Every finding on record at The Carrolton of Dunn

Based on observation, record review, and interviews with staff, Hospice Nurse, Hospice Physician, and the Medical Director, the facility failed to prevent a significant medication error when Nurse #4 incorrectly entered a physician order for morphine sulfate (a potent opioid pain medication) oral solution to administer 9.5 milliliters (mL) instead of the ordered 0.5 mL. The medication error resulted in Resident #1 being administered a 19 times greater dose of 190 milligrams (mg) of morphine sulfate oral solution instead of the ordered 10 mg per dose in two separate doses for a total of 380 mg on 8/09/26. Resident #1 exhibited sluggish pupils and moaning after the second 9.5 mL (190 mg) dose of the morphine sulfate and required two doses of Narcan (an emergency medication that reverses the effects of an opioid overdose). The life-threatening doses of morphine sulfate oral solution of 190 mg per dose (administered twice) had the high likelihood to cause serious harm or death. This deficient practice affected 1of 3 residents reviewed for significant medication error (Resident #1). The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses including muscle wasting and atrophy, vascular dementia, and chronic pain syndrome.The care plan last revised on 05/23/2026 indicated that Resident #1 had a care plan in place for chronic pain with interventions that included monitor/document/report as needed (PRN) adverse reactions to analgesic therapy. The care plan also indicated the resident received hospice services. Resident #1's significant change Minimum Data Set (MDS) assessment dated [DATE] indicated that the resident had severe cognitive impairment. Resident #1 was not coded for the use of opioid medication or pain presence. The MDS assessment further indicated the resident's weight was 131 pounds and was coded for hospice services. Resident #1 had a physician order dated 7/27/2026 for morphine sulfate oral solution 100 mg per 5 ml (mg/mL is the amount of milligrams of the active ingredient in every 1 mL of liquid); give 0.5 ml (10 mg) by mouth every 6 hours for pain relief. The order was discontinued on 8/08/2026. The nursing note dated 8/08/26 at 2:31 PM by the DON revealed Hospice Nurse #7 was present in the facility and Resident #1 had nonverbal signs of pain. Verbal orders were received from Hospice Nurse #7 and the Hospice Physician to increase Resident #1's morphine sulfate by 20mg/ml 0.5 mL from every 6 hours to every 4 hours. A physician order dated 8/08/2026 for morphine sulfate oral solution 20 mg/ml; give 0.5 mL (10 mg) by mouth every 4 hours for end-of-life pain/air hunger and PRN (as needed) every 2 hours. The order was created by the Director of Nursing (DON). The Medication Administration Record (MAR) revealed the 10 mg of morphine sulfate was administered to Resident #1 as scheduled on 8/09/2026 at 12:30 AM and 4:30 AM. Resident #1's scheduled doses at 2:30 AM and 6:30 AM were noted as not administered due to resident sleeping. No additional doses were administered and the order was discontinued on 8/09/2026. Resident #1 had a physician order dated 8/09/2026 with a start time of 6:00 AM for morphine sulfate oral solution 20 mg/5 mL; give 9.5 mL by mouth every 4 hours for end-of-life care. The order was created by Nurse #4. The eMAR (electronic Medication Administration Record) integrated pharmacy tool (real-time medication warnings, interaction alerts, and safety notifications used to help staff prevent adverse drug events) populated the following warning notification for the physician order entered by Nurse #4 on 8/09/2026: This order is outside of the recommended dose or frequency. The dosing regimen of 9.5 mL 6 times per day exceeds the usual dosing regimen of 0.125 mL daily to 3.75 mL 12 times per day. The single dose of 9.5 mL exceeds the maximum single dose of 7.5 mL. The usual dosing regimen is 0.125 mL daily to 3.75 mL every 12 hours. Review of the MAR for 8/09/2026 revealed the scheduled dose of morphine sulfate oral solution 9.5 mL was documented as not administered at 6:00 AM due to Resident #1 being asleep. The MAR further revealed the morphine sulfate oral solution 9.5 mL was documented as administered to Resident #1 on 8/09/2026 at 10:00 AM by Nurse #5 and 2:00 PM by Medication Aide (MA)# 7. Review of the vital signs on 8/09/2026 at 2:35 PM revealed the Resident #1's blood pressure was 80/60 (normal range 120/80), respiratory rate was 8 to 10 breaths per minute (normal range is 12 to 20) before the first dose of Narcan was administered. Resident #1's blood pressure and respiratory rate improved after the first emergency dose of Narcan to 90/60 and 12 breaths per minute. After the second emergency dose of Narcan, Resident #1's blood pressure was noted to be 128/80, and the respiratory rate was 14 breaths per minute. The facility incident report dated 8/09/2026 revealed that Resident #1 received the wrong dose of morphine sulfate oral solution concentrate. Resident #1 was noted to have received 9.5 mL (360 mg) of the medication. The facility incident report further noted that the DON, Medical Director and Hospice services were notified of the medication error by Nurse #4 and orders were obtained to administer 2 doses of Narcan. Resident #1 was noted to have improved vital signs, was able to open his eyes, and began grunting after the 2 doses of Narcan were administered. The incident report noted that Resident #1 was put on every 15 minute checks. During an observation and interview on 08/18/2026 at 2:51 PM with the DON, she provided Resident #1's morphine sulfate oral solution bottle which was labeled with a concentration of 100mg/5 mL (20mg/mL). The DON confirmed that Resident #1's doses of the 9.5 mL on 8/09/2026 by Nurse #5 and MA #7 was removed from the bottle that contained the concentration of 100 mg/5 mL of the morphine sulfate oral solution and that each dose contained 190 mg of morphine sulfate.During an interview on 08/18/2026 at 3:00 PM, Nurse #4 reported that on 08/09/2026 she was notified that Resident #1's morphine sulfate order was changed from every 6 hours to every 4 hours but she could not recall who communicated the change to her. Nurse #4 stated she entered an incorrect dose of 9.5 mL instead of the correct dose of 0.5 mL in error. She stated she was unaware of her error, and no staff at the facility had pointed out that the dosage was higher than necessary until approximately 2:30 PM on 8/09/2026 after reporting to work for her 2:00 PM shift. Nurse #4 stated that MA # 7 informed her that Resident #1's morphine sulfate was ordered for 9.5 mL. She stated she was shocked when she realized that although she had made the change, it was not meant to be 9.5 mL, she immediately notified the Director of Nursing (DON) and contacted the Physician. Nurse #4 also added that the Physician ordered the administration of Narcan twice. She stated the resident was sluggish before the Narcan was administered. Nurse #4 acknowledged the mistake and confirmed the morphine was taken from the 100mg/5mL bottle that was in use for the resident which had 190 mg of medication per dose. Nurse #4 stated she did not see the warning instructions when she entered the order for Resident #1's morphine sulfate oral solution. During the interview on 08/18/2026 at 3:18 PM with MA #7 she reported that she was assigned to administer medication to Resident #1 on 8/09/2026 and she noticed that the morphine sulfate dose was 9.5 mL. MA #7 expressed that she was uncomfortable administering this dose of medication at 10:00 AM and informed Nurse #5 (who was responsible for the supervision of MA) of her concerns. MA #7 stated she observed Nurse #5 administer the morphine sulfate at 10:00 AM to Resident #1. She stated she administered the 9.5 mL of morphine sulfate to Resident #1 at 2:40 PM because she had observed Nurse #5 give it earlier and the resident was due for his medication. She stated when Nurse #4 arrived on the unit around 3:00 PM, she informed Nurse #4 about the morphine sulfate dosage being 9.5 mL and Nurse #4 reported she felt it was an excessively high dose. MA#7 stated that Nurse #4 checked the MAR and confirmed the dosage was incorrect for the resident. Nurse #4 then notified the Director of Nursing (DON) and the Medical Director. An interview was conducted on 08/18/2026 at 3:08 PM with Nurse #5 who reported that she was assigned to the resident during the first shift on 08/09/2026. She stated that she noted resident's morphine medication had been increased due to reported pain, but she did not question the amount of the increase. Nurse #5 confirmed she administered the 10:00 AM morphine sulfate 9.5 mL dose to Resident #1, Nurse #5 reported that around 11:00 AM she completed Resident #1's wound treatment and she did not observe any decline in the resident's condition at that time. Nurse #5 mentioned that she was not present at the facility when the Narcan was administered at 2:40 PM because she had left the facility after the end of her shift. During an interview on 08/19/2026 at 11:00 AM, Hospice Nurse #7 reported that facility staff notified her that Resident #1 received an incorrect dose of morphine sulfate, specifically that 9.5 mL was administered. She stated that this dose was more than ordered amount and more than the resident should have received on 08/09/2026. Hospice Nurse #7 indicated that Resident #1's life could have been at risk due to receiving 9.5 mL (190 mg) of morphine sulfate, which exceeded the ordered dosage of 0.5 mL (10 mg). During the telephone interview on 08/19/2026 at 11:25 AM the Hospice Physician stated Hospice Nurse #7 requested an adjustment to Resident #1's morphine sulfate order, as it was not effectively controlling the resident's pain. The Hospice Physician stated he gave a verbal order to increase Resident #1's morphine sulfate order for 0.5 mL from every 6 hours to every 4 hours. The Hospice Physician acknowledged being informed about Resident #1 being administered 9.5 mL which was significantly more than the prescribed 0.5 mL. The Hospice Physician expressed concern that this medication error could be life-threatening for Resident #1. During telephone interview conducted on 08/18/2026 at 12:05 PM with the Medical Director he reported Nurse #4 notified him that 9.5 mL of morphine sulfate (190 mg per dose, 380 mg total) had been administered to Resident #1 in error. The Medical Director stated he ordered two doses of Narcan to be administered to Resident #1. He stated the nurses must exercise extreme caution when administering narcotic medications. The Medical Director further stated that the morphine sulfate dose of 9.5 mL, (reported as a total of 380 mg), was dangerously high and had the potential to cause serious harm, which included death, to Resident #1. During an interview on 08/18/2026 at 12:30 PM with the DON she reported that Nurse #4 informed her of an error made while transcribing the morphine sulfate oral solution medication to the MAR. She clarified that she transcribed the medication correctly; however, the administration times populated incorrectly every 2 hours instead of every 4 hours so when Nurse #4 attempted to change the medication administration times to every 4 hours at 0.5 mL, she mistakenly entered 9.5 mL. The DON stated Nurse #4 called the Medical Director who ordered the Narcan to be administered to Resident #1 when the error was identified on 8/09/2026. The DON expressed her expectation was that staff exercise caution when transcribing residents' medications. The DON stated the facility did not have a process in place at the time of the error, and she was unable to say what went wrong. During the interview on 08/18/2026 at 1:00 PM the Administrator stated an order for Resident #1 was entered by the DON with the incorrect administration times and Nurse #4 inaccurately added the incorrect dosage. The Administrator stated that his expectation was for the nurses to enter the times and dosage of the medications for all residents accurately.The Administrator was notified of Immediate Jeopardy on 08/19/2026 at 1:37PM.The facility provided the following corrective action plan:1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.On 8/8/2026 at 2:21 pm the DON entered an order for Morphine Sulfate (concentrate) oral solution that populated in the electronic medical record with incorrect administration times.On 8/9/2026 at 5:46 am Nurse #4, in an attempt to correct the administration time for the 8/8/2026 (2:21 pm) order, entered an order for Morphine Sulfate (concentrate) oral solution with an incorrect dose.There were two incorrect doses of Morphine Sulfate (concentrate) oral solution administered on 8/9/2026, one dose at 10:00 am for 9.5 ml (190 mg) and one dose at 2:00 pm for 9.5 ml (190 mg). At approximately 2:35 pm on 8/09/2026 Nurse #4 noted that the order she wrote on 8/9/2026 at 5:46 am was entered with an incorrect medication dose. Nurse #4 contacted the Director of Nursing (DON) on 8/9/2026 at 2:40 pm and reported that the order was written incorrectly, and had resulted in two incorrect administrations. Nurse #4 contacted the Medical Director on 8/09/2026 at approximately 2:45 pm after realizing the medication error. Nurse #4 reported to the Medical Director that the resident received two incorrect doses of morphine. During this phone call, Nurse #4 received orders to administer Narcan (2 doses) to the resident. Nurse #4 administered Narcan while the Medical Director remained the phone. The Medical Director gave Nurse #4 an order to hold all narcotics for 24 hours. The facility Registered Nurse (RN), Nurse #4, assessed the resident at approximately 2:55 pm (before Narcan administration) and again after the Narcan administration. The DON contacted the Chief Clinical Officer, the Chief Operating Officer, and the Facility Nurse Consultant on 8/9/2026 at 3:30 pm. The Facility Nurse Consultant went to the building to investigate the incident. At approximately 4:30 PM Nurse #4 reported to the DON that the resident was responding appropriately and his vital signs were within normal limits.Nurse #4 corrected the morphine order in the electronic medical record at approximately 4:30 pm. Nurse #4 contacted Hospice. The Hospice RN came to the facility to assess the resident on 8/9/2026 approximately 5:00 pm. The Facility Nurse Consultant assessed the resident at approximately 6:00 pm and also noted that his vital signs were within normal limits. The Facility Nurse Consultant also reviewed all orders for this resident and verified that they had been entered correctly. Upon further review of the incident, the Facility Nurse Consultant noted that two orders were entered incorrectly in the electronic medical records.On 8/08/26, an order was entered by the DON with the incorrect administration times. The administration times were noted as every two (2) hours instead of every four (4) hours. The medication was held for two doses because the resident was sleeping. The facility Medical Director has a standing order to hold narcotics for sedation or sleeping. In an attempt to correct the error on the 8/08/26 order, Nurse #4 entered the incorrect dose- 9.5 mL (190 mg) as opposed to 0.5 mL (10 mg). This resulted in two medication errors. Narcotics were held for the resident until 8/10/2026. The resident has been monitored closely with continued daily hospice visits. The Facility Nurse Consultant re-educated the DON on 8/09/2026 on medication administration, including reviewing and verifying the accuracy of entered Medication orders for prescribed dosage, medication, route, and frequency. Nurse #4 was re-educated on 8/09/2026 by the Facility Nurse Consultant on medication administration, including reviewing and verifying the accuracy of entered medication orders (including prescribed dosage, medication, route, and frequency). The DON re-educated Medication Aide #7 on 8/09/2026 on medication administration, including verifying any questionable dosage orders with a nurse. The Medication Aide was also instructed to verify with a second nurse if the order is still questionable. Nurse #5 was re-educated by the Facility Nurse Consultant on 8/10/2026 on medication administration, including reviewing and verifying the accuracy of entered Medication orders, including prescribed dosage, and verifying any questionable dosage orders, medication, route, and frequency. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice.Identification of other residents having the potential to be affected was accomplished by:All residents receiving medications have the potential to be affected by medication errors.The DON audited 100% of hospice residents with narcotic medication orders active on 8/10/2026. The audit found no additional medication order errors. The DON reviewed all active narcotic orders against alerts in the electronic medical record. All questionable doses were verified by the consulting pharmacist. On 8/17/2026 this audit was expanded to include all active residents with narcotic orders. On 8/10/2026 the Director of Nursing and Facility Nurse Consultant utilized the audit findings to develop training sessions for licensed nurses and medication aides as part of this plan of correction to prevent significant medication errors. The plan of correction and audit schedules were reviewed in an ad hoc Quality Assessment Performance Improvement (QAPI) meeting on 8/10/2026 and was added to the audit schedule for monitoring by the QAPI team. The team reviewed all findings with the Medical Director on 8/10/2026. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.Nursing personnel, including all Licensed Practical Nurses (LPNs) and Registered Nurses (RNs) received in-service training on proper order entry, modification, and verification of medication orders by the DON on 8/17/2026. Medication Aides were educated on verification of medication orders by the DON on 8/18/2026.This in-service covered the following: Verification of medication, dose, route, frequency, administration time, and resident when entering all medications against the current provider order before finalizing any new or modified medication order. All orders that are entered must be reviewed in their entirety for accuracy prior to completion (nurses only). All new medication orders must be verified by a second nurse. Verification of any questionable dosage orders will be done with the consulting pharmacists.All nursing staff, including LPNs, RNs, and Medication Aides not present for this in-service, will be educated prior to working. The DON will be responsible to ensure that all staff are educated. Newly hired nursing staff, including all LPNs and RNs, will receive training on policies related to order entry, including verifying narcotic orders (including questionable doses) by the Director of Nursing, Assistant Director of Nursing, or RN Supervisor during the orientation process. Newly hired medication aides will receive training on policies for verifying narcotic orders (including questionable doses) by the Director of Nursing, Assistant Director of Nursing, or RN Supervisor during orientation. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.100% of narcotic orders will be audited daily for four (4) weeks by the DON or designee to ensure that orders have been transcribed correctly. Licensed nurses will be immediately re-educated as needed to address any negative findings. The daily audit will be completed by using the orders listing report in the electronic medical record. The audit will include the following:Review of any alerts in the electronic medical record Verify accuracy of order transcriptionEnsure second nurse verification on all medications.All questionable orders will be clarified by the Medical Director or consulting pharmacist. We will utilize the order verification section in the electronic medical record to ensure second nurse verification.The Quality Assurance Performance Improvement (QAPI) committee will review audit records biweekly until consistent, substantial compliance is achieved.Immediate Jeopardy removal date and compliance date: August 18, 2026. The corrective action plan was validated on 08/19/2026 by reviewing the initial audits, monitoring audits, and the education the licensed nursing staff received which included: verification of medication, dose, route, frequency, administration time, and resident when entering all medications against the current provider order before finalizing any new or modified medication order. All orders that are entered must be reviewed in their entirety for accuracy prior to completion (nurses only). All new medication orders must be verified by a second nurse. The licensed nursing staff were able to verbalize the education that was provided. QAPI review was verified to have been completed on 08/10/2026. The immediate jeopardy removal date and compliance date of 08/18/2026 was verified.

Based on record review and staff interviews, the facility failed to provide 8 hours of Registered Nurse (RN) coverage for 2 of 30 days reviewed for staffing (8/30/25 and 8/31/25). The findings included: Review of the facility's daily nurse staffing postings for 8/10/25 through 9/10/25 revealed there was not a RN scheduled for at least 8 hours a day on 8/30/25 and 8/31/25. During an interview with the Director of Nursing (DON) on 9/11/25 at 3:45pm revealed there was no RN coverage in the facility on 8/30/25 and 8/31/25 because the scheduled weekend RN called out. The DON stated she was not notified on either day (8/30/25 and 8/31/25) the RN called out and did not find out the facility had no RN coverage until Monday morning (9/1/25). The DON indicated she knew the facility was required to have 8 hours of RN coverage each day and she expected to be notified when the scheduled RN called out. The Administrator was interviewed on 9/11/25 at 6:28pm and he stated he expected the facility to have a RN coverage 8 hours a day 7 days a week.

Based on record review and staff interviews, the facility failed to provide a Centers for Medicare and Medicaid Services (CMS) Form 10055- Skilled Nursing Facility (SNF) Advanced Beneficiary Notification (ABN) when the facility-initiated discharge from Medicare Part A Services when benefit days were not exhausted. This was for 2 of 3 residents reviewed for beneficiary notice protection (Resident #8 and Resident #68).Findings included:1. Resident #8 was admitted to the facility on [DATE] under Medicare Part A covered skilled services.Resident #8's Medicare Part A covered skilled services ended on 5/30/25. She remained in the facility.A review of Resident #8's medical record revealed no evidence Resident #8 was provided with a CMS SNF-ABN.On 9/11/25 at 5:23 PM an interview with the Business Office Manager (BOM) indicated Resident #8's Medicare Part A covered skilled services began on 5/19/25. She stated when these covered services ended on 5/30/25, Resident #8 had days remaining and had not used all 100 covered days. She stated the resident's discharge was initiated by her insurance company, which sent a CMS NOMNC form via email for the facility to present to the resident. The BOM stated she was not aware a SNF-ABN also needed to be provided. She also stated she was aware of the SNF-ABN form which provided the resident's out-of-pocket cost, but that form was not used at the facility. She reported Resident #8 had remained in the facility.On 9/11/25 at 5:35 PM an interview with the Social Worker (SW) revealed she had not been employed by the facility when Resident #8 was issued the CMS NOMNC form; but the SW employed at that time would have been responsible for providing the CMS NOMNC form to Resident #8 when she was discharged from her Medicare Part A covered services on 5/30/25. The SW reported she had only provided the CMS NOMNC form to a resident and had never provided the CMS SNF-ABN form. She stated for an insurance-initiated discharge, the insurance provider would send a blank CMS NOMNC form via email to be completed by the facility and be provided to a resident. The SW discussed not being aware she was required to provide both a NOMNC and SNF-ABN. She stated she was unaware of the SNF-ABN form which provided a resident with an estimated out-of-pocket cost, but the Business Office would be responsible for providing the out-of-pocket cost to a resident.An interview on 09/11/25 at 6:15 PM with the Administrator revealed he had knowledge of the CMS SNF-ABN and CMS NOMNC forms. He stated his expectation would have been for the appropriate notices to be given to Resident #8. The Administrator stated he was aware of a form which provided a resident with an estimated out-of-pocket cost, but he had not seen the form at this facility.2. Resident #68 was admitted to the facility on [DATE] under Medicare Part A covered skilled services.Resident #68's Medicare Part A covered skilled services ended on 9/5/25. She remained in the facility.A review of Resident #68's medical record revealed no evidence Resident #68 was provided with a CMS SNF-ABN.On 9/11/25 at 5:23 PM an interview with the Business Office Manager (BOM) indicated Resident #68's Medicare Part A covered skilled services began on 8/19/25. She stated when these covered services ended on 9/5/25, Resident #68 had days remaining and had not used all 100 covered days. She stated Resident #68's discharge was initiated by her insurance company, which sent a CMS NOMNC form via email for the facility to present to the resident. The BOM stated she was not aware a SNF-ABN also needed to be provided. She also stated she was aware of the SNF-ABN form which provided the resident's out-of-pocket cost, but that form was not used at the facility. She reported Resident #68 had remained in the facility. On 9/11/25 at 5:35 PM an interview with the Social Worker (SW) revealed she issued the CMS NOMNC form to Resident #68 when she was discharged from her Medicare Part A covered services on 9/5/25. She reported Resident #68's insurance provider initiated her discharge and sent a blank CMS NOMNC form via email to be completed and issued by the facility to Resident #68. The SW discussed not being aware she was required to provide both a NOMNC and SNF-ABN. She stated she was unaware of the SNF-ABN which provided a resident with an estimated out-of-pocket cost, but the Business Office would be responsible for providing the cost estimate to a resident.An interview on 09/11/25 at 6:15 PM with the Administrator revealed he had knowledge of the CMS SNF-ABN and CMS NOMNC forms. He stated his expectation would have been for the appropriate notices to be given to Resident #68. The Administrator stated he was aware of a form which provided a resident with an estimated out-of-pocket cost, but he had not seen the form at this facility.

Based on observations and staff interviews the facility failed to label and date leftover food items and failed to discard food with signs of spoilage in 1 of 1 walk-in cooler and 1 of 1 walk-in freezer. The facility also failed to ensure clean dishes were not stacked wet and ensure dishes that were ready for use were clean for 1 of 2 kitchen observations. These practices had the potential to affect food served to residents.The findings included:a. An initial observation with the Dietary Manager of the kitchen on 09/08/2025 at 11:00 AM revealed the following in the walk-in cooler: Five (5) of the 5 cantaloupes in the walk-in cooler had soft, brown and black spots with white fuzz. Fourteen (14) of the 14 lettuce heads in the walk-in cooler were brown and slimy with spots of white fuzz.b. An initial observation with the Dietary Manager of the kitchen on 09/08/2025 at 11:10 AM revealed the following in the walk-in freezer:One half (1/2) of a two-pound bag of meatballs in the freezer was opened to the air, undated, and had a layer of ice crystals.One half (1/2) of a two-pound bag of French fries in the freezer was opened to the air, undated, and had a layer of ice crystals. One fourth (1/4) of a two-pound bag of peas in the freezer was opened to the air, undated, and had a layer of ice crystals.c. An initial observation with the Dietary Manager of the kitchen on 09/08/2025 at 11:30 AM revealed the following on the tray line:Eleven (11) of 12 clean bowls that were on the tray line ready for use were stacked wet.Two (2) of 3 clean quarter pans that were ready for use were stacked wet.Ten (10) of 10 divided plates that were on the tray line ready for use were stacked wet.Thirty-one (31) of 57 plate covers that were on the tray line ready for use were stacked wet.Seven (7) of 10 divided plates that were on the tray line ready for use had black, yellow, and brown spots on them.Two (2) of 57 plate covers that were on the tray line ready for use had black and brown spots on them. An interview with the Dietary Manager on 09/08/2025 at 11:00 AM stated she had been working in the kitchen for about three months. The Dietary Manager stated the person who washed the dishes was new to his position, and she had educated him that the dishes needed to be dry before they were stacked and that he needed to check the dishes for cleanliness before placing them on the tray line. Furthermore, she stated today (09/08/2025) was the day she went through the kitchen and made sure that everything was dated, and that there was no food spoilage. The Dietary Manager explained she performed this task every Monday. She did not identify if any other dietary staff were responsible for the task of ensuring that the food items were accurately labeled and dated. Additionally, food items that were identified as spoiled would be discarded. The Dietary Manager stated the food items identified during the observation should have been discarded.An interview on 09/11/2025 at 4:41 PM with the Administrator revealed he was told about the concerns identified in the kitchen. The Dietary Manger made him aware of the wet dishes and undated food. The Administrator stated he was unaware of food with signs of spoilage. Furthermore, the Administrator stated he expected the dietary staff to label and date open food items in the walk-in, ensure that clean dishes were stacked dry, and ensure that food with signs of spoilage was properly disposed of.

Based on record review, resident interviews and staff interviews, the facility failed to honor residents the choice to warm meals brought from outside the facility for 3 of 3 residents reviewed for choices (Resident #8, Resident #25 and Resident #5). The findings included: 1a. Resident #8 was admitted to the facility on [DATE]. Her diagnoses included type 2 diabetes mellitus, anxiety disorder, and gastroesophageal reflux disease (GERD). The quarterly Minimum Data Set (MDS) assessment for Resident #8 dated 7/21/25 indicated her cognition was intact, she had no upper extremity impairments and was independent with eating. An interview with Resident #8 on 9/9/25 at 9:10am revealed Resident #8 was upset that she could no longer warm meals brought to her by her family. Resident #8 stated there was a microwave in the dining room where she was able to warm soups and other things her family brought her. Resident #8 stated about a month ago the microwave was removed. She was told by the kitchen staff that they are not allowed to bring personal food items into the kitchen to heat them. Resident #8 indicated she had complained about having no way to heat meals, but she was told it was a safety hazard. Resident #8 revealed she did not like most of the meals or alternative choices served and would just like to be able to heat up a bowl of soup or chili. b. Resident #25 was admitted to the facility on [DATE] with diagnosis including diabetes mellitus. Resident #25's quarterly MDS assessment dated [DATE] revealed she was cognitively intact, had no upper extremity impairments and was able to eat independently with set up from staff. An interview with Resident #25 was conducted during an impromptu Resident Council meeting on 9/10/25 at 3:22pm. Resident #4 stated the facility had removed the microwave from the dining room about a month ago. She had food that was delivered and was unable to microwave the items to heat them. Resident #4 stated she was upset that she had food at the facility she could not eat. c. Resident #5 was admitted to the facility on [DATE] with diagnoses including depression. Resident #5's quarterly MDS assessment dated [DATE] revealed she was cognitively intact, had one upper extremity impairment and was able to eat independently with set up assistance. During an impromptu Resident Council meeting on 9/10/25 at 3:22pm, Resident #5 revealed the facility had removed the microwave from resident use and staff would not heat food for her if it was not prepared by the kitchen. She stated she was no longer able to heat food brought from outside the facility. If she wanted to save something to eat a later time, she would have to eat it cold. Resident #5 stated she did not think it was fair she had to eat what the facility provided since no outside food could be warmed or reheated. An interview completed with Nurse # 7 on 9/11/25 at 10:32am revealed there was no access to a microwave to warm residents' food. Nurse #7 revealed the microwave was once available for residents and residents' family to use, but it had recently been removed. Nurse #7 stated she tried to let family members know there was no access to warm up food bought from outside, but families could bring resident's food to the facility already warmed. Nurse #7 indicated there were residents and family members upset with change. Interview conducted with the Dietary Manager on 9/11/25 at 4:48pm revealed the microwave the residents used had been removed from the dining room. She indicated she was unsure why the microwave was removed she was told by management that it was a safety concern. The Dietary Manager stated she could provide soup served from the kitchen to Resident #8, but Resident #8 could not bring soup purchased outside the facility into the kitchen to warm it. An Interview conducted with the Director of Nursing (DON) on 9/11/25 at 2:13pm revealed the facility policy stated they could not have a microwave due to safety concerns. The DON indicated the microwave was in the dining room but had been removed about a month and a half ago. No residents at the facility suffered injury while operating or using the microwave at the facility. The DON stated the reason the microwave was removed from the dining room was because the facility was unable to monitor the temperature of the food items residents were heating up in the microwave. Removing the microwave would ensure residents did not burn themselves. The DON indicated the facility would get soup brands and preferences from the residents so the kitchen could purchase something comparable to the brand the resident desired. Resident #8 and other residents were upset about not being able to heat foods they purchased. Resident #8's family brought cans of soup for her to warm. Residents had occasionally used the microwave when the facility meal being served, or alternatives weren't to their liking. Residents were upset about not having access to a microwave or being able to heat food brought in from outside sources. The DON further stated the facility had no way of knowing the temperature of microwaved foods after they had been heated. She further revealed the facility had not considered staff heating food items and temping items food items for safety. An interview was conducted with the Administrator on 9/11/25 at 6:28pm. During the interview the Administrator revealed the microwave was removed from the dining room for safety reasons. There were concerns a resident may burn themselves and his understanding was no outside food could be taken into the kitchen to warm or reheat. The Administrator revealed he expected the residents to have choices, but the microwave was removed for safety.

