Every finding on record at The Greens at Spruce Pines

Based on observations and staff interviews, the facility failed to maintain a clean floor and walls in of 1 of 1 kitchen dry food storage room.The findings included:On 5/11/26 at 9:56 AM an observation was made of the kitchen's dry food storage room with the Dietary Manager. The dry food storage room floor had vinyl tiles, painted walls and vinyl wall base molding. The front wall to the left of the door was 10 feet wide and backed up to the walk-in freezer on the other side of the wall. There were three, 6-foot-tall shelves the full length of front wall from left to right including a 2-foot-wide wire rack shelf on wheels, a 2-foot-wide stationary solid metal can shelf, and a 4-foot- wide wire rack shelf on wheels. The left wall was 10 feet wide, had wire rack shelving on wheels covering the wall's full length, and backed up to the building's exterior on the other side of the wall. Scattered dark floor and wall stains were partly visible through the lower wire rack shelves on the front and left walls. The Dietary Manager pulled the wire rack shelving on wheels away from the front and left walls which allowed for closer observation of the walls. The following observations were noted:The front wall had circular and irregularly shaped dry black stains from a quarter inch to 3 inches as well as streaks and black spots with powdery/stringy material which flaked off when scraped by the surveyor's fingernail. One-inch vertical streaks were scattered 6-feet across the wall from the right side coming up 4 to16-inches on the base molding and the wall. The left wall had scattered dry black stains from a half inch to 6-inches and powdery/stringy material which flaked when scraped by the surveyor's fingernail which were scattered in streaks 3 feet from the corner with the front wall and up 2 to 3 feet on the base molding and the wall.The floor below the front and left walls in the corner had a solid, slightly shiny triangular 5-inch by 8-inch dried black spot and scattered black, irregularly shaped black stains out 2 feet from the wall below the front wall and 6 feet from the corner. The floor below the left wall had scattered dried irregularly shaped black stains 3-inches to 6-inches from the wall and fifteen 1-inch circular stains next to the wall. Food debris observed under the left wall and 3 feet under the left side of the back wall included three salt packets, cereal flakes scattered in a 4-inch area, five small jelly packets which had been broken open and stuck to the floor with dark blue dried sticky material, and a pile of 6 ketchup packets which were stuck together.An interview was conducted with the Dietary Manager on 5/11/26 at 10:10 AM during the dry food storage room observation. The Dietary Manager revealed he had not known about the dark stains on the walls and floors or food debris behind the shelving. He stated the brown circular stains could have been from spilled syrup or applesauce and the black spots and streaks on the lower walls and floors might have been from water damage from the freezer or from water intrusion from the outside. He explained he didn't keep a floor or wall cleaning check list, but the dry food storage room was cleaned weekly on Mondays, usually in the afternoon after staff finished unpacking the food from the Monday delivery. The Dietary Manager further explained he usually swept and mopped the dry food storage room floor himself and it was difficult to get all the way under shelves with the mop because of the awkward angle and it was hard to see without being able to move the stationary can shelf on the front wall. The Dietary Manager stated wall cleaning in the dry food storage room was scheduled monthly. He further stated he had last cleaned the front wall a few months ago in mid-March after the big snow storm when there had been half an inch of standing water in the corner between the front and left walls. The Dietary Manager revealed he had not moved the can shelf to clean behind it because they were focused on getting the water cleaned up but had not seen any black spots on the rest of the walls or floor at that time. The Dietary Manager further stated he had not seen any food debris or black spots when he last cleaned the left, back, and right walls in mid-April but could not recall the exact date. The Dietary Manager explained he had not cleaned the front wall in April because there had not been anyone to help him move the can shelf.The Regional Director of Operations was interviewed 5/11/26 at 10:30 AM with the Administrator present, while they were observing the walls and floor in the dry food storage room. The Regional Director of Operations confirmed she saw black spots and streaks on the front wall of the dry food storage room spanning an area six feet wide from the right side of the wall, up 16 inches from the floor in places as well as scattered black spots and streaks on the right wall. She further confirmed that on the floor there were scattered dried black circular stains, and scattered spots of powdery/stringy material that lifted up when scraped under the front and left walls. The Regional Director of Operations revealed that these black spots and black material looked like they could have been from water damage. The Maintenance Director was interviewed on 5/13/26 at 4:13 PM and explained there was a drain line for the freezer condenser which drained through a pipe to the outside that did not have a current leak but might have had a previous leak. The Maintenance Director said they were not exactly sure what caused the black spots on the dry food storage room walls and floors but would monitor for water problems from the freezer or from outside. In an interview with the Administrator 5/13/26 at 4:20 PM with the Maintenance Director present, she explained that later the same day the spots were found on 5/11/26, they did not find moisture accumulation in the walls or leaks in the freezer. The Administrator further explained that in the past and during and the big snow storm a few months ago in March, they did get a half inch of standing water on the left wall side of the dry food storage room but since roof repairs and adding a French drain, the floor had remained dry when it rained. She revealed they could not say for certain what caused the black spots and streaks on the floor and walls of the dry food storage room, but it may have been from water from outside or it may have been from an old leak coming from the freezer. The Administrator revealed the expectation was that food be stored in a clean environment and having black stains and powdery/stringy material on the walls in the dry food storage was a situation that could potentially impact food safety for the residents. The Administrator stated they would continue to monitor the freezer drain line and exterior water drainage. ++ age Food brought from home

Based on record review, observations, and interviews with staff, Speech Therapist (ST), Physician Assistant (PA), and Medical Director, the facility failed to provide speech therapy evaluation and services to Resident #70 during his stay. Resident #70 was admitted to the facility from the hospital on 12/17/24 with a recent history of aspiration pneumonitis (a type of lung infection that is due to a relatively large amount of material from the stomach or mouth entering the lungs) and acute hypoxic respiratory failure (a medical condition where the body rapidly fails to adequately oxygenate the blood, leading to a severe lack of oxygen in the tissues). Resident #70 required a mechanical soft diet with nectar thickened liquids when he was admitted on [DATE]. On 12/18/24 Resident #70 was diagnosed with pneumonia at the facility and treated with a 7-day course of antibiotics. His diet was downgraded to puree with nectar thick liquids by Unit Manager (UM) #1 on 12/19/24. Resident #70 was not evaluated by speech therapy after his diet was downgraded. On 1/7/25 Resident #70 had a choking and aspiration episode at the facility and was sent to the emergency department. Resident #70 was admitted to the hospital and returned to the facility on [DATE]. The hospital discharge summary indicated Resident #70 was to receive speech therapy and was diagnosed with esophageal dysphagia (difficulty swallowing), aspiration pneumonia, and acute hypoxic (low blood oxygen level) respiratory failure secondary to aspiration pneumonia. Speech therapy was not initiated upon readmission to the facility, and no one identified the absence of the service. This deficient practice occurred for 1 of 1 resident reviewed for rehabilitation services (Resident #70). Immediate jeopardy began on 12/19/24 when speech therapy did not evaluate Resident #70 after his diet had been downgraded by Unit Manager (UM) #1 due to staff reporting he had coughing when eating and was not doing well with his diet. Immediate jeopardy was removed on 2/5/25 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective and to address the deficient practice. The findings included: A hospital progress note dated 12/14/24 read in part under problem list: Aspiration event, currently consistent with aspiration pneumonitis, no evidence of subsequent pneumonia at this time but still early and could develop. Acute hypoxic respiratory failure, secondary to above. Under plan, the progress note indicated he was being treated with antibiotics and given the aspiration event would likely lean towards treating him with a 14-day course. The note indicated the 14-day course of antibiotics would be completed on 12/16/24. A review of the facility's hospital records for Resident #70 revealed a physician progress note dated 12/15/24 that read: Speech-language pathology following; International dysphagia diet standardization initiative (IDDSI) level 4 pureed food, level 3 moderately thick/honey thick liquids. A hospital discharge summary for Resident #70 dated 12/17/24 indicated his hospital course was complicated by aspiration resulting in significant episode of respiratory distress. The hospital discharge summary reported he had been followed closely by speech therapy and was able to start back on a restricted International dysphagia diet standardization initiative (IDDSI) diet (a system for describing food textures and drink thicknesses for people with swallowing difficulties. The IDDSI framework helps to prevent choking and improve safety when eating and drinking.). The hospital discharge summary did not indicate the type of IDDSI diet. The hospital discharge summary indicated he was seen by palliative care during his hospital stay and would be discharged to the skilled nursing facility (SNF) with hospice. Resident #70 was admitted to the facility on [DATE]. His diagnoses included: chronic obstructive pulmonary disease (COPD), acute cholecystitis (inflammation of the gallbladder), acute metabolic encephalopathy (a brain condition that causes confusion), and muscle weakness. A review of the facility admission physician orders did not reveal any orders for hospice services. There was an active order dated 12/17/24 that read: speech therapy may evaluate and treat as indicated. A diet order dated 12/17/24 read, regular diet, mechanical soft texture, nectar thick liquids. Entered by Nurse #4. A baseline care plan completed by Nurse # dated 12/17/24 read under dietary: Diet order, regular mechanical soft thickened liquids. Under dietary risks, risk for swallowing problems was marked. Under the section entitled therapy, speech therapy was marked. A telephone interview was conducted on 1/24/25 at 5:37 PM with Nurse #4. She recalled completing Resident #70's admission on 12/17/24. She stated she would not have entered a modified diet order for mechanical soft with nectar thick liquids, unless she had found it somewhere in Resident #70's admission paperwork. She did not recall specifically where she had found the diet in his paperwork. She did not recall taking report from the hospital for Resident #70. She was not sure who had taken the report. Nurse #4 reported that if a diet order was not present in a resident's admission paperwork, she would call the hospital to ask what the diet was and then call the facility provider to clarify if they wanted to continue that diet. Nurse #4 reported she did not remember calling the hospital and doing that for Resident #70's diet. She said she did not recall calling the provider about his diet. Nurse #4 explained she did not do a therapy communication on admission for Resident #70 because typically admissions were talked about in the management morning meetings with therapy. A progress note by the PA dated 12/18/24 indicated Resident #70 had been seen and evaluated for worsening cough and shortness of breath. The physical exam stated he had diffuse adventitious (abnormal lung sounds, like crackles or wheezes, can be heard widespread throughout a large area of the chest when listening with a stethoscope) breath sounds throughout the right side of his lungs. The note indicated a plan to obtain a chest x-ray due to right sided adventitious breath sounds and high risk for aspiration given swallowing dysfunction. A chest x-ray was completed on 12/18/24 and read: patchy opacity in right mid lung may represent pneumonia. A review of physician orders revealed the following antibiotic orders: -An order dated 12/18/24 for Doxycycline (antibiotic) 100 milligram (mg) oral tablet, give 100 mg by mouth every 12 hours for pneumonia for 14 doses. -An order dated 12/19/24 for Amoxicillin (antibiotic) extended release (ER) oral tablet 1,000-62.5 mg tablet, give 2 grams by mouth two times a day for pneumonia for 7 days. A progress note by the PA dated 12/19/24 indicated Resident #70 had been seen for follow up of his chest x-ray and cough. The note included a diagnosis of pneumonia, that he was high risk for aspiration pneumonia, and a plan for antibiotic treatment. The note read: high risk for aspiration pneumonia given swallowing dysfunction and also at risk for healthcare associated pneumonia given recent prolonged hospitalization and intubation. Currently on doxycycline 100 mg by mouth twice daily for 7 days. Given patient risk factors and significant comorbidities we will add additional coverage with Augmentin 2 grams by mouth two times daily in conjunction with his doxycycline for 7 days. The 12/17/24 regular diet, mechanical soft texture, nectar thick liquids order was discontinued on 12/19/24 by Unit Manager (UM) #1. A new diet order dated 12/19/24 read, regular diet, puree texture, nectar thick liquids. An interview was conducted on 1/24/25 at 1:01 PM with UM #1. She recalled downgrading Resident #70's diet to from mechanical soft texture to pureed texture because he had trouble with the mechanical soft diet. She said she had not completed a therapy referral communication form. UM #1 explained the order from 12/17/14 that read, speech therapy may evaluate as indicated was part of the facility's standard orders entered for all new admissions. A follow up interview was conducted on 2/7/25 at 1:03 PM with UM #1. UM #1 reported a Nurse or NA had told her Resident #70 was not doing well on the mechanical soft diet and was coughing when eating it. She did not remember who had reported it to her. She explained she had not observed Resident #70 eating or drinking. UM #1 recalled Resident #70 had an increased cough on 12/18/24 and a chest x-ray was performed that had shown pneumonia. UM #1 explained she had downgraded Resident #70's diet on 12/19/24 because it had been reported to her, he had coughing when eating the mechanical soft diet, and she had thought his pneumonia might possibly be related to aspiration. She said she had not completed a therapy referral communication form because all orders, including diet changes were discussed during the morning meeting that was attended by the Director of Rehab, who was also the ST. UM #1 explained she attended the morning meetings and thought she recalled Resident #70's diet downgrade from 12/19/24 being discussed in the morning meeting. UM #1 stated she had assumed the ST would look at him, but did not remember the ST saying specifically she would. UM #1 stated she thought she probably should have done a therapy communication form and that it would have helped cover that she had told the ST about Resident #70's diet downgrade. She reported she had trusted the ST would follow up but did not ask her specifically. UM #1 reported she did not follow up with the ST to see if she had seen Resident #70. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #70 was cognitively intact. The MDS documented he had no behavior or rejection of care. The MDS indicated Resident #70 required substantial/ maximal assistance from staff with eating. He was coded on the MDS as having a mechanically altered diet. He was not coded on the MDS for a swallowing disorder or receiving speech therapy. A physician's order was dated 12/30/24 for a chest x-ray for pneumonia follow up. The start date of the order was 1/3/25. The chest x-ray report dated 1/3/25 read: no acute process in the chest. A nursing note dated 1/7/25 by Nurse #6 indicated Resident #70 was sent to the emergency department for evaluation due to an aspiration/choking incident. A situation background assessment recommendation (SBAR) note dated 1/7/25 by Nurse #6 revealed Resident #70's had increased confusion, swallowing difficulty, shortness of breath, abnormal lung sounds (rales, rhonchi, wheezing), nausea/ vomiting, and abnormal pulse. The note stated Resident #70 appears to have aspirated on apple juice. He vomited up some of the fluid and is now in respiratory distress. The note indicated the provider was notified with recommendations to send him to the emergency department. Oxygen was listed under intervention orders. The SBAR note indicated Resident #70's heart rate was 130, respiration rate was 25, and his oxygen saturation level was 78% with oxygen in place via nasal cannula. A telephone interview was conducted on 1/22/25 at 6:38 PM with Nurse #6. She remembered being Resident #70's assigned nurse on 1/7/25 and recalled the choking and aspiration incident. Nurse #6 recalled after dinner an NA alerted her Resident #70 as not doing well. She did not remember the name of the NA. Nurse #6 explained she went to Resident #70's room to assess him. She stated he had thrown up after dinner. She said his dinner meal tray had already been removed from his room. She recalled Resident #70 had a cup of thickened apple juice beside him on his bedside table. Nurse #6 stated she had not seen him drink the apple juice, but said what he had thrown up was the same color as the apple juice. Nurse #6 indicated she had assumed the apple juice had been what Resident #6 had drunk and that he had aspirated on the apple juice or the vomit. A follow-up telephone interview was conducted with Nurse #6 on 2/7/25 at 11:37 PM. Nurse #6 recalled when she went to Resident #70's room to assess him he had not been doing well. She stated he was having difficulty breathing and was short of breath. She explained she checked his oxygen saturation level, and it was in the 70's. She recalled Resident #70 had already been wearing oxygen and she had turned the oxygen flow rate up, but she did not remember what she had turned it up to. Nurse #6 stated she had not seen his meal tray and that she did not remember what had been served for dinner that night. She stated Resident #70 was able to talk to her. She explained she could see inside his mouth when he was talking and there had not been anything in his mouth. Nurse #6 stated Resident #70 had not mentioned what he had been eating. She recalled his vomit had been yellowish in color with very small white pieces mixed in it. An interview was conducted with Nurse Aide (NA) #5 on 2/7/25 at 12:03 PM. NA #5 recalled the chocking and aspiration incident from 1/7/25 with Resident #70. She reported she had been assisting him in his room with his dinner meal at the time of the incident. She recalled the only thing he had wanted to eat had been the puree fruit from his meal tray. She stated he did not have any coughing or issues when he ate the puree fruit. She did not remember what else had been served for dinner or was on his meal tray, but did recall he had puree food on his meal tray. NA #5 said she remembered Resident #70 had wanted something to drink and she gave him thickened apple juice. She reported that the apple juice had been nectar thick. NA #5 stated when she gave Resident #70 the thickened apple juice and he drank it he choked and started coughing. She reported he had been positioned sitting upright in bed. She said the first time she gave him the apple juice to drink he was able to cough and clear it. NA #5 reported he had wanted more juice and when she gave him the apple juice to drink the second time he started coughing and choking more, turned red in the face, and was unable to clear it. She remembered Resident #70 was able to talk and had said I'm choking, I'm choking. NA #5 reported Resident #70 started to vomit, and she gave him a basin. She reported she stuck her head out Resident #70's door and asked NA #2 to get Nurse #6. She recalled Nurse #6 came to assess Resident #70 and sent him to the hospital. She recalled the vomit had been yellow in color and looked like the apple juice he had been drinking. She remembered there had not been food in the vomit. NA #5 recalled Resident #70 wore oxygen, and he had his oxygen on. NA #5 stated she had assisted Resident #70 with his meals prior to the incident. She reported he did not have problems with coughing or choking when he ate the puree food but said when he would drink the nectar thick liquids it would go down wrong sometimes and he would start coughing. She reported the coughing he had prior when he drank the thickened liquids was not as bad as during the choking incident and he was able to clear it. She reported the coughing happened more when he would drink the thickened liquids fast. NA #5 stated she had reported Resident #70's coughing when drinking the nectar thick liquids to a Nurse and told them she thought he may need thicker fluids, but she did not remember who she had reported it to or when she had reported it. A hospital history and physical (H&P) note dated 1/8/25 indicated Resident #70 had presented to the emergency department of the local hospital and a chest scan had shown significant food bolus with severe dilation of esophagus. The note said lung imaging was also concerning for underlying aspiration. The note indicated his oxygen saturation upon arrival was 74% on 3 liters of oxygen via nasal cannula (Normal oxygen saturation is 95% or greater). The H&P note reported Resident #70 was subsequently started on BiPAP (a type of non-invasive ventilation using a machine that helps people breath by delivering pressurized air into the airways). It indicated his oxygen levels improved with BiPAP therapy. His white blood cell count was found to be elevated, and he was started on antibiotics. The H&P indicated Resident #70 had been transferred to the current hospital for further evaluation of the food bolus with gastroenterology. A hospital discharge summary dated 1/13/25 revealed Resident #70 had been admitted to the hospital on 1/8/25 and was discharged on [DATE]. His discharge diagnoses included: esophageal dysphagia, aspiration pneumonia, and acute hypoxic respiratory failure secondary to aspiration pneumonia. The discharge summary indicated on 1/8/25 Resident #70 had a esophagogastroduodenoscopy (EGD) (a medical procedure that examines the upper gastrointestinal tract). It said, no bolus seen (may have passed) but abnormal esophagus, biopsies done showing inflammatory cells. The discharge summary said Resident #70 was discharged on a puree diet with honey thick liquids and would get speech therapy at rehab. He was readmitted to the facility on [DATE] following hospitalization . There was not an order written for speech therapy by the facility from the 1/13/25 hospital discharge summary. A review of the physician orders following the hospital readmission of 1/13/25 did not reveal any orders for hospice services. There was an order entered on 1/21/25 that was pending confirmation and read: speech therapy to eval and treat as indicated. A continuous observation was completed on 1/21/25 from 1:08 PM to 1:14 PM of NA #1 assisting Resident #70 in his room with his lunch meal. At 1:08 PM NA #1 went to a red hydration cooler sitting on top of Resident #70's dresser, removed a carton of thickened liquid from the cooler, and poured the thickened liquid from the carton into a small plastic cup. NA #1 put a straw in the cup and gave it to Resident #70. Resident #70 was observed as he drank the thickened liquid from the cup using the straw. After drinking the liquid Resident #70 was heard coughing. Resident #70's meal ticket was reviewed with NA #1. His meal ticket indicated honey thick liquids were ordered. The carton of thickened liquids from the cooler was reviewed with NA #1, it was the only carton present in the cooler and had an open date of 1/21/25 written on the carton. NA #1 confirmed nectar thick liquid was printed on the carton of lemon water. NA #1 was interviewed at 1:10 PM and stated she was unsure about the nectar thickened liquids in the hydration cooler located in Resident #70's room. She explained she had not looked on the carton to check what type of thickened liquid it was, but had assumed it was the correct thickened liquid for Resident #70 since the carton was in his cooler. An interview was conducted on 1/21/25 at 3:37 PM with the Speech Therapist (ST). The ST said she had not received a speech therapy referral or been asked to evaluate Resident #70 before 1/21/25. The ST explained she had been asked to see Resident #70 on 1/21/25 after an incident at lunch where Resident #70 had been given nectar thick liquids instead of honey thick liquids. The ST reported she attended the morning meetings and new admissions were discussed in the morning meetings. The ST recalled Resident #70 had been admitted to the facility in December under long term care not short-term rehab. The ST said she had been told he was going to receive hospice at the facility during the morning meeting when he was admitted in December. The ST further explained, therapy did not evaluate or see hospice patients unless specifically asked to do so and therapy was approved by hospice. She recalled no one had communicated to her that Resident #70 had decided he did not want hospice and was not admitted to hospice. The ST reported all short stay residents were evaluated by all therapy disciplines, including speech therapy. She stated long-term care admission residents were not automatically evaluated on admission unless a therapy referral was submitted using the therapy communication form. She stated she had not received a therapy communication form or therapy referral for Resident #70 since he had been admitted on [DATE]. The ST explained the order entered on 12/17/24 that read, speech therapy may evaluate as indicated was not an order for him to be evaluated by speech therapy. She explained it was part of the facility's standard admission orders that was entered for all residents on admission and allowed speech therapy to evaluate them if needed. The ST stated she had not been aware he had issues with aspiration during his December 2024 hospitalization , or that he had been treated for pneumonia in December after being admitted to the facility. The ST reported she had not been aware Resident #70's diet had been downgraded on 12/19/24 from mechanical soft to puree. The ST further stated she had not been aware Resident #70 had been hospitalized in January for aspiration pneumonia, had been changed from nectar thick liquids to honey thick liquids during his January hospitalization , or that his January hospital discharge summary indicated he needed speech therapy services. She stated it was possible Resident #70 could have needed honey thick liquids in December, but she did not know for sure because she did not see him. The ST stated she had completed a bedside swallow study today. She reported she trialed nectar thick liquids during the bedside swallow study and Resident #70 had shown signs of aspiration with nectar thick liquids, which were coughing. The ST stated Resident #70 needed honey thick liquids. The ST reported Resident #70 needed an instrumental swallow study, which was a fiberoptic endoscopic evaluation of swallowing (FEES) (a procedure that examines how well someone swallows) to further assess his swallowing. An interview was conducted on 1/23/25 at 9:38 AM with the PA. The PA reported Resident #70 had aspiration that resulted in respiratory failure during his hospital stay in December before being admitted to the facility. The PA further explained, Resident #70 had been treated for pneumonia at the facility with antibiotic therapy starting on 12/18/24, she said his pneumonia was aspiration pneumonia. She said Resident #70 had a worsening cough and she ordered a chest x-ray because he had new symptoms, to check if there was anything else acute going on in the chest that could have caused an increased cough. She reported the chest x-ray had showed pneumonia. The PA explained it could take a while for pneumonia to clear off a chest x-ray. She stated it would be hard to differentiate if a pneumonia was new or old on a chest x-ray, but said regardless if someone had new/ worsening symptoms you would treat it the same with antibiotics. She explained if someone aspirated it would take a few days before the pneumonia would show up on a chest x-ray, she said it would not show up immediately. She reported it would have been too soon for aspiration pneumonia to show up on the 12/18/24 chest x-ray if Resident #70 had aspirated at the facility after being admitted on [DATE], she said it would not show up that quick. The PA stated Resident #70's diet consistency had been downgraded from mechanical soft to puree on 12/19/24. She recalled that no one had consulted with her about Resident #70's diet. The PA explained she had ordered a follow up chest x-ray that had been completed on 1/3/25, to ensure Resident #70's pneumonia had been resolved. She reported the chest x-ray from 1/3/25 had been negative. She stated Resident #70 had a choking and aspiration episode at the facility on 1/7/25 and was sent to the hospital for evaluation. The PA explained Resident #70 had been admitted to the hospital with aspiration pneumonia and had returned to the facility on [DATE]. She further explained, prior to his hospitalization Resident #70 had nectar thick liquids ordered but he had been changed to honey thick liquids during his hospitalization . The PA had thought Resident #70 had been receiving speech therapy services at the facility. She said the discharge summary from Resident #70's January hospitalization clearly stated, he was supposed to receive speech therapy, and she was not aware that it was not taking place. The PA said Resident #70 should have been evaluated by speech therapy when he was originally admitted to the facility in December. She reported she expected for speech therapy to evaluate a resident typically within 2 days of admission or receiving a referral. An interview was conducted with the Admissions Coordinator on 1/24/25 at 10:45 AM. She reported hospice services had been mentioned in the hospital paperwork for Resident #70 in December. She said Resident #70's spouse had been going back and forth at the hospital between doing therapy or hospice. She recalled Resident #70's spouse had called and spoken to her before he was admitted to the facility and said they wanted intensive therapy and did not want hospice. The Admissions coordinator remembered she had discussed it during the morning meeting about Resident #70 wanting therapy and not hospice. A follow up interview with the ST was conducted on 1/24/25 at 11:00 AM. The ST reported she was present at the facility and would have attended the morning meetings on 12/17/24, 12/18/24 and 1/13/25. She reported that if she was unable to attend the morning meeting, she had someone from therapy attend the meeting in her place. An interview was conducted with the Director of Nursing (DON) on 1/24/25 at 11:53 AM. The DON recalled hospice had been discussed with Resident #70 and his spouse the day after he was admitted on [DATE] and that they had not wanted hospice. The DON reported Resident #70 should have been evaluated by all therapy disciplines when he said he did not want hospice because he was a new admission. The DON stated she was not aware speech therapy had not evaluated Resident #70 and had not known he was not hospice. She reported the rehab director, who was also the ST attended the morning meetings. The DON recalled Resident #70 not wanting hospice and needing to be evaluated by therapy being discussed in the morning meeting. She reported on admission Resident #70's payor source had not been hospice so therapy could have evaluated him. The DON said in the morning meeting all residents who were admitted the day prior were discussed. The DON stated she could not say why therapy did not know they needed to evaluate him or that he was not hospice. The DON said a new admission resident that had a diet change should have been a trigger for speech therapy to evaluate them. She explained she had assumed speech therapy had evaluated Resident #70 but had not looked to make sure. The DON stated she could not say where the ball was dropped with Resident #70 not being evaluated by therapy. An interview was conducted with the Administrator on 1/24/25 at 3:10 PM. The Administrator reported the facility went over admissions in their morning meeting and the rehab director attended the morning meetings. The Administrator explained the electronic documentation system used by therapy was different than the electronic documentation system used by the facility. She further explained that the facility could not access therapy's electronic system to see the notes or to see if someone had been evaluated by therapy. The Administrator said when Resident #70's diet had been downgraded from mechanical soft to puree on 12/19/24 it should have triggered an evaluation by speech therapy at that time. An interview was conducted with the Medical Director on 1/24/25 at 4:09 PM. The Medical Director said residents who received a modified diet, thickened liquids, or had their diet downgraded should be evaluated by speech therapy. The Medical Director stated if Resident #70's diet had been downgraded then speech therapy should have seen him. The Medical Director reported it could take a while for pneumonia to clear off a chest x-ray. She explained, if someone aspirated, they might have symptoms, but it may take a few days for it to show up on a chest x-ray. She said Resident #70 was admitted on [DATE] and the chest x-ray from 12/18/24 would probably have been too soon for aspiration pneumonia to show up on the chest x-ray if he had aspirated at the facility. The Medical Director said it would be hard to tell if Resident #70's pneumonia was new or old on his 12/18/24 chest x-ray, but clinically he was worse and that was why he was treated. She explained that you could not tell 100% if pneumonia was new or old on a chest x-ray unless it was in a different location or there was a negative chest x-ray prior to the one showing the pneumonia. The Medical Director said Resident #70 was at continued ongoing risk for aspiration. She could not say if having speech therapy involved would have made a difference in his aspiration risk or prevented his hospitalization in January. A follow up interview was conducted with the PA on 2/7/25 at 2:15 PM. The PA explained that aspiration pneumonia occurred more prominently on the right side of the lungs because the right bronchus (large airway that carries air from the windpipe to the lungs) was shorter. She said aspiration pneumonia typically showed up on a chest x-ray as a right sided pneumonia. The PA further explained, she thought Resident #70's pneumonia from 12/18/24 had been aspiration pneumonia because of his background and all of his risk factors combined with his chest x-ray that had shown right side pneumonia. She said Resident #70's risk factors included his history of aspiration and dysphagia. The PA indicated she looked at the entire clinical picture and that was why she was more inclined to think aspiration was involved. She said Resident #70 had a modified diet and speech therapy was important to see if the modified diet he was on was the appropriate diet for him. The PA said puree food could potentially cause a food bolus that could get stuck in the esophagus but was unlikely to do so. She explained the imaging from the scan done during Resident #70's 1/8/25 hospitalization had indicated there was a concern something was seen in his esophagus, but the EGD was to identify what it was. She said the EGD was what was definitive and when the EGD had been performed a food bolus had not been seen. The PA said there was no way to know for sure if a food bolus had been present or not, but that it had not been seen on the EGD. A follow up interview was conducted with the DON on 2/7/25 at 3:00 PM. The DON said Nurse #4 had called the hospital when Resident #70 was admitted in December and asked what his diet was supposed to be and had been told his diet was mechanical soft with nectar thick liquids. She reported she did not know who Nurse #4 had spoken to at the hospital. The DON thought anyone who received a modified diet should be evaluated by speech therapy to determine if the diet was appropriate and safe. The DON did not specifically remember Resident #70's downgraded diet from 12/19/24 being discussed during the morning meeting on 12/20/24, but the DON said she printed all the orders entered into the electronic computer system the prior day and reviewed them all during the morning meeting. The facility's Administrator was informed of the immediate jeopardy on 2/7/25 at 4:57 PM. The facility submitted the following credible allegation of immediate jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance On 12/17/24 Resident #70 was admitted to the facility from hospital with diagnosis of cholecystitis, and a diet order of mechanical soft and nectar thick liquids. Upon admission from the hospital, all documentation related to admission stated that Resident #70 would be receiving hospice services. With the presumed knowledge of this resident being under hospice services, speech therapy did not evaluate the resident. After admission to the facility Resident #70

