policy review that the facility completed the following actions to remove the IJ: 1. The SA validated through interview and record review that a 100% audit was completed by the DON and TCU Nurse on ,[DATE]//18, of 20 residents, with [DIAGNOSES REDACTED]. The SA validated through interview and record review that the facility NP reviewed residents with a [DIAGNOSES REDACTED]. Six (6) residents with a determined unstable [MEDICAL CONDITION] condition remained on daily weights and 14 residents were changed/added for weekly weights. The residents on [MEDICAL TREATMENT] are monitored and treated by the local [MEDICAL TREATMENT] center and weights are recorded weekly at the facility. 2. The SA validated through interview and record review that care plans for all residents with [MEDICAL CONDITION] were reviewed by the Regional MDS RN on [DATE], to ensure they reflected all the weight monitoring orders and that care plans were developed and implemented for each resident with [MEDICAL CONDITION] with no concerns found. No further issues were identified during record review. 3. The SA validated through interview, sign-in sheets from in-services, and record review that on [DATE], an in-service was initiated for clinical staff members which included one (1) of one (1) Social Services Director (SSD), one (1) of one (1) Nursing Home Administrator, one (1) of one (1) Life Connections Coordinator, two (2) of 11 Registered Nurses, five (5) of 16 LPNs, and three (3) of 33 Certified Nursing Assistants (CNAs) by the DON regarding the procedure for daily weights, documentation, and signs and symptoms of [MEDICAL CONDITION] including: Daily/weekly weights for residents with [MEDICAL CONDITION] are done on 11:00 PM-7:00 AM shift in the mornings by the CNA, and documented by the Nurse in the Medication Administration Record [REDACTED]. Daily/weekly weights are reviewed by the Clinical Team consisting of the DON, TCU RN, MDS #1, MDS #2, Medical Records LPN, Dietary Manager, and Social Services Director (SSD) in the clinical meeting every morning during the week. The Weekend RN Supervisor reviews the daily/weekly weights on the weekends. The MD/NP are notified by the TCU Manager during the week, and the Weekend RN Supervisor during the weekend, of a daily gain of three (3) lbs or a five (5) lb gain within a week. All [MEDICATION NAME] and weight orders are care planned and updated as they are received by MDS #1 or MDS #2 Nurse. Signs and symptoms of [MEDICAL CONDITION] include: Shortness of breath especially when lying flat, tired, run-down feeling, swelling in feet, ankles, and legs, weight gain, and confusion. Staff interviews across all disciplines revealed in-services were attended, understood, and followed. 4. The SA validated through sign-in sheets and staff interview, that on [DATE], an emergency Quality Assurance Improvement Meeting (QAPI) was held with the Medical Director and QAPI team including the Medical Director, DON, Facility Administrator, Social Services Director, MDS #1, and MDS #2. The following procedure was adopted and implemented: All residents with [MEDICAL CONDITION] that have daily weights ordered will be discussed in the morning clinical meeting by the Clinical Team. The facility weight policy was reviewed with no changes made on [DATE]. 5. The SA validated by interview that the Medical Director was notified of the IJ concerning Resident #2 and Resident #3 on [DATE]. 6. The SA validated through interview and record review of sign-in sheets that a QAPI meeting was held on [DATE], which included the Medical Director, Director of Nursing, Facility Administrator, Social Services Director, MDS Nurse #1, and MDS Nurse #2. Facility policies for medication administration, physician orders, developing and implementing care plans were reviewed with no changes made on [DATE]. Interview with nursing staff and Administrative staff revealed the following procedures were reviewed and adopted by the Medical Director and QAPI team regarding obtaining daily weights, initiating and updating care plans to reflect correct plan of care regarding weights, and following [MEDICATION NAME] parameters. Daily/weekly weights will be monitored daily during morning clinical meeting by the Clinical Team including DON, TCU RN, MDS #1, MDS #2, Medical Records LPN, Dietary Manager, and Social Services Director on week days and Weekend RN Supervisor on the weekends, to ensure that all daily weights are obtained and properly addressed. This monitor will be documented by the DON during the week and the Weekend RN Supervisor on the weekends, by a Care Plan & Weight Audit check list tool. This monitor will be gathered from the Medication Administration Record [REDACTED] All new orders will be reviewed daily during morning clinical meeting by the Clinical Team consisting of the DON, MDS #1, MDS #2, Medical Records LPN, TCU RN, Social Services Director, and the Dietary Manager during week days and the Weekend RN Supervisor on weekends, to ensure that parameters are being performed and documented properly as ordered. All new orders obtained for daily/weekly weights will be added to the care plan at the time of review during clinical meeting by the clinical team on weekdays and RN supervisor on weekends. All care plans initiated or revised regarding daily/weekly weights will be reviewed daily, to ensure completeness and accuracy by the Clinical Team on weekdays and Weekend RN Supervisor on weekends, to ensure completeness. This monitor will be documented by the DON during the week and the Weekend RN Supervisor on the weekends by a Care Plan & Weight Audit check list tool. This monitor will be gathered from the care plan. 7. The SA validated by interview, record review and sign-in sheet review, that on [DATE], an in-service was initiated by the Director of Nursing and Facility Administrator for all staff members regarding daily weights are to be done on 11:00 PM-7:00 AM in the AM, unless otherwise specified by residents of alternate time. Daily/weekly weights will be reviewed by the Clinical Team consisting of the DON, TCU RN, MDS #1, MDS #2, Medical Records LPN, Dietary Manager, and Social Services Director (SSD) in the clinical meeting every morning during the week. The Weekend RN Supervisor will review the daily/weekly weights on the weekends. The MD/NP will be notified by the TCU Manager during the week and the Weekend RN Supervisor during the weekend of a daily gain of three (3) lbs or a five (5) lb gain within a week. The following staff were present at the in-service: RNs-11 of 11, LPNs-14 of 14, CNAs-28 of 28, Administrator-one (1) of one (1), Therapy Department-34 of 34, Dietary-seven (7) of seven (7) , Housekeeping/Laundry-seven (7) of seven (7), Maintenance Director-one (1) of one (1), Business Office Manager-one (1) of one (1), Marketing Director-one (1) of one (1), Social Service Director-one (1) of one (1), and Life Connections-one (1) of one (1). Review of the employee roster revealed no staff was allowed to work at the facility until in-serviced, which included new hires; this will be monitored by the Facility Administrator. The SA validated through interview and review of care plans, that on [DATE], an in-service was initiated by the Regional Minimum Data Set (MDS) Registered Nurse regarding ensuring residents with [MEDICAL CONDITION] and residents receiving [MEDICAL TREATMENT], should all have weights as ordered included in the plan of care for MDS #1, MDS #2, Medical Records LPN, and the DON. 8. The SA validated that all corrective actions were completed by the facility as of [DATE] and the IJ removed on [DATE], prior to the SA exit.