Based on record review and staff interviews, the facility failed to implement their abuse policy and procedure for immediately reporting an allegation of staff to resident physical abuse to the Administrator resulting in the allegation not being reported to the State Agency, local law enforcement, and to Adult Protective Services within the required time frame. Additionally, the initial report did not accurately reflect the date and time the facility became aware of the abuse allegation. This was for 1 of 3 residents reviewed for abuse (Resident #37). The findings included: A review of the facility policy titled Abuse, Neglect and Exploitation, revised 3/20/23 indicated violations needed to be reported to the Administrator, State Agency, Adult Protective Services, and to all required agencies (law enforcement if applicable) immediately but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Resident #37 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37 was cognitively intact. A review of the facility grievances revealed on 8/19/25 the Admissions Director had completed a grievance form after she spoke with Resident #37 who stated, the girl who gave me a bath-she beat me up. Resident #37 stated, she was a black girl, but I don't know her name. She slapped me all in my face and I don't remember her, but she has pearls in her hair. The Admissions Director was interviewed on 9/10/25 at 10:22 am. She stated she had worked late (did not specify a time) on 8/19/25 and when she walked by Resident #37's room the resident called her into her room and told her that on 8/18/25 while taking her shower the Nurse Aide (NA) hit her in the face for no reason. Resident #37 was unable to recall the name of the NA. Admissions Director shared that she did not recall the exact details of what Resident #37 shared with her on 8/19/25. The Admissions Director stated she filled out a grievance form on 8/19/25 and did not report the allegation to nursing staff, Director of Nursing (DON), or Administrator until the morning of 8/20/25 during the morning meeting around 9:30 am when she reported the allegation of abuse to the Administrator. The Admissions Director stated she knew she should have reported the allegation right away but stated it was late and had been a long day. She stated that evening (8/19/25) she had not observed any markings on Resident #37 and didn't think about telling the Administrator at that time. She stated there were no signs of abuse, no bruises, scratches or red marks on 8/19/25. An initial allegation report dated 8/20/25 at 9:35 am, was completed by the Administrator. The initial report documented the facility initially became aware of the allegation of abuse on 8/20/25. The Administrator interviewed Resident #37 on 8/20/25 and the resident reported she was hit in the face by a black lady with pearls in her hair while receiving a bed bath the afternoon of 8/16/25. Resident #37 stated she was hit in the face multiple times, the lady hit her using her fist. The initial report did not indicate Adult Protective services or law enforcement was notified. The initial report was faxed to the State Agency on 8/20/25 at 3:30 pm. The investigation report dated 8/22/25 completed by the Administrator revealed the allegation of staff to resident abuse was unsubstantiated. The investigation report was faxed to the State Agency on 8/22/25 at 7:13 pm. Adult Protective Services (APS) was notified by Administrator on 8/20/25. A review of Resident #37's skin assessment completed on 8/20/25 by Nurse #1 revealed no trauma to her face or issues with her skin other than a dime size pressure spot to Resident #37's right pinky toe. An interview with Nurse #1 was conducted on 09/09/25 at 4:25pm. She stated she completed a skin assessment on the day the Facility Nurse Consultant asked her to do it (she was unable to recall the date). Nurse #1 discussed during the skin assessment she did not observe any concerns on Resident #37's face, no signs of trauma, no redness, bruising, scratches or discoloration. Resident #37's skin was intact. The DON was interviewed on 9/10/25 at 10:45 am. She stated if a resident shared with staff that they had been abused, the staff member should have notified her or the Administrator right away so the facility could report the allegation of abuse to the State Agency in 2 hours. An interview with the Administrator occurred on 9/10/25 at 10:55 am. He stated the Admissions Director notified him of Resident #37's allegation of abuse on 8/20/25 during the morning meeting around 9:00 am. He indicated that the Admissions Director was notified of the allegation of abuse on 8/19/25 and failed to report to him until the next day (8/20/25), which was why the Administrator stated he dated the initial allegation for 8/20/25. He stated he wanted staff to notify him immediately when they became aware of any abuse allegations. The Administrator discussed contacting Adult Protective Services on 8/20/25 but not law enforcement due to no injury to Resident #37.

Based on observation, record review, and staff and resident interviews, the facility failed to treat residents in a dignified manner by failing to knock on doors or ask permission to enter resident rooms for 3 of 8 residents (Resident #2, Resident #10 and Resident #13) reviewed for dignity. The reasonable person concept was applied to this deficiency as individuals have the expectation of a person knocking and identifying themself before entering their room. Findings included: 1. Resident #2 was admitted to the facility on [DATE]. Resident #2's most recent Minimum Data Set (MDS) assessment dated [DATE], a significant change assessment, revealed he was severely cognitively impaired. He was assessed as usually able to understand others and having some distinct words. During an observation on 7/7/25 at 12:01 PM Nurse Aide (NA) #1 entered Resident #2's room without knocking to deliver his lunch tray. During an interview on 7/7/25 at 12:05 PM NA #1 indicated she did not knock or ask permission to enter Resident #2's room. The NA stated she was aware she should do so and could not articulate why she did not. On 7/8/25 at 12:05 PM NA #1 was observed to enter Resident #2's room without knocking to deliver his lunch tray. Attempts to interview Resident #2 were unsuccessful. An interview was conducted with the facility's Wound Nurse on 7/8/25 at 12:10 PM and she stated staff should always knock and introduce themselves when entering a resident's room. During an interview with the Administrator on 7/7/25 at 5:38 PM he stated staff had been trained in resident rights and dignity and stated NA #1 should have knocked and announced herself prior to entering a resident's room. An additional interview was conducted with the Administrator on 7/8/25 at 12:45 PM who stated he personally in-serviced staff on treating residents with dignity and respect since 7/7/25 and was aware NA #1 attended in-services on 7/7/24 and 7/8/25. The Administrator stated the NA should have knocked prior to entering Resident #2's room. 2. Resident #10 was admitted to the facility on [DATE]. Resident #10's most recent Minimum Data Set (MDS) assessment dated [DATE], a quarterly assessment, revealed she was assessed as cognitively intact. During an observation on 7/7/25 at 12:02 PM Nurse Aide (NA) #1 entered Resident #10's room without knocking to deliver her lunch tray. During an interview on 7/7/25 at 12:05 PM NA #1 indicated she did not knock or ask permission to enter Resident #10's room. The NA stated she was aware she should do so and could not articulate why she did not. During an observation on 7/8/25 at 12:06 PM NA #1 entered Resident #10's room without knocking to deliver her lunch tray. On 7/8/25 at 12:09 PM Resident #10 was interviewed and could not state how she felt about staff not knocking on her door prior to entrance and instead wanted to talk about her doll. An interview was conducted with the facility's Wound Nurse on 7/8/25 at 12:10 PM and she stated staff should always knock and introduce themselves when entering a resident's room. During an interview with the Administrator on 7/7/25 at 5:38 PM he stated staff had been trained in resident rights and dignity and stated NA #1 should have knocked and announced herself prior to entering a resident's room. An additional interview was conducted with the Administrator on 7/8/25 at 12:45 PM who stated he personally in-serviced staff on treating residents with dignity and respect since 7/7/25 and was aware NA #1 attended in-services on 7/7/24 and 7/8/25. The Administrator stated NA #1 should have knocked prior to entering Resident #10's room. 3. Resident #13 was admitted to the facility on [DATE]. Resident #13's most recent Minimum Data Set (MDS) assessment dated [DATE], a quarterly assessment, revealed she was assessed as having moderate cognitive impairment. She was assessed as being understood and being able to understand others. During an observation on 7/8/25 at 12:05 PM Nurse Aide (NA) #1 entered Resident #13's room without knocking to deliver her lunch tray. An attempted interview was conducted with Resident #13 on 7/8/25 at 12:15 PM, The resident did not respond to any questions asked. During a previous interview on 7/7/25 at 12:05 PM NA #1 indicated she did not knock or ask permission to enter resident rooms. The NA stated she was aware she should do so and could not articulate why she did not. An interview was conducted with the facility's Wound Nurse on 7/8/25 at 12:10 PM and she stated staff should always knock and introduce themselves when entering a resident's room. An interview was conducted with the Administrator on 7/8/25 at 12:45 PM who stated he personally in-serviced staff on treating residents with dignity and respect since 7/7/25 and was aware NA #1 attended in-services on 7/7/24 and 7/8/25. The Administrator stated the NA should have knocked prior to entering Resident #13's room.

Based on record review, and interviews with staff, therapy staff, and the Physician the facility failed to notify the physician when Resident # 3 experienced a change in status resulting in a decline observed by multiple staff members. Resident # 3 entered the facility for rehabilitation. Therapists and Nurse Aides revealed Resident # 3 was initially making progress in therapy to the degree that she could feed herself, ambulate short distances with therapy in parallel bars or with a quad cane, toilet to the commode, and communicate her needs by gestures. Multiple days prior to a transfer to the hospital, Resident # 3 had declined in functional status and was noted to have symptoms which included dizziness, lightheadedness, nausea, periods of altered responsiveness, change in communication ability, dry mouth, poor oral intake, less urine output, dark stools, and a positive COVID (Coronavirus Disease) test. The physician was not notified of the resident's significant change in status for multiple days although it was documented that therapy had talked with nursing staff about a decline and there was a plan to communicate with the physician or DON to determine why the resident was declining. The physician reported he had not been made aware of the change in condition and decline. If he had been made aware, the physician reported he would have seen the resident, probably ordered stat (right away) blood work, and probably sent her back to the hospital. Resident #3 was transferred to the emergency room on [DATE]. At time of hospitalization Resident # 3 was found to be septic (when an individual's body has an extreme reaction to an infection and which can lead to organ failure) due to her COVID infection. The resident was additionally found to have gastrointestinal bleeding, which resulted in a critical hemoglobin of 4.0 and required three units of blood. The resident was hospitalized in the Intensive Care Unit. The resident's 4/8/25 hospital discharge summary noted the resident had sustained heart injury due to the sepsis. This was for 1 of 3 sampled residents reviewed for acute medical conditions (Resident # 3). Immediate jeopardy began on 3/21/25 when a licensed Physical Therapist identified Resident # 3 had an overall change in status and the physician was not notified. Immediate Jeopardy was removed on 6/6/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity D to ensure education is completed and monitoring systems put in place are effective. The findings included: Record review revealed Resident # 3 was admitted to the facility on [DATE] after being hospitalized on [DATE]. Review of Resident # 3's 3/3/25 hospital history and physical and the resident's 3/8/25 hospital discharge summary revealed the following information. Prior to hospitalization the resident resided independently at home and presented to the hospital on 3/3/25 with slurred speech. While hospitalized the resident underwent an MRI (Magnetic Resonance Imaging) which revealed multiple acute small infarcts (areas of brain damage from a lack of oxygen). The resident was diagnosed with a stroke with right-sided weakness and slurred speech. The discharging physician further noted Resident # 3 needed to be evaluated as an outpatient for chronic blood loss and further gastrointestinal workup would be deferred to the primary care physician. She was also discharged on anticoagulant medications due to her stroke. The resident's 3/8/25 discharge summary also noted the resident had benign hypertension. Review of the facility record revealed an admission nursing note on 3/8/25 at 3:08 PM which noted the resident had a right sided deficit, was awake, alert, oriented to self, and denied any discomfort. Facility physician orders, dated 3/25/25, revealed Resident # 3 was a full code. Occupational Therapy, Speech Therapy, and Physical Therapy were ordered on 3/10/25. Physical Therapist (PT) # 1's notes revealed on 3/10/25 Resident # 3 actively participated with physical therapy. PT # 1 documented the following information regarding the treatment session on 3/10/25. She (PT # 1) directed Resident # 3 to go from a supine (lying) position to a sitting position. The resident transferred with good balance and with bilateral upper extremities and bilateral lower extremities supported. The resident was able to transfer to the toilet with both PT # 1 and an Occupational Therapist present. PT # 1 helped Resident # 3 with trials of transfers with a quad cane and the future plan was to do a trial with the quad cane or hemiwalker (a mobility device for individuals who have limited use of one of their hands) during transfers and ambulation during the next therapy session. According to the record there was one documented visit from the facility physician while the resident resided at the facility on 3/11/25. Within the 3/11/25 physician's progress note, the physician included further diagnoses of thrombocytosis (elevated platelets), cardiomyopathy (disease of the heart muscle), dyslipidemia (elevated cholesterol or fats), and aphasia (loss of ability to express speech clearly or understand). There was no further documentation that the physician saw the resident while she resided at the facility. On 3/11/25 ST (Speech Therapist) # 1 documented the following in a speech therapy progress note, Pt assessed with her lunch meal. Pt [patient] alert and sitting up in her wheelchair. Pt able to feed herself with her left hand for the most part. ST # 1 further noted Resident # 1 consumed 40 percent of her meal before indicating she did not want any more and that she was able to brush her teeth with intermittent minimal assistance. The ST also noted Resident # 3 was receptive to education. On 3/12/25 Physical Therapy Assistant (PTA) # 1 documented multiple treatment modalities in a physical therapy progress note. One included that gait training was begun in the parallel bars, and the resident was able to complete the length of the parallel bars with minimal assistance two times while resting in between. On 3/14/25 PTA # 1 documented in a therapy progress note for the session of 3/13/25 the following information. She (PTA # 1) instructed Resident # 3 in the use of the hemiwalker and quad cane and the resident required minimal to moderate assist due to impulsivity, the need to support her right upper extremity, and balance deficits. The resident was documented as walking 12 feet with both the hemi walker and the quad cane on 3/13/25. The resident was documented as needing minimal assistance for transfers on the session date of 3/13/25. The resident had declined wheelchair mobility because she (the resident) wanted to focus on transfers and gait. Resident # 3's admission MDS (Minimum Data Set) assessment, dated 3/14/25 coded the resident as having unclear speech and was moderately cognitively impaired. She was assessed to need substantial to maximum assistance with bathing, dressing, and hygiene. PTA # 1 documented in a therapy progress note for the session of 3/14/25 the following information. She (PTA #1) had instructed the resident on the proper use of the quad cane because she was not using it properly. The resident had also participated in bean bag tossing, transfers from sitting to standing, and ball kicking. PTA # 1 documented in a therapy progress note for the session of 3/17/25 Resident # 3 needed minimal assistance to transfer to the left and that training was done with a Nurse Aide (NA) to allow for the resident to be toileted by the Nurse Aide. ST #1 documented in a speech therapy progress note for the session of 3/17/25 the following information. Pt [patient] participated with expressive language tasks for simple phrase completion and simple responsive naming tasks with improvement noted. Pt completed tasks with 80% accuracy given min to mod [minimal to moderate] verbal cueing. Pt read simple functional phrases out loud with improved fluency. Pt approximately 75% intelligible when reading simple phrases given moderate cueing [pt wearing glasses for reading task]. Pt alert and up in her wheelchair for po [oral] trials. ST # 1 further noted she educated the resident on swallowing recommendations and the resident was able to participate in solid food trials with minimal improvement in pocketing. Review of weight records revealed on 3/18/25 Resident # 3's weight was documented as 150.3 pounds, which indicated she had gained weight from her documented 3/8/25 admission weight of 147.1. ST # 1 documented in a speech therapy progress note for the session of 3/18/25 the following information. Resident # 3 was dysarthric (difficulty speaking) but she participated with naming common pictured items with 75 % accuracy when given minimal to moderate cueing. Her speech was approximately 75 % intelligible. During the session the resident's right side of her face suddenly started to twitch and Resident # 3 grabbed her face. The physician was notified via nursing. The resident was able to brush her teeth with minimal assistance. The resident was able to drink through a straw without signs of aspiration. ST # 1 was interviewed on 6/3/25 at 3:35 PM and reported the following information. During the first part of Resident # 3's speech therapy she was feeding herself. It was not perfect but all things considered she was doing good. She also had the will to do good. She started to use a divided plate to help with meals. There was a day when the resident had some facial twitching. The resident seemed aware of it and then it went away. The nurse was told about the facial twitching. During the end of therapy, the resident had some general malaise. The date of 3/18/25 was the last date that the resident received speech therapy. ST # 1 reported she was out of work following 3/18/25. On 3/18/25 at 11:20 AM Nurse # 1 completed a SBAR narrative (situation, background, assessment, and recommendation) which noted the following information. Speech therapy had been in with the resident and the resident experiencing twitching to the right side of her face with slower speech than baseline per therapy. Her vitals were within normal limits. The physician was notified and ordered baclofen 10 mg (a muscle relaxer medication) twice per day as needed for spasms. This was the last documented notification to the physician in the narrative nursing notes about a change in the resident's condition prior to 3/25/25. Interview with Nurse # 1 on 6/4/25 at 3:50 PM revealed the only thing she was aware of on 3/18/25 was that the resident had some twitching. She had talked to the physician and the physician thought the twitching was related possibly to residual effects of her stroke. Nurse # 1 reported she did not see any further change in the resident on 3/18/25. On 6/4/25 at 2:00 PM Nurse # 2 entered a late entry into the nursing notes for the date of 3/20/25 at 3:52 PM which read, Therapist brought resident back to room saying resident unable to participate. No [mechanical lift pad] under resident. Assist X 3 to bed. Assist X 2 to get situated in bed. VS WNL [vital signs within normal limit] for resident bed low. Call light in reach. PTA # 1 documented in a therapy progress note for the session of 3/20/25 the following information. Resident # 3 was brought to the gym for therapy and while working on transfers, PTA # 1 documented, With each attempt (2 attempts made) patient required increased assist. When asking patient about what was wrong patient noted to not be attempting to verbalize as per her usual. When asked if she felt bad patient nodded yes. When asked if she was hurting anywhere patient again nodded yes. When asked where she was hurting patient put left had [as written] to her head. Immediately returned patient to her room and informed nursing. Patient became less responsive and was assisted to bed with dependent assist. Patient placed in supine and hall nurse and DON (Director of Nursing) assessed patient. Later in day patient noted to not be in bed and this therapist was informed she was in WC [wheelchair] with activities for bingo. Still later found patient in her room slumped with head back and eyes open, partially responsive. Returned patient to bed with max/dep [maximum dependent] assist and notified nursing. Spoke with activities who stated patient was sitting with head back during activities and said she wanted to go back to bed so she was pushed to her room and call bell activated. PTA # 1 was interviewed on 6/3/25 at 4:22 PM and reported the following information. The first few days when Resident # 3 resided at the facility, she was making progress. She could walk with help and had some really, really good days. She also could get her point across with gestures and she communicated with staff in that manner. Then one day she had a big change. She stopped trying to gesture and stopped trying to verbalize. She started to need a lot more assistance in therapy with transfers. She (PTA #1) had reported this to the nursing staff. Review of a facility investigative file regarding the care Resident # 3 had received while at the facility revealed Nurse # 2 had cared for Resident # 3 on the day of 3/20/25. Additionally, the file noted Nurse # 2 had cared for Resident # 3 on 3/17/25, 3/19/25, 3/20/25 and 3/24/25. Nurse # 2's signed 3/26/25 statement read in part, In my opinion [Resident # 3] was a candidate for hospice. [Resident # 3] was unable to speak, she moaned and pointed a lot. Nurse # 2 was interviewed on 6/4/25 at 3:40 PM and reported the following information. She did not routinely work with Resident # 3 and only recalled working with Resident # 3 twice. The resident always seemed to be in bed and not doing well when she cared for her. Nothing had ever been communicated to her (Nurse # 2) that the resident had been making progress in therapy and had been walking in therapy. She recalled a therapist one day saying the resident could not participate in therapy, and she wondered, given what she knew about the resident, why therapy had the resident out of bed. The nurse reported there had been some communication breakdown because if she had known the resident had in recent weeks been able to walk with a quad cane she would have had her sent out to the hospital. She validated she had not called the physician on 3/20/25. On 3/21/25 licensed PT # 1 documented the following, PT [Physical Therapist] completes progress note with patient today. Patient found in supine with appearance that she is ready to get up. PT directs patient in rolling L & R [left and right] to finish putting pants on. Patient requires mod A [moderate assist] to roll to L side and CGA cues [contact guard assist cues] for rolling to R side. PT directs patient in 2X supine < >EOB (Edge of Bed) transfers with max A [maximum assistance] and cues with both attempts patient reporting dizziness, lightheadedness, nausea, and overall not feeling well. PT takes BP [blood pressure], during second attempt noting it to be 118/60 in seated from 132/58 in supine at rest. PT notes this to be a mild decrease in BP, however not enough to be considered orthostatic hypotension. PT discusses this change in BP with nurse and overall change in status from admission. Nurse plans to pass the message along to DON and/or doctor for potential further workup on why patient is declining in functional status & overall feeling. Patient is only able to respond to questions with head nocks/shakes [as written] for yes/no questions. PT # 1 was interviewed on 6/3/25 at 4:10 PM and reported the following information. When Resident # 3 was initially admitted , she and the Occupational Therapist conducted their initial evaluations together. The resident was able to go to the bathroom with moderate assistance. In therapy she began walking with a quad cane. In her progression of therapy, the resident went up and did really well and then went down. In the beginning of therapy, the resident could shake her head yes and no to communicate. She was doing better with communication near the beginning. Near the end of her stay she was minimally communicating. She went from transferring and walking with the quad cane to being totally dependent for transfers near the end of her stay. It had been Nurse # 1 who had been in the room on the day that the resident's blood pressure was taken and dropped. Nurse # 1 (who was assigned to care for Resident # 3 on 3/21/25) was interviewed on 6/4/25 at 3:50 PM and reported the following information. She knew Resident # 3 had a major stroke when she was admitted to the facility and had always had right sided neglect (where a person's awareness of one side of their body is impaired after a stroke). She seemed to be the same the times she took care of her, and it had never been communicated to her that the resident could stand, pivot, and was progressing with therapy soon after admission. She did not ever witness that herself. She did not recall therapy talking to her about changes or problems. She had not called the physician. If she had known the resident had previously in therapy been doing more for herself to the degree that she could stand and pivot, then she would have for sure called the physician. At times therapy also communicated with the Unit Manager about things. The Unit Manager was interviewed on 6/5/25 at 11:22 AM and reported she was not aware of a change in condition for Resident # 3 and had not notified the physician. The DON (Director of Nursing) was interviewed on 6/5/25 at 4:00 PM. The DON reported the following. She only recalled one time when a change in condition had been mentioned to her about Resident # 3 and that was regarding the twitching the resident had on 3/18/25. She (the DON) knew physician orders were obtained for that and she was not aware of the resident's decline. Therefore, she had not communicated with the physician since it had not been made clear to her. On 3/22/25 a Point of Care Testing Result for COVID showed Resident # 3 tested positive for a COVID infection. On the form, the resident was checked as having no symptoms. On 3/22/25 at 11:20 AM Nurse # 1 documented she had called and talked to Resident # 3's responsible party and that the resident's vitals were stable. The resident had left sided neglect, had difficulty swallowing, was pocketing food, and she was receiving therapy services. On 3/22/25 at 6:02 PM the Unit Manager documented, Writer called first Emergency contact and informed her of resident testing positive for COVID received verbal consent to start antiviral medication. Record review revealed no notation in the progress notes or on the COVID test result that the physician was notified of the resident testing positive for COVID on 3/22/25. On 6/4/25 at 2:15 PM the Administrator, DON, Nurse Consultant, and Chief Clinical Officer were interviewed and reported the following information. The Administrator reported they had an outbreak of COVID on 3/18/25 and Resident # 3 did not test positive until 3/22/25. When residents tested positive, there was a procedure that the Unit Manager was supposed to contact the physician and determine if he wanted them to receive antiviral treatment. They could not find in the record that was done. The Unit Manager was interviewed on 6/5/25 at 11:22 AM and reported the following information. There was a lot that happened during the outbreak, and she could not recall for sure whether she had contacted the physician and what he said about Resident # 3 having COVID. On 3/23/25 OTA# 1 (Occupational Therapist Assistant) documented Resident # 3 was unable to follow commands, utilize utensils, or engage in self-feeding in any manner without total assistance. OTA # 1 further noted, Pt appeared dehydrated. Pt (patient) able to utilize straw for sucking for brief period and did not react to bringing drink or food to mouth. Collaborated with nursing regarding PO [oral] intake to improve therapeutic potential, however Pt (patient) unable to engage in meal task at this time. OTA # 1 was interviewed on 6/5/25 at 9:30 AM and reported the following. She could not recall specific details of who she had talked to in nursing or working with Resident # 3 on 3/23/25. She would not have written the resident appeared dehydrated unless the resident's mouth was dry or the resident did not pass the skin pinch test. (A test to assess hydration and skin elasticity by seeing how quickly the skin returns to its normal position when pinched and released) On 3/23/25 at 3:24 PM Nurse # 1 documented the following in a nursing note. Resident # 3 continued with right-sided neglect and her right side was flaccid. The resident was moving her left side, but without purposeful movements. The resident would look when spoken to and her eyes would drift towards the left side. Her vitals were stable and she was not in apparent distress. On 3/23/25 at 8:23 PM Nurse # 1 noted, correction R sided neglect. On 3/24/25 COTA # 2 (Certified Occupational Therapist Assistant) wrote, Pt very lethargic. Required max cues to maintain alertness and participate. Pt was dependent for all tasks. Licensed Occupational Therapist # 1 was interviewed on 6/3/25 at 3:53 PM and reported the following. The resident could stand and pivot at the start of her therapy treatment. She would make eye contact and try to tell the staff things when she first started therapy. The therapy staff noticed a distinct change a few days before she was discharged from the facility. She was not functioning per her normal and was not as alert. This had been communicated to the nurses, but the licensed OT could not recall which nurses had been told. Review of a facility investigative file regarding the care Resident # 3 had received while at the facility revealed Nurse Aide (NA) #1 had cared for Resident # 3 on the dates of 3/10/25, 3/11/25, 3/15/25, 3/16/25, 3/18/25, 3/19/25, 3/24/25, and 3/25/25. Review of NA # 1's signed 3/26/25 statement in the investigative file revealed in part the following information. When [Resident # 3] first arrived at the facility [Resident # 3] was unable to verbalize her needs; she used her hands and head to communicate. [Resident # 3] needed assistance with feeding. As a few days went by she was getting up in her wheelchair and was able to feed herself. I noticed a change in condition on approximately 3/18/25, [Resident # 3] was acting differently having facial twitching. I noticed [Resident # 3] eating less and [Resident # 3] was unable to sit up in a wheelchair like she had been doing previously. I notified the hall in the change of condition (as written), not sure which nurse was working that day. The nurse went into the room and assessed [Resident # 3]. NA # 1's statement specifically included information about the date of 3/24/25 which read, On 3/24/25 I noticed [Resident # 3] was placing her hands in her brief, pulling off her clothes and at lunch, [Resident # 3] had pulled her lunch tray off of the over the bed table into the bed. [Resident # 3] was also staring off into space and moaning, but unable to verbalize if anything was wrong when she was asked. I reported the changes to the hall nurse [Nurse # 2]. [Nurse #2] went into the room and assessed [Resident # 3]. NA # 1 was interviewed on 6/3/25 at 2:40 PM and reported the following information. When Resident # 1 was admitted the resident worked with therapy and could sit up all day in her wheelchair. She could eat and drink with her good hand. She could pivot to the toilet and have a bowel movement. She could communicate by motioning for her needs. Prior to Resident # 3 testing positive for COVID there was a day when she (NA # 1) had observed Resident # 3 slumped over in her wheelchair. The resident's head was bent over near her knees, and she was almost ready to hit the floor. She (NA # 1) recalled she obtained the assistance of NA # 2 and they lifted the resident back to bed. The resident was limp and seemed out of it. At some point after that episode, she (NA #1) recalled Resident # 3 started to twitch. It was not just in her face but at times her shoulder would move up and down with the twitching. The twitching continued but was better some days than other days. The resident would stare off in space and not eat. She seemed to have less urine in her brief. She (NA #1) changed her about two times per shift. The resident would put her hand in her brief. Prior to the change that she (NA #1) noticed, the resident seemed to be cold in nature. After the change, Resident # 3 would snatch off her clothes. NA # 2 was interviewed on 6/3/25 at 2:52 PM and reported the following information. She was the Lead NA and helped everywhere. She did recall there was a day when she had helped NA # 1 get Resident # 3 back to bed because the resident was slouching and it seemed like she could not sit up. That was new for Resident # 3 and she did not seem herself. Review of a facility investigative file regarding the care Resident # 3 had received while at the facility revealed NA # 3 had cared for Resident # 3 on the dates of 3/13/25, 3/14/25, 3/17/25, 3/20/25, 3/22/25, and 3/23/25. Review of NA # 3's 3/26/25 signed statement in the investigative file revealed in part the following information. When [Resident # 3] first arrived at the facility [Resident # 3] would attempt to communicate utilizing paper, [Resident # 3] was unable to communicate verbally. After [Resident # 3] was diagnosed with COVID her condition changed. [Resident # 3] started placing hand in her brief, staring off in to space, taking off her clothes and twisting and turning in the bed. NA # 3 further added in her statement that she had worked the weekend of 3/22/25 and 3/23/25 with Resident # 3. She had not noted a difference in the resident's urination or bowels, but the resident did not eat or drink much either day which NA # 3 noted was a change when compared to before the time the resident had COVID. NA # 3 was interviewed on 6/3/25 at 9:22 AM and reported the following information. When Resident # 3 was admitted the resident had worked with therapy and she (NA # #3) had watched the therapist use the gait belt and take Resident # 3 to the bathroom. She (NA # 3) learned to do this from the therapist, and Resident # 3 could stand and pivot to the wheelchair and then stand and pivot to the toilet. The resident made attempts to communicate with paper with her family. The resident would get up for meals and progressed to the point where she could feed herself. After the resident got COVID she did a complete 360 and changed. She would look off into space. When she (NA #3) helped turn the resident in bed, the resident would swing her arms as if falling. She would rip her brief off her body and dig in her brief. She had to be fed and did not eat or drink much. Her mouth looked dry as if she had a film over it. She (NA # 3) would tell the nurses she worked with that this person is not right. She recalled Nurse # 1 saying that Resident # 3 was declining. Review of a facility investigative file regarding the care Resident # 3 had received while at the facility revealed NA # 4 had cared for Resident # 3 on the dates of 3/20/25, 3/21/25, and 3/24/25 during the 3:00 PM to 11:00 PM shift. Review of NA # 4's signed 3/25/25 statement in the investigative file revealed in part the following information. I'm not real familiar with [Resident # 3] due to the fact I only worked with [Resident # 3] on a few occasions. I attempted to feed [Resident # 3] and get [Resident # 3] to drink something the days I was assigned to [Resident # 3] but [Resident # 3] would refuse. I was in the room when a therapist stated they had attempted to get [Resident # 3] to eat and drink but were unable to get [Resident # 3] to do either. When I provided incontinent care [Resident # 3] had urinated a small amount. I do recall that [Resident # 3] had a small bowel movement that was noted to be black in color. I do not recall foul odors; I do remember her placing her hands in her brief and picking at the brief. I do recall [Resident # 3] would throw her pillows on the floor consistently. [Resident # 3] would constantly stare at the ceiling. Family member came in on 3/24/25 asking about how much [Resident # 3] was eating. I informed family member that she didn't' eat dinner for you [as written]. Family went to [Nurse # 2] asked [Nurse # 2] about how much [Resident # 3] had eaten on 3/24/25. The family member seemed concerned and confused. NA # 4 was interviewed on 6/3/25 at 3:06 PM and reported the following information. She did not know how Resident # 3 had been when she first arrived at the facility. When she cared for her, the resident would stare off distantly and seemed fixated on the ceiling. She (NA # 4) could not get her to focus. It was very noticeable that she would pick at her brief. There was one day when the therapist was in the room and the resident would not swallow. When the resident had a dark stool, she (NA #4) thought that the resident was possibly on iron and she did not notice blood or a foul odor with the stool. There was no documentation in the record of the physician being notified the resident was not eating, staring off distantly, would not focus, was having dark bowel movements while also exhibiting these symptoms. Review of a facility investigative file regarding the care Resident # 3 had received while at the facility revealed NA # 5 had cared for Resident # 3 on the 11:00 PM shift to 7:00 AM shift on 3/15/25, 3/16/25, 3/17/25, 3/19/25, 3/20/25, 3/21/25, 3/24/25. Review of NA # 5's signed statement in the investigative file revealed the following information. I worked 3rd shift I never observed [Resident # 3] eating or drinking but food/snacks were in her room. [Resident # 3] never communicated with me or used her call light while I was working. [Resident # 3] was incontinent and did not urinate or have a lot of bowel movements. [Resident # 3] moved around a lot in bed, moved her legs, removed her bed covers, removed her brief and would throw her pillow on the floor. On 3/24/25, I noticed around [Resident # 3's] mouth that it was dry. During incontinent care [Resident # 3] had a dark, almost black bowel movement on the morning of 3/25/25. At approximately 5:15 AM while providing incontinent care I noticed a rattling sound in her throat, that I had not heard before, I notified [Nurse # 5] and [Nurse #6] . I witnessed [Nurse # 5] go into [Resident # 3's] room for approximately 2-3 minutes. I did not go back into the room again before the end of my shift. NA # 5 was interviewed on 6/3/25 at 11:20 PM and reported the following information. When she cared for Resident # 3 the resident would be awake at night. She would move her legs back and forth and she always appeared that way when she had cared for her. On the last night she had cared for Resident # 3, she (NA # 5) had been in the room at 5:15 AM and could hear a rattle in the resident's throat while standing at her bedside. The resident had her eyes open but she would not respond. She saw Nurse # 5 go into the resident's room after she reported the rattle. She (NA # 5) did not go back in the room after the nurse went to check on the resident. Nurse # 5 was interviewed on 6/3/25 at 11:12 PM and reported she had not been assigned to Resident # 3, was not aware of a change in the resident, and did not call the physician. Nurse # 6 had cared for Resident # 3 on the shift which began at 7:00 PM on 3/24/25 and ended at 7:00 AM on 3/25/25. Nurse # 6 reported the following. She had not called the physician when Resident # 3 was observed rattling on the night shift. She did not recall this being reported to her or any other change that warranted a phone call to the physician prior to the dayshift staff coming on duty on 3/25/25. That was when the dayshift Nurse Aide (NA # 1) reported the resident was not right and she had been telling the nurses on daysh[TRUNCATED]