Based on observations and staff interviews, the facility failed to clean and maintain the reach-in refrigerator, walk-in refrigerator and the steam table knobs in the kitchen. The facility also failed to remove expired tube feeding containers from 1 of 2 nourishment rooms. This practice had the potential to affect residents in the facility. Findings included a. An observation of the kitchen's reach-in refrigerator was made with the Dietary Manager (DM) on [DATE] at 10:38 AM. The observation found the inside floor of the refrigerator and the bottom of the inside side of the door contained splattered, sticky to touch red substance. The reach-in refrigerator's circulatory fan cover was observed covered with thick brown/gray debris that was crumbly to touch. b. On [DATE] at 10:46 AM the walk-in refrigerator ceiling was found to contain gray in color, loosely hanging debris. The debris was crumbly to touch and was in the back of the walk-refrigerator near the cooling fan. c. On [DATE] at 10:49 AM each of the six the steam table knobs used to turn on and adjust the temperature of the steam table were found with a build-up substance that was sticky to touch. On [DATE] at 11:24 AM a follow-up observation of the kitchen found the reach-in refrigerator, walk-in refrigerator, and steam table knobs remained unchanged. d. On [DATE] at 4:00 PM the main nourishment room was observed with the DM. The nourishment room contained 21 8 oz tube feeding cartons with an expiration date of [DATE]. The DM stated during the observation that Central Supply staff stocked and maintained the tube feeding inventory. The Central Supply Manager was interviewed on [DATE] at 4:06 PM. She stated Central Supply staff stocked the tube feeding containers, checked expiration dates and removed expired tube feeding containers. She stated the tube feeding containers were checked monthly for expiration when the nourishment room was stocked. The Central Supply Manager stated she had overlooked the expired tube feedings. On [DATE] at 11:39 AM the DM stated the reach-in refrigerator was cleaned on a weekly basis and was not cleaned the previous week. He stated the debris on the ceiling of the walk-in cooler was overlooked and was not included in a cleaning schedule. The DM said the steam table knobs were not included on a cleaning schedule and had been overlooked. The Administrator stated on [DATE] at 3:16 PM the kitchen should have been clean and tidy and on a regular cleaning schedule.

Based on observations and staff interviews, the facility failed to maintain and repair 1 of 1 leaking steam cooker for 1 of 1 steam cooker observed. Findings included On 1/23/25 at 12:11 PM an observation of the kitchen's steam cooker found hot water dripping from the bottom of the steam cooker door while in use. The steam cooker was observed spewing steam out from each side of the closed steam cooker door when it was being used to heat food. The Dietary Manager (DM) stated the steamer had been leaking water and steam since he had become the DM in August 2024. The DM said he had not informed the Maintenance Director the steamer needed repair since he became the DM, and he thought the door seal needed to be replaced to keep the steam and water from leaking out when in use. The DM stated when something needed to be repaired in the kitchen, he verbally communicated it to the Maintenance Director who would complete the repairs or outsource to complete the repairs. The Maintenance Director was interviewed on 1/24/25 at 11:26 AM. He stated the steam cooker seal had been repaired once before by the appliance service company in January 2024 who repaired the kitchen equipment when needed. The Maintenance Director stated he had not been aware of or notified that the steamer needed to be repaired. On 1/24/25 at 11:36 AM a second interview conducted in conjunction with an observation with the Maintenance Director found the steam cooker leaking steam. The Maintenance Director inspected the door seal, revealing it was not fully attached and stated the door seal needed to be replaced. The Maintenance Director stated he would call the appliance service company to repair the steamer. The Administrator was interviewed on 1/24/25 at 3:16 PM. She stated the Maintenance Director should have been notified the steamer needed to be repaired.

Based on record review, observation, and staff interviews, the facility failed to develop an accurate baseline care plan for a resident (Resident #70) when the care plan did not include the type of thickened liquids ordered for Resident #70. This deficient practice occurred for 1 of 1 resident reviewed for baseline care plans. Findings included: Resident #70 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #70 was cognitively intact. He was coded on the MDS as having a mechanically altered diet. A diet order dated 12/17/24 read, regular diet, mechanical soft texture, nectar thick liquids. The order was discontinued on 12/19/24. A baseline care plan dated 12/17/24 read under dietary: Diet order, regular mechanical soft thickened liquids. A diet order dated 12/19/24 read, regular diet, puree texture, nectar thick liquids. The order was discontinued on 1/13/25. A hospital discharge summary for Resident #70 dated 1/13/25 revealed he was admitted to the hospital on 1/8/25 and was discharged on [DATE]. His discharge diagnoses included: esophageal dysphagia (difficulty swallowing), aspiration pneumonia (lung infection that occurs when food/liquid is inhaled into the lungs), and acute hypoxic (low blood oxygen level) respiratory failure secondary to aspiration pneumonia. The discharge summary said Resident #70 was discharged on a puree diet with honey thick liquids. A diet order dated 1/13/25 read, regular diet, puree texture, honey thick liquids. A care plan dated 12/17/24 and revised on 1/14/25 read: Resident #70 has a nutritional problem or potential nutritional problem and is reliant on thickened liquids and pureed food at this time. The care plan intervention said to provide and serve diet as ordered. An interview was conducted with the Minimum Data Set (MDS) nurse on 1/24/25 at 2:42 PM. He explained baseline care plans were completed by the admitting nurse. He further explained he reviewed the baseline care plans to make sure they were completed and then used it for the basis of the comprehensive care plan. He said the care plan should read diet as ordered or thickened liquids as ordered. He stated staff would have to ask the nurse what Resident #70's diet/ thickened liquid order was if it was not on the care plan. The MDS Nurse thought it would be best for the diet order and the type of thickened liquids a resident was supposed to receive to be included in the care plan. An interview was conducted on 1/24/25 at 5:37 PM with Nurse #4. She recalled completing Resident #70's admission on 12/17/24. Nurse #4 said she had completed the baseline care plan when she did his admission. She stated she should have put the type of thickened liquids ordered for Resident #70 on the care plan but did not think about it. An interview was conducted with the Director of Nursing on 1/24/25 at 11:53 AM. She explained the baseline care plan could be done by any nurse on admission and then it was reviewed by the MDS nurse. The DON said staff would have to look at Resident #70's dietary ticket or ask the nurse to look up the order to see what type of thickened liquids Resident #70 was supposed to have if it was not listed on the care plan. She stated the type of thickened liquids Resident #70 received should have been listed on the care plan. An interview was conducted with the Administrator on 1/24/25 at 3: 10 PM. The Administrator stated the care plan should match the physician orders and the kitchen dietary ticket; she stated they should all match. She said the care plan should have said what type of thickened liquids were ordered for Resident #70.

Based on record review, observation, staff and Physician Assistant (PA) interviews, the facility failed to provide thickened liquids as ordered to a resident (Resident #70) when Nurse Aide (NA) #1 gave Resident #70 nectar thick liquids to drink instead of honey thick liquids. Resident #70 required honey thick liquids due to his risk of aspiration and history of aspiration pneumonia. This deficient practice occurred for 1 of 3 residents reviewed for accident hazards. The findings included: Resident #70 was admitted to the facility on [DATE]. He was readmitted to the facility on [DATE] following hospitalization . The admission minimum data set (MDS) dated [DATE] revealed Resident #70 was cognitively intact. The MDS documented he had no behavior or rejection of care. The MDS indicated Resident #70 required substantial/ maximal assistance from staff with eating. He was coded on the MDS as having a mechanically altered diet. The hospital discharge summary for Resident #70 dated 1/13/25 revealed he was admitted to the hospital on 1/8/25 and was discharged on [DATE]. His discharge diagnoses included: esophageal dysphagia (difficulty swallowing), aspiration pneumonia (lung infection that occurs when food/liquid enters the lungs), and acute hypoxic (low blood oxygen level) respiratory failure secondary to aspiration pneumonia. The discharge summary said Resident #70 was discharged on a puree diet with honey thick liquids and would get speech therapy (ST) at rehab. A diet order dated 1/13/25 read, regular diet, puree texture, honey thick liquids. Resident #70 had a care plan revised on 1/14/25 that read: Resident #70 has a nutritional problem or potential nutritional problem and is reliant on thickened liquids and puree food at this time. The care plan intervention said to provide and serve diet as ordered. On 1/22/24 the Kardex for Resident #70 was reviewed and revealed it did not indicate the type of thickened liquids he was supposed receive. A continuous observation was completed on 1/21/25 from 12:58 PM to 1:14 PM of NA #1 assisting Resident #70 in his room with his lunch meal. NA #1 setup Resident #70's meal tray. She checked his meal tray card. His head of bed was elevated in an upright position. He had a clear cup with thickened liquids on his tray. Resident #70 was observed as he attempted to drink the thickened liquids out of the cup through a straw, he said nothing was coming out of the cup. NA #1 exited the room at 1:07 PM and returned to the room at 1:08 PM with a small clear plastic cup. NA #1 went to a red hydration cooler sitting on top of Resident #70's dresser, removed a carton from the cooler, and poured the thickened liquid from the carton into the small plastic cup. NA #1 put a straw in the cup and gave it to Resident #70. Resident #70 was observed as he drank the thickened liquid from the cup using the straw. After drinking the liquid Resident #70 was heard coughing. Resident #70's meal ticket was reviewed with NA #1. His meal ticket indicated honey thick liquids were ordered. The carton of thickened liquids from the cooler was reviewed with NA #1, it was the only carton present in the cooler and had an open date of 1/21/25 written on the carton. NA #1 confirmed nectar thick liquid was printed on the carton of lemon water. She confirmed the liquids sent by the kitchen on his meal tray were honey thick liquids. NA #1 was interviewed at 1:10 PM and stated she was unsure about the nectar thickened liquids in the hydration cooler located in Resident #70's room. She explained she had not looked on the carton to check what type of thickened liquid it was, but had assumed it was the correct thickened liquid for Resident #70 since the carton was in his cooler. NA #1 reported she did not know Resident #70 that well and would go get NA #2 who was more familiar with him. NA #1 exited the room at 1:13 PM to retrieve NA #2. NA #1 returned to Resident #70's room at 1:14 PM with NA #2. NA #1 removed the nectar thick liquids from Resident #70's meal tray and continued to assist him with his meal. An interview was conducted with NA #2 on 1/21/25 at 1:15 PM. NA #2 reported she did not know when Resident #70 had been placed on honey thick liquids but stated he could not drink the honey thick liquid out of his cup using a straw because they were too thick. NA #2 explained Resident #70 did not do well with honey thick liquids because he became frustrated when he tried to drink it. NA #2 added she thought Resident #70 did better with nectar thick liquids because he could drink them easier. NA #2 said she had not spoken to anyone about Resident #70's thickened liquids. She further explained that the carton of nectar thickened liquids was already in Resident #70's hydration cooler when she arrived to work this morning. An interview was conducted with Nurse #3 on 1/21/25 at 1:28 PM. Nurse #3 was the assigned nurse for Resident #70. Nurse #3 reviewed Resident #70's physician orders and confirmed he had honey thick liquids ordered. Nurse #3 stated Resident #70 should only have honey thick liquids and should not be given nectar thick liquids or have them in the cooler in his room. Nurse #3 explained that nectar thick liquids were not thick enough for Resident #70 and if he was given fluids that were not thick enough, he could aspirate. Nurse #3 stated he would remove the carton of nectar thick liquids from Resident #70's room. An interview was conducted with NA #3 on 1/22/25 at 3:23 PM. NA #3 worked the night shift on Monday night 1/20/25 on 300 hall and was Resident #70's assigned NA. She explained she refilled Resident #70's bedside hydration cooler with thickened liquids on night shift. NA #3 said there had not been thickened liquids in the nourishment room Monday night and she had asked Nurse #2 for thickened liquids for Resident #70. She said Nurse #2 had gone to the kitchen to get thickened liquids for Resident #70. NA #3 recalled Nurse #2 gave her a carton of nectar thick lemon water. NA #3 said she had assumed the thickened liquids Nurse #2 had given her for Resident #70 was what he was supposed to have. She said she thought Resident #70 was supposed to have nectar thick liquids. An interview was conducted with Nurse #2 on 1/24/25 at 8:17 AM. Nurse #2 explained NA #3 had asked her for thickened liquids for Resident #70 on Monday night because she could not find the thickened liquids in the nourishment room. Nurse #2 reported she went to the kitchen and got a container of thickened liquids and gave it to NA #3 for Resident #70. Nurse #2 said she had looked at the carton and it said, thickened liquid. She did not recall what type of thickened liquids were labeled on the carton but said she had thought it would okay since it had said thickened on the carton. Nurse #2 stated she knew Resident #70 had returned from the hospital on thickened liquids but did not know what type of thickened liquids he was supposed to have. She did not know he had honey thick liquids ordered. An interview was conducted on 1/21/25 at 3:37 PM with the Speech Therapist (ST). The ST said she had received a ST referral or been asked to evaluate Resident #70 before today. The ST explained she had been asked to see Resident #70 today after the incident at lunch where he had been given nectar thick liquids instead of honey thick liquids. The ST stated she had completed a bedside swallow study. She reported she trialed nectar thick liquids and a safety straw today during the bedside swallow study. She stated Resident #70 had shown signs of aspiration with nectar thick liquids, which were coughing. The ST stated Resident #70 needed honey thick liquids. The ST explained honey thick liquids would be very difficult to drink out of a straw and should be drunk using cup sips. An interview was conducted on 1/23/25 at 9:38 AM with the PA. The PA reported Resident #70 had a choking/ aspiration episode at the facility on 1/7/25 and was sent to the hospital for evaluation. She explained Resident #70 had been admitted to the hospital with aspiration pneumonia and had returned to the facility on [DATE]. She explained prior to his hospitalization he had nectar thick liquids ordered but he had been changed to honey thick liquids during his hospitalization . The PA stated Resident #70 was ordered to receive honey thick liquids. The PA said nectar thick liquid was not as thick as honey thick liquid, she said it was not as risky as thin liquid, but was not what Resident #70 should have had. She explained Resident #70 was high risk for aspiration. An interview was conducted with the Director of Nursing (DON) on 1/23/25 at 8:54 AM. The DON stated Resident #70 had been changed to honey thick liquids during his hospitalization and had honey thick liquids ordered when he returned from the hospital on 1/13/25. The DON said she was not sure why Resident #70 had nectar thick liquids in the hydration cooler in his room. She said Resident #70 should not have been given nectar thick liquids and that he needed honey thick liquids to help prevent aspiration. An interview was conducted with the Administrator on 1/24/25 at 3:10 PM. The Administrator stated Resident #70 should have received honey thick liquids and staff should have been aware of what liquids he was supposed to receive.

Based on observations, record review, staff, Physician Assistant (PA), and Pharmacist interviews the facility failed to maintain a medication error rate of less than 5% by having 3 errors out of 35 opportunities which resulted in an 8.57% medication error rate. This affected 1 of 4 residents observed for medication administration (Resident #19). Findings included: Resident #19 was admitted to the facility on [DATE]. Her medical diagnoses included: hypertension (high blood pressure), angina (chest pain), chronic obstructive pulmonary disease (COPD) (chronic respiratory disease), and gastro-esophageal reflux disease (GERD). A Physician's order dated 9/26/24 read, may crush medications unless contraindicated. A physician's order dated 9/27/24 read Isosorbide Mononitrate (cardiac medication) extended release (ER) 24-hour 30 milligram (mg) oral tablet, give one tablet by mouth one time a day for angina. The manufacturer's package insert instructions for the administration of Isosorbide Mononitrate dated 2/2025 included: Isosorbide Mononitrate extended-release tablets should not be chewed or crushed A physician's order dated 9/26/24 read Mucinex (medication that thins mucus) extended release (ER) 12-hour 600 milligram (mg) oral tablet, give one tablet by mouth two time a day for congestion. The manufacturer's package insert instructions for administration of Mucinex ER 600 mg dated 9/2023 included: do not crush, chew, or break tablet. A physician's order dated 1/9/25 read Pantoprazole Sodium (medication for acid reflux) oral packet 40 mg, give 1 packet by mouth one time a day for GERD. The manufacturer's package insert instructions for administration of Pantoprazole Sodium delayed-release oral suspension dated 5/2024 included: Do not split, chew, or crush pantoprazole sodium for delayed-release oral suspension. An observation and interview was conducted on 1/23/25 at 8:00 AM of Nurse #5 preparing Resident #19's medication at the 300-hall medication cart. She placed the Isosorbide Mononitrate ER 30 mg tablet, Pantoprazole 40 mg tablet, and Mucinex 600 mg ER tablet into a medication cup along with all of Resident #19's other prepared medications. She placed the medications from the medication cup into a clear plastic pill crushing pouch. Nurse #5 placed the pouch containing Resident #19's medications into the pill crusher and crushed the medications. She emptied the crushed medications into a medication cup with applesauce. Nurse #5 entered Resident #19's room and approached her to administer the medications. Nurse #5 was stopped by the surveyor and asked to return to the medication cart. An interview was conducted with Nurse #5 at 8:10 AM. Nurse #5 explained she thought the directions for the pantoprazole had been mistakenly entered as a packet instead of a tablet. She said the blister card of pantoprazole tablets was what was on hand on the medication cart for Resident #19 and she thought it was okay to give the tablet. She did not know if the pantoprazole had been ordered as a packet because Resident #19 needed her medications crushed. Nurse #5 said she thought it was okay to crush the ER tablets because they were tablets and not a capsule. She thought since it was a tablet the ER medication would not be released all at once if they were crushed and it was okay to crush them. Nurse #5 then said she was not sure. She said if she was not sure if a medication could be crushed, she would ask Unit Manager (UM) #1 or call the pharmacy. Nurse #5 said she was going to go ask UM #1 about the medication. On 1/23/25 at 8:13 AM Nurse #5 returned to the 300-hall medication cart with UM #1 and an interview was conducted with UM #1. UM #1 stated ER medications and should not be crushed because all the medication would be released at one time. UM #1 said she did not think pantoprazole tablets could be crushed. An interview was conducted with the Director of Nursing (DON) on 1/23/25 at 8:54 AM. The DON explained if ER medication were crushed it would change the release time of the medication. She said ER medications were intended to be slow release and if they were crushed the medication would be released all at one time. The DON stated she did not think Isosorbide Mononitrate ER should be crushed but was not sure about the Mucinex ER tablet and Pantoprazole tablet. She thought a pharmacist had told her in the past it was okay to crush Mucinex ER tablets, but she was not sure and would have to check. She said she did not know why Nurse #5 had thought it was okay to crush Resident #19's Isosorbide Mononitrate ER tablet. On 1/23/25 at 9:38 AM an interview was conducted with the PA. The PA stated ER medications should not be crushed because the medication would be released all at one time. She said to her knowledge Isosorbide Mononitrate ER, Pantoprazole, and Mucinex ER should not be crushed but crushing it would not be significant or have an impact to the resident. An interview was conducted with the Pharmacist on 1/23/25 at 12:06 PM. The Pharmacist said you do not crush ER medications. She stated Isosorbide Mononitrate ER should not be crushed or chewed. She said if the Isosorbide Mononitrate ER was crushed it would be released all at one time. The Pharmacist explained if the medication was released in the body all at one time it could cause lightheadedness from a decrease in blood pressure or heart rate. She was not sure about the potential impact it could have and could not say if it could be significant or not. The Pharmacist further stated, pantoprazole tablets and Mucinex ER tablets were not supposed to be crushed because the medication would be released all at one time. She said the Pantoprazole tablet packet insert said not to crush the medication and that the medication should not be crushed. The Pharmacist explained if the Pantoprazole tablet was crushed it would decrease the bio availability of the medication, which meant it would make the medication less effective. The Pharmacist stated Mucinex ER tablets were formulated with an ER side. She stated if the Mucinex ER tablet was crushed the medication would not be released over time and would not treat the patient's symptoms over time the way it was intended. The Pharmacist further explained Mucinex ER was formulated to release over 12 hours to treat symptoms over a 12 hour period of time and if the tablet was crushed it would not provide the 12 hours of symptom management. An interview was conducted with the Administrator on 1/24/25 at 3:10 PM. She said nurses should follow physician orders when administering medication. She said ER medications should not be crushed because the medication would be released all at once. The Administrator said the pharmacy or physician should be consulted about if it was okay to crush ER medications.

