Every finding on record at Valley Nursing and Rehabilitation Center

Based on record review, staff, family, police department and Medical Director interviews, the facility failed to protect a resident's right to be free from physical abuse when Resident #1 became combative during incontinence care and Nurse Aide (NA) #1 forcibly continued to provide care and grabbed [the resident] by the lower thigh and back and then gave him a hard push in an attempt to finish care. This resulted in the resident suffering a broken femur (thighbone) in the resident requiring traction (the application of a slow, steady pulling force to a part of the body) and 200 micrograms (mcg) of Fentanyl (an opioid medication given for pain) while in transit to the emergency room. The resident was administered Dilaudid (another opioid medication) while in the emergency room for pain, and required surgical intervention. This was for 1 of 3 residents reviewed for prevent employee-to-resident abuse. (Resident #1). The findings included: Resident #1 was an [AGE] year old resident who admitted to the facility 06/25/25 with diagnoses that included Parkinson's disease, depression, muscle weakness, hypertension, dementia, and disorientation. Review of Resident #1's quarterly Minimum Data Set assessment dated [DATE] revealed the resident was moderately cognitively impaired with no delusions, behaviors, rejection of care, or instances of wandering. Resident #1 was coded with no impairments to his upper extremities but with impairments to both sides of his lower extremities. Resident #1 was coded as requiring limited assistance with oral hygiene and rolling left and right in bed. He required extensive assistance with toileting hygiene, bathing, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. Resident #1 was dependent on others for going from sitting to lying, lying to sitting, sitting to standing, and all transfers. Resident #1 was coded as always incontinent of bowel and bladder and taking antidepressant, antibiotic, and antiplatelet medications.Review of Resident #1's care plan, last updated on 04/14/26, revealed the following care area: [Resident #1] is resistive to care, i.e. yells/screams/pushes staff. Interventions included to allow Resident #1 to make self-determination and have freedom of choice; give a clear explanation of all care activities prior to and as they occur during each contact; if [Resident #1] resists with activities of daily living (ADLs), reassure him, leave, and return in 5-10 minutes later and try again; and praise [Resident #1] when behavior is appropriate.Review of the facility's reportable incidents revealed a report filed with the state survey agency dated 5/02/26 in which it was reported the facility was made aware on 5/02/26 at 5:20 PM that Resident #1 was reporting that a nurse aide (NA #1) had injured his leg while providing care. Per the initial notification to the state survey agency, Resident #1 was discharged to the hospital for evaluation and NA #1 was suspended pending a complete investigation. The initial report was dated 5/02/26 at 6:25 PM.Review of the facility's investigation dated 05/07/26 revealed they interviewed Resident #1, NA #1, and Nurse #1 since they were the staff and resident involved. The facility's final investigation report indicated that after completing the investigation, they were unable to substantiate the allegation of physical abuse by NA #1. The report alleged there was no evidence of caregiver misconduct and due to the resident's acute pain outside of his baseline, the facility provider was notified and provided orders to send Resident #1 to the emergency room for further evaluation. The facility's investigation also indicated that the police department responded to the facility in response to a call about a possible injury during care.Review of Resident #1's hospital records dated 5/02/26 revealed Resident #1 arrived at the emergency room with a concern of a left leg injury and was in traction and provided 200 micrograms of Fentanyl in route. Per the hospital records, Resident #1 appeared alert, calm and could answer simple questions with Parkinson's and significant dementia. Resident #1 was treated for a left closed femur fracture and treated with Dilaudid (an opioid medication) for pain and surgical intervention for the femur fracture.Review of Resident #1's x-ray diagnostics revealed a minimally comminuted (crushed or splintered) oblique fracture of the mid femoral diaphysis with anterior and lateral angulation (a break in the middle of the thigh bone with an angled fracture line with minor fragmentation, and the broken segments are shifted and tilted outward and forward).Multiple attempts to reach Resident #1 via telephone call on 5/21/26 and 5/22/26 were unsuccessful. (He was residing at another skilled nursing facility.)Review of Resident #1's undated written statement in the facility's investigation revealed the following: When asking [Resident #1] what happened, he replied with 'that son of a b.'. A telephone interview on 5/20/26 at 9:19 AM with Resident #1's Family Member revealed she was aware of the incident that occurred on 5/02/26 and that Resident #1 had told her that there was a guy who came into his room to change him and fell on him. Resident #1's Family Member reported Resident #1's femur was broken completely in two and he had to have surgery to repair it. She continued, stating that she did not ask a lot of questions about what happened.An interview with NA #1 on 5/21/26 at 1:48 PM revealed he remembered the interaction with Resident #1 that occurred on 5/02/26. NA #1 reported he was working at the time as an agency nurse aide on an as needed basis and 5/02/26 was his 2nd shift he had worked at the facility. He reported when he arrived at the facility for the start of his shift, he observed several residents that needed to be changed including Resident #1. He stated when he went into Resident #1's room, he found Resident #1 in bed and described him as being soaked with urine and feces and he also noted Resident #1 had what appeared to be blood on his brief and bedsheet. NA #1 reported when he observed the blood on Resident #1's brief and bed sheet, he left the room and notified Nurse #1 who walked into Resident #1's room, looked at Resident #1, and then stated to NA #1 that she would report the condition of Resident #1 to the supervisor. NA #1 stated he did not know who the supervisor was that evening. NA #1 stated that Nurse #1 then left the room and he left to retrieve a new bed sheet. NA #1 reported he returned to Resident #1's room, spoke to Resident #1 and explained what care he was there to provide. NA #1 stated Resident #1 did not respond to him and NA #1 began the process of changing Resident #1. NA #1 stated as he began to provide care to Resident #1, Resident #1 became aggressive and attempted to elbow and punch at him but did not strike him. NA #1 stated when Resident #1 became aggressive, he stopped providing care and stepped back from Resident #1. He stated Resident #1 then settled back down moments after he stepped back, so he reapproached Resident #1 and continued providing care. NA #1 stated as he rolled Resident #1 onto his right side, Resident #1 became aggressive and agitated again attempting to knee NA #1. NA #1 reported deflecting the attempted strikes and grabbed Resident #1 on his left leg right near his knee and continued to roll Resident #1 over onto his right side. He stated while doing this, he felt a popping sensation and stopped providing care, released his hands from Resident #1 and went and reported the situation to Nurse #1. NA #1 stated although it was his 2nd shift working in the facility, no one had informed him that Resident #1 had a history of refusing care and aggressive behaviors towards staff. He stated he had been a nurse aide for 7 years and had briefly received training on resistive and combative residents. He reported with residents who were resistive or combative during care, he would typically stop care and go and get another nurse aide to assist in providing the care. NA #1 also reported he had access to Resident #1's electronic health record but indicated that he had not reviewed Resident #1's care plan and did not know if he even had access to review it, stating he did not have time for it.Review of NA #1's written statement that was provided to the facility when he was questioned by the police department on 5/02/26 read as follows: I went to change [Resident #1]. [Resident #1] was covered in feces and there was blood in his brief. I went to get the nurse [Nurse #1] to report the witnessing of blood in his brief. His drawsheet also had blood, urine, and feces on it. [Nurse #1] witnessed the blood and stated I don't know what that's from. I'll have to report it to supervision. I then went to get a drawsheet and reentered the room, told [Resident #1] what I was going to do, stating hey buddy, I've got to change your brief. I started to roll him and he became resistant. He started pushing back so I gave him an extra push. [Resident #1] then tried to elbow me. I dodged it. Then he attempted to elbow me again then I let him roll back a little and then he tried to punch me twice and then tried to knee me, almost hitting me in the mouth. I grabbed him by the lower thigh and back and then gave him a hard push by both [thigh and back] to try and finish cleaning him. I felt a series of pops. I let go and reported it to the nurse.A review of NA #1's personnel file revealed he was 6'5 with no listed weight.An interview with Nurse #1 on 5/20/26 at 11:58 AM revealed she remembered the incident on 5/02/26. She stated she was initially informed that there was a little blood in Resident #1's brief. She indicated she observed the blood and believed it to be due to some rawness on Resident #1's bottom. She then stated shortly after, she was standing outside of Resident #1's room with Medication Aide (MA) #1 when NA #1 walked out of the room, threw his hands up in the air and stated, his leg is broke. Nurse #1 reported NA #1 was shaking and appeared panicked or worried and did not appear angry or frustrated. She stated she went into the room and asked Resident #1 what happened and all Resident #1 said was that son of a b. She stated there was no bruising or redness to Resident #1's leg but that she could easily tell something was not right with his leg, stating, it was kind of raised at the top. Nurse #1 stated she left the room and stayed with NA #1 while she called the on-call physician who provided her a verbal order to send Resident #1 to the hospital. She stated she contacted emergency medical services and then the Director of Nursing to inform her of the incident. She stated while speaking with the Director of Nursing, she was told to send NA #1 home immediately to which she relayed to NA #1 who simply replied ok and left without incident.Review of Nurse #1's written statement in the facility's investigation read as follows: I was standing on the 100 hall with [MA #1] when [NA #1] came out of [Resident #1's] room with hands up screaming his leg is broke. I walked in the room and looked at his (Resident #1's) leg. I asked [Resident #1] what happened and he responded with that son of a b I asked [NA #1] what happened and he stated that the resident was trying to kick and [he] tried to block it and grabbed his leg. I notified Nurse Practitioner. and the Director of Nursing [DON]. Called EMS [emergency medical services] after.An interview with MA #1 on 5/21/26 at 9:19 AM revealed she was standing in the hallway outside of Resident #1's room with Nurse #1 when NA #1 came out of Resident #1's room panicked and pale. She stated she had recently provided Resident #1 his evening medications and reported he was calm and pleasant during her interaction with him. She stated she did hear NA #1 introduce himself and tell Resident #1 he was there to check him real quick. MA #1 stated if she had to estimate, NA #1 was not in Resident #1's room for more than a minute before he walked out of the room and stated that Resident #1 was being combative.An interview with Police Officer #1 on 5/20/26 at 11:28 AM revealed he was one of the responding officers to the facility on 5/02/26. He reported they were dispatched to the facility along with EMS regarding a possible injury that occurred during care. Police Officer #1 stated when he arrived, he found Resident #1 in his room. He stated Resident #1 was lethargic and complaining about pain in his knee and Resident #1 had a visible deformity in his femur. Police Officer #1 stated that he was able to question NA #1 at the time and that NA #1 had reported to him that he had gone into Resident #1's room to provide care when he found Resident #1 covered in excrement (waste matter discharged from the body). He stated while NA #1 was being questioned, he became increasingly agitated and was very defensive. He stated NA #1 complained about a previous resident he had provided care to who had taken their brief off and flung it at him. NA #1 reported to him that while he was attempting to provide Resident #1 care, Resident #1 had become resistive and attempted to hit him multiple times. NA #1 also informed him that while he was pushing resident onto his side to continue with care, NA #1 heard an audible pop. The Police Officer reported that their investigation was still ongoing.An interview with the DON on 5/20/26 at 3:13 PM revealed she was not in the facility at the time of the incident related to NA #1 and Resident #1 on 5/02/26 and was informed via telephone call around 5:30 PM by Nurse #1 who told her that Resident #1 was going to the hospital because he was complaining of leg pain. The DON stated she was told that NA #1 reported to Nurse #1 that Resident #1 was being combative during care and NA #1 had exited Resident #1's room saying something about Resident #1's leg. The DON stated that EMS arrived to the building along with the police department before she arrived at the facility. The DON reported she informed Nurse #1 while speaking to her on the phone to go ahead and send NA #1 home due to her not fully understanding what happened during the care. She continued, stating when she arrived at the facility, NA #1 was not at the facility, and she contacted him via telephone, and he reported to her that he had gone into Resident #1's room to provide incontinence care. NA #1 reported to her as he went to roll Resident #1 onto his side, Resident #1 attempted to either kick or knee him. NA #1 reported to the DON that he caught Resident #1's leg to prevent him from being kicked and that's when he heard a pop. The DON reported she believed that NA #1 had worked in the facility 3 times over several months. The DON reported ideally, she would want her staff to stop care immediately when a resident became combative or resistive, ensured the resident was safe, and then reapproach the resident later. The DON stated NA #1 did not meet that expectation by continuing to try and provide care to Resident #1 who had become combative. The DON stated NA #1 should have stopped care when Resident #1 became resistive or combative and walked out of the room. The DON verified that Resident #1 was care planned for resistive and combative behaviors but had not received any recent complaints of Resident #1 being combative or resistive during care. The DON stated she was unable to personally speak to Resident #1 because when she arrived at the facility, he had already been transported to the hospital but stated she was on the phone with Nurse #1 when she went into Resident #1's room and inquired with him about what happened and she heard Resident #1 simply reply that son of a b. The DON also reported that while there were cameras in the facility, the only ones that were currently in operation were ones that covered the exits of the facility.An interview with the Administrator on 5/20/26 at 4:07 PM revealed she was first notified of the incident related to NA #1 and Resident #1 from the DON via telephone call on 5/02/26. She stated it was explained to her that Resident #1 was being sent out to the hospital after becoming combative during care and while NA #1 was attempting to provide care, Resident #1 suffered, what could have been a broken leg. The Administrator stated the DON and herself spoke with NA #1 who stated he was trying to provide care when Resident #1 attempted to kick him and while NA #1 had his hands on Resident #1, he heard a pop. She stated NA #1 stated after he heard the pop, he left Resident #1's room and retrieved the nurse. The Administrator stated it was her understanding that Resident #1 was actively resisting care at the time the pop was heard. She also reported that it was her understanding that NA #1 did pause briefly providing care when Resident #1 became resistive but returned shortly to continue providing care. She stated she felt that NA #1 was really focused on getting [Resident #1] changed. The Administrator stated when she arrived at the facility, Resident #1, NA #1, EMS, nor the police department were at the facility. She stated she expected her staff to immediately stop providing care to residents who become resistive or combative and reapproach them in 5-15 minutes with a different approach. She stated she would also like for her staff to report combative or resistive behaviors to the hall nurses. The Administrator indicated while the facility investigated an allegation of employee to resident abuse, it was ultimately unsubstantiated due to the belief that NA #1 did not intentionally mean to harm Resident #1.An interview with the Medical Director via telephone call on 5/20/26 at 2:14 PM revealed he was not at the facility at the time of the incident but was made aware of it via the administrative team. The Medical Director stated Resident #1 was an elderly man with cognitive impairments. He reported it was his understanding that Resident #1 was kicking at a nurse aide who was attempting to provide care and then was complaining about leg pain. He continued, stating he had contacted the hospital where Resident #1 was sent and was told that Resident #1 had suffered a femur fracture. He stated the femur was a really hard bone to break stating that it was usually something you would see in traumatic accidents. He reported he was shocked the Resident #1's femur had been fractured and stated he began investigating further and found that it appeared as though Resident #1 had some osteopenia (bone density degradation) and relayed that it could have developed from the use of some medications that Resident #1 had been taking. The Medical Director stated he determined that although the end result was a fracture of the femur, he believed there was some underlying softness to Resident #1's bones which may have caused Resident #1's femur to break more easily. He reported he was familiar with Resident #1 and stated there had been instances where Resident #1 was resistive or aggressive with he and his team. He also reported for a resident with cognitive deficits, it would be typical to attempt to redirect the resident or to stop care and reapproach the resident 10-15 minutes later. The Medical Director finished by reporting that it was quite possible that if Resident #1 kicked someone and made contact, the femur could have broken but he did not believe it would have broken simply by touching the area.The facility provided a corrective action plan that was not accepted by the state agency.

Based on observation, record review and staff interviews, the facility failed to secure controlled substance medications under a double lock in 1 of 3 medication rooms reviewed for medication storage (Main medication room).The findings included:On 01/07/26 at 11:15 AM the unlocked refrigerator in the Main medication room was checked for medication storage along with the Director of Nursing (DON). The observation yielded four bottles of liquid lorazepam (benzodiazepine) with 30 ml each and two bottles of liquid morphine (opioid pain reliever) with 30 ml each, which are controlled substances. The liquid lorazepam and the liquid morphine were in a box affixed to the inside of the refrigerator, but the box was unlocked. The DON explained that Nurse #2 had the key to the box and the box should be always locked.At 11:30 AM on 01/07/26 an interview was conducted with Nurse #2 who confirmed that she had the key to the controlled substance locked box in the refrigerator that contained the lorazepam and morphine. The Nurse explained that she counted the medications with the third shift nurse earlier that morning and she must have forgotten to lock the box back after the medications were counted.An interview was conducted with the Administrator on 01/09/26 at 2:55 PM. The Administrator indicated her expectation was that the controlled substances be locked up no matter if they were in the medication cart or refrigerator.