Based on record review and interviews with staff, responsible party (RP), therapy staff, and the Physician, the facility failed to obtain labs as directed by the physician and ensure staff effectively communicated amongst themselves in order that a change in condition be recognized by the licensed nursing staff and a resident receive evaluation and necessary medical treatment. Resident # 3 entered the facility for rehabilitation. Therapists and Nurse Aides revealed Resident # 3 was initially making progress in therapy to the degree that she could feed herself, ambulate short distances with therapy in parallel bars or with a quad cane, toilet to the commode, and communicate her needs by gestures. Days prior to a hospital discharge, Resident # 3 had a decline in functional status that included symptoms of dizziness, lightheadedness, nausea, and periods of altered responsiveness. Following this decline, Resident # 3 tested positive for COVID (Coronavirus Disease) on 3/22/25 with no indication of evaluation or treatment for her decline and COVID infection. Following 3/22/25, the resident had a poor appetite, her mouth appeared dry, she would stare off in space, and not focus on staff. The resident did not receive evaluation and medical treatment to treat her change in condition until she was transferred to the hospital on 3/25/25 where she was found to be septic (when an individual's body has an extreme reaction to an infection, and which can lead to organ failure) due to her COVID infection. The resident was additionally found to have gastrointestinal bleeding, which resulted in a critical hemoglobin of 4.0 (normal 12-16) and required three units of blood. The resident was hospitalized in the Intensive Care Unit. The resident's 4/8/25 hospital discharge summary noted the resident had sustained heart injury due to the sepsis. This was for 1 of 3 sampled residents reviewed for professional standards of practice to address a change in medical condition (Resident # 3). Immediate jeopardy began on 3/21/25 when a significant decline in Resident #3's condition was identified and a comprehensive evaluation was not conducted and treatment was not implemented. Immediate Jeopardy was removed on 6/6/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity D to ensure education is completed and monitoring systems put in place are effective. The findings included: Review of Resident # 3's 3/3/25 hospital history and physical and the resident's 3/8/25 hospital discharge summary revealed the following information. Prior to hospitalization the resident resided independently at home and presented to the hospital on 3/3/25 with slurred speech. While hospitalized the resident underwent an MRI (Magnetic Resonance Imaging) which revealed multiple acute small infarcts (areas of brain damage from a lack of oxygen). The resident was diagnosed with a stroke with right-sided weakness and slurred speech. At the time of the 3/8/25 hospital discharge the resident's physical exam showed left sided facial deviation (drooping), right upper extremity strength of 2 out of 5, right lower extremity strength of 5 out of 5 and left upper and left lower extremity strength of 5 out of 5 (five indicating normal strength against gravity and resistance whereas 2 representing a degree of impairment in muscle strength). Discharge medications included Plavix 75 milligrams (mg) every day for 41 doses (an anticoagulant), Lovenox 40 mg injection for 13 days (an anticoagulant), and Aspirin 81 mg every day for 17 doses. Resident # 3 was also identified to have microcytic, hypochromic anemia (a general term for anemia when the red blood cells are pale) with no evidence of acute blood loss. The resident's Hgb and Hct (hemoglobin and hematocrit) were documented to be stable at time of her 3/8/25 discharge. The discharging physician further noted Resident # 3 needed to be evaluated as an outpatient for chronic blood loss and further gastrointestinal workup would be deferred to the primary care physician. The resident's 3/8/25 discharge summary also noted the resident had benign hypertension. Resident # 3 was admitted to the facility on [DATE] with diagnoses of stroke, anemia, and hypertension. An admission nursing note on 3/8/25 at 3:08 PM noted the resident had a right sided deficit, was awake, alert, oriented to self, and denied any discomfort. Physician orders revealed Resident # 3 was a full code. Occupational Therapy, Physical Therapy, and Speech Therapy were ordered on 3/10/25. Resident # 3's care plan initiated on 3/10/25 indicated the resident had a self-care deficit related to weakness, deconditioning, and mobility limitations related to her stroke. The care plan noted Resident # 3 would receive therapy. There were also directions on the care plan to monitor/document as needed any changes and any potential for improvement, reasons for self-care deficit, expected course and declines in function. Physical Therapist (PT) # 1's notes revealed on 3/10/25 Resident # 3 actively participated with physical therapy. PT # 1 documented the following information regarding the treatment session on 3/10/25. She (PT # 1) directed Resident # 3 to go from a supine (lying) position to a sitting position. The resident transferred with good balance and with bilateral upper extremities and bilateral lower extremities supported. The resident was able to transfer to the toilet with both PT # 1 and an Occupational Therapist present. PT # 1 helped Resident # 3 with trials of transfers with a quad cane and the future plan was to do a trial with the quad cane or hemi-walker (a mobility device for individuals who have limited use of one of their hands) during transfers and ambulation during the next therapy session. According to the record there was one documented visit from the facility physician while the resident resided at the facility on 3/11/25. Within the 3/11/25 physician's progress note, the physician included further diagnoses of thrombocytosis (elevated platelets), cardiomyopathy (disease of the heart muscle), dyslipidemia (elevated cholesterol or fats), and aphasia (loss of ability to express speech clearly or understand). The physician noted the plan was to complete labs which included a complete blood count, a thyroid stimulating hormone, Vitamin B 12 level, Vitamin D level, folate, liver panel, basic metabolic panel, and c-reactive protein. The physician's plan also included therapy and the resident's prognosis was documented as fair. Review of the facility record revealed no orders for the lab work the physician had documented in the plan in the 3/11/25 progress note were entered into the computer and they were never completed while the resident resided at the facility. Interview with Resident # 3's Physician on 6/4/25 at 5:50 PM revealed he made rounds with the nurses, instructed nurses to read his notes, and follow the directions in his notes. According to the Physician, the labs noted in the 3/11/25 physician note should have been done. On 3/11/25 PTA (Physical Therapy Assistant) # 1 documented a care plan was held with the resident, family, social worker, and that the family's plan was that Resident # 3 go home with family after therapy and discharge. On 3/11/25 ST (Speech Therapist) # 1 documented the following in a speech therapy progress note, Pt [Patient] assessed with her lunch meal. Pt alert and sitting up in her wheelchair. Pt able to feed herself with her left hand for the most part. ST # 1 further noted Resident # 1 consumed 40 percent of her meal before indicating she did not want any more and that she was able to brush her teeth with intermittent minimal assistance. The ST also noted Resident # 3 was receptive to education. On 3/12/25 PTA # 1 documented multiple treatment modalities in a physical therapy progress note. One included that gait training was begun in the parallel bars and the resident was able to complete the length of the parallel bars with minimal assistance two times while resting in between. On 3/14/25 PTA # 1 documented in a therapy progress note for the session of 3/13/25 the following information. She (PTA # 1) instructed Resident # 3 in the use of the hemi-walker and quad cane and the resident required minimal to moderate assist due to impulsivity, the need to support her right upper extremity, and balance deficits. The resident was documented as walking 12 feet with both the hemi-walker and the quad cane on 3/13/25. The resident was documented as needing minimal assistance for transfers on the session date of 3/13/25. The resident had declined wheelchair mobility because she (the resident) wanted to focus on transfers and gait. Resident # 3's admission MDS (Minimum Data Set) assessment, dated 3/14/25 coded the resident as having unclear speech and was moderately cognitively impaired. She was assessed to need substantial to maximum assistance with bathing, dressing, and hygiene. PTA # 1 documented in a therapy progress note for the session of 3/14/25 the following information. She (PTA #1) had instructed the resident on the proper use of the quad cane because she was not using it properly. The resident had also participated in bean bag tossing, transfers from sitting to standing, and ball kicking. PTA # 1 documented in a therapy progress note for the session of 3/17/25 that Resident # 3 needed minimal assistance to transfer to the left and that training was done with a Nurse Aide (NA) to allow for the resident to be toileted by the Nurse Aide. ST #1 documented in a speech therapy progress note for the session of 3/17/25 the following information. Pt participated with expressive language tasks for simple phrase completion and simple responsive naming tasks with improvement noted. Pt completed tasks with 80% accuracy given min to mod [minimal to moderate] verbal cueing. Pt read simple functional phrases out loud with improved fluency. Pt approximately 75% intelligible when reading simple phrases given moderate cueing (pt wearing glasses for reading task). Pt alert and up in her wheelchair for po [oral] trials. ST # 1 further noted she educated the resident on swallowing recommendations and the resident participated with eating solid food with minimal improvement in pocketing food. Review of weight records revealed on 3/18/25 Resident # 3's weight was documented as 150.3 pounds, which indicated she had gained weight from her documented 3/8/25 admission weight of 147.1. ST # 1 documented in a speech therapy progress note for the session of 3/18/25 the following information. Resident # 3 was dysarthric (difficulty speaking) but she participated with naming common pictured items with 75% accuracy when given minimal to moderate cueing. Her speech was approximately 75% intelligible. During the session the resident's right side of her face suddenly started to twitch and Resident # 3 grabbed her face. The physician was notified via nursing. The resident was able to brush her teeth with minimal assistance. The resident was able to drink through a straw without signs of aspiration. ST # 1 was interviewed on 6/3/25 at 3:35 PM and reported the following information. During the first part of Resident # 3's speech therapy she was feeding herself. It was not perfect but all things considered she was doing good. She also had the will to do good. She started to use a divided plate to help with meals. There was a day when the resident had some facial twitching. The resident seemed aware of it and then it went away. The nurse was told about the facial twitching. During the end of therapy, the resident had some general malaise (general feeling of being unwell). The date of 3/18/25 was the last date that the resident received speech therapy. ST # 1 reported she was out of work following 3/18/25. On 3/18/25 at 11:20 AM Nurse # 1 completed a SBAR narrative (situation, background, assessment, and recommendation) which noted the following information. Speech therapy had been in with the resident and the resident experiencing twitching to the right side of her face with slower speech than baseline per therapy. Her vitals were within normal limits. The physician was notified and ordered baclofen 10 mg (a muscle relaxer medication) twice per day as needed for spasms. Interview with Nurse # 1 on 6/4/25 at 3:50 PM revealed the only thing she was aware of on 3/18/25 was that the resident had some twitching. She had talked to the physician and the physician thought the twitching was related possibly to residual effects of her stroke. Nurse # 1 reported she did not see any further change in the resident on 3/18/25. PTA # 1 documented in a therapy progress note for the session of 3/20/25 the following information. Resident # 3 was brought to the gym for therapy and while working on transfers, PTA # 1 documented, With each attempt (2 attempts made) patient required increased assist. When asking patient about what was wrong patient noted to not be attempting to verbalize as per her usual. When asked if she felt bad patient nodded yes. When asked if she was hurting anywhere patient again nodded yes. When asked where she was hurting patient put left had [as written] to her head. Immediately returned patient to her room and informed nursing. Patient became less responsive and was assisted to bed with dependent assist. Patient placed in supine and hall nurse and DON [Director of Nursing] assessed patient. Later in day patient noted to not be in bed and this therapist was informed she was in WC [wheelchair] with activities for bingo. Still later found patient in her room slumped with head back and eyes open, partially responsive. Returned patient to bed with max/dep [maximum dependent] assist and notified nursing. Spoke with activities who stated patient was sitting with head back during activities and said she wanted to go back to bed so she was pushed to her room and call bell activated. PTA # 1 was interviewed on 6/3/25 at 4:22 PM and reported the following information. The first few days when Resident # 3 resided at the facility, she was making progress. She could walk with help and had some really, really good days. She also could get her point across with gestures and she communicated with staff in that manner. Then one day she had a big change. She stopped trying to gesture and stopped trying to verbalize. She started to need a lot more assistance in therapy with transfers. She (PTA #1) had reported this to the nursing staff. On 6/4/25 at 2:00 PM Nurse # 2 entered a late entry into the nursing notes for the date of 3/20/25 at 3:52 PM which read, Therapist brought resident back to room saying resident unable to participate. No [mechanical lift pad] under resident. Assist X 3 [assistance of 3 persons] to bed. Assist X 2 to get situated in bed. VS WNL [vital signs within normal limits] for resident Bed low. Call light in reach. Review of a facility investigative file regarding the care Resident # 3 had received while at the facility revealed Nurse # 2 had cared for Resident # 3 on the day of 3/20/25. Additionally the file noted Nurse # 2 had cared for Resident # 3 on 3/17/25, 3/19/25, 3/20/25 and 3/24/25. Nurse # 2's 3/26/25 signed statement included, In my opinion [Resident # 3] was a candidate for hospice. [Resident # 3] was unable to speak, she moaned and pointed a lot. Nurse # 2 was interviewed on 6/4/25 at 3:40 PM and reported the following information. She did not routinely work with Resident # 3 and only recalled working with Resident # 3 twice. The resident always seemed to be in bed and not doing well when she cared for her. Nothing had ever been communicated to her (Nurse # 2) that the resident had been making progress in therapy and had been walking in therapy. She recalled a therapist one day saying the resident could not participate in therapy, and she wondered, given what she knew about the resident, why therapy had the resident out of bed. The nurse reported there had been some communication breakdown because if she had known the resident had in recent weeks been able to walk with a quad cane she would have had her sent out to the hospital. Nurse #2 indicated she never recalled a nurse aide telling her Resident #3 had a change in condition. On 3/21/25 there was no narrative nursing progress notes. On 3/21/25 PT # 1 documented the following, PT completes progress note with patient today. Patient found in supine with appearance that she is ready to get up. PT directs patient in rolling L & R [left and right] to finish putting pants on. Patient requires mod A (moderate assist) to roll to L side and CGA cues [contact guard assist cues] for rolling to R side. PT directs patient in 2 X supine < >EOB (Edge of Bed) transfers with max A [maximum assistance] and cues with both attempts patient reporting dizziness, lightheadedness, nausea, and overall not feeling well. PT takes BP [blood pressure], during second attempt noting it to be 118/60 in seated from 132/58 in supine at rest. PT notes this to be a mild decrease in BP, however, not enough to be considered orthostatic hypotension. PT discusses this change in BP with nurse and overall change in status from admission. Nurse plans to pass the message along to DON and/or doctor for potential further workup on why patient is declining in functional status & overall feeling. Patient is only able to respond to questions with head nocks/shakes [as written] for yes/no questions. PT # 1 was interviewed on 6/3/25 at 4:10 PM and reported the following information. When Resident # 3 was initially admitted , she and the Occupational Therapist conducted their initial evaluations together. The resident was able to go to the bathroom with moderate assistance. In therapy she began walking with a quad cane. In her progression of therapy, the resident went up and did really well and then went down. In the beginning of therapy, the resident could shake her head yes and no to communicate. She was doing better with communication near the beginning. Near the end of her stay she was minimally communicating. She went from transferring and walking with the quad cane to being totally dependent for transfers near the end of her stay. It had been Nurse # 1 who had been in the room on the day that the resident's blood pressure was taken and dropped. Nurse # 1 (who was assigned to care for Resident # 3 on 3/21/25) was interviewed on 6/4/25 at 3:50 PM and reported the following information. She knew Resident # 3 had a major stroke when she was admitted to the facility and had always had right sided neglect (where a person's awareness of one side of their body is impaired after a stroke). She seemed to be the same the times she took care of her, and it had never been communicated to her that the resident could stand, pivot, and was progressing with therapy soon after admission. She did not ever witness that herself. She did not recall therapy talking to her about changes. At times, therapy talked to the Unit Manager. The DON was interviewed on 6/5/25 at 4:00 PM. The DON reported the following. She only recalled one time when a change in condition had been mentioned to her about Resident # 3 and that was regarding the twitching the resident had on 3/18/25. She (the DON) knew physician orders were obtained for that and she was not aware of the resident's decline. On 3/22/25 a Point of Care Testing Result for COVID showed Resident # 3 tested positive for a COVID infection. On the form, the resident was checked as having no symptoms. On 3/22/25 at 11:20 AM Nurse # 1 documented she had called and talked to Resident # 3's responsible party and that the resident's vitals were stable. The resident had left sided neglect, had difficulty swallowing, was pocketing food, and she was receiving therapy services. On 3/22/25 at 6:02 PM the Unit Manager documented, Writer called first Emergency contact and informed her of resident testing positive for COVID received verbal consent to start antiviral medication. Review of the record revealed no medication treatment orders were begun on 3/22/25. The Unit Manager was interviewed on 6/5/25 at 11:22 AM and reported the following information. She had tested residents during the COVID outbreak. Typically, the symptoms they were seeing with COVID positive residents were a runny nose and/or cough. Resident # 3 did not have those symptoms when Resident # 3 tested positive on 3/22/25. She (the Unit Manager) had called the family and asked for permission about placing the resident on an antiviral if the physician chose to do so when the resident tested positive. There was a lot that happened during the outbreak, and she could not recall for sure whether she had contacted the physician and what he said about Resident # 3 having COVID. At times in general she knew that he was hesitant about antivirals because of kidney function. She had not realized Resident # 3 was having a decline. If it had been communicated to her clearly and she had realized this, then she would have gone into action to make sure she got treatment. On 6/4/25 at 2:15 PM the Administrator and DON were interviewed with the Nurse Consultant and Chief Clinical Officer also present. The following information was present. The Administrator reported they had an outbreak of COVID on 3/18/25 and Resident # 3 did not test positive until 3/22/25. The DON and Administrator reported the Unit Manager tested the residents. The DON further reported when residents tested positive, there was a procedure that the Unit Manager was supposed to contact the physician and determine if he wanted them to receive antiviral treatment. The family would also be notified. Because some of the antivirals could affect kidney function, the use of any ordered antiviral would also be reviewed by the pharmacy in conjunction with a resident's kidney function before starting the medication. They (these administrative staff) had looked at Resident # 3's medical record the previous evening (6/3/25). Excluding the Unit Manager's actions to obtain family consent for an antiviral, they could find no record this procedure had been done for Resident # 3. On 3/23/25 OTA # 1 (Occupational Therapist Assistant) documented Resident # 3 was unable to follow commands, utilize utensils, or engage in self-feeding in any manner without total assistance. OTA # 1 further noted, Pt appeared dehydrated. Pt able to utilize straw for sucking for brief period and did not react to bringing drink or food to mouth. Collaborated with nursing regarding PO intake to improve therapeutic potential, however Pt unable to engage in meal task at this time. OTA # 1 was interviewed on 6/5/25 at 9:30 AM and reported the following. She could not recall specific details of who she had talked to in nursing or working with Resident # 3 on 3/23/25. She would not have written the resident appeared dehydrated unless the resident's mouth was dry or the resident did not pass the skin pinch test (assesses skin elasticity and potentially indicate dehydration). On 3/23/25 at 3:24 PM Nurse # 1 documented the following in a nursing note. Resident # 3 continued with right-sided neglect and her right side was flaccid. The resident was moving her left side, but without purposeful movements. The resident would look when spoken to and her eyes would drift towards the left side. Her vitals were stable and she was not in apparent distress. On 3/23/25 at 8:23 PM Nurse # 1 noted, correction R sided neglect. Nurse # 7 had cared for Resident # 3 on the shift which began at 7 PM on 3/23/25 and ended on 3/24/25. Nurse # 7 was interviewed on 6/3/25 at 4:56 PM and reported the following information. She did not recall a big change in Resident # 3. Resident # 3 had always been sluggish and to her knowledge had been admitted that way. She filled in as a nurse at the facility and she had never been told in report that the resident had been up walking or trying to eat on her own. If so, she would have been more concerned about any sluggishness she had noted. Review of narrative nursing progress notes revealed no notation for the date of 3/24/25. On 3/24/25 COTA # 2 (Certified Occupational Therapist Assistant) wrote, Pt very lethargic. Required max cues to maintain alertness and participate. Pt was dependent for all tasks. Occupational Therapist # 1 was interviewed on 6/3/25 at 3:53 PM and reported the following. The resident could stand and pivot at the start of her therapy treatment. She would make eye contact and try to tell the staff things when she first started therapy. The therapy staff noticed a distinct change a few days before she was discharged from the facility. She was not functioning per her normal and was not as alert. This had been communicated to the nurses, but OT # 1 could not recall which nurses had been told. Review of a facility investigative file regarding the care Resident # 3 had received while at the facility revealed Nurse Aide (NA) #1 had cared for Resident # 3 on the dates of 3/10/25, 3/11/25, 3/15/25, 3/16/25, 3/18/25, 3/19/25, 3/24/25, and 3/25/25. Review of NA # 1's 3/26/25 signed statement in the investigative file revealed the following information. When [Resident # 3] first arrived at the facility [Resident # 3] was unable to verbalize her needs; she used her hands and head to communicate. [Resident # 3] needed assistance with feeding. As a few days went by she was getting up in her wheelchair and was able to feed herself. I noticed a change in condition on approximately 3/18/25, [Resident # 3] was acting differently having facial twitching. I noticed [Resident # 3] eating less and [Resident # 3] was unable to sit up in a wheelchair like she had been doing previously. I notified the hall in the change of condition [as written], not sure which nurse was working that day. The nurse went into the room and assessed [Resident # 3]. NA # 1's statement specifically included information about the date of 3/24/25 which read, On 3/24/25 I noticed [Resident # 3] was placing her hands in her brief, pulling off her clothes and at lunch, [Resident # 3] had pulled her lunch tray off of the over the bed table into the bed. [Resident # 3] was also staring off into space and moaning, but unable to verbalize if anything was wrong when she was asked. I reported the changes to the hall nurse [Nurse # 2]. [Nurse #2] went into the room and assessed [Resident # 3]. Nurse Aide (NA) # 1 was interviewed on 6/3/25 at 2:40 PM and reported the following information. When Resident # 3 was admitted the resident worked with therapy and could sit up all day in her wheelchair. She could eat and drink with her good hand. She could pivot to the toilet and have a bowel movement. She could communicate by motioning for her needs. Prior to Resident # 3 testing positive for COVID there was a day when she (NA # 1) had observed Resident # 3 slumped over in her wheelchair. The resident's head was bent over near her knees and she was almost ready to hit the floor. She (NA # 1) recalled she obtained the assistance of NA # 2 and they lifted the resident back to bed. The resident was limp and seemed out of it. At some point after that episode, she (NA #1) recalled Resident # 3 started to twitch. It was not just in her face but at times her shoulder would move up and down with the twitching. The twitching continued but was better some days than other days. The resident would stare off in space and not eat. She seemed to have less urine in her brief. She (NA #1) changed her about two times per shift. The resident would put her hand in her brief. Prior to the change that she (NA #1) noticed, the resident seemed to be cold in nature. After the change, Resident # 3 would snatch off her clothes. NA # 2 was interviewed on 6/3/25 at 2:52 PM and reported the following information. She was the Lead NA and helped everywhere. She did recall there was a day when she had helped NA # 1 get Resident # 3 back to bed because the resident was slouching and it seemed like she could not sit up. That was new for Resident # 3 and she did not seem herself. Review of a facility investigative file regarding the care Resident # 3 had received while at the facility revealed NA # 3 had cared for Resident # 3 on the dates of 3/13/25, 3/14/25, 3/17/25, 3/20/25, 3/22/25, and 3/23/25. Review of NA # 3's signed 3/26/25 statement in the investigative file revealed in part the following information. When [Resident # 3] first arrived at the facility [Resident # 3] would attempt to communicate utilizing paper, [Resident # 3] was unable to communicate verbally. After [Resident # 3] was diagnosed with COVID her condition changed. [Resident # 3] started placing hand in her brief, staring off in to space, taking off her clothes and twisting and turning in the bed. NA # 3 further added in her statement that she had worked the weekend of 3/22/25 and 3/23/25 with Resident # 3. She had not noted a difference in the resident's urination or bowels but the resident did not eat or drink much either day which NA # 3 noted was a change when compared to before the time the resident had COVID. NA # 3 was interviewed on 6/3/25 at 9:22 AM and reported the following information. When Resident # 3 was admitted the resident had worked with therapy and she (NA # #3) had watched the therapist use the gait belt and take Resident # 3 to the bathroom. She (NA # 3) learned to do this from the therapist, and Resident # 3 could stand and pivot to the wheelchair and then stand and pivot to the toilet. The resident made attempts to communicate with paper with her family. The resident would get up for meals and progressed to the point where she could feed herself. After the resident got COVID she did a complete 360 and changed. She would look off into space. When she (NA #3) helped turn the resident in bed, the resident would swing her arms as if falling. She would rip her brief off her body and dig in her brief. She had to be fed and did not eat or drink much. Her mouth looked dry as if she had a film over it. She (NA # 3) would tell the nurses she worked with that this person is not right. She recalled Nurse # 1 saying that Resident # 3 was declining. Review of a facility investigative file regarding the care Resident # 3 had received while at the facility revealed NA # 4 had cared for Resident # 3 on the dates of 3/20/25, 3/21/25, and 3/24/25 during the 3:00 PM to 11:00 PM shift. Review of NA # 4's signed 3/25/25 statement in the investigative file revealed the following information. I'm not real familiar with [Resident # 3] due to the fact I only worked with [Resident # 3] on a few occasions. I attempted to feed [Resident # 3] and get [Resident # 3] to drink something the days I was assigned to [Resident # 3] but [Resident # 3] would refuse. I was in the room when a therapist stated they had attempted to get [Resident # 3] to eat and drink but were unable to get [Resident # 3] to do either. When I provided incontinent care [Resident # 3] had urinated a small amount. I do recall that [Resident # 3] had a small bowel movement that was noted to be black in color. I do not recall foul odors; I do remember her placing her hands in her brief and picking at the brief. I do recall [Resident # 3] would throw her pillows on the floor consistently. [Resident # 3] would constantly stare at the ceiling. Family member came in on 3/24/25 asking about how much [Resident # 3] was eating. I informed family member that she didn't' eat dinner for you [as written]. Family went to [Nurse # 2] asked [Nurse # 2] about how much [Resident # 3] had eaten on 3/24/25. The family member seemed concerned and confused. NA # 4 was interviewed on 6/3/25 at 3:06 PM and reported the following information. She did not know how Resident # 3 had been when she first arrived at the facility. When she cared for her, the resident would stare off distantly and seemed fixated on the ceiling. She (NA # 4) could not get [TRUNCATED]