Based on observations and staff interviews, the facility failed to ensure the 400-hall medication cart was secured while unattended. This was for 1 of 5 medication carts observed (400 hall). Findings included An observation on 1/22/25 at 1:52 PM revealed the 400-hall medication cart was unattended and unlocked with the lock in the outward position. The medication cart was located directly outside the nurses' station and across the hall from a resident activity room. A continuous observation of the medication cart occurred on 1/22/25 from 1:52 PM to 2:03 PM in which 16 facility staff passed the unlocked cart. A resident was observed sitting in their wheelchair approximately 10 feet from the cart while unlocked. Nurse #1 who was assigned to the 400 hall nurses cart arrived back to the medication cart on 1/22/25 at 2:03 PM, locked the cart and was interviewed. Nurse #1 stated she had placed the medication cart by the nurses' station and did not double check that the cart was locked. She stated she normally locked the cart and should have locked the cart before leaving it unattended. The Director of Nursing (DON) stated on 1/24/25 at 11:58 AM the medication cart should be locked if unattended by a nurse or not within the eye site of a nurse. The DON said any staff who had noticed an unlocked and unattended medication cart should report it to her and lock the cart. The Administrator stated on 1/24/25 at 3:16 PM that Nurse # 1's medication cart should have been locked when unattended by the nurse.

Based on observation, record review, and staff interviews, the facility failed to provide drinks consistent with the resident's needs for 1 of 1 sampled resident (Resident #70) reviewed for drinks available to meet resident needs. The findings included: Resident #70 was readmitted to the facility on [DATE]. A diagnosis of dysphagia (difficulty swallowing) was listed on Resident #70's 1/13/25 hospital discharge summary. A diet order dated 1/13/25 read, regular diet, puree texture, honey thick liquids. Resident #70 had a care plan revised on 1/14/25 that read: Resident #70 has a nutritional problem or potential nutritional problem and is reliant on thickened liquids and puree food at this time. The care plan intervention said to provide and serve diet as ordered. An observation was completed on 1/21/25 at 1:10 PM of the hydration cooler in Resident #70's room. The cooler contained a carton labeled nectar thick lemon water. The carton was dated with an open date of 1/21/25. An interview was conducted with Nurse Aide (NA) #2 on 1/21/25 at 1:15 PM. NA #2 explained that the carton of nectar thickened liquids was already in Resident #70's hydration cooler when she arrived at work this morning. An interview was conducted with Nurse #3 on 1/21/25 at 1:28 PM. Nurse #3 was the assigned nurse for Resident #70. Nurse #3 reviewed Resident #70's physician orders and confirmed he had honey thick liquids ordered. Nurse #3 stated Resident #70 should only have honey thick liquids and should not be given nectar thick liquids or have them in the cooler in his room. Nurse #3 said he would remove the carton of nectar thick liquids from Resident #70's room. An interview was conducted with NA #3 on 1/22/25 at 3:23 PM. NA #3 worked the night shift on Monday night 1/20/25 on 300 hall and was Resident #70's assigned NA. She explained Resident #70 had asked for something to drink and was saying he was thirsty Monday night. NA #3 reported there had not been any thickened liquids in the hydration cooler in Resident #70's room. NA #3 stated there had not been thickened liquids in the nourishment room Monday night and she had asked Nurse #2 for thickened liquids for Resident #70. She said Nurse #2 had gone to the kitchen to get thickened liquids for Resident #70. NA #3 recalled Nurse #2 gave her the carton of nectar thick lemon water for Resident #70. An interview was conducted with Nurse #2 on 1/24/25 at 8:17 AM. Nurse #2 explained NA #3 had asked her for thickened liquids for Resident #70 on Monday night because she could not find the thickened liquids in the nourishment room. She reported Resident #70 was saying he was very thirsty. Nurse #2 said she looked and could not find any thickened liquids in the nourishment room or on 100 hall. Nurse #2 reported she went to the kitchen to look for thickened liquids and she had only been able to find one container of thickened liquids. She stated the facility usually had packets of thickener, but she was unable to find any thickener packets. Nurse #2 reported she gave the container of thickened liquids she had found in the kitchen to NA #3 for Resident #70. Nurse #2 recalled she had looked at the carton and it said, thickened liquid. She did not recall what type of thickened liquids were labeled on the carton but had thought it would be okay since it had said thickened on the carton and Resident #70 was saying he was thirsty. Nurse #2 said she told a dietary staff member Tuesday morning about needing thickened liquids. She did not recall who she had told. An interview was conducted with the Dietary Manager on 1/22/24 at 1:29 PM. The DM stated the facility ran out of pre-thickened honey thick liquids Monday night. He said he had ordered honey thick liquids on 1/21/25 when he became aware the facility had run out. The DM reported he contacted a sister facility this morning (1/21/25) after breakfast when he realized the facility was out of the pre thickened honey thick liquids and the sister facility had provided a supply of honey thick liquids and extra thickener packets to the facility. The DM said they had received the interim supply of honey thick liquids from the sister facility sometime after lunch on 1/21/25. He explained the facility had thickener packets available at the facility, not the pre-thickened honey thick liquids. He did not know why the staff could not locate the thickener packets. An interview was conducted with the Director of Nursing (DON) on 1/23/25 at 8:54 AM. The DON said she was not sure why Resident #70 had nectar thick liquids in the hydration cooler in his room. She explained Resident #70 should not have been given nectar thick liquids and that he needed honey thick liquids to help prevent aspiration. An interview was conducted with the Administrator on 1/24/25 at 3:10 PM. The Administrator stated Resident #70 should have received honey thick liquids. She said the facility should have had honey thick fluids available.

Based on record review and staff interviews the facility failed to provide a hazard-free environment by leaving a pair of blunt tipped scissors unsecured in the dining room of the locked memory care unit, resulting in a resident obtaining the scissors and making multiple superficial cuts to his penis. This deficient practice occurred for 1 of 3 residents reviewed for accidents (Resident #1). Findings included: Resident #1 was admitted to the facility 08/15/24 with a diagnosis including non-Alzheimer's dementia. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was moderately cognitively impaired and did not have behaviors during the look back period. An interview with Nurse Aide (NA) #1 on 10/22/24 at 11:00 AM revealed she was caring for Resident #1 on 09/02/24 on the 7:00 AM to 3:00 PM shift. She stated she and NA #2 went into Resident #1's room the morning of 09/02/24 to assist him out of bed when she noticed blood on his bed sheet. NA #1 stated she thought Resident #1 had scratched himself in his private area and she assisted him to the bathroom to help clean him up. She stated when she checked Resident #1's private area she saw multiple lacerations to his penis that were bleeding a small amount. NA #1 stated she notified the Administrator and Nurse #1 immediately and Nurse #1 assessed Resident #1. An interview with NA #2 on 10/22/24 at 11:10 AM revealed she was caring for Resident #1 on 09/02/24 on the 7:00 AM to 3:00 PM shift. NA #2 stated she and NA #1 went into Resident #1's room the morning of 09/02/24 to assist him out of bed. She stated as they entered the room, she and NA #1 saw a small amount of blood on Resident #1's bottom sheet. NA #2 stated NA #1 assisted Resident #1 to the bathroom to help him get cleaned up and she left the room to get clean linen. She stated when she returned to Resident #1's room, she saw a pair of yellow blunt tipped scissors with what appeared to be blood on them, lying on the unoccupied bed in Resident #1's semi-private room. NA #2 stated she placed the scissors in the sharps (puncture resistant) container. She stated she had never seen scissors like the pair in Resident #1's room on the unit before and was not sure where they came from. A telephone interview with Nurse #1 on 10/22/24 at 12:57 PM revealed he was caring for Resident #1 on 09/02/24 on the day shift. He stated he was passing medications the morning of 09/02/24 when a NA notified him Resident #1 was bleeding. Nurse #1 stated he immediately went to Resident #1's room and noted some superficial cuts to Resident #1's penis. He stated he cleaned the lacerations and notified the NP of the incident. Nurse #1 stated when he asked Resident #1 what happened, Resident #1 explained he had wrecked on his motorcycle and had to cut himself out of barbed wire. He stated the entire unit was searched for scissors and no other scissors were found. Nurse #1 stated he had never seen blunt tipped scissors on the unit before and he did not know how Resident #1 obtained the scissors. A telephone interview with NA #3 on 10/22/24 at 3:37 PM revealed she cared for Resident #1 on 09/01/24 on the 11:00 PM to 7:00 AM shift. She stated she noticed a pair of yellow scissors with blunt tips sitting behind the sink in the day room/dining room when she began her shift on 09/01/24. NA #3 stated she had never seen the scissors on the unit before that shift and did not think about storing the scissors in the locked closet in the day room/dining room because residents were never in the room without supervision. She stated when she worked on the locked memory care unit, she usually sat in a chair in the doorway of the day room/dining room to monitor residents because she could visualize all resident rooms to see if residents exited their rooms. NA #3 stated Resident #1 did not leave his room during her shift on 09/01/24 and no other resident came in the day room/dining room the entire night. She stated Resident #1 seemed his usual self when she did her last round before her shift ended and she would have notified the nurse immediately if she had seen Resident #1 with scissors or noted any blood on his sheets. An interview with the Activities Director on 10/22/24 at 11:53 AM revealed the activities department did have some blunt tipped scissors, but they were never allowed on the locked memory care unit. She stated when crafts were done on the memory care unit the activities department pre-cut any items that needed to be cut and she did not know how or why scissors would be on the unit. A telephone interview with the Nurse Practitioner (NP) on 10/22/24 at 12:42 PM revealed she was asked to evaluate Resident #1 on 09/02/24 due to cuts on his penis. She stated nursing staff reported to her that Resident #1 had a pair of blunt tipped scissors and it was presumed he used the scissors to cut multiple areas on his penis. The NP stated the lacerations were superficial and she ordered antibiotic ointment and gauze to the area twice a day. She stated prior to this incident Resident #1 had not demonstrated any behaviors which indicated he might cause himself harm. An interview with the Physician on 10/22/24 at 1:42 PM revealed she evaluated Resident #1 on 09/03/24 for lacerations on his penis. She stated the lacerations were superficial and did not show any signs or symptoms of infection. The Physician stated she asked Resident #1 why he had cuts on his penis, and he explained to her that he had gotten stuck in some barbed wire, and he removed the barbed wire from his person. She stated Resident #1 had not routinely been having hallucinations prior to this incident and there was no indication he would harm himself. The Physician stated Resident #1 was very mobile and he could have obtained the scissors from another resident's room, and it was not possible to police every item that came in and out of the unit. She stated it was never determined how or where the scissors came from because they were not similar to any scissors kept in the facility. An interview with the Director of Nursing (DON) on 10/22/24 at 2:37 PM revealed she was on vacation when Resident #1 cut himself with scissors, but the facility was unable to identify where the scissors came from or how he obtained the scissors. She stated scissors should not be on the memory care unit. An interview with the Administrator on 10/22/24 at 2:42 PM revealed she was notified NAs went into Resident #1's room the morning of 09/02/24 to provide incontinence care, noted blood on his bedsheets, saw lacerations on his penis, and a pair of yellow blunt tipped scissors were found in Resident #1's room. The Administrator stated she did not visualize the areas but was told the lacerations were more like abrasions. She stated it was determined that sometime the morning of 09/02/24 Resident #1 had obtained a pair of scissors and cut his penis and scrotum. The Administrator stated she did not observe the scissors Resident #1 used because they had been placed in the sharps container before she could observe them, but their description did not match any scissors that kept in the facility. The Administrator stated she was never able to identify how Resident #1 was able to obtain the scissors or where the scissors came from, and the scissors should not have been on the memory care unit.

Based on observations and staff interviews, the facility failed to remove expired food items stored for use in the walk-in freezer, cooler, and dry goods storage room in the kitchen and failed to remove and/or label and date food items available for use in 1 of 2 nourishment rooms (100 Hall nourishment room). These practices had the potential to affect food served to residents. Findings included: 1. An observation and interview conducted on [DATE] at 9:35 AM with the Dietary District Manager revealed during the initial kitchen tour a bag of 11 frozen Salisbury steaks were observed to be undated in the walk-in freezer. The observation further revealed in the dry goods storage room was three cereals with the discard date [DATE], [DATE], and [DATE]. Also included were flour tortillas with discard date [DATE], and 14 46 fl. ounce cartons of emergency orange juice with discard date [DATE]. The dietary District Manager stated the items observed should have been discarded. 2. An observation and interview conducted on [DATE] at 10:00 AM with Nurse #1 revealed the nourishment room on the 100-hall had a pizza pocket in the freezer that was not labeled. The observation further revealed a peach yogurt with discard date [DATE] located in the refrigerator labeled with a resident's name. Nurse #1 indicated it was dietary staff's responsibility to check the nourishment rooms daily. Nurse #1 stated nursing staff had been educated on labeling residents' food and discarding of food also if observed expired. 3. An observation conducted on [DATE] at 11:45 AM with the Dietary District Manager revealed a bag of unopened cabbage in the cooler with the discard date [DATE]. The Dietary District Manager further revealed the bag should have been discarded and dietary staff had been educated on checking refrigerators daily and discarding expired food. An interview conducted with the Dietary Manager (DM) on [DATE] at 2:30 PM revealed dietary staff had been educated checking all food and drinks daily in the kitchen. The DM further revealed the nourishment rooms were checked two times a day by dietary and items should have been discarded if expired as well. The DM indicated nursing staff was responsible for labeling residents items but does not know who the pizza pocket belonged to. The DM stated all foods observed found during observation should have been discarded or labeled. An interview conducted with the Administrator on [DATE] at 6:05 PM revealed she expected dietary and nursing staff to discard expired foods found in the kitchen or nourishment rooms. The Administrator further revealed nursing staff and dietary had been educated on discarding and labeling dietary items.

Based on observations, record review, and staff and resident interviews the facility failed to label a tube feeding formula bag for 1 of 2 residents (Resident # 204). The findings included: Resident #204 was admitted to the facility on [DATE] with diagnoses which included hemiplegia to the left dominant side, and gastrostomy status (surgical procedure for inserting a tube through the abdomen wall and into the stomach. The tube is used for feeding or drainage). Review of Resident #204's nursing admission assessment revealed the resident was cognitively intact and was independent with eating (oral intake) but was dependent for continuous tube feedings. Review of Resident #204's baseline care plan dated 09/23/23 revealed the resident received tube feedings. The goal for Resident #204 was to maintain weight. Review of a physician order dated 09/24/23 revealed an order for Resident #204 to receive Two Cal HN 120 millimeters (ml) per hour (hr) administered over a 2-hour period and to equal 240 ml three times a day via G-tube by kangaroo feeding pump at 6 AM, 3 PM, and 11 PM. Review of the MAR also revealed Nurse #7 signed off Resident #204 received his enteral tube feeding at 7:00 AM 09/25/23. Review of the Medication Administration Record (MAR) revealed Nurse #3 signed off Resident #204 received his eternal tube feeding at 11:00 PM on 09/25/23. An interview conducted with Nurse #3 on 09/28/23 at 5:00 PM revealed she had administered Resident #204's tube feeding at 7 AM and 11 PM on 09/25/23. Nurse #3 further revealed she had cleaned Resident #204 ' s reusable tube feeding formula bag around midnight on 09/25/23 and does not recall why she did not label the bag. Nurse #3 indicated she had been educated on labeling tube feeding formula bags with date, amount, and time. An observation and interview conducted with Resident #204 on 09/26/23 at 11:40 AM revealed the residents tube feeding formula bag was not labeled. Resident #204 further revealed nursing staff had not labeled the tube feeding formula bag. Resident #204 indicated nursing staff normally did and was supposed to. An observation conducted on 09/26/23 at 1:10 PM revealed Resident #204's tube feeding formula bag was not labeled. During an observation and interview on 09/26/23 at 2:50 PM Nurse #2 confirmed Resident #204's tube formula bag was not labeled. Nurse #2 stated Nurse #3 was responsible for hanging the feeding tube formula bag during the 11 PM to 7 AM shift. Nurse #2 further revealed Nurse #3 hung the bags during third shift on 09/25/23. Nurse #2 indicated the bags should have been labeled with the resident's name, date, feeding amount, and time. The interview further revealed Nurse #2 had been educated to label tube feedings bags. An interview conducted with the Director of Nursing (DON) on 09/28/23 at 4:50 PM revealed she expected all tube feeding formula bags to be labeled. The DON further revealed nursing staff had been educated on labeling and hanging tube feeding formal bags. The DON indicated the bags should be labeled with date, time, and feeding amount. An interview conducted with the Administrator on 09/28/23 at 6:00 PM revealed she expected all tube feeding formula bags to be labeled. The DON further revealed nursing staff had been educated.

Based on record reviews, staff, Physician Assistant (PA), and Medical Director (MD) interviews, the facility failed to notify the physician when two medications, an intravenous (IV) antibiotic and an antiarrhythmic medication (a medicine used to treat irregular heartbeat) were unable to be delivered to the facility and failed to notify the physician when the medications were unable to be administered. Resident #1 missed three doses of the IV antibiotic and four doses of the antiarrhythmic medications after admission to the facility. Additionally, the facility failed to notify the physician when Resident #1 missed three additional doses of the IV antibiotic due to the antibiotic being unavailable. This was for 1 of 3 sampled residents reviewed for notification (Resident #1). By not receiving these medications there was the high likelihood for bacterial regrowth, sepsis, resistance to antibiotic, heart arrhythmias and/or return to hospital. Immediate jeopardy began on 12/11/22 when the facility failed to notify the physician when two medications (an intravenous antibiotic and antiarrhythmic medication) were unable to be administered to Resident #1. Immediate jeopardy was removed on 01/20/23 when the facility implemented an acceptable credible allegations of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of E no actual harm with potential for more than minimal harm that is not immediate jeopardy to ensure monitoring systems and staff education put into place are effective. Findings included: Review of hospital discharge summary physician order dated 12/10/22 revealed an order for Cefazolin Sodium-Dextrose Solution 2-4 Grams (GM)/100Milliliters (ML)-% (antibiotic used to treat bacterial infection). Use 100 ML intravenously every 8 hours for bacteremia for 18 days. Review of hospital discharge summary physician order dated 12/10/22 revealed an order for Flecainide Acetate Tablet 100 milligrams (MG) (medication used to prevent irregular heartbeat). Give 1 tablet by mouth two times a day for atrial fibrillation (A-fib). Resident #1 was admitted to the facility on Sunday, 12/11/22 with diagnoses to include bacteremia due to methicillin susceptible staphylococcus, chronic atrial fibrillation, and diabetes. Interview conducted with Nurse #1 on 01/19/22 at 12:20 PM revealed she confirmed Resident #1's medication orders and sent the orders electronically to the pharmacy on 12/11/22. Nurse #1 stated she was aware Resident #1 did not have his IV antibiotic and antiarrhythmic medication available upon admission and would not receive them until the following day, Monday (12/12/22). Nurse #1 stated she did not notify the physician about Resident #1's medications not being available upon admission or any missed doses on 12/11/22. Review of Medication Administration Record (MAR) for December 2022 revealed Resident #1 was to receive the following: Cefazolin Sodium-Dextrose Solution 2-4 GM/100ML-%. Use 100ML intravenously every 8 hours (6AM, 2PM, 10PM) for bacteremia for 18 days starting 12/10/22. Resident #1 was not administered doses on 12/11/22 at 10 PM, 12/12/22 at 6AM, 12/12/22 at 2PM, 12/19/22 at 2PM, 12/19/22 at 10PM, and on 12/20/22 at 6AM due to being on order from pharmacy and not available at facility. Flecainide Acetate Tablet 100 milligrams (MG). Give one tablet by mouth two times daily (8AM, 8PM) for atrial fibrillation (A-fib) starting 12/10/22. Resident #1 was not administered doses on 12/11/22 at 8PM, 12/12/22 at 8AM, 12/12/22 at 8PM, and 12/13/22 at 8AM due to being on order from pharmacy and not available at facility. Review of Resident #1's electronic medical record and physician correspondence notebook revealed there was no documentation of the physician being notified of Resident #1's missed medication doses or medications not being available at facility. A telephone interview was conducted with Nurse #2 on 01/19/23 at 5:45 PM revealed when she arrived at work on 12/11/22 for her 6:30PM to 7AM shift she was told Resident #1 was a new admission and his medication orders had been sent to pharmacy and medications would not be arriving until the following day, 12/12/22. She stated a notebook had been available at nurse's station for nursing staff to leave correspondence or notify the physician about issues with residents to include issues with medications, but she does not recall if she informed physician or made a note in the notebook of Resident #1's missed doses of IV antibiotic or antiarrhythmic medication not being available to be administered. A telephone interview was conducted with Nurse #3 on 01/19/23 at 6:41 PM revealed she was familiar with Resident #1 and not receiving his medications upon his admission on 12/11/22 until the evening of 12/12/22. She stated when she arrived at work on 12/12/22 for her 6:30AM to 7PM shift she was told Resident #1 was a new admission and his medications had been sent to pharmacy and were waiting for arrival to the facility and his medications to include his IV antibiotic and medication for atrial fibrillation had been administered. Nurse #3 stated she did not notify the physician of being unable to administer the medications. She revealed a notebook had been available at nurse's station for nursing staff to correspond with physician about any issues with residents but she did not leave any correspondence about Resident #1 because she assumed the nurse from previous shift had notified physician. A second interview was conducted with Nurse #1 on 01/19/23 at 12:20 PM. She stated on 12/19/22 she was administering Resident #1 his medications and his IV antibiotic was unavailable. She revealed she does not recall informing the physician of Resident #1 missing his dosage of IV antibiotic on 12/19/22 during her 6:30AM to 7PM shift. Nurse #1 stated a notebook was located at nurse's station for physician correspondence to include issues with medications, but she does not recall writing down any correspondence about Resident #1's missed doses and medication not being available. A telephone interview was conducted with Nurse #4 on 01/23/23 at 11:05 AM revealed she was familiar with Resident #1 and had been responsible for administering his medications. She stated she was working at the facility on the evening of 12/19/22 and had been assigned to Resident #1. She revealed she did not administer Resident #1 evening dose of his IV antibiotic. Nurse #4 stated she did not administer Resident #1's morning dose of his IV antibiotic on 12/20/22 due to the medication being on order and not available at the facility. She revealed she did not notify the physician Resident #1 missed doses of his IV antibiotic on 12/19/22 or 12/20/22. An interview was conducted with Physician Assistant (PA) on 01/18/23 at 4:18 PM revealed Resident #1 was admitted to the facility on Sunday 12/11/22 and she was made aware on 12/12/22 by Resident #1 that his medications had been delayed and when asked nursing staff about Resident #1 medication was told they were enroute from pharmacy and would be available later that day. The PA revealed she was not made aware of Resident #1 missed doses of his IV antibiotic on 12/19/22 and 12/20/22 and had she been told she could have investigated another way of receiving the antibiotic and ordered a culture to see if there had been any growth. A second interview was conducted with Physician Assistant (PA) on 01/19/23 at 12:54 PM that revealed Resident #1 was admitted with diagnosis of having atrial fibrillation (a-fib) which can cause an irregular heartbeat and was ordered an antiarrhythmic medication to be administered two times a day. The PA revealed she was not notified of Resident #1 missing four doses of his a-fib medication (from 12/11/22 through 12/12/22) and the medication not being available at the facility and had she been told she could have administered another medication until medication was available and monitored for any signs of A-fib. An interview was conducted with Administrator and Director of Nursing (DON) on 01/18/23 at 5:56 PM revealed they were both familiar with Resident #1 and had not been made aware until today by the State Agency of the issues with him not being administered ordered medications when admitted and during his stay due to pharmacy issues. They stated no knowledge if medical providers were notified of Resident missed doses of his IV antibiotics. The Administrator and DON revealed nursing staff should have contacted medical providers or left a note in the medical provider notebook located at nurses' station to inform of missed doses. A telephone interview was conducted with Medical Director (MD) on 01/19/23 at 3:02 PM revealed he saw residents at the facility every Friday and was familiar with Resident #1. He stated he had not been made aware of any issues with residents not receiving their medications and pharmacy not being able to provide medications upon resident admission and or during their stay at facility. He revealed he was not made aware of Resident #1 missing doses of his IV antibiotic or antiarrhythmic medication while at the facility, and had he been made aware he could have looked at prescribing similar medications for Resident #1 to be administered until ordered medications arrived. The facility was notified of immediate jeopardy on 01/19/23 at 10:10 AM. The facility provided the following plan for IJ removal. o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Resident #1 was admitted on [DATE], with a primary diagnosis of chronic respiratory failure after a hospitalization for GI Bleed and Bacteremia. From December 11 through December 21, 2022, facility failed to ensure an ordered IV antibiotic to treat sepsis for Resident #1 was available for 6 of the 42 ordered administrations. *Resident #1 was at risk of suffering from the deficient practice placing him at increased risk for rehospitalization , however showed no adverse outcome as a result of non-compliance. Resident had planned discharge to home on 12/22/2022 and continued his Cefazolin IV antibiotic with a stop date of 12/28/22. *All other residents prescribed medications are also at risk from suffering from the deficient practice. On 01/18/23, an audit of all residents with orders for IV medications ordered between 12/11/2022 and 01/18/2023 was conducted by the Director of Nursing (DON) with no unavailable IV medications or missed medications identified. An audit of all medications was completed on 1/19/23 for all residents from 1/12/23 to 1/19/23 by DON, ADON, and MDS Nurse to identify other missed doses. All residents/responsible parties and the physician were notified of any identified missed medications for further guidance and orders for the audit of 1/19/23. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete 0n 01/18/2023, the DON was educated by Regional Clinical Director on the process for obtaining all medications from pharmacy, the utilization of the stat safe (an electronic emergency/stat dose medication cabinet), the process of obtaining back up services from pharmacy, and the requirement to notify the DON and Physician of any medication that cannot be obtained through the stat safe, or the backup services provided by pharmacy. On 01/18/2023, the DON educated all licensed nurses, including agency nurses, in person or via phone on the process for obtaining medications from pharmacy, the utilization of the stat safe, the process of obtaining back up services from pharmacy and the requirement to notify the physician of any medication that cannot be obtained through the stat safe, or the backup services provided by pharmacy. Licensed nurses and medication aides newly hired including agency will receive education prior to working their initial shift as part of their orientation. The DON or designee is responsible to ensure education occurs by obtaining a signature attestation of education. The education consisted of the following: Medications must be administered as ordered by the medical provider. When a medication is ordered the nurse/medication aide is responsible to medicate the resident as ordered. If the medication is not available to be administered the nurse must notify the medical provider and document the providers response as well as an order to support the response. When all medications orders are confirmed electronically, between the hours of 9am - 5pm Monday through Friday, the pharmacy is electronically alerted, and medications are prepared and will arrive on the next scheduled pharmacy delivery to the facility. All medication orders confirmed electronically during the hours of 5pm - 9am, and on weekends, holidays, or any other scheduled closure, requires the individual confirming the order electronically to call pharmacy and speak with the on-call pharmacist to initiate back up services through the stat safe, or other stat back up services. If prescribed medication(s) cannot be obtained by utilizing regular or back up stat pharmacy services prior to the scheduled administration time of the medication, the physician must be notified for further guidance and orders. Alleged IJ removal date is 01/20/2023. On 1/25/23, the facility's credible allegation for immediate jeopardy removal effective 1/20/23 was validated by the following: Staff interviews revealed they had received education on how and when to notify the on-call or in-house physician if medications were not available and/or unable to be administered. The facility provided evidence in-service education. It was determined in-service education was completed for staff. The facility provided evidence of audits.