Based on interview, record review, and policy review, the facility neglected resident care as evidenced by the failure to evaluate Resident #2's weight daily, a resident with a [DIAGNOSES REDACTED]. Resident #2 had a total of 17 missed daily weights and was admitted to the hospital with [REDACTED].#3, a resident with a history of [MEDICAL CONDITION], as ordered, to monitor her medical condition. Resident #3 had a total of 10 missed daily weights. Resident #3 was admitted to the hospital with [REDACTED]. This affected two (2) of six (6) sampled residents and five (5) un-sampled residents reviewed. The facility's failure to obtain/evaluate Resident #2's weights to administer the [MEDICATION NAME] as ordered, and failure to obtain daily weights on Resident #3 to monitor her condition, placed Resident #2, Resident #3 and all other residents with daily weights and/or medication to administer according to weight gain, or with a [DIAGNOSES REDACTED]. This situation was determined to be an Immediate Jeopardy (IJ), which began on [DATE], when Resident #2 was admitted to the hospital with [REDACTED]. The facility's Administrator and the Director of Nursing (DON) was notified on [DATE] at 10:30 AM, of the IJ. An acceptable Credible Allegation of Compliance (AoC) was received on [DATE], in which the facility alleged the removal of the IJ on [DATE]. The State Agency (SA) determined the IJ to be removed on [DATE], prior to exit. The scope and severity for the IJ at CFR(s) 483.12 (a) (1) F600 Freedom from Abuse, Neglect, and Exploitation, was lowered to a D while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: The facility's policy, titled, Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan, dated (MONTH) 23, (YEAR), revealed the resident has the right to be free from abuse, neglect and misappropriation of resident property and exploitation as defined below The policy defined neglect as the failure of the facility, it's employees or service providers to provide goods and services to a resident necessary to avoid physical harm, mental anguish, or emotional distress. Review of the Weight Monitoring Program, dated [DATE], revealed:: It is the policy of this facility, that each residents' weight will be monitored monthly, or as indicated by the residents' condition or physician's orders [REDACTED].>The facility's policy, titled, physician's orders [REDACTED]. Resident #2 The facility admitted Resident #2 on [DATE], with the [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #2 was cognitively intact. Review of the hospital Cardiology Assessment and Plan, printed [DATE], prior to facility admit, revealed for Acute on Chronic Diastolic Heart Failure: Continue by mouth [MEDICATION NAME] on discharge, intake and output and daily weights. A review of the physician's orders [REDACTED]. (MONTH) increase to 40 mg if weight gain greater than three (3) pounds (lbs) overnight or five (5) lbs in one (1) week, with the start date of [DATE], for Acute on Chronic Diastolic (Congestive) Heart Failure. (Resident's weight on admit, [DATE], was 247.2 lbs) Resident #2 had facility documented weights on [DATE] of 247.2 lbs (admission-not documented how), [DATE] of 247.2 lbs (mechanical lift), [DATE] of 247 lbs (mechanical lift), [DATE] of 235.8 lbs (standing), and [DATE] of 235 lbs (not documented how), with a total of 17 missed weights from [DATE] through [DATE]. Review of Cardiology records as well as hospital records, dated [DATE], revealed Resident #2 weighed 262 pounds, which indicated a weight gain of 27 pounds from the last weight obtained by the facility on [DATE] of 235 pounds. A review of the Medication Administration Record [REDACTED]. These MARs and review of the Weights and Vitals Summary form, documented a total of 17 missed daily weights, which should have been done daily during a 22 day stay, in order to administer [MEDICATION NAME] as needed. The (MONTH) (YEAR) MAR indicated [REDACTED]. There was no documented weight for this date. A review of the Cardiology evaluation, dated [DATE], revealed: Resident #2 weighed 262 pounds. The resident reported over the past week or more she has developed an increase in Shortness of Breath (SOB) and Lower Extremity (LE) [MEDICAL CONDITION], especially at the right calf. The prior weight per Cardiology documentation on [DATE], was 239.8 pounds, which indicated a weight gain of 23 pounds in approximately three (3) months. The Cardiology note documented: Due to increasing [MEDICAL CONDITION] LE [MEDICAL CONDITION], shortness of breath, and recent procedures to included trans-catheter aortic valve replacement and pacemaker implantation on [DATE], she was asked to proceed to the ER for evaluation. Her Creatinine is elevated to 1.69 and she may require diuresis that will require close monitoring . Review of a Nursing Home to Hospital Transfer Form, dated [DATE], revealed Resident #2's weight was 235 pounds, with reason for transfer: admitted from a Medical Doctor (MD) appointment with Gastro-intestinal (GI) Bleed. A review of the Hospitalist Admission Note on [DATE], revealed Resident #2 presented to the hospital with Dyspnea (shortness of breath), which started a few weeks ago, was seen by the Cardiologist today and was sent to the emergency room to be evaluated for Dyspnea. Resident #2 was given IV [MEDICATION NAME], 40 mg and admitted to the hospital. A review of the Hospitalist Discharge Note on [DATE], revealed Resident #2 was admitted on [DATE], and discharged on [DATE], with a discharge [DIAGNOSES REDACTED]. The Hospital Course noted: Resident #2 was a direct admit from the Cardiologist office due to evidence of severe volume overload and Acute and Chronic Diastolic Heart Failure Exacerbation. On arrival she appeared to be in Active Diastolic Heart Failure Exacerbations and had gained approximately 20 pounds over the preceding several weeks and had evidence of [MEDICAL CONDITIONS] and severe lower extremity anti-[MEDICAL CONDITION]. A repeat echocardiogram did reveal evidence of significant Diastolic Failure with a least moderate [DIAGNOSES REDACTED] and severe bilateral dilation and elevated [MEDICAL CONDITION] pressures. ([MEDICAL CONDITION]). Her outpatient [MEDICATION NAME] dosage has been increased to 40 mg twice daily and will continue to follow up with the outpatient [MEDICAL CONDITION] clinic. A review of Resident #2's NT Pro Brain Natriuretic Peptide (BNP) lab report, on [DATE], on admission to the hospital, was 1,335 with the hospital reference range of less than 1,800 picogram (pg)/milliliters (ml). Comments on the lab report included: Among patients with Dyspnea, NT-proBNP is highly sensitive for the detection of Acute [MEDICAL CONDITION]. In addition, a NT-proBNP <300 pg/ml effectively rules out Acute [MEDICAL CONDITION] with 99% negative predictive value. This indicated that [MEDICAL CONDITION] could not be ruled out for Resident #2. Review of the facility's Discharge Summary, dated [DATE], revealed Resident #2 was admitted on [DATE], for Chronic [MEDICAL CONDITION], Acute onset Diastolic Heart Failure, [MEDICAL CONDITION] and [MEDICAL CONDITION] Fibrillation. The Progress section included the resident did progress with Activity of Daily Living (ADL) but had [MEDICAL CONDITION] to lower extremities and was at times having a difficult time breathing. The reason for discharge documented the resident was sent to a Physician's appointment for evaluation and was admitted to the hospital. The most recent weight, documented on the Discharge Summary, was 235.0 pounds on [DATE]. A telephone interview with Resident #2's Responsible Party (RP) on [DATE] at 4:02 PM, revealed the resident was admitted to the facility and weights were not done as ordered and [MEDICATION NAME] was not increased or given based on weights. The RP stated, That's why they ordered her to be weighed daily, to adjust her medication. Resident #2's RP stated the staff did not come in to weigh the resident in the mornings as they should have, and the resident had said that she had only been weighed a few times. The RP stated the documentation they had been given showed the resident had only been weighed twice the whole time she was at the facility. The RP reported Resident #2 wanted to get well and return home and stated she had never refused to be weighed because she knew how important it was for her. The RP reported Resident #2 was taken immediately to the Cardiologist upon leaving the facility, because she was unable to speak a full sentence, and because she was so short of breath and that she could only take a few steps. The RP stated the resident was admitted to the hospital and the Doctor said she had an excess of 35 lbs of fluid weight gain and was again in Heart Failure. The RP stated, I believe she was neglected because they did not give her medication, her [MEDICATION NAME], right and she almost died . I brought her home with me, she is at home now, because I don't trust them. During an interview on [DATE] at 9:20 AM, the Director of Nursing (DON) acknowledged the physician's orders [REDACTED].