Based on observation, record review, and resident and staff interviews, the facility failed to follow professional standards of practice for the safe administration of medications for 1 of 1 resident reviewed for self-administration of medications (Resident #65). Resident #65, who had been assessed as unable to self-administer medications, had medications left at his bedside without nursing supervision.The findings included:Resident #65 was admitted to the facility on [DATE] with diagnoses that included respiratory failure and generalized muscle weakness. Resident #65's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was cognitively intact and had no behaviors or rejection of care. A Self-Medication assessment dated [DATE] revealed Resident #65 was assessed as unable to self-administer medications. An observation on 1/05/26 at 8:42 AM revealed Resident #65 lying in his bed with his head raised. A medication cup, on his bedside table within reach, contained 3 round light green pills, 3 round white pills, 1 smaller round white pill, 2 oval white pills and 2 round dark orange pills. An additional medication cup containing an amber liquid was also observed on the bedside table. Resident #65 indicated he knew what all his pills were because he had been taking them for so long that he was able to recognize them. He revealed the nurse would leave his pills with him and return later to get the empty cups. Resident #65 indicated he could take his pills by himself and didn't need anyone watching him. He declined to name the medications in the cup.An interview on 1/05/26 at 10:28 AM with Nurse #3 revealed Resident #65 asked her to leave his medications with him as he wanted to take them by himself. She indicated it was his preference to have his medications left, and he would become angry if you stood over him to watch him take his medication. Nurse #3 revealed she didn't know if Resident #65 had been assessed as safe to self-administer his medications and stated she should not have left the medication on his bedside table and walked out of his room. On 1/07/26 at 9:41 AM an interview with the Director of Nursing (DON) revealed the admitting nurse should complete self-medication assessment and communicate the outcome to the nurses on the hall. She indicated Nurse #3 should not have left Resident #65's medications by his bedside to self-administer as he had been assessed as unable to self-administer. The DON revealed she was aware of the incident and had begun education to nurses on resident self-administration of medications. An interview conducted on 1/08/26 at 11:02 AM with the Administrator revealed that Resident #65 should not have had his medications left at the bedside for self-administration. The Administrator stated that Resident #65 required reassessment for self-administration of medications and that nursing staff would be re-educated on the facility's process for resident self-administration of medications.

Based on observation, record review, and staff interviews, the facility failed to follow their Handwashing/Hand Hygiene policy when the Wound Nurse did not doff (remove) her gloves, perform hand hygiene and don (put on) clean gloves before moving to a second wound on Resident #10. The deficient practice occurred for 1 of 4 staff members observed for infection control practices (Wound Nurse).The findings included: Review of the facility's policy and procedure entitled Hand Hygiene and dated October 2023 read in part:Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene:Immediately before touching a resident.Before performing an aseptic taskAfter contact with blood, body fluids, or contaminated surfaces.After touching a residentAfter touching the resident's environmentBefore moving from working on a soiled body site to a clean body site on the same resident; andImmediately after glove removal. A wound treatment observation was made on 01/06/26 at 10:01 AM on Resident #10 with the Wound Nurse. The Wound Nurse donned a clean gown and clean gloves. She then removed the old dressing from Resident #10's left hip, doffed her gloves, sanitized her hands, donned clean gloves and cleaned the wound to Resident #10's left hip. While wearing the same gloves the Wound Nurse then applied collagen powder with silver alginate to the left hip wound. The Wound nurse then proceeded to move to the next wound located on Resident #10's right ankle without doffing her gloves and sanitizing her hands. The Wound Nurse applied skin prep (skin protectant film) to the right ankle. She then collected all of her supplies and threw them into the trash can. The Wound Nurse doffed her gown, gloves and washed her hands. An interview conducted on 01/06/26 at 10:21 AM with the Wound Nurse revealed she was aware that she had not sanitized her hands and changed her gloves between the dressing changes on Resident #10's left hip and right ankle. She stated there was a lot going on in the room which made her nervous and she had just moved to the next wound without thinking. The Wound Nurse stated she had received ongoing education on infection control and dressing changes, that it was just a mistake. An interview on 01/07/26 at 2:22 PM with the Director of Nursing (DON) and Infection Preventionist revealed they both were aware of the Wound Nurse's errors during wound care. The DON said the Wound Nurse had been provided with additional education regarding doffing and donning and sanitizing in between wound care. The DON and Infection Preventionist stated it was their expectation for the Wound Nurse to follow infection control best practices to avoid introducing microorganisms into the wounds. An interview on 01/07/26 at 11:28 AM with the Administrator revealed she would expect the Wound Nurse to follow the Hand Hygiene policy for wound care.

Based on observations, record reviews, and staff and Nurse Practitioner interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 26 opportunities, resulting in a medication error rate of 7.69% for 1 of 4 residents observed during the medication administration (Resident #6).The findings included:Resident #6 was admitted to the facility on [DATE] with diagnoses that included hypertension.Review of Resident #6's physician orders revealed an order dated 11/07/25 for folic acid (a vitamin critical for making new cells to prevent anemia) 800 micrograms (mcg) by mouth once a day. There was an order dated 11/26/25 for carvedilol (used to treat high blood pressure) 6.25 milligrams (mg) by mouth twice a day for hypertension. Hold for systolic blood pressure below 100 and heart rate below 60.On 01/06/26 at 8:30 AM an observation of a medication pass was conducted with Nurse #1. The Nurse prepared medications for Resident #6 which included carvedilol 6.25 mg and administered the medication to the Resident without assessing the Resident's blood pressure and heart rate before giving Resident #6 the carvedilol. During the same medication observation, Nurse #1 did not administer the folic acid 800 mcg to Resident #6.At 9:30 AM on 01/06/26 an interview was conducted with Nurse #1 who explained that she did not notice the parameters for the blood pressure and heart rate that was attached to the carvedilol order and stated it must have been added since the last time she worked with Resident #6. The Nurse stated she must have overlooked the order for the folic acid. On 01/07/2026 at 10:07 AM an interview was conducted with the Nurse Practitioner (NP) who stated that she was already aware of the medication errors that Nurse #1 had made. She explained that there were parameters on the carvedilol for a reason because it could drop the blood pressure and heart rate and that it would be necessary for a base reading to be obtained before the medication was given. The NP stated Nurse #1 should have read the medication record closer to obtain the blood pressure and heart rate prior to administration of the medication. The NP stated that medications were ordered for a reason, and she expected the nurses to give the medications that were ordered. She stated Nurse #1 should have looked closer at the medication administration record to avoid making errors.An interview was conducted with the Director of Nursing (DON) on 01/07/2026 at 2:45 PM, who explained that she was aware of the medication errors made by Nurse #1 not administering the folic acid and not checking the blood pressure and heart rate for Resident #6. The DON stated that the provider who entered the order for the carvedilol did not set up the parameters for the blood pressure and heart rate correctly in the system because if they had, the system would not have allowed Nurse #1 to check it off as being given without the parameters being documented. The DON stated the Nurse should have checked each medication order three times to prevent the medication errors.

Based on record review, and staff and resident representative interviews, the facility failed to complete a comprehensive discharge summary that included the name of the home health company and their contact information and failed to ensure education regarding catheter care was provided to the Resident Representative prior to discharge for 1 of 3 residents reviewed for discharge (Resident #1).The findings included:Resident #1 was admitted to the facility on [DATE] with diagnoses that included stroke and neuromuscular dysfunction of bladder.Review of Resident #1's discharge Minimum Data Set assessment revealed him to be severely cognitively impaired and was coded as having an indwelling urinary catheter.Review of Resident #1's electronic medical record revealed a discharge summary document dated 08/07/25 and titled CCH Bridge to Home Discharge Summary - v2 that it was still in progress.Additional review of the document revealed there was no information in the Social Services section regarding home health nor was there documentation that education was provided to either Resident #1 or his responsible party regarding catheter care. Resident #1 was discharged to his home on [DATE].An interview with Nurse #1 via telephone on 08/25/25 at 2:26 PM revealed she completed the discharge note and indicated she had completed the nursing section of the discharge summary. She reported the day of Resident #1's discharge, she had discussed Resident #1's discharge information with Resident #1's representative, which included therapy notes, and medications. Nurse #1 stated she also discussed Resident #1's wound care and asked if Resident #1's representative had questions regarding his urinary catheter which Nurse #1 reported Resident #1's representative stated no. Nurse #1 indicated that no official education regarding Resident #1's urinary catheter care was provided to Resident #1's representative and also indicated that she should have completed the catheter education on Resident #1's discharge summary. Nurse #1 reported she provided the discharge summary to Resident #1's representative.An interview with the Business Office Manager on 08/25/25 at 11:17 AM revealed she was currently serving in a dual role where she completed business office tasks and served as the facility's social worker. The Business Office Manager reported she had completed the social work section of Resident #1's discharge summary and stated before Resident #1 had discharged , she thought that Resident #1 would be receiving home health from Home Health Company #1 and had initially placed that information into the discharge summary but was notified on 08/11/25 by Resident #1's representative that Home Health Company #1 had not shown up to provide home health 5 days post Resident #1's discharge. The Business Office Manager stated at that time, she set up home health for Resident #1 through Home Health Company #2 and stated she had reopened Resident #1's discharge summary and removed Home Health Company #1 from the discharge summary and had forgotten to update the discharge summary with Home Health Company #2's information. She indicated that it should have been updated and the discharge summary closed. An interview with Resident #1's representative via telephone on 08/26/25 at 9:41 AM revealed Resident #1 did not have a urinary catheter prior to his hospitalization before being admitted to the facility. She stated she had not received any education upon discharge from any person at the facility regarding how to take care of a urinary catheter and stated she had no prior knowledge on how to care for a urinary catheter. Resident #1's representative stated she had to do her own research on how to care for Resident #1's urinary catheter until Home Health Company #2 began coming out to the home on [DATE]. Resident #1's representative reported she had not received any paperwork at the time of Resident #1's discharge other than a list of Resident #1's medications and some paper medication prescriptions. Multiple attempts to reach Home Health Company #2 via telephone were unsuccessful.An interview with the Administrator on 08/25/25 at 2:32 PM revealed it was her understanding that Resident #1's discharge summary was completed fully and there was a change in the home health provider, so the discharge summary was reopened to be edited. She reported that, ideally, when a change was made and verification was provided that a new home health provider was going to begin to see Resident #1, that the discharge summary should be updated and completed. She also indicated that if urinary catheter care education was provided, it should be marked in the discharge summary.

Based on record review, and Resident, Resident Responsible Party (RP), facility staff, Nurse Practitioner (NP), and Medical Director interviews the facility failed to notify the Medical Director of Resident #1's documented allergy to aspirin with a history of a gastrointestinal bleed, recent fall with fracture, and new immobility for further orders regarding anticoagulation. Resident #1's family had expressed concerns to the Director of Nursing (DON) on 12/11/2024 regarding Resident #1 not receiving an anticoagulant after falling at home and sustaining multiple fractures of her pelvis and lumbar spine. Resident #1 had a documented allergy to aspirin and the NP instructed the Assistant Director of Nursing (ADON) to reach out to the MD for further direction. The facility also failed to notify the NP that an ordered venous doppler study (an ultrasound used to diagnose blood clots) on 12/27/2024 could not be completed until the following week. On 12/28/2024, Resident #1 and the RP requested Resident #1 be transferred to the Emergency Department (ED). Upon arrival, Resident #1 was diagnosed with extensive deep vein thrombosis (DVT) of both lower extremities, was placed on a heparin infusion (blood thinning medication used to prevent or break up blood clots), and admitted . The deficient practice occurred for 1 of 3 residents (Resident #1) reviewed for change in condition. Immediate jeopardy began on 12/11/2024 when the facility failed to notify the Medical Director that Resident #1 had a documented allergy to Aspirin and the Resident's RP was concerned that she was not receiving an anticoagulant. Immediate jeopardy was removed on 1/7/2025 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 education is completed and monitoring systems put into place are effective. The findings included: Hospital records from 11/25/2024 through 12/2/2024 revealed Resident #1 had experienced a fall and was found to have multiple fractures. Orthopedics was consulted while Resident #1 was in the ED. Orthopedics stated they felt none of Resident #1's fractures required surgical intervention and recommended admission for pain control and monitoring of functional status. Resident #1 received subcutaneous heparin injections while in the hospital, prior to her discharge to the facility on [DATE]. Resident #1 was discharged to the facility on [DATE] and was not prescribed an anticoagulant upon discharge. Resident #1 was admitted to the facility on [DATE] with diagnoses which included multiple pelvic fractures, fracture of the lumbosacral spine (lower back and tailbone), and a history of a gastrointestinal bleed (bleeding in the digestive tract). An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact. A nursing note dated 12/11/2024, authored by the Assistant Director of Nursing (ADON), revealed Resident #1's Responsible Party (RP) had requested for Resident #1 to be placed on anticoagulant therapy and the Nurse Practitioner (NP) was notified. An order was received for Aspirin. Resident #1 had an allergy to Aspirin. The order for Aspirin was discontinued. The RP requested anticoagulation due to enoxaparin being given at the hospital. Resident #1 and the RP explained that Resident #1 had a past medical history of gastrointestinal bleeding. Education was provided to Resident #1 and RP, that anticoagulation therapy would put Resident #1 at risk for developing a gastrointestinal bleed. A NP note dated 12/27/2024 revealed Resident #1 was noted to have increased pain and swelling in her left lower extremity. Resident #1 was documented to have 2+ edema, increased pain, and a positive Homan's sign (pain behind the knee when the persons toes are pointed towards their head in her left lower extremity, indicative of a deep vein thrombosis/blood clot). The NP recommended a venous doppler study and for Resident #1 to be non-weight bearing to her left lower extremity. A provider communication form dated 12/27/2024 revealed Resident #1 was ordered an in-house venous doppler study of the left lower extremity with a diagnosis of edema and pain as well as non-weight bearing on left lower extremity until the doppler studies were available. A nursing note dated 12/28/2024 at 10:25 am, authored by Nurse #2, revealed Resident #1 requested to go to the ED for left leg pain, swelling, and tenderness. Resident #1 stated she was hurting in the calf, behind the knee, and in her pelvic area. An ultrasound doppler was ordered but the company was not available on 12/27/2024 or over the weekend (12/28/2024-12/29/2024). Resident #1 and the RP were concerned about the pain and swelling, which is why they requested her to be sent to the ED. Nurse #2 spoke with the RP and the RP was going to meet Resident #1 at the hospital. The on-call provider was called prior to calling Emergency Medical Services (EMS) and a message was left for them to call back. Change of condition documentation dated 12/28/2024, authored by Nurse #2, revealed Resident #1 had requested to go to the ED. Resident #1's left leg was swollen (from hip to toes), painful, and tender to touch. The venous doppler study ordered 12/27/24 was unable to be performed before next week. Resident #1 was documented as having pain of a 4 on scale of 0-10 on the numerical pain scale (indicative of moderate pain) in the left knee, groin, and left lower leg. Nurse #2 attempted to notify the physician, but there was no answer, a message was left. An ED note dated 12/28/2024 revealed Resident #1 presented to the ED from the facility for evaluation of bilateral lower extremity swelling, which had worsened over the last 2 weeks. A bilateral venous doppler study was conducted in the ED which revealed extensive deep vein thrombosis in the left and right leg. A tibia/fibula (bones in the lower leg) x-ray revealed diffuse edema. Resident #1 was admitted to the hospital and placed on a heparin infusion with plans to later transition to Eliquis, an anticoagulant. An interview was conducted on 1/6/2025 at 11:34 am via telephone with Resident #1's RP. The RP stated she had gone to speak with the Director of Nursing (DON) on 12/11/2024 regarding her concern about Resident #1 not being on an anticoagulant due to her immobility/fractures, swelling in her legs, and a family history of blood clots. The RP stated Resident #1 had received blood thinner shots at the hospital prior to admission to the facility and was concerned that Resident #1 was not currently on an anticoagulant. An interview was conducted on 1/3/2025 at 4:00 pm with the NP. The NP stated she received notification from the ADON on 12/11/2024 that Resident #1's RP had requested Resident #1 to be placed on an anticoagulant. The NP stated she ordered aspirin to be administered daily and was later the same day contacted by the ADON about Resident #1 having an allergy to aspirin. The NP stated she instructed the ADON to refer to the Medical Director for further direction regarding anticoagulation. The NP verbalized she had not had any follow-up regarding anticoagulation after 12/11/2024. The NP stated the last time she saw Resident #1 was on 12/27/2024 for left leg pain at which time Resident #1 was having increased pain and swelling to her left lower extremity. The NP stated that she had ordered an in-house venous doppler study