Based on record reviews, staff, Pharmacist, Physician Assistant (PA), and Medical Director (MD) interviews, the facility failed to have an effective system in place to ensure a physician ordered Intravenous (IV) antibiotic and an antiarrhythmic medication (medication used to prevent irregular heartbeat) was available to administer for 1 of 3 residents (Resident #1) reviewed for pharmacy services. Resident #1 was ordered an IV antibiotic for bacteremia and did not receive the first three doses of the antibiotic due to the medication being on order from pharmacy and not available at the facility. Resident #1 did not receive another three doses of the IV antibiotic beginning on 12/19/22 due to being on reorder from the pharmacy and staff not checking the facility back-up safe for the medication. Resident #1 was also ordered an antiarrhythmic medication for atrial fibrillation (A-fib) and did not receive the first four doses of this medication due to the medication being on order from pharmacy and not available at the facility. By not receiving these medications there was the high likelihood for bacterial regrowth, sepsis, resistance to antibiotic, heart arrhythmias or return to hospital. Immediate jeopardy began on 12/11/22 when facility failed to obtain Resident #1's antibiotic and antiarrhythmic medications. Immediate jeopardy was removed on 01/20/23 when the facility implemented an acceptable credible allegations of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of E no actual harm with potential for more than minimal harm that is not immediate jeopardy to ensure monitoring systems and staff education put into place are effective. Findings included: Review of facility medication order policy revised July 2022 revealed read in part under documentation of medical order: Clarify order and call, fax, or electronically submit the medication orders to Pharmacy. The facility began using the current pharmacy on 07/01/22. Review of the hospital discharge physician order dated 12/10/22 revealed an order for Cefazolin Sodium-Dextrose Solution 2-4 Grams (GM)/100Milliliters (ML)-%. Use 100 ML intravenously every 8 hours for bacteremia for 18 days. Review of the hospital discharge physician order dated 12/10/22 revealed order for Flecainide Acetate Tablet 100 milligram (MG). Give 1 tablet by mouth two times a day for atrial fibrillation (A-fib). Resident #1 was admitted to the facility on Sunday 12/11/22 and discharged home on 12/22/22 with diagnoses to include bacteremia due to methicillin susceptible staph, chronic atrial fibrillation, and diabetes. Interview conducted with Nurse #1 on 01/19/22 at 12:20 PM revealed she was familiar with Resident #1 and had been responsible for completing his admission paperwork, confirming his medication orders, and sending the orders electronically to the pharmacy on 12/11/22. Nurse #1 stated she was aware Resident #1 did not have his ordered medications including his IV antibiotic and his antiarrhythmic medication available upon admission and would not be available until the following day 12/12/22. Nurse #1 revealed residents not receiving their ordered medications upon admission and having to wait a day or two to receive their medications from the pharmacy was an ongoing issue, especially for residents admitted on the weekends due to the pharmacy not delivering medications on the weekends. She stated unless the medication for a resident was available in the facility back-up safe, residents would not receive ordered medications until they arrived from pharmacy. Review of the Medication Administration Record (MAR) for December 2022 revealed the following: Cefazolin Sodium-Dextrose Solution 2-4 GM/100ML-%. Use 100ML intravenously every 8 hours (6AM, 2PM, 10PM) for bacteremia for 18 days starting 12/10/22. Resident #1 was not administered doses at 10 PM on 12/11/22, 6AM on 12/12/22, 2PM on 12/12/22, 2PM on 12/19/22, 10PM on 12/19/22, and 6AM on 12/20/22 due to being on order from pharmacy and not available at facility. Flecainide Acetate Tablet 100 MG. Give 1 tablet by mouth two times a day (8AM, 8PM) for atrial fibrillation. Resident #1 was not administered scheduled doses at 8PM on 12/11/22, 8AM on 12/12/22, 8PM on 12/12/22, and 8AM on 12/13/22 due to being on order from pharmacy and not available at facility. A telephone interview conducted with Nurse #2 on 01/19/23 at 5:45 PM revealed she was familiar with Resident #1 and not having medications available upon his admission on 12/11/22 until the following day. She stated when she arrived at work on 12/11/22 at 6:30 PM she was told Resident #1 was a new admission and his medication orders had been sent to pharmacy and medications would not be arriving until the following day. She revealed there have been on-going issues with pharmacy and resident's not having their prescribed medications upon admission and having to wait a day or two to receive their medications and nursing staff has expressed these issues to the Director of Nursing (DON). She stated she did not recall if she checked the back-up safe to see if there were any medications available including Resident #1's IV antibiotic and a-fib medication that could have been administered. A telephone interview conducted with Nurse #3 on 01/19/23 at 6:41 PM revealed she was familiar with Resident #1 and him not having received his medications upon his admission on 12/11/22 until the evening of 12/12/22. She stated when she arrived at work on 12/12/22 at 6:30 AM she was told Resident #1 was a new admission and his medication orders had been sent to pharmacy and were waiting for arrival to the facility and none of his medications to include his IV antibiotic and medication for atrial fibrillation had been administered. She stated she contacted the pharmacy who stated Resident #1 medications were enroute. She revealed this had been an on-going issue with pharmacy and not having resident medications available upon admission or medications not being reordered and having to wait a day or two for resident medications to arrive to be administered. Nurse #3 stated residents not having their medications happens weekly and the issues with pharmacy have been brought to the Director of Nursing's (DON) attention and it continued to happen. She revealed she did not recall if she had checked the facility back-up safe to see if IV antibiotic or a-fib medication was available that could have been administered to Resident #1. An interview conducted with Nurse #1 on 01/19/23 at 12:20 PM revealed she was familiar with Resident #1 and had been responsible for administering his medications. She stated on 12/19/22 she was administering Resident #1 his medications and his IV antibiotic was unavailable. She revealed she contacted the pharmacy and was told IV antibiotic had been reordered and was enroute to facility. Nurse #1 stated this was an ongoing issue with pharmacy and not receiving medications on time and residents having to wait for their medications and she had spoken with her Director of Nursing (DON) about these issues and was told it was a pharmacy issue. She revealed she does not recall if she checked the facility back-up safe for medications that could have been administered to Resident #1. A telephone interview conducted with Nurse #4 on 01/23/23 at 11:05 AM revealed she was familiar with Resident #1 and had been responsible for administering his medications. She stated she was working at the facility on the evening of 12/19/22 and had been assigned to Resident #1. She revealed she did not administer Resident #1 evening dose of his IV antibiotic due to being told by the daytime nurse the medication was on order from the pharmacy and not available at the facility and the MD had been aware. Nurse #4 stated she did not administer Resident #1's morning dose of his IV antibiotic on 12/20/22 due to the medication being on order and not available at the facility. She also stated she had not been given access to the back-up safe and was not able to check for any back-up medications. Nurse #4 revealed there had been on-going issues with pharmacy and medications not being available for residents upon their admission and during their stay at the facility and she had made the DON aware of these concerns and was told it was a pharmacy issue and nothing else was done. An interview conducted with Physician Assistant (PA) on 01/18/23 at 4:18 PM revealed she was familiar with Resident #1. She stated Resident #1 was admitted to the facility on Sunday 12/11/22 and she was made aware on 12/12/22 his IV antibiotic and antiarrhythmic medication for a-fib had been delayed but was enroute from pharmacy and would be available later that day. She revealed this had been an ongoing issue with pharmacy and medications not being available upon resident admission and she has had to call pharmacy herself about medication orders and had also spoken with the DON about the pharmacy issues and was told it was a pharmacy issue. A telephone interview conducted with Pharmacist on 01/18/23 at 4:57 PM revealed the pharmacy received the medication orders electronically for Resident #1 on 12/11/22 at 3:25 PM. She stated the medication order was filled and sent out to the facility on [DATE] at 11:00 AM. She also stated if an order for medication was received on a workday prior to 2PM the order would be filled on the same day and sent out for night delivery, and if an order for medication was received after 5PM during the workday or received on the weekend the medication would be filled the morning of the next working day and sent out for delivery before lunch. The Pharmacist revealed although Resident #1 IV antibiotic order was for 18 days the pharmacy sent a 7-day supply for the IV antibiotic. She stated the IV antibiotic was on automatic reorder and the next 7-day supply was filled at 8:22 PM on 12/19/22 and sent out to the facility between 9PM and 10PM. The Pharmacist revealed the facility should have had enough doses of IV antibiotics available on 12/19/22 for Resident #1 and should not have missed any of his doses. She stated the facility also had a back-up safe in the facility with extra medications and 1-gram bags of the IV medication for Resident #1 was available in the back-up safe. She revealed the facility could have administered Resident #1 the 1-gram bags of IV antibiotics back-to-back to make the 2 grams and no doses would have been missed. She stated she had no knowledge if staff had been made aware of the IV antibiotic being available in facility back-up safe. A follow up telephone interview conducted with the Pharmacist on 01/23/22 at 9:45 AM revealed the pharmacy received Resident #1's order for the Flecainide Acetate, a-fib medication on 12/11/22 at 3:25 PM and the medication was filled and sent out to the facility on [DATE] at 11:00 AM with his other medications. She stated Resident #1's a-fib medication was available at the facility for his evening dose on 12/12/22 and his morning dose on 12/13/22 and should not have been missed due to pharmacy issues or not being available at the facility. An interview conducted with Administrator and Director of Nursing (DON) on 01/18/23 at 5:56 PM revealed they were both familiar with Resident #1 and had not been made aware until today of the issues with him not being administered ordered medications when admitted and during his stay due to pharmacy issues. They stated when a resident was going to be admitted to the facility, they received a list of ordered medications prior to admission but were not able to send order for medication to pharmacy until the resident was in the building. They revealed they were not aware of pharmacy delivery times on weekends but through the week medication orders and reorders had to be sent to pharmacy before 5PM for late delivery. The Administrator and DON stated the facility did not have back-up contracts with the hospital or any of the local pharmacies. They revealed the pharmacy would be responsible for contacting another local pharmacy about a resident's medications and for making sure resident receive their medications. They stated they were not aware of what medications had been available in the facility back-up safe and did not understand why pharmacy did not inform nursing staff when they called on 12/19/22 about back-up IV antibiotics being available for Resident #1. The Administrator and DON stated the facility had switched to the current on pharmacy on 07/01/22 and there had been on-going issues with pharmacy and medications not being available upon admission and not being reordered or sent to facility on time and they have spoken with upper management about the issues. A telephone interview was conducted with Medical Director (MD) on 01/19/23 at 3:02 PM revealed he saw residents at the facility every Friday and was familiar with Resident #1. He stated he had not been made aware of any issues with residents not receiving their medications and pharmacy not being able to provide medications upon resident admission and or during their stay at facility. He revealed he was not made aware of Resident #1 missing doses of his IV antibiotic or of his a-fib medication while at the facility, and had he been made aware he could have looked at prescribing similar medications for Resident #1 to be administered until ordered medications arrived. The MD revealed he had spoken with the Administrator about the facility did not having a back-up contract with the hospital and other local pharmacies to be able to send in an order and receive medications when not available from main pharmacy and was told that was a pharmacy issue and the main pharmacy out of [NAME] was responsible for contacting other pharmacies if they had issues with medications. A telephone interview conducted with Hospital Physician on 01/23/23 at 3:22 PM revealed he was familiar with Resident #1 and had treated him prior to his admission to the facility for multiple medical issues including bacteremia which is bacterial infection in the bloodstream and atrial fibrillation (a-fib) which is when the heartbeat is out of rhythm or an irregular heartbeat. He stated he had ordered Resident #1 and IV antibiotic to be administered uninterrupted every 8 hours for 18 days for treatment of bacteremia. He revealed best practice would have been for Resident #1 to have received all of his scheduled doses of IV antibiotic and missing doses could have caused bacterial regrowth and a possible return to hospital. He stated he had ordered antiarrhythmic medication for Resident #1 to be administered twice daily to continue his heartbeat at a normal rhythm and administering this medication as prescribed was best practice. He revealed Resident #1 missing his doses of his a-fib medication was a potential for harm due to each resident being different in how they respond to missed doses of a-fib medication. The Hospital Physician stated every resident responds to a-fib differently and some residents might be able to miss doses of medication and have no issues and other residents may miss one dose of medication and it would send them into a-fib and they would have to be sent back to hospital and there is no way of knowing how each resident would respond. He revealed the hospital informs the facility prior to any discharge of ordered medications to ensure the medications would be available for resident at facility upon admission. He stated if the facility was not able to ensure medications would be available upon admission, then the facility would inform the hospital prior to discharge so the resident could remain at the hospital for another day and receive their ordered medication doses the following morning and then be discharged to accommodate facility being able to receive medications from pharmacy in time for next dose and keep residents from missing multiple doses of their ordered medications. The facility was notified of immediate jeopardy on 01/19/23 at 10:10 AM. The facility provided the following plan for IJ removal. Resident #1 was admitted on [DATE], with a primary diagnosis of chronic respiratory failure after a hospitalization for GI Bleed, bacteremia, atrial fibrillation. From December 11 through December 21, 2022, facility failed to ensure an ordered IV antibiotic to treat sepsis was available for 6 of the 42 ordered administrations, and failed to ensure an antiarrhythmic medication was available for 4 missed doses for Resident #1. *Resident #1 was at risk of suffering from the deficient practice placing him at increased risk for rehospitalization , however showed no adverse outcome as a result of non-compliance. Resident had planned discharge to home on 12/22/2022 and continued his Cefazolin IV antibiotic with a stop date of 12/28/22. *All other residents prescribed medications are also at risk from suffering from the deficient practice. On 01/18/23, an audit of all residents with orders for IV medications ordered between 12/11/2022 and 01/18/2023 was conducted by the Director of Nursing (DON) with no unavailable IV medications or missed medications identified. An audit of all medications was completed on 1/19/23 for all residents from 1/12/23 to 1/19/23 by DON, ADON, and MDS Nurse to identify other missed doses. All residents/responsible parties and the physician were notified of any identified missed medications for further guidance and orders for the audit of 1/19/23. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete 0n 01/18/2023, the DON was educated by Regional Clinical Director on the process for obtaining all medications from pharmacy, the utilization of the stat safe (an electronic emergency/stat dose medication cabinet), the process of obtaining back up services from pharmacy, and the requirement to notify the DON and Physician of any medication that cannot be obtained through the stat safe, or the backup services provided by pharmacy. On 01/18/2023, the DON educated all licensed nurses, including agency nurses, in person or via phone on the process for obtaining medications from pharmacy, the utilization of the stat safe, the process of obtaining back up services from pharmacy and the requirement to notify the physician of any medication that cannot be obtained through the stat safe, or the backup services provided by pharmacy. Licensed nurses and medication aides newly hired including agency will receive education prior to working their initial shift as part of their orientation. The DON or designee is responsible to ensure education occurs by obtaining a signature attestation of education. The education consisted of the following: Medications must be administered as ordered by the medical provider. When a medication is ordered the nurse/medication aide is responsible to medicate the resident as ordered. If the medication is not available to be administered the nurse must notify the medical provider and document the providers response as well as an order to support the response. When all medications orders are confirmed electronically, between the hours of 9am - 5pm Monday through Friday, the pharmacy is electronically alerted, and medications are prepared and will arrive on the next scheduled pharmacy delivery to the facility. All medication orders confirmed electronically during the hours of 5pm - 9am, and on weekends, holidays, or any other scheduled closure, requires the individual confirming the order electronically to call pharmacy and speak with the on-call pharmacist to initiate back up services through the stat safe, or other stat back up services. If prescribed medication(s) cannot be obtained by utilizing regular or back up stat pharmacy services prior to the scheduled administration time of the medication, the physician must be notified for further guidance and orders. Alleged IJ removal date is 01/20/2023. On 1/25/23, the facility's credible allegation for immediate jeopardy removal effective 1/20/23 was validated by the following: Staff interviews revealed they had received education on medication administration, obtaining medicine through pharmacy, and how to notify the on call or in-house provider if medicines are not available. Facility stat safe was observed in locked medication room behind nurse's station where nursing staff have a personalized code to enter for access to receive back-up medications for residents and staff interviews revealed if resident medication was not available on medication cart they were to utilize stat safe first and if not there then to contact pharmacy about other option for receiving medication and to notify physicians of missing medication. Audits were completed to residents who had received IV medication and missed medication for all residents in the facility.