#2. The DON confirmed the Nurse who administered medication for Resident #2 should have reviewed a weight in order to administer the [MEDICATION NAME] and/or extra [MEDICATION NAME], but they didn't. The DON stated Resident #2 did have an order for [REDACTED].#2 the IM [MEDICATION NAME] on [DATE], due to 3+ [MEDICAL CONDITION] in the lower extremities and because the resident was short of breath, but the resident wasn't weighed at that time. She stated it was her fault the daily weight didn't get into the computer. In an interview on [DATE] at 2:20 PM, MDS Nurse, LPN #2, stated if an order for [REDACTED]. An interview on [DATE] at 1:55 PM, with LPN #3 revealed she did not look at the drop down box of the MAR indicated [REDACTED]. (The drop down box is where the completed order would be listed) LPN #3 stated if the [MEDICATION NAME] was not given correctly, and as ordered to be adjusted by the resident's weight, then they would not be following physician's orders [REDACTED].#3 was asked why the daily weights had been missed for Resident #2 and she stated, I'm not sure why it was missed. I don't ever remember her getting weighed. An interview on [DATE] at 10:00 AM, with the Nurse Practitioner (NP) confirmed [MEDICATION NAME] 20 mg was ordered for Resident #2 and should have been increased to 40 mg if she had more than a three (3) pound weight gain overnight and/or five (5) pounds in a week. The NP confirmed not giving the [MEDICATION NAME] correctly could have resulted in [MEDICAL CONDITION]. The NP stated she had noticed and had concerns that weights were sometimes not obtained and had spoken to the DON about it. The NP also stated, The residents would tell me that they have not been weighed. The NP stated if she noticed a weight not being done she would go to the Nurse and stress to them the weights are to be done before breakfast daily. The NP stated she had even had complaints from the Cardiologist of weights not being obtained. In an interview on [DATE] at 1:40 PM, the Medical Director stated he was notified last week of residents with daily weights not being done as ordered. He stated if weights are ordered, they need to be done. The Medical Director confirmed [MEDICATION NAME] was not given as ordered for Resident #2. He stated if staff did not obtain her daily weights, and base the dose of [MEDICATION NAME] on that weight, it could result in fluid gain for the resident. In an interview on [DATE] at 7:58 AM, LPN #5 stated if a resident is to have a medication based on daily weights and not weighed, then the medication cannot be given safely. When asked if this could cause harm, LPN #5 responded, Yes. LPN #5 acknowledged Resident #2 didn't receive services as needed or as ordered. Resident #3 The facility admitted Resident #3 on [DATE], with the [DIAGNOSES REDACTED]. A review of the Admission MDS, with the ARD of [DATE], revealed Resident #3 had a BIMS score of 9, which indicated moderate cognitive impairment. A review of the 60 day assessment MDS, with the ARD of [DATE], revealed Resident #3 had a BIMS score of 12, which indicated she was more cognitively intact. An interview on [DATE] at 5:00 PM, with Resident #3, revealed she does not refuse to be weighed. Resident #3 stated the staff does not weigh her every day but every couple of days and stated she understands how important it is to be weighed because of her fluid buildup. Review of the care plan, for Resident #3, initiated [DATE], revealed to weigh as ordered and prn. Review of physician's orders [REDACTED].#3 daily every night shift. (Resident #3 was discharged home on [DATE] and re-admitted on [DATE]). Review of the MAR for (MONTH) (YEAR), revealed daily weights were to be obtained every night shift with a start date of [DATE]. Review of the Weights and Vital Summary form, revealed Resident #3 weighed 167.2 pounds on [DATE]. On [DATE], the resident weighed 174.0 pounds, a 9.8 pound gain in one (1) week. Resident #3's weight on [DATE] was 172.6 pounds, the day she was admitted to the hospital, which was a 5.4 pound weight gain from [DATE] until [DATE], in less than two (2) weeks after re-admission. A review of the Hospitalist Admission Note on [DATE], noted Resident #3 was admitted to the hospital with [REDACTED]. The family reported swelling in the arm and legs for the past few months. The note documented 3+ [MEDICAL CONDITION] in the bilateral lower extremities and left upper extremity. The admission Chest X-Ray (CXR) revealed the impression of bilateral Pleural Effusions which indicated fluid on the lungs. The Assessment/Plan for the #3's [DIAGNOSES REDACTED]. The Brain Natriuretic Peptide (BNP) was 20,481, with the Latest Reference Range of less than 1,800 pg/ml. Resident #3 was hospitalized from [DATE] through [DATE] and received IV [MEDICATION NAME] and was discharged back to the facility with daily weights ordered. A review of the physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. Weight on [DATE] was 172.6, and on [DATE] weight was 177.6. Daily weights were not obtained as ordered, so that staff could evaluate the resident for [MEDICAL CONDITION] and/or other medical issues and implement intervention as needed. Dates of missed weights, that should have been obtained on the night shift, included [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. An interview on [DATE] at 2:10 PM, with MDS Nurse, Licensed Practical Nurse (LPN) #1, confirmed if the staff fails to follow the physician's orders [REDACTED]. In an interview on [DATE] at 11:55 AM, CNA #1 stated two (2) nights last week she had 19 to 20 residents and weights didn't get done. She stated, The nurse tells us who to weigh at the beginning of the shift. Also sometimes other workers have to leave in the middle of the shift, and that puts us short and not enough help. CNA #1 confirmed weights didn't always get done as they should and could considered neglectful. An interview on [DATE] at 12:20 PM, with LPN #4, revealed she worked the night shift and stated the Nurse on night shift is responsible for making sure the CNAs obtain the ordered weights. She stated there was a few days that the lift would not work properly, but was fixed now. She stated there had been in-services about abuse and neglect about two (2) weeks prior. She stated she had heard from residents that CNAs were not coming in to get weights at intervals. She acknowledged the services weren't always provided with obtaining daily weights. The facility submitted an acceptable Allegation of Compliance (AoC) on [DATE], for the Immediate Jeopardy. Review of the facility's AoC revealed the facility took the following corrective actions to remove the IJ: Brief Summary of Event: At 10:32 AM, on Monday [DATE], the State Complaint Surveyor informed the Facility Administrator the facility was in Immediate Jeopardy (IJ) status concerning Resident #2 and Resident #3. Resident #2 attended a follow-up appointment related to post Aortic Valve Replacement at a local Cardiology Clinic on [DATE]. Resident #2 was noted to have shortness of breath and an increase in weight of 23 pounds (lbs) since the previous [DATE] Cardiology visit per Cardiology consult note. Resident #2 was transported to the local hospital emergency room (ER). Resident #2 was admitted to the hospital on [DATE], with an admitting [DIAGNOSES