Based on observations, record reviews, staff and physician interviews, the facility failed to notify the physician of tube feedings (nutrition administered through a tube directly into the stomach) that were ordered continuously being turned off for 2 of 2 residents (Resident #60 and Resident #74) for an undetermined amount of time and instances. During observations on 10/3/24 Resident #60's and Resident #74's feeding tube pumps (the mechanism that delivers the nutrition) were observed off. Nurse #1 confirmed she turned Resident #60's and Resident #74's tube feedings off without notifying the physician despite her knowledge that the tube feedings were ordered continuously because she believed their stomach needed a rest. Nurse #1 also confirmed this was not an isolated incident for either resident and she had done this before without notifying the physician. Deviating from the physician orders by turning off the tube feedings without notifying the physician deprived Resident #60 and Resident #74 of their assessed nutritional needs. Nurse #1 had a history of disciplinary action at the facility for substandard work in July of 2024 and in response she was to be monitored while she was working her shift. This deficient practice was identified for 2 of 2 residents (Resident #60 and Resident #74) reviewed for physician notification. Immediate jeopardy began on 10/3/24 when Nurse #1 turned off Resident #60's and Resident #74's tube feeding without notifying the physician. Immediate jeopardy was removed on 10/4/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity D to ensure education is completed and monitoring systems put in place are effective. The findings included: Review of Nurse #1's personnel file revealed she was employed in February 2024. Nurse #1's personnel file contained 1 employee disciplinary form from on 7/25/24 when she received a first warning for substandard work. The details of the occurrence documented Nurse #1 was the assigned nurse to supervise the medication aide and multiple medications including seizure medications were not documented as administered. During an interview with the Facility Nurse Consultant, Director of Nursing (DON), and Chief Clinical Officer on 10/4/24 at 12:33 pm, the Chief Clinical Officer stated the nursing supervision and monitoring interventions in place for Nurse #1 after the incident in July 2024 included daily monitoring of essential reports in the electronic medical record (EMR) to assure nurse supervision of medication aides and all medications were completed timely and as ordered by the physician were completed by the Facility Nurse Consultant. The Facility Nurse Consultant did not state the length of time for the monitoring of Nurse #1 and there was no written documentation for this plan of action for monitoring Nurse #1 provided by the facility. The Chief Clinical Officer explained that new nurses hired had a competency evaluation with a nurse skills checklist that was completed during orientation. Nurse #1's competency skills checklist was unable to be located. Review of the nursing assignment sheets from 8/8/24 through 10/3/24 revealed Nurse #1 was assigned to Resident #60's and Resident #74's hall 32 days. The assignment sheet also revealed Nurse #1 shifts worked were double shifts (7:00 am until 3:30 pm and 3:30 pm until 11:30 pm). a. Resident #60 was readmitted to the facility 8/7/24 with diagnoses which included anoxic brain damage, dysphagia (difficulty swallowing), chronic obstructive pulmonary disease, and acute respiratory failure. The Registered Dietician's (RD) nutritional assessment dated [DATE] recommended Resident #60 needed 1728 kilocalories (kcal) with 1708 cubic centimeters (cc) free water and 90.4 grams (g) of protein daily from her continuous tube feeding. Review of the RD's progress note for Resident #60 dated 8/21/24 revealed a readmission evaluation on 8/21/24. Resident #60's weight was 268 pounds. The tube feeding order was noted as 50 milliliters per hour (ml/hr) with 135 cc water flushes every 6 hours. No recommendations, tube feeding adequate as ordered, and well tolerated with weight stability. Resident #60's active physician orders related to his tube feeding included the following: - every day and night shift tube feeding at 60 milliliters per hour (ml/hr) continuous (initiated on 9/30/24) An observation on 10/3/24 at 3:08 am revealed Resident #60's feeding tube pump was turned off. An empty tube feeding bottle was hanging on the feeding tube pole. In an interview on 10/3/24 at 3:43 am with Nurse #1 she indicated she was the nurse assigned for Resident #60 on night shift (11:00 pm until 7:30 am). When Nurse #1 was asked why the feeding tube pump was off for Resident #60, she replied she intentionally turned the feeding tube pump off because she thought her stomach needed a rest. Nurse #1 explained the tube feeding formula was thick and sometimes clogged the feeding tubes and she just thought her stomach needed a rest. Nurse #1 explained she made the decision on her own to turn the tube feeding pump off for 2 to 3 hours to give her stomach a rest. Nurse #1 indicated she was aware Resident #60 was on continuous tube feeding per physician orders. Nurse #1 stated she did not notify the physician when she turned the feeding tube pump off for Resident #60 because there was no significant change in her condition. Nurse #1 did not remember what time she turned the feeding tube pump off for Resident #60 on 10/3/24. The following additional observations were made of Resident #60: - 10/3/24 at 3:53 am Resident #60's feeding tube pump continued to be turned off. - 10/3/24 at 7:53 am Resident #60's feeding tube pump was on with a new bottle of tube feeding dated 10/3/24 at 5:43 am hanging on the feeding tube pole In a second interview on 10/3/24 at 3:26 pm with Nurse #1 she stated she turned Resident #60's feeding tube pump off when she thought her stomach needed a rest. Nurse #1 stated this was not a regular thing and she did this when she felt [the resident] needed a break. Nurse #1 did not give a specific answer as to how many times she had turned the feeding tube pump off or when she first began turning off the feeding tube pump. She stated she turned [the tube feeding pump] off when she thought [the resident's stomach] needed a rest. She revealed she did not notify the physician she turned the tube feeding off on any previous instance. During an interview with the Registered Dietician (RD) on 10/3/24 at 9:00 am, he stated Resident #60 had lost some weight possibly due to being in and out of the hospital. Resident #60 was readmitted from the hospital on 8/7/24. The RD was not aware of Resident #60's feeding tube pump being turned off and did not understand why Nurse #1 intentionally turned the feeding tube pump off without notifying the physician. The RD indicated a continuous tube feeding may be turned off for a short amount of time to perform activities of daily living (ADL's) or due to a change in condition, but not for 2 to 3 hours at a time unless ordered by the physician. The RD further explained Nurse #1 needed a physician's order to turn off the feeding tube pump, and he had not recommended this to the physician. The RD further stated turning the feeding tube pump off could have caused weight loss; however, his concern was the loss of calories and nutrients provided by the tube feeding. b. Resident #74 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing), failure to thrive, dementia, and type 2 diabetes mellitus. The Registered Dietician's (RD) nutritional assessment dated [DATE] recommended Resident #74 needed 1980 kilocalories (kcal) with 1963 cubic centimeters (cc) free water and 83 grams (g) protein daily from her tube feeding for 22 continuous hours. Resident #74's active physician orders related to his tube feeding included the following orders: - continuous tube feeding via pump at 55 milliliters per hour (ml/hr) for nutritional support for 22 hours estimated 2 hours (scheduled for 8:00 am until 10:00 am) downtime to allow for activities of daily living (ADL) care (initiated on 7/11/24) An observation on 10/3/24 at 3:10 am revealed Resident #74's feeding tube pump was turned off. A tube feeding bottle with approximately 100 cubic centimeters (cc) was hanging on feeding tube pole. In an interview on 10/3/24 at 3:43 am with Nurse #1 she indicated she was the nurse assigned for Resident #74 on night shift (11:00 pm until 7:30 am). When asked Nurse #1 why the feeding tube pump was off for Resident #74, she replied she intentionally turned the feeding tube pump off because she thought her stomach needed a rest. Nurse #1 explained the tube feeding formula was thick and sometimes clogged the feeding tubes and she just thought her stomach needed a rest. Nurse #1 explained she made the decision on her own to turn the tube feeding pump off for 2 to 3 hours to give her stomach a rest. Nurse #1 indicated she was aware Resident #74 was on continuous tube feeding per physician orders. Nurse #1 further stated she did not notify the physician when she turned the feeding tube pump off for Resident #60 because there was no significant change in her condition. Nurse #1 did not remember what time she turned the feeding tube pump off for Resident #74. The following additional observations were made of Resident #74: - 10/3/24 at 3:55 am Resident #74's feeding tube pump continued to be turned off. - 10/3/24 at 7:55 am Resident #74's feeding tube pump was on with a new bottle of tube feeding dated 10/3/24 at 4:30 am. In a second interview on 10/3/24 at 3:26 pm with Nurse #1 she stated she turned Resident #74's feeding tube pump off when she thought her stomach needed a rest. Nurse #1 stated this was not a regular thing and she did this when she felt [the resident] needed a break. Nurse #1 did not give a specific answer as to how many times she had turned the feeding tube pump off or when she first began turning off the feeding tube pump. She stated she turned [the tube feeding pump] off when she thought [the resident's stomach] needed a rest. She revealed she did not notify the physician she turned the tube feeding off on any previous instance. During an interview with the Registered Dietician (RD) on 10/3/24 at 9:00 am, he stated Resident #74's weight had been stable. The RD was not aware of Resident #74's feeding tube pump being turned off and did not understand why Nurse #1 intentionally turned the feeding tube pump off without notifying the physician. The RD indicated continuous tube feedings may be turned off for a short amount of time to perform activities of daily living or due to a change in condition, but not for 2 to 3 hours at a time unless ordered by the physician. The RD further indicated Resident #74 had a physician's order for her feeding tube pump to be turned off 2 hours a day to allow downtime for ADL care. The RD further explained Nurse #1 needed a physician's order to turn off the feeding tube pumps, and he had not recommended this to the physician. The RD further stated turning the feeding tube pump off could have caused weight loss; however, his concern was the loss of calories and nutrients provided by the tube feeding. In an interview on 10/3/24 at 9:15 am with the Director of Nursing (DON), she stated continuous tube feedings should not be turned off without a physician's order. The DON further stated she was unaware of Nurse #1 turning the feeding tube pumps off for Resident #60 and Resident #74 which disregarded the physician's order. The DON further stated Nurse #1 should have assessed the residents (Resident #60 and Resident #74) and notified the physician of any changes in their condition before making any decisions on her own. The DON indicated she expected the nursing staff to follow the physician's orders and to notify the physician for any significant change that required deviation from the orders. During an interview on 10/3/24 at 12:00 pm with the Physician, he stated he was not aware that Resident #60's and Resident #74's feeding tube pumps were being turned off by Nurse #1. The Physician further stated if there had been a change in the residents' condition such as shortness of breath (SOB), vomiting, or gurgling that could have explained the feeding tube pumps being turned off; however, he was not notified of this for Resident #60 or Resident #74 at all. The physician explained one of his concerns with turning off the tube feedings was that Resident #60 and Resident #74 were not receiving the calories and the nutrients provided from the tube feeding. Another concern noted by the physician was the fact that Nurse #1 intentionally turned the feeding tube pumps off without notifying him before taking this action. The Physician indicated he did not like the nurses to make unreasonable decisions on their own without any notification. The Physician indicated that weight loss could happen as a result of the tube feeding pumps being turned off. He further explained Nurse #1's reason for the feeding tube pumps being turned off was not a good enough reason for Nurse #1 to make that decision. The Administrator was notified of Immediate Jeopardy on 10/4/24 at 6:37 pm. The facility provided the following credible allegation of immediate jeopardy removal: Identify recipients who have suffered or are likely to suffer a serious adverse outcome as a result of the non-compliance. On 10/3/24 the feeding pumps for Residents # 60 and # 74 were observed off for an undetermined amount of time. Both Residents # 60 and # 74 were determined to be at risk for harm based on the actions of Nurse # 1. Nurse # 1 failed to follow the physician orders for Resident # 60 for continuous tube feeding, 24 hours per day. Nurse #1 failed to follow the physician orders for Resident #74 for continuous tube feeding, 22 hours per day. Nurse #1 failed to notify the MD of her deviant practice for both residents #60 and #74. All residents in the facility are deemed to be at risk for serious adverse outcome based on the actions of Nurse #1. On the morning of 10/3/24, upon notification of the problem, the Director of Nursing went immediately to the rooms of Residents #60 and #74 to assess the tube feeding status. Both residents were found to have feeding pumps that were on and both residents were found to have currently dated and timed feedings infusing per MD orders. The Director of Nursing reviewed the patient medical records for physician notification on the morning of 10/3/24. There was no evidence of MD notification by Nurse #1. The physician was notified of the order deviance and behavior of the nurse on 10/3/24. He was notified by the Administrator. Specify the action the entity will take to alter the system failure to prevent serious adverse outcomes from occurring or recurring. The facility confirmed that all residents with enteral feedings, including residents # 60 and #74, were resumed and infusing at the rate ordered by the physician. This confirmation was made on the morning of 10/3/24 at approximately 9:00 am by the Director of Nursing. On 10/3/24 the Director of Nursing and the Chief Clinical Officer called Nurse #1 to the facility for interview. Nurse # 1 was notified of her failure to follow MD orders and she was interviewed about her conversations during the night with the surveyors. Nurse #1 acknowledged that she did not have a physician order to stop the tube feedings and did not notify the physician of the deviant practice. The Board of Nursing Complaint Evaluation Tool was completed and reviewed with Nurse #1 on the evening of 10/3/24. The employee meeting was conducted by the Administrator, DON, Chief Clinical Officer, and Nurse Clinical Consultant. Prior to suspension, the DON and Chief Clinical Officer counseled and re-educated Nurse # 1 about her deviant practices. After consultation with the Chief Clinical Officer and the Chief Operating Officer, she was suspended at approximately 7:30 pm. Education sessions were begun on 10/3/24 with all licensed nurses and included the following subjects: Consult and notify the MD of resident changes and need to alter treatments Provision of care to ensure that MD orders are followed at all times, including orders for enteral feedings. The DON and Corporate Clinical Nurse and Chief Clinical Officer conducted the education sessions. Education sessions will continue with all staff members until 100% of the licensed nurses have received education. The Director of Nursing, ADON, and nurse managers will review education session sign ins daily to ensure that all staff have received the material effectively and to ensure that no staff members worked prior to receiving it. No licensed nurses will be allowed to work until they have received the education. The Chief Clinical Officer notified the Facility Nurse Consultant on 10/3/24 that new licensed nursing staff will be trained in orientation and education will continue within the facility to ensure understanding of the importance to notify the MD of significant changes in resident's physical, mental, and psychological status, the need to alter resident treatments significantly, and our ZERO tolerance position for [NAME] employees. On 10/3/24 the Chief Clinical Officer notified the Director of Nursing for the need and requirement to complete education prior to employees returning to work. The DON notified the hall nurses at the beginning of shifts that an inservice would be held prior to the shift beginning. These education sessions will continue until 100% of the licensed nurses have been trained. Date of immediate jeopardy removal: 10/4/24 Validation of the immediate jeopardy removal plan was completed on 10/8/24: Interviews confirmed the physician was notified of the tube feedings being turned off on 10/3/24 by the Administrator and that Nurse #1 verified she did not notify the physician when she turned the tube feedings off. A review of Nurse #1's Human Resource (HR) records revealed documentation of her disciplinary forms and a North Carolina Board of Nursing (NCBON) Complaint Evaluation Tool which was completed on 10/3/24. The signed in-service roster and staff interviews of licensed nurses verified education was providing on consulting and notifying the physician of resident changes and need to alter treatments and ensuring that physician orders are followed at all times to include orders for tube feeding. No licensed nurse worked after 10/3/24 without receiving the education. The following residents' tube feeding were observed, and orders checked for accuracy: Resident #s 4, 28, 38, 41, 60, 64, 74, 80, and 341. All tube feedings were running or on hold as ordered. The immediate jeopardy removal date of 10/4/24 was validated.

Based on record review, observation, and staff and physician interviews, the facility failed to protect the residents' right to be free from neglect when Nurse #1 did not provide the necessary care and services as assessed and ordered by the physician to Resident #60 and Resident #74. On 10/03/24 Nurse #1 turned their continuous tube feedings (nutrition administered through a tube directly into the stomach) off because she believed their stomachs needed a rest. Nurse #1 was aware of the physician's orders, she deliberately disregarded them, and she independently made the decision to deviate from the physician's orders and turn the tube feedings off depriving the residents of their assessed nutritional needs. She revealed this was not a new practice for her and she had done this previously for both residents an undetermined number of times. When staff purposefully disregard physician's orders and make treatment decisions on their own, it places all residents at risk of serious harm and/or death. Nurse #1 had a history of disciplinary action at the facility for substandard work in July of 2024 and in response she was to be monitored while she was working her shift. This deficient practice affected 2 of 2 residents reviewed for neglect (Resident #60 and Resident #74). Immediate jeopardy began on 10/3/24 when Nurse #1 disregarded physician's orders and turned off Resident #60's and Resident #74's tube feeding. Immediate jeopardy was removed on 10/5/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity D to ensure education is completed and monitoring systems put in place are effective. The findings included: Review of Nurse #1's personnel file revealed she was employed in February 2024. Nurse #1's personnel file documented orientation training of the facility policies and procedures which included written tests on these policies and procedures. Nurse #1's personnel file also contained 1 employee disciplinary form. The first disciplinary action was on 7/25/24 when she received a first warning for substandard work. The details of the occurrence documented Nurse #1 was the assigned nurse to supervise the medication aide and multiple medications including seizure medications were not documented as administered. During an interview with the Facility Nurse Consultant (FNC), Director of Nursing (DON), and Chief Clinical Officer (CCO) on 10/4/24 at 12:33 pm, the CCO stated the nursing supervision and monitoring interventions in place for Nurse #1 after the incident in July 2024 included daily monitoring of essential reports in the electronic medical record (EMR) to assure nurse supervision of medication aides and all medications were completed timely and as ordered by the physician were completed by the FNC. The FNC did not state the length of time for the monitoring of Nurse #1 and there was no written documentation for this plan of action for monitoring Nurse #1 provided by the facility. The CCO explained that new nurses hired have a competency evaluation with a nurse skills checklist that is completed during orientation. Nurse #1's competency skills checklist was unable to be located. Review of the nursing assignment sheets from 8/8/24 through 10/3/24 revealed Nurse #1 was assigned to Resident #60's and Resident #74's hall 32 days. The assignment sheet also revealed Nurse #1 shifts worked were double shifts (7:00 am until 3:30 pm and 3:30 pm until 11:30 pm). a. Resident #60 was readmitted to the facility 8/7/24 with diagnoses which included anoxic brain damage, dysphagia (difficulty swallowing), chronic obstructive pulmonary disease, and acute respiratory failure. Resident #60's care plan dated 4/15/24 revealed a focus for required tube feeding related to dysphagia. The interventions included to monitor, document, report any signs/symptoms of aspiration, fever, shortness of breath (SOB), tube dislodged or tube malfunction. Resident #60 was dependent with tube feeding and water flushes. Review of Resident #60's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. Resident #60 had bilateral (left and right) impairment of the upper and lower extremities, completely dependent upon staff for all activities of daily living and coded for a feeding tube. Resident #60's weight on quarterly MDS was 268 pounds. Review of Resident #60's weights revealed the following: - 6/3/24 255.0 pounds - 7/2/24 249.8 pounds - 8/8/24 267.8 pounds - 9/9/24 247.5 pounds Resident #60's active physician orders related to his tube feeding included the following: - every day and night shift tube feeding at 60 milliliters per hour (ml/hr) continuous (initiated on 9/30/24) - every 6 hours flush with 135 cubic centimeters (cc) for water flushes (initiated on 8/7/24) The Registered Dietician's (RD) nutritional assessment dated [DATE] recommended Resident #60 needed 1728 kilocalories (kcal) with 1708 cubic centimeters (cc) free water and 90.4 grams (g) of protein daily from her continuous tube feeding. Review of the RD's progress note for Resident #60 dated 8/21/24 revealed a readmission evaluation on 8/21/24. Resident #60's weight was 268 pounds. The tube feeding order was noted as 50 ml/hr with 135 cc water flushes every 6 hours. No recommendations, tube feeding adequate as ordered, and well tolerated with weight stability. The following observation was made of Resident #60: - 10/3/24 at 3:08 am Resident #60's feeding tube pump was turned off. An empty tube feeding bottle was hanging on the feeding tube pole In an interview on 10/3/24 at 3:43 am with Nurse #1 she indicated she was the nurse assigned for Resident #60 from 11:00 pm on 10/02/24 until 7:30 am on 10/03/24 (night shift). When asked Nurse #1 why the feeding tube pump was off for Resident #60, she replied she intentionally turned the feeding tube pump off because she thought her stomach needed a rest. Nurse #1 explained the tube feeding formula was thick and sometimes clogged the feeding tubes and she just thought her stomach needed a rest. Nurse #1 explained she made the decision on her own to turn the tube feeding pump off for 2 to 3 hours to give her stomach a rest. Nurse #1 indicated she was aware Resident #60 was on continuous tube feeding per physician orders Nurse #1 stated she did not notify the physician when she turned the feeding tube pump off for Resident #60 because there was no significant change in her condition. Nurse #1 did not remember what time she turned the feeding tube pump off for Resident #60 on 10/3/24. The following additional observations were made of Resident #60: - 10/3/24 at 3:53 am Resident #60's feeding tube pump continued to be turned off. - 10/3/24 at 7:53 am Resident #60's feeding tube pump was on with a new bottle of tube feeding dated 10/3/24 at 5:43 am hanging on the feeding tube pole Review of Resident #60's electronic medical record (EMR) revealed no progress notes which documented turning the feeding tube pump off by Nurse #1. Review of Resident #60's October Medication Administration Record (MAR) revealed enteral feed order every day and night shift [name of tube feeding formula] at 60 ml/hr with Nurse #1's initials electronically signed for the night hours (12HR) on 10/2/24. In a second interview on 10/3/24 at 3:26 pm with Nurse #1 she stated she turned Resident #60's feeding tube pump off when she thought her stomach needed a rest. Nurse #1 stated this was not a regular thing and did this when she felt they needed a break. Nurse #1 did not give a specific answer as to how many times she had turned the feeding tube pump off or when she first began turning off the feeding tube pump. She stated she turned them off when she thought their stomachs needed a rest. When Nurse #1 was asked when she turned the feeding tube pump back on, Nurse #1 indicated Resident #60's feeding tube pump was turned on when she hung a new bottle of tube feeding at 5:43 am on 10/3/24. During an interview with the Registered Dietician (RD) on 10/3/24 at 9:00 am, he stated Resident #60 had lost some weight possibly due to being in and out of the hospital. Resident #60 was readmitted from the hospital on 8/7/24. The RD was not aware of Resident #60's feeding tube pump being turned off and did not understand why Nurse #1 intentionally turned the feeding tube pump off without notifying the physician. The RD indicated a continuous tube feeding may be turned off for a short amount of time to perform activities of daily living (ADL) or due to a change in condition, but not for 2 to 3 hours at a time unless ordered by the physician. The RD further explained Nurse #1 needed a physician's order to turn off the feeding tube pump, and he had not recommended this to the physician. The RD further stated turning the feeding tube pump off could have caused weight loss; however, his concern was the loss of calories and nutrients provided by the tube feeding. Review of the RD's progress note for Resident #60 dated 10/7/24 revealed he increased Resident #60's tube feeding on 9/19/24 due to weight loss. Resident #60's weight was noted to be 255 pounds with prior weight loss and noted weight regain, and IV fluids during hospital stay as attributing to weight fluctuations. b. Resident #74 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing), failure to thrive, dementia, and type 2 diabetes mellitus. The Registered Dietician's (RD) nutritional assessment dated [DATE] recommended Resident #74 needed 1980 kilocalories (kcal) with 1963 cubic centimeters (cc) free water and 83 grams (g) protein daily from her tube feeding for 22 continuous hours. Resident #74's care plan dated 8/7/24 revealed a focus for tube feeding for nutrition. The interventions included monitor, document, report any signs/symptoms of aspiration, fever, shortness of breath (SOB), tube dislodged or tube malfunction. Resident #74 was dependent with tube feeding and water flushes. Review of Resident #74's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. Resident #74 required maximum assistance from staff with activities of daily living and coded for a feeding tube. Review of Resident #74's weights revealed the following weights: - 7/11/24 154.9 pounds - 7/22/24 154.9 pounds - 8/6/24 156.6 pounds - 9/6/24 160.0 pounds Resident #74's active physician orders related to his tube feeding included the following orders: - continuous tube feeding via pump at 55 milliliters per hour (ml/hr) for nutritional support for 22 hours estimated 2 hours (scheduled for 8:00 am until 10:00 am) downtime to allow for activities of daily living (ADL) care (initiated on 7/11/24) - water flushes every 3 hours of 120 milliliters The following observation was made of Resident #74: - 10/3/24 at 3:10 am Resident #74's feeding tube pump was turned off. A tube feeding bottle with approximately 100 cubic centimeters (cc) was hanging on feeding tube pole. In an interview on 10/3/24 at 3:43 am with Nurse #1 she indicated she was the nurse assigned for Resident #74 from 11:00 pm on 10/02/24 until 7:30 am on 10/03/24 (night shift). When asked Nurse #1 why the feeding tube pump was off for Resident #74, she replied she intentionally turned the feeding tube pump off because she thought her stomach needed a rest. Nurse #1 explained the tube feeding formula was thick and sometimes clogged the feeding tubes and she just thought her stomach needed a rest. Nurse #1 explained she made the decision on her own to turn the tube feeding pump off for 2 to 3 hours to give her stomach a rest. Nurse #1 indicated she was aware Resident #74 was on continuous tube feeding per physician orders. Nurse #1 further stated she did not notify the physician when she turned the feeding tube pump off for Resident #60 because there was no significant change in her condition. Nurse #1 did not remember what time she turned the feeding tube pump off for Resident #74. Review of Resident #74's EMR revealed no progress notes which documented turning the feeding tube pump off by Nurse #1. Review of Resident #74's October Medication Administration Record (MAR) revealed the enteral feed order every shift for nutritional support/supplementation [name of tube feeding formula] at 55 ml/hr with Nurse #1's initials electronically signed for the night hours on 10/2/24. The following additional observations were made of Resident #74: - 10/3/24 at 3:55 am Resident #74's feeding tube pump continued to be turned off. - 10/3/24 at 7:55 am Resident #74's feeding tube pump was on with a new bottle of tube feeding dated 10/3/24 at 4:30 am. In a second interview on 10/3/24 at 3:26 pm with Nurse #1 she stated she turned Resident #74's feeding tube pump off when she thought her stomach needed a rest. Nurse #1 stated this was not a regular thing and did this when she felt they needed a break. Nurse #1 did not give a specific answer as to how many times she had turned the feeding tube pump off or when she first began turning off the feeding tube pump. She stated she turned them off when she thought their stomachs needed a rest. When Nurse #1 was asked when she turned the feeding tube pump back on, Nurse #1 indicated Resident #74's feeding tube pump was turned on when she hung a new bottle of tube feeding at 10/3/24 at 4:30 am. During an interview with the Registered Dietician (RD) on 10/3/24 at 9:00 am, he stated Resident #74's weight had been stable. The RD was not aware of Resident #74's feeding tube pump being turned off and did not understand why Nurse #1 intentionally turned the feeding tube pump off without notifying the physician. The RD indicated continuous tube feedings may be turned off for a short amount of time to perform activities of daily living or due to a change in condition, but not for 2 to 3 hours at a time unless ordered by the physician. The RD further indicated Resident #74 had a physician's order for her feeding tube pump to be turned off 2 hours a day to allow downtime for ADL care. The RD further explained Nurse #1 needed a physician's order to turn off the feeding tube pumps, and he had not recommended this to the physician. The RD further stated turning the feeding tube pump off could have caused weight loss; however, his concern was the loss of calories and nutrients provided by the tube feeding. In an interview on 10/3/24 at 9:15 am with the Director of Nursing (DON), she stated continuous tube feedings should not be turned off without a physician's order. The DON further stated she was unaware of Nurse #1 turning the feeding tube pumps off for Resident #60 and Resident #74 which disregarded the physician's order. The DON further stated Nurse #1 should have assessed the residents (Resident #60 and Resident #74) and notified the physician of any changes in their condition before making any decisions on her own. The DON indicated she expected the nursing staff to follow the physician's orders as written as a part of a resident's necessary care and services. During an interview on 10/3/24 at 12:00 pm with the Physician, he stated he was not aware of Resident #60's and Resident #74's feeding tube pumps were being turned off. The Physician further stated if there had been a change in the residents' condition such as shortness of breath (SOB), vomiting, or gurgling that could have explained the feeding tube pumps being turned off; however, he was not notified of this for Resident #60 or Resident #74 at all. The physician explained one of his concerns were Resident #60 and Resident #74 not receiving the calories, and the nutrients provided from the tube feeding. Another concern noted by the Physician was the fact that Nurse #1 intentionally turned the feeding tube pumps off without notifying him before taking this action. The Physician indicated he did not like the nurses to make unreasonable decisions on their own without any notification. The Physician indicated that weight loss could happen as a result of the tube feeding pumps being turned off. He further explained Nurse #1's reason for the feeding tube pumps being turned off was not a good enough reason for Nurse #1 to make that decision. The Administrator was notified of Immediate Jeopardy on 10/4/24 at 6:37 pm. The facility provided the following credible allegation of immediate jeopardy removal: Identify recipients who have suffered or are likely to suffer a serious adverse outcome as a result of the non-compliance. On 10/3/24 the feeding pumps for Residents # 60 and # 74 were observed off for an undetermined amount of time. Both Residents # 60 and # 74 were determined to be at risk for neglect based on the actions of Nurse # 1. Nurse #1 was removed from the facility at approximately 7:30 pm on 10/3/24. Nurse #1 was terminated on 10/4/24. All residents in the facility are deemed to be at risk for serious adverse outcome including neglect, based on the actions of Nurse #1. On the morning of 10/3/24, upon notification of the problem, the Director of Nursing immediately went to the rooms of all tube feeders (9 in total) to assess the pump settings, dates and times of currently hung feedings, that pumps were on appropriately (per MD settings) and that feedings were infusing accurately (based on MD orders). Specify the action the entity will take to alter the system failure to prevent serious adverse outcomes from occurring or recurring. On the morning of 10/3/24 at approximately 8:30 am, the surveyors notified the Administrator of the tube feeding problem. Within minutes of the state notification, the Administrator notified the DON. The time was approximately 8:40 am. The Director of Nursing went immediately to the rooms of Residents #60 and #74 to assess the tube feeding status. Both residents were found to have feedings pumps that were on, both residents were found to have currently dated and timed feedings infusing per MD orders. The facility will ensure that all residents including residents # 60 and #74 are free from neglect - at all times. The Administrator, DON, and Corporate team will monitor the facility and patient care delivery every shift to ensure that the nutrition and hydration needs of all patients are met based on MD orders. The team will utilize our newly hired administrative nurse managers (including ADON, MDS nurses, treatment nurse, and resource nurses) facility management team, and lead CNAs to accomplish the shift to shift rounding. This rounding was initiated on 10/3/24. As additional personnel is utilized to complete this rounding, they will be educated. The DON, ADON, and nurse managers will review findings first thing every morning to ensure that appropriate and necessary action has been taken to remedy all identified negative findings. The Director will ensure that the MD is notified timely of all discrepancies and plans for correction. The Administrator, Director of Nursing, Corporate Clinical Director and RN / MDS Nurses began education sessions on 10/4/24 with all staff and included the following subjects: Resident rights to be free from abuse and neglect Reporting abuse and neglect Facility policy on Abuse, Neglect, and Exploitation Definitions of abuse and neglect Facility policies to ensure all residents are free of neglect and [NAME] employees. Education sessions will continue with all staff members until 100% of the employees have received education. No employee will be allowed to work until they have received the education. New hires are trained in orientation and education will continue within the facility to ensure understanding of abuse and neglect prevention, including our ZERO TOLERANCE position for [NAME] employees. The Chief Clinical Officer reviewed the general orientation requirements with the Clinical Nurse Consultant. This meeting was held on 10/3/24 the requirement for abuse training was re-enforced. The Director of Nursing, ADON, and nurse managers will review education session daily to ensure that all staff have received and that no staff members work prior to receiving it. Date of immediate jeopardy removal - 10/5/24 Validation of the credible allegation of IJ removal was completed on 10/8/24: Nurse #1 was suspended from the facility on 10/3/24. Nurse #1 was terminated on 10/4/24. In review of Nurse #1's Human Resource (HR) records revealed documentation of her disciplinary forms and a North Carolina Board of Nursing (NCBON) Complaint Evaluation Tool (CET) which was completed on 10/3/24 with an appointment scheduled with the Board of Nursing (BON) for Nurse #1 on 10/7/24 at 10 am. There was a signed roster of staff in all departments who participated in in-service for abuse and neglect dated 10/3/24 and 10/4/24. There was a signed roster of nursing staff who participated in in-service for tube feeding and following the physician order dated 10/3/24 and 10/4/24. The in-services were completed by 10/4/24. The following residents' tube feeding were observed, and orders checked for accuracy: Resident #s 4, 28, 38, 41, 60, 64, 74, 80, and 341. All tube feedings were running or on hold as ordered. On 10/8/24 at 11:30 am 2 nurses, 4 nursing assistants, the newly hired Assistant Director of Nursing (second day) and 1 housekeeping staff were interviewed. All staff had participated in abuse/neglect in-service and nursing staff participated in tube feed/following physician orders in-service in addition to the abuse in-service. The Director of Nursing provided documentation of the daily on-going audits of all residents that have an order for tube feeding to evaluate the status of the pump status/infusion rate and type of feed per physician order. The immediate jeopardy removal date of 10/5/24 was validated.