Based on record reviews, staff, Pharmacist, Physician Assistant (PA), Medical Director (MD) and Hospital Physician interviews, the facility failed to administer antibiotics for 1 of 3 residents (Resident #1) reviewed for pharmacy services. Resident #1 was not administered the first three doses of an Intravenous (IV) antibiotic for bacteremia as ordered due to the medication being on order from pharmacy and not available at facility. Resident #1 did not receive another three doses of the IV antibiotic beginning on 12/19/22. The facility also failed to administer the first four doses of an antiarrhythmic medication (medication used to treat or prevent irregular heartbeats) due to being on order from the pharmacy and staff not checking the facility back-up safe for the medication. There was the high likelihood for bacterial regrowth, sepsis, resistance to antibiotic, heart arrhythmias, or return to hospital due to the missed medications. Immediate jeopardy began on 12/11/22 when facility failed to administer Resident #1's antibiotic medication and antiarrhythmic medication. Immediate jeopardy was removed on 01/20/23 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of E no actual harm with potential for more than minimal harm that is not immediate jeopardy to ensure monitoring systems and staff education put into place are effective. Findings included: 1a. Resident #1 was admitted to the facility on Sunday 12/11/22 with diagnoses to include bacteremia due to methicillin susceptible staphylococcus aureus (an infection the blood that can lead to sepsis and death), chronic atrial fibrillation, and diabetes. Resident discharged home on 12/22/2022. Review of hospital discharge summary dated 12/10/22 revealed Resident #1was anticipated to be discharged to facility on 12/11/22 with diagnoses to include methicillin susceptible staphylococcus aureus (MSSA) bacteremia due to positive blood culture for growth. Physician ordered medications included an intravenous (IV) antibiotic (Cefazolin 2 grams) every 8 hours with an end date of 12/28/22. Review of hospital discharge physician order dated 12/10/22 revealed order for Cefazolin Sodium-Dextrose Solution 2-4 Grams (GM)/100Milliliters (ML)-%. Use 100 ML intravenously every 8 hours for bacteremia for 18 days. Review of the Medication Administration Record (MAR) for December 2022 revealed the following: Cefazolin Sodium-Dextrose Solution 2-4 GM/100ML-%. Use 100ML intravenously every 8 hours (6AM, 2PM, 10PM) for bacteremia for 18 days starting 12/10/22. Resident #1 was not administered doses at 10 PM on 12/11/22, 6AM on 12/12/22, 2PM on 12/12/22, 2PM on 12/19/22, 10PM on 12/19/22, and 6AM on 12/20/22 due to being on order from pharmacy and not available at facility. A telephone interview conducted with the Hospital Physician on 01/23/23 at 3:22 PM revealed he was familiar with Resident #1 and had treated him prior to his admission to the facility for multiple medical issues including bacteremia and methicillin-susceptible staph bacteremia or MSSA (bacterial infection in bloodstream). He stated he had ordered an IV antibiotic as treatment for Resident #1's MSSA to be administered uninterrupted every 8 hours for 18 days ending on 12/28/22 and administering this medication as prescribed was best practice. The Hospital Physician revealed the hospital informs the facility prior to any discharge of ordered medications to ensure the medications would be available for resident at facility upon admission. He stated if the facility was not able to ensure medications would be available upon admission, then the facility would inform the hospital prior to discharge so the resident could remain at the hospital for another day and receive their ordered medication doses the following morning and then be discharged to accommodate facility being able to receive medications from pharmacy in time for next dose and keep residents from missing multiple doses of their ordered medications. Review of admission nursing note written by Nurse #1 dated 12/11/22 at 1:53 PM read in part: Resident #1 arrived via hospital van to the facility on 3 liters of oxygen. He was alert and oriented to person, place, time, and event. Resident #1 had a peripherally inserted central catheter (PICC), used for access of large central veins near the heart, and was to receive medications through the PICC line. Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact and coded for intravenous medications and receiving antibiotics. Interview conducted with Nurse #1 on 01/19/22 at 12:20 PM revealed she was familiar with Resident #1 and had been responsible for completing his admission paperwork, confirming his medication orders and sending the orders electronically to the pharmacy on 12/11/22. Nurse #1 stated she was aware Resident #1 did not have his ordered medications including his IV antibiotic available upon admission and did not receive them until the following day. Nurse #1 revealed residents not receiving their ordered medications upon admission and having to wait a day or two to receive their medications from pharmacy was an ongoing issue, especially for residents admitted on the weekends due to the pharmacy not delivering medications on the weekends. She stated unless the medication for a resident was available in the facility back-up safe for them to use, residents would not receive ordered medications until they arrived from pharmacy. Review of nursing note written by Nurse #2 dated 12/11/22 revealed Cefazolin Sodium-Dextrose Solution 2-4 GM/100ML-%. Use 100 ML intravenously every 8 hours for bacteremia for 18 Days. On order. Review of nursing note written by Nurse #2 dated 12/12/22 revealed Cefazolin Sodium-Dextrose Solution 2-4 GM/100ML-%. Use 100 ml intravenously every 8 hours for bacteremia for 18 Days. On order. A telephone interview conducted with Nurse #2 on 01/19/23 at 5:45 PM revealed she was familiar with Resident #1 and not receiving medications upon his admission on 12/11/22 until the following day. She stated when she arrived at work on 12/11/22 she was told by Nurse #1 who had worked the previous shift, Resident #1 was a new admission and his medication orders had been sent to pharmacy and medications would not be arriving until the following day. She revealed there have been on-going issues with the pharmacy and resident's not having their prescribed medications upon admission and having to wait a day or two to receive their medications, she reported nursing staff had expressed these issues to supervisors. Nurse #2 stated the facility does have a back-up safe for medications that can be administered to residents until they receive their medications from the pharmacy, but she could not recall if she checked the back-up safe to see if there were any medications to include Resident #1's IV antibiotic. A telephone interview conducted with Nurse #3 on 01/19/23 at 6:41 PM revealed she was familiar with Resident #1 and him not receiving his medications upon admission on 12/11/22 until the evening of 12/12/22. She stated when she arrived at work on 12/12/22 she was told by Nurse #2 who had worked the previous shift, Resident #1 was a new admission and his medications had been sent to pharmacy and were waiting for arrival to the facility and none of his medications to include his IV antibiotic and medication for atrial fibrillation had been administered. She revealed this has been an on-going issue with pharmacy not having resident medications available upon admission or not being reordered and having to wait a day or two for resident medications to arrive to be administered. Nurse #3 stated when a resident did not have their medications she looked to see if the medications had been ordered and sent to pharmacy and then she checked to see if the medication were available in the facility back-up safe. She stated she did not recall if she had checked the facility back-up safe to see if medications to include IV antibiotic were available that could have been administered to Resident #1. Review of nursing note written by Nurse #1 dated 12/19/22 revealed Cefazolin Sodium-Dextrose Solution 2-4 GM/100ML-%. Use 100 ml intravenously every 8 hours for bacteremia for 18 Days. Unavailable. An interview conducted with Nurse #1 on 01/19/23 at 12:20 PM revealed she was familiar with Resident #1 and had been responsible for administering his medications. She stated on 12/19/22 she was administering Resident #1 his medications and his IV antibiotic was unavailable. She revealed she contacted pharmacy and was told the IV antibiotic had been reordered and was enroute to facility. Nurse #1 stated this was an ongoing issue with pharmacy and not receiving medications on time and residents having to wait for their medications and she had spoken with her supervisors about these issues. She revealed she did not recall if she checked the facility back-up safe for the medications. Review of nursing note written by Nurse #4 dated 12/19/22 read in part Cefazolin Sodium-Dextrose Solution 2-4 GM/100ML-%. Use 100 ml intravenously every 8 hours for bacteremia for 18 Days. Awaiting pharmacy. MD aware. A telephone interview conducted with Nurse #4 on 01/23/23 at 11:05 AM revealed she was familiar with Resident #1 and had been responsible for administering his medications. She stated she was working at the facility on the evening of 12/19/22 and had been assigned to Resident #1. She revealed she did not administer Resident #1's evening dose of his IV antibiotic due to being told by the daytime nurse the medication was on order from the pharmacy and not available at the facility and the MD had been aware. Nurse #4 stated she did not administer Resident #1's morning dose of his IV antibiotic on 12/20/22 due to the medication being on order and not available at the facility. She stated she was not given access to the facility back-up safe and would not have been able to check and see if there were any back-up doses of IV antibiotic for Resident #1 that could have been administered. Nurse #4 revealed there had been on-going issues with pharmacy and medications not being available for residents upon their admission and during their stay at the facility and she had made her supervisors including the DON aware of these concerns and was told it was a pharmacy issue and nothing else was done. Review of the facility Physician Assistant (PA) progress note dated 12/12/22 revealed Resident #1 had been admitted to the facility on [DATE] from the hospital with multiple medical diagnosis to include methicillin susceptible staphylococcus aureus infection and bacteremia with an ordered IV antibiotic for treatment to be administered every 8 hours for 18 days. The PA noted when speaking with Resident #1 he was anxious his medications had not yet arrived from pharmacy, and he was concerned he would decompensate if he had to wait much longer. The PA reviewed the medication administration record (MAR) and noted medication enroute today. An interview conducted with Physician Assistant (PA) on 01/18/23 at 4:18 PM revealed she was familiar with Resident #1. She stated Resident #1 was admitted to the facility on Sunday 12/11/22 and she was made aware on 12/12/22 by Resident #1 his IV antibiotic had been delayed and when she checked with nursing, she was told Resident #1's medications were enroute from pharmacy and would be available later that day. She revealed this had been an ongoing issue with pharmacy and medications not being available upon resident admission and she has called the pharmacy herself about medication orders and had also spoken with the DON about the pharmacy issues and was told it was a pharmacy issue. The PA revealed she was not made aware of Resident #1's missed doses of his IV antibiotic on 12/19/22 and 12/20/22 and had she been told she could have investigated another way of receiving the antibiotic and ordered a culture to see if there had been any new bacterial growth. She stated Resident #1's missing doses of his IV antibiotic could have caused bacterial growth, sepsis, or to become resistant to the antibiotic. She revealed Resident #1's IV antibiotic was ordered because of his culture and the IV antibiotic ordered was specific to his treatment and not any antibiotic could have been used. A telephone interview conducted with the facility Pharmacist on 01/18/23 at 4:57 PM revealed the pharmacy received the medication orders electronically for Resident #1 on 12/11/22 at 3:25 PM. She stated the medication order was filled and sent out to the facility on [DATE] at 11:00 AM. The Pharmacist revealed although Resident #1's IV antibiotic order was for 18 days, the pharmacy sent out the antibiotic in a 7-day supply. She stated the IV antibiotic was on automatic reorder and the next 7-day supply was filled at 8:22 PM on 12/19/22 and sent out to the facility between 9PM and 10PM. The Pharmacist revealed the facility should have had enough doses of IV antibiotics available on 12/19/22 for Resident #1 and should not have missed any of his doses. She stated the facility also had a back-up safe in the facility with extra medications and 1-gram bags of the IV medication ordered for Resident #1. She revealed the facility could have administered Resident #1 the 1-gram bags of IV antibiotics back-to-back to make the 2 grams and no doses would have been missed. The Pharmacist stated Resident #1's IV antibiotic had a half-life of 1.8 hours and missing 3 doses at a time, the IV antibiotic would be completely out of Resident #1's system and could cause bacteria growth, sepsis, or Resident #1 to become resistant to antibiotic. An interview conducted with Administrator and Director of Nursing (DON) on 01/18/23 at 5:56 PM revealed they were both familiar with Resident #1 and had not been made aware until today of the issues with him not being administered ordered medications when admitted and during his stay due to pharmacy issues. They stated when a resident was going to be admitted to the facility, they received a list of ordered medications prior to admission but were not able to send order for medication to pharmacy until the resident was in the building. They revealed they were not aware of pharmacy delivery times on weekends but through the week medication orders and reorders had to be sent to pharmacy before 5:00 PM for late delivery. The Administrator and DON stated the facility did not have back-up contracts with the hospital or any of the local pharmacies. They revealed the pharmacy would be responsible for contacting another local pharmacy about a resident's medications and for making sure resident received their medications. They stated they were not aware of what medications had been available in the facility back-up safe and did not understand why the pharmacy did not inform nursing staff when they called on 12/19/22 about the back-up IV antibiotics being available for Resident #1 in the safe. The Administrator and DON revealed nursing staff should always check the back-up safe for medications that could have been administered to residents. They stated there had been on-going issues with pharmacy and medications not being available upon admission and not being reordered or sent to facility on time. Review of Medical Director (MD) progress note dated 12/16/22 revealed Resident #1 had been admitted to the facility on [DATE] from the hospital with multiple medical diagnosis to include bacteremia and methicillin susceptible staphylococcus aureus infection as the cause of diseases classified elsewhere and will continue IV antibiotic through and including 12/28/22. A telephone interview conducted with Medical Director (MD) on 01/19/23 at 3:02 PM revealed he saw residents at the facility every Friday and was familiar with Resident #1. He stated he had not been made aware of any issues with residents not receiving their medications and pharmacy not being able to provide medications upon resident admission and or during their stay at facility. He revealed he was not made aware of Resident #1 missing doses of his IV antibiotic or of his a-fib medication while at the facility, and had he been made aware he could have looked at prescribing similar medications for Resident #1 to be administered until ordered medications arrived. He stated Resident #1's IV antibiotic was ordered as a treatment for sepsis and should have been given as prescribed and by not doing so could have caused bacterial growth or for him to become septic again. b. Review of physician order for Resident #1 from discharge summary dated 12/10/22 revealed order for Flecainide Acetate Tablet 100 milligram (MG). Give 1 tablet by mouth two times a day for atrial fibrillation (A-fib). Resident #1 was admitted to the facility on [DATE] (Sunday) with diagnoses to include sepsis due to methicillin susceptible staphylococcus aureus, chronic atrial fibrillation, and diabetes. Review of the admission minimum data set (MDS) dated [DATE] revealed Resident #1 was coded for atrial fibrillation (a-fib). Interview conducted with Nurse #1 on 01/19/22 at 12:20 PM revealed she was familiar with Resident #1 and had been responsible for completing his admission paperwork, confirming his medication orders, and sending the orders electronically to the pharmacy on 12/11/22. Nurse #1 stated she was aware Resident #1 did not have his ordered medications including his a-fib medication available upon admission and was not to receive them until the following day. Nurse #1 revealed residents not receiving their ordered medications upon admission and having to wait a day or two to receive their medications from pharmacy was an ongoing issue, especially for residents admitted on the weekends due to pharmacy not delivering medications on the weekends. She stated unless the medication for a resident was available in the facility back-up safe for them to use, resident would not receive ordered medications until they arrived from pharmacy. Review of medication administration record (MAR) for December 2022 revealed Resident #1 was to receive Flecainide Acetate Tablet 100 MG. Give 1 tablet by mouth two times a day (8AM, 8PM) for atrial fibrillation. Resident #1 was not administered scheduled doses at 8PM on 12/11/22, 8AM on 12/12/22, 8PM on 12/12/22, and 8AM on 12/13/22 due to being on order from pharmacy and not available at facility. Review of nursing note written by Nurse #2 dated 12/11/22 revealed Flecainide Acetate Tablet 100 MG. Give 1 tablet by mouth two times a day for atrial fibrillation (A-fib). On order. A telephone interview conducted with Nurse #2 on 01/19/23 at 5:45 PM revealed she was familiar with Resident #1 and not receiving medications upon his admission on 12/11/22 until the following day. She stated when she arrived at work at 6:30 PM on 12/11/22 she was told Resident #1 was a new admission and his medication orders had been sent to pharmacy and medications would not be arriving until the following day. She revealed there have been on-going issues with pharmacy and resident's not having their prescribed medications upon admission and having to wait a day or two to receive their medications and nursing staff had expressed these issues to supervisors. Nurse #2 stated the facility does have a back-up safe for medications that can be administered to residents until they receive their medications from pharmacy. She stated she did not recall if she checked the back-up safe to see if there were any medications to include Resident #1's medications for atrial fibrillation that could have been administered to Resident #1 until his medications arrived. A telephone interview conducted with Nurse #3 on 01/19/23 at 6:41 PM revealed she was familiar with Resident #1 and not having his medications available until the following day. She stated when she arrived at work on 12/12/22 she was told Resident #1 was a new admission and his medications had been sent to pharmacy and were waiting for arrival to the facility and none of his medications to include his medication for atrial fibrillation had been administered. She stated she contacted the pharmacy who stated Resident #1's medications were enroute and she informed Resident #1 and his wife. She revealed this has been an on-going issue with pharmacy not having resident medications available upon admission or not being reordered and having to wait a day or two for resident medications to arrive to be administered. Nurse #3 stated when a resident did not have their medications she would first look to see if the medications had been ordered and sent to pharmacy and then she checked to see if the medication was available in the facility back-up safe. She revealed residents not having their medications happens weekly and the issues and have been brought to supervisors' attention. She revealed she was not made aware from nursing staff who had worked the previous day of Resident #1's a-fib medication being available on 12/13/22 and believed it to still be on order from the pharmacy and not available at the facility due to not being on medication cart. Nurse #3 also revealed if she had been made aware Resident #1's a-fib medication had been available for his morning dose on 12/13/22 she would have administered the medication as ordered. She stated she did not recall if she had checked the facility back-up safe on 12/12/22 or 12/13/22 to see if medication for atrial fibrillation was available that could have been administered to Resident #1. A telephone interview conducted with the Pharmacist on 01/23/22 at 9:45 AM revealed the pharmacy received Resident #1 order for an a-fib medication on 12/11/22 at 3:25 PM and the medication was filled and sent out to the facility on [DATE] at 11:00 AM with his other medications. She stated Resident #1's a-fib medication was available at the facility for his evening dose on 12/12/22 and his morning dose on 12/13/22 and should not have been missed due to pharmacy issues or not being available at the facility. An interview conducted with Administrator and Director of Nursing (DON) on 01/18/23 at 5:56 PM revealed they were both familiar with Resident #1 and had not been made aware until today of the issues of him not being administered medications for atrial fibrillation (a-fib). They stated nursing staff should checked the back-up safe to see if there was a back-up supply of medications that could have been administered. An interview conducted with Physician Assistant (PA) on 01/19/23 at 12:54 PM revealed Resident #1 was admitted to the facility with diagnosis of having atrial fibrillation (a-fib) which can cause an irregular heartbeat and was ordered an antiarrhythmic medication to be administered two times a day. The PA revealed medication for atrial fibrillation (a-fib) should have been given as prescribed and when not given could have caused the heart to get out of rhythm which could have led to cardiac arrest. A telephone interview conducted with Medical Director (MD) on 01/19/23 at 3:02 PM revealed Resident #1 a-fib medications should had been administered as prescribed and missing doses could had resulted in irregular heartbeats. A telephone interview conducted with Hospital Physician on 01/23/23 at 3:22 PM revealed he was familiar with Resident #1 and had treated him prior to his admission to the facility for multiple medical issues including atrial fibrillation (a-fib) which is when the heartbeat is out of rhythm or an irregular heartbeat. He stated he had ordered antiarrhythmic medication for Resident #1 to be administered twice daily to continue his heartbeat at a normal rhythm and administering this medication as prescribed was best practice. He revealed Resident #1 missing his doses of his a-fib medication was a potential for harm due to each resident being different in how they respond to missed doses of a-fib medication. The Hospital Physician stated every resident responds to a-fib differently and some residents might be able to miss doses of medication and have no issues and other residents may miss one dose of medication and it would send them into a-fib and they would have to be sent back to hospital and there is no way of knowing how each resident would respond. He revealed the hospital informs the facility prior to any discharge of ordered medications to ensure the medications would be available for resident at facility upon admission. He stated if the facility was not able to ensure medications would be available upon admission, then the facility would inform the hospital prior to discharge so the resident could remain at the hospital for another day and receive their ordered medication doses the following morning and then be discharged to accommodate facility being able to receive medications from pharmacy in time for next dose and keep residents from missing multiple doses of their ordered medications. The facility was notified of immediate jeopardy on 01/19/23 at 10:10 AM. The facility provided the following plan for IJ removal. o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Resident #1 was admitted on [DATE], with a primary diagnosis of chronic respiratory failure after a hospitalization for GI Bleed, Bacteremia, and atrial fibrillation. On December 11, 12, 19 & 20, 2022, facility failed to administer six doses of ordered intravenous (IV)antibiotic, Cefazolin, and four doses of and antiarrhythmic medication, Flecainide Acetate, to Resident #1 with adverse outcome. *Resident #1 was at increased risk for rehospitalization as result from the deficient practice; however, resulted in no adverse outcomes. *All other residents prescribed an intravenous (IV) antibiotic and antiarrhythmic medications are also at risk from suffering from the deficient practice. Resident #1 was discharged home from the facility on 12/22/22 with a written order for IV antibiotic, Cefazolin, with the stop date of 12/28/22. On 01/18/23, an audit of all residents with orders for IV medications ordered between 12/11/2022 and 01/18/2023 was conducted by the Director of Nursing (DON) with no unavailable IV medications or missed medications identified. An audit of all medications was completed on 1/19/23 for all residents from 1/12/23 to 1/19/23 by DON, ADON, and MDS Nurse to identify other missed doses. All residents/responsible parties and the physician were notified of any identified missed medications for further guidance and orders from the audit of 1/19/23. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. 0n 01/18/2023, the DON was educated by Regional Clinical Director on the process for obtaining medications from pharmacy, the utilization of the stat safe, the process of obtaining back up services from pharmacy and the requirement to notify the physician of any medication that cannot be obtained through the stat safe, or the backup services provided by pharmacy. On 01/18/2023, the DON educated all licensed nurses, including agency nurses, in person or via phone on the process for obtaining medications from pharmacy, the utilization of the stat safe, the process of obtaining back up services from pharmacy and the requirement to notify the physician of any medication that cannot be obtained through the stat safe, or the backup services provided by pharmacy. Licensed nurses and medication aides newly hired including agency will receive education prior to working their initial shift as part of their orientation. The DON or designee is responsible to ensure education occurs by obtaining a signature attestation of education. The education consisted of the following: Medications must be administered as ordered by the medical provider. When a medication is ordered the nurse/medication aide is responsible to medicate the resident as ordered. If the medication is not available to be administered the nurse must notify the medical provider and document the providers response as well as an order to support the response. When all medications orders are confirmed electronically, between the hours of 9am - 5pm Monday through Friday, the pharmacy is electronically alerted, and medications are prepared and will arrive on the next scheduled pharmacy delivery to the facility. All medication orders confirmed electronically during the hours of 5pm - 9am, and on weekends, holidays, or any other scheduled closure, requires the individual confirming the order electronically to call pharmacy and speak with the on-call pharmacist to initiate back up services through the stat safe, an electronic emergency/stat dose medication cabinet, or other stat back up services. If prescribed medication(s) cannot be obtained by utilizing regular or back up stat pharmacy services prior to the scheduled administration time of the medication, the physician must be notified for further guidance and orders. Alleged IJ removal date is 01/20/2023. On 1/25/23, the facility's credible allegation for immediate jeopardy removal effective 1/20/23 was validated by the following: Staff interviews revealed they had received education on medication administration, obtaining medicine through pharmacy, and how to notify the on call or in-house provider if medicines are not available. Facility stat safe was observed in locked medication room behind nurse's station where nursing staff have a personalized code to enter for access to receive back-up medications for residents and staff interviews revealed if resident medication was not available on medication cart they were to utilize stat safe first and if not there then to contact pharmacy about other option for receiving medication and to notify physicians of missing medication. Audits were completed to residents who had received IV medication and missed medication for all residents in the facility.

Based on record reviews, family member, and staff interviews, the facility failed to provide assistance with bathing for 1 of 3 dependent residents (Resident #12) reviewed for providing activities of daily living (ADL) care to residents. The findings included: Resident #12 was admitted to the facility on [DATE] with diagnoses which included a history of prostate and bladder cancer with urostomy, chronic obstructive pulmonary disease, and heart failure and was discharged to the local hospital on 01/17/23. Review of Resident #12's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired and required extensive assistance of 2 staff for bed mobility, transfers and toileting and required extensive assistance of 1 staff with personal hygiene and bathing. The assessment also revealed Resident #12 had no rejection of care behaviors. Review of Resident #12's care plan dated 12/19/22 revealed he had a focus area for having an activities of daily living (ADL) self-care performance deficit related to his disease process. Resident requires assistance to completed ADL tasks daily and fluctuations are expected related to his diagnoses. He is at risk for decline in physical function due to confusion, fatigue, impaired balance, and limited mobility. The interventions included: bathing/showering the resident required extensive assistance of 1 staff with bathing/showering as necessary, bed mobility the resident required extensive assistance of 2 staff, dressing the resident required extensive assistance of 1 staff, encourage the resident to participate to the fullest extent possible with each interaction, encourage the resident to use bell to call for assistance, Hygiene/grooming the resident required extensive assistance of 1 staff, toileting extensive assistance of 2 staff and transfers extensive assistance of 2 staff. Review of the shower schedule for the 200 hall where the resident resided revealed Resident #12 was scheduled for bed baths/showers on Tuesday and Friday on first shift (7:00 AM to 3:00 PM) each week. Review of the bathing report for Resident #12 from 12/12/22 through 01/17/23 revealed the following: 12/13/22 - missed bed bath/shower - no documentation as to why it was not provided. 12/16/22 at 11:36 AM (Friday) - resident refused shower and was not provided bed bath - no documentation as to why bed bath not provided. 12/20/22 - missed bed bath/shower - no documentation as to why it was not provided. 12/23/22 - missed bed bath/shower - no documentation as to why it was not provided. 12/27/22 - missed bed bath/shower - no documentation as to why it was not provided. 12/29/22 at 3:47 PM (Thursday) - bed bath or shower was provided. 12/30/22 - missed bed bath/shower - no documentation as to why it was not provided but had received one the day prior. 01/02/23 - missed bed bath/shower - no documentation as to why it was not provided. 01/06/23 at 11:42 AM (Saturday) - bed bath or shower was provided. 01/09/23 at 10:42 AM (Tuesday) - bed bath or shower was provided. 01/12/23 - missed bed bath/shower - no documentation as to why it was not provided. 01/16/22 at 3:46 PM (Tuesday) - bed bath or shower was provided. According to the facility's documentation, Resident #12 missed 6 bed baths/showers out of 11 for the time of 12/12/22 through 01/17/23. A phone interview on 01/24/23 at 10:35 AM with Resident #12's family member revealed she visited him every weekend because of the distance of the facility from her residence. The family member stated the resident was not getting his bed baths or showers like he was supposed to because of the way he looked and smelled so the quality time she preferred to spend with him had to be spent providing him care and bathing him on the weekend. She further stated when she visited him every weekend, he looked disheveled, and he had body odor. She indicated she had expressed her feelings to the nurses caring for Resident #12 on the weekends she had visited and had expressed her concerns to the Hospice nurse assigned to the resident. An interview on 01/25/23 at 11:50 AM with Nurse Aide (NA) #1 who cared for Resident #12 on 01/12/23 along with NA #4 revealed the shower schedule for each hall did not always match the showers scheduled for each day. She stated she always documented her showers in Point of Care (POC) which was the facility's documentation system for Nurse Aides. NA #1 could not recall why Resident #12's bed bath or shower was not provided and said it may have been that NA #4 was assigned to give his shower on that date or his shower was not included in the daily assignment. NA #1 reported she had not bathed or showered Resident #12 on 01/12/23. A phone interview on 01/24/23 at 4:27 PM with the Hospice nurse revealed they were secondary payor to the Veteran's Administration for Resident #12 and provided nursing, social services and chaplan services for the resident but had not provided nurse aide assistance for the resident. The Hospice nurse further stated the facility was responsible for activities of daily living care for the resident. A phone interview on 01/25/23 at 3:00 PM with NA #3 who cared for Resident #12 on 12/13/22 revealed she was not sure why Resident #12 had not received his shower on 12/13/22 unless she had been pulled to another hall to assist with caring for residents. She further stated the schedule did not always match the showers assigned and said it may have been missed for that reason. NA #3 indicated the facility had not used shower sheets and what was documented in POC should have been accurate. Several attempts were made to contact NA #4 who was assigned to care for Resident #12 on 12/20/22, 12/23/22, 12/27/22 and 01/02/23 with voicemail's left with no return call. A phone interview on 01/25/23 at 3:36 PM with the Director of Nursing (DON) revealed she was not aware that Resident #12 had missed showers during his stay at the facility. She stated she was not aware of the schedule not matching assigned showers daily and said they should match unless they were including showers not completed from the day before for whatever reason. The DON further stated she would check into the schedule to assure it was accurate and matched the assignments given to the NAs. She indicated it was her expectation that residents received their showers as scheduled unless they refused and then the refusal should be brought to the nurse's attention and documented in the record.