REDACTED]. Per hospital lab result sheet, less than (<)300 pg/ml effectively rules out Acute [MEDICAL CONDITIONS] and greater than (>) 300 pg/ml could be indicative of Acute [MEDICAL CONDITION]. The facility failed to obtain 20 daily weights since admission to the facility on [DATE]. The facility failed to assess the weight in order to provide the proper dose of [MEDICATION NAME] according to parameters set by the physician order. The order included [MEDICATION NAME] 20 milligrams (mg) per day, may increase to 40 mg if weight gain is greater than three (3) lbs over night or five (5) lbs in a week. The facility failed to develop and implement a care plan regarding obtaining daily weights. The facility failed to develop and implement a care plan regarding [MEDICATION NAME] therapy with weight changes. This resulted in the resident being hospitalized from [DATE] to [DATE], with the hospital discharge summary stating Resident #2 had a [DIAGNOSES REDACTED]. The Facility failed to obtain nine (9) daily weights for Resident #3. Resident #3's initial admission weight from [DATE] was 167.2 lbs and her discharge weight to the hospital on [DATE], was 172.6 lbs; a weight change of 5.4 lbs. The facility failed to implement a care plan for daily weights for Resident #3, who has a history of [MEDICAL CONDITION]. Resident #3 was sent to the local emergency room related to Altered Mental Status on [DATE], and was admitted to the hospital with [REDACTED]. Resident received treatment of [REDACTED]. Resident #3 was discharged from the hospital on [DATE] back to the facility with a [DIAGNOSES REDACTED]. Facility Actions: 1. On [DATE], a 100 percent (%) audit of a total of 20 residents, with [DIAGNOSES REDACTED]. The facility Nurse Practitioner (NP) reviewed all residents with a [DIAGNOSES REDACTED]. Six (6) residents with a determined unstable [MEDICAL CONDITION] condition remained on daily weights and 14 residents were added for weekly weights. The residents on [MEDICAL TREATMENT] are being monitored and treated by the local [MEDICAL TREATMENT] center and weights are being recorded weekly at the facility. 2. Care plans for all residents with [MEDICAL CONDITION] were reviewed by the Regional Minimum Data Set (MDS) Registered Nurse on [DATE], to ensure they reflected all the weight monitoring orders and that care plans were developed and implemented for each resident with [MEDICAL CONDITION], with no concerns found. 3. On [DATE] at 4:00 PM, an in-service was initiated for clinical staff members which included one (1) of one (1) Social Services Director (SSD), one (1) of one (1) Nursing Home Administrator, one (1) of one (1) Life Connections Coordinator, two (2) of 11 Registered Nurses, five (5) of 16 LPN, and three (3) of 33 Certified Nursing Assistants (CNAs) by the DON regarding the procedure for daily weights, documentation, and signs and symptoms of [MEDICAL CONDITION] including: Daily/weekly weights for residents with [MEDICAL CONDITION] are to be done on 11:00 PM-7:00 AM shift in the AM by the CNA, and documented by the Nurse in the Medication Administration Record [REDACTED]. Daily/weekly weights will be reviewed by the Clinical Team consisting of the DON, TCU RN, MDS #1, MDS #2, Medical Records LPN, Dietary Manager, and Social Services Director (SSD) in the clinical meeting every morning during the week. The Weekend RN Supervisor will review the daily/weekly weights on the weekends. The MD/NP will be notified by the TCU Manager during the week and the Weekend RN Supervisor during the weekend of a daily gain of three (3) lbs or a five (5) lb gain within a week. All [MEDICATION NAME] and weight orders will be care planned and updated as they are received by MDS #1 or MDS #2 Nurse. Signs and symptoms of [MEDICAL CONDITION] include: Shortness of breath especially when lying flat, tired, run-down feeling, swelling in feet, ankles, and legs, weight gain, and confusion. 4. On [DATE] at 4:30 PM, an emergency Quality Assurance Improvement Meeting (QAPI) was held with the Medical Director and QAPI team including the Medical Director, DON, Facility Administrator, Social Services Director, MDS #1, and MDS #2. In this meeting residents with [MEDICAL CONDITION] were discussed and the following procedure was adopted and implemented: All residents with [MEDICAL CONDITION] that have daily weights ordered will be discussed in the morning clinical meeting by the Clinical Team. The facility weight policy was reviewed with no changes made on [DATE]. 5. On [DATE] at 10:40 AM, the Medical Director was notified of the IJ concerning Resident #2 and Resident #3. 6. A QAPI meeting was held on [DATE] at 5:00 PM, with the following staff members present: Medical Director, Director of Nursing, Facility Administrator, Social Services Director, MDS Nurse #1, and MDS Nurse #2. Facility policies for medication administration, physician orders, and developing and implementing care plans, were reviewed with no changes made on [DATE]. The following procedures were reviewed and adopted by the Medical Director and QAPI team regarding obtaining daily weights, initiating and updating care plans to reflect correct plan of care regarding weights, and following [MEDICATION NAME] parameters: Daily/weekly weights will be monitored daily during morning clinical meeting by the Clinical Team including DON, TCU RN, MDS #1, MDS #2, Medical Records LPN, Dietary Manager, and Social Services Director on week days, and Weekend RN Supervisor on the weekends, to ensure that all daily weights are obtained and properly addressed. This monitor will be documented by the DON during the week, and the Weekend RN Supervisor on the weekends, by a Care Plan & Weight Audit check list tool. This monitor will be gathered from the Medication Administration Record [REDACTED] All new orders will be reviewed daily during morning clinical meeting by the Clinical Team consisting of the DON, MDS #1, MDS #2, Medical Records LPN, TCU RN, Social Services Director, and the Dietary Manager during week days, and the Weekend RN Supervisor on weekends, to ensure that parameters are being performed and documented properly as ordered. All new orders obtained for daily/weekly weights will be added to the care plan at the time of review during clinical meeting, by the clinical team on weekdays, and RN supervisor on weekends. All care plans initiated or revised regarding daily/weekly weights will be reviewed daily to ensure completeness and accuracy, by the Clinical Team on weekdays and Weekend RN Supervisor on weekends, to ensure completeness. This monitor will be documented by the DON during the week and the Weekend RN Supervisor on the weekends, by a Care Plan & Weight Audit check list tool. This monitor will be gathered from the care plan. 7. On [DATE], an in-service was initiated by the Director of Nursing and Facility Administrator for all staff members regarding daily weights are to be done on 11:00 PM-7:00 AM in the AM, unless otherwise specified by residents of alternate time. Daily/weekly weights will be reviewed by the Clinical Team consisting of the DON, TCU RN, MDS #1, MDS #2, Medical Records LPN, Dietary Manager, and Social Services Director (SSD) in the clinical meeting every morning during the week. The Weekend RN Supervisor will review the daily/weekly weights on the weekends. The MD/NP will be notified by the TCU Manager during the week and the Weekend RN Supervisor during the weekend, of a daily gain of three (3) lbs or a five (5) lb gain within a week. The following staff were present at the in-service: RNs-11 of 11, LPNs-14 of 14, CNAs-28 of 28, Administrator-one (1) of one (1), Therapy Department-34 of 34, Dietary-seven (7) of seven (7), Housekeeping/Laundry-seven (7) of seven (7), Maintenance Director-one (1) of one (1), Business Office Manager-one (1) of one (1), Marketing Director-one (1) of one (1), Social Service Director-one (1) of one (1), and Life Connections-one (1) of one (1). No staff will be allowed to work at the facility until