Based on record review and staff interviews, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required 14-day timeframe after the Assessment Reference Date (ARD, the last day of the assessment look-back period) for 8 of 21 residents' MDS assessments reviewed (Resident #s 5, 10, 13, 49, 62, 63, 69, and 71). Findings included: a. Resident #49 was admitted on [DATE]. Resident #49's quarterly MDS assessment with an Assessment Reference Date (ARD, the last day of the assessment look-back period) of 7/19/24 was incomplete when reviewed on 10/3/24. b. Resident #5 was admitted on [DATE]. Resident #5's quarterly MDS assessment with an Assessment Reference Date (ARD, the last day of the assessment look-back period) of 9/17/24 was in progress and was incomplete when reviewed on 10/3/24. c. Resident #71 was admitted on [DATE]. Resident #71's quarterly MDS assessment with an Assessment Reference Date (ARD, the last day of the assessment look-back period) of 9/13/24 was listed as in progress and was incomplete when reviewed on 10/3/24. 41387 d. Resident #13 was admitted on [DATE]. Resident #13's quarterly MDS assessment with an Assessment Reference Date (ARD, the last day of the assessment look-back period) of 9/16/24 was noted as in progress and was incomplete as of 10/2/24. e. Resident #62 was admitted on [DATE]. Resident #62's quarterly MDS assessment with an Assessment Reference Date (ARD, the last day of the assessment look-back period) of 8/29/24 was signed as completed on 10/2/24. f. Resident #63 was admitted on [DATE]. Resident #63's quarterly MDS assessment with an Assessment Reference Date (ARD, the last day of the assessment look-back period) of 8/15/24 was signed as completed on 9/24/24. g. Resident #69 was admitted on [DATE]. Resident #69's quarterly MDS assessment with an Assessment Reference Date (ARD, the last day of the assessment look-back period) of 8/17/24 was signed as completed on 9/24/24. h. Resident #10 was admitted to the facility on [DATE]. Resident #10's quarterly MDS assessment with an Assessment Reference Date (ARD, the last day of the assessment look-back period) of 8/13/24 was signed as completed on 9/24/24. During an interview with the Resource Nurse on 10/3/24 at 5:06 pm, she explained that quarterly MDS assessments were not completed within the 14 day time frame prior to 9/30/24 because there were no consistent MDS staff at the facility to complete the assessments except a part-time MDS nurse who worked twice a week. She further explained that the Administrator was aware the completion of quarterly MDS assessments were backed up and on 9/3/24 the administration asked her to help the MDS department to get caught up. During an interview with MDS Nurse #1 on 10/3/24 at 4:57 pm, she stated she started to work at the facility on 9/30/24. She explained there were several quarterly MDS assessments discovered on 9/30/24 which were incomplete, and they were working to complete these assessments. She further explained that quarterly MDS assessments were to be completed within fourteen days of the ARD. During an interview with the Clinical Nurse Consultant on 10/3/24 at 4:46 pm, she stated the quarterly MDS assessments should have been completed within the fourteen day regulation time frame. During an interview with the Administrator on 10/3/24 at 4:50 pm, he stated the quarterly MDS assessments needed to be completed within the regulatory fourteen day time frame. In a follow up interview on 10/4/24 at 1:15 pm, he explained when he started at the facility on 8/30/2024 he was aware the facility was behind in completing quarterly MDS assessments. He stated the facility had hired two MDS nurses and remote MDS nurses to help the facility catch up in completing the quarterly MDS assessments

Based on observations, record reviews, staff and physician interviews, the facility failed to administer tube feedings via a gastrostomy tube as ordered by the physician for 3 of 3 residents reviewed for nutrition maintenance (Resident #60, Resident #74, and Resident #341). The findings included: 1. Resident #60 was readmitted to the facility 8/7/24 with diagnoses which included anoxic brain damage, dysphagia (difficulty swallowing), chronic obstructive pulmonary disease, and acute respiratory failure. Review of Resident #60's Minimum Data Set (MDS) dated [DATE] revealed she was severely cognitively impaired. Resident #60 and completely dependent upon staff for all activities of daily living (ADL) and was coded for a feeding tube. Resident #60's active physician orders related to her tube feeding included the following: - every day and night shift tube feeding at 60 milliliters per hour (ml/hr) continuous (initiated on 9/30/24) - every 6 hours flush with 135 cubic centimeters (cc) for water flushes (initiated on 8/7/24) The Registered Dietician's (RD) nutritional assessment dated [DATE] recommended Resident #60 needed 1728 kilocalories (kcal) with 1708 cubic centimeters (cc) free water and 90.4 grams (g) of protein daily from her continuous tube feeding. Review of the RD's progress note for Resident #60 dated 8/21/24 revealed completed a readmission evaluation on 8/21/24 and noted no new recommendations, the tube feeding was adequate as ordered, and well tolerated with weight stability. The following observation was made of Resident #60: - 10/3/24 at 3:08 am Resident #60's feeding tube pump was turned off. An empty tube feeding bottle was hanging on the feeding tube pole. Review of Resident #60's weights revealed the following weights: - 6/3/24 255.0 pounds - 7/2/24 249.8 pounds - 8/8/24 267.8 pounds - 9/9/24 247.5 pounds In an interview on 10/3/24 at 3:43 am with Nurse #1 she indicated she was the nurse assigned for Resident #60. When asked Nurse #1 why the feeding tube pump was off for Resident #60, she replied she intentionally turned the feeding tube pump off because she thought her stomach needed a rest. Nurse #1 explained she made the decision on her own to turn the tube feeding pump off for 2 to 3 hours to give her stomach a rest. Nurse #1 indicated she was aware Resident #60 was on continuous tube feeding per physician orders which is part of Resident #60's necessary care and services. Review of Resident #60's electronic medical record (EMR) revealed no progress notes which documented turning the feeding tube pump off by Nurse #1. The following additional observations were made of Resident #60: - 10/3/24 at 3:53 am Resident #60's feeding tube pump continued to be turned off. - 10/3/24 at 7:53 am Resident #60's feeding tube pump was on with a new bottle of tube feeding dated 10/3/24 at 5:43 am. In a second interview on 10/3/24 at 3:26 pm with Nurse #1 she stated she turned Resident #60's and feeding tube pump off when she thought her stomach needed a rest. Nurse #1 stated she did this now and then but did not give a specific answer as to how many times she had turned the feeding tube pump off or when she first began turning off the feeding tube pump. When Nurse #1 was asked when she turned the feeding tube pump back on, Nurse #1 indicated Resident #60's feeding tube pump was turned on when she hung a new bottle of tube feeding at 5:43 am on 10/3/24. During an interview with the Registered Dietician (RD) on 10/3/24 at 9:00 am, he stated Resident #60 had lost some weight possibly due to being in and out of the hospital. Resident #60 was readmitted from the hospital on 8/7/24. The RD was not aware of Resident #60's feeding tube pump being turned off and did not understand why Nurse #1 intentionally turned the feeding tube pump off without notifying the physician. The RD indicated a continuous tube feeding may be turned off for a short amount of time to perform activities of daily living (ADL) or due to a change in condition, but not for 2 to 3 hours at a time unless ordered by the physician. The RD further explained Nurse #1 needed a physician's order to turn off the feeding tube pump, and he had not recommended this to the physician. The RD further stated turning the feeding tube pump off could have caused weight loss; however, his concern was the loss of calories and nutrients provided by the tube feeding. In an interview on 10/3/24 at 9:15 am with the Director of Nursing (DON), she stated continuous tube feedings should not be turned off without a physician's order. The DON further stated she was unaware of Nurse#1 turning the feeding tube pump off for Resident #60 which disregarded the physician's order. The DON further stated Nurse #1 should have assessed Resident #60 and notified the physician of any changes in her condition before making any decisions on her own. The DON indicated she expected the nursing staff to follow the physician's orders as written as a part of a resident's necessary care and services. During an interview on 10/3/24 at 12:00 pm with the Physician, he stated he was not aware of Resident #60's feeding tube pump being turned off. The Physician further stated if there had been a change in the residents' condition such as shortness of breath (SOB), vomiting, or gurgling that could have explained the feeding tube pump being turned off; however, he was not notified at all. The Physician explained one of his concerns was Resident #60 not receiving the calories, and the nutrients provided from the tube feeding. Another concern noted by the Physician was the fact that Nurse #1 intentionally turned the feeding tube pump off without notifying him before taking this action. The Physician indicated he did not like the nurses to make unreasonable decisions on their own without any notification. The Physician indicated that weight loss could happen as a result of the tube feeding pump being turned off. He further explained Nurse #1's reason for the feeding tube pump being turned off was not a good enough reason for Nurse #1 to make that decision. 2. Resident #74 was admitted to the facility on [DATE] with diagnoses which included dysphagia (difficulty swallowing), failure to thrive, dementia, and type 2 diabetes mellitus. The Registered Dietician's (RD) nutritional assessment dated [DATE] recommended Resident #74 needed 1980 kilocalories (kcal) with 1963 cubic centimeters (cc) free water and 83 grams (g) protein daily from her tube feeding for 22 continuous hours. Review of Resident #74's Minimum Data Set (MDS) dated [DATE] revealed she was severely cognitively impaired. Resident #74 required maximum assistance from staff with activities of daily living (ADL) and was coded for a feeding tube. Resident #74's active physician orders related to her tube feeding included the following orders: - continuous tube feeding via pump at 55 milliliters per hour (ml/hr) for nutritional support for 22 hours estimated 2 hours (scheduled for 8:00 am until 10:00 am) downtime to allow for activities of daily living (ADL) care (initiated on 7/11/24) - water flushes every 3 hours of 120 milliliters The following observation was made of Resident #74: - 10/3/24 at 3:10 am Resident #74's feeding tube pump was turned off. A tube feeding bottle with approximately 100 cubic centimeters (cc) was hanging on feeding tube pole. Review of Resident #74's weights revealed the following weights: - 7/11/24 154.9 pounds - 7/22/24 154.9 pounds - 8/6/24 156.6 pounds - 9/6/24 160.0 pounds In an interview on 10/3/24 at 3:43 am with Nurse #1 she indicated she was the nurse assigned for Resident #74. When asked Nurse #1 why the feeding tube pump was off for Resident #74, she replied she intentionally turned the feeding tube pump off because she thought her stomach needed a rest. Nurse #1 explained she made the decision on her own to turn the tube feeding pump off for 2 to 3 hours to give her stomach a rest. Nurse #1 indicated she was aware Resident #74 was on continuous tube feeding per physician orders which is part of Resident #74's necessary care and services. Review of Resident #74's electronic medical record (EMR) revealed no progress notes which documented turning the feeding tube pump off by Nurse #1. The following additional observations were made of Resident #74: - 10/3/24 at 3:55 am Resident #74's feeding tube pump continued to be turned off. - 10/3/24 at 7:55 am Resident #74's feeding tube pump was on with a new bottle of tube feeding dated 10/3/24 at 4:30 am. In a second interview on 10/3/24 at 3:26 pm with Nurse #1 she stated she turned Resident #74's feeding tube pump off when she thought her stomach needed a rest. Nurse #1 stated she did this now and then but did not give a specific answer as to how many times she had turned the feeding tube pump off or when she first began turning off the feeding tube pump. When Nurse #1 was asked when she turned the feeding tube pump back on, Nurse #1 indicated Resident #74's feeding tube pump was turned on when she hung a new bottle of tube feeding at 4:30 am on 10/3/24. During an interview with the Registered Dietician (RD) on 10/3/24 at 9:00 am, he stated Resident #74's weight had been stable. The RD was not aware of Resident #74's feeding tube pump being turned off and did not understand why Nurse #1 intentionally turned the feeding tube pump off without notifying the physician. The RD indicated continuous tube feedings may be turned off for a short amount of time to perform activities of daily living (ADL) or due to a change in condition, but not for 2 to 3 hours at a time unless ordered by the physician. The RD further indicated Resident #74 had a physician's order for her feeding tube pump to be turned off 2 hours a day (2hrs/day) to allow downtime for ADL care. The RD further explained Nurse #1 needed a physician's order to turn off the feeding tube pumps, and he had not recommended this to the physician. The RD further stated turning the feeding tube pump off could have caused weight loss; however, his concern was the loss of calories and nutrients provided by the tube feeding. During an interview with the Facility Nurse Consultant, Director Of Nursing, and Chief Clinical Officer on 10/4/24 at 12:33 pm, revealed the nursing supervision and monitoring interventions in place for Nurse # 1 after the incident in July 2024, included daily monitoring of essential reports in the electronic medical record (EMR) to assure nurse supervision of medication aides and all medications were completed timely and as ordered by the physician, and random unannounced facility visits which included evening, night, and weekend shifts. There was no written documentation for the plan of action for monitoring Nurse #1 provided by the facility. The Chief Clinical Officer explained that new nurses hired have a competency evaluation with a nurse skills checklist that is completed during orientation. Nurse #1's competency skills checklist was unable to be located. In an interview on 10/3/24 at 9:15 am with the Director of Nursing (DON), she stated continuous tube feedings should not be turned off without a physician's order. The DON further stated she was unaware of Nurse#1 turning the feeding tube pump off for Resident #74 which disregarded the physician's order. The DON further stated Nurse #1 should have assessed Resident #74 and notified the physician of any changes in their condition before making any decisions on her own. The DON indicated she expected the nursing staff to follow the physician's orders as written as a part of a resident's necessary care and services. During an interview on 10/3/24 at 12:00 pm with the Physician, he stated he was not aware of Resident #74's feeding tube pump being turned off. The Physician further stated if there had been a change in the residents' condition such as shortness of breath (SOB), vomiting, or gurgling that could have explained the feeding tube pumps being turned off; however, he was not notified at all. The Physician explained one of his concerns was Resident #74 not receiving the calories, and the nutrients provided from the tube feeding. Another concern noted by the physician was the fact that Nurse #1 intentionally turned the feeding tube pump off without notifying him before taking this action. The Physician indicated he did not like the nurses to make unreasonable decisions on their own without any notification. The Physician indicated that weight loss could happen as a result of the tube feeding pump being turned off. He further explained Nurse #1's reason for the feeding tube pump being turned off was not a good enough reason for Nurse #1 to make that decision. 50234 3. Resident #341 admitted to the facility on [DATE] with diagnoses including nontraumatic intracerebral hemorrhage (brain bleed), dysphagia (trouble swallowing), and had a gastrostomy tube (a g-tube, feeding tube into the stomach) and tracheostomy (breathing tube into the trachea). Resident #341's Minimum Data Set (MDS) dated [DATE] noted he was unable to participate in the assessment, had an altered level of consciousness, had a tracheostomy, and he had a g-tube and consumed more than 51% of his calories and more than 501 cubic centimeters (cc) of fluids through the g-tube. The MDS indicated he had an unhealed Stage IV wound (a wound down to the bone). Resident #341's physician orders dated 9/12/24 noted he was to receive tube feeding 1.5 calorie formula at 50 cc an hour and a water flush at a rate of 200 ml every 6 hours. Observation on 9/30/24 at 11:24 AM revealed Resident #341 was laying in bed with his eyes closed. He did not respond to any questions. The resident had a g-tube pump with a bottle of tube feeding 1.5 calorie formula and a bag of fluids hanging with formula infusing into the resident's g-tube. The pump settings were set to infuse 40 cc of formula every hour and 100 milliliters (ml) of fluid every 6 hours. There was approximately 250 cc remaining in the bottle. The tubing was the color of the resident's formula, indicating the formula was infusing into the resident's stomach. Observation on 09/30/24 at 3:47 PM revealed Resident #341 was laying in bed with his eyes closed. He did not respond to any questions. The resident had a g-tube pump with an almost full bottle of tube feeding 1.5 calorie formula and a bag of fluids hanging with formula infusing into the resident's g-tube. The pump settings were set to infuse 40 cc of formula every hour and 100 milliliters (ml) of fluid every 6 hours. The formula bottle was labeled as being started on 9/30 at 1:55 PM. There were no nurse's name or initials to indicate who had started the formula. The tubing was the color of the resident's formula, indicating the formula was infusing into the resident's stomach. Observation on 10/01/24 at 2:17 PM revealed Resident #341's g-tube pump settings were still set to infuse 40 cc of formula every hour and 100 milliliters (ml) of fluid every 6 hours. The tubing was the color of the resident's formula, indicating the formula was infusing into the resident's stomach. The formula bottle was labeled as being started on 9/30 at 1:55 PM and there was less than 200 cc left in the bottle. The bag of fluids were dated 9/30/24 and was approximately half full. In an interview on 10/01/24 02:23 PM, Nurse #2 said she had started Resident #341's g-tube formula on 9/20/24. She said she wrote down the formula and fluid rate based on what was already programmed into the pump but had not confirmed the rate with the orders. She said she had not seen any coughing, residual, reflux, or distress when she had worked with him that week that would cause her to reduce the rate of the feeding. She said one of the night shift nurses (name not recalled) told her the resident had been coughing a few days ago and thought the rate may have been reduced by the night nurse. She was not sure if the doctor was notified about the coughing. She looks for the most current order and confirmed the pump should have been set to infuse the formula at 50 cc an hour and for the fluids to be set to 200 ml every 6 hours. She was unable to find any other orders in the resident's chart. Attempts to interview the nurse who worked on 9/28-9/30/24 were not successful. In an interview on 10/03/24 at 10:43 AM, the Registered Dietitian (RD) said Resident #341's formula rate had been increased to provide extra nutrients for the resident's Stage IV wound. He said the resident would still be getting enough calories for the wound, but it was important for the resident to receive the ordered nutrients. In an interview on 10/03/24 at 12:06 PM, Resident #341's Physician said the resident needed to receive the ordered rate of formula for wound healing. The Physician said the resident was getting approximately 300 fewer calories, which was not enough to help heal his wound. The Physician was not notified by any staff that Resident #341 had been coughing or that he had any symptoms that would indicate a need to reduce the feeding rate. He said nurses should not be changing the resident's feeding rate without consulting him first. In an interview on 10/03/24 at 2:14 PM, the Director of Nursing (DON) said Resident #341 should have received the ordered feeding rate and she had not been notified of him being in distress which would indicate a need to turn the rate lower.

Based on interviews with staff and record reviews, the facility failed to ensure a resident's code status election was accurate throughout the medical record for 1 of 2 residents reviewed for advanced directives (Resident #341). The findings included: Resident #341 admitted to the facility on [DATE]. Resident #341's physician orders dated 9/09/24 through 10/01/24 did not note an order for a code status. In an interview on 10/01/24 02:23 PM, Nurse #2 said thought that Resident #341 had an order for a Full Code code status, meaning to attempt all resuscitative measures in case of cardiac arrest. She said she was told in report by another nurse (name not recalled) that he had a full code order. She said in an emergency, she would have looked in the medical record at the orders to see what his code status was. She looked in the resident's chart but was unable to find a code status order. She continued to review the resident's chart and found a hospital note dated 8/25/24 which indicated his code status was code with limitations. Nurse #2 said she did not know what that meant. She said when a resident was about to be admitted to the facility, the procedure was that the admissions office staff would tell nursing what the code status was. She said because there was no Do Not Resuscitate (DNR) order in the chart, Resident #341 would have been treated as as full code order and would have received all measures in case of an emergency. In an interview on 10/01/24 at 3:47 PM, the Admission Director said when a resident was admitted , she met with the resident and the resident's representative (RR). She explained what advanced directives were to the resident or RR. If the resident or RR requested a DNR, the Admissions Director filled out a form with them formally requesting a DNR code status and then provided it to the charge nurse on duty, who would then request an order and complete the DNR notification form. Resident #341's RR made the decision on code status because the resident was unable to make his own wishes known. The RR requested a DNR order and signed the with the Admissions Director. The Admissions Director notified the charge nurse but was not aware of what happened after that notification. She said she did not remember the name of the nurse because the nurse was new at the time but no longer worked at the facility. Resident #341's Do Not Resuscitate Request form dated 9/09/24 revealed the RR signed the form indicating Resident #341 was to have a DNR order. In an interview on 10/01/24 at 4:53 PM, the director of nurses (DON) said Resident #341 did not have a DNR order and said one was obtained and a notification form completed on 10/01/24 after the concern was identified by surveyor.

Based on record review and staff interviews, the facility failed to complete the admission Minimum Data Set (MDS) assessment within the required timeframe for 1 of 1 newly admitted resident reviewed for MDS assessments (Resident #341). Findings included: Resident #341 was admitted on [DATE]. Resident #341's admission Minimum Data Set (MDS) dated [DATE] had not been completed when reviewed on 10/01/24. During an interview on 10/03/24 at 3:17 pm, MDS Nurse #1 stated she was aware there were MDS assessments that had not been completed because there had been no full-time MDS staff for approximately 3 months until 9/30/24. The MDS staff were back-tracking to complete all assessments that were not completed. During an interview on 10/04/24 at 1:15 pm, the Administrator stated he was made aware that there were MDS assessments that had not been completed timely. He stated the facility had hired 2 full-time MDS nurses, and remote MDS nurses were helping the facility to get caught up.

Based on record review and staff interviews, the facility failed to ensure that a resident with diagnoses of mental disorders had received a Level 2 Preadmission Screening and Resident Review (PASRR) after admission to the facility for 1 of 2 residents reviewed for PASRR (Resident #26). Findings included: A PASRR Level 1 dated 6/22/2015 indicated Resident #26 did not meet the federal definition for mental illness and mental retardation. Resident #26 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a serious mental health condition that affects how people think, feel and behave) and bipolar disorder (a serious mental illness characterized by extreme mood swings). A physician order dated 8/2/24 recorded Resident #26 was ordered Haloperidol (an antipsychotic medication) 2 milligrams twice a day for paranoid schizophrenia. The admission Minimum Data Set (MDS) assessment dated [DATE] noted Resident #26 was not currently considered by the state level II PASRR process to have a serious mental illness. Resident #26's care plan dated 8/18/24 included the use of antipsychotic medications related to schizophrenia. Interventions included administering antipsychotic medications as physician ordered and monitoring for effectiveness. A psychiatric physician note dated 8/26/24 recorded Resident #26 had a history of paranoid schizophrenia and a bipolar disorder and reported Resident #26's history of behaviors included hallucinations, the refusal of foods, agitation and verbal aggression. The psychiatric physician plan for treatment consisted of no change in Resident #26's medication regimen. A quarterly MDS assessment dated [DATE] indicated Resident #26 was cognitively intact and received antipsychotic medications on a routine basis. A review of the September 2024 and October 2024 Medication Administration Record documented Resident #26's refusal of medications as a behavior. Haloperidol 2 milligrams was recorded as given daily as ordered. During a phone interview with the Social Worker on 10/3/24 at 4:25 pm, she explained Resident #26 was admitted prior to her employment at the facility at the end of September 2024. She stated she had not reviewed Resident #26's diagnoses since starting at the facility and this should have been reviewed on admission. She explained Resident #26's PASRR Level 1 determination was only valid for thirty days from the time of hospitalization . She further explained she had started the process for a PASRR Level 2 screening on 10/2/24 after there had been an inquiry regarding Resident #26's PASRR status. During an interview with the Clinical Nurse Consultant with the Administrator present on 10/3/24 at 4:31 pm, she stated the Social Worker should have submitted a PASRR Level 2 for Resident #26 due to Resident #26's admitting diagnoses of schizophrenia and bipolar disorder. The Clinical Nurse Consultant and the Administrator were unable to explain why a PASRR Level 2 had not been submitted for Resident #26.

Based on record review and staff interviews, the facility failed to create a baseline care plan within 48 hours of a resident's admission for 1 of 2 residents (Resident #341) reviewed for baseline care plans. The findings included: Resident #341 was admitted to the facility on [DATE] with diagnoses including nontraumatic intracerebral hemorrhage (brain bleed) and dysphagia (trouble swallowing). Resident #341's Minimum Data Set (MDS) assessment dated [DATE] noted he had no speech, could rarely or was unable to understand others, was unable to participate in the assessment, and had an unhealed Stage IV wound (a wound down to the bone). There was no documentation in the electronic medical record of a baseline care plan for Resident #341. In an interview on 10/03/24 at 4:54 PM, the Director of Nursing (DON) confirmed there was no baseline care plan completed for Resident #341. She said the baseline care plan should have been completed by the charge nurse within 48 hours of admission.

Based on record review, observation, resident representative interview, and staff interviews, the facility failed to provide incontinence care to a resident that was dependent on staff for activities of daily living (ADL) for 1 of 1 resident reviewed (Resident #20). Findings included: Resident #20 was admitted to the facility on [DATE] with diagnoses included non-Alzheimer's dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was moderately cognitively impaired and was frequently incontinent of urine and stool. The quarterly MDS indicated Resident #20 required partial assistance with toileting. Resident #20's care plan that was last reviewed on 8/3/24 stated Resident #20 was at risk for a not performing ADL due to impaired mobility and impaired cognition. Interventions included staff providing extensive assistance with toileting needs. Resident #20's care plan also included a focus for bowel and bladder incontinence. Interventions included staff monitoring Resident #20 for incontinence of urine and stool and cleaning the perineum (space between the anus and genitals) with each incontinent episode. On 10/2/24 at 11:20 am in an interview with Resident #20's Resident Representative, Resident #23 (who was also Resident #20's roommate), Resident #23 stated Resident #20's adult brief had not been changed since 9:00 pm on 10/1/24. Resident #23 stated no one had been into their room (Resident #20's and Resident #23's room) except to assist Resident #20 to eat breakfast. Resident #23's quarterly MDS assessment dated [DATE] indicated he was cognitively intact and he was observed during interviews alert and oriented to person, place, time and situation. On 10/2/24 at 11:25 am an interview was conducted with Resident #20. When Resident #20 was asked if her adult brief needed changing, she stated she did not think she was wet. Resident #20 agreed for nursing staff to check the adult brief for incontinence. On 10/2/24 at 11:26 am upon request of the surveyor, Nurse Aide (NA) #2 was observed checking Resident #20's adult brief for incontinence. Resident #20's adult brief was observed saturated with dark amber colored urine at the top of the adult brief. NA #2 stated Resident #20's adult brief was soaked and the pad underneath the resident was wet with urine also. There was no redness observed to Resident #20's skin. NA #2 was observed providing incontinent care to Resident #20, applying a clean adult brief and a new pad under Resident #20. On 10/02/24 at 11:30 am in an interview with NA #2, she explained NA #3 was the assigned nurse aide for Resident #20. On 10/2/24 at 11:33 am in an interview with NA #3, she stated at that time she had not checked Resident #20 for incontinence of urine or stool since she began her shift at 7:15 am. She stated she had only assisted Resident #20 with her breakfast meal and had informed Resident #20 she would come back. NA #3 stated she was to check residents every two hours and had been providing ADL care to other residents and was planning to address Resident #20's bath and incontinent needs next. In a follow up interview with NA #3 on 10/2/24 at 2:27 pm, she stated 10/2/24 was the first time caring for Resident #20 since she was readmitted to the facility. She explained before hospitalization , Resident #20 would inform the nursing staff when her adult brief needed to be changed. She explained Resident #20 informed her (NA #3) her adult brief did not need changed after assisting Resident #20 with feeding her breakfast. NA #3 stated she did not check Resident #20 at that time. NA #3 admitted Resident #20's ADL needs had changed since returning to the facility included assisting Resident #20 with feeding and the need to provide incontinent care because the resident wasn't able to walk to the bathroom and wasn't using her call light to communicate incontinent needs. On 10/2/24 at 3:45 pm in a phone interview with NA #1, she stated she had worked the 7:00 pm to 7:00 am shift on 10/1/24 and was assigned to Resident #20. She admitted she provided incontinent care to Resident #20 on 10/1/24 at approximately 10:00 pm and did not recheck Resident #20 for incontinent care needs the remaining time of her shift because Resident #23 (Resident #20's representative and roommate) had told her (NA #1) not to worry about checking on Resident #20 until day shift. NA #1 stated NA #4, who was assisting her with Resident #20's incontinent care, overheard Resident #23 requesting not to check Resident #20 during the night. NA #1 explained Resident #20 had not verbalized the need for incontinent care during her night shift. She reported there was a change in Resident #20's ADL abilities as she was no longer able to walk to the bathroom and use the call bell to verbalize incontinent needs since readmission to the facility. NA #1 said she did not notify the nurse or nurse aide reporting for the day shift on 10/2/24 that Resident #20 had not been checked or changed during the night because NA #3, who was assigned to Resident #20 on 10/2/24, had not reported to work before she left the facility. On 10/2/24 at 4:40 pm in an interview with NA #4, he stated he had helped NA #1 changed Resident #20's adult brief on the evening of 10/1/24. NA #4 recalled seeing NA #1 and Resident #23 (Resident #20's representative and roommate) talking and stated he did not recall hearing Resident #23 telling NA #1 not to check Resident #20 for ADL care during the night of 10/1/24. NA #4 stated nurse aides were to check all residents every 2-3 hours and as needed. On 10/2/24 at 4:43 pm in a follow up interview with Resident #23, he stated no one entered the room of Resident #20 and Resident #23 during the night of 10/1/24 and stated he did not tell NA #1 not to come into the room during the night to check on Resident #20 or that the morning nursing staff would change Resident #20. On 10/2/24 at 11:47 am in an interview with the Director of Nursing she stated nurse aides were to check Resident #20 every two hours entering Resident #20's room to check for incontinent needs. The DON stated since readmission to the facility due to a change in her health, Resident #20 required the nurse aides to check her for incontinent needs every two hours.

Based on record review and staff interviews, the facility failed to conduct and document an admission screening assessment to identify and communicate any changes in the resident's cognitive and functional levels after an hospitalization for 1 of 1 resident reviewed for activities of daily living (Resident #20). Findings included: Resident #20 was admitted to the facility on [DATE], with diagnoses that included non-Alzheimer's dementia. Resident #20 was discharged from the facility on 9/23/24 and readmitted to the facility on [DATE] with a diagnosis that included a fracture to right hip. The significant change Minimum Data Set (MDS) assessment dated [DATE] was reported as in progress and was not complete. The quarterly MDS dated [DATE] indicated resident #20 was moderately cognitively impaired and required assistance setting up her meal for eating, and supervision for mobility and transfers and partial assistance with toileting. The MDS also indicated Resident #20 was frequently incontinent of urine and stool. There was no nursing documentation since Resident #20's re-admission to the facility communicating the cognitive state and level of function of Resident #20 in the electronic medical record There was no admission screening assessment (an assessment that would determine changes in Resident #20's cognitive and functional levels) located in Resident #20's electronic medical record since her readmission on 09/27/24. In an interview with the Director of Nursing (DON) on 10/2/24 at 11:47 am, she stated on readmission to the facility, Resident #20 was not able to recognize her incontinent needs, and staff would need to check on Resident #20 every 2 hours. In an follow up interview with the DON on 10/2/24 at 4:34 pm, she stated Resident #20's admission screening assessment that would identify and communicate changes in Resident #20 when she was readmitted to the facility after hospitalization should have been completed for Resident #20 within 24 to 48 hours after returning to the facility. The DON further stated she was the nurse assigned to Resident #20's on 9/27/24 when Resident #20 returned to the facility, and she did not complete the admission screening assessment. The DON stated she left a packet with Resident #20's admission screening assessment inside at the nurses station and did not verbally inform Nurse #5, who was working 7:00pm to 7:00 am (night shift) on 9/27/24 of the need to complete Resident #20's admission screening assessment. In an interview with Nurse #5 on 10/3/24 at 3:20 am, she stated she worked from 7:00 pm to 7:00 am (night shift) on 9/27/24. She explained if Resident #20 returned to the facility at 6:00pm on 9/27/24, the DON assigned to Resident #20 was responsible for completing the admission screening assessment. Nurse #5 stated no one reported to her on 9/27/24 upon reporting to work that Resident #20 needed the admission screening assessment completed, and she had not seen a packet for Resident #20 with the admission screening assessment at the nurse's station. In an interview with the Clinical Nurse Consultant on 10/3/24 at 4:35 pm, she stated when Resident #20 was readmitted to the facility on [DATE], the DON assigned to Resident #20 should have started Resident #20's admission screening assessment to determine cognitive and functional changes. She explained if the DON was not able to complete Resident #20's admission screening assessment, the DON should have communicated the need for Resident #20's admission screening assessment to be completed to Nurse #5 who was working the night shift on 9/27/24.

Based on record review and staff interviews, the facility failed to have a registered nurse daily for 8 consecutive hours, 7 days a week for 3 of 60 days reviewed (8/3/24, 8/18/24 and 9/15/24). Findings included: A review of the facility's daily nurse staffing totals and nursing clock-in sheets for August and September of 2024 documented there was no registered nurse present for dates 8/3/24, 8/18/24, and 9/15/24. A telephone interview with the prior Director of Nursing was unsuccessful. On 10/3/24 at 5:30 pm an interview was conducted with the Chief Clinical Officer. The Chief Clinical Officer stated there was not a registered nurse present as required on 8/3/24, 8/18/24, and 9/15/24. The schedule only had licensed practical nurses and medication aides scheduled due to a lack of registered nurses available at the time. The facility had offered overtime and bonuses to the existing staff to cover. On 10/3/24 at 5:40 pm an interview was conducted with the Administrator. He stated he was not aware of the lack of registered nurses for the 3 dates.