Based on record reviews, resident, family member, staff, and Physician's Assistant (PA) interviews, the facility failed to change a urostomy bag (special bag used to collect urine on the abdomen after removal of the bladder), as ordered for 1 of 1 resident (Resident #12) reviewed for providing care for urostomy as ordered by the physician. The findings included: Resident #12 was admitted to the facility on [DATE] with diagnoses which included a history of prostate and bladder cancer with urostomy, chronic obstructive pulmonary disease, and heart failure. Review of a physician order written for Resident #12 on 12/14/22 revealed the following order: Change urostomy bag every 4 days on day shift every 4 days effective 12/15/22. Review of Resident #12's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he required extensive assistance of 1 to 2 staff with most activities of daily living (ADL). The assessment also revealed he was incontinent of bowel and bladder and had a urostomy bag. Review of Resident #12's care plan dated 12/19/22 revealed he had a focus area for having a urostomy to drainage bag related to malignant neoplasm of bladder and prostate. The interventions included hand washing before and after delivery of care, observe for signs and symptoms of discomfort on urination and frequency, observe/document for pain/discomfort due to urostomy and observe/record/report to provider any signs and symptoms of urinary tract infection such as pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse or temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior and change in eating patterns. Review of Resident #12's Treatment Administration Record (TAR) for December 2022, revealed his urostomy bag was scheduled to be changed on 12/15/22. The block for 12/15/22 was initialed it had been changed by Nurse #5. Phone interview on 01/24/23 at 10:35 AM with the family member revealed when she visited on 12/18/22 Resident #12 still had the same bag on from 12/12/22 which was the date on the bag. She stated it had not been changed since his admission to the facility. Interview on 01/24/23 at 1:42 PM with Nurse #5 who was assigned to Resident #12 on 12/15/22 revealed she had initialed the treatment as his bag being patent and flowing into the urinary bag without difficulty but admitted she had not changed the urostomy bag because it was changed on 12/12/22 and it had not been 4 days. Nurse #5 stated she had spoken with the Unit Manager and asked if the dates could be changed and said she wasn't sure why they had not been changed. Review of Resident #12's TAR for January 2023 revealed his urostomy bag was scheduled to be changed on 01/08/23. The block for 01/08/23 was blank. The bag was due to be changed again on 01/12/23 and the block was marked by Nurse #5 as though she had changed the bag. Phone interview on 01/24/23 at 10:35 AM with the family member revealed when she visited Resident #12 on the evening of 01/08/23 the urostomy bag had not been changed and was dated 01/04/23. The family member contacted the Hospice Nurse who agreed to visit the resident on 01/09/23 and told her she would change the bag on her visit. The family member stated she had visited Resident #12 again on 01/15/23 and said on that visit the urostomy bag was dated 01/09/22 and had not been changed on 01/12/23 as scheduled. Interview on 01/24/23 at 1:42 PM with Nurse #5 who was assigned to Resident #12 on 01/12/23 revealed she had initialed the treatment as his bag being patent and flowing into the urinary bag without difficulty but admitted she had not changed the urostomy bag because it was changed on 01/09/23 by the Hospice Nurse and it had not been 4 days. She further stated it had been changed on 01/09/23 because Nurse #6 had not changed it on 01/08/23 as scheduled on the TAR. Nurse #5 indicated the Hospice Nurse changed the urostomy bag on 01/09/23. Phone interview on 01/25/23 at 11:33 AM with Nurse #6 revealed she had taken care of Resident #12 on 01/08/23, 01/09/23, and the following weekend on 01/15/23. She stated she could not recall why she had not changed the bag on 01/08/23 as scheduled but probably just forgot to go back and change it before she left for the day. Nurse #6 further stated she did recall changing the urostomy bag on 01/15/23. Nurse #6 indicated she had changed the bag on 01/15/23 because the family member wanted it changed. Nurse #6 further indicated she had taken care of the resident on 01/16/23 and the bag was due to be changed but said the Unit Manager told her not to change it since she had changed it the day before and just to mark the block for 01/16/23 as though she had changed it. Several attempts were made to contact the Unit Manager by phone and voicemails left with no return call. Phone interview on 01/25/23 at 4:27 PM with the Hospice nurse who was assigned to care for Resident #12 revealed she tried to coordinate between the family member and facility staff to ensure the resident's bag was changed as ordered by the physician. The Hospice nurse stated there had been difficulty trying to get the urostomy bag changed and the changes recorded correctly on the Treatment Administration Record (TAR). An interview on 01/25/23 at 1:40 PM with the Physician's Assistant (PA) working at the facility revealed she had spoken with the Hospice nurse and she had informed her the resident's urostomy bag had not been changed according to the physician's order. The PA stated she had discussed the concern the resident's bag was not being changed with the Director of Nursing and was told by the DON there was a plan in place to ensure the bag was changed. A phone interview on 01/25/23 at 3:36 PM with the Director of Nursing (DON) revealed she had devised a plan with Resident #12's family member to ensure his urostomy bag was changed as ordered but said he was discharged out to the hospital before the plan was executed. The DON stated she knew about one time the bag was not changed when it should have been and it was an error on the part of Nurse #5. She further stated she was unsure why it was left blank on 01/08/23 but could only assume it had not been changed as scheduled by Nurse #6. The DON indicated she was not aware Resident #12's urostomy bag had not been changed on 12/15/22 as ordered by Nurse #5 and said she would have expected all the nurses to have changed his urostomy bag as ordered or consult with the Unit Manager, Assistant Director of Nursing, or her if there were any questions about the order or they needed further direction. Review of Resident #12's hospital record revealed he was discharged to the local hospital on 01/17/23 and admitted with diagnoses which included pneumonia and urinary tract infection. The culture from the urinalysis grew out 3 different bacteria for which the resident was placed on intravenous (IV) antibiotics. The resident was discharged to another facility on 01/20/23. Interview on 01/25/23 with the Medical Director (MD) he remembered the resident but not specifics about him without looking at his medical chart. The MD stated he didn't recall hearing anything about his urostomy bag not being changed as ordered. The MD further stated the urostomy bag should have been changed as ordered.

Based on record review, staff interviews and physician interview, the facility failed to operationalize effective systems so staff could respond to an emergency situation as needed for 1 of 3 residents (Resident #1) reviewed for cardiopulmonary resuscitation. When Resident # 1 required cardiopulmonary resuscitation (CPR) and suctioning, only chest compressions were provided until emergency medical services arrived. EMS transported Resident # 1 to the hospital and given the extended [CONDITION(S)] time of 32 minutes and the lack of neurologic responsiveness Resident #1 was intubated and admitted to the intensive care unit (ICU). Resident #1 was transitioned to comfort care and palliatively extubated. Resident #1 passed away on [DATE]. Immediate Jeopardy began on [DATE] when Resident #1 who was a full code, was not provided airway ventilation as part of CPR, until EMS arrived on scene. The immediate jeopardy was removed on [DATE] when the facility provided and implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of an D (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and monitoring systems put into place are effective. The findings included: The facility policy based on guidelines from the American Heart Association for Cardiopulmonary Resuscitation (CPR) dated [DATE] stated, If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden [CONDITION(S)] is likely, begin CPR. The policy read the sequence of events were referred to as C-A-B (chest compressions, airway, breathing). Airway included to tilt the residents head back and lift the chin to clear the airway. Breathing included after 30 chest compressions to provide 2 breaths via ambu bag or manually with a CPR shield. Resident #1 was admitted into the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A nursing progress note dated [DATE] at 3:45 PM written by Nurse#1 revealed Resident #1 had just arrived at the facility by EMS. Resident #1 was alert and oriented with no pain. The resident had oxygen at 2 liters via nasal cannula and his medications were verified with the medical director. Record review revealed an initial admission nursing assessment had not been completed for Resident #1. The code status of Resident #1 was located under the orders tab in the electronic medical record. Resident #1 was a full code. A nursing progress note dated [DATE] at 9:10 PM written by Nurse #2 revealed at 8:00 PM Resident #1 was alert and oriented with an oxygen saturation level of 96%. The note revealed around 9:15 PM Resident #1 began to complain of having trouble breathing. Nurse #2 increased the resident's supplemental oxygen to 3 liters via nasal cannula. Resident #1 began turning blue in color, had a faint pulse and became unresponsive. Life saving measure took place until Emergency Medical Services (EMS) arrived. Nurse #2 documented she called the on-call physician and Resident #1 left the facility for the hospital at 9:45 PM. On [DATE] at 3:35 PM an interview with Nurse #1 revealed she had received Resident #1 as a new admission during her shift on [DATE]. She stated he was alert and oriented when he came into the facility and had shown no signs of distress. An interview conducted with Nurse #2 on [DATE] at 11:05 AM revealed on [DATE] she came on shift at 7:00 PM and received report from Nurse #1 that Resident #1 was a new admission and was doing well. She stated she completed rounding and saw Resident #1 at 7:45 PM laying in bed in no distress. The interview revealed she was completing her medication pass when she went into his room around 8:30 and Resident #1 stated to her that he was having trouble breathing. She stated she placed the pulse oximetry monitor on his finger and his oxygen saturation level would not show on the pulse oximetry meter which meant his oxygen level was low. Nurse #2 asked Resident #1 if he had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated she immediately looked into his mouth to make sure there was nothing impeding his airway. Nurse #2 then laid the resident back onto the bed and began chest compressions while yelling for help from another nurse. She stated Nurse Aide #1 came into the room and she stated she needed the crash cart. Nurse #3, Nurse #4, and Nurse #5 also entered the room. She stated someone brought the crash cart into the room however it was locked, and the nurses did not know where the key was located. Nurse #3 stayed with her to rotate chest compressions. Nurse #5 ran out of the room to find the key to the crash cart and Nurse #4 went to call emergency medical services. Resident #1 began to have white foam around his mouth. Nurse #2 stated a suction canister was located on the top of the crash cart but the tubing to the suction was located inside of the cart so she could not suction Resident #1's mouth. She stated nothing on the crash cart was helpful to her in a time of need. Nurse #2 stated the ambu bag to provide airway support to the resident was also locked in the crash cart. Nurse #3 returned to the room and assisted Nurse #2 in 5 rounds of chest compressions until EMS arrived. She stated she had one of the NAs to go get a nebulizer machine but once it was in the room the machine malfunctioned and would not work. She stated Resident #1 had oxygen in his nose at 3 liters via nasal cannula during the incident. She stated once EMS arrived, they took over with the resident in the room for approximately 30 minutes before transporting him to the hospital. Nurse #2 stated she was an agency nurse and had never used the crash cart in the facility prior to that night. She stated she had no idea the cart was kept locked and nobody in the facility had told her where the key was located. The interview revealed she still worked in the facility and did not know where the crash cart key was located. She stated she was extremely upset after the incident and called the Unit Manager #1 to explain to her what had happened. She stated she told the Unit Manager #1 that she felt she didn't have the proper equipment to save Resident #1's life and knew she hadn't done everything possible in a time of need. She stated Unit Manager #1 apologized to her and stated she would do some education with the staff. Nurse #2 stated she never received any education following the incident. An interview was conducted with Nurse #4 on [DATE] at 11:21 AM. Nurse #4 stated she was working on the 200 hall on the night of [DATE]. She stated she had just completed her medication pass between 8:,d+[DATE]:00 PM and went to the nurse's station when someone came out of Resident #1's room and yelled there was a code. Nurse #4 stated she got up and ran to the room to see how she could help. She stated she saw Nurse #2 laying the resident back onto the bed, calling his name and began giving chest compressions to the resident and she left the room to call EMS. She stated the nurses could not use the crash cart because it was locked and nobody in the building knew where the key was located. She stated they later learned there was another crash cart in the building that was unlocked but it had been covered with Halloween decorations at the time of the incident and nobody saw it. She stated she had never had to run a code in the building, and she had worked there since [DATE]. The interview revealed Nurse #2 did not have access to an ambu bag or suction supplies. She stated by the time a Nurse Aide obtained an ambu bag EMS had arrived in the building. Nurse #4 stated during orientation she did not remember the crash cart being discussed. An interview was conducted with Nurse #3 on [DATE] at 1:21 PM. Nurse #3 stated he was in the television room of the facility when he saw Nurse #4 looked panicked. He went to Resident #1's room and saw Nurse #2 doing chest compressions. He stated he stayed with Nurse #2 and when she became tired, he would take over doing chest compressions. He stated Nurse #5 came in the room stating she could not find the crash cart key so he went to look for it and she took his place. The interview revealed the nurses completed approximately 15 minutes of chest compressions before EMS arrived. He stated a staff member brought in the crash cart but they couldn't use it because it was locked. Nurse #3 stated they did not have access to an ambu bag or suctioning. The interview revealed he and a NA had gone to central supply to get the suction tubing and an ambu bag but by that time EMS arrived in the building. Nurse #3 stated he observed Resident #1 to be blue in color with white foam around his mouth. He stated there was another crash cart in the building, but he didn't work on that hall and he wasn't aware of it. He stated it was covered with decorations and they couldn't see it. An interview conducted on [DATE] at 11:43 AM with Nurse #5 revealed she was getting ready to go on her break around 8:30 PM on [DATE] and went down the 100 hall to see if they needed anything when she realized there was a code. Upon entering the room, she saw Nurse #2 and Nurse #3 initiating chest compressions on Resident #1. She stated they asked her where the key to the crash cart was, so she went out of the room and back to the nurse's station to find it. The interview revealed Nurse #4 was on the phone with EMS. She stated she looked everywhere she knew and could not find the crash cart key. Nurse #5 went back to the room and asked what the nurses needed. She stated they needed suction tubing, so she took over doing chest compressions for Nurse #3 and he went to find the tubing and crash cart key. She stated in total the nurses completed 5 rounds of chest compressions prior to EMS arrival. The interview revealed following the incident they learned the crash cart key was taped to the bottom of a drawer in the nurse's station after they called Unit Manager #1 to tell her what had happened. She stated she was agency and didn't know where anything was in the facility. Nurse #5 stated she felt incompetent by not being able to take care of Resident #1 because she was not properly oriented to the facility. An interview conducted on [DATE] at 11:59 AM with NA #1 revealed she was walking down the hall when she heard Nurse #2 say there was a code. She stated she went looking for the crash cart but when they got it to the room it was locked. The interview revealed she left the room and began looking for the key to the cart. She stated after she could not find the key, she remembered she had seen a ambu bag in the supply room so she went and got it. NA #1 stated by the time she got back to Resident #1's room EMS had arrived in the building. On [DATE] at 12:05 PM an interview was conducted with Unit Manager #1. She stated Nurse #2 called her and said they had to send Resident #1 out of the facility. She stated the nurse told her the resident had coded and the staff could only do chest compressions. Nurse #2 asked her where the key for the crash cart was located, and she instructed her it was taped to the bottom of a drawer in the nurses station and there was another cart on 100 hall. Unit Manager #1 stated to her that she did not know where the crash cart key was located during the code. She stated the key had been there for years and she thought it was odd out of the 4 nurses working that night that nobody knew where it was located. The interview revealed the staff were oriented to the facility by her and she stated she usually completed the orientation training. She stated the orientation consisted of telling the nurses where the crash cart was located along with the key. An interview conducted on [DATE] at 12:15 PM with the Director of Nursing (DON) revealed she was alerted to the situation by Unit Manager #1 on [DATE]. She stated Unit Manager #1 had been the on-call staff member working that night when staff called her stating they could not find the crash cart key. The DON explained the crash cart was locked because residents would get into it and the key had been in the same location for over a year. She stated agency staff received a packet with information in it for orientation and are shown around the facility. The DON stated she did not directly speak with Nurse #2 about the incident or ask about details of what had happened because she felt like Unit Manager #1 handled the situation. She stated Unit Manager #1 had went around asking everyone if they knew where the crash cart was located and if they did not know she would show them. The DON stated there was no written documentation of a in-service. On [DATE] at 1:03 PM an interview was conducted with the Medical Director (MD). During the interview he stated that during CPR giving chest compressions alone would not be 100% effective. He stated there had been changes in CPR techniques, but ventilation was important to a successful resuscitation. The interview revealed a full code status meant full scope of CPR including chest compressions and airway support. The Medical Director further stated an emergent situation was not the time to be looking for a key. The interview revealed Resident #1 was admitted on the evening of [DATE] and discharged on the same date within a few hours of being in the facility. Review of the hospital records dated [DATE] revealed Resident #1 arrived at the hospital intubated without sedation and unresponsive. Resident #1 was diagnosed with profound [CONDITION(S)] affecting basic brain functions that control wakefulness, breathing, heartbeat and temperature. Resident #1 displayed no organized neurologic activity, had a blown pupil on the left side and a negative head computed tomography (CT). The report read given the extended [CONDITION(S)] time of 32 minutes per emergency medical services and Resident #1's lack of neurologic responsiveness he was admitted to the Intensive Care Unit. Resident #1 was transitioned to comfort care on [DATE] and palliatively extubated with the family at bedside. Resident #1 passed on [DATE] at 1:45 PM. The Emergency Medical Services (EMS) was unable to locate the report from [DATE]. The facility Administrator was notified of the immediate jeopardy on [DATE] at 5:30 PM. o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance * On [DATE] the facility failed to provide basic life support to include ventilation and suctioning. * On [DATE] resident #1 required CPR and received chest compressions with no ventilation or suctioning. *All other residents who have advanced directives that require a full code are at risk from suffering from the deficient practice. On [DATE], The DON and ADON completed an audit to determine all residents who have advanced directives that require full code. All residents identified to have advanced directives that require full code were assessed for signs or symptoms of [CONDITION(S)] on [DATE] with no concerns found. On [DATE], an audit was performed by the DON on all crash carts to ensure they are unlocked and are complete with suctioning equipment and an Ambu bag. Both crash carts have been relocated to the nurses' stations and are fully stocked, unlocked, and accessible to all staff. Both crash carts require a key to be locked. The keys to both crash carts were removed and secured by the DON to ensure the carts remain unlocked and keys are no longer accessible for staff use. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete 0n [DATE], education was provided to the Administrator, Director of Nursing (DON), and the Assistant Director of Nursing (ADON) by the Corporate Consultant, Regional Director of Operations, regarding emergency procedures and cardio-pulmonary resuscitation. On [DATE], after being reeducated as outlined above, education for all staff including agency staff, was completed in person or via phone by the Administrator, DON, ADON or designee. The education consisted of the following: The need to Maintain equipment and supplies necessary for CPR/BLS in the facility at all times. It is the Director of Nurses responsibility to ensure equipment is maintained and supplies necessary for CPR/BLS are accessible to staff at all times. Crash carts are to remain stored at the each nurses' station unlocked, and be equipped with suctioning equipment and an Ambu bag. The facility's procedure for administering CPR shall incorporate the steps covered in the Emergency Cardiovascular Care or facility BLS training material. If the first responder is not CPR-certified, that person will call 911 and follow the 911 operator's instructions until a CPR-certified staff member arrives. If an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden [CONDITION(S)] is likely, begin CPR by: a. Facility nurse will instruct a staff member to activate the emergency response system (code) and call 911. b. Facility nurse will instruct a staff member to bring the crash cart to the code location. c. Facility nurse will verify or instruct a staff member to verify the DNR or code status of the individual. d. Clinical staff to Initiate the basic life support (BLS) sequence of events. The BLS sequence of events is referred to as C-A-B (chest compressions, airway, breathing). Alleged IJ removal date is [DATE]. The credible allegation was verified on [DATE] as evidenced by observations, staff interviews and record review. Interviews were conducted with the nursing staff to confirm in-services were completed on how and when to conduct CPR, how and when to request assistance with CPR and where to find the crash carts. Observations were made of the unlocked crash carts and supply audits were competed. The facility's immediate jeopardy removal dated of [DATE] was validated.

Based on observations, record reviews, and staff interviews, the facility failed to implement their policy for Personal Protective Equipment (PPE) when 1 of 4 staff members (Nurse Aide #3) failed to change her mask and disinfect her goggles after providing care to a COVID-19 positive resident and before providing care to a COVID-19 negative resident reviewed for infection control practices. The facility's policy and procedure did not specifically address what to do with personal protective equipment when non-dedicated staff members transitioned care from a COVID positive resident to a COVID negative resident. The findings included: The facility's policy entitled: Coronavirus Disease (COVID-19) - Using Personal Protective Equipment/Source Control read as follows under Policy Interpretation and Implementation read in part: If personal protective equipment is used during the care of a resident for which a NIOSH-approved respirator or facemask is indicated for personal protective equipment (PPE) (i.e., NIOSH approved particulate respirators with N95 filters or higher during the care of a resident with COVID-19 infection, facemask during care of a resident on Droplet Precautions), they should be removed and discarded after the resident care encounter and new one should be donned. An observation of the 100 hall on 11/21/22 at 9:40 AM revealed rooms 104, 105, 107, 109, 110, 112 and 117 all were on enhanced droplet contact precautions for COVID-19 and were COVID-19 positive. A continuous observation from 9:45 AM to 9:59 AM revealed NA #3 went into room [ROOM NUMBER] to provide care to resident who was COVID-19 positive. The Nurse Aide (NA) donned a gown, and gloves and with N95 mask and goggles went into the room. NA #3 exited the room after providing care, doffed her gloves and gown, sanitized her hands and proceeded down the hall and into room [ROOM NUMBER] who was not on enhanced contact precautions and was COVID-19 negative with the same mask and goggles that had not been cleaned and provided care to the resident. NA #3 failed to change her mask and clean her goggles when going from a COVID-19 positive resident to a COVID-19 negative resident. An interview on 11/21/22 at 10:24 AM with NA #3 revealed she had taken care of the resident in room [ROOM NUMBER] who was COVID-19 positive and then the resident in room [ROOM NUMBER] who was COVID-19 negative. NA #3 further revealed she should have changed her mask and cleaned her goggles when exiting room [ROOM NUMBER] who was COVID-19 positive and before entering room [ROOM NUMBER] who was COVID-19 negative but had not done so. An interview on 11/21/22 at 11:29 AM with the Director of Nursing (DON) who also served as the Infection Preventionist revealed NA #3 should have changed her mask, cleaned her goggles and sanitized her hands after exiting room [ROOM NUMBER] and before entering room [ROOM NUMBER]. The DON stated there were plenty of personal protective equipment (PPE) supplies and were provided in bins outside each room on enhanced contact precautions for COVID-19 and NA #3 should have cleaned her goggles and changed her mask after exiting room [ROOM NUMBER]. The DON further stated any time staff transitioned care from a COVID positive resident to a COVID negative resident they should change their mask, clean their goggles or face shield and sanitize their hands prior to entering the COVID negative resident's room. She indicated if the policy did not address the use of PPE between COVID positive and COVID negative residents they would need to ensure it was updated to reflect the most current infection control guidelines. An interview on 11/21/22 at 11:45 AM with the Administrator revealed staff had just been educated on the proper use of PPE in COVID-19 positive rooms and what to do when working between COVID-19 positive and negative residents. The Administrator stated they would follow up with NA #3 and provide one on one education to ensure she understood proper procedures with PPE.