in-serviced, which includes new hires; this will be monitored by the Facility Administrator. -On [DATE] at 11:30 AM, an in-service was initiated by the Regional Minimum Data Set (MDS) Registered Nurse regarding ensuring residents with [MEDICAL CONDITION] and residents receiving [MEDICAL TREATMENT], should all have weights as ordered included in the plan of care for MDS #1, MDS #2, Medical Records LPN, and the DON. 8. The facility alleges that all corrective actions have been completed as of [DATE], and the Jeopardy was removed as of [DATE]. The SA validated through interview, record review, observation and policy review that the facility completed the following actions to remove the IJ: 1. The SA validated through interview and record review that a 100% audit was completed by the DON and TCU Nurse on ,[DATE]//18, of 20 residents, with [DIAGNOSES REDACTED]. The SA validated through interview and record review that the facility NP reviewed residents with a [DIAGNOSES REDACTED]. Six (6) residents with a determined unstable [MEDICAL CONDITION] condition remained on daily weights and 14 residents were changed/added for weekly weights. The residents on [MEDICAL TREATMENT] are monitored and treated by the local [MEDICAL TREATMENT] center and weights are recorded weekly at the facility. 2. The SA validated through interview and record review that care plans for all residents with [MEDICAL CONDITION] were reviewed by the Regional MDS RN on [DATE], to ensure they reflected all the weight monitoring orders and that care plans were developed and implemented for each resident with [MEDICAL CONDITION] with no concerns found. No further issues were identified during record review. 3. The SA validated through interview, sign-in sheets from in-services, and record review that on [DATE], an in-service was initiated for clinical staff members which included one (1) of one (1) Social Services Director (SSD), one (1) of one (1) Nursing Home Administrator, one (1) of one (1) Life Connections Coordinator, two (2) of 11 Registered Nurses, five (5) of 16 LPNs, and three (3) of 33 Certified Nursing Assistants (CNAs) by the DON regarding the procedure for daily weights, documentation, and signs and symptoms of [MEDICAL CONDITION] including: Daily/weekly weights for residents with [MEDICAL CONDITION] are done on 11:00 PM-7:00 AM shift in the mornings by the CNA, and documented by the Nurse in the Medication Administration Record [REDACTED]. Daily/weekly weights are reviewed by the Clinical Team consisting of the DON, TCU RN, MDS #1, MDS #2, Medical Records LPN, Dietary Manager, and Social Services Director (SSD) in the clinical meeting every morning during the week. The Weekend RN Supervisor reviews the daily/weekly weights on the weekends. The MD/NP are notified by the TCU Manager during the week, and the Weekend RN Supervisor during the weekend, of a daily gain of three (3) lbs or a five (5) lb gain within a week. All [MEDICATION NAME] and weight orders are care planned and updated as they are received by MDS #1 or MDS #2 Nurse. Signs and symptoms of [MEDICAL CONDITION] include: Shortness of breath especially when lying flat, tired, run-down feeling, swelling in feet, ankles, and legs, weight gain, and confusion. Staff interviews across all disciplines revealed in-services were attended, understood, and followed. 4. The SA validated through sign-in sheets and staff interview, that on [DATE], an emergency Quality Assurance Improvement Meeting (QAPI) was held with the Medical Director and QAPI team including the Medical Director, DON, Facility Administrator, Social Services Director, MDS #1, and MDS #2. The following procedure was adopted and implemented: All residents with [MEDICAL CONDITION] that have daily weights ordered will be discussed in the morning clinical meeting by the Clinical Team. The facility weight policy was reviewed with no changes made on [DATE]. 5. The SA validated by interview that the Medical Di

Based on interview, record review, and policy review, the facility failed to develop and follow the care plan to obtain daily weights for Resident #2, for a total of 17 days, so that the medication [MEDICATION NAME] could be adjusted, as ordered, according to the daily weights, for accurate monitoring to prevent fluid overload and [MEDICAL CONDITIONS]. The facility also failed to obtain daily weights as ordered for a total of 10 days for Resident #3, to monitor for fluid overload and/or [MEDICAL CONDITION]; for two (2) of six (6) sampled residents and five (5) un-sampled residents reviewed. Resident #2 had a weight gain of approximately 27 pounds in a two (2) week period from [DATE] until [DATE], when she was admitted to the hospital was aggressive Intravenous (IV) treatment for [REDACTED].#3 had an approximate nine (9) pound weight gain in a two (2) week period from [DATE] until [DATE], when she was admitted to the hospital with [REDACTED]. The failure to develop and/or implement the care plan for the adjustment medication administration, related to weight gain, and/or failure to obtain daily weights for residents with [MEDICAL CONDITIONS], placed Resident #2, Resident #3, and other residents in the facility with orders for daily weights and/or medications to adjust for weight gain, at risk for serious injury, harm, impairment or death. This situation was determined to be an Immediate Jeopardy (IJ), which began on [DATE], when Resident #2's care plan was not developed and/or followed for weight monitoring and medication adjustment, which lead to the resident's admission to the hospital, with a [DIAGNOSES REDACTED]. The facility's Administrator and the Director of Nursing (DON) was notified on [DATE] at 10:30 AM, of the IJ. An acceptable Credible Allegation of Compliance (AoC) was received on [DATE], in which the facility alleged the removal of the IJ on [DATE]. The State Agency (SA) determined the IJ to be removed on [DATE], prior to exit. The scope and severity for the IJ at CFR (s) 483.21 (b), F656, Comprehensive Resident Centered Care Plans, was lowered to a D while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: The facility's policy, titled, Goals and Objectives, undated, noted it is the policy of the facility that care plans incorporate goals and objectives which lead to the resident's highest obtainable level of independence as determined by the Interdisciplinary Team and in accordance with the resident's personal wishes and cultural preferences. The facility's policy, titled, Care Plan-Baseline, undated, noted, it is the policy of this facility that an individualized baseline care plan be developed within 48 hours of admission that includes instructions needed to provide effective person centered care of the resident that meets professional standards of quality care, maintained and/or updated, while a comprehensive care plan is developed. The facility's Care Plan-Comprehensive Policy Statement, undated, revealed it is the policy of this facility to develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs. Care plans are revised as changes in the resident's condition dictates. Daily care and documentation should be consistent with the resident's care plan. Resident #2: A review of Resident #2's Care Plan documented as follows: [DATE] Focus: I have altered cardiovascular status related to [MEDICAL CONDITIONS], /Cardiac Pacemaker, [MEDICAL CONDITION] Fibrillation, Prosthetic Heart Valve, Non-rheumatic [DIAGNOSES REDACTED], Hypertension (HTN), and Diabetes Mellitus (DM). Goal: The resident will be free from complications of cardiac problems through the review date. Interventions included: Administer medications and supplements as ordered and PRN (as needed) and, Assess for shortness of breath and cyanosis every day. The facility failed to develop a care plan for weights, and medication adjustment based on those weights, per physician's orders [REDACTED]. The facility admitted Resident #2 on [DATE], with [DIAGNOSES REDACTED]. Resident #2's