Based on record review, staff and physician interviews, the facility failed to immediately notify the physician of a significant change in a resident's condition for 1 (Resident #1) of 3 sampled residents. The resident had episodes of nausea and vomiting, low blood pressure, and yellow skin discoloration. The resident was transferred to the hospital. The Immediate Jeopardy began on 5/31/14. The administrator was notified of the Immediate Jeopardy on 6/30/14 at 9:10 am. The Immediate Jeopardy was removed on 6/30/14 at 8:59 pm when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy (D). The facility was in the process of full implementation and monitoring of their corrective action. The findings included: Resident #1 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. The nurses note dated 5/28/14 through 5/30/14 documented the resident was alert and oriented. Review of the nurses note dated 5/31/14 at 1:21pm by Nurse #1 documented the resident was alert and oriented. The same note documented "resident has been sick this shift and has not eaten since breakfast, [MEDICATION NAME] administered for nausea and vomiting." The nurse's note further documented "Resident has been nauseated and throwing up since before lunch. Call light cord within reach." On 6/13/14 at 12:09 pm NA #2 was interviewed. NA #2 worked on the 7am -3 pm shift on 5/30/14 and 5/31/14 and she was assigned to take care of the resident. NA #2 stated the resident told her she did not feel well on Saturday (5/31/14) morning, she stated she (the resident) was nauseated. NA #2 stated she set Resident #1 up with her breakfast tray. She stated after Resident #1 took a couple of bites, she started throwing up. She stated she took the resident's vital signs after the vomiting episode and her blood pressure was low in the 80's over 50's. She stated "I think it was 89/50 to be exact." NA #2 stated she informed Nurse #1 of the resident's vital signs and recorded the vital signs on the sheet at the nurse's station. The NA stated Resident #1 did not eat lunch. The NA further stated the resident's family members came in around lunch time and asked why the resident was looking yellow. The NA stated she informed the family member that the resident was sick and not feeling well. The NA stated she informed the nurse of the resident's family members concerns and the resident's continued complaints of not feeling well. NA #2 further stated "(Resident #1) did not even go to therapy today because she was so sick and too weak." Review of the written statement by RN supervisor documented in part "On May 31st around lunchtime, I was called to (Resident #1's) room. When I entered the room, (Nurse #1) was cleaning up some vomitus off the resident's gown. The vomitus appeared to be some of the food resident was eating." During an interview on 6/13/14 at 12:58 pm, the OTA (Occupational Therapist Assistant) #1 stated the resident complained of not feeling well on 5/31/14. She further stated she worked with the resident from 12:15 pm to 12:30 pm approximately. She stated the resident complained of feeling tired and sick. She stated she scooted the resident up in bed to prepare her for her lunch meal. She stated the resident was sick and throwing up. She further indicated the resident was puffy and glossy from the [MEDICAL CONDITION]. She further stated she went and got Nurse #1. The OTA further stated after Nurse #1 assessed the resident and the nurse withheld treatment of [REDACTED]. She stated Nurse #1 informed her that she was calling the physician and possibly sending the resident out to the hospital. The OTA stated she went back about 30 minutes later to check on Resident #1 and could not understand why the resident had not been sent out to the hospital. The OT (Occupational Therapy) Daily Treatment Note dated 5/31/14 by OTA #1 read "Pt (patient) dependent with bed mobility. Pt provided optimal positioning in bed for lunch as pt too fatigued and complaining of nausea. Pt presented with cool moist skin and moderate [MEDICAL CONDITION] noted. After a couple of bites of food and sips of beverage patient vomited, OTA called nurse (Nurse #1) to room. After nurse assessment, nursing withheld treatment of [REDACTED]." On 6/13/14 at 11:17 am, NA #1 was interviewed. NA #1 worked the 7-3 shift on 5/31/14 but she was not responsible for this resident during this shift. NA#1 was responsible for this resident on the 3 pm -11 pm shift on 5/31/14. NA #1 stated Resident #1 complained of not feeling well at the beginning of the shift. She further stated Resident #1 vomited during her breakfast meal. NA #1 stated Resident #1 was not acting her normal self. The NA further stated "She was out of it, tired, sleepy and weak." NA #1 stated NA #2 had taken the resident's vital signs that morning after the vomiting episode and the blood pressure was low. The NA stated she remembered seeing the blood pressure reading on the machine after NA #2 took the vital signs for Resident #1. NA #1 further stated she worked a double shift and after 3 pm she was assigned to Resident #1. She stated when she went in to check on Resident #1 shortly after 3 pm, Resident #1's skin was yellow and her mouth was open. She stated she asked NA #3 to come and verify with her that the resident's color was yellow. She stated the resident was not talking straight to them. NA #2 further stated she went to the nurse's station and reported the findings to Nurse #1. She stated Nurse #1 told her she had given the resident some medication earlier. The NA stated she told Nurse#1 that the resident was still not feeling well. She stated after she left Nurse #1, she stopped by the Medication Aide on duty and informed her that the resident was not feeling well and was yellow in color. Review of a written statement by NA#1 documented in part "On Saturday, 5/31/14 (Resident #1) was very sick, sick vomiting and having diarrhea. As the day went on, (Resident #1) was still feeling bad. I asked (Nurse #1) around 2:45pm, what would we do about (Resident #1) because she was still doing bad. She raised her voice at me and stated "I can't send her out for vomiting and diarrhea. I then walked away. Around (time unclear) she was looking yellow. I told (NA #3) to look at her and she agreed with me. I then went to RN supervisor and asked her to look at (Resident #1) and she stated 'I'm sending her out, I've called EMS!'" During an interview on 6/13/14 at 11:40 am, Medication Aide #1 (worked 3-11 shift on 5/31/14) stated she was not informed of the resident's condition by the off-going nurse. The medication aide further stated she did not go in and actually see the resident after she assumed her duties for the hall at 3pm. She stated she was informed later in the shift by NA #1 that was on duty of the resident being sick during the day and vomiting. Review of the nurse's note dated 5/31/14 at 5:31pm by RN supervisor documented "Med Tech and CNA asked writer to come to room to assess resident (rsdt). Resident's family member was present and stated that resident was not responding normally, that she was pale in color and swollen. Writer noticed that resident was hard to arouse, cool and clammy with shallow respirations of 28. Oxygen saturation =78%. Foley with tea colored urine. Also, CNA informed writer that resident was not able to participate in PT (physical therapy) today. Writer, physician and resident's family member agree to send resident to the hospital for evaluation." Review of the "Physician Please Sign and Return" form revealed an order dated 5/31/14 at 4:55 pm for "Resident to hospital for evaluation for change in mental status, nausea and vomiting, weakness, Temperature of 99 degrees axillary per RP (responsible party) request, O2 sat =76%." On 6/13/14 at 10:32 am in an interview, the RN supervisor stated she was initially called to the resident's room about lunch time. She stated the resident had vomited a little bit and the assigned hall nurse stated she was going to give the resident a dose of [MEDICATION NAME]. The RN supervisor stated she was later told by the assigned nurse somewhere between 1pm and 2pm that the resident was just resting. The RN supervisor stated she did not personally do an assessment of the resident at the time of the vomiting episode. She further stated she looked at the emesis and it looked like the food she was eating. She stated the resident appeared [MEDICAL CONDITION] to her but she thought it was just obesity. The RN supervisor further stated she was not familiar with the resident because the resident was a new admission to the facility. She further indicated she was later called to the resident's room approximately 4:45 pm at the family member's request. She stated the resident's color had changed and her blood pressure was down. The RN supervisor stated she was aware of the resident's blood pressure being low earlier in the shift but she was advised by the assigned nurse that the resident's blood pressure normally run low. The RN supervisor stated she did not personally review the resident's recorded blood pressures to verify any history of low blood pressures. The RN supervisor further stated the resident's oxygen saturation was 76% on room air. The RN supervisor stated she went by the resident's room later during the day but she did not stop to check on the resident personally because she was told by the assigned hall nurse that the resident was resting. Review of written documentation from the local EMS (Emergency Medical Services) revealed the EMS unit arrival to the facility was 5:14 pm. Review of the patient record of the local Emergency Medical Services documented on 5/31/14 at 5:16 pm revealed "it was noted that the patient didn't have a radial pulse." The resident's record documented on 5/31/14 at 5:17 pm "Respirations 8 and shallow, pulse rate 38 and oxygen saturation of 78%." Further review of the patient record of the local Emergency Services documented "oxygen was initiated at 5:18 pm at 15 liters per a non-rebreather (nrb) mask due to SPO2 (peripheral capillary oxygen saturation) and decreased respirations. " Multiple attempts to contact Nurse #1 were unsuccessful. Attempts to contact Nurse #1 were made on 6/13/14 at 12:50 pm, 2:49 pm and 5:37 pm. The last attempt to contact Nurse #1 was made on 6/30/14 at 9:43 am. On 6/13/14 at 2:55 pm in an interview, the attending physician stated it was his expectation that the facility notify him immediately of a change in a resident's condition. After discussing the reports per the staff of the resident having nausea and vomiting, low blood pressure reading and yellow skin discoloration, the physician further stated "The three symptoms together meant something was going wrong here." The administrator was notified of the Immediate Jeopardy on 6/30/14 at 9:10 am. The Immediate Jeopardy was removed on 6/30/14 at 8:59 pm. The credible allegation read as follows: Resident # 1 was assessed by hall nurse on 5/31/14 and observed to have skin warm and dry, breathing even and unlabored, no productive cough present, lung sounds normal, 02 sats at 95% and nausea and vomited food. [MEDICATION NAME] given for Nausea and Vomiting on 5/31/14 by hall nurse per PRN as needed order. Med tech and Certified Nursing Assistant summons nursing supervisor to come to residents room to assess resident on 5/31/14. Resident #1 was assessed on 5/31/14 by the nursing supervisor for response, color, [MEDICAL CONDITION], respirations, 02 sats, and urine color in Foley. The RP was present during the assessment of resident #1 by nursing supervisor. The attending physician was made aware by telephone of resident #1 condition on being hard to arouse, cool and clammy with shallow respirations of 28, 02 sats at 76%, tea colored urine in Foley and not able to participate in therapy on 5/31/14. A telephone order was received on 5/31/14 from the attending physician at 4:55pm for resident #1 to be sent to (the hospital) for evaluation. Hall nurse on 7-3pm shift assigned to resident #1 during the acute change resigned on 6/2/14. All other licensed nurses were in-serviced on 6/18/14 by Staff Facilitator (Staff Educator) regarding notification to physician by telephone when an acute change in condition to include cognitive status, behavior, immune system response, normal body system functioning, changes in cognitive status, changes in behavior, changes in oral intake to include fluids, changes in immune system, changes in normal body functioning, Panic laboratory values, resident's condition warrants based upon nurse's assessment; If you are unable to reach Attending Physician, you may call On-call for physician; If you are unable to reach attending or on-call physician, you may call the facility's Medical Director. Notification of the physician of these types of changes in a resident's condition by fax is not acceptable. As of 6/30/14, all licensed nurses have been in-serviced on notification to physician by telephone when an acute change in condition to include cognitive status, behavior, immune system response, normal body system functioning, acute change in resident condition, changes in cognitive status, changes in behavior, changes in oral intake to include fluids, changes in immune system, changes in normal body functioning, Panic laboratory values, resident's condition warrants based upon nurse's assessment; If you are unable to reach Attending Physician, you may call On-call for physician; If you are unable to reach attending or on-call physician, you may call the facility's Medical Director; and Notification of the physician of these types of changes in a resident's condition by fax is not acceptable. Acute Change is defined as anything outside the norm for a resident to include but not limited to change in mental alertness and orientation, increased weakness or fatigue, change in abilities to feed, bathe, or groom self, change is sitting balance, transfer, or walk, change in appetite, change in ability to chew/swallow food, difficulty with breathing, complaints of dizziness, change in bowel elimination habits, complaints of nausea and vomiting, and falls. 100% audit of all resident's daily progress notes in last 30 days was initiated by MDS nurse Coordinator, MDS nurse, QI (quality improvement) nurse, Treatment nurse and Staff Facilitator on 6/19/14. 6/20/14, 6/21/14, 6/22/14, 6/23/14, 6/24/14, 6/25/14, 6/26/14, 6/27/14, 6/28/14, 6/29/14, and completed by 6/30/14 to ensure residents who have had an acute change in condition to include but not limited to change in mental alertness and orientation, increased weakness or fatigue, change in abilities to feed, bathe, or groom self, change is sitting balance, transfer, or walk, change in appetite, change in ability to chew/swallow food, difficulty with breathing, complaints of dizziness, change in bowel elimination habits, complaints of nausea and vomiting, and falls were assessed to include vital signs and 02 sats, appropriate interventions placed, and Attending Physician and Responsible Party were notified of acute change. One resident was identified to not have Attending Physician notification. The resident was assessed and Attending Physician notified on 6/19/14. This assessment along with interventions, Attending Physician and Responsible Party notification will be documented in the progress notes by the hall nurse. 100% head to toe assessment was completed by ADON, (assistant director of nursing) Staff Facilitator, QI nurse, MDS Coordinator, MDS nurse and Treatment nurse on 6/30/14 on all residents for any acute change in condition to include but not limited to change in mental alertness and orientation, increased weakness or fatigue, change in abilities to feed, bathe, or groom self, change is sitting balance, transfer, or walk, change in appetite, change in ability to chew/swallow food, difficulty with breathing, complaints of dizziness, change in bowel elimination habits, complaints of nausea and vomiting, and falls. The Attending Physician and Responsible Party will be notified and appropriate interventions initiated with all identified changes in condition to include but limited to change in mental alertness and orientation, increased weakness or fatigue, change in abilities to feed, bathe, or groom self, change is sitting balance, transfer, or walk, change in appetite, change in ability to chew/swallow food, difficulty with breathing, complaints of dizziness, change in bowel elimination habits, complaints of nausea and vomiting, and falls. This assessment, Attending Physician, Responsible Party notifications and appropriate interventions documented in the progress notes by the hall nurse. 100% of licensed nurses have been in-serviced on notification to physician by telephone when an acute changes in condition occur, including changes in cognitive status, behavior, oral changes to include fluids, immune system response, normal body system functioning, Panic laboratory values, resident's condition warrants based upon nurse's assessment; If you are unable to reach Attending Physician, you may call On-call for physician; If you are unable to reach attending or on-call physician, you may call the facility's Medical Director. Notification of the physician of these types of changes in a resident's condition by fax is not acceptable. All licensed nurses working have been in-serviced in notification of the physician completed on 6/30/14. The Staff nurse is responsible to assess, document, provide appropriate intervention and notify Attending Physician and Responsible Part of any acute changes in condition noted. The staff nurse will implement appropriate interventions based on the needs of the resident and notify Attending Physician and Responsible Party. All staff nurses will document all acute changes in condition on the 24 hour report/communication board daily. The staff nurses will communicate all acute changes utilizing the communication board during shift report. DON (director of nursing), ADON, and Weekend Supervisor will review the 24 hour/communication board utilizing a 24 hour report/communication tool daily to ensure all acute changes are identified and followed up with an assessment/intervention and Attending Physician and Responsible Party notification. The credible allegation completion date was set to be 6/30/14. On 6/30/14 at 9:01 pm, verification of the credible allegation was evidenced by interviews of licensed nursing staff related to notification of physician related to changes in a resident's condition. The licensed nursing staff verified examples of acute changes and the need for documentation in the medical record. The licensed nurses also verified the need to implement medical intervention as indicated for the change in condition and document the interventions.

Based on record review and staff interviews, the facility failed to comprehensively assess a change in a resident 's condition for 1 (Resident #1) of 3 sampled residents; and failed to initiate medical treatment of [REDACTED].#1) of 3 residents with an oxygen saturation of 78% for greater than 15 minutes. The Immediate Jeopardy began on [DATE]. The administrator was notified of the Immediate Jeopardy on [DATE] at 9:10 am. The Immediate Jeopardy was removed on [DATE] at 8:59 pm when the facility provided an acceptable Credible Allegation of Compliance. The facility will remain out of compliance at a scope and severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy (D). The facility was in the process of full implementation and monitoring their corrective action. The findings included: Resident #1 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. The nurses note dated [DATE] through [DATE] documented the resident was alert and oriented. Review of a written statement by NA #2 documented "On Saturday I told Nurse #1 that morning that Resident #1 was sick. She was vomiting that morning. I told her and she said that she gave her a pill. I got her blood pressure and it was too low and her pulse. Family member came in and said that she did not look right. I told Nurse #1 and she said that the resident was fine. I told her that morning that the woman should be sent out." On [DATE] at 12:09 pm NA #2 was interviewed. NA #2 worked on the 7am -3 pm shift on [DATE] and [DATE] and she was assigned to take care of the resident. NA #2 stated Resident #1 was feeling good the day before on Friday. She stated the resident stated she did not feel well on Saturday ([DATE]) morning, she stated she was nauseated. NA #2 stated she set Resident #1 up with her breakfast tray. She stated after Resident #1 took a couple of bites, she started throwing up. She stated she took the resident's vital signs after the vomiting episode and her blood pressure was low in the 80's over 50's. She stated "I think it was ,[DATE] to be exact." NA #2 stated she informed Nurse #1 of the resident's vital signs and recorded the vital signs on the sheet at the nurse's station. The NA stated Resident #1 did not eat lunch. The NA further stated the resident's family members came in around lunch time and asked why the resident was looking yellow. The NA stated she informed the family member that the resident was sick and not feeling well. The NA stated she informed the nurse of the resident's family members' concerns and the resident's continued complaints of not feeling well. She further stated "Resident #1 did not even go to therapy today because she was so sick and too weak." Review of the OT (Occupational Therapy) Daily Treatment Note dated [DATE] by OTA (Occupational Therapy Assistant) #1 documented "Pt (patient) dependent with bed mobility. Pt provided optimal positioning in bed for lunch as pt too fatigued and complaining of nausea. Pt presented with cool moist skin and moderate [MEDICAL CONDITION] noted. After a couple of bites of food and sips of beverage patient vomited, OTA called nurse to room. After nurse assessment, nursing withheld treatment of [REDACTED]." During an interview on [DATE] at 12:58 pm, the OTA (Occupational Therapist Assistant) #1 stated the resident complained of not feeling well on [DATE]. She further stated she worked with the resident from 12:15 pm to 12:30 pm approximately. She stated the resident complained of feeling tired and sick. She stated she scooted the resident up in bed to prepare her for her lunch meal. She stated the resident was sick and throwing up. She further indicated the resident was puffy and glossy from the [MEDICAL CONDITION]. She further stated she went and got Nurse #1. The OTA further stated after Nurse #1 assessed the resident and the nurse withheld treatment of [REDACTED]. She stated Nurse #1 informed her that she was calling the physician and possibly sending the resident out to the hospital. The OTA stated she went back about 30 minutes later to check on Resident #1 and could not understand why the resident had not been sent out to the hospital. Review of the nurses note dated [DATE] at 1:21 pm by Nurse #1 documented the resident was alert and oriented. The same note documented "resident has been sick this shift and has not eaten since breakfast, [MEDICATION NAME] administered for nausea and vomiting." The nurse's note further documented "resident resting in room. Able to make wants/needs known to staff. Skin warm and dry. Breathing even and unlabored. Meds tolerated well. Resident has been nausea and throwing up since before lunch. Call light cord within reach." Review of the Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. Multiple attempts to contact Nurse #1 were unsuccessful. Attempts to contact Nurse #1 were made on ,[DATE] at 12:50 pm, 2:49 pm and 5:37 pm. The last attempt to contact Nurse #1 was made on [DATE] at 9:43 am. Review of a written statement by NA #1 read in part "On Saturday, [DATE] Resident #1 was very sick, sick vomiting and having diarrhea. Her Aid (NA#2) took her vitals and informed Nurse #1 that she wasn't doing well. As the day went on, Resident #1 was still feeling bad. I asked Nurse #1 around 2:45pm, what would we do about Resident #1 because she was still doing bad. She raised her voice at me and stated "I can't send her out for vomiting and diarrhea. I then walked away. Around (time unclear) she was looking yellow. I told NA #3 to look at her and she agreed with me. I then went to RN supervisor and asked her to look at Resident #1 and she stated "I'm sending her out, I've called EMS!" Nurse #1 was asked to get oxygen for Resident #1. After about ,[DATE] minutes, I looked for Nurse #1. She was at the nurse's station doing her MARS (Medication Administration Records). I asked Nurse #1 where was the oxygen? Nurse #1 stated "I don't have keys to the room and I'm not on the hall anymore. She never got the oxygen that the RN supervisor asked her to get." On [DATE] at 11:17 am NA #1 was interviewed. NA #1 worked the ,[DATE] shift on [DATE] but she was not responsible for this resident during this shift. NA#1 was responsible for this resident on the 3 pm -11 pm shift on [DATE]. NA #1 stated Resident #1 complained of not feeling well at the beginning of the shift. She further stated Resident #1 vomited during her breakfast meal. NA #1 stated Resident #1 was not acting her normal self. The NA further stated "She was out of it, tired, sleepy and weak." NA #1 stated NA #2 had taken the resident's vital signs that morning after the vomiting episode and the blood pressure was low. The NA stated she remembered seeing the blood pressure reading on the machine after NA #2 took the vital signs for Resident #1. NA #1 further stated she worked a double shift and after 3 pm she was assigned to Resident #1. She stated when she went in to check on Resident #1 shortly after 3 pm, Resident #1's skin was yellow and her mouth was open. She stated she asked NA #3 to come and verify with her that the resident's color was yellow. She stated the resident was not talking straight to them. NA #2 further stated she went to the nurse's station and reported the findings to Nurse #1. She stated Nurse #1 told her she had given the resident some medication earlier. The NA stated she told Nurse #1 that the resident was still not feeling well. She stated after she left Nurse #1, she stopped by the Medication Aide on duty and informed her that the resident was not feeling well and was yellow in color. In an interview on [DATE] at 1:52 pm, NA # 3 stated she was asked by NA #1 on [DATE] to come look at the resident to see if she looked yellow to her. The NA stated Resident #1 was sick and her skin was yellow. NA #3 further stated "She did not look good and she was just laying there." During an interview on [DATE] at 11:40 am, Medication Aide #1 (worked ,[DATE] shift on [DATE]) stated she was not informed of the resident's condition by the off-going nurse. The Medication Aide further stated she did not go in and actually see the resident after she assumed her duties for the hall at 3pm. She stated she was informed later in the shift by NA #1 that was on duty of the resident being sick during the day and vomiting. The Medication Aide stated the daughter came up to her in the hall around 4:30 pm and asked what was wrong with Resident #1. She stated she informed the family member that nothing was wrong with the resident that she was aware of. The medication aide stated she continued her medication pass. She further stated a few minutes later she asked the RN supervisor to go and check the resident. The Medication Aide stated she was informed by the RN supervisor later that the resident was being sent to the hospital. Review of the nurse's note dated [DATE] at 5:31 pm by RN supervisor read "Med Tech and CNA asked writer to come to room to assess resident (rsdt). Resident's family member was present and stated that resident was not responding normally, that she was pale in color and swollen. Writer noticed that resident was hard to arouse, cool and clammy with shallow respirations of 28. Oxygen saturation =78%. Foley with tea colored urine. Also, CNA informed writer that resident was not able to participate in PT (physical therapy) today. Writer, physician and resident's family member agree to send resident to the hospital for evaluation. See VS's (vital signs). Resident's family member to meet resident at the hospital." Review of the written statement by RN supervisor read in part "On [DATE]st around lunchtime, I was called to (Resident #1's) room. When I entered the room, Nurse #1 was cleaning up some vomitus off the resident's gown. The vomitus appeared to be some of the food resident was eating. Then around 4:45 pm, I was called to (Resident #1's) room again. This time I was greeted by the resident's family member who asked if I could help her with Resident #1. I asked her what she needed me to do and she stated Resident #1 was not doing good. I asked her what she thought was different about Resident #1. She told me that Resident #1 was swollen, that her color was not good and that she was not acting right. I told the resident's family member that I could send Resident #1 out to the hospital for evaluation and she agreed. After the resident's family member was out of the room, I quickly assessed the resident. EMS and the attending physician were called. Nurse #1 did offer to get the oxygen but did not immediately because EMS had already been called. However after a few minutes and the fact that EMS had not gotten there, I asked the CNA to have Nurse #1 get oxygen. CNA came back to the room and stated that Nurse #1 said she was off the floor and someone else needed to get the oxygen. EMS arrived shortly and resident was transferred to the hospital." On [DATE] at 10:32 am in an interview, the RN supervisor stated she was initially called to the resident's room about lunch time. She stated the resident had vomited a little bit and the assigned hall nurse stated she was going to give the resident a dose of [MEDICATION NAME]. The RN supervisor stated she was later told by the assigned nurse somewhere between 1pm and 2pm that the resident was just resting. The RN supervisor stated she did not personally do an assessment of the resident at the time of the vomiting episode. She further stated she looked at the emesis and it looked like the food she was eating. She stated the resident appeared [MEDICAL CONDITION] to her but she thought it was just obesity. The RN supervisor further stated she was not familiar with the resident because the resident was a new admission to the facility. She further indicated she was later called to the resident's room approximately 4:45 pm at the family member's request. She stated the family member was concerned about the resident and stated she was not acting right. She stated the resident's color had changed and her blood pressure was down. The RN supervisor stated she was aware of the resident ' s blood pressure being low earlier in the shift but she was advised by the assigned nurse that the resident's blood pressure was normally low. The RN supervisor stated she did not personally review the resident's recorded blood pressures to verify any history of low blood pressures. The RN supervisor further stated the resident's oxygen saturation was 76% on room air. The RN supervisor stated she did not provide any medical intervention for the resident's low oxygen saturation because EMS had been called and they usually get there within a few minutes. She further stated that EMS took longer to get to the facility on [DATE] but she did not provide any oxygen to the resident. The RN supervisor stated she was later told after she sent the resident to the hospital that the resident was not able to participate in therapy that morning because she was too weak. The RN supervisor stated she went by the resident's room later during the day but she did not stop to check on the resident personally because she was told by the assigned hall nurse that the resident was resting. Review of the "Physician Please Sign and Return" form revealed an order dated [DATE] at 4:55 pm for "Resident to hospital for evaluation for change in mental status, nausea and vomiting, weakness, Temperature of 99 degrees axillary per RP (responsible party) request, O2 sat =76%." Review of the Emergency Medical Services Report dated [DATE] documented "the patient was found lying in bed not real responsive and was very pale almost light blue in color from the neck up." Review of written documentation from the local EMS (Emergency Medical Services) documented the 911 call was placed at 5:00 pm and the time of the EMS unit arrival to the facility was 5:14 pm. Review of the patient record of the local emergency services dated on [DATE] at 5:16pm read, " it was noted that the patient didn't have a radial pulse." The patient record documented on [DATE] at 5:17 pm "Respirations 8 and shallow, pulse rate 38 and oxygen saturation of 78%." Further review of the patient record of the local emergency services documented "oxygen was initiated at 5:18 pm at 15 liters per a non-rebreather (nrb) mask due to SPO2 (peripheral capillary oxygen saturation) and decreased respirations." The same report documented on [DATE] at 5:28 pm read "the patient's SPO2 started to improve and her color also started to improve." Review of the local hospital emergency room report documented "when EMS arrived, the patient was basically a [MEDICATION NAME] (sic) and blood pressure was in the 60 systolic." On [DATE] at 2:55 pm in an interview, the attending physician stated the sooner a resident is evaluated, the more likely the outcome would be different for the resident. After discussing the reports per the staff of the resident having nausea and vomiting, low blood pressure reading and yellow skin discoloration, the physician further stated, "The three symptoms together meant something was going wrong here." In an interview on [DATE] at 11:38 am, the Director of Nursing (DON) stated an investigation was initiated on [DATE] regarding the care delivery for Resident #1. The DON further revealed the facility was not aware of the oxygen not being readily accessible to the nurses until [DATE] at which time the lock on the oxygen room was changed to a keypad where a key would not be required. During an interview on [DATE] at 11:48 am, the Director of Emergency Services stated Resident #1 was cyanotic (blue in color) from a lack of oxygen on EMS arrival to the facility. He further stated the resident did not have a palpable pulse at the wrist due to the low blood pressure. He stated EMS was not able to obtain a blood pressure initially but the first obtainable blood pressure was ,[DATE]. The resident died on [DATE]. The facility provided the following Credible Allegation on [DATE] at 8:59 pm. Credible Allegation of Compliance: F-Tag 309 For the Provision of Care to Maintain the highest level of function for residents. Completion date [DATE] ? Resident # 1 was assessed by hall nurse on [DATE] and observed to have skin warm and dry, breathing even and unlabored, no productive cough present, lung sounds normal, 02 sats at 95% and nausea and vomited food. [MEDICATION NAME] given for Nausea and Vomiting on [DATE] by hall nurse per PRN as needed order. Med tech and Certified Nursing Assistant summons nursing supervisor to come to residents room to assess resident on [DATE]. Resident #1 was assessed on [DATE] by the nursing supervisor for response, color, [MEDICAL CONDITION], respirations, 02 sats, and urine color in foley. The RP was present during the assessment of resident #1 by nursing supervisor. The attending physician was made aware by telephone of resident #1 condition on being hard to arouse, cool and clammy with shallow respirations of 28, 02 sats at 76%, tea colored urine in foley and not able to participate in therapy on [DATE]. A telephone order was received on [DATE] from the attending physician at 4:55pm for resident #1 to be sent to Betsy Johnson Hospital for evaluation. Hall nurse assigned to resident #1 during the acute change resigned on [DATE]. All other licensed nurses were in-serviced on [DATE] by Staff Facilitator (Staff Educator) regarding notification to physician by telephone when an acute change in condition to include cognitive status, behavior, immune system response, normal body system functioning, changes in cognitive status, changes in behavior, changes in oral intake to include fluids, changes in immune system, changes in normal body functioning, Panic laboratory values, resident ' s condition warrants based upon nurse ' s assessment; If you are unable to reach Attending Physician, you may call On-call for physician; If you are unable to reach attending or on-call physician, you may call the facility ' s Medical Director. Notification of the physician of these types of changes in a resident ' s condition by fax is not acceptable. As of [DATE], all licensed nurses have been in-serviced on notification to physician by telephone when an acute change in condition to include cognitive status, behavior, immune system response, normal body system functioning, acute change in resident condition, changes in cognitive status, changes in behavior, changes in oral intake to include fluids, changes in immune system, changes in normal body functioning, Panic laboratory values, resident ' s condition warrants based upon nurse ' s assessment; If you are unable to reach Attending Physician, you may call On-call for physician; If you are unable to reach attending or on-call physician, you may call the facility ' s Medical Director; and Notification of the physician of these types of changes in a resident ' s condition by fax is not acceptable. ? Acute Change is defined as anything outside the norm for a resident to include but not limited to change in mental alertness and orientation, increased weakness or fatigue, change in abilities to feed, bathe, or groom self, change is sitting balance, transfer, or walk, change in appetite, change in ability to chew/swallow food, difficulty with breathing, complaints of dizziness, change in bowel elimination habits, complaints of nausea and vomiting, and falls. ? 100% audit of all residents daily progress notes in last 30 days was initiated by MDS nurse Coordinator, MDS nurse, QI nurse, Treatment nurse and Staff Facilitator [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and completed by [DATE] to ensure residents who have had an acute change in condition to include but not limited to change in mental alertness and orientation, increased weakness or fatigue, change in abilities to feed, bathe, or groom self, change is sitting balance, transfer, or walk, change in appetite, change in ability to chew/swallow food, difficulty with breathing, complaints of dizziness, change in bowel elimination habits, complaints of nausea and vomiting, and falls were assessed to include vital signs and 02 sats, appropriate interventions placed, and Attending Physician and Responsible Party were notified of acute change. One resident was identified to not have Attending Physician notification. The resident was assessed and Attending Physician notified on [DATE]. This assessment along with interventions, Attending Physician and Responsible Party notification will be documented in the progress notes by the hall nurse. 100% head to toe assessment was completed by ADON, Staff Facilitator, QI nurse, MDS Coordinator, MDS nurse and Treatment nurse on [DATE] on all residents for any acute change in condition to include but not limited to change in mental alertness and orientation, increased weakness or fatigue, change in abilities to feed, bathe, or groom self, change is sitting balance, transfer, or walk, change in appetite, change in ability to chew/swallow food, difficulty with breathing, complaints of dizziness, change in bowel elimination habits, complaints of nausea and vomiting, and falls. The Attending Physician and Responsible Party will be notified and appropriate interventions initiated with all identified changes in condition to include but limited to change in mental alertness and orientation, increased weakness or fatigue, change in abilities to feed, bathe, or groom self, change is sitting balance, transfer, or walk, change in appetite, change in ability to chew/swallow food, difficulty with breathing, complaints of dizziness, change in bowel elimination habits, complaints of nausea and vomiting, and falls. This assessment, the Attending Physician, Responsible Party notifications and appropriate interventions will be documented in the progress notes by the hall nurse. ? 100% in-service was initiated with all C.N.A ' s, Housekeeping, Dietary and Therapy staff on [DATE] on all shifts by Staff Facilitator regarding observation and reporting changes in resident ' s condition promptly to the hall nurse or supervisor. 100% in-service was initiated on [DATE] on the completion of The Early Warning Tool " Stop and Watch " tool and to be completed by C.N.A ' s, licensed nurses, housekeeping, dietary, Therapy staff on any acute change in condition noted to include Seems different than usual, talks or communicates less than usual, overall needs more help than usual, participated in activities less than usual, ate less than usual (not because of dislike of food), Drank less than usual, weight change, agitated or nervous more than usual, tired, weak, confused, or drowsy, change in skin color or condition, and help with walking, transferring, toileting more than usual and given to hall nurse. No staff will be allowed to work until they have received in-service. The hall nurse will follow up when the Early Warning Tool by assessing the resident, reporting to Attending Physician and Responsible Party, appropriate interventions initiated and documentation is in progress notes. The Early Warning Tool will be placed in the DON mailbox for review to ensure that the resident was assessed, reporting to Attending Physician and Responsible Party was completed, appropriate interventions initiated and documentation is in progress notes. Other examples of changes in resident condition in-service included in the in-service were; change in mental alertness and orientation, increased weakness or fatigue, change in abilities to feed, bathe, or groom self, change in sitting balance, transfer, or walk, change in appetite, change in ability to chew/swallow food, difficulty with breathing, complaints of dizziness, change in bowel elimination habits, complaints of nausea and vomiting, and falls; If you notice an acute change in a resident you must report it to the hall nurse immediately; If you feel that the resident ' s acute change in condition has not been addressed; report the change in the resident to the supervisor or another hall nurse if supervisor is not available; If you feel that the acute change has still not been addressed, then the DON or ADON must be notified. All but four staff members have been in-serviced regarding observation and reporting changes in condition promptly to the hall nurse. These four employees will not be allowed to work until in-serviced. All newly hired C.N.A ' s, Housekeeping, Dietary and Therapy Staff will be in-serviced in orientation regarding acute changes in condition. 100% of all licensed nurses have been in-serviced on notification to physician by telephone to include second shift, third shift and weekends; when an acute changes in condition occur, including changes in cognitive status, behavior, oral changes to include fluids, immune system response, normal body system functioning, Panic laboratory values, resident ' s condition warrants based upon nurse ' s assessment; If you are unable to reach Attending Physician, you may call On-call for physician; If you are unable to reach attending or on-call physician, you may call the facility ' s Medical Director. Notification of the physician of these types of changes in a resident ' s condition by fax is not acceptable. All licensed nurses working have been in-serviced in notification of the physician completed on [DATE]. All newly hired licensed nurses will be in-serviced in orientation on notification of physician on resident acute changes in condition. ? The Staff nurse is responsible to assess, document, provide appropriate intervention and notify Attending Physician and Responsible Part of any acute changes in condition noted. The staff nurse will implement appropriate interventions based on the needs of the resident and notify Attending Physician and Responsible Party. All staff nurses will document all acute changes in condition on the 24 hour report/communication board daily. The staff nurses will communicate all acute changes utilizing the communication board during shift report. DON, ADON, and Weekend Supervisor will review the 24 hour/communication board utilizing a 24 hour report/communication tool daily to ensure all acute changes are identified and followed up with an assessment/intervention and Attending Physician and Responsible Party notification. On [DATE] at 8:59 pm, verification of the credible allegation was evidenced by interviews of licensed nursing staff related to acute changes, assessment and documentation in the medical record. Nurses verified the need to assess a resident exhibiting a change in condition, document the findings and notify the physician and responsible party. Verification of the credible allegation was also evidenced by interviews of all staff on reporting change to the hall nurse continuing up to the DON or ADON if necessary. The staff verified the implementation of the STOP WATCH documentation to be completed when a change in condition is identified in a resident.