of the left lower extremity and recommended Resident #1 be non-weight bearing to the left leg. The NP stated Resident #1 had swelling and a positive Homan's sign at that time, but did not notice any redness or warmth. The NP stated she was not aware, and was not notified by the DON, the venous doppler study would not be performed until the following week. The NP stated she would have been okay with waiting until Monday for the venous doppler study to be completed but would have wanted to be notified if the venous doppler study could not have been performed until the first of the following week at which point she would have considered sending Resident #1 to the ED. An interview was conducted on 1/6/2025 at 12:59 pm with the DON. The DON stated she had first spoken to Resident #1's RP on 12/11/24 when the RP was concerned that Resident #1 was not on anticoagulation, was not ambulatory and had redness to her leg. The DON stated she had the NP evaluate Resident #1 on 12/27/2024 and a venous doppler study was ordered. The DON stated she had called the scheduler for the venous doppler study and was told the order would not be looked at until Monday (12/30/24). The DON stated she had told the NP about the delay in obtaining a venous doppler study and verbalized the NP was okay with it. An interview was conducted on 1/3/2025 at 5:22 pm with the ADON. The ADON stated she was in the DON's office on 12/11/2024 when Resident #1's RP voiced concerns about Resident #1 not being on an anticoagulant. The ADON stated she contacted the NP, at which time aspirin was ordered, and later discontinued after realizing Resident #1 had an allergy to aspirin. The ADON stated she did not recall the NP instructing her to reach out to the Medical Director for additional guidance regarding anticoagulation. The ADON stated she cared for Resident #1 on 12/25/2024 and noted swelling to Resident #1's left leg at that time, and stated she assumed it was normal because of the rash. The ADON stated Resident #1's left leg was not red warm to touch at that time. The ADON stated Resident #1 did not complain of pain when she applied the hydrocortisone cream. The ADON stated after she cared for Resident #1, she developed swelling from her hip to her toes on the left side and had pain and tenderness on 12/27/2024. The ADON stated the NP had ordered a venous doppler study on 12/27/24 which could not be conducted until the following week. The ADON stated the company had up to 7 days to complete venous doppler studies at the facility. An interview was conducted on 1/5/2025 at 4:17 pm with the Medical Director. The Medical Director stated he had seen Resident #1 shortly after admission to the facility but had not seen her since. The Medical Director stated the facility staff, nor the NP had reached out to him with concerns regarding Resident #1. The Medical Director stated if he had been contacted on 12/11/2024 regarding anticoagulation, he would have referred to orthopedics and evaluated whether Resident #1 was ambulatory to see if anticoagulation was needed. The Medical Director stated if Resident #1 had redness and swelling in her leg, he would have ordered a venous doppler study to have been performed on 12/27/2024. The Medical Director stated if he would have known there would have been a delay and Resident #1 had increased pain and swelling, he would have considered sending Resident #1 to the ED. The Medical Director did not specify if he wanted to be notified about the anticoagulant and events on 12/27/2024. An interview was conducted on 1/6/2025 at 5:31 pm with the Assistant Administrator. The Assistant Administrator stated if the NP had concerns that she felt like she could not handled she should consulted the Medical Director. The Administrator was notified of immediate jeopardy on 1/6/2025 at 6:08 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 12/11/2024, facility failed to notify Medical Director of Resident #1's documented allergy to aspirin based on history of gastrointestinal bleeding, and family's concern and request for further orders for anticoagulation. The facility also failed to notify the medical provider that Resident #1's swelling and pain was not improving and was getting worse from 12/18/24 to 12/27/24 and that Resident #1 was not as mobile as she had been previously. On 12/27/2024, facility failed to notify Nurse Practitioner that an ordered venous doppler could not be completed before the next week. On 12/28/2024, Resident #1 and her family insisted on being transferred to the Emergency Department for evaluation and was transferred to hospital for this evaluation. All other residents with concerns regarding anticoagulation are at risk for this deficient practice. All other residents with complaints of leg pain and swelling (or signs and symptoms of a blood clot) are at risk for this deficient practice. On 12/28/2024, Resident #1 discharged from the facility. On 01/06/2025, an audit of all residents with significant changes between 11/27/2024 & 12/27/2024 was conducted by the Director of Nursing (DON) and Assistant Director of Nursing (ADON) with no additional failures to notify provider of delayed studies, treatment or transfer identified. On 01/06/2025, the medical director notified by DON of all residents with documented allergy or intolerance to aspirin due to a history of GI bleed and reviewed for any resident needing anticoagulation orders with no additional residents identified. No other residents identified with ordered diagnostic studies that were delayed; no other residents identified with unreported leg pain and swelling or concerns regarding a lack of anticoagulation. 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 01/06/2025, all licensed nurses, medication aides, and certified nursing assistants were educated by the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on requirement to notify physician of all significant changes in condition to ensure timely treatment or transfers. Licensed nurses, medication aides and certified nursing assessments who are newly hired, including agency, will receive in-service prior to working their initial shift. Director of Nursing and/or Staff Development coordinator will be responsible to ensure education is received. Facility administrator communicated this responsibility on 01/06/2025. The education consisted of the following: -Ordered studies should be scheduled same day of order -If vendor is unable to perform study on same day of order, provider is to be notified by licensed nurse of expected date of study. -New orders from medical providers given to address changes in condition should be implemented on day of order, unless otherwise noted by provider. If orders are unable to be implemented timely, provider must be made aware immediately in order to ensure any new intervention or transfer is then implemented timely. -In this case, licensed nurse is to document notification and any new orders, to include transfer to hospital, deemed necessary by medical provider. -Physician or physician extender is to be made aware by licensed nurse of all residents with aspirin allergy to determine any needs for anticoagulation. This notification to occur upon admission or readmission with any newly identified aspirin allergy. -Certified nursing assistants and medication aides who identify changes in condition should notify licensed nurse. This removal of immediate jeopardy allegation was reviewed and approved by an ad hoc QAPI meeting on 01/06/2025. Facility administrator notified DON of responsibility for completion of this immediate jeopardy allegation removal on 01/06/2025. Alleged date of IJ removal: 01/07/2025. A validation of immediate jeopardy removal was conducted on 1/13/2025. Initial audits conducted revealed residents with an aspirin allergy were identified and their potential need for anticoagulation was addressed. Audits conducted regarding previous diagnostic studies from 11/27/2024 through 12/27/2024 revealed there were no other delays in obtaining ordered diagnostic testing. Interviews with facility nursing staff (Nurses, Medication Aides, and Nurse Aides) revealed staff had received education on having ordered studies performed on the same day the order was written, if the study is unable to be performed the day it was ordered staff is to notify the provider of the expected date of the study to see if the resident should have a different intervention or should be transferred to the hospital, and the Medical Director is to be made aware of residents with aspirin allergies on admission to determine if there should be any anticoagulation ordered. The immediate jeopardy removal date of 1/7/2025 was validated.

Based on record review, and staff, Resident, Responsible Party (RP), Nurse Practitioner, and Medical Director interviews, the facility failed to protect a resident's right to be free from neglect when they failed to notify the Medical Director that Resident #1 had a documented allergy to aspirin with a history of gastrointestinal bleed, recent fall with fracture, and new immobility on 12/11/24 when Resident #1's family expressed concerns to the Director of Nursing (DON) that Resident #1 was not receiving anticoagulant. The Nurse Practitioner instructed the Assistant Director of Nursing to reach out the Medical Director for guidance an anticoagulation and failed to communicate or collaborate with the Medical Director herself. The facility further failed to recognize the seriousness of pain and leg swelling that started on 12/11/2024 and neglected to act on the severity of a potential blood clot when a resident (Resident #1) continued to experience increased pain and swelling to her left lower extremity. On 12/27/2024, Resident #1 was noted to have increased edema (swelling), a positive Homan's sign (pain behind the knee when the person's toes are pointed towards their head, indicative of a deep vein thrombosis/blood clot), and increased pain to her left lower extremity. The facility failed to seek emergent medical attention when they knew a venous doppler study could not be scheduled for at least three days after it was ordered on 12/27/24. On 12/28/2024, Resident #1 continued to have increased swelling, pain, and redness to her left lower extremity and at her (Resident #1) request, was transferred to the hospital at 10:45 am via Emergency Medical Services (EMS). Resident #1 was diagnosed with extensive deep vein thrombosis (DVT) of both lower extremities, was placed on a heparin infusion (blood thinning medication used to prevent or break up blood clots), and admitted . Resident #1 has remained in the hospital since she was transferred from the facility. Deep vein thrombosis (DVT) can be very dangerous because a blood clot formed in a deep vein can break loose and travel to the lungs, causing a pulmonary embolism which can be life-threatening. The deficient practice occurred for 1 of 3 residents (Resident #1) reviewed for neglect. Immediate jeopardy began on 12/11/24 when the facility failed to notify the Medical Director that Resident #1 had a documented allergy to aspirin and the RP was concerned about Resident #1 not receiving an anticoagulant, had increased edema and pain indicative of deep vein thrombosis. Immediate jeopardy was removed on 1/7/2025 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance with a lower scope and severity of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The findings included: This tag is cross-referenced to: F580: Based on record review, and Resident, Resident Responsible Party (RP), facility staff, Nurse Practitioner (NP), and Medical Director interviews the facility failed to notify the Medical Director of Resident #1's documented allergy to aspirin with a history of a gastrointestinal bleed, recent fall with fracture, and new immobility for further orders regarding anticoagulation. Resident #1's family had expressed concerns to the Director of Nursing (DON) on 12/11/2024 regarding Resident #1 not receiving an anticoagulant after falling at home and sustaining multiple fractures of her pelvis and lumbar spine. Resident #1 had a documented allergy to aspirin and the NP instructed the Assistant Director of Nursing (ADON) to reach out to the MD for further direction. The facility also failed to notify the NP that an ordered venous doppler study (an ultrasound used to diagnose blood clots) on 12/27/2024 could not be completed until the following week. On 12/28/2024, Resident #1 and the RP requested Resident #1 be transferred to the Emergency Department (ED). Upon arrival, Resident #1 was diagnosed with extensive deep vein thrombosis (DVT) of both lower extremities, was placed on a heparin infusion (blood thinning medication used to prevent or break up blood clots administer intravenously), and admitted . The deficient practice occurred for 1 of 3 residents (Resident #1) reviewed for change in condition. F684: Based on record review, and Resident, Resident Responsible Party (RP), facility staff, Nurse Practitioner (NP), and Medical Director interviews, the facility failed to seek emergent medical attention when Resident #1 who had a recent history of spine and pelvic fractures and anticoagulation therapy prior to admission, experienced increased leg swelling, pain and an ordered venous doppler study (a non-invasive diagnostic procedure that uses sound waves to examine the circulation in the body's veins and arteries) could not be scheduled for at least three days after it was ordered. On 12/27/2024, Resident #1 was noted to have increased edema (swelling), a positive Homan's sign (pain behind the knee when the person's toes are pointed towards their head, indicative of a deep vein thrombosis/blood clot), and pain to her left lower extremity. The facility failed to seek emergent medical attention when they knew a venous doppler study could not be scheduled for at least three days after it was ordered. On 12/28/2024, Resident #1 continued to have increased swelling, pain, and redness to her left lower extremity and was transferred to the hospital at 10:45 am via Emergency Medical Services (EMS). Resident #1 was diagnosed with extensive deep vein thrombosis (DVT) of both lower extremities, was placed on a heparin infusion (blood thinning medication used to prevent or break up blood clots), and admitted . As of 1/6/2025, Resident #1 has remained in the hospital since she was transferred from the facility. Deep vein thrombosis (DVT) can be very dangerous because a blood clot formed in a deep vein can break loose and travel to the lungs, causing a pulmonary embolism which can be life-threatening. The deficient practice occurred for 1 of 3 residents (Resident #1) reviewed for change in condition. F714: Based on record review, staff, Resident, Resident Responsible Party (RP), Nurse Practitioner, and Medical Director interview the facility Nurse Practitioner (NP) failed to communicate and collaborate with the Medical Director after Resident #1's RP voiced concerns on 12/11/2024 that Resident #1 was not receiving an anticoagulant (blood thinning medication, used to prevent blood clots) after having a fall at home and sustaining multiple fractures of the pelvis and lumbar (lower back) spine, and was not as mobile as she had been prior to admission to the facility. The Assistant Director of Nursing (ADON) contacted the NP on 12/11/2024 at which time the NP ordered aspirin which was later discontinued due to a listed allergy due to a history of gastrointestinal bleeding. The NP instructed the ADON to consult the Medical Director for further guidance regarding anticoagulation for Resident #1 and failed to reach out to the MD herself. On 12/27/2024 Resident #1 was evaluated by the NP at which time Resident #1 had pain, increased swelling, and a positive Homan's sign (pain behind the knee when the person's toes are pointed towards their head, indicative of a deep vein thrombosis/blood clot) in her left lower extremity. Resident #1 was transferred to the hospital on 12/28/2024 where she was diagnosed with the serious adverse outcome of deep vein thrombi to her bilateral lateral lower extremities, requiring anticoagulation, and hospitalization . The deficient practice was identified for 1 of 3 residents (Resident #1) reviewed for change in condition. An interview was conducted on 1/13/2025 at 2:07 pm with the DON. The DON stated examples of neglect would include staff letting someone lay in bed without changing them, not feeding a resident, and not treating pain when a resident reported it. The DON stated she had not felt like Resident #1 experienced neglect because the facility had provided interventions such as having the Nurse Practitioner evaluate Resident #1. The DON stated as soon as Resident #1 requested to go to the Emergency Department on 12/28/2024, she was sent. The Administrator was notified of immediate jeopardy on 1/6/2025 at 6:08 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: The facility failed to recognize the seriousness of leg swelling and pain, manage Residents #1's pain, notify the medical director of a documented aspirin allergy with a history of a Gastrointestinal (GI) bleed for further anticoagulation orders. The Nurse practitioner neglected to communicate with the medical director and ensure the resident received necessary care and services, necessary medical evaluation and treatment. On 12/28/2024, Resident #1 discharged from the facility and was admitted to the hospital with blood clots to her bilateral lower extremities and was started on a heparin (used to break up clots) drip. On 01/06/2025, All residents had skin and pain user defined assessments conducted and documented in the medical record to include interview questions, for all interviewable residents, and observation by Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit manager (UM) or Wound Care Nurse for non-interviewable residents with additional findings addressed and provider notified. On 01/06/2025, an audit of all residents noted with significant change in condition (changes in status outside of residents baseline) assessments completed from 11/27/2024 to current was conducted by the Director of Nursing (DON) and Assistant Director of Nursing (ADON) to identify any unaddressed new or worsening pain or swelling. Audit of einteract Change in Condition user defined assessments (UDA) revealed no additional concerns noted. 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 01/06/2025, the DON, ADON, Staff Development (SDC) and Unit Managers began education for all licensed nurses, medication aides and certified nursing aides on Abuse and Neglect as it is related to not acting or following up on reported and assessed pain or changes in condition. Nursing staff newly hired, including agency, will receive in-service education prior to working their initial shift. Director of Nursing and/or Staff Development coordinator will be responsible to ensure education is received. Facility Administrator communicated this responsibility on 01/06/2025. On 1/6/25 Abuse and neglect policy was reviewed by Administrator prior to providing staff education, no changes to policy are required at this time. The education consisted of the following: - Identification of pain via verbal and non-verbal cues. - Pharmacological and non-pharmacological interventions for pain and swelling. - Failing to act on pain or change in condition is considered neglect. - Medical provider must be notified of any changes in condition to include acute pain. - Provider orders and interventions must be implemented timely. - Changes in condition to include pain should have timely follow up to ensure effectiveness of interventions. This credible allegation of immediate jeopardy removal plan was reviewed and approved by an ad hoc QAPI meeting on 01/06/2025. Facility administrator notified DON of responsibility for completion of this credible allegation of immediate jeopardy removal on 01/06/2025. Alleged IJ removal date is 01/07/2025. A validation of immediate jeopardy removal was conducted on 1/13/2025. Initial audits conducted on 1/6/2025 revealed residents were assessed for any concerns/new findings, if a provider had been notified of the concern/finding, if a resident was in pain, and if a resident had any new or worsening swelling. Concerns were identified and addressed. Interviews with facility staff revealed they had received education on neglect, examples of neglect, addressing pain (bother verbal and non-verbal indicators), administering pharmacological and nonpharmacological interventions for pain and/or swelling, acting on a change in condition, notifying a provider with concerns or a change in condition, and following through on intervention effectiveness. The immediate jeopardy removal date of 1/7/2025 was validated.