Admission Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated Resident #2 was cognitively intact. A review of the physician's orders [REDACTED]. Increase to 40 mg if weight gain greater than three (3) lbs. overnight or five (5) lbs. in one (1) week, with a start date of [DATE]. The orders also included daily weights for three (3) days for new admit. A three(3) pound weight gain overnight could not be assessed with [REDACTED]. A review of the Medication Administration Record [REDACTED]. One (1) injection of [MEDICATION NAME] 20 mg, administered Intramuscular (IM), had been documented on [DATE], for 3+ [MEDICAL CONDITION], with no weight documented. The MAR for (MONTH) (YEAR), and (MONTH) (YEAR), revealed a total of 17 missed weights, which should have been obtained in order to adjust the [MEDICATION NAME] as needed per weight gain, during the 22 day stay. The care plan was not developed to include the specific orders to adjust [MEDICATION NAME] per weights. Review of a Cardiology note, dated [DATE], revealed Resident #3 was sent to the Hospital emergency room (ER) for an evaluation related to weight gain of over 20 pounds over the past three (3) months and difficulty breathing. A review of the Hospitalist Admission Note from the ER, on [DATE], revealed Resident #2 presented to the hospital with Dyspnea (shortness of breath), which had started a few weeks prior, and was admitted to the Hospital. Her weight was documented at 262 pounds. The last facility weight on [DATE] was 235 pounds, which was an increase of 27 pounds from [DATE] until [DATE]. A review of the Hospitalist Discharge Note on [DATE], revealed Resident #2 was discharged with one of the [DIAGNOSES REDACTED]. The Hospital Course noted that Resident #2 was a direct admit from the Cardiologist office due to evidence of severe volume overload and Acute and Chronic Diastolic Heart Failure Exacerbation. The note documented: On arrival the resident appeared to be an Active Diastolic Heart Failure Exacerbations and had gained approximately 20 pounds over the preceding several weeks and had evidence of [MEDICAL CONDITIONS] and severe lower extremity anti-[MEDICAL CONDITION]. A repeat echocardiogram did reveal evidence of significant Diastolic Failure with a least moderate [DIAGNOSES REDACTED] and severe bilateral dilation and elevated [MEDICAL CONDITION] pressures, which is also part of [MEDICAL CONDITION]. During an interview with the Director of Nursing (DON) on [DATE] at 9:20 AM, she stated, I forgot to enter the order for daily weights - that was my fault. The DON confirmed when the order did not get entered into the computer and it did not trigger on the MAR indicated [REDACTED]. She stated the nurses should have still picked up on it, because the order was specific to the resident's weights. She also stated the MDS Nurses should have picked up on it when the care plan was developed. The DON confirmed Resident #2 did have an order for [REDACTED]. A telephone interview with Resident #2's Responsible Party (RP) on [DATE] at 4:02 PM, revealed the resident was admitted to the facility and weights were not done as ordered and [MEDICATION NAME] was not increased or given based on weights. The RP stated, That's why they ordered her to be weighed daily, to adjust her medication. The RP reported Resident #2 was taken immediately to the Cardiologist upon leaving the facility because she was unable to speak a full sentence and because she was so short of breath and that she was admitted to the hospital for [MEDICAL CONDITIONS], and per the doctor, with a 35 lb fluid weight gain. The RP stated, they did not give her [MEDICATION NAME] right, and she almost died . An interview on [DATE] at 1:55 PM, with LPN #3, revealed she did not look at the drop down box of the MAR indicated [REDACTED]. LPN #3 stated if the [MEDICATION NAME] was not given correctly, and as ordered, then they would not be following physician's orders [REDACTED]. LPN #3 was asked why the daily weights had been missed for Resident #2 and she stated, I'm not sure why it was missed. I don't ever remember her getting weighed. An interview on [DATE] at 2:20 PM, with MDS Nurse, LPN #2, revealed if an order for [REDACTED]. An interview on [DATE] at 10:00 AM, with the Nurse Practitioner (NP) confirmed [MEDICATION NAME] 20 mg was ordered for Resident #2 and should have been increased to 40 mg if she had more than three (3) lb. weight gain overnight or 5 lbs. in a week. The NP confirmed not giving the [MEDICATION NAME] correctly could have resulted in [MEDICAL CONDITION]. Resident #3 A review of Resident #3's current Care Plan documented as follows: [DATE]: Focus: I am at risk for potential fluid deficit related to diuretic use. Goal: I will be free from symptoms of dehydration and maintain moist mucous membranes, good skin turgor. Interventions included: Weigh as ordered and as needed (PRN). The facility admitted Resident #3 on [DATE], with [DIAGNOSES REDACTED]. A review of the 60 day assessment MDS with the ARD of [DATE], revealed Resident #3 had a BIMS score of 12, which indicated she was cognitively intact. An interview on [DATE] at 5:00 PM, with Resident #3, revealed the staff did not weigh her every day, but every couple of days. She stated she understood how important it is to be weighed, because of her fluid buildup. A review of the physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. A review of the Hospitalist Admission Note on [DATE], noted Resident #3 was admitted to the hospital with [REDACTED]. The admission Chest X-Ray (CXR) revealed the impression of bilateral pleural effusions which indicated fluid on the lungs. The Assessment/Plan for the [DIAGNOSES REDACTED]. Resident #3 was treated for [REDACTED]. During an interview on [DATE] at 9:20 AM, the Director of Nursing (DON) acknowledged weights should be done as ordered and care planned. Interview on [DATE] at 2:10 PM, with MDS Nurse, LPN #1, revealed if the staff failed to follow the physician's orders [REDACTED]. When asked who is responsible for assuring the care plans are followed, LPN #1 responded, We all are responsible to see if they are followed. An interview on [DATE] at 11:55 AM, with CNA #1, revealed two (2) nights last week she had 19 to 20 residents and the weights didn't get done. She stated the nurse tells the CNAs who to weigh at the beginning of the shift; sometimes other workers have to leave in the middle of the shift and that puts them short-staffed with not enough help. She stated, The care plan is on the Kiosk. She stated the care plan wasn't followed if the weights didn't get done. Interview with CNA #3 on [DATE], revealed sometimes the weights are missed because they didn't have time to do them. She confirmed by not getting the weights, the care plan wasn't followed. She stated the Nurse tells the CNAs which weights to get and they were also in the Kiosk, for the CNAs to review and follow direction. The facility submitted an acceptable Allegation of Compliance (AoC) on [DATE], for the Immediate Jeopardy. Review of the facility's AoC revealed the facility took the following corrective actions to remove the IJ: Brief Summary of Event: At 10:32 AM, on Monday [DATE], the State Complaint Surveyor informed the Facility Administrator the facility was in Immediate Jeopardy (IJ) status concerning Resident #2 and Resident #3. Resident #2 attended a follow-up appointment related to post Aortic Valve Replacement at a local Cardiology Clinic on [DATE]. Resident #2 was noted to have shortness of breath and an increase in weight of 23 pounds (lbs) since the previous [DATE] Cardiology visit per Cardiology consult note. Resident #2 was transported to the local hospital emergency room (ER). Resident #2 was admitted to the hospital on [DATE], with an admitting [DIAGNOSES REDACTED]. Per hospital lab result sheet, less than (<)300 pg/ml effectively rules out Acute [MEDICAL CONDITIONS] and greater than (>) 300 pg/ml could be indicative of Acute [MEDICAL CONDITION]. The facility failed to obtain 20 daily weights