Based on staff interviews and record review, the facility failed to intervene for a resident experiencing pain with associated injury for 1 of 3 resident's (resident #1) reviewed for pain. Findings include: Resident #1 was admitted on [DATE] with cumulative [DIAGNOSES REDACTED]. Her annual Minimum (MDS) data set [DATE] indicated she had severe cognitive impairment and required extensive assistance with bed mobility, total assistance of one using a lift, non-ambulatory and total assistance for all other activities of daily living. Resident #1 was care planned for pain associated with [MEDICAL CONDITION], arthritis and decreased mobility. A nursing note dated 5/1/14 and timed 8:07 AM, read that resident #1 was fussy during the beginning of third shift. Nursing assistant (NA) #1 was concerned about resident #1's right upper leg. Nurse #1 assessed the leg and noted slight swelling but resident #1 able to move both legs without problem. There was no noted increased grimacing when moving her right leg. A nursing note dated 5/1/14 and timed 2:41 PM, read the third staff noted abnormal rotation and [MEDICAL CONDITION] to resident #1's right upper leg. The leg was outwardly rotated and absent of obvious signs of trauma such as bruising. There was noted increased pain. An x-ray was ordered. A review of an incident report dated 5/1/14 indicated resident #1 was noted with abnormal rotation of the right leg by the third shift staff. There was observed swelling to the right thigh and evidence of pain. Witness statements from NA #1 indicated resident #1 was yelling when she came in at 11:00 PM. She recalled resident #1 yelling most of the shift and other staff working witnessed her yelling. NA #1 notified the nurse that resident #1's right foot was turned outward the right thigh was swollen. The witness statement from nurse #1 stated that NA #1 reported resident #1 was fussy but would quiet down. She administered her breathing treatment and medicated her with Tylenol for pain at the beginning of the shift. It was around 3:30 AM, NA#1 reported concerns about resident #1's right leg. Nurse #1 assessed her and resident #1 was able to move both legs and did not yell. At the end of the shift she stated the right foot looked more rotated. In an interview on 5/14/14 at 12:10 PM, nurse #2 who worked first shift on 5/1/14 stated nurse #1 reported to her that resident #1 was fussy on third shift and that NA #1 thought something was wrong with her leg. Nurse # 1 and nurse #2 went to assess resident #1. Nurse #2 stated she knew immediately something was wrong with resident #1's right leg and she was moaning. Nurse #2 went and got the staff facilitator and physical therapist to assess resident #1's leg. Nurse #2 advised nurse #1 she needed to notify the physician and get an order for [REDACTED].#2 stated the x-ray technician stated resident #1 was experiencing pain during x-ray so he stopped and spoke with the assistant director of nursing (ADON) about resident #1 pain. Nurse #2 stated the x-ray was positive for a right femur fracture and she notified the RP and physician. The physician ordered an orthopedic consult and a medication for pain. Nurse #2 stated she was unable to get an appointment with an orthopedic doctor until the following Monday but due to resident #1's pain, the RP requested resident #1 to be sent to the hospital for an evaluation. She stated she administered the ordered pain medication to resident #1 at 12:00 PM prior to her being transported to the hospital. In an interview on 5/14/14 at 12:20 PM, nurse #3 recalled resident # 1 slept most of the day on second shift on 4/30/14. She recalled the NA #3 put resident #1 to bed at the early part of second shift and it was at the end of the shift she noted resident #1 yelling. Nurse #3 stated she did not go and assess resident #1 because she had reported off to nurse #1. In an interview on 5/14/14 at 12:40 PM, NA #2 stated she worked with resident #1 on first shift 4/30/14 and she had gotten resident #1 up in her chair using the lift before lunch and when she left for the day, resident #1 was still sitting up in her chair. NA #2 stated resident #1's care guide indicated she was a lift with one person assistance. She exhibited her usual behavior of babbling but expressed no yelling or evidence of pain. In a telephone interview on 5/14/14 at 12:45 PM, NA #1stated she heard resident #1 yelling when she came in on for her shift at 11:00 PM on 4/30/14. NA #1 stated she requested nurse #1 give resident #1 something for pain and she continued with making her first rounds of the shift. NA #1 stated it was about 10 minutes later that resident #1 again began yelling and she noted her peers discussed that something was wrong with resident #1 because it was not like her to yell. Na #1 stated she went into the room and pulled the cover back to check to see if resident #1 was wet and she noticed her thigh was swollen. NA #1 stated she went and told nurse #1 but nurse #1 did not go and assess resident #1 at that time. NA #1 stated at around 3:00 AM or 4:00 AM, she and nurse #1 went together to look at resident #1's right leg. Nurse #1 stated it looked normal but did appear slightly swollen to her right thigh. At the end of her shift, NA # 1 noted resident #1 was still yelling when she left at 7:00 AM. In an interview on 5/14/14 at 1:40 PM, the ADON stated resident #1 never yelled or screamed and her normal behavior was verbal gibberish. She recalled the staff facilitator telling her that resident #1's leg did not look right but she did not appear in pain. She recalled getting an order for [REDACTED].#1 pain and got an order for [REDACTED]. In a telephone interview on 5/14/14 at 1:45 PM, NA #3 stated when she came in at 3:00 PM on 5/1/14, resident #1 was sitting up in her chair. She stated she used the lift to put resident #1 into the bed and made rounds on her at approximately 8:00 PM and again at 10:30 PM. NA #3 recalled resident #1 being wet at 10:30 PM so she rolled resident #1 onto her left side using the lift pad and changed her brief. NA #3 stated resident #1 did not exhibit any overt signs of pain while care was provided. It was at around 10:50 PM, she heard resident #1 yelling. She stated she went into the room to check resident #1 but did not touch her or remove her covers to see her body. In an interview on 5/14/14 at 2:20 PM, the staff facilitator stated nurse #2 asked her to assess resident #1's right leg. She recalled asking the physical therapist (PT) to go with her to assess resident #1. The staff facilitator stated resident #1's right foot was turned outward and her right thigh was swollen but resident #1 was not yelling out in pain. In an interview on 5/14/14 at 2:30 PM, the PT stated on assessment of resident #1's right leg on 5/1/14, she observed resident #1 thrashing about in the bed. She was not screaming but she was crying and grimacing. The PT stated she felt a boney prominence to the right lateral side of the hip and thought resident #1 ' s right leg was either dislocated or fractured. The PT noted the leg being externally rotated as well. She suggested an x-ray of the entire leg and not just the hip to rule out a femur fracture. In a telephone interview on 5/14/14 at 2:45 PM, NA #4 stated she heard resident #1 yelling and hollering when she came in on third shift 5/1/14. She recalled discussing with her peers that something wrong with resident #1 because she does not normally behave in that manner. In a telephone interview on 5/14/14 at 2:50 PM, the nurse practitioner (NP) stated she recalled speaking to the ADON about not being able to get resident #1 into to see an orthopedic doctor and she gave an order for [REDACTED]. In a telephone interview on 5/14/14 at 3:00 PM, NA #5 stated resident #1 was known to throw her legs over the side of the bed and she would babble when she was cold or wet. NA #5 stated she was working on 200 hall on 5/1/14 and did not hear resident #1 yelling but she did recall hearing her peers discussing concerns about why resident #1 was yelling. In a telephone interview on 5/14/14 at 3:20 PM, nurse #1 stated she recalled NA #1 approaching her midway through third shift stating that resident #1 was fussy. She stated she gave her Tylenol and later in the shift NA #1 asked her to look at resident #1's right leg. Nurse #1 stated resident #1 was moving her legs but the right leg look more turned outward so she notified the NP around 6:45 AM. The NP ordered an x-ray of right leg. Nurse #1 stated she did not hear resident #1 yelling or screaming on her shift. In a review of the hospital emergency room record, resident #1 was diagnosed with [REDACTED]. In an interview on 5/14/14 at 4:00 PM, the administrator and the DON stated it was their expectation that the staff call the physician and not wait when a resident exhibits evidence of pain or injury.

Based on facility record review, physician, staff and family interviews the facility failed to contact the physician for a resident who had a change in condition which resulted in decline and had loose stools for greater than forty eight hours for 1 of 4 sampled residents (resident #1). Immediate jeopardy was identified on [DATE] at 12:25 PM. The immediate jeopardy began on [DATE] and was removed on [DATE] at 6:45 PM when the facility demonstrated they had implemented their credible allegation of compliance. The facility was left out of compliance at no actual harm with potential for more than minimum harm that is not immediate jeopardy (D) so that ongoing monitoring of physician notification for resident change in condition could be accomplished. Findings included: A facility policy titled "Notification of Physician for Change in Resident's Condition", page forty from the Nursing Policy Manual version ,[DATE] read; "It is the policy of the facility to notify the physician when a significant change in a resident's condition occurs with documentation." Resident #1 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A hospital history and physical dated [DATE] revealed resident #1 fell at home and suffered a left [MEDICAL CONDITION] that required surgical intervention. During her hospital stay she required a blood transfusion and developed an elevated body temperature and received extended intravenous antibiotic therapy of [MEDICATION NAME]. A hospital progress note dated [DATE] indicated resident #1 was constipated. There was no documentation to support if the resident had a bowel movement before she was discharged to the facility. Resident #1 was discharged to the skilled nursing facility for rehabilitation on [DATE]. The five day minimum data set assessment dated [DATE] revealed resident #1 was cognitively intact with no impairment in daily decision making ability. She required extensive one person physical assistance for bed mobility, dressing, toilet use, personal hygiene and bathing. She was assessed as always incontinent of bowel and bladder. Review of the physician's admission orders [REDACTED]. [MEDICATION NAME] contains [MEDICATION NAME] (an opiate pain reliever) which can cause constipation, and [MEDICATION NAME] (a pain reliever and fever reducer), 2) Iron 325 mg one tablet by mouth every day. Iron can cause constipation, 3) [MEDICATION NAME] 17 grams mixed in water by mouth everyday, 4) [MEDICATION NAME] 10 mg by mouth everyday, 4) Milk of Magnesia 30 milliliters every day as needed for constipation. [MEDICATION NAME] and Milk of Magnesia are laxatives (medications that prevent constipation). The facility's standing orders for diarrhea included: [MEDICATION NAME] 4 mg by mouth initially, followed by 2 mg after each loose stool up to a maximum of 16 mg in 24 hours. If diarrhea persists for more than 48 hours, call the physician. The facility's standing orders for nausea or vomiting included: [MEDICATION NAME] 25 mg suppository, intramuscularly or by mouth every four hours for four doses as needed for nausea or vomiting. Call the physician if no relief. A nurse's note dated [DATE] indicated resident #1 was alert and verbal. Her skin was warm and dry and she did not have any shortness of breath. Her lung sounds were clear and her abdomen had bowel sounds in all four quadrants. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. She received [MEDICATION NAME] and [MEDICATION NAME] from [DATE] through [DATE]. There were no concerns documented on the 24 Hour Reports or in the nurses notes related to the bowel status for resident #1 from [DATE] through [DATE]. On [DATE] the 24 Hour Report indicated that Resident #1 had diarrhea and [MEDICATION NAME] and [MEDICATION NAME] needed to be held. The MAR indicated [REDACTED]. The bowel movement record had three large loose bowel movements recorded on [DATE]. Resident #1 had a body temperature of 100.0 degrees Fahrenheit recorded on the vital sign tracker. There were no nurses notes related to the residents bowel status or body temperature for [DATE]. On [DATE] at 9:50 AM nurse #6 said she was the nurse who initiated the 24 Hour Report on [DATE]. She indicated that a NA had reported a loose stool to her sometime during the early morning on [DATE] and that was why she wrote "hold [MEDICATION NAME] and [MEDICATION NAME]" on the 24 hour report for [DATE]. Nurse #6 was not aware of any loose stools prior to [DATE]. She could not recall which NA reported to her that resident #1 had a loose stool on [DATE]. Nurse #6 indicated she did not initiate standing orders for diarrhea on [DATE] or notify the physician because only one loose stool was reported. Nurse #6 said report is given verbally by the nurses from shift to shift along with a review of the 24 hour report during verbal report so she was confident the oncoming nurse was made aware of the resident ' s loose stool on [DATE]. Staffing sheets indicated that nurse #6 worked third shift on [DATE], [DATE], [DATE] and [DATE]. On [DATE] at 1:22 PM nurse #1 indicated she wrote on the [DATE] 24 Hour report "laxatives held, loose stools all weekend." She said that on [DATE] resident #1's family informed her that the resident had had diarrhea all weekend. Nurse #1 said the resident was alert, oriented and appeared to be her normal self. She did not eat much that morning but drank through out the day. Nurse #1 said she did not review the bowel record for resident #1 and that the nursing assistants (NA) did not report that the resident had loose stools on [DATE]. Nurse #1 recalled she did not administer the scheduled [MEDICATION NAME] and [MEDICATION NAME] laxatives on [DATE] because the resident complained of loose stools and she initiated standing orders for diarrhea which included [MEDICATION NAME]. Nurse #1 said that she attempted to contact the physician on [DATE] with no returned call. Nurse #1 said she reported to nurse #4 that the physician had not returned her call at the end of her shift on [DATE]. Staffing sheets revealed nurse #1 worked first shift on [DATE]. On [DATE] at 12:32 PM nurse #4 said she worked second shift on [DATE]. She recalled that nurse #1 was the first nurse who reported loose stools to her during shift change and at that time she believed that the doctor had been contacted but she was not sure of the date. Later in the interview, nurse #4 recalled on [DATE] that nurse #1 reported she had been unable to reach the physician and she had also made an attempt but he did not return her call. She said she reported to nurse #6 that the physician had not been reached. Nurse #4 indicated she would have reported this information at change of shift at approximately 11:00 PM, she could not find documentation to support that she had attempted to contact the physician or that she passed this information along in report to nurse #6. Staffing sheets revealed nurse #6 worked third shift on [DATE]. On [DATE] the 24 Hour report for resident #1 revealed [MEDICATION NAME] and [MEDICATION NAME] were held and the resident was given [MEDICATION NAME] for nausea and [MEDICATION NAME] for diarrhea. A nurse's note written by nurse #2 on [DATE] at 5:42 PM indicated the resident's [MEDICATION NAME] and [MEDICATION NAME] were held that morning due to diarrhea, [MEDICATION NAME] was given, [MEDICATION NAME] was given for complaints of nausea and the interventions were effective with no further complaints during the shift. PT notes dated [DATE] indicated the resident did not feel well and she had attempted to eat tomato soup the night before but it had "run right through her." The resident discussed that she may need an IV (device inserted into a vein to deliver fluids) with the PT. During the PT session she required several rest breaks and requested a fan be turned on secondary to feeling very hot. The PT session was ended early. There was no documentation in the PT note to suggest that nursing was notified of the resident's reaction to therapy. The PT Weekly Progress Report dated [DATE] listed that the resident had been sick for three days as a barrier to progress. Per the MAR, [MEDICATION NAME] and [MEDICATION NAME] were held on [DATE] and resident #1 received one dose of [MEDICATION NAME] 25 mg by mouth and two doses of [MEDICATION NAME] by mouth. On [DATE], the resident had a body temperature of 99.6 degrees Fahrenheit on the vital sign report and two large loose stools were documented on the bowel record. On [DATE] at 3:10 PM nurse #2 said she was only aware of the resident having diarrhea on [DATE] when she administered [MEDICATION NAME]. She said the resident complained to her that she had diarrhea the morning of [DATE] so she held the residents [MEDICATION NAME] and [MEDICATION NAME]. Nurse #2 said she did not ask the resident how long she had had loose stools, she did not assess the resident ' s abdomen and she did not assess the residents stool. Nurse #2 indicated she did not contact the physician on [DATE] because the resident did not appear uncomfortable or sick and did not voice any further concerns to her. Nurse #2 documented on the 24 hour report that the residents laxatives were held and that she had given the resident [MEDICATION NAME] and [MEDICATION NAME] and said she passed the information to the next nurse but could not recall who she told. Staffing sheets revealed nurse #2 worked first shift on [DATE]. On [DATE] at 1:22 PM, nurse #1 recalled that she worked again on [DATE] and that the resident ' s family voiced concerns that she had continued to have diarrhea and was dehydrated. She said the physician was contacted and orders were received for a supplement on her meal trays and for IV fluids. Staffing sheets revealed nurse #1 worked first shift on [DATE]. A nurse's note written by nurse #1 on [DATE] at 5:26 PM stated the resident's family member was at the bedside that morning and had voiced concern that his wife had a poor appetite and had loose stools. The resident reported to the nurse she had one loose stool early that morning. The physician was notified and orders were received to discontinue [MEDICATION NAME] and [MEDICATION NAME]. A supplement was ordered for each meal and to obtain a stool sample to test for [MEDICAL CONDITIONS] toxin. A nurse's note written by the ADON on [DATE] at 5:30 PM revealed the resident stated she had only had two loose stools on [DATE]. The nurse documented the resident's oral mucous membranes were moist and her color was good. The physician was called and orders were received for intravenous fluids and if the resident did not get better for the facility to send her to the emergency room . An IV was started. On [DATE] at 5:53 PM the nurses note stated the physician called the facility and ordered [MEDICATION NAME] (an antibiotic used to treat [MEDICAL CONDITION]) and to send the resident to the emergency room if the family chose to as they had called the physician themselves several times. The 24 Hour report revealed [MEDICATION NAME] had been given twice, laxatives were discontinued, a supplement was ordered with meal trays, a stool sample was to be sent for [MEDICAL CONDITION] and the resident had IV fluids ordered. The bowel record had one medium loose stool documented. [MEDICATION NAME] and [MEDICATION NAME] were held and [MEDICATION NAME] was administered twice according to the MAR. A physician order [REDACTED]. A separate order dated [DATE] read; administer half strength normal saline intravenously at an infusion rate of 100 ml per hour for a total of one liter of fluid. An additional separate order dated [DATE] read; administer [MEDICATION NAME] 500 mg by mouth three times a day and to send the resident to the emergency room if the family chose to do so. On [DATE] at 9:26 AM family member #1 said she called the physician herself on [DATE] and left a message that resident #1 was very sick and needed to go to the hospital. On [DATE] a nurse's note at 2:16 AM indicated resident #1 felt better and IV therapy was in progress. At 7:15 AM on [DATE] a nurse's note stated the resident's family member went to the nurse's cart and stated he wanted the resident to go to the emergency room because he felt she needed more IV fluids. The resident was transported to the hospital and admitted . The bowel record indicated the resident had one medium firm stool and one medium loose stool on [DATE]. At 3:46 PM on [DATE] the ADON provided a handwritten note dated [DATE] that did not have a resident name on it and she indicated the note was for resident #1. The note dated [DATE] at 5:00 AM read; "Writer noted that resds (resident's) IV in L (left) hand was out. Writer attempted to start an IV in R (right) hand, no luck with IV stick. (Nurse #6) attempted 2 times with no luck." The note was written by nurse # 5. On [DATE] at 1:48 PM nurse #5 could not recall the date but said resident #1 had an IV placed and early the next morning it had came out of the resident's hand. She said she did not know why the resident had the IV and did not know how much of the fluid resident #1 had received when the IV came out. She and nurse #1 attempted to restart the IV but were unsuccessful. Nurse #5 said she did not notify the physician. On [DATE] at 1:22 PM, nurse #1 recalled the morning of [DATE] resident #1's family said they wanted the resident to go to the hospital because her IV had come out and she needed more IV fluids. The resident was sent to the emergency room and admitted . Staffing sheets revealed nurse #1 worked first shift on [DATE]. On [DATE] at 5:21 PM family member #2 said he stayed at resident #1 bedside everyday while she was in the facility and he only left to shower and change clothes. He said the resident started having diarrhea the second day she was at the facility. He was unable to give specific dates but said he had told the nurses on several occasions not to give the resident any more laxatives and made them aware of her diarrhea. Family member #2 said on one occasion he asked the nurse to send the resident to the hospital and she told him they would have to call the doctor to get permission, he could not recall the date but said it was not on [DATE]. He indicated that the facility did start IV fluids but the resident only received a little over half the bag before the IV came out of her hand. Family member #2 said every day resident #1 was weaker and weaker and he told staff everyday he was concerned over her. He said the facility did not do anything to help her diarrhea. The hospital emergency room records dated [DATE] at 9:00 AM revealed the resident complained of eight to ten episodes of diarrhea daily. An admission history and physical dated [DATE] revealed resident #1 complained of diarrhea and feeling extremely weak and tired. It was noted her diarrhea was likely due to [MEDICAL CONDITION]. Her white blood cell count, an indicator for infection, was elevated at 47.4 (normal range 4XXX,[DATE]). Her sodium level was severely low at 115 (normal ,[DATE]), chloride level was low at 84 (normal ,[DATE]) and carbon [MEDICATION NAME] was low at 18 (normal ,[DATE]). Her blood urea nitrogen level was elevated at 34 (normal range ,[DATE]) and her creatinine was elevated at 2.82 (normal 0XXX,[DATE].3). She was admitted with the [DIAGNOSES REDACTED]. Within twenty four hours of her hospital admission she experienced respiratory distress, septic shock and was put on a ventilator. On [DATE] [MEDICAL CONDITION] screen was reported as positive. Resident #1 expired on [DATE]. A hospital death summary dated [DATE] revealed the following diagnosis; 1) [MEDICAL CONDITION] syndrome with septic shock and multiorgan system failure secondary to fulminant [MEDICAL CONDITIONS], present on admission, 2) Acute [MEDICAL CONDITION] secondary to #1, 3) Lactic acidosis secondary to #1, 4) Acute [MEDICAL CONDITION] secondary to #1, 5) Profound metabolic acidosis secondary to lactic acidosis and also secondary to nongap metabolic acidosis due to acute [MEDICAL CONDITION] and gastrointestinal fluid losses, and 6) [MEDICAL CONDITION] (low sodium level) likely secondary to gastrointestinal fluid losses. On [DATE] at 3:45 PM the Assistant Director of Nursing (ADON) indicated the first time she was made aware of resident #1 having loose stools was the evening of [DATE] when the resident's family asked for something to be done for the resident's diarrhea. She said at that time the physician was contacted and orders were received for IV fluids. The ADON said she started the IV and she encouraged the resident to eat. She said the resident's only complaint was that she had been having loose stools and was not feeling well that day. She said she did not assess the resident because nurse #1 was her primary nurse; she only went to start the IV. The ADON indicated the nurses communicated by 24 Hour reports and a verbal report. Her expectation was that the nurses should have communicated the resident's bowel status by the 24 hour reports and verbal reports. The ADON indicated that she could not give her expectation for a time frame of nurses notifying the physician that a resident had diarrhea but would have expected the nurses notify the ADON, the Director of Nursing (DON) and the doctor if the resident continued to have loose stools despite laxatives being held. The ADON said she would also expect the NA to report the loose stool to the nurse and the nurse to perform an assessment of the resident's abdomen and the stool. On [DATE] at 2:10 PM the Physical Therapy Assistant (PTA) recalled resident #1 initially participated in therapy and walked with her walker in the room but she developed diarrhea and began to refuse therapy and said she didn't feel well. She recalled on [DATE] she ended her therapy session early because the resident became tired and hot, and she had to lie down. The PTA could not recall if she reported to the nurse because she did not document that she reported the concerns. The PTA added that anytime a resident did not feel well or could not complete therapy she informed nursing. On [DATE] at 2:52 PM the ADON said her expectation was that if a nurse could not reach a physician for the nurse to notify the ADON or DON and they could contact the facility's medical director. On [DATE] at 4:55 PM the DON said her expectation was that laxatives would be held if a resident was having loose stool and that the doctor be contacted if a laxative is held more than once. She would also expect the nurse to assess the loose stool if that was what the medication was held for and begin to monitor for hydration. On [DATE] at 3:57 PM the Medical Assistant for the physician said she kept a log of all calls she received and she was unable to find where the facility had contacted her on [DATE]. She said the first time she was contacted about resident #1 was on [DATE] by the resident's family member who complained that resident #1 had a fever and diarrhea. On [DATE] at 4:03 PM the physician said he was contacted on [DATE] which was the day before the resident was admitted to the hospital. He recalled the facility reported that the resident was on laxatives and had diarrhea. He explained that while resident #1 was in the hospital she had a fever and required additional days of IV antibiotics so he had concerns that her diarrhea could be [MEDICAL CONDITION] and he ordered IV fluids, a [MEDICAL CONDITION] screen and [MEDICATION NAME] to treat the c-dif. The physician said he told the facility to send the resident to the emergency room if the family wished for her to go because they had contacted his office. He said he had planned to see resident #1 the morning of [DATE] to evaluate her and order blood work but when he arrived at the facility on [DATE] the resident had already been taken to the hospital. The physician said he was not aware how long the resident had diarrhea or that she had missed physical therapy due to weakness. On [DATE] at 4:20 PM the DON explained that the 24 Hour Reports are initiated by the third shift nurse. After three shifts have documented on the 24 Hour Reports they are placed in her door and she reads them every morning and looks for concerns. The DON recalled that on Monday [DATE] when she read through the reports resident #1 had diarrhea. She said she told nurse #1 to contact the physician to get an order to discontinue the laxatives. She did not follow up with nurse #1 and said that her expectation was for the nurse to inform her if she was unable to reach a physician. Her expectation was that any discipline report an abnormal stool to the nursing staff and that the nursing staff investigate the concern and to notify the ADON, DON and to call the physician for a resolution and follow through. On [DATE] at 5:06 PM NA #5 said she no longer worked at the facility however she was able to recall resident #1. NA #5 said she could not recall the date but on several occasions a family member of resident #1 voiced concerns about her loose stools to her, she said anytime the family member voiced concerns she told the nurse. She could not recall which nurse she told. NA #5 said the residents stool was loose and runny; she could not recall a description of the stool but said the resident's roommate often complained of the smell, she said she thinks she told either nurse #1 or nurse #3 about the stool being loose, runny and having a bad smell. NA #5 indicated all bowel movements are recorded in the bowel movement tracker system after each stool and any concerns should be reported to the nurse immediately. NA #5 said she had never been educated on [MEDICAL CONDITION] and did not know what it was; she said that to her knowledge she had never worked with a [MEDICAL CONDITION] resident. On [DATE] at 10:20 AM NA #6 indicated she worked second shift on one occasion with resident #1. She said the resident was incontinent of bowel and bladder and she needed assistance to provide incontinent care. NA #6 said that nurse #4 assisted her with incontinent care on one occasion but could not recall the date. She said during incontinent care the resident had a small amount of loose, sticky, light brown stool between her buttocks and that nurse #4 was aware. NA #6 said it was not a normal looking stool and that she would have reported it as an abnormal stool had nurse #4 not been with her. NA #6 said she could not recall if the smell was unusual. NA #6 said anytime a resident has an abnormal stool or no stool she would tell the nurse and document the stool in the bowel tracking computer system. The administrator was notified of the immediate jeopardy on [DATE] at 12:25 PM. The facility provided a credible allegation of compliance on [DATE] at 3:20 PM. The following interventions were put in place. ? Resident number one had her [MEDICATION NAME] 17 grams and [MEDICATION NAME] 10 mg for loose stool held on [DATE], [DATE], [DATE], [DATE] at 9:00 am by the staff nurse. The attending physician was notified via telephone of resident number ones loose stool on [DATE] and orders were obtained to discontinue the [MEDICATION NAME] 17 grams and [MEDICATION NAME] 10mg. An order was obtained [DATE] by telephone to test for [MEDICAL CONDITION] from the attending physician. An order was obtained by telephone from the attending physician on [DATE] to start [MEDICATION NAME] 500 po TID. The attending physician was made aware by telephone of resident number ones condition of loose stools by the Assistant Director of Nursing on [DATE]. An order was received on [DATE] by the attending physician by telephone to the ADON for IV of ? NS@ 100 ml/hr to run 1 liter of fluid. Resident number one was assessed by ADON on [DATE] for pain, mucus membranes, skin color, and then started the IV per physician's order [REDACTED]. Family did not request resident to be sent to the local hospital on [DATE]. A new telephone order was received on [DATE] for Resident number one to be sent to the local hospital at family request. Resident number one was transferred to the local hospital on [DATE] aprox. 7:30 am at family request. All licensed nurses to include the nurses that worked on [DATE], [DATE], [DATE], and [DATE] during 1st, 2nd, and 3rd shifts were in - serviced on [DATE] and [DATE] by the SF, staff faciitator LPN, and DON regarding notification to physician by telephone when acute change in resident condition occurs to include loose, watery diarrhea , jelly like, and foul odor stool. Residents medical record from the hospital indicated that resident number one received [MEDICATION NAME] 1 g daily and [MEDICATION NAME] 600 mg Q 8 hours prior to admission to this facility on [DATE]. ? Acute Change is defined as anything outside the norm for a resident to include but not limited to, abnormal behaviors,abnormal vital signs, changes in mental status, increased pain, changes in bowel pattern to include loose stools. ? Pattern is defined as 48 hours or more of loose stool. 100 % audit of all residents to include 200, 300, 400, and 500 halls bowel pattern for loose stools ie: unformed, jelly like, foul odor, and liquid, was completed on [DATE] through residents BM record review, and staff interview by the DON and the ADON. No residents exhibited signs / symptoms of [MEDICAL CONDITION]; jelly like stools or foul odors. A second 100 % audit was completed by the DON, ADON, QI, SF, MDS nurses and the Administrator through residents bm record review , staff interview , and observation of all bowel movement patterns of consistent loose stools x 48 hours, i.e.: unformed, jelly like, foul odor, and liquid, was on [DATE]. 33 Residents were identified with a pattern, 48 hours of loose stools, and had appropriate action to include: assessment of stool for color, odor, consistency, frequency, as well as tenderness, distension, bowel sounds, and firmness of the abdomen, MD notification via telephone of acute changes to include treatment being withheld, inability to tolerate or compete an order including IV or therapy, RP notification, and stool for [MEDICAL CONDITION] per MD order. Of the 33 residents identified with pattern of loose stool for 48 hours none of the residents exhibited signs or symptoms of [MEDICAL CONDITION], or jelly like stool or foul odor. These assessments were documented in the nurse ' s notes by the staff nurse. ? All licensed nurses to include the nurses that worked on [DATE], [DATE], [DATE], and [DATE] during 1st, 2nd, and 3rd shifts were in - serviced on [DATE] and [DATE] by the SF, staff facilitator, and the DON regarding notification to physician by telephone and if you are unable to reach attending physician , you may call on call physician , if you are unable to reach the attending on call physician you may call the facility's Medical Director and document all attempts on the communication board, when any acute change in resident condition occurs to include treatment being withheld or not tolerated, inability to complete treatment order such as IV , loose, watery diarrhea , jelly like, and foul odor stool. All licensed nurses will communicate physician notification from shift to shift verbally and on the 24 hour report/ communication board. If there is no order to hold a medication the staff nurse would call the MD prior to holding the medication regarding the status of communication with MD. All licensed nurses working have completed in -service related to notification of the physician except for one LPN, who received in- service education material by certified mail. ? The QI nurse, SF, MDS nurses, treatment nurse and weekend supervisors are reviewing the BM records utilizing a BM record audit tool daily for 8 weeks and then 3 times a week ongoing for all residents for bowel patterns to include loose stools. This review began on [DATE]. Residents identified with a pattern of loose stool will have appropriate action taken to include: assessment of stool for color, odor, consistency frequency, as well as tenderness, distension, bowel sounds, and firmness of the abdomen, MD notification, RP notification, and stool for [MEDICAL CONDITION] per MD order. These interventions are documented in the nurse's notes by the staff nurse. The Administrator reviews the BM QI tool 5x per week for 8 weeks and then weekly for 2 months for completion of follow up. In the absence of the administrator the DON or her designee will review the BM audits. There are no agency people in the facility at this time. ? QI Committee will review the BM audit tools weekly for 6 months. The QI committee members consist of the QI Nurse, DON, LNHA .The quality assurance committee will review the results of the BM audit tools at the monthly QI meeting monthly for 6 months for the need to continue monitoring and the frequency of monitoring. ? Cornerstone Nursing and Rehabilitation Center alleges compliance for Tag F157 on [DATE]. Verification of the credible allegation was evidenced on [DATE] at 6:45 PM by the following: 1) review of the facility record for residents identified in audits, 2) 24 hour reports and the communication board were reviewed, 3) Staff nurses were observed during shift change report, 4)A copy of in-service attendance and in-service materials were reviewed, 5) Staff interview regarding in-service topics and recall of covered material.