Based on record review, and Resident, Resident Responsible Party (RP), facility staff, Nurse Practitioner (NP), and Medical Director interviews, the facility failed to seek emergent medical attention when Resident #1 who had a recent history of spine and pelvic fractures and anticoagulation therapy prior to admission, experienced increased leg swelling, pain and an ordered venous doppler study (a non-invasive diagnostic procedure that uses sound waves to examine the circulation in the body's veins and arteries) could not be scheduled for at least three days after it was ordered. On 12/27/2024, Resident #1 was noted to have increased edema (swelling), a positive Homan's sign (pain behind the knee when the person's toes are pointed towards their head, indicative of a deep vein thrombosis/blood clot), and pain to her left lower extremity. The facility failed to seek emergent medical attention when they knew a venous doppler study could not be scheduled for at least three days after it was ordered. On 12/28/2024, Resident #1 continued to have increased swelling, pain, and redness to her left lower extremity and was transferred to the hospital at 10:45 am via Emergency Medical Services (EMS). Resident #1 was diagnosed with extensive deep vein thrombosis (DVT) of both lower extremities, was placed on a heparin infusion (blood thinning medication used to prevent or break up blood clots), and admitted . As of 1/6/2025, Resident #1 has remained in the hospital since she was transferred from the facility. Deep vein thrombosis (DVT) can be very dangerous because a blood clot formed in a deep vein can break loose and travel to the lungs, causing a pulmonary embolism which can be life-threatening. The deficient practice occurred for 1 of 3 residents (Resident #1) reviewed for change in condition. Immediate jeopardy began on Friday, 12/27/2024 when Resident #1 had increased edema, pain behind the knee indicative of deep vein thrombosis and the ordered venous doppler study could not be scheduled until Monday, 12/30/24. Immediate jeopardy was removed on 1/7/2025 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance with a lower scope and severity of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The findings included: Hospital records from 11/25/2024 through 12/2/2024 revealed Resident #1 had experienced a fall and was found to have multiple fractures. Orthopedics was consulted while Resident #1 was in the Emergency Department (ED). Orthopedics stated they felt none of Resident #1's fractures required surgical intervention and recommended admission for pain control and monitoring of functional status. Resident #1 received subcutaneous heparin injections (blood thinning shots given through the skin) while in the hospital, prior to her discharge to the facility on [DATE]. Resident #1 was admitted to the facility on [DATE] with diagnoses which included multiple pelvic fractures, fracture of the lumbosacral spine (lower back and tailbone), and a history of a gastrointestinal bleed (bleeding in the digestive tract). Resident #1's medical record revealed Resident #1 had an allergy to aspirin with unknown reactions and severity. A therapy note dated 12/6/2024 revealed nursing was to address Resident #1's pre-treatment pain. Resident #1 was educated on need for movement in decreasing pain from fracture. Resident #1 performed supine, head of bed elevated, to sitting at the edge of bed transfer with maximum assistance for lower extremity management. Resident #1 required significant increase in time for transfer due to pain. An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact, had impairment on both sides of her lower extremities, and utilized a wheelchair, received as needed pain medications, had pain frequently during the assessment period and rated pain at a 7 on a scaled of 0 -10. Pain assessments dated 12/11/2024 revealed Resident #1 had a pain level of 8 out of 10 on the numerical pain scale of 0 to 10 (indicative of severe pain) at 6:20 am and a pain level of 5 out of 10 on the numerical pain scale (indicative of moderate pain) at 3:33 pm. A nursing note dated 12/11/2024, authored by the Assistant Director of Nursing (ADON), revealed Resident #1's Responsible Party (RP) had requested anticoagulant therapy for Resident #1 and the Nurse Practitioner (NP) was notified. An order was received for Aspirin. Resident #1 had an allergy to Aspirin. The order for Aspirin was discontinued. The RP requested anticoagulation due to enoxaparin, an anticoagulant, being given at the hospital. Resident #1 and the RP explained that Resident #1 had a past medical history of gastrointestinal bleeding. The ADON provided education to Resident #1 and RP, that anticoagulation therapy would put Resident #1 at risk for developing a gastrointestinal bleed. An NP note dated 12/11/2024 revealed Resident #1 was evaluated per staff request due to chest congestion and was noted to have congestion and trace edema in bilateral lower extremities. The NP ordered a chest x-ray, guaifenesin (medication used to break up mucous), and breathing treatments. A care plan dated 12/13/2024 revealed Resident #1 acute pain related to multiple fractures with interventions which included administering analgesia as ordered and notifying the physician if interventions were unsuccessful or if current complaint is a significant change from residents past experience of pain. A NP note dated 12/13/2024 revealed Resident #1 was evaluated following an abnormal chest x-ray. Resident #1 was noted to have increased cough, congestion, and trace edema in bilateral lower extremities. Resident #1's chest x-ray revealed central pulmonary venous congestion (when blood pools instead of flowing properly). Resident was ordered furosemide (diuretic, used to treat edema and fluid retention) and staff were to monitor for a decrease in symptoms. A physician's order dated 12/13/2024 revealed Resident #1 was prescribed furosemide 40 milligrams (mg) by mouth once daily for venous congestion for 5 days. Change in condition documentation dated 12/18/2024, authored by the Director of Nursing (DON), revealed Resident #1 was noted to have a rash on her left lower extremity and was prescribed hydrocortisone cream. A pain assessment dated [DATE] revealed Resident #1 had a pain level of 7 out of 10 on the numerical pain scale at 9:59 pm. A provider communication form dated 12/18/2024 revealed Resident #1 had a rash to her left lower extremity and was ordered hydrocortisone cream to be administered twice daily for 5 days. An NP note dated 12/18/2024 revealed Resident #1 was evaluated for a rash to bilateral lower extremities and a dry, rough, red rash to the left lower extremity. Resident #1 complained of mild itching and was noted to have trace edema to bilateral lower extremities. The NP recommended hydrocortisone cream 1% to be applied to the left lower extremity twice daily for 5 days. An NP note dated 12/27/2024 revealed Resident #1 was noted to have increased pain and swelling in her left lower extremity. Resident #1 was documented to have 2+ edema, increased pain, and a positive Homan's sign in her left lower extremity. The NP recommended a venous doppler study and for Resident #1 to be non-weight bearing to her left lower extremity. A a provider communication form dated 12/27/2024 revealed Resident #1 was ordered an in-house venous doppler study of the left lower extremity with diagnoses of edema and pain as well as non-weight bearing on left lower extremity until the doppler studies were available. A nursing note dated Friday, 12/27/2024, authored by the DON, revealed Resident #1's RP was notified that a venous doppler study would not be available before Monday. The RP was fine with that knowledge and declined to send her to the Emergency Department (ED). Vital signs dated 12/28/2024 at 7:47 am revealed Resident #1's blood pressure was 128/70, heart rate was 75 beats per minute (normal is between 60 to 100 beats per minute), a respiration rate of 19 (normal is between 12 to 20 breaths per minute), a temperature of 97.4 degrees Fahrenheit, and an oxygen saturation level of 98%. A nursing note dated 12/28/2024 at 10:25 am, authored by Nurse #2, revealed Resident #1 requested to go to the Emergency Department (ED) for left leg pain, swelling, and tenderness. Resident #1 stated she was hurting in the calf, behind the knee, and in her pelvic area. An ultrasound doppler was ordered but the company was not available on 12/27/2024 or over the weekend (12/28/2024-12/29/2024). Resident #1 and the RP were concerned about the pain and swelling, which is why they requested her to be sent to the ED. Change of condition documentation dated 12/28/2024, authored by Nurse #2, revealed Resident #1 had requested to go to the Emergency Department (ED). Resident #1's left leg was swollen (from hip to toes), painful, and tender to touch. The venous doppler study ordered 12/27/24 was unable to be performed before next week. Resident #1 was documented as having pain of a 4 on scale of 0-10 on the numerical pain scale (indicative of moderate pain) in the left knee, groin, and left lower leg. Nurse #2 attempted to notify the physician, but there was no answer, a message was left. An EMS report dated 12/28/2024 revealed the facility had notified dispatch at 10:18 am regarding a sick person. EMS arrived at Resident #1's room at 10:31 am. Upon arrival to the facility, staff advised EMS that Resident #1 had broken her pelvis on both sides around 11/27/2024, starting 2 weeks ago Resident #1 had noticed her left lower leg was starting to swell, and a week ago began to feel pain in the leg. Facility informed EMS the MD was aware and had ordered a doppler study which would not be available until later the following week which is why they wanted to transfer Resident #1 to the hospital. EMS obtained vital signs at 10:41 am at which time Resident #1 had a blood pressure of 182/74 (normal is 120/80), a heart rate of 90 beats per minute (normal is 60 to 100 beats per minute), a respiration rate of 18 breaths per minute (normal is 12 to 20 breaths per minute), a temperature of 98.8 degrees, and a pain level of 8 out of 10 on the numerical pain scale (indicative of severe pain). Resident #1 was transferred to the hospital at 10:45 am. While enroute to the hospital, EMS administered 4 milligrams of morphine for pain intravenously (through a catheter inserted in a vein). An ED note dated 12/28/2024 revealed Resident #1 presented to the ED from the facility for evaluation of bilateral lower extremity swelling, which had worsened over the last 2 weeks. A bilateral venous doppler study was conducted in the ED which revealed extensive deep vein thrombosis in the left and right leg. A tibia/fibula (bones in the lower leg) x-ray revealed diffuse edema. Resident #1 was admitted to the hospital and placed on a heparin infusion with plans to later transition to Eliquis, an anticoagulant. An interview was conducted on 1/6/2025 at 11:41 am via telephone with Resident #1. Resident #1 stated while she was at the facility she had experienced left lower leg pain and swelling. Resident #1 stated she noticed increased leg swelling and pain that began on 12/18/2024. Resident #1 stated the swelling and pain continued to get worse, and recalled her leg being so swollen on Christmas (12/25/2024) that she tried to prop her leg up and stated her leg brace was much tighter than normal. Resident #1 stated on 12/27/2024, her left leg was really swollen. Resident #1 stated she experienced an achy pain and rated the pain as an 8-9 out of 10 on the numerical pain scale. Resident #1 stated the NP evaluated her on 12/27/2024 and ordered a test to be done at the facility. Resident #1 stated on 12/28/2024 she called the RP around 8:00 am and informed her that her left leg pain and swelling had gotten worse overnight and that she thought she needed to go to the hospital. Prior to Resident #1's conversation with the RP, Resident #1 recalled two nurse aides (NAs) commented on her leg and how swollen it was. An interview was conducted on 1/6/2025 at 11:34 am via telephone with Resident #1's RP. The RP stated she had gone to speak with the Director of Nursing (DON) on 12/11/2024 regarding her concern about Resident #1 not being on an anticoagulant due to her immobility/fractures, swelling in her legs, and a family history of blood clots. The RP stated Resident #1 had received blood thinner shots at the hospital prior to admission to the facility. The RP stated Resident #1 was seen by the NP on 12/18/2024 at which time she had discoloration to her left leg as well as swelling and was diagnosed with a rash. The RP stated the facility contacted her on 12/25/2024 about a planned discharge and insurance denial, at which time she expressed her concern over Resident #1's swollen left leg. The RP stated she spoke with the DON again on 12/27/2024, at which time she expressed concern about Resident #1 continuing to have swelling and pain in her left leg. The RP stated the DON had the NP evaluate Resident #1 at which time they ordered a venous doppler study. The RP stated neither the DON nor any facility staff offered to have Resident #1 sent to the hospital on 12/27/2024 for further evaluation. The RP stated she received a call on 12/28/2024 at 8:08 am (per her cell phone call log) from Resident #1 stating that her leg was hurting/more swollen and thought she needed to go to the hospital. The RP stated she called the facility at 10:08 am and insisted that the facility call EMS to have Resident #1 transferred to the hospital for further evaluation. The RP stated she received a phone call from a facility staff member at 10:21 am, at which time they reported EMS had been called. The RP stated when Resident #1 arrived at the hospital, a doppler study was performed in the ED, and Resident #1 was diagnosed with blood clots in her bilateral lower extremities and started on heparin. An interview was conducted on 1/5/2025 at 12:55 pm with Nurse Aide (NA) #1. NA #1 stated she worked on night shift (7:00 pm to 7:00 am) at the facility and stated the last night that she worked with Resident #1 was on 12/26/2024 at which time she noticed Resident #1's left leg was a little red and swollen, nothing too serious. NA #1 stated Resident #1 expressed she was in pain at which time she notified Nurse #1. Nurse #1 was unavailable for interview. An interview was conducted on 1/5/2025 at 1:24 pm with NA #3. NA #3 stated she worked dayshift (7:00 am to 7:00 pm) on 12/27/2024 and was assigned Resident #1. NA #3 stated Resident #1's left leg was more swollen than the other leg and stated Nurse #3 was aware of the swelling and Resident #1 was evaluated by the NP on 12/27/2024. An interview was conducted on 1/3/2025 at 4:09 pm with Nurse #3. Nurse #3 stated she worked dayshift (7:00 am to 7:00 pm) and had been assigned Resident #1 on multiple occasions, including 12/27/2024. Nurse #3 stated Resident #1's legs started swelling before Christmas, 12/25/2024. Nurse #3 stated she the NP had evaluated her (unsure of date) and ordered cream to be administered. Nurse #3 stated the swelling in Resident #1's left leg had worsened and when she was assigned Resident #1 on 12/27/2024 and had the DON come assess Resident #1's leg with her. Nurse #3 was unable to recall if Resident #1 was in pain. An interview was conducted on 1/5/2025 at 1:51 pm with Nurse #4. Nurse #4 stated she worked nightshift and had been assigned Resident #1 on 12/25/2024. Nurse #4 stated Resident #1 was not able to ambulate, required full assist, and was bedbound mostly. Nurse #4 stated Resident #1 had been admitted to the facility with an injury to her hip and always had a lot of pain. Nurse #4 was unable to recall Resident #1 having any swelling to her left or right leg. An interview was conducted on 1/6/2025 at 10:30 am with NA #2. NA #2 stated she worked dayshift and was assigned Resident #1 on 12/28/2024. NA #2 stated when she rounded on Resident #1 between 7:30 am and 8:00 am, she noticed Resident #1 she had noticeable swelling of her left leg, redness near the ankle, and warmness to the touch. NA #2 stated Resident #1 had also expressed pain in her left leg. NA #2 stated she immediately notified Nurse #2 and stated Resident #1 was transferred to the hospital later that morning on 12/28/2024. An interview was conducted on 1/5/2025 at 4:48 pm with NA #4. NA #4 stated she worked dayshift and assisted with caring for Resident #1 on 12/28/2024. NA #4 stated when she went in Resident #1's room at the beginning of the shift (between 7:00 am and 8:00 am) Resident #1 was complaining about her left leg being swollen. NA #4 stated Resident #1 had swelling from her left hip down to her toes. NA #4 stated there was redness towards the bottom of Resident #1's left lower leg, and stated Resident #1 was in a lot of pain. NA #4 stated she reported the concerns to Nurse #2. An interview was conducted on 1/5/2025 at 12:48 pm with Nurse #2. Nurse #2 stated she worked dayshift and 12/28/2024 she was assigned Resident #1 for the first time. Nurse #2 stated Medication Aide (MA) #1 was also assigned Resident #1. Nurse #2 stated she was approached by a staff member (unable to remember who) about Resident #1's left leg being swollen. Nurse #2 stated she assessed Resident #1's left leg was significantly more swollen than the right leg, had redness from the knee to the ankle, was warm to the touch, and painful (from behind the knee, the calve, and the pelvic area). Nurse #2 stated Resident #1's RP called her and asked to have Resident #1 sent to the hospital for evaluation. Nurse #2 stated she tried to call the on-call provider and there was no answer, so she left a message for a return call. Nurse #2 stated she then decided to call EMS. An interview was conducted on 1/5/2025 at 3:16 pm with the Rehabilitation Director. The Rehabilitation Director stated Resident #1 was seen by both Occupational Therapy (OT) and Physical Therapy (PT). The Rehabilitation Director stated Resident #1 was originally assessed by OT on 12/4/2024 at which time she required moderate assistance and was unable to stand. The Rehabilitation Director stated Resident #1 was initially assessed by PT on 12/6/2024 at which time she was unable to do much due to pain and required maximum assistance with transfers and bed mobility. The Rehabilitation Director stated Resident #1 had left foot drop and required a brace from a previous injury. The Rehabilitation Director stated he worked with Resident #1 on 12/24/2024, at which time he was able to apply the brace to the left leg. The Rehabilitation Director stated he noticed minor signs of swelling, but no discoloration. The Rehabilitation Director stated he reported the minor swelling to nursing staff. The Rehabilitation Director stated the RP reached out to him on 12/27/2024 over concerns regarding Resident #1 having leg swelling and overall concern about Resident #1 not being ready for discharge. The Rehabilitation Director stated he reported the RP's concerns to nursing staff (unable to recall who). An interview was conducted on 1/3/2025 at 4:00 pm with the NP. The NP stated she received notification from the ADON on 12/11/2024 that Resident #1's RP had requested Resident #1 to be placed on an anticoagulant. The NP stated she ordered aspirin to be administered daily and was later contacted by the ADON about Resident #1 having an allergy to aspirin. The NP stated she instructed the ADON to refer to the MD for further direction regarding anticoagulation. The NP stated she had evaluated Resident #1 on 12/11/2024 per staff request for chest congestion at which time Resident #1 had trace edema to bilateral lower extremities and a congested cough and stated she ordered a chest x-ray, guaifenesin, and breathing treatments. The NP stated she evaluated Resident #1 on 12/13/14 following an abnormal chest x-ray which revealed central pulmonary venous congestion and stated she ordered furosemide, a diuretic, to