Based on observations, record review, and resident, family, staff, Psychiatric Nurse Practitioner, and Physician interviews, the facility failed to protect an [AGE] year old female resident with severe cognitive impairment (Resident #1) from a sexual encounter from a [AGE] year old male resident with intact cognition (Resident #2) for 1 of 3 residents reviewed for abuse. Resident #2 was observed standing up beside the bed, Resident #1 was lying on the bed and both were completely naked. Immediate Jeopardy began on 08/21/22 when Resident #2, who was cognitively intact, was found by nursing staff in Resident #1's room with the door closed and Resident #2 was observed standing up beside the bed, Resident #1 was lying on the bed and both were completely naked. Immediate Jeopardy was removed on 09/01/22 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring systems put into place are effective. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #1 with severe impairment in cognition. She required limited staff assistance with activities of daily living except for eating and displayed wandering behavior 1 to 3 days during the MDS assessment period. Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS assessment dated [DATE] assessed Resident #2 with intact cognition. He was assessed as being independent or needing supervision (cueing, oversight) with activities of daily living. Review of the nurse progress notes revealed an entry written by the Assistant Director of Nursing (ADON) dated 08/21/22 at 6:20 PM that read in part, Resident #1 was found to have a male visitor in her room privately. Male was redirected by staff to his room. Review of the nurse progress notes revealed an entry written by the ADON dated 08/21/22 at 6:19 PM that read in part, Resident #2 was found visiting in another resident room and was redirected back to his room. During an observation and attempted interview on 08/30/22 at 9:20 AM, Resident #1 was unable to recall Resident #2 or the incident that occurred on 08/21/22. Resident #1 was sitting in her recliner with her baby doll lying on the bed beside her. During the interaction, Resident #1 kept referring to her baby doll as her real child and how good he was being with company. During an interview on 08/30/22 at 9:57 AM and follow-up telephone interview on 09/07/22 at 1:31 PM, Resident #1's Responsible Party (RP) recalled on 08/21/22 at approximately 5:00 PM she was contacted by facility staff and informed of an incident that had occurred between Resident #1 and Resident #2. The RP could not recall the name of the staff member but stated she was told when a Nurse Aide had gone to Resident #1's room, Resident #1 was found lying on the bed naked and a male resident was standing by her bed also naked. Resident #1 was checked by 2 nurses, there was no semen found on Resident #1 and the male resident was removed from the room. The RP added she was also advised not to come to the facility that night as Resident #1 was calmed down and sleeping. The RP stated she didn't sleep all night worrying about Resident #1 and arrived at the facility first thing the next morning. She stated Resident #1 did not recall details of the incident and when the RP pushed her through the facility in her wheelchair, she waved at various residents but could not state or point out who the resident was that had been in her room. The RP stated Resident #1 had severe dementia and there was no way she could consent to any type of intimate or sexual relationship with any resident. During interviews on 08/30/22 at 5:05 PM and 08/31/22 at 9:10 AM, Resident #2 could not recall the exact date but stated he had walked to Resident #1's room to visit with her, she invited him into the room, he shut the door and they sat down on the side of the bed. Resident #1 stated he saw an opening with her, started kissing her, and one thing led to another. Resident #2 stated the interaction with Resident #1 was a mutual agreement and at first stated he took off Resident #1's clothes but later stated he assisted her with taking off her clothes. Resident #2 could not state at what point Resident #1 laid down on the bed and explained they did not have sexual intercourse but if staff had not come into the room, it would have led to that. He stated they both cared for one another and he did not do anything to her that she had not wanted. Resident #2 indicated both he and Resident #1 were both consenting to the relationship and what transpired. During interviews on 08/30/22 at 1:45 PM and 08/31/22 at 9:55 AM, Nurse Aide (NA) #1 recalled at approximately 3:00 PM on 08/21/22 she was completing the last round of her shift and when she got to Resident #1's door, it was closed which was not unusual if her family was visiting. When she knocked and opened the door, she saw Resident #2 standing by the bed in between the bed and door, with his back toward the door and Resident #1 was lying on the bed, both completely naked. NA #1 stated she was unable to open the door completely and stayed in the doorway as she called for Nurse #1 to come to the room. NA #1 stated after Nurse #1 looked into the room and saw Resident #1 and Resident #2, Nurse #1 left the room to go and get Nurse #2 while she remained standing in the doorway of the room and by the time both Nurse #1 and Nurse #2 got back to the room, Resident #2 had started to put his pants back on and Resident #1 had walked to her bed by the window and laid down. NA #1 stated Resident #2 had his back to the door and she did not visualize him from the front and could not state if he was aroused. She explained Resident #1 and Resident #2 did not appear to be in a state of arousal because they were both in a calm state. NA #1 stated Resident #1 had impaired cognition and did not feel she would be able to consent to a sexual encounter. For instance, NA #1 explained Resident #1 believed her baby doll was real and even attempted to feed her baby from her daily meal trays. NA #1 explained prior to the incident on 08/21/22 she had no inclination of any type of relationship between Resident #1 and Resident #2 nor had she noticed either one visiting the other. During a telephone interview on 08/30/22 at 1:28 PM, NA #2 stated she was not assigned to Resident #1 and Resident #2's hall but she had heard the commotion and thought maybe Resident #1 had fallen. She could not recall the time it had occurred when she went down to Resident #1's room but stated other staff were already there, and she saw Resident #2 standing by the bed with his back toward the door completely naked and Resident #1 was lying on the bed by the door completely naked except for one sock. NA #2 stated Resident #2 was still in his right mind but Resident #1 had impaired cognition and she did not feel Resident #1 would be able to consent to a sexual encounter. During a telephone interview on 09/01/22 at 10:15 AM, Nurse #1 recalled on 08/21/22 NA #1 called her down to Resident #1's room and when she arrived at the door, Resident #2 was standing by the bed next to the door, with his back toward the door, pulling up his pants and Resident #2 was lying in her bed by the window and acted as if she was asleep. Nurse #1 left to get Nurse #2 while NA #1 stayed at the doorway of Resident #1's room. When Nurse #1 and Nurse #2 got back to Resident #1's room, Nurse #2 asked Resident #2 to go back to his room. Nurse #1 stated she remained in the room as Nurse #2 assessed Resident #1 who found no visual evidence of sexual intercourse. Nurse #1 recalled Resident #1 was lying in her bed, completely naked, and did not appear in any distress. After Resident #1 was assessed, she and Nurse #2 went to Resident #2's room to speak with him about what had occurred. Nurse #1 recalled Resident #2 told her that when he walked down to Resident #1's room, she was standing in the doorway in just her briefs and it woke something up in him. She added Resident #2 denied having sex with Resident #1. Nurse #1 stated while she was sitting down next to Resident #2 talking with him, she could smell Resident #1 on his hands and described it as a vaginal smell. Nurse #1 recalled during their conversation, Resident #2 had stated he and Resident #1 were in a relationship which she thought was odd and explained Resident #1 thought Resident #2's roommate was her husband and when she wandered into their room, Resident #2 would tell Resident #1 he didn't want her in the room. Nurse #1 stated Resident #1 had impaired cognition and did not feel that she was able to consent to an intimate or sexual relationship with Resident #2. During an interview on 08/30/22 at 3:57 PM, Nurse #2 recalled on 08/21/22 she went to Resident #1's room with Nurse #1 to assess the situation and when she arrived, Resident #2 was buckling up his pants and Resident #1 was lying in the bed by the window covered with a blanket. Nurse #2 told Resident #2 he needed to get back to his room and he said he was headed that way. Nurse #2 stated Resident #1 could not tell her what had happened but did state she was washing her pants, which were noticed in the sink wet. She added Resident #1 could probably take her own clothing off but it would take her some time and it was not normal for her to undress herself or lie in the bed naked. Nurse #2 recalled Resident #1 was completely naked under the blanket and when she completed a visual body examination, she found no evidence of a sexual encounter such as semen or other bodily fluids on the bed linens or Resident #1's vaginal area. When Resident #2 was questioned, he reported they did not have sexual intercourse. Nurse #1 added due to Resident #1's cognition and confused state she felt Resident #1 would not be able to provide consent. Nurse #1 stated both residents were placed on 15 minute checks but staff had to keep redirecting Resident #2 from trying to go back into Resident #1's room. During an interview on 08/30/22 at 3:28 PM, the Administrator stated she was informed of the incident on 08/21/22 and came into the facility to start an investigation. She discussed the incident with the Regional Director of Operations (RDO) and based on what was reported to them from staff there was no evidence of a sexual encounter. The Administrator added Resident #2 stated Resident #1 had invited him into her room and neither Resident #1 nor Resident #2 showed any signs of distress. Resident #2 was returned to his room and both residents were placed on 15 minute checks for a period of 72 hours; however, Resident #1's 15 minute checks were discontinued on 08/22/22 when she was moved to a hall with keypad access. The Administrator stated since neither Resident #1 nor Resident #2 displayed any signs of distress, Resident #1 was making logical statements at the time and invited Resident #2 into her room, Resident #1 did not attempt to cover up her nakedness until staff entered the room, and Resident #2 felt Resident #1 was a willing participant, the Administrator and RDO both felt the incident between Resident #1 and Resident #2 was mutual and not reportable. During a joint interview with the Administrator on 08/31/22 at 5:45 PM, the RDO explained when nursing staff discovered Resident #1 and Resident #2 both undressed in Resident #1's room on 08/21/22, Resident #1 was calm, showing no signs of distress or requesting Resident #2 to get out of her room. The RDO confirmed no one asked Resident #1 if she wanted to have sexual contact with Resident #2 and explained the nursing staff were probably caught off guard when they saw both residents undressed in the room and were unsure of what to ask. The RDO restated based on Resident #1's demeanor at the time of the incident, there was every indication she wanted the contact with Resident #2. During a telephone interview on 08/31/22 at 5:03 PM, the Psychiatric Nurse Practitioner (NP) explained she was new to the facility but had seen Resident #1 on a few occasions. The Psychiatric NP explained during their interactions, Resident #1 hadn't been able to provide a good history or recall. Based on her interactions and conversations with Resident #1, the Psychiatric NP stated she did not feel Resident #1 could give consent for a sexual relationship. During a telephone interview on 09/01/22 at 11:49 AM, the facility's Medical Doctor (MD) revealed she was informed of the incident that occurred between Resident #1 and Resident #2 on 08/21/22 and upon the nurse's assessment of Resident #1, there was no evidence of semen, other bodily fluids, or trauma. The MD added Resident #1 had no [MEDICATION(S)] effects as a result of the incident. The MD stated it was her medical opinion that Resident #1 did not have the mental capacity to consent to any type of sexual or intimate relationship due to her impaired cognition. The Administrator was notified of Immediate Jeopardy on 08/31/22 at 4:35 PM. The facility provided the following Credible Allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On 8/21/22 the facility failed to protect a resident with severe cognitive impairment from sexual advances from a cognitively intact male. Resident #1 was at risk of suffering from the deficient practice. Resident #1 is no longer a resident as of 8/30/22 as she had a planned discharge on 8/30/22. All cognitively impaired residents are also at risk from suffering from the deficient practice. Resident #2 is still in the facility. He will remain on 15 min checks until his planned discharge home. On 8/31/22, all staff in all departments were interviewed by members of the interdisciplinary team (IDT) that consists of Administrator, Director of Nursing (DON), Assistant Director of Nursing, Unit Managers (ADON), Social Worker, Activities Director, Business Office Manager, Admissions Director, Rehab Manager, and Office Assistant, to determine if any other resident may have been affected and if they had observed and not reported any behaviors or verbalizations of a sexual nature. The interview included questioning about Resident #2 and any other residents that could be identified with behaviors, or verbalizations. Behavior is defined in the education as verbalizations, unwanted sexual touching, or any other activity of a sexual nature that could represent intent for sexual misconduct. On 8/31/22, an audit of all residents with a Brief Interview of Mental Status (BIMS) of 10 or above, was completed by the DON, ADON, Unit Manager, Social Worker, and Rehab Manager to determine if they have experienced any unwanted touching or any other interaction of a sexual nature. No concerns were found. On 8/31/22, an audit consisting of thorough skin assessment of all residents with a BIMS of 9 or less was completed by DON, ADON and MDS Nurse to determine if there is evidence that they have experienced any unwanted touching or any other interaction of a sexual nature. No concerns were found. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: 0n 8/31/22, education was provided to the Administrator and DON by the Corporate Consultant, Regional Clinical Director and Regional Director of Operations, regarding the meaning of consensual (relating to or involving consent or consensus) and how to evaluate and make determinations of a resident's ability/capacity to consent to sexual relations. For evaluation of residents who admit to the facility with a BIMS of 9 or less (which demonstrates cognitive impairment) and express a desire to participate in sexual activity on the Sexual History Assessment or make verbalizations, demonstrate inappropriate sexual behavior such as unwanted touching or other advances of a sexual nature, will be evaluated by their physician to determine their capacity to consent to sexual activity. These findings will be discussed with the resident's responsible party by Administrator, DON, ADON, Unit Manager, or Social Worker. Administrator and Director of nursing were also re-educated on 8/31/22 by the Corporate Consultant, Regional Clinical Director and Regional Director of Operations, of the requirement for facility new hire orientation to include Abuse education for all new hires including agency employees. On 8/31/22, after being reeducated as outlined above education for all staff was completed by the Administrator and DON. The education consisted of the following: The definition of abuse (including sexual abuse), and the need to immediately notify their supervisor of all issues related to these infractions. Supervisors must inform the Administrator or DON immediately in person or by phone if not in the facility. The need to report all resident verbalizations, behaviors, inappropriate or unwanted touching that is sexual in nature. Staff members must notify their supervisor immediately. Supervisors must inform the Administrator or DON immediately and by phone if not in the facility. The need to be vigilant in observing and protecting all residents from verbalizations, behaviors, and inappropriate or unwanted touching that is sexual in nature All staff in all departments including as needed and agency staff were re-educated on the facility Abuse and Neglect protocols, which included sexual abuse, in person or by phone on 8/31/22. No one will be allowed to work prior to receiving this education and it will be included in new hire orientation. The department supervisor is responsible to ensure the orientation packet to include abuse education is completed with all staff including agency staff prior to starting their first shift. Alleged IJ removal date 9/1/22. On 09/07/22, the facility's credible allegation for Immediate Jeopardy removal effective 09/01/22 was validated by the following: Resident #2 remained on 15 minute checks with no inappropriate behaviors noted and interviews with alert and oriented residents revealed they felt safe in the facility. Staff interviews revealed they had received education on resident abuse and verbalized if they observed any inappropriate behaviors/abuse, they were to immediately intervene, separate the residents involved, and immediately report what was observed to the Administrator. Review of the facility's documentation revealed staff education was completed on 08/31/22. Skin assessments were conducted on all cognitively impaired residents with no concerns identified and alert and oriented residents were interviewed who all reported they felt safe at the facility and had not experienced any unwanted touching or other interactions of a sexual nature. Staff questionnaires were completed by all facility staff and revealed no one reported knowledge of any resident in the building who had exhibited behaviors or verbalizations that would alert them to a possible interaction of a sexual nature.

Based on observations, record review, and resident, family, and staff interviews, the facility failed to implement their abuse policy in the areas of identification, reporting and thoroughly investigating resident to resident sexual abuse for 1 of 3 residents reviewed for abuse (Resident #1). On 08/21/22, Resident #2, a [AGE] year old male with intact cognition, was observed standing up beside Resident #1's bed while Resident #1, an [AGE] year old female with severe cognitive impairment, was lying on the bed and both were completely naked. In response to the incident, the facility completed an investigation but the investigation did not include: 1) identifying and assessing other residents, including those with impaired cognition, to determine if they had experienced unwanted touching or behaviors of a sexual nature, 2) report the incident of resident to resident sexual abuse to the State Agency within 2 hours of being notified and notifying law enforcement and Adult Protective Services, and 3) interview all staff to determine if they had observed and not reported resident behaviors or verbalizations of a sexual nature, assess Resident #2, and have Resident #1 assessed by licensed professionals trained to assess for sexual abuse after being found in a compromising position. The facility also failed to include in their abuse policy the regulatory requirement for reporting abuse to the Adult Protective Services and having a qualified professional assess a resident after a suspected or alleged sexual encounter. Immediate Jeopardy began on 08/21/22 when the facility failed to identify the event as sexual abuse which placed other cognitively impaired residents at risk. Immediate Jeopardy was removed on 09/01/22 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring systems put into place are effective. Findings included: The facility's Abuse and Neglect Protocol, with a revised date of 06/13/21, read in part: It is the responsibility of our employees, facility consultants, attending Physicians, etc. to promptly report any incident or suspected incident of neglect or resident abuse to facility management. All reports of abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. The Policy Interpretation and Implementation section specified in part: 2 c. Sexual abuse is defined as, non-consensual sexual contact or any type with a resident. 10. Upon receiving reports of physical or sexual abuse, a licensed nurse or physician shall immediately examine the resident. Findings of the examination must be recorded in the resident's medical record. Note: If sexual abuse is suspected, DO NOT bathe the resident or wash the resident's clothing or linen. Do not take items from the area in which the incident occurred. Call the police immediately. The policy did not include a trained ro qualified person to assess the victim. 12. If an incident of suspected abuse occurs, facility shall report immediately, but not later than 2 hours after forming the suspicion if the events that cause the suspicion result in serious bodily injury or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury to the designated state agency. 13. The individual conducting the investigation will, at a minimum: .g) interview the person(s) reporting the incident, h) interview any witnesses to the incident, i) interview the resident (as medically appropriate), k) interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. The policy did not include notification to Adult Protective Services. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #1 with severe impairment in cognition. She required limited staff assistance with activities of daily living except for eating and displayed wandering behavior 1 to 3 days during the MDS assessment period. Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS assessment dated [DATE] assessed Resident #2 with intact cognition. He was assessed as being independent or needing supervision (cueing, oversight) with activities of daily living. The facility's investigation documentation of the incident on 08/21/22 involving Resident #1 and Resident #2 was reviewed. There was no documentation that initial or investigative reports were submitted to the State Agency or law enforcement was notified. There was documentation of a skin assessment completed 08/21/22 on Resident #1 but there was no evidence of an assessment completed 08/21/22 on Resident #2 or other residents in the facility. An undated and unsigned timeline of events read in part, Approximately 3:15 PM Resident #2 was found standing in Resident #1's room nude. Resident #2 was lying in the empty bed nude. Nurse responded to Resident #1's room. Both Resident #1 and Resident #2 were found to be at their baseline and in no distress. Resident #2 dressed himself and was redirected back to his room. Investigation was implemented immediately . The investigation documentation included witness statements from NA #1, Nurse #1, Nurse #2, and a summary of events signed by the Administrator but no other staff interviews were included. During an interview on 08/30/22 at 2:58 PM, the Assistant Director of Nursing (ADON) revealed she was the manager on call when Nurse #2 had contacted her on 08/21/22 to report a Nurse Aide (NA) (she couldn't recall which NA) had found Resident #2 in Resident #1's room putting on his pants with Resident #1 undressed and lying in bed. The ADON stated she wasn't sure what to do since this was the first time something like that had happened. She immediately contacted the Administrator to inform her of the incident and from that point on, the Administrator pretty much handled the investigation. The ADON stated when she arrived at the facility, she entered progress notes in both Resident #1's and Resident #2's medical record noting Resident #2 was found in Resident #1's room but did not assess or interview either resident or staff involved. The ADON added she was not instructed by the Administrator to submit the initial report to the State Agency, notify law enforcement or Adult Protective Services. During an observation and attempted interview on 08/30/22 at 9:20 AM, Resident #1 was unable to recall Resident #2 or the incident that occurred on 08/21/22. Resident #1 was sitting in her recliner with her baby doll lying on the bed beside her. During the interaction, Resident #1 kept referring to her baby doll as her real child and how good he was being with company. During an interview on 08/30/22 at 9:57 AM and follow-up telephone interview on 09/07/22 at 1:31 PM, Resident #1's Responsible Party (RP) recalled on 08/21/22 at approximately 5:00 PM she was contacted by facility staff and informed of an incident that had occurred between Resident #1 and Resident #2. The RP could not recall the name of the staff member but stated she was told when a Nurse Aide had gone to Resident #1's room, Resident #1 was found lying on the bed naked and a male resident was standing by her bed also naked. Resident #1 was checked by 2 nurses, there was no semen found on Resident #1 and the male resident was removed from the room. The RP added she was also advised not to come to the facility that night as Resident #1 was calmed down and sleeping. The RP could not remember the date or the name of the staff member she spoke with but stated she was advised against having Resident #1 sent to the hospital for an evaluation and tested for [CONDITION(S)] (STD) because the examination was pretty intense and they were not sure Resident #1 could tolerate it. The RP stated she didn't sleep all night worrying about Resident #1 and arrived at the facility first thing the next morning. She stated Resident #1 did not recall details of the incident and when the RP pushed her through the facility in her wheelchair, she waved at various residents but could not state or point out who the resident was that had been in her room. The RP stated Resident #1 had severe dementia and there was no way she could consent to any type of intimate or sexual relationship with any resident. During interviews on 08/30/22 at 5:05 PM and 08/31/22 at 9:10 AM, Resident #2 could not recall the exact date but stated he had walked to Resident #1's room to visit with her, she invited him into the room, he shut the door and they sat down on the side of the bed. Resident #1 stated he saw an opening with her, started kissing her, and one thing led to another. Resident #2 stated the interaction with Resident #1 was a mutual agreement and at first stated he took off Resident #1's clothes but later stated he assisted her with taking off her clothes. Resident #2 could not state at what point Resident #1 laid down on the bed and explained they did not have sexual intercourse but if staff had not come into the room, it would have led to that. He stated they both cared for one another and he did not do anything to her that she had not wanted. Resident #2 indicated both he and Resident #1 were both consenting to the relationship and what transpired. A signed witness statement written by NA #1 on 08/21/22 read in part, Doing my 3:00 PM round, I knocked on Resident #1's door and promptly entered to check on her and change her. I walked in to find Resident #2 standing in the nude several feet from Resident #1 who was lying nude on bed #1. Residents were not touching or communicating upon entrance. I stopped immediately and looked out into the hall and saw Nurse #1 and alerted her to come to the room. I stayed in the room while Nurse #1 responded. Resident #2 had started to dress himself and Resident #1 got up, left bed #1, went and got into her bed which is bed #2. Residents were at their baseline, with no signs or symptoms of distress or in a state of arousal. There was no indication that a sexual encounter had occurred. During interviews on 08/30/22 at 1:45 PM and 08/31/22 at 9:55 AM, Nurse Aide (NA) #1 recalled at approximately 3:00 PM on 08/21/22 she was completing the last round of her shift and when she got to Resident #1's door, it was closed which was not unusual if her family was visiting. When she knocked and opened the door, she saw Resident #2 standing by the bed in between the bed and door, with his back toward the door and Resident #1 was lying on the bed, both completely naked. NA #1 stated she was unable to open the door completely and stayed in the doorway as she called for Nurse #1 to come to the room. NA #1 stated after Nurse #1 looked into the room and saw Resident #1 and Resident #2, Nurse #1 left the room to go and get Nurse #2 while she remained standing in the doorway of the room and by the time both Nurse #1 and Nurse #2 got back to the room, Resident #2 had started to put his pants back on and Resident #1 had walked to her bed by the window and laid down. NA #1 stated Resident #2 had his back to the door and she did not visualize him from the front and could not state if he was aroused. She explained Resident #1 and Resident #2 did not appear to be in a state of arousal because they were both in a calm state. NA #1 stated Resident #1 had impaired cognition and did not feel she would be able to consent to a sexual encounter. For instance, NA #1 explained Resident #1 believed her baby doll was real and even attempted to feed her baby from her daily meal trays. NA #1 explained prior to the incident on 08/21/22 she had no inclination of any type of relationship between Resident #1 and Resident #2 nor had she noticed either one visiting the other. During a telephone interview on 08/30/22 at 1:28 PM, NA #2 stated she was not assigned to Resident #1 and Resident #2's hall but she had heard the commotion and thought maybe Resident #1 had fallen. She could not recall the time it had occurred when she went down to Resident #1's room but stated other staff were already there, and she saw Resident #2 standing by the bed with his back toward the door completely naked and Resident #1 was lying on the bed by the door completely naked except for one sock. NA #2 stated after Resident #1 was assessed by Nurse #2, she was instructed to assist Resident #1 with getting dressed. NA #2 stated Resident #2 was still in his right mind but Resident #1 had impaired cognition and she did not feel Resident #1 would be able to consent to a sexual encounter. A witness statement written by Nurse #1 dated 08/21/22 read in part, At approximately 3:15 PM, NA #1 alerted me to come to Resident #1's room. Upon entering the room, Resident #2 was standing naked in front of the first bed with his back to the door and was starting to put his pants back on. Resident #1 was laying on the second bed and threw the blanket over herself. Resident #2 was redirected to his room after he was dressed. This Nurse notified Nurse #2 of the incident and waited for next directions. I assisted Nurse #2 conduct a body audit on Resident #1. Residents were interviewed and found to be at their baseline. It was determined that residents did not have sex but Resident #2 reported that one thing led to another. Resident #2 was educated that he was not allowed to go back into Resident #1's room. Both residents were placed on every 15 minute checks. During a telephone interview on 09/01/22 at 10:15 AM, Nurse #1 recalled on 08/21/22 NA #1 called her down to Resident #1's room and when she arrived at the door, Resident #2 was standing by the bed next to the door, with his back toward the door, pulling up his pants and Resident #2 was lying in her bed by the window and acted as if she was asleep. Nurse #1 left to get Nurse #2 while NA #1 stayed at the doorway of Resident #1's room. When Nurse #1 and Nurse #2 got back to Resident #1's room, Nurse #2 asked Resident #2 to go back to his room. Nurse #1 stated she remained in the room as Nurse #2 assessed Resident #1 who found no visual evidence of sexual intercourse. Nurse #1 recalled Resident #1 was lying in her bed, completely naked, and did not appear in any distress. After Resident #1 was assessed, she and Nurse #2 went to Resident #2's room to speak with him about what had occurred. Nurse #1 recalled Resident #2 told her that when he walked down to Resident #1's room, she was standing in the doorway in just her briefs and it woke something up in him. She added Resident #2 denied having sex with Resident #1. Nurse #1 stated while she was sitting down next to Resident #2 talking with him, she could smell Resident #1 on his hands and described it as a vaginal smell. Nurse #1 recalled during their conversation, Resident #2 had stated he and Resident #1 were in a relationship which she thought was odd and explained Resident #1 thought Resident #2's roommate was her husband and when she wandered into their room, Resident #2 would tell Resident #1 he didn't want her in the room. Nurse #1 stated Resident #1 had impaired cognition and did not feel that she was able to consent to an intimate or sexual relationship with Resident #2. A witness statement dated 08/21/22 by Nurse #2 read in part, at about 3:20 PM, Nurse #1 notified this Nurse that Resident #2 was naked in Resident #1's room. This Nurse went to Resident #1's room to find Resident #2 standing in the middle of the room pulling his pants up and Resident #1 was lying in her bed covered with a blanket. This nurse redirected Resident #2 back to his room and notified the ADON. With the assistance of Nurse #1, this Nurse conducted a head to toe assessment of Resident #1. Resident #1 was found to be at baseline and no injuries were found. Resident #1 had no clothing on and the NA was instructed to assist Resident #1 with getting dressed. This Nurse and Nurse #1 interviewed Resident #2 who reported Resident #1 was in her underwear, he got excited and one thing led to another. Resident #2 stated, it was a mutual agreement. This Nurse asked if he had sex with Resident #1 and he stated he did not have sex with her. Resident #2 was educated that he could not go back into Resident #1's room and both residents were placed on every 15 minute checks. During an interview on 08/30/22 at 3:57 PM, Nurse #2 recalled on 08/21/22 she went to Resident #1's room with Nurse #1 to assess the situation and when she arrived, Resident #2 was buckling up his pants and Resident #1 was lying in the bed by the window covered with a blanket. Nurse #2 told Resident #2 he needed to get back to his room and he said he was headed that way. Nurse #2 stated Resident #1 could not tell her what had happened but did state she was washing her pants, which were noticed in the sink wet. She added Resident #1 could probably take her own clothing off but it would take her some time and it was not normal for her to undress herself or lie in the bed naked. Nurse #2 recalled Resident #1 was completely naked under the blanket and when she completed a visual body examination, she found no evidence of a sexual encounter such as semen or other bodily fluids on the bed linens or Resident #1's vaginal area. When Resident #2 was questioned, he reported they did not have sexual intercourse. Nurse #1 added due to Resident #1's cognition and confused state she felt Resident #1 would not be able to provide consent. Nurse #1 stated both residents were placed on 15 minute checks but staff had to keep redirecting Resident #2 from trying to go back into Resident #1's room. During an interview on 08/30/22 at 3:28 PM, the Administrator stated on 08/21/22 at approximately 3:15 PM, she was notified by the ADON of the incident involving Resident #1 and Resident #2. The Administrator explained staff had already separated the two residents and placed them both on 15 minute checks so she instructed them to conduct a head-to-toe assessment on Resident #1 and get statements from both Resident #1 and Resident #2. The Administrator added she arrived at the facility approximately 4:30 PM and started her investigation which included talking with both Resident #1 and Resident #2 and conducting interviews with staff who had direct knowledge of the incident and residents residing on the same hall as Resident #1 and Resident #2. The Administrator explained when she interviewed additional staff, if they did not actually witness the incident or have direct knowledge of Resident #1 and Resident #2's behaviors, she did not have staff write a statement or include their interviews as part of the investigation. The Administrator also verified other than Resident #2, no other residents were assessed on 08/21/22. She discussed the incident with the Regional Director of Operations (RDO) and based on what was reported from staff they both felt there was no evidence of a sexual encounter. The Administrator explained since neither Resident #1 nor Resident #2 displayed any signs of distress, Resident #1 was making logical statements at the time and invited Resident #2 into her room, Resident #1 did not attempt to cover up her nakedness until staff entered the room, and Resident #2 felt Resident #1 was a willing participant, the Administrator and RDO both felt the incident between Resident #1 and Resident #2 was mutual and not reportable. The Administrator verified she did not nor did she instruct staff to notify law enforcement, Adult Protective Services, or submit the initial investigation report to the state agency regarding the incident on 08/21/22 involving Resident #1 and Resident #2. The Administrator stated she felt a thorough investigation was completed, no one alleged abuse and at the end of the day, it was determined what they had were 2 residents unclothed and in the same room with no evidence a sexual encounter had occurred and if she had suspected abuse, she would have reported it immediately. The Administrator was notified of Immediate Jeopardy on 08/31/22 at 4:35 PM. The facility provided the following Credible Allegation of Immediate Jeopardy removal: o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and On 8/21/22, the facility failed to follow the abuse policy in the areas of identification, prevention, protection, and reporting to law enforcement, and APS. *Resident #1 was at risk of suffering from the deficient practice. Resident #1 is no longer a resident as of 8/30/22 as she had a planned discharge on 8/30/22. *Cognitively impaired residents are also at risk from suffering from the deficient practice. The facility will determine cognitive impairment based on Brief Interview for Mental Status (BIMS) scores. A score of 9 or below will represent a cognitively impaired resident who is at risk. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete On 8/31/22, the facility reported the incident between Resident #1 and Resident #2 that occurred on 8/21/22 to the law enforcement, and Adult Protective Services by facility Administrator. Resident #1's family and physician were notified of the incident on 8/21/22. Resident #2's physician was also notified on 8/21/22. A skin assessment was completed by DON on 8/31/22. On 8/31/22, an audit was completed by interviewing all residents with a Brief Interview of Mental Status (BIMS) of 10 or above by the Director of Nursing (DON) and designees to determine if they have experienced any unwanted touching or any other interaction of a sexual nature. No concerns were noted. On 8/31/22, an audit consisting of thorough skin assessment of all residents with a BIMS of 9 or less was completed by DON and designees to determine if there is evidence that they have experienced any unwanted touching or any other interaction of a sexual nature. No concerns were noted. On 8/31/222, all staff in all departments were interviewed by members of the interdisciplinary team (IDT) that consists of Administrator, Director of Nursing (DON), Assistant Director of Nursing, Unit Managers (ADON), Social Worker, Activities Director, Business Office Manager, Admissions Director, Rehab Manager, and Office Assistant, to determine if any other resident may have been affected and if they had observed and not reported any behaviors or verbalizations of a sexual nature. The interview included questioning about Resident #2 and any other residents that could be identified with behaviors, or verbalizations. Behavior is defined in the education as verbalizations, unwanted sexual touching, or any other activity of a sexual nature that could represent intent for sexual misconduct. On 8/31/22 the Administrator and DON were also re-educated by the Regional Clinical Director and the Regional Director of Operations on all components of the facility's abuse policy and how to identify abuse. Education included the definition of abuse, reporting requirements to all required agencies including law enforcement and Adult Protective Services, the need to protect cognitively impaired residents by assessing all cognitive impaired residents for the identification of abuse, the assessment of both victim and perpetrator by qualified individuals per policy [if family is in agreement, facility will send resident(s) to be evaluated in the emergency room setting], and conducting a thorough investigation when allegations of sexual abuse are present. Regional Clinical Director or Regional Director of Operations will provide oversight weekly to ensure that reporting requirements are met and that facility investigations are completed according to policy. Alleged IJ removal date 9/1/22. On 09/07/22, the facility's credible allegation for Immediate Jeopardy removal effective 09/01/22 was validated by the following: Staff interviews revealed they had received education on resident abuse and verbalized if they observed any inappropriate behaviors/abuse, they were to immediately intervene, separate the residents involved, and immediately report what was observed to the Administrator. The Regional Director of Operations educated the Administrator and Director of Nursing on abuse to include reporting requirements and the meaning of consensual. Review of the facility's documentation revealed staff education was completed on 08/31/22 including the Administrator and Director of Nursing. Staff questionnaires were completed by all facility staff and revealed no one reported knowledge of any resident in the building who had exhibited behaviors or verbalizations that would alert them to a possible interaction of a sexual nature. All residents identified as alert and oriented by the facility were interviewed and asked if they had experienced any unwanted touching or other interactions of a sexual nature with no concerns voiced. Skin assessments were completed by Registered Nurses on all cognitively impaired residents with no concerns identified.