Based on facility record review, physician, staff and family interviews the facility failed to identify a resident (#1) who had a decline in her overall condition, including continuing abnormal stools and to assess the resident's condition as being symptomatic of [MEDICAL CONDITION] and treat accordingly for 1 of 4 sampled residents. Immediate jeopardy was identified on [DATE] at 12:25 PM. The immediate jeopardy began on [DATE] and was removed on [DATE] at 6:45 PM when the facility demonstrated they had implemented their credible allegation of compliance. The facility was left out of compliance at no actual harm with potential for more than minimum harm that is not immediate jeopardy (D) so that ongoing monitoring of resident change in condition could be accomplished. Findings included: Resident #1 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A hospital history and physical dated [DATE] revealed resident #1 fell at home and suffered a left [MEDICAL CONDITION] that required surgical intervention. During her hospital stay she required a blood transfusion and developed an elevated body temperature and received extended intravenous antibiotic therapy of [MEDICATION NAME]. A hospital progress note dated [DATE] indicated resident #1 was constipated. There was no documentation to support if the resident had a bowel movement before she was discharged to the facility. Resident #1 was discharged to the skilled nursing facility for rehabilitation on [DATE]. The five day minimum data set assessment dated [DATE] revealed resident #1 was cognitively intact with no impairment in daily decision making ability. She required extensive one person physical assistance for bed mobility, dressing, toilet use, personal hygiene and bathing. She was assessed as always incontinent of bowel and bladder. On [DATE] at 11:05 AM the Assistant Director of Nursing (ADON) provided an undated "Resident Care Guide" with resident #1's name on the guide. The ADON indicated the Resident Care Guide was interim care plan for resident #1. The Resident Care Guide was reviewed and had no information related to the resident's bowel status marked. Review of the physician's admission orders [REDACTED]. [MEDICATION NAME] contains [MEDICATION NAME] (an opiate pain reliever) which can cause constipation, and [MEDICATION NAME] (a pain reliever and fever reducer), 2) Iron 325 mg one tablet by mouth every day. Iron can cause constipation, 3) [MEDICATION NAME] 17 grams mixed in water by mouth everyday, 4) [MEDICATION NAME] 10 mg by mouth everyday, 4) Milk of Magnesia 30 milliliters every day as needed for constipation. [MEDICATION NAME] and Milk of Magnesia are laxatives (medications that prevent constipation). The facility's standing orders for diarrhea included: [MEDICATION NAME] 4 mg by mouth initially, followed by 2 mg after each loose stool up to a maximum of 16 mg in 24 hours. If diarrhea persists for more than 48 hours, call the physician. The facility's standing orders for nausea or vomiting included: [MEDICATION NAME] 25 mg suppository, intramuscularly or by mouth every four hours for four doses as needed for nausea or vomiting. Call the physician if no relief. A nurse's note dated [DATE] indicated resident #1 was alert and verbal. Her skin was warm and dry and she did not have any shortness of breath. Her lung sounds were clear and her abdomen had bowel sounds in all four quadrants. On [DATE] at 3:27 PM nursing assistant (NA) #3 said she worked second shift (3:00 PM-11:00 PM) when resident #1 was admitted to the facility on [DATE]. She said the resident had a large watery stool the evening she was admitted and she reported the stool to nurse #4. NA #3 said she did not work the following day and when she returned to work second shift on [DATE] resident #1 had "green, jelly-like" stool with an "unusual smell" which she could not describe. NA #3 could not recall if she reported the green jelly stool to the nurse on [DATE]. She recalled on average the resident had three loose stools per shift and they were always mixed bowel movement and urine. NA #3 could not recall if resident #1 ever complained of abdominal discomfort but said she mostly just stayed in bed. NA #3 said she tried to record bowel movements for resident #1 in the bowel tracker system as she had them. NA #3 could not explain why no bowel movements were recorded in the bowel tracker for resident #1 on [DATE] for second shift. On [DATE] at 12:32 PM nurse #4 said she worked when resident #1 was admitted to the facility on [DATE]. She said she was never told by the NA that the resident had had a watery stool on [DATE]. She said it was the NA responsibility to report any loose stool to the nurse. Staffing sheets revealed nurse #4 worked second shift with resident #1 on [DATE]. On [DATE] at 9:26 AM family member #1 said resident #1 had diarrhea on [DATE], the day after she was admitted to the facility. She said she arrived at the facility on [DATE] after 6:00 PM and the resident told her she had diarrhea, at that time she talked to the nurse on duty whose name she could not recall and said the nurse told her the resident "probably had the norovirus, it had been going around and would run its course." Family member #1 said she visited resident #1 every evening and she could tell that the resident declined daily. She said the resident did not have an appetite and she had no energy. Family member #1 said no one at the facility did anything to her knowledge to prevent the resident's diarrhea so she took sports drinks to the resident which she was able to tolerate and sip on throughout the day. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. She received [MEDICATION NAME] and [MEDICATION NAME] from [DATE] through [DATE]. There were no concerns documented on the 24 Hour Reports or in the nurses notes related to the bowel status for resident #1 from [DATE] through [DATE]. On [DATE] the 24 Hour Report indicated that Resident #1 had diarrhea and [MEDICATION NAME] and [MEDICATION NAME] needed to be held. The MAR indicated [REDACTED]. The bowel movement record had three large loose bowel movements recorded on [DATE]. Resident #1 had a body temperature of 100.0 degrees Fahrenheit recorded on the vital sign tracker. There were no nurses notes related to the residents bowel status or body temperature for [DATE]. On [DATE] at 2:46 PM NA #1 indicated that resident #1's loose stools started on [DATE] and described her stool as loose and mucous in appearance, she could not recall if the stool had an unusual odor. NA #1 worked first shift (7:00 AM until 3:00 PM) with resident #1 on [DATE] and [DATE] but could not recall on average how many loose stools the resident had each shift. NA #1 could not recall which nurse she had reported the loose stool to on [DATE] but said she reported the loose stools. NA #1 said anytime a resident had a loose or abnormal stool the NA was supposed to report it to the nurse. The facility staffing sheets were reviewed with NA #1 for [DATE] and she said she still could not recall which nurse she reported the loose stools to. On [DATE] at 9:50 AM nurse #6 said she was the nurse who initiated the 24 Hour Report on [DATE]. She indicated that a NA had reported a loose stool to her sometime during the early morning on [DATE] and that was why she wrote "hold [MEDICATION NAME] and [MEDICATION NAME]" on the 24 hour report for [DATE]. Nurse #6 was not aware of any loose stools prior to [DATE]. She could not recall which NA reported to her that resident #1 had a loose stool on [DATE]. Nurse #6 indicated she did not initiate standing orders for diarrhea on [DATE] or notify the physician because only one loose stool was reported. Nurse #6 stated any NA should report any abnormal stool to the nurse and the nurse should go talk with the resident, assess the resident for pain and assess the residents bowel sounds. Nurse #6 indicated she could not recall that she assessed resident #1 when the NA reported the loose stool the morning of [DATE]. Nurse #6 stated she never observed any stool that the resident had and she never asked the NA to let her see the residents stool when incontinent care was provided. Nurse #6 indicated report is given verbally by the nurses from shift to shift along with a review of the 24 hour report during verbal report so she was confident the oncoming nurse was made aware of the resident's loose stool on [DATE]. Staffing sheets indicated that nurse #6 worked third shift on [DATE], [DATE], [DATE] and [DATE]. A physical therapy (PT) note dated [DATE] indicated resident #1 was in bed with bowel movement noted on her sheets from loose stools. The resident was cleaned and the PT reported the bowel movement to the nurse who indicated she would give the resident medication to slow down the diarrhea. The occupational therapy (OT) note dated [DATE] revealed the resident did not feel well during her session and had diarrhea. On [DATE] at 1:58 PM the Certified Occupational Therapy Assistant (COTA) indicated resident #1 had diarrhea on [DATE] while she co-treated the resident with PT. She said the bowel movement was saturated through the resident's incontinent brief and was on the bed linens. She recalled it was not a normal bowel movement and said it was medium texture, yellow in color and there was a very large amount of stool. She said she and the PT cleaned the resident and the PT indicated she would tell the nurse assigned to the resident therefore she did not tell the nurse. The COTA said there was an obvious decline in the resident's strength and endurance from the time she was admitted on [DATE] until she was transferred to the hospital on [DATE]. On [DATE] at 2:10 PM the PT recalled on [DATE], when she co-treated resident #1 with the COTA, the resident had an extremely large runny stool. She and the COTA cleaned the resident and she reported the loose stool to nurse #2 who told her she would give the resident something for her diarrhea. The PT said resident #1 had declined therapy and sessions had to be cut short due to her ongoing diarrhea. On [DATE] at 3:10 PM nurse #2 said she was only aware resident #1 had diarrhea on [DATE] when she administered [MEDICATION NAME]. On [DATE] at 1:23 PM nurse #2 said she did not recall being told in report on [DATE] that resident #1 had loose stools. Nurse #2 reviewed the 24 hour report and indicated the 24 hour report is used in conjunction with verbal report to ensure concerns are passed from shift to shift. She said that since the 24 hour report indicated to hold resident #1's [MEDICATION NAME] and [MEDICATION NAME] for diarrhea she should have been aware that the resident had loose stools on [DATE]. Nurse #2 said she would have been the nurse to administer the morning medications to resident #1 and although she did not write "hold" on the MAR by [MEDICATION NAME] and [MEDICATION NAME] she did not ask the resident about her bowel status or assess the resident's loose stool. Nurse #2 stated "I possibly could have given her [MEDICATION NAME] (brand name for [MEDICATION NAME]) and forgot to write it, I can't remember." Staffing sheets revealed nurse #2 worked with resident #1 7:00 AM until 7:00 PM on [DATE] and first shift on [DATE]. On [DATE] at 11:30 AM NA #4 recalled on one occasion PT helped her get resident #1 changed but could not recall the date. Staffing sheets indicated NA #4 was assigned to the 200 hall where resident #1 was located first shift on [DATE]. She said resident #1's stool was not orange but was not a normal brown color and was "jelly" in appearance. She could not recall if there was an unusual odor. She recalled there was not a large amount of stool and it was contained in the incontinent brief so she did not report the stool to the nurse. On [DATE] at 2:02 PM NA #4 indicated any time a resident had an abnormal stool the NA was supposed to report it to the nurse on the hall. She said she did not report the stool to the nurse because she did not know if the stool was normal for resident #1 and no one had told her that resident #1 had any problems. NA #4 stated she had not been trained on [MEDICAL CONDITION] and to her knowledge had never worked with a resident that had it. On [DATE] at 3:05 PM NA #2 said she had worked third shift (11:00 PM until 7:00 AM) with resident #1 on [DATE] and [DATE]. She recalled that resident #1 was incontinent of both bowel and bladder and she described her stools as "pasty, like a mud pie", not formed, soft and thick. NA #2 said she always worked third shift and staffing sheets indicated she was assigned to the 200 hall where resident #1 was located nightly from [DATE] through [DATE] except for the night of [DATE]. She said resident #1 averaged one stool on each shift she worked with her. NA #2 could not recall that the resident had ever expressed concerns to her about loose stools therefore; she had not reported any concerns to the nurse. She could not explain why no bowel movements were recorded on the bowel tracker for the dates she worked with resident #1, she said she recorded bowel movements in the bowel trackers as a resident had them. The MAR indicated [REDACTED]. One large loose bowel movement and one medium loose bowel movement were recorded on the bowel movement record. There were no nurses notes related to the resident's bowel status on [DATE]. Nurse #3 worked 7:00 AM until 7:00 PM on [DATE] per facility staffing sheets. On [DATE] at 12:06 PM nurse #3 indicated she administered resident #1 [MEDICATION NAME] and [MEDICATION NAME] on [DATE] because the resident did not complain of loose stools and the NA did not report loose stools to her. Nurse #3 said she could not recall specifically if she asked resident #1 if she was having loose stools prior to administering the laxatives. She was unable to recall if she was aware the laxatives had been held on [DATE]. Nurse #3 indicated she would not have looked back on the previous days 24 hour report and she denied any concerns being reported to her during shift change. Nurse #3 indicated she did not review the bowel movement record; she depended on the resident or the NA to report loose stools. On [DATE] the 24 Hour Report for resident #1 revealed "laxatives held, loose stools all weekend." A nurse's note by nurse #1 at 4:08 PM on [DATE] indicated the resident complained to staff that she had loose stools all weekend. All laxatives were held and the resident had a loose stool in the afternoon. Standing orders were initiated and the resident was administered [MEDICATION NAME] (anti-diarrhea medication) 4 mg. The MAR indicated [REDACTED]. The bowel record dated [DATE] noted one medium loose stool and one large loose stool. A PT note dated [DATE] revealed the resident complained of loose stools for several days and felt "wiped out." The resident declined physical therapy. On [DATE] at 1:22 PM nurse #1 indicated she wrote on the [DATE] 24 Hour report "laxatives held, loose stools all weekend." She said that on [DATE] resident #1's family informed her that the resident had had diarrhea all weekend. Nurse #1 said the resident was alert, oriented and appeared to be her normal self. She did not eat much that morning but drank through out the day. Nurse #1 indicated she did not perform an abdominal assessment or assess the resident's bowel movement. She said she did not review the bowel record for resident #1 and that the nursing assistants (NA) did not report that the resident had loose stools on [DATE]. Nurse #1 recalled she did not administer the scheduled [MEDICATION NAME] and [MEDICATION NAME] laxatives on [DATE] because the resident complained of loose stools and she initiated standing orders for diarrhea which included [MEDICATION NAME]. Nurse #1 said that she attempted to contact the physician on [DATE] with no returned call. Nurse #1 said she reported to nurse #4 that the physician had not returned her call at the end of her shift on [DATE]. Staffing sheets revealed nurse #1 worked first shift on [DATE]. On [DATE] at 2:05 PM nurse #1 said she was unsure what time she administered the [MEDICATION NAME] on [DATE] but she talked to resident #1 at approximately 4:08 PM and she did not complain of any further loose stools. On [DATE] at 12:32 PM nurse #4 said she worked second shift on [DATE]. She recalled that nurse #1 was the first nurse who reported loose stools to her during shift change and at that time she believed that the doctor had been contacted but she was not sure of the date. Later in the interview, nurse #4 recalled on [DATE] that nurse #1 reported she had been unable to reach the physician and she had also made an attempt but he did not return her call. She said she reported to nurse #6 that the physician had not been reached. Nurse #4 indicated she would have reported this information at change of shift at approximately 11:00 PM, she could not find documentation to support that she had attpemted to contact the physician or that she passed this information along in report to nurse #6. Nurse #4 indicated she did not perform an assessment on resident #1 or visually assess her loose stools. Staffing sheets revealed nurse #6 worked third shift on [DATE]. On [DATE] the 24 Hour report for resident #1 revealed [MEDICATION NAME] and [MEDICATION NAME] were held and the resident was given [MEDICATION NAME] for nausea and [MEDICATION NAME] for diarrhea. A nurse's note written by nurse #2 on [DATE] at 5:42 PM indicated the resident's [MEDICATION NAME] and [MEDICATION NAME] were held that morning due to diarrhea, [MEDICATION NAME] was given, [MEDICATION NAME] was given for complaints of nausea and the interventions were effective with no further complaints during the shift. PT notes dated [DATE] indicated the resident did not feel well and she had attempted to eat tomato soup the night before but it had "run right through her." The resident discussed that she may need an IV (device inserted into a vein to deliver fluids) with the PT. During the PT session she required several rest breaks and requested a fan be turned on secondary to feeling very hot. The PT session was ended early. There was no documentation in the PT note to suggest that nursing was notified of the resident's reaction to therapy. The PT Weekly Progress Report dated [DATE] listed that the resident had been sick for three days as a barrier to progress. The OT Weekly Progress Report dated [DATE] indicated the resident had made slow gains secondary to being sick with diarrhea and also listed diarrhea as a barrier to progress. Per the MAR, [MEDICATION NAME] and [MEDICATION NAME] were held on [DATE] and resident #1 received one dose of [MEDICATION NAME] 25 mg by mouth and two doses of [MEDICATION NAME] by mouth. On [DATE], the resident had a body temperature of 99.6 degrees Fahrenheit on the vital sign report and two large loose stools were documented on the bowel record. On [DATE] at 3:10 PM nurse #2 said she was only aware of the resident having diarrhea on [DATE] when she administered [MEDICATION NAME]. She said the resident complained to her that she had diarrhea the morning of [DATE] so she held the residents [MEDICATION NAME] and [MEDICATION NAME]. Nurse #2 said she did not ask the resident how long she had had loose stools, she did not assess the resident's abdomen and she did not assess the residents stool. Nurse #2 indicated she did not contact the physician on [DATE] because the resident did not appear uncomfortable or sick and did not voice any further concerns to her. Nurse #2 documented on the 24 hour report that the residents laxatives were held and that she had given the resident [MEDICATION NAME] and [MEDICATION NAME] and said she passed the information to the next nurse but could not recall who she told. Staffing sheets revealed nurse #2 worked first shift on [DATE]. On [DATE] at 1:22 PM, nurse #1 recalled that she worked again on [DATE] and that the resident's family voiced concerns that she had continued to have diarrhea and was dehydrated. She said the physician was contacted and orders were received for a supplement on her meal trays and for IV fluids. Staffing sheets revealed nurse #1 worked first shift on [DATE]. A PT note on [DATE] at 5:02 PM indicated resident #1 declined therapy due to diarrhea. A nurse's note written by nurse #1 on [DATE] at 5:26 PM stated the resident's family member was at the bedside that morning and had voiced concern that his wife had a poor appetite and had loose stools. The resident reported to the nurse she had one loose stool early that morning. The physician was notified and orders were received to discontinue [MEDICATION NAME] and [MEDICATION NAME]. A supplement was ordered for each meal and to obtain a stool sample to test for [MEDICAL CONDITIONS] toxin. A nurse's note written by the ADON on [DATE] at 5:30 PM revealed the resident stated she had only had two loose stools on [DATE]. The nurse documented the resident's oral mucous membranes were moist and her color was good. The physician was called and orders were received for intravenous fluids and if the resident did not get better for the facility to send her to the emergency room . An IV was started. On [DATE] at 5:53 PM the nurses note stated the physician called the facility and ordered [MEDICATION NAME] (an antibiotic used to treat [MEDICAL CONDITION]) and to send the resident to the emergency room if the family chose to as they had called the physician themselves several times. The 24 Hour report revealed [MEDICATION NAME] had been given twice, laxatives were discontinued, a supplement was ordered with meal trays, a stool sample was to be sent for [MEDICAL CONDITION] and the resident had IV fluids ordered. The bowel record had one medium loose stool documented. [MEDICATION NAME] and [MEDICATION NAME] were held and [MEDICATION NAME] was administered twice according to the MAR. A physician order [REDACTED]. A separate order dated [DATE] read; administer half strength normal saline intravenously at an infusion rate of 100 ml per hour for a total of one liter of fluid. An additional separate order dated [DATE] read; administer [MEDICATION NAME] 500 mg by mouth three times a day and to send the resident to the emergency room if the family chose to do so. On [DATE] at 9:26 AM family member #1 said she called the physician herself on [DATE] and left a message that resident #1 was very sick and needed to go to the hospital. On [DATE] a nurse's note at 2:16 AM indicated resident #1 felt better and IV therapy was in progress. At 7:15 AM on [DATE] a nurse's note stated the resident's family member went to the nurse's cart and stated he wanted the resident to go to the emergency room because he felt she needed more IV fluids. The resident was transported to the hospital and admitted . The bowel record indicated the resident had one medium firm stool and one medium loose stool on [DATE]. At 3:46 PM on [DATE] the ADON provided a handwritten note dated [DATE] that did not have a resident name on it and she indicated the note was for resident #1. The note dated [DATE] at 5:00 AM read; "Writer noted that resds (resident's) IV in L (left) hand was out. Writer attempted to start an IV in R (right) hand, no luck with IV stick. (Nurse #6) attempted 2 times with no luck." The note was written by nurse # 5. On [DATE] at 1:48 PM nurse #5 could not recall the date but said resident #1 had an IV placed and early the next morning it had came out of the resident's hand. She said she did not know why the resident had the IV and did not know how much of the fluid resident #1 had received when the IV came out. She and nurse #1 attempted to restart the IV but were unsuccessful. Nurse #5 said she did not notify the physician. On [DATE] at 1:22 PM, nurse #1 recalled the morning of [DATE] resident #1's family said they wanted the resident to go to the hospital because her IV had come out and she needed more IV fluids. The resident was sent to the emergency room and admitted . Staffing sheets revealed nurse #1 worked first shift on [DATE]. On [DATE] at 5:21 PM family member #2 said he stayed at resident #1 bedside everyday while she was in the facility and he only left to shower and change clothes. He said the resident started having diarrhea the second day she was at the facility. He was unable to give specific dates but said he had told the nurses on several occasions not to give the resident any more laxatives and made them aware of her diarrhea. Family member #2 said on one occasion he asked the nurse to send the resident to the hospital and she told him they would have to call the doctor to get permission, he could not recall the date but said it was not on [DATE]. He indicated that the facility did start IV fluids but the resident only received a little over half the bag before the IV came out of her hand. Family member #2 said every day resident #1 was weaker and weaker and he told staff everyday he was concerned over her. He said the facility did not do anything to help her diarrhea. The hospital emergency room records dated [DATE] at 9:00 AM revealed the resident complained of eight to ten episodes of diarrhea daily. An admission history and physical dated [DATE] revealed resident #1 complained of diarrhea and feeling extremely weak and tired. It was noted her diarrhea was likely due to [MEDICAL CONDITION]. Her white blood cell count, an indicator for infection, was elevated at 47.4 (normal range 4XXX,[DATE]). Her sodium level was severely low at 115 (normal ,[DATE]), chloride level was low at 84 (normal ,[DATE]) and carbon [MEDICATION NAME] was low at 18 (normal ,[DATE]). Her blood urea nitrogen level was elevated at 34 (normal range ,[DATE]) and her creatinine was elevated at 2.82 (normal 0XXX,[DATE].3). She was admitted with the [DIAGNOSES REDACTED]. Within twenty four hours of her hospital admission she experienced respiratory distress, septic shock and was put on a ventilator. On [DATE] [MEDICAL CONDITION] screen was reported as positive. Resident #1 expired on [DATE]. A hospital death summary dated [DATE] revealed the following diagnosis; 1) [MEDICAL CONDITION] syndrome with septic shock and multiorgan system failure secondary to fulminant [MEDICAL CONDITIONS], present on admission, 2) Acute [MEDICAL CONDITION] secondary to #1, 3) Lactic acidosis secondary to #1, 4) Acute [MEDICAL CONDITION] secondary to #1, 5) Profound metabolic acidosis secondary to lactic acidosis and also secondary to nongap metabolic acidosis due to acute [MEDICAL CONDITION] and gastrointestinal fluid losses, and 6) [MEDICAL CONDITION] (low sodium level) likely secondary to gastrointestinal fluid losses. On [DATE] at 3:45 PM the Assistant Director of Nursing (ADON) indicated the first time she was made aware of resident #1 having loose stools was the evening of [DATE] when the resident's family asked for something to be done for the resident's diarrhea. She said at that time the physician was contacted and orders were received for IV fluids. The ADON said she started the IV and she encouraged the resident to eat. She said the resident's only complaint was that she had been having loose stools and was not feeling well that day. She said she did not assess the resident because nurse #1 was her primary nurse; she only went to start the IV. The ADON indicated the nurses communicated by 24 Hour reports and a verbal report. Her expectation was that the nurses should have communicated the resident's bowel status by the 24 hour reports and verbal reports. The ADON indicated that she could not give her expectation for a time frame of nurses notifying the physician that a resident had diarrhea but would have expected the nurses notify the ADON, the Director of Nursing (DON) and the doctor if the resident continued to have loose stools despite laxatives being held. The ADON said she would also expect the NA to report the loose stool to the nurse and the nurse to perform an assessment of the resident ' s abdomen and the stool. On [DATE] at 2:52 PM the ADON said her expectation was that if a nurse could not reach a physician for the nurse to notify the ADON or DON and they could contact the facility's medical director. On [DATE] at 4:55 PM the DON said her expectation was that laxatives would be held if a resident was having loose stool and that the doctor be contacted if a laxative is held more than once. She would also expect the nurse to assess the loose stool if that was what the medication was held for and begin to monitor for hydration. On [DATE] at 4:03 PM the physician said he was contacted on [DATE] which was the day before the resident was admitted to the hospital. He recalled the facility reported that the resident was on laxatives and had diarrhea. He explained that while resident #1 was in the hospital she had a fever and required additional days of IV antibiotics so he had concerns that her diarrhea could be [MEDICAL CONDITION] and he ordered IV fluids, a [MEDICAL CONDITION] screen and [MEDICATION NAME] to treat the c-dif. The physician said he told the facility to send the resident to the emergency room if the family wished for her to go because they had contacted his office. He said he had planned to see resident #1 the morning of [DATE] to evaluate her and order blood work but when he arrived at the facility on [DATE] the resident had already been taken to the hospital. The physician said he was not aware how long the resident had diarrhea or that she had missed physical therapy due to weakness. On [DATE] at 5:06 PM NA #5 said she no longer worked at the facility however she was able to recall resident #1. NA #5 said she could not recall the date but on several occasions a family member of resident #1 voiced concerns about her loose stools to her, she said anytime the family member voiced concerns she told the nurse. She could not recall which nurse she told. NA #5 said the residents stool was loose and runny; she could not recall a description of the stool but said the resident's roommate often complained of the smell, she said she thinks she told either nurse #1 or nurse #3 about the stool being loose, runny and having a bad smell. NA #5 indicated all bowel movements are recorded in the bowel movement tracker system after each stool and any concerns should be reported to the nurse immediately. NA #5 said she had never been educated on [MEDICAL CONDITION] and did not know what it was; she said that to her knowledge she had never worked with a [MEDICAL CONDITION] resident. On [DATE] at 10:20 AM NA #6 indicated she worked second shift on one occasion with resident #1. She said the resident was incontinent of bowel and bladder and she needed assistance to provide incontinent care. NA #6 said that nurse #4 assisted her with incontinent care on one occasion but could not recall the date. She said during incontinent care the resident had a small amount of loose, sticky, light brown stool between her buttocks and that nurse #4 was aware. NA #6 said it was not a normal looking stool and that she would have reported it as an abnormal stool had nurse #4 not been with her. NA #6 said she could not recall if the smell was unusual. NA #6 said anytime a resident has an abnormal stool or no stool she would tell the nurse and document the stool in the bowel tracking computer system. The administrator was notified of the immediate jeopardy on [DATE] at 12:25 PM. The facility provided a credible allegation of compliance on [DATE] at 3:20 PM. The following interventions were put in place. ? Resident number one had her [MEDICATION NAME] 17 grams and [MEDICATION NAME] 10 mg for loose stool held on [DATE], [DATE],[DATE], [DATE] at 9:00 am by the staff nurse. The attending physician was notified via telephone of resident number ones loose stool on [DATE] and orders were obtained to discontinue the [MEDICATION NAME] 17 grams and [MEDICATION NAME] 10mg. An order was obtained [DATE] by telephone to test for [MEDICAL CONDITION] from the attending physician. An order was obtained by telephone from the attending physician on [DATE] to start [MEDICATION NAME] 500 po TID. The attending physician was made aw