be administered daily for 5 days. The NP stated she evaluated Resident #1 on 12/18/2024 due to a rash to her left lower extremity, trace edema in bilateral lower extremities, and stated she ordered hydrocortisone cream 1% to be administered to the left lower extremity twice a day for 5 days. The NP stated the last time she saw Resident #1 was on 12/27/2024 for left leg pain at which time Resident #1 was having increased pain and swelling to her left lower extremity. The NP stated that she had ordered an in-house venous doppler study of the left lower extremity and recommended Resident #1 be non-weight bearing to the left leg. The NP stated Resident #1 had swelling and a positive Homan's sign at that time, but did not notice any redness or warmth. The NP stated she was not aware the venous doppler study would not be performed until the following week. The NP stated she would have been okay with waiting until Monday for the venous doppler study to be completed but would have considered sending Resident #1 to the ED if it could not have been obtained until after Monday. The NP stated she had seen Resident #1 on multiple occasions since she was admitted to the facility and was familiar with Resident #1's history. An interview was conducted on 1/3/2025 at 5:22 pm with the ADON. The ADON stated she was in the DON's office on 12/11/2024 when Resident #1's RP voiced concerns about Resident #1 not being on an anticoagulant. The ADON stated she contacted the NP, at which time aspirin was ordered, and later discontinued after realizing Resident #1 had an allergy to aspirin. The ADON stated she did not recall the NP instructing her to reach out to the MD for additional guidance regarding anticoagulation. The ADON stated Resident #1 was seen by the NP on 12/18/2024 due to a rash on her left lower leg at which time hydrocortisone cream was ordered. The ADON stated she cared for Resident #1 on 12/25/2024 and noted swelling to Resident #1's left leg at that time, and stated she assumed it was normal because of the rash. The ADON stated Resident #1's left leg was not red or warm to touch at that time. The ADON stated Resident #1 did not complain of pain when she applied the hydrocortisone cream. The ADON stated after she cared for Resident #1, she developed swelling from her hip to her toes on the left side and had pain and tenderness. The ADON stated the NP had ordered a venous doppler study which could not be conducted until the following week. The ADON stated that per documentation the RP had declined to send Resident #1 to the ED on 12/27/2024. The ADON stated Resident #1 was sent to the ED on 12/28/2024 and did not return to the facility. An interview was conducted on 1/6/2025 at 12:59 pm with the DON. The DON stated she had first spoken to Resident #1's RP after Resident #1 had been prescribed hydrocortisone cream for a rash when she was concerned it had not been applied. The DON stated she received a call from the RP on 12/27/2024 at which time the RP was upset about an insurance denial, Resident #1 not being able to ambulate, and about Resident #1's left leg being red. The DON stated she had the NP evaluate Resident #1 on 12/27/2024 and a venous doppler study was ordered. The DON stated she had called the scheduler for the venous doppler study and was told the order would not be looked at until Monday. The DON stated she had told the NP about the delay in obtaining a venous doppler study and verbalized the NP was okay with it. The DON stated she told the RP about the delay of the venous doppler study and offered to send Resident #1 to the hospital at which time the RP declined. An interview was conducted on 1/5/2025 at 4:17 pm with the Medical Director. The Medical Director stated he had seen Resident #1 shortly after admission to the facility but had not seen her since. The Medical Director stated the facility staff, nor the NP had reached out to him with concerns regarding Resident #1. The Medical Director stated if he had been contacted on 12/11/2024 regarding anticoagulation, he would have referred to orthopedics and evaluated whether Resident #1 was ambulatory to see if anticoagulation was needed. The Medical Director stated if Resident #1 had redness and swelling in her leg, he would have ordered a venous doppler study to have been performed on 12/27/2024. The Medical Director stated if he would have known there would have been a delay and Resident #1 had increased pain and swelling, he would have considered sending Resident #1 to the ED. The Administrator was notified of immediate jeopardy on 1/6/2025 at 6:08 pm. The facility provided the following credible allegation of immediate jeopardy removal: Identify those recipients who have suffered and those who are likely to suffer a serious adverse outcome as result of the noncompliance: The facility failed to recognize the severity or seriousness of bilateral leg swelling and pain for resident #1. Resident #1 had a recent history of fall with fractures in her lumbar spine and pelvis and was not as mobile as she had been previously and was not on an anticoagulant (to prevent blood clot) medication. The facility failed to seek necessary medical attention. On 12/28/24 resident#1 was discharged to the hospital where she was admitted with bilateral blood clots and placed on a heparin (used to break up blood clots) drip. On 1/6/25 the Director of Nursing (DON) and Nursing Leadership team which includes the Assistant Director of Nursing (ADON) and Unit Managers, assessed all current facility residents via a head-to-toe body audit and pain assessment to ensure that no other resident was experiencing pain, leg swelling or redness with no additional residents identified. 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 1/6/25 the DON, ADON, Staff Development (SDC) and Unit Managers began education for licensed nurses, medication aides and certified nursing assistants on assessing and responding to pain and signs/symptoms of blood clots. Licensed nurses, medication aides, and certified nursing assistants newly hired, including agency, will receive in-service prior to working their initial shift. Director of Nursing and/or Staff Development coordinator will be responsible to ensure education is received. Facility administrator communicated this responsibility on 01/06/2025. Education included: -How to recognize deep vein thrombosis (DVT) is a blood clot -Symptoms: Pain, Swelling, Discoloration, Warmth, Positive Homan's sign -Explaining the seriousness of DVT and how they can be life threatening to Responsible Party's or families so they can make informed decisions. As of 01/06 /2025, 24-hour report will be reviewed at least five days weekly by the DON, ADON or a unit manager to identify any residents with leg swelling or pain requiring follow-up from provider. The Administrator communicated the responsibility of reviewing 24-hour reports to the DON, ADON and Unit Managers on 01/06/2025. This credible allegation of immediate jeopardy removal plan was reviewed and approved by an ad hoc QAPI meeting on 01/06/2025. Facility administrator notified DON of responsibility for completion of this credible allegation of immediate jeopardy removal plan on 01/06/2025. Alleged date of IJ removal: 01/07/2025. A validation of immediate jeopardy removal was conducted on 1/13/2025. Initial audits conducted revealed residents were evaluated for the presense of pain, if a provider had been notified, and for new/worsening leg swelling. Interviews with facility nursing staff (Nurses, Medication Aides, Nurse Aides) revealed staff had received education regarding pain assessment, change in condition, and how to report changes in condition to a medical provider without delay. Facility nursing staff were also educated about recognizing the signs and symptoms of a deep vein thrombosis and recognizing the seriousness of the development of a deep vein thrombosis. Facility nursing staff verbalized they were to explain the seriousness of a deep vein thrombosis to the resident and/or responsible party so they could make informed decisions involving care and treatment. The immediate jeopardy removal date of 1/7/2025 was validated.

Based on record review, and staff, Resident, Resident Responsible Party (RP), Nurse Practitioner, and Medical Director interview the facility Nurse Practitioner (NP) failed to communicate and collaborate with the Medical Director after Resident #1's RP voiced concerns on 12/11/2024 that Resident #1 was not receiving an anticoagulant (blood thinning medication, used to prevent blood clots) after having a fall at home and sustaining multiple fractures of the pelvis and lumbar (lower back) spine, and was not as mobile as she had been prior to admission to the facility. The Assistant Director of Nursing (ADON) contacted the NP on 12/11/2024 at which time the NP ordered aspirin which was later discontinued due to a listed allergy due to a history of gastrointestinal bleeding. The NP instructed the ADON to consult the Medical Director for further guidance regarding anticoagulation for Resident #1 and failed to reach out to the MD herself. On 12/27/2024 Resident #1 was evaluated by the NP at which time Resident #1 had pain, increased swelling, and a positive Homan's sign (pain behind the knee when the person's toes are pointed towards their head, indicative of a deep vein thrombosis/blood clot) in her left lower extremity. Resident #1 was transferred to the hospital on 12/28/2024 where she was diagnosed with the serious adverse outcome of deep vein thrombosis to her bilateral lateral lower extremities, requiring anticoagulation, and hospitalization . The deficient practice was identified for 1 of 3 residents (Resident #1) reviewed for change in condition. Immediate jeopardy began on 12/11/2024 when the NP failed to collaborate with the Medical Director for guidance about anticoagulation concerns raised by Resident #1's RP. Immediate jeopardy was removed on 1/8/2025 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance with a lower scope and severity of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The findings included: A Collaborative Practice Agreement (Nurse Practitioner) revealed the undersigned Nurse Practitioner (NP) and the undersigned physician (Physician) agree that NP shall practice in collaborative practice with Physician in accordance with terms of this Collaborative Practice Agreement (this Agreement). The Physician shall be continuously available for communication, consultation, collaboration, referral, and evaluation of care provided by NP. Consultation, which may include telecommunication, with Physician shall occur, at a minimum, (i) in any circumstance where NP feels uncertain regarding management of any patient problem or concern; (ii) when medical management is beyond NP's scope of practice; and (iii) when a patient requests the involved Physician. The Collaborate Practice Agreement was signed by the NP on 11/23/2024 and the Medical Director on 11/24/2024. Resident #1 was admitted to the facility on [DATE] with diagnoses which included multiple pelvic fractures, fracture of the lumbosacral spine (lower back and tailbone), and a history of a gastrointestinal bleed (bleeding in the digestive tract). Resident #1's medical record revealed Resident #1 had an allergy to aspirin with unknown reactions and severity. A nursing note dated 12/11/2024, authored by the Assistant Director of Nursing (ADON), revealed Resident #1's Responsible Party (RP) had requested to be placed on anticoagulant therapy and the Nurse Practitioner (NP) was notified. An order was received for Aspirin. Resident #1 had an allergy to Aspirin. The order for Aspirin was discontinued. The RP requested anticoagulation (blood thinning medication, used to prevent blood clots) due to enoxaparin (an anticoagulant injection used to prevent blood clots) being given at the hospital. Resident #1 and the RP explained that Resident #1 had a past medical history of gastrointestinal bleeding. The ADON provided education to Resident #1 and RP, that anticoagulation therapy would put Resident #1 at risk for developing a gastrointestinal bleed. An interview was conducted on 1/3/2025 at 4:00 pm with the NP. The NP stated she received notification from the ADON on 12/11/2024 that Resident #1's RP had requested Resident #1 to be placed on an anticoagulant. The NP stated she ordered aspirin to be administered daily and was later contacted by the ADON about Resident #1 having an allergy to aspirin. The NP stated she instructed the ADON to refer to the MD for further direction regarding anticoagulation. The NP stated she did not reach out or collaborate with the MD because she had instructed the ADON to do so. An NP note dated 12/18/2024 revealed Resident #1 was evaluated for a rash to bilateral lower extremities and a dry, rough, red rash to the left lower extremity. Resident #1 complained of mild itching and was noted to have trace edema to bilateral lower extremities. The NP recommended hydrocortisone cream 1% to be applied to the left lower extremity twice daily for 5 days. An NP note dated 12/27/2024 revealed Resident #1 was noted to have increased pain and swelling in her left lower extremity. Resident #1 was documented to have 2+ edema, increased pain, and a positive Homan's sign. The NP recommended a venous doppler study and for Resident #1 to be non-weight bearing to her left lower extremity. A provider communication form dated 12/27/2024 revealed Resident #1 was ordered an in-house venous doppler study of the left lower extremity with a diagnosis of edema and pain as well as non-weight bearing on left lower extremity until the doppler studies were available. Review of a nursing note dated 12/27/2024, authored by the DON, revealed Resident #1's RP was notified that a venous doppler study would not be available before Monday. The RP was fine with that knowledge and declined to send her to the Emergency Department (ED). An interview was conducted on 1/6/2025 at 11:34 am via telephone with Resident #1's RP. The RP stated she had gone to speak with the Director of Nursing (DON) on 12/11/2024 regarding her concern about Resident #1 not being on an anticoagulant due to her immobility/fractures, swelling in her legs, and a family history of blood clots. The RP stated Resident #1 had received blood thinner shots at the hospital prior to admission to the facility. The RP stated Resident #1 was seen by the NP on 12/18/2024 at which time she had discoloration to her left leg as well as swelling and was diagnosed with a rash. The RP stated the facility contacted her on 12/25/2024 about a planned discharge and insurance denial, at which time she expressed her concern over Resident #1's swollen left leg. The RP stated she spoke with the DON again on 12/27/2024, at which time she expressed concern about Resident #1 continuing to have swelling and pain in her left leg. The RP stated the DON had the NP evaluate Resident #1 at which time they ordered a venous doppler study. The RP stated neither the DON nor any facility staff offered to have Resident #1 sent to the hospital on 12/27/2024 for further evaluation. The RP stated she received a call on 12/28/2024 at 8:08 am (per her cell phone call log) from Resident #1 stating that her leg was hurting/more swollen and thought she needed to go to the hospital. The RP stated she called the facility at 10:08 am and insisted that the facility call EMS to have Resident #1 transferred to the hospital for further evaluation. The RP stated she received a phone call from a facility staff member at 10:21 am, at which time they reported EMS had been called. The RP stated when Resident #1 arrived at the hospital, a doppler study was performed in the ED, and Resident #1 was diagnosed with blood clots in her bilateral lower extremities and started on heparin. A nursing note dated 12/28/2024 at 10:25 am, authored by Nurse #2, revealed Resident #1 requested to go to the Emergency Department (ED) for left leg pain, swelling, and tenderness. Resident #1 stated she was hurting in the calf, behind the knee, and in her pelvic area. An ultrasound doppler was ordered but the company was not available on 12/27/2024 or over the weekend (12/28/2024-12/29/2024). Resident #1 and the RP were concerned about the pain and swelling, which is why they requested her to be sent to the ED. Change of condition documentation dated 12/28/2024, authored by Nurse #2, revealed Resident #1 had requested to go to the Emergency Department (ED). Resident #1's left leg was swollen (from hip to toes), painful, and tender to touch. The venous doppler study ordered 12/27/24 was unable to be performed before next week. Resident #1 was documented as having pain of a 4 on scale of 0-10 on the numerical pain scale (indicative of moderate pain) in the left knee, groin, and left lower leg. Nurse #2 attempted to notify the physician, but there was no answer, a message was left. An interview was conducted on 1/6/2025 at 11:41 am via telephone with Resident #1. Resident #1 stated while she was at the facility she had experienced left lower leg pain and swelling. Resident #1 stated she noticed increased leg swelling and pain that began on 12/18/2024. Resident #1 stated the swelling and pain continued to get worse, and recalled her leg being so swollen on Christmas (12/25/2024) that she tried to prop her leg up and stated her leg brace was much tighter than normal. Resident #1 stated on 12/27/2024, her left leg was really swollen. Resident #1 stated she experienced an achy pain and rated the pain as an 8-9 out of 10 on the numerical pain scale. Resident #1 stated the NP evaluated her on 12/27/2024 and ordered a test to be done at the facility. Resident #1 stated on 12/28/2024 she called the RP around 8:00 am and informed her that her left leg pain and swelling had gotten worse overnight and that she thought she needed to go to the hospital. Prior to Resident #1's conversation with the RP, Resident #1 stated there were two Nurse Aides (NAs) commented on her leg and how swollen it was. An EMS report dated 12/28/2024 revealed the facility had notified dispatch at 10:18 am regarding a sick person. EMS arrived at Resident #1's room at 10:31 am. Upon arrival to the facility, staff advised EMS that Resident #1 had broken her pelvis on both sides around 11/27/2024. Documentation revealed Resident #1 had noticed her left lower leg was starting to swell two weeks prior, and a week ago began to feel pain in the leg. Facility informed EMS the MD was aware and had ordered a doppler study which would not be available until later the following week which is why they wanted to transfer Resident #1 to the hospital. EMS obtained vital signs at 10:41 am at which time Resident #1 had a blood pressure of 182/74 (normal is 120/80), a heart rate of 90 beats per minute (normal is 60 to 100 beats per minute), a respiration rate of 18 breaths per minute (normal is 12 to 20 breaths per minute), a temperature of 98.8 degrees, and a pain level of 8 out of 10 on the numerical pain scale (indicative of severe pain). Resident #1 was transferred to the hospital at 10:45 am. EMS administered 4 milligrams (mg) of morphine for pain intravenously (through a catheter inserted in a vein). An Emergency Department (ED) note dated 12/28/2024 revealed Resident #1 presented to the ED from the facility for evaluation of bilateral lower extremity swelling, which had worsened over the last 2 weeks. A bilateral venous doppler study was conducted in the ED which revealed extensive deep vein thrombi in the left and right leg. A tibia/fibula (bones in the lower leg) x-ray revealed diffuse edema. Resident #1 was admitted to the hospital and placed on a heparin infusion with plans to later transition to Eliquis, an anticoagulant. Resident #1 remained in the hospital and did not return to the facility. As of date, she was still in the hospital was unsure of her actual discharge date from the hospital to another Skilled Nursing Facility. An interview was conducted on 1/6/2025 at 5:31 pm with the Assistant Administrator. The Assistant Administrator verbalized there was an agreement between the NP and the Medical Director regarding caring for residents. The Assistant Administrator stated if the NP needed guidance she was to reach out to the Medical Director. An interview was conducted on 1/7/2025 at 9:32 am with the Medical Director. The Medical Director stated that he collaborated with the NP by reading her notes. The Medical Director stated that he was never notified by the NP or any of the facility staff regarding Resident #1. The Medical Director stated he would have only expected the NP to reach out if there was a situation that she did not feel comfortable handling. The Medical Director stated if he had been notified about the increase in pain and swelling to Resident #1's left leg, he would have ordered a venous doppler study to be done within a day. The Medical Director stated if the venous doppler study would have been positive, indicating a blood clot, he would have started Resident #1 on an anticoagulant. The Medical Director stated if he would have been made aware the venous doppler study could not have been completed until the following week after it was ordered, he would have considered sending Resident #1 to the ED if she had experienced an increase in pain and swelling. The Administrator was notified of immediate jeopardy on 1/7/2025 at 11:10 am. 