since admission to the facility on [DATE]. The facility failed to assess the weight in order to provide the proper dose of [MEDICATION NAME] according to parameters set by the physician order. The order included [MEDICATION NAME] 20 milligrams (mg) per day, may increase to 40 mg if weight gain is greater than three (3) lbs over night or five (5) lbs in a week. The facility failed to develop and implement a care plan regarding obtaining daily weights. The facility failed to develop and implement a care plan regarding [MEDICATION NAME] therapy with weight changes. This resulted in the resident being hospitalized from [DATE] to [DATE], with the hospital discharge summary stating Resident #2 had a [DIAGNOSES REDACTED]. The Facility failed to obtain nine (9) daily weights for Resident #3. Resident #3's initial admission weight from [DATE] was 167.2 lbs and her discharge weight to the hospital on [DATE], was 172.6 lbs; a weight change of 5.4 lbs. The facility failed to implement a care plan for daily weights for Resident #3, who has a history of [MEDICAL CONDITION]. Resident #3 was sent to the local emergency room related to Altered Mental Status on [DATE], and was admitted to the hospital with [REDACTED]. Resident received treatment of [REDACTED]. Resident #3 was discharged from the hospital on [DATE] back to the facility with a [DIAGNOSES REDACTED]. Facility Actions: 1. On [DATE], a 100 percent (%) audit of a total of 20 residents, with [DIAGNOSES REDACTED]. The facility Nurse Practitioner (NP) reviewed all residents with a [DIAGNOSES REDACTED]. Six (6) residents with a determined unstable [MEDICAL CONDITION] condition remained on daily weights and 14 residents were added for weekly weights. The residents on [MEDICAL TREATMENT] are being monitored and treated by the local [MEDICAL TREATMENT] center and weights are being recorded weekly at the facility. 2. Care plans for all residents with [MEDICAL CONDITION] were reviewed by the Regional Minimum Data Set (MDS) Registered Nurse on [DATE], to ensure they reflected all the weight monitoring orders and that care plans were developed and implemented for each resident with [MEDICAL CONDITION], with no concerns found. 3. On [DATE] at 4:00 PM, an in-service was initiated for clinical staff members which included one (1) of one (1) Social Services Director (SSD), one (1) of one (1) Nursing Home Administrator, one (1) of one (1) Life Connections Coordinator, two (2) of 11 Registered Nurses, five (5) of 16 LPN, and three (3) of 33 Certified Nursing Assistants (CNAs) by the DON regarding the procedure for daily weights, documentation, and signs and symptoms of [MEDICAL CONDITION] including: Daily/weekly weights for residents with [MEDICAL CONDITION] are to be done on 11:00 PM-7:00 AM shift in the AM by the CNA, and documented by the Nurse in the Medication Administration Record [REDACTED]. Daily/weekly weights will be reviewed by the Clinical Team consisting of the DON, TCU RN, MDS #1, MDS #2, Medical Records LPN, Dietary Manager, and Social Services Director (SSD) in the clinical meeting every morning during the week. The Weekend RN Supervisor will review the daily/weekly weights on the weekends. The MD/NP will be notified by the TCU Manager during the week and the Weekend RN Supervisor during the weekend of a daily gain of three (3) lbs or a five (5) lb gain within a week. All [MEDICATION NAME] and weight orders will be care planned and updated as they are received by MDS #1 or MDS #2 Nurse. Signs and symptoms of [MEDICAL CONDITION] include: Shortness of breath especially when lying flat, tired, run-down feeling, swelling in feet, ankles, and legs, weight gain, and confusion. 4. On [DATE] at 4:30 PM, an emergency Quality Assurance Improvement Meeting (QAPI) was held with the Medical Director and QAPI team including the Medical Director, DON, Facility Administrator, Social Services Director, MDS #1, and MDS #2. In this meeting residents with [MEDICAL CONDITION] were discussed and the following procedure was adopted and implemented: All residents with [MEDICAL CONDITION] that have daily weights ordered will be discussed in the morning clinical meeting by the Clinical Team. The facility weight policy was reviewed with no changes made on [DATE]. 5. On [DATE] at 10:40 AM, the Medical Director was notified of the IJ concerning Resident #2 and Resident #3. 6. A QAPI meeting was held on [DATE] at 5:00 PM, with the following staff members present: Medical Director, Director of Nursing, Facility Administrator, Social Services Director, MDS Nurse #1, and MDS Nurse #2. Facility policies for medication administration, physician orders, and developing and implementing care plans, were reviewed with no changes made on [DATE]. The following procedures were reviewed and adopted by the Medical Director and QAPI team regarding obtaining daily weights, initiating and updating care plans to reflect correct plan of care regarding weights, and following [MEDICATION NAME] parameters: Daily/weekly weights will be monitored daily during morning clinical meeting by the Clinical Team including DON, TCU RN, MDS #1, MDS #2, Medical Records LPN, Dietary Manager, and Social Services Director on week days, and Weekend RN Supervisor on the weekends, to ensure that all daily weights are obtained and properly addressed. This monitor will be documented by the DON during the week, and the Weekend RN Supervisor on the weekends, by a Care Plan & Weight Audit check list tool. This monitor will be gathered from the Medication Administration Record [REDACTED] All new orders will be reviewed daily during morning clinical meeting by the Clinical Team consisting of the DON, MDS #1, MDS #2, Medical Records LPN, TCU RN, Social Services Director, and the Dietary Manager during week days, and the Weekend RN Supervisor on weekends, to ensure that parameters are being performed and documented properly as ordered. All new orders obtained for daily/weekly weights will be added to the care plan at the time of review during clinical meeting, by the clinical team on weekdays, and RN supervisor on weekends. All care plans initiated or revised regarding daily/weekly weights will be reviewed daily to ensure completeness and accuracy, by the Clinical Team on weekdays and Weekend RN Supervisor on weekends, to ensure completeness. This monitor will be documented by the DON during the week and the Weekend RN Supervisor on the weekends, by a Care Plan & Weight Audit check list tool. This monitor will be gathered from the care plan. 7. On [DATE], an in-service was initiated by the Director of Nursing and Facility Administrator for all staff members regarding daily weights are to be done on 11:00 PM-7:00 AM in the AM, unless otherwise specified by residents of alternate time. Daily/weekly weights will be reviewed by the Clinical Team consisting of the DON, TCU RN, MDS #1, MDS #2, Medical Records LPN, Dietary Manager, and Social Services Director (SSD) in the clinical meeting every morning during the week. The Weekend RN Supervisor will review the daily/weekly weights on the weekends. The MD/NP will be notified by the TCU Manager during the week and the Weekend RN Supervisor during the weekend, of a daily gain of three (3) lbs or a five (5) lb gain within a week. The following staff were present at the in-service: RNs-11 of 11, LPNs-14 of 14, CNAs-28 of 28, Administrator-one (1) of one (1), Therapy Department-34 of 34, Dietary-seven (7) of seven (7), Housekeeping/Laundry-seven (7) of seven (7), Maintenance Director-one (1) of one (1), Business Office Manager-one (1) of one (1), Marketing Director-one (1) of one (1), Social Service Director-one (1) of one (1), and Life Connections-one (1) of one (1). No staff will be allowed to work at the facility until in-serviced, which includes new hires; this will be monitored by the Facility Administrator. -On [DATE] at 11:30 AM, an in-service was initiated by the Regional Minimum Data Set (MDS) Registered Nurse regarding ensuring residents with [MEDICAL CONDITION] and residents receiving [MEDICAL TREATMENT], should all have weights as ordered included in the plan of care for MDS #1, MDS #2, Medical Records LPN, and the DON. 8. The facility alleges that all corrective actions have been completed as of [DATE], and the Jeopardy was removed as of [DATE]. The SA validated through interview, record review, observation and policy review that the facility completed the following actions to remove the IJ: 1. The SA validated through interview and record review that a 100% audit was completed by the DON and TCU Nurse on ,[DATE]//18, of 20 residents, with [DIAGNOSES REDACTED]. The SA validated through interview and record review that the facility NP reviewed residents with a [DIAGNOSES REDACTED]. Six (6) residents with a determined unstable [MEDICAL CONDITION] condition remained on daily weights and 14 residents were changed/added for weekly weights. The residents on [MEDICAL TREATMENT] are monitored and treated by the local [MEDICAL TREATMENT] center and weights are recorded weekly at the facility. 