Based on observations, record reviews, and staff interviews, the facility failed to prevent 1 of 2 cognitively impaired residents from exiting the facility (Resident #35) by not ensuring a wanderguard bracelet (a device that would trigger an alarm when a resident gets in the proximity of the exit door) was in working order. In addition, the facility failed to supervise a resident (Resident #151) to prevent her from putting a rubber exercise band in her mouth for 1 of 2 sampled residents reviewed for accidents. Immediate Jeopardy began on [DATE] when Resident #35 left the facility unsupervised by staff and was located across the street in the parking lot of tennis courts after his wanderguard bracelet did not sound to alert staff of his exit. Resident #35 sustained no injuries. Immediate Jeopardy was removed on [DATE] when the facility implemented a Credible Allegation of Compliance. The facility remains out of compliance at a scope and severity level of D (no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy) for continued monitoring. Example #2 (Resident #151) was cited at a scope and severity of a D where a plan of correction is required. The findings included: 1. Resident #35 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A care plan was established [DATE] which addressed Resident #35 being at risk for elopement related to adjustment in the nursing facility, having impaired safety awareness, and wandering aimlessly. Interventions included: *check function of wanderguard daily on night shift; *check placement of wanderguard every shift; and *observed for fatigue and weight loss. Nursing notes dated [DATE] at 2:12 PM revealed Resident #35 was very agitated and pacing the halls. Resident was wanting to leave and has neared the doors. The wanderguard bracelet was in place and has alarmed at the exits. Resident #35 began seeing the psychiatrist on [DATE] due to disorganized, confused thinking. Nursing notes dated [DATE] at 1:32 PM revealed Resident #35 was wandering the halls asking to get out of here. He was reoriented 4 times before being medicated with as needed [MEDICATION NAME] (an antipsychotic medication) at 9:00 AM. Per the psychiatric progress note dated [DATE], staff reported Resident #35 had been wandering the halls, wondering what he was supposed to do and where he was supposed to go, and questioning if he was (his name). At this time [MEDICATION NAME] was changed from an as needed basis to a routine basis. The physician's progress note dated [DATE] at 1:15 PM noted that staff reported the resident with increased confusion, getting anxious and starts to look for a way to leave. At this time the antipsychotic medication [MEDICATION NAME] 25 milligrams (MG) at bedtime was initiated. The annual Minimum Data Set ((MDS) dated [DATE] coded him with long and short term memory impairments, severely impaired decision making skills, having continuous inattention and disorganized thinking, having no wandering behaviors, and requiring limited assistance with activities of daily living skills. Nursing notes dated [DATE] at 9:06 AM revealed Resident #35 had become increasingly confused in the past month. The recent medication changes have not been effective. The resident had been redirected 12 times this morning. The psychiatric progress notes revealed Resident #35 was seen on [DATE] due to staff reports of the resident having increased confusion, becoming anxious and started to look for a way to leave the facility. A change in medication was initiated at this time. which included discontinuing [MEDICATION NAME] and starting the antipsychotic medication [MEDICATION NAME] 0.25 mg twice a day. Review of the Treatment Administration Records revealed that Resident #35's wanderguard bracelet had been checked as functioning during the night shift of [DATE]. Nursing notes dated [DATE] at 7:30 PM revealed that at 3:00 PM, a visitor came to nurse aide (NA) #1 and told her a resident was out of the building walking towards the tennis courts across the road. NA #1 immediately left the facility to get the resident. When she reached him he had crossed the road and was in the parking lot of the tennis courts. The visitor who saw the resident stated he exited through the main entrance. The alarm did not sound and after testing the resident's wanderguard, it was found not to be working. A new wanderguard was placed on the resident, tested and found to be working. A head to toe assessment was completed and no injury was noted. Resident #35 was placed on every 15 minute checks. The physician was called and medication changes were made. Also a urinalysis was obtained and taken to the lab. Observations on [DATE] at 2:30 PM revealed the tennis courts were across a two lane street in front of the facility's parking lot. The two lane road's signage stated the speed limit was 20 miles an hour. The road passed the facility and ended directly into a community park with a swimming pool, picnic areas and a ball park. The facility sat at the crest of the hill. The tennis courts were not visible from the front door of the facility. Per the weather history, the high temperature for [DATE] was 84 degrees Fahrenheit with a mean temperature of 74 degrees Fahrenheit. The mileage from the front entrance to the tennis courts was 0.1 miles. The wandergard system was observed to be in working order. A phone interview with NA #1 on [DATE] at 4:46 PM revealed she was working on a different hall and a visitor informed her that a resident was outside. Resident #35 was found almost at the tennis courts and was wearing nonskid socks and no shoes. She could not recall what he was wearing that day. NA #1 stated it was damp outside and he was a little difficult to get him back in the building and other staff came to help. NA #1 was unable to recall the other staff who assisted her. She further stated she had little contact with Resident #35 as she worked every other weekend on a different hall. A written statement by Nurse #1 dated [DATE] revealed she had seen and heard Resident #35 multiple times at the nurses station from around 2:00 PM until 2:55 PM to 3:00 PM. He was stating he was lost. A phone interview with Nurse #1 on [DATE] at 3:20 PM revealed she was employed by an agency and had just come for her shift. She recalled Resident #35 was at the nursing station, asking general questions and then the next thing she knew he was found outside. A phone interview was conducted on [DATE] at 9:53 AM with NA #2 who worked the night shift on [DATE] into [DATE]. She stated the wanderguards were checked nightly by nurse aides using the list of residents with wanderguard bracelets and a device with which to check them. She recalled no problems with Resident #35's wanderguard that night or ever. A phone interview was conducted on [DATE] at 8:32 AM with NA #3 who was working on [DATE] on the 2:30 PM to 10:30 PM shift on Resident #35's hall. NA #3 stated he recalled Resident #35 wandering the halls per usual. NA #3 did not recall the resident talking about leaving that day but the resident sometimes talked about leaving as he was very confused. NA #3 could not recall any other details about the incident other than he tried to keep him close to him the remainder of his shift. Interview with the Director of Nursing (DON) on [DATE] at 9:13 AM revealed she was the assistant DON at the time when Resident #35 left the facility. The DON stated she was working the floor at the time of the incident. She verified that Resident #35 was wearing the wanderguard bracelet but that when tested upon reentry into the facility, she found it did not work and it was replaced. She could not locate the visitor who found him (for either identification or additional information) but assumed a visitor let him out because even if the wanderguard quit working, he needed a numeric code to exit the front door, which she believed he was incapable of knowing or remembering. The DON further stated the wanderguard that was on Resident #35's wrist had been checked the previous night which found it functional and the wanderguard was not yet expired per expiration date. Review of the maintenance logs revealed that the Maintenance Director checked the function of the wanderguards at each door daily which was noted as working properly. The Administrator was informed of immediate jeopardy on [DATE] at 2:30 PM. The Administrator provided the following Credible Allegation: Facility's Corrective Action Plan: 1. Resident #35 was assessed as being at risk for elopement and a Wanderguard was initiated upon admission on [DATE]. On [DATE], at approximately 3:00 pm, a visitor reported to NA#1 that Resident #35 was observed in the facility parking lot. Resident #35 was assisted back into the facility by the NA#1. Resident's Wanderguard bracelet was determined to be defective upon re-entry to facility as it did not trigger alarm and was not expired per manufacturer expiration date. Resident's Wanderguard was documented to have been in place every shift and the prior shift and was documented that functioning was verified on the previous night shift. 2. Assistant Director of Nursing, (ADON), immediately completed a head to toe assessment of Resident #35 with no injuries noted. Assistant Director of Nursing removed Wanderguard bracelet and replaced it with a new Wanderguard bracelet which was verified to be functioning properly. Increased supervision was initiated for Resident #35 to include every 15 minute checks to monitor location. These checks were completed by the Nursing Assistants and documented for 24 hours following the incident. Additionally, facility initiated medication changes, labs, and increased observations and redirection of resident as needed by facility staff and Interdisciplinary Team (IDT). ADON conducted a complete head count of all residents in facility and determined all residents were accounted for. Resident #35's care plan was reviewed and updated by the ADON on [DATE]. An updated Elopement Assessment was completed for Resident #35 on [DATE] by the MDS Coordinator. On [DATE] Administrator, DON, and Maintenance Director referred to manufacture user instruction but was unable to determine why device stop working prematurely. 3. ADON notified Resident #35's Responsible Party and Physician regarding Resident #35 exiting the facility, resident's physical assessment following the event, and the plan for increased monitoring on [DATE] which included every 15 minute checks and increased observations by staff and IDT with redirection as needed. New physician's orders [REDACTED]. An Investigation was completed by ADON on [DATE] which included an incident report. Based on the results of the ADON's investigation on [DATE], it was determined that Resident #35's Wanderguard bracelet malfunctioned and likely resulted in resident exiting the facility via the front door when a visitor exited the facility. Additional signage warning visitors to not allow anyone to leave the facility as they enter or exit facility was typed and added to facility entrance/exit doors. On [DATE] Incident and Accident reports for the last 90 days were reviewed by the ADON with the Administrator via phone and it was determined that there were no other unsupervised exits reported for Resident #35. There were no other unsupervised exits reported for other residents assessed at risk for elopement during the last 90 days. To the knowledge of Facility Staff and Leadership, Resident #35 has had no other instances of exiting the facility without supervision. To the knowledge of staff and leadership no other residents have exited the facility without supervision since [DATE]. The Maintenance Director completed a review of the Wanderguard System including validation of proper functioning of Door key pads and Wanderguard keypads/alarms for all facility doors on [DATE]. There was no repair needed or required to the door key pads or Wanderguard System. The code for the entrance/exit doors were changed on [DATE] requiring a visitor(s) to need the new code and allowing facility to provide verbal education prior to visitor(s)being able to exit facility. Additional signage was placed on each exit door on [DATE] a STOP sign was placed on [DATE] by Maintenance Director to provide increased visual reminders to not assist other in exiting the facility. The Maintenance Director changed all door codes [DATE]. Visitors only have code to exit doors. All Visitors on all shifts were verbally educated by facility employees including Receptionist, IDT team members, Managers, and other facility staff members when visitor(s) exited building for the first time after exit door codes were changed as well as educated to keep the code discrete, to not allow others to exit the facility when entering/exiting the facility, and refer others to see staff for assistance with exiting the facility. New Family members are provided the code and provided education to keep the code discrete, not allow others to exit the facility with them when exiting the facility, and refer others to see facility staff for assistance with exiting the facility upon admission or their initial visit to the facility. Verbal education from facility staff members, the signage, and stop signs all serve as forms of education as well as continuous reminders to keep the code discrete, to not allow others to exit the facility when entering/exiting the facility, and refer others to see staff for assistance with exiting the facility to not assist others to exit the facility. The Maintenance Director, Maintenance Assistant, or Restorative Aides have continued to monitor the doors to ensure the door locking system and keypad and Wanderguard System and key pad are functioning properly since [DATE] without any problems identified. Results were reviewed and discussed in the facilities QA Process. The ADON completed an audit of all current residents with Wanderguards and validated placement and function of each device on [DATE]. Wanderguard will continue to be checked for placement each shift and daily for function by the CNAs and document on the treatment record by their nurse. Since [DATE], the Aides have continued to validate the placement each shift and function of Resident #35's Wanderguard daily without any problems identified. Director of nursing or designee monitor treatment record to ensure check for placement and function are completed. On [DATE], the MDS Coordinators and Unit Manager conducted an audit of all current residents at risk for elopement to include a review of current Elopement Assessments for accuracy. Elopement care plans were reviewed by IDT team and validated on [DATE] by the MDS coordinators. The facility and staff leadership have no knowledge of any other residents having supervised exits from the facility. The Admissions Director will continue to review future referrals for potential admissions with identified exit seeking behaviors with the Director of Nursing and/or Administrator prior to offering placement to ensure proper placement. The Director of Nursing and Assistant Director of Nursing will continue to review new admissions and readmission daily during the Clinical Morning Meeting to validate accurate elopement assessments and care plans as required. The Director of Nursing and Nurse Managers will review current residents assessed at risk for elopement monthly to validate accurate assessments and care plans. 4. Although facility policy was followed, on [DATE] ADON initiated re-education of elopement policy and procedures. From [DATE], to [DATE] the Director of Nursing and ADON re-educated All Facility Staff by reviewing the facility's policy and procedures with emphasis on increased observation and redirection for Resident #35 and any resident on the need for increased need for observation and redirection as needed for Resident #35 or other resident identified at risk, change of door codes, to educate visitor when informing them of door code including to keep door code discrete, do not allow other to exit with you, and to refer others to facility staff for assistance with exit. On [DATE] the Maintenance Director changed the code for all doors Wanderguard System and conducted an impromptu elopement drill with staff on duty at that time on [DATE]. Resident elopement will continue to be reported immediately to the Facility's Administrator or Director of Nursing and an Incident and Accident report will be completed. No staff shall work after [DATE] before receiving this education. This education has been added to the Facility Orientation program for all new hires and agency staff to be completed prior to beginning work after [DATE]. The facility Administrator is responsible for implementing the acceptable plan of correction. Immediate Jeopardy was removed on [DATE] at 5:54 PM when interviews with direct and supervisory staff confirmed they had been inserviced on the policy and procedures for elopement. This was also confirmed with record review. Family interviews confirmed they had been educated on not letting unknown persons leave the facility with them. Observations revealed that all residents with wanderguards were in working order. Record reviews revealed all wanderguards were checked for function every night and for placement every shift. Record reviews revealed that the alarmed doors were checked for function daily and the code changed. Observations revealed new larger signage were in place on the exit doors. The facility remains out of compliance at a lower scope and severity. 2. Resident #151 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] revealed Resident #151 was severely impaired for cognition and required extensive assistance for bed mobility, transfers, dressing, and personal hygiene. The admission Care Area Assessment (CAA) dated [DATE] for activities revealed Resident #151 had dementia that affected her cognitive ability and the facility was to provide 1 to 1 activities such as sensory therapy, conversation, and fidget items to stimulate cognitive abilities. The initial care plan dated [DATE] for activities stated that Resident #151 needed 1:1 bedside/in-room visits and that she should be engaged in simple, structured activities such as folding wash cloths and offering other fidget items of interest. Observation of Resident #151 on [DATE] at 8:40 am revealed resident sitting in a wheelchair alone in her room biting on an orange rubber exercise band. An interview on [DATE] at 8:43 am with the nurse aide (NA) caring for Resident #151 revealed the resident had the rubber exercise band to occupy her hands. The NA stated she wasn't sure how Resident #151 got the rubber exercise band. An interview on [DATE] at 10:55 am with the speech therapist (ST) working with Resident #151 revealed that the resident was sensory seeking and was known to chew on items such as blankets, clothing protectors, and stuffed animals. The ST also stated that Resident #151 should be supervised when using a rubber exercise band due to the risk of being a choking hazard. The ST further stated she did not use rubber exercise bands with the resident. An interview on [DATE] at 11:25 am with the physical therapy assistant (PTA) working with Resident #151 revealed that the resident should be supervised when using a rubber exercise band because she was known to place items in her mouth. The PTA was not sure why Resident #151 had a rubber exercise band in her room or how it got there. An interview on [DATE] at 11:35 am with the physical therapist (PT) working with Resident #151 revealed that the resident was very sensory seeking and was known to chew on her clothing. The PT further stated that Resident #151 should be supervised when using a rubber exercise band. The PT was not sure why Resident #151 had a rubber exercise band in her room or how it got there. An interview with the Director of Nursing (DON) on [DATE] at 4:00 pm revealed that it was her expectation that Resident #151 be supervised when using a rubber exercise band. The DON stated she didn't know why Resident #151 had a rubber exercise band in her room or how it got there. An interview with the activities director on [DATE] at 2:22 pm revealed that Resident #151 was known to place items such as stuffed animals in her mouth and that she did not use a rubber exercise band with the resident.