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: The facility Nurse Practitioner (NP) failed to communicate and collaborate with the Medical Director (MD) after Resident #1's family voiced concerns regarding anticoagulation therapy. The NP ordered Aspirin and later discontinued due to a documented allergy and because of history of gastrointestinal bleeding. The NP failed to collaborate with the MD for guidance of how to proceed. The NP did not consult with nor collaborate with the physician regarding the resident's symptoms. Resident had risk factors for Deep Vein Thrombosis (DVT), should have had coagulation therapy and sent out to the hospital for Doppler (diagnostic test to diagnose a blood clot or DVT). The NP delegated the collaboration to the Assistant Director of Nursing (ADON) instead of collaborating with the MD herself. Resident #1 was transferred to the hospital on 12/28/24 where she was diagnosed with blood clots to her bilateral lower extremities. Resident #1 required anticoagulation and hospital admission. All residents are at risk related to deficient practice On 1/7/25 the MD audited residents seen within the last thirty days by the NP to ensure if further collaboration was required. No residents identified at risk. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be completed: On 1/7/25 the Administrator met with the Medical Director and NP and reviewed the expectations of the MD and NP communicating and collaborating with each other. NP should consult with MD in any circumstance regarding medical management needing a higher level of care or beyond his/her scope of practice. The agreement between the providers was reviewed, no changes were made to the provider agreement. The NP was educated on when she should consult with the MD based on review of scope of practice and collaborative provider agreement. On 1/7/25 the Medical Director/Senior partner of provider group educated the MD and all attending Physicians and on call that the NP should consult with MD in any circumstance regarding medical management needing a higher level of care or beyond his/her scope of practice defined by the North Carolina Medical Board and North Carolina Board of Nursing. On 1/7/25 The Medical Director informed the Administrator and DON that the MD and NP will have weekly meetings to ensure ongoing collaboration, and the MD will report any results of the meetings to Administrator and DON. This credible allegation of immediate jeopardy removal reviewed and approved by an AD Hoc QAPI meeting on 1/7/25. Facility administrator notified MD of responsibility for credible allegation of immediate jeopardy removal on 01/07/25. Alleged IJ removal date is 1/8/2025 A validation of immediate jeopardy removal was conducted on 1/13/2025. Initial audits conducted revealed the Medical Director had reviewed all resident visits for the last thirty days with no further issues present. Interviews with facility staff revealed the Nurse Practitioner was to collaborate with the Medical Director regarding any issues/concerns regarding the care of a resident. Facility nursing staff verbalized they were also to alert nursing management regarding issues/concerns so that nursing management could ensure follow-through. Interviews with the Nurse Practitioner and the Medical Director revealed they had received education regarding collaborating about resident care. The Nurse Practitioner verbalized understanding that she was supposed to reach out to the Medical Director if there was an issue in question or if something out of her scope needed to be addressed. The immediate jeopardy removal date of 1/8/2025 was validated.

Based on record review, Nurse Practitioner (NP), Resident, Resident Responsible Party (RP), and staff interviews, the facility failed to manage a resident's pain (Resident #1) when she experienced increased pain combined with swelling and redness on 12/18/2024 in her left lower extremity. Resident #1 reported she had experienced pain to her left leg on 12/18/2024 and it got worse until she called her family and requested to go the hospital on 12/28/2024. Resident #1's RP called the facility on 12/28/2024 and requested that Resident #1 be sent to the hospital due to increased pain and swelling in her left leg. Emergency Medical Services (EMS) were called to the facility and noted Resident #1 to have an elevated blood pressure of 182/74 (normal is 120/80) and pain of 8 out of 10 on a numerical pain scale (indicative of severe pain). EMS administered morphine (narcotic pain medication) 4 milligrams (mgs) to Resident #1 before arriving at the hospital. Resident #1 experienced pain at 8-9 out of 10 on the numerical pain scale. The deficient practice was identified for one of three residents reviewed for pain management (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included multiple pelvic fractures, fracture of the lumbosacral spine (lower back and tailbone), and a history of a gastrointestinal bleed (bleeding in the digestive tract). A care plan dated 12/2/2024 revealed Resident #1 had acute pain related to multiple fractures with interventions which included for staff to administer analgesia per order, observe/report changes in usual routine, sleep patterns, decrease in functional abilities, decreased range of motion, withdrawal or resistance to care, and to notify the physician if interventions were not successful or if the current complaint is a significant change from Resident #1's past experience of pain. A physician's order dated 12/3/2024 revealed Resident #1 was ordered oxycodone-acetaminophen 5-325 milligrams (mg) every 4 hours as needed for pain. The December 2024 Medication Administration Record (MAR), from 12/3/2024 through 12/8/2024, revealed Resident #1 had received as needed (PRN) pain medication, oxycodone-acetaminophen 5-325 mg and it was effective. An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact, had impairment on both sides of her lower extremities, utilized a wheelchair, received as needed pain medications, received scheduled pain medication regimen in the last 5 days, had pain frequently during the assessment period and rated pain at a 7 on a scaled of 0 -10. The December 2024 MAR, from 12/9/2024 through 12/11/2024, revealed Resident #1 had received as needed (PRN) pain medication, oxycodone-acetaminophen 5-325 mg, and it was effective. A physician's order dated 12/11/2024 revealed Resident #1 was ordered acetaminophen 650 mg three times a day for pain (9:00 am, 2:00 pm, and 9:00 pm) for pain in addition to the as needed oxycodone-acetaminophen. The December 2024 MAR, from 12/12/2024 through 12/17/2024, revealed Resident #1 had received as needed (PRN) pain medication, oxycodone-acetaminophen 5-325 mg. and it was effective. An interview was conducted on 1/6/2025 at 11:41 am via telephone with Resident #1. Resident #1 stated while she was at the facility she had experienced left lower leg pain and swelling around 12/18/2024. Resident #1 stated she noticed worsened leg swelling and pain that began on 12/18/2024. A change in condition evaluation dated 12/18/2024 at 11:45 am, completed by the Director of Nursing (DON), revealed Resident #1 had edema and redness to her left lower leg. There was no pain status evaluation performed at that time. A pain assessment conducted on 12/18/2024 at 9:59 pm, by Nurse #4, revealed Resident #1 rated her pain as a 7 out of 10 on the numerical pain scale and was documented as having received oxycodone 5-325 mg. On 12/18/2024 at 9:59 pm there was a documented pain level of 7 out of 10. There was no source of pain identified. The medication administration was documented as effective. The December 2024 MAR, from 12/22/2024 through 12/25/2024, revealed Resident #1 had received as needed (PRN) pain medication, oxycodone-acetaminophen 5-325 mg on 12/22/2024 at 9:28 pm for a documented pain level of 3 out of 10. There was no source of pain identified. The medication administration was documented as effective. An interview was conducted on 1/6/2025 at 11:41 am via telephone with Resident #1. Resident #1 stated the swelling and pain continued to get worse, and recalled her leg being so swollen on Christmas (12/25/2024) that she tried to prop her leg up and stated her leg brace was much tighter than normal. An interview was conducted on 1/5/2025 at 1:51 pm with Nurse #4. Nurse #4 stated she worked nightshift and had been assigned Resident #1 on 12/25/2024. Nurse #4 was unable to recall Resident #1 having any swelling to her left or right leg. Nurse #4 stated she administered pain medication when she assessed Resident #1 to have pain. According to the December 2024 MAR, there was a documented pain level of 7 out of 10 on 12/26/2024 at 4:48 pm. There was no source of pain identified. The medication administration was documented as effective. There was no administration of PRN medications given after 4:48 pm on 12/26/2024. An interview was conducted on 1/5/2025 at 12:55 pm with Nurse Aide (NA) #1. NA #1 stated she worked on night shift (7:00 pm to 7:00 am) at the facility and stated the last night that she worked with Resident #1 was on 12/26/2024 at which time she noticed Resident #1's left leg was a little red and swollen, nothing too serious. NA #1 stated Resident #1 expressed she was in pain at which time she notified Nurse #1. NA #1 was unable to recall if Nurse #1 administered any medication for pain. Nurse #1 was unavailable for interview. An interview was conducted on 1/6/2025 at 11:41 am via telephone with Resident #1. Resident #1 stated on 12/27/2024, her left leg was really swollen. Resident #1 stated she experienced an achy pain and rated the pain as an 8-9 out of 10 on the numerical pain scale. Resident #1 stated the NP evaluated her on 12/27/2024 and ordered a test to be done at the facility. An interview was conducted on 1/6/2025 at 11:34 am via telephone with Resident #1's RP. The RP stated she spoke with the DON on 12/27/2024, at which time she expressed concern about Resident #1 continuing to have swelling and pain in her left leg. The RP stated the DON had the NP evaluate Resident #1 at which time they ordered a venous doppler study. The RP stated neither the DON nor any facility staff offered to have Resident #1 sent to the hospital on 12/27/2024 for further evaluation. A pain assessment conducted on 12/27/2024, by Medication Aide (MA) #2, between 7:00 am and 7:00 pm, revealed Resident #1 had a pain level of 8 out of 10 on the numerical pain scale (indicative of severe pain). There were no documented administrations of as needed oxycodone-acetaminophen 5-325 mg on 12/27/2024. An interview was conducted on 1/5/2025 at 3:27 pm with MA #2. MA #2 stated she worked on 12/27/2024. MA #2 stated she was unable to recall Resident #1. An interview was conducted on 1/5/2025 at 1:24 pm with NA #3. NA #3 stated she worked dayshift (7:00 am to 7:00 pm) on 12/27/2024 and was assigned Resident #1. NA #3 stated Resident #1's left leg was more swollen than the other leg and stated Nurse #3 was aware of the swelling and Resident #1 was evaluated by the NP on 12/27/2024. NA #3 was unable to recall if Resident #1 was in any pain. An interview was conducted on 1/3/2025 at 4:09 pm with Nurse #3. Nurse #3 stated she worked dayshift (7:00 am to 7:00 pm) and had been assigned Resident #1 on multiple occasions, including 12/27/2024. Nurse #3 stated Resident #1's legs started swelling before Christmas, 12/25/2024. Nurse #3 stated the NP had previously evaluated Resident #1 and ordered cream to be administered. Nurse #3 stated the swelling in Resident #1's left leg had worsened and when she was assigned Resident #1 on 12/27/2024 she had the DON come assess Resident #1's leg with her. Nurse #3 stated on 12/27/2024 Resident #1's left leg was swollen; she was unable to recall the leg being hot and was unable to recall if Resident #1 was in pain on 12/27/2024. Nurse #3 stated the DON had the NP come back to evaluate Resident #1 at which time a venous doppler study was ordered. An interview was conducted on 1/3/2025 at 4:00 pm with the NP. The NP stated the last time she saw Resident #1 was on 12/27/2024 for left leg pain at which time Resident #1 was having increased pain and swelling to her left lower extremity. The NP stated that she had ordered an in-house venous doppler study of the left lower extremity and recommended Resident #1 be non-weight bearing to the left leg. The NP stated Resident #1 had swelling and a positive Homan's sign (pain behind the knee when the persons toes are pointed towards their head in her left lower extremity, indicative of a deep vein thrombosis/blood clot) at that time. The NP stated Resident #1 did complain of pain at the time of the visit. A follow up interview was conducted on 1/13/2025 at 12:43 pm with the NP. The NP stated she had no further comments about Resident #1's pain and stated to refer to her notes. An interview was conducted on 1/6/2025 at 11:41 am via telephone with Resident #1. Resident #1 stated on 12/28/2024 she called the RP around 8:00 am and informed her that her left leg pain and swelling had gotten worse overnight and that she thought she needed to go to the hospital. Prior to Resident #1's conversation with the RP, Resident #1 stated there were two NAs that commented on her leg and how swollen it was. The December 2024 MAR revealed Resident #1 was documented as having received acetaminophen 650 mg as scheduled daily except for 12/28/2024 at which time Resident #1 was documented as hospitalized for the 9:00 am dose of acetaminophen 650 mg by Medication Aide (MA) #1. An interview was conducted on 1/6/2025 at 11:34 am via telephone with Resident #1's RP. The RP stated she received a call on 12/28/2024 at 8:08 am (per her cell phone call log) from Resident #1 stating that her leg was hurting/more swollen and thought she needed to go to the hospital. The RP stated she called the facility at 10:08 am and insisted that the facility call EMS to have Resident #1 transferred to the hospital for further evaluation. An interview was conducted on 1/6/2025 at 10:30 am with NA #2. NA #2 stated she worked dayshift and was assigned Resident #1 on 12/28/2024. NA #2 stated when she rounded on Resident #1 between 7:30 am and 8:00 am, she noticed Resident #1 she had noticeable swelling of her left leg, redness near the ankle, and warmness to the touch. NA #2 stated Resident #1 had also expressed she had pain in her left leg. NA #2 stated she immediately notified Nurse #2 and stated Resident #1 was transferred to the hospital later that morning on 12/28/2024. An interview was conducted on 1/5/2025 at 4:48 pm with NA #4. NA #4 stated she worked dayshift and assisted with caring for Resident #1 on 12/28/2024. NA #4 stated when she went in Resident #1's room at the beginning of the shift (between 7:00 am and 8:00 am) Resident #1 was complaining about her left leg being swollen. NA #4 stated Resident #1 had swelling from her left hip down to her toes. NA #4 stated there was redness towards the bottom of Resident #1's left lower leg, and stated Resident #1 was in a lot of pain. NA #4 stated she reported the concerns to Nurse #2. An interview was conducted on 1/5/2025 at 12:48 pm with Nurse #2. Nurse #2 stated she worked dayshift and 12/28/2024 she was assigned Resident #1 for the first time. Nurse #2 stated she was approached by a staff member (unable to remember who) about Resident #1's left leg being swollen. Nurse #2 stated she assessed Resident #1's left leg was significantly more swollen than the right leg, had redness from the knee to the ankle, was warm to the touch, and painful (from behind the knee, the calve, and the pelvic area). Nurse #2 stated Resident #1 was experiencing pain in her left leg at that time. Nurse #2 stated Resident #1's RP called her and asked to have Resident #1 sent to the hospital for evaluation. Nurse #2 stated she tried to call the on-call provider and there was no answer, so she left a message for a return call. Nurse #2 stated she then decided to call Emergency Medical Services (EMS). An interview was conducted on 1/6/2025 at 1:00 pm with the Director of Nursing (DON). The DON stated she was familiar with Resident #1. The DON stated she had spoken with the RP on the day Resident #1 was supposed to be discharged , 12/27/2024, about Resident #1's leg being red. The DON stated she went to Resident #1's room on 12/27/2024 and stated Resident #1 was not in any pain and stated she witnessed Resident #1 get up and walk to the bathroom. The DON stated Resident #1 was given her scheduled acetaminophen as ordered on 12/27/2024 and stated she was unsure why Resident #1 had not received her 9:00 am dose of acetaminophen on 12/28/2024. The DON stated if Resident #1 would have complained of pain, she would have expected the nurse to administer acetaminophen, and if the pain did not improve, she would have expected the nurse to then administer oxycodone-acetaminophen as ordered. The DON was unable to explain why Resident #1 was not given any pain medication on 12/28/2024. An EMS report dated 12/28/2024 revealed the facility had notified dispatch at 10:18 am regarding a sick person. EMS arrived at Resident #1's room at 10:31 am. Upon arrival to the facility, staff advised EMS that Resident #1 had broken her pelvis on both sides around 11/27/2024, starting 2 weeks ago Resident #1 had noticed her left lower leg was starting to swell, and a week ago began to feel pain in the leg. EMS obtained vital signs at 10:41 am at which time Resident #1 had a blood pressure of 182/74 (normal is 120/80), a heart rate of 90 beats per minute (normal is 60 to 100 beats per minute), a respiration rate of 18 breaths per minute (normal is 12 to 20 breaths per minute), a temperature of 98.8 degrees, and a pain level of 8 out of 10 on the numerical pain scale (indicative of severe pain). While enroute to the hospital, EMS administered 4 milligrams of morphine (narcotic pain medication) for pain intravenously (through a catheter inserted in a vein). An Emergency Department (ED) note dated 12/28/2024 revealed Resident #1 presented to the ED from the facility for evaluation of bilateral lower extremity swelling, which had worsened over the last 2 weeks. A bilateral venous doppler study was conducted in the ED which revealed extensive deep vein thrombi in the left and right leg. A tibia/fibula (bones in the lower leg) x-ray revealed diffuse edema. Resident #1 was admitted to the hospital and placed on a heparin infusion with plans to later transition to Eliquis, an anticoagulant.