2. The SA validated through interview and record review that care plans for all residents with [MEDICAL CONDITION] were reviewed by the Regional MDS RN on [DATE], to ensure they reflected all the weight monitoring orders and that care plans were developed and implemented for each resident with [MEDICAL CONDITION] with no concerns found. No further issues were identified during record review. 3. The SA validated through interview, sign-in sheets from in-services, and record review that on [DATE], an in-service was initiated for clinical staff members which included one (1) of one (1) Social Services Director (SSD), one (1) of one (1) Nursing Home Administrator, one (1) of one (1) Life Connections Coordinator, two (2) of 11 Registered Nurses, five (5) of 16 LPNs, and three (3) of 33 Certified Nursing Assistants (CNAs) by the DON regarding the procedure for daily weights, documentation, and signs and symptoms of [MEDICAL CONDITION] including: Daily/weekly weights for residents with [MEDICAL CONDITION] are done on 11:00 PM-7:00 AM shift in the mornings by the CNA, and documented by the Nurse in the Medication Administration Record [REDACTED]. Daily/weekly weights are reviewed by the Clinical Team consisting of the DON, TCU RN, MDS #1, MDS #2, Medical Records LPN, Dietary Manager, and Social Services Director (SSD) in the clinical meeting every morning during the week. The Weekend RN Supervisor reviews the daily/weekly weights on the weekends. The MD/NP are notified by the TCU Manager during the week, and the Weekend RN Supervisor during the weekend, of a daily gain of three (3) lbs or a five (5) lb gain within a week. All [MEDICATION NAME] and weight orders are care planned and updated as they are received by MDS #1 or MDS #2 Nurse. Signs and symptoms of [MEDICAL CONDITION] include: Shortness of breath especially when lying flat, tired, run-down feeling, swelling in feet, ankles, and legs, weight gain, and confusion. Staff interviews across all disciplines revealed in-services were attended, understood, and followed. 4. The SA validated through sign-in sheets and staff interview, that on [DATE], an emergency Quality Assurance Improvement Meeting (QAPI) was held with the Medical Director and QAPI team including the Medical Director, DON, Facility Administrator, Social Services Director, MDS #1, and MDS #2. The following procedure was adopted and implemented: All residents with [MEDICAL CONDITION] that have daily weights ordered will be discussed in the morning clinical meeting by the Clinical Team. The facility weight policy was reviewed with no changes made on [DATE]. 5. The SA validated by interview that the Medical Director was notified of the IJ concerning Resident #2 and Resident #3 on [DATE]. 6. The SA validated through interview and record review of sign-in sheets that a QAPI meeting was held on [DATE], which included the Medical Director, Director of Nursing, Facility Administrator, Social Services Director, MDS Nurse #1, and MDS Nurse #2. Facility policies for medication administration, physician orders, developing and implementing care plans were reviewed with no changes made on [DATE]. Interview with nursing staff and Administrative staff revealed the following procedures were reviewed and adopted by the Medical Director and QAPI team regarding obtaining daily weights, initiating and updating care plans to reflect correct plan of care regarding weights, and following [MEDICATION NAME] parameters. Daily/weekly weights will be monitored daily during morning clinical meeting by the Clinical Team including DON, TCU RN, MDS #1, MDS #2, Medical Records LPN, Dietary Manager, and Social Services Director on week days and Weekend RN Supervisor on the weekends, to ensure that all daily weights are obtained and properly addressed. This monitor will be documented by the DON during the week and the Weekend RN Supervisor on the weekends, by a Care Plan & Weight Audit check list tool. This monitor will be gathered from the Medication Administration Record [REDACTED] All new orders will be reviewed daily during morning clinical meeting by the Clinical Team consisting of the DON, MDS #1, MDS #2, Medical Records LPN, TCU RN, Social Services Director, and the Dietary Manager during week days and the Weekend RN Supervisor on weekends, to ensure that parameters are being performed and documented properly as ordered. All new orders obtained for daily/weekly weights will be added to the care plan at the time of review during clinical meeting by the clinical team on weekdays and RN supervisor on weekends. All care plans initiated or revised regarding daily/weekly weights will be reviewed daily, to ensure completeness and accuracy by the Clinical Team on weekdays and Weekend RN Supervisor on weekends, to ensure completeness. This monitor will be documented by the DON during the week and the Weekend RN Supervisor on the weekends by a Care Plan & Weight Audit check list tool. This monitor will be gathered from the care plan. 7. The SA validated by interview, record review and sign-in sheet review, that on [DATE], an in-service was initiated by the Director of Nursing and Facility Administrator for all staff members regarding daily weights are to be done on 11:00 PM-7:00 AM in the AM, unless otherwise specified by residents of alternate time. Daily/weekly weights will be reviewed by the Clinical Team consisting of the DON, TCU RN, MDS #1, MDS #2, Medical Records LPN, Dietary Manager, and Social Services Director (SSD) in the clinical meeting every morning during the week. The Weekend RN Supervisor will review the daily/weekly weights on the weekends. The MD/NP will be notified by the TCU Manager during the week and the Weekend RN Supervisor during the weekend of a daily gain of three (3) lbs or a five (5) lb gain within a week. The following staff were present at the in-service: RNs-11 of 11, LPNs-14 of 14, CNAs-28 of 28, Administrator-one (1) of one (1), Therapy Department-34 of 34, Dietary-seven (7) of seven (7) , Housekeeping/Laundry-seven (7) of seven (7), Maintenance Director-one (1) of one (1), Business Office Manager-one (1) of one (1), Marketing Director-one (1) of one (1), Social Service Director-one (1) of one (1), and Life Connections-one (1) of one (1). Review of the employee roster revealed no staff was allowed to work at the facility until in-serviced, which included new hires; this will be monitored by the Facility Administrator. The SA validated through interview and review of care plans, that on [DATE], an in-service was initiated by the Regional Minimum Data Set (MDS) Registered Nurse regarding ensuring residents with [MEDICAL CONDITION] and residents receiving [MEDICAL TREATMENT], should all have weights as ordered included in the plan of care for MDS #1, MDS #2, Medical Records LPN, and the DON. 8. The SA validated that all corrective actions were completed by the facility as of [DATE] and the IJ removed on [DATE], prior to the SA exit.