Based on record review, and staff interviews, the facility failed to report an allegation of neglect to the state survey agency for 1 of 3 residents reviewed for neglect (Resident #1). The findings included: The Administrator, Assistant Administrator, and Regional Nurse Consultant #1 were notified by a State Surveyor on 1/6/2025 at 6:08 pm of neglect that affected Resident #1. An interview was conducted on 1/13/2025 at 2:00 pm with the Assistant Director of Nursing (ADON). The ADON stated that when anyone reported an allegation of abuse or neglect, the abuse coordinator (the Administrator) was responsible for filing a report with the state survey agency. The ADON stated she was not sure if the Administrator had filed an Initial Allegation Report following the notification of allegation of neglect on 1/6/2025. Verification with the Complaint Intake Unit for the State Survey Agency was conducted on 1/13/2025 at 12:48 pm revealed the facility had not filed a report for an allegation of neglect related to Resident #1. An interview was conducted on 1/13/2025 at 2:07 pm with the Director of Nursing (DON). The DON stated the facility was required file a 2-hour report, 24-hour report, and then a 5-day investigation. The DON stated the abuse coordinator, the Administrator, was responsible for filing reports to the state. The DON stated she did not think that the Administrator had filed a report after being made aware of the allegation of neglect on 1/6/2025 at 6:08 PM and stated there should have been a report made. An interview was conducted on 1/13/2025 at 2:15 pm with the Assistant Administrator. The Assistant Administrator stated when a resident or family member alleged abuse or neglect, the Administrator was responsible for filing a report to the state immediately. The Assistant Administrator verbalized that a report had not been filed after notification of neglect on 1/6/2025 because Resident #1 or Resident #1's Responsible Party (RP) had not voiced concerns of neglect to the facility. An interview was conducted on 1/13/2025 at 3:31 pm with the Director of Clinical Operations. The Director of Clinical Operations stated the facility had not filed a report after the allegation of neglect was made on 1/6/2025. The Director of Clinical Operations stated the facility had written an abatement (plan to correct the immediate problem) for the allegation of neglect and the state was already aware of the allegation and there was no reason to report it to the state. The Administrator was not available for an interview on 1/13/2025.

Based on record review, observation, crash cart checklist, and staff, Respiratory Therapist, and Medical Director (MD) interviews the facility failed to immediately initiate Cardiopulmonary Resuscitation (CPR) when Resident #103, who was a full code had agonal breathing (a state of breathing of gasping for air due to the brain receiving insufficient oxygen) and went pulseless, failed to immediately utilize the overhead paging system to call staff to Resident #103's room (code blue), and failed to immediately active Emergency Medical [NAME] (EMS). Once the Respiratory Therapy recognized the need for CPR, they failed to implement the use of the Automated External Defibrillator (AED), failed to have available or use an oral airway, and the regulator on the emergency oxygen tank on the crash cart only went to 10 liters. Resident #103 was pronounced deceased and resuscitative efforts were stopped. This affected 1 of 1 resident reviewed for CPR. Immediate jeopardy began on [DATE] when the staff failed to immediately initiate CPR for Resident #103 who was a full code. Immediate jeopardy was removed on [DATE] 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 education is completed and monitoring systems put into place are effective. The findings included: A review of the facility's Emergency Procedure - Cardiopulmonary Resuscitation policy dated 2022 revealed the facility's procedure for administering CPR shall incorporate the steps covered in the American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care of facility Basic Life Support (BLS) training material. The policy stated the facility should maintain equipment and supplies necessary for CPR/BLS in the facility at all times and if an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: instruct a staff member to activate the emergency response system. Review of the American Heart Association Guidelines for Adult Basic Life Support for Healthcare providers dated 2020 read in part, verify scene, check for responsiveness, shout for help, activate emergency response, get AED and emergency equipment. Start CPR, perform cycles of 30 compressions and 2 breaths, and use AED as soon as it is available. A review of the standard Crash Cart checklist located on top of the crash cart, not dated, revealed a full tank of oxygen with a 15-liter regulator, oxygen wrench, sharps container, backboard, suction machine with tubing, bag-valve mask, and clipboard with paper should be kept outside of the cart. Gauze, a flashlight, a roll of tape, alcohol pads, safety needs, CPR kit, Narcan, 3-milliliter (ml) syringe, 10 ml syringe, pulse oximetry device, lubricant, tongue blades, saline bullets, and needles should be kept in the top drawer of the crash cart. A non-rebreather face mask, simple face mask, oxygen tubing, suction catheter kits, nasal cannula, oral airway (a devise used to keep the tongue from covering the airway), suction, and sterile water should be kept in the second drawer of the crash cart. A saline flush, intravenous (IV, needle or catheter placed in the vein to deliver medications/fluids) kits, IV cap, IV connector, Huber needle (used to access ports), Normal Saline, central line dressing change kit, and IV tubing should be kept in the third drawer of the crash cart. Various sizes of gloves, a stethoscope, blood pressure cuff, spill kit, and AED with 2 sets of pads should be kept in the bottom drawer of the code cart. Resident #103 was admitted to the facility on [DATE] with a diagnosis of a fracture (break) of the right femur (long bone located at the top of the leg) and post right periprosthetic hip fracture (a broken bone that occurs around the implant of a total hip replacement). Review of an admission Minimum Data Set (MDS) dated [DATE] revealed Resident #103 was moderately cognitively impaired. Review of a physician's order dated [DATE] revealed Resident #103 was a full code and wanted to receive cardiopulmonary resuscitation (CPR). A review of the [DATE] Medication Administration Record (MAR) revealed Resident #103 was documented as having received ondansetron (medication used to treat nausea and vomiting) 4 milligrams (mg) by mouth on [DATE] at 5:21 pm. A review of a nursing note dated [DATE] and the time of entry was 8:43 PM, authored by Nurse #3, revealed Resident #103's family requested ondansetron for nausea for Resident #103. The dose was given at 5:21 pm. Resident #103 had returned from a doctor's appointment vomiting green fluid with no food particles per Resident #103's family. Resident #103 refused supper and ondansetron was effective. The family later came to the nurses' station and stated Resident #103 was not responding. A sternal rub was performed by Nurse #3 with minimal response from Resident #103. Vital signs were taken, and the resident had a blood pressure of ,d+[DATE] (normal range is ,d+[DATE] to ,d+[DATE]), heart rate of 90 beats per minute (normal range is 60 to 100 beats per minute), respiration rate of 18 breaths per minute (normal range is 12 to 20 breaths per minute), and a temperature of 96.7 degrees (normal is 98.6 degrees Fahrenheit). Resident #103's oxygen saturation level dropped into the 70's (normal range is greater than or equal to 92%) and Resident #103 was placed on oxygen (unspecified amount). 911 was called and CPR was started on Resident #103. Resident #103 was pronounced deceased at 7:50 pm. Nurse #3 was unavailable for an interview. Review of a telephone statement dated [DATE], taken by the former Director of Nursing (DON), who was the Assistant Director of Nursing at the time) on behalf of Nurse #3, revealed at approximately 4:00 pm on [DATE], Resident #103 returned to the facility from a doctor's (orthopedic) appointment with green bile on him that he had vomited in the car with his family. Resident #103's family had assumed Resident #103 had gotten car sick. The family came to the nurses' station around 5:15 pm and requested ondansetron (medication used to treat nausea and vomiting) for Resident #103. Ondansetron was administered at 5:21 pm. The family came and got Nurse #3 around 6:30 pm and Nurse #3 went into Resident #103's room and assessed him. Nurse #3 checked Resident #103's vital signs, and his blood pressure was low, pulse and respirations were good, and he did not have a fever. Nurse #3 performed a sternal rub on Resident #103, and he opened his eyes. The family thought Resident #103 was sleepy. Nurse #3 reported she was going to send Resident #103 to the hospital but did not know where the on-call provider number was and then the second shift (7:00 pm to 7:00 am) nurse came in. Nurse #3 stated she informed Nurse #8 that Resident #103 was not doing well and they proceeded to go to Resident #103's room. Nurse #3 reported she called 911 and told EMS it was emergent, and someone had paged a Code Blue. Nurse #3 reported Nurse #8 performed CPR until EMS got there and took over. Nurse #3 reported Resident #103 was pronounced dead at 7:50 pm. An interview was conducted on [DATE] at 9:32 am with Nurse Aide (NA) #2. NA #2 stated she worked on [DATE] during second shift (3:00 pm to 11:00 pm) and was assigned Resident #103. NA #2 stated she was in the process of taking her lunch break, around 7:00 pm, and was approached by Nurse #3 in the hall. NA #2 stated that Nurse #3 panicked and did not know what to do and stated that Resident #103 had coded. NA #2 stated she showed her where the crash cart was at the nurses' station and instructed Nurse #3 to call 911. NA #2 stated Nurse #3 did not initiate CPR and had someone use the overhead paging system to call a Code Blue. NA #2 stated several minutes passed by when she was assisting Nurse #3 locate the crash cart and directing her to call 911 for EMS. NA #2 stated she stood at Resident #103's door with the family until the nurses and Respiratory Therapist entered the room, CPR was then initiated several minutes later. NA #2 stated she stayed out in the hall with Resident #103's family. A review of a typed statement dated [DATE], authored by Nurse #9, revealed the staff told her a resident was gone (had expired). Nurse #9 ran down to the 600 hall and told staff to call a Code Blue over the intercom. Nurse #9 arrived at the room around 7:00 pm after she received report from the 200-hall nurse. Nurse #3 was sitting at the nurses' station on the phone with Emergency Medical Services (EMS). Nurse #9 documented the crash cart was in the room and Nurse #8 was monitoring the situation. Nurse #9 documented Resident #103 had a pulse, but did not look good, and noticed his fingers were blue. Nurse #9 checked on the family member in the hallway and informed her Resident #103 was still alive, at which time staff called out of the room that they had started chest compressions. Nurse #9 documented Nurse #14 started compressions, and the RT began bagging (ventilating) Resident #103. Nurse #3 remained on the phone with EMS. EMS arrived in the room and placed a CPR vest (mechanical chest compression device that goes around the resident's chest) on Resident #103. An interview was conducted on [DATE] at 3:46 pm with Nurse #9. Nurse #9 stated she worked second shift (3:00 pm to 11:00 pm) on [DATE] and was not assigned Resident #103. Nurse #9 stated an NA (name unknown) came to her and told her to go to Resident #103's room because they needed help. Nurse #9 stated when she arrived at Resident #103's room, Nurse #3 was calling EMS from the nurse's station and the family was in the hall. Nurse #9 stated she spoke with Nurse #8 and was told by Nurse #8 Resident #103 was not breathing well. Nurse #9 stated she went into the room and yelled for someone to get the crash cart and call a Code Blue. Nurse #9 stated she did not perform CPR and comforted the family member in the hall. A review of a Report on a Code Blue event dated [DATE], authored by the agency RT and submitted to her supervisor, revealed that at approximately 7:15 pm, an overhead announcement for a Code Blue was called for Resident #103. The RT responded to Resident #103's room at which time she observed Resident #103 was unresponsive, with an oxygen saturation level at 76% and dropping, CPR had not been initiated. The RT instructed staff to begin CPR and requested a bag-valve mask (mask used to give breaths during CPR using positive pressure, squeezing bag). Resident #103 was observed with a simple mask on with insufficient oxygen flow, which she documented as likely causing carbon dioxide retention. The bag-valve mask did not inflate properly which indicated inadequate oxygenation. Challenges faced were documented as a delay in CPR initiation: initial hesitation and lack of coordinated effort from the team delayed effective CPR. The resident's pupils were fixed and dilated, indicating a critical need for timely intervention. Equipment and flow issues: the bag-valve mask did not inflate properly, raising concerns about oxygen delivery. The outcome was documented as despite multiple efforts, including epinephrine administration and advanced airway management attempts, the patient remained unresponsive. After approximately 25 minutes of high-performance CPR, the resident was pronounced dead at 7:50 pm. Post-event reflection documentation revealed the RT had spoken with Nurse #3 at which time Nurse #3 reported she was called to check on Resident #103, who had agonal breathing, however, CPR was not started promptly. The RT emphasized the importance of initiating CPR immediately upon finding a resident without a pulse and ensuing continuous efforts are made until help arrives, as per the American Heart Association (AHA) guidelines. The conclusion documentation stated This event highlights the critical need for prompt and coordinated response during Code Blue situations. Immediate initiation of CPR and effective team communication are essential to improve resident outcomes. Further training and drills are recommended to ensure all staff are prepared to respond effectively to similar emergencies in the future. The report was electronically signed by the RT. An interview was conducted on [DATE] at 10:24 am with the agency Respiratory Therapist (RT). The RT stated she worked as an RT on night shift 7:00 pm to 7:00 am and responded to the Code Blue called on [DATE] for Resident #103. The RT stated she was in the RT office when she heard a Code Blue paged overhead on the intercom for Resident #103's room around 7:15 pm and immediately responded (The RT's office was approximately 400 feet from the resident's room). The RT stated upon entering the room, there was a nurse and an NA standing beside the resident's bed, Resident #103 was hooked up to a vital sign machine, was on oxygen via face mask, and had an oxygen saturation of 76% (normal oxygen saturation range is >92%). The RT stated that she immediately assessed Resident #103 at which time he had no carotid pulse (pulse in the neck), fixed/dilated pupils, and agonal breathing, but was warm to touch. The RT stated other nurses had arrived in the room behind her and she instructed them to initiate CPR. The RT stated during the code the oxygen tank on the crash cart would only go up to 10 liters of oxygen per minute (instead of 15 liters per minute) and that the pressure that came out of the oxygen tank was not enough to inflate the bag on the bag-valve-mask, there was no oral airway in the cart, and she was unsure if there was an AED in the crash cart. The RT stated chest compression and ventilation were performed by a nurse (name unknown) until EMS arrived on scene. The RT stated CPR continued until EMS called a time of death. After the Code Blue the RT approached Nurse #3 and asked her why she had not initiated CPR and was told by Nurse #3 it was because she was alone and did not have any shoes on. An interview was conducted on [DATE] at 1:35 pm with Nurse #8. Nurse #8 stated she was an agency nurse, and was scheduled to work from 7:00 pm to 7:00 am on [DATE]. Nurse #8 stated on [DATE] she arrived at work late around 7:15 PM and was met in the hall by staff and was told Resident #103 did not look well. Nurse #8 stated she asked Nurse #3 about Resident #103 and urgently grabbed the vital sign equipment and ran into the room. Nurse #8 stated when she arrived in Resident #103's room the resident had difficulty breathing and he was unable to get a pulse oximetry reading. Nurse #8 stated the RT entered the room; she could not feel a pulse and began CPR. Nurse #8 stated the RT ran the code and instructed staff. Nurse #8 stated 2 other nurses arrived at the room and they rotated chest compressions every two minutes and one nurse called 911. Nurse #8 stated 2 to 3 rounds of CPR were performed and the RT remained at the head of the bed prior to EMS arrival, ventilating (supplying breaths) the resident, Nurse #8 stated when EMS arrived, they placed a defibrillator (an electrical shock across the chest used to treat life-threatening arrhythmias such as ventricular tachycardia and ventricular fibrillation) on Resident #103 and the chest compression device. Nurse #8 recalled EMS defibrillating (shocking) Resident #103 after he was placed on the cardiac monitor. Nurse #8 stated EMS spoke with the family, and the family wanted to stop chest compressions, and the time of death was called. Nurse #8 stated the AED was not on the crash cart which is why it was not placed on Resident #103 prior to EMS arrival. An observation of the crash cart on [DATE] at 10:43 AM along with the Unit Manager revealed there was an Automated External Defibrillator (AED) in the bottom drawer of the cart. A review of an EMS report dated [DATE] revealed EMS call was received at 7:22 PM, the call was reported as emergent with lights and sirens for cardiac arrest. EMS arrived on scene at 7:28 PM, and arrived at Resident #103 at 7:36 PM at which time CPR was being performed by facility staff on Resident #103. CPR had been performed for approximately 10 minutes prior to EMS arrival. Resident #103 had a shockable rhythm and was manually defibrillated at 7:41 pm and again at 7:43 pm. Time of death was documented at 7:50 pm. An interview was conducted on [DATE] at 9:37 am with DON. The DON stated on [DATE] she was in the position of Assistant Director of Nursing (ADON). The DON stated after the Code Blue on [DATE] which involved Resident #103, she was asked by the Former DON, to gather written statements from Nurse #3 and Nurse #8. The DON stated she was told by Nurse #3 that Resident #103 had gone to a doctor's appointment and when he returned to the facility, he stated having nausea. The DON stated the family had later approached Nurse #3 and said that something was not right. DON was told by Nurse #3 that Nurse #3 and Nurse #8 had gone to the room to assess Resident #103 at which time they called a Code Blue and initiated CPR. The DON stated Nurse #3 was terminated following the Code Blue incident on [DATE]. A telephone interview was conducted on [DATE] at 10:31 am with the Former DON. The Former DON stated she was not able to recall much about the Code Blue event which involved Resident #103. An interview was conducted on [DATE] at 10:04 am with the Medical Director (MD). The MD stated Resident #103 had been admitted to the facility following a hip fracture. The MD was made aware of Resident #103 requiring CPR and later deceased . The MD stated he was not aware that the AED had not been applied prior to EMS arrival at the facility and was not aware that EMS had defibrillated Resident #103 two times after their arrival on scene. The MD stated the application would have not hurt his chance of survival had it been applied by facility staff and said that it was hard to say if it would have changed the outcome of the situation. The MD stated he suspected Resident #103 may have died of a pulmonary embolism (a blood clot that stops the flow of blood to an artery in the lungs). The MD stated that if a resident was a full code and in distress, he would expect them to initiate EMS and CPR if indicated. An interview was conducted on [DATE] with the Administrator. The Administrator stated she was familiar with Resident #103 and recalled that on [DATE] Resident #103 had gone out of the facility to a doctor's appointment and passed away later that night. The Administrator stated she was informed about the Code Blue during the morning meeting on [DATE]. The Administrator stated she had read some statements from facility staff regarding the Code Blue. She had not been made aware the RT's written statement had been emailed to the Respiratory Therapy Supervisor who was an administrative staff member at the facility. Had she been made aware that the email which outlined a delay in response and initiation of CPR and equipment failure she would have immediately addressed the issues. The Administration was notified of Immediate Jeopardy on [DATE] at 3:33 pm. The facility provided the following credible allegation of Immediate Jeopardy Removal: Identify those recipients who have suffered and those who are likely to suffer a serious adverse outcome as result of the noncompliance: Beginning on [DATE] on the ,d+[DATE] shift, Resident #103 had a change in condition which led to resident becoming unresponsive and went into Cardiopulmonary arrest. The staff failed to respond timely to initiate CPR and delayed in calling 911. The facility staff failed to implement the use of the AED. The center failed to have available or use an oral airway during event and the emergency tank on crash cart had a regulator which only went to 10 liters. On [DATE] at approximately 4:00 p.m. the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) completed an audit of the centers three Crash Carts to ensure that they were adequately supplied, all carts noted to be supplied with all required supplies/equipment in working order (Full O2 tank with 15-LPM Regulator, Suction machine and tubing, Oxygen wrench, sharps container, backboard, clipboard with paper, ambu bag, gauze 4x4, flashlight, tape, alcohol pads, Huber needle, 3cc syringe, 10cc syringe, safety needles, Surgi lube, tongue blades, saline, pulse oximeter, IV start kits, IV cap, IV tubing, IV connector, 20, 22 & 24G Jelco catheters, non-rebreather face mask, face mask, oxygen tubing, suction cath kit, nasal cannula, oral airway, Yankaur, gloves, stethoscope, BP cuff, Spill kit). Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. The center has a policy that has been reviewed by the IDT and medical director, the policy indicates that the center will perform BLS level CPR. Policy states a licensed staff member is responsible for providing BLS CPR. Policy review dated [DATE]. On [DATE] the Director of Nursing validated that all three crash carts have emergency oxygen tanks that go to 15 liters. On [DATE] the Administrator and Medical Director decided to remove the AED's from the center. A note was place on each crash cart indicating that the AEDs are no longer in use at the center. On [DATE] center HR Director reviewed all current staff and agency staff cpr certification and they were current. The center HR Director and /or the Assistant Administrator verifies agency staff are cpr certified upon their assignment to the center. On [DATE] the center Administrator notified the Director of Nursing of immediate implementation of Mock Code Drills increasing from Quarterly to Monthly. Mock Code Drills are conducted by the DON or ADON. On [DATE] at approximately 5:00 p.m. the Director of Nursing and Nursing Leadership Team which includes ADON, Unit Managers, Wound Nurse, initiated education for all licensed nurses and Respiratory Therapy on Assessing and Responding to Changes in Condition to include abnormal vital signs. Education also included review of the center CPR policy and how and when to call a Code Blue and when to call 911, immediate initiation of CPR in cardiopulmonary arrest and the Location of Crash Carts/Emergency Supplies. During education staff have been informed that the AEDs have been removed from the center. On [DATE] at approximately 5:00 pm the Regional Nurse initiated education with all staff to include, Administrative Staff, Maintenance, Dietary, Laundry, Housekeeping, Licensed staff, Nurse Aides, and Therapy Staff on the Location of the Crash Carts/Emergency Supplies, how to call Code Blue and to notify a nurse with any noted change in a resident condition. This education included the Nurse's Aides responsibility in alerting licensed staff immediately of abnormal vital signs and/or unresponsive residents. Education includes per policy that the licensed staff will call 911 for Cardiorespiratory events. This education includes Full-Time, Part Time, PRN and Agency Staff. No staff shall work until they receive this education. Director of Nursing is responsible for making sure all receive the above education. Director of Nursing informed the Staff Development Coordinator on [DATE] that she would be responsible for new hire and new agency education on the above, to include assigning supervisory staff members to provide the education in her absence. Education will be included in new hire orientation and new agency orientation via in person review or a written education packet by a member of the Nurse Management Team (DON, ADON, SDC, Unit Managers, Shift Supervisors). Training to occur prior to the beginning of an unsupervised shift. Night shift charge nurses are responsible for checking the crash carts nightly to ensure appropriately stocked, licensed nurses re-educated to this process as of [DATE] by director of nursing or other member of nurse leadership team. Beginning [DATE] ADON or DON will check the crash carts weekly to ensure that they are appropriately stocked and in working order. Alleged date of IJ removal: [DATE]. A validation of IJ removal was conducted on [DATE]. All three facility crash carts were observed to have the needed emergency supplies and were in working order. Each cart contained a sign alerting the staff that the AED machines had been removed and contained a checklist that had been initialed nightly by the night shift nurse. The facility's CPR policy was reviewed as was the center's list of CPR certified staff. Nursing staff interviews revealed that they had received the education on CPR, responding to emergencies, location of crash carts, calling EMS services and the overhead page of Code Blue when an emergency was identified. Interviews with non-nursing departments revealed that they were aware of their role during an emergency and were able to verbalize tasks that they could do in the event of a Cod Blue. The facility conducted a mock Code Blue drill on [DATE] which was also observed without concerns. The nursing staff secured the crash cart, notified emergency personnel, and all staff including the RT responded and began performing CPR on the victim. The IJ removal date of [DATE] was validated.

Based on observations, record review, and resident, staff, Nurse Practitioner (NP), Medical Director (MD), and Pharmacist interviews the facility failed to assess a resident and initiate the sepsis protocol when Resident #96, who was continuously ventilator dependent, was found by Nurse #1 between 8:00 and 9:00 pm on 9/16/2024 to have a fever of 100.4 degrees Fahrenheit (F) (normal is 98.6 degrees), a heart rate of 116 beats per minute (normal is 60-100 beats per minute), and a respiratory rate of 24 breaths per minute (normal is 12-20 breaths per minute). Nurse #1 did not initiate the sepsis protocol when Resident #96 met two criteria on the Ventilator Unit Sepsis Protocol (a heart rate greater than 90 beats per minute and a respiration rate of greater than or equal to 20 breaths per minute), failed to re-check Resident #96's temperature for the remainder of the shift, and did not administer fever reducing medication. Then on 09/17/24 at approximately 6:30 AM to 7:00 AM Nurse Aide (NA) #1 obtained another set of vital signs that revealed a temperature of a 103 degrees Fahrenheit, a heart of rate of 121, and respiratory rate of 22 breaths per minute and reported the vital signs to Nurse #1 (who was the night shift nurse) that was reporting off to Nurse #2. Resident #96 was given Acetaminophen (medication used to reduce fever) 650 milligrams (mg) and Ibuprofen (medication used to reduce fever) 400 mg between 9:00 am and 11:00 am by Nurse #2. Nurse #2 failed to recheck Resident #96's temperature until approximately 3:00 pm at which time it was 102.3 degrees Fahrenheit after being prompted by the Unit Manager. The Unit Manager reported a temperature should have been obtained between 30 minutes to an hour after the administration of fever-reducing medication. At 3:00 pm, the Unit Manager contacted the NP and initiated the Sepsis Protocol (set of orders to follow when a resident has signs/symptoms of infection). Resident #96 was sent to the Emergency Department at approximately 4:15 pm and was later admitted to the Intensive Care Unit (ICU) with sepsis (life-threatening infection), urinary tract infection (UTI), an infected sacral (buttocks) wound, and dehydration. The deficient practice occurred for 1 of 3 residents (Resident #96) reviewed for change in condition. Immediate jeopardy began on 9/16/2024 when Resident #96 was found by Nurse #1 to have a change in condition and did not reassess Resident #96 after he was found to have a temperature of 100.4 degrees F, a heart rate of 116 beats per minute, and a respiration rate of 24 breaths per minute, which met the facility's sepsis criteria. Immediate jeopardy was removed on 09/19/24 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 education is completed and monitoring systems put into place are effective. The findings included: The Ventilator Unit Sepsis Protocol revealed it was to be initiated if a patient exhibits two or more of the following Systemic Inflammatory Response Syndrome (SIRS, exaggerated defense response) criteria: temperature greater than 100.4 degrees or less than 96.8 degrees, heart rate greater than 90 beats per minute, respiratory rate greater than or equal to 20 breaths per minute, or a white blood count greater than or equal to 12,000 cubic millimeters (mm3) or less than or equal to 4,000 (mm3) and suspected or proven infection. Protocol interventions included staff were to obtain immediate labs, a chest x-ray, and begin cefepime 2 grams intravenously (IV) every 12 hours for 7 days or doxycycline 100 mg IV every 12 hours for 7 days. If the systolic blood pressure (top number on a blood pressure reading) was less than 100, staff should administer normal saline IV at 100 milliliters (ml) per hour for 48 hours. Staff should monitor intake and output for 48 hours for residents with a catheter. Staff should notify the MD or NP during their next visit to the facility. The protocol had an area for the nurse who initiated the protocol to sign. Resident #96 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure (lungs are unable to exchange oxygen and carbon dioxide), ventilator associated pneumonia (a lung infection that develops when a person is on a ventilator), quadriplegia (inability to move all four extremities), unstageable pressure wound of the sacral region, gastrostomy tube (tube inserted through the stomach used to provide nutrition and medications), and dependence on a respiratory ventilator (machine used for breathing). A review of a care plan dated 8/2/2024 revealed Resident #96 was at risk for respiratory complications related to ventilator (a machine used to help breathe) and tracheostomy (an opening in the neck to facilitate breathing). Staff were to monitor for signs and symptoms of pneumonia (an infection of the lungs), bronchitis (inflammation of the linings of the lungs), etc. and advise the medical provider of any abnormal findings. A review of an annual Minimum Data Set (MDS) dated [DATE] revealed Resident #96 was severely cognitively impaired, required extensive assistance for mobility and was coded for a tracheostomy mechanical ventilator, suctioning (used to remove secretions from the respiratory tract), oxygen, and intravenous (IV, given through the veins) medications. A physician's order dated 9/9/2024 revealed Resident #96 was ordered ceftazidime (an antibiotic used to treat bacterial infections) injection 1 gram intravenously (IV, infused through the vein) every 8 hours for 10 days for a urinary tract infection and ciprofloxacin (an antibiotic used to treat infections) 500 milligrams (mg) via gastrostomy tube twice a day for 10 days for pseudomonas (an infection that can affect your skin, blood, lungs, and gastrointestinal tract) in the sputum. The Medication Administration Record (MAR) revealed documentation that Resident #96 had received ceftazidime on 9/9/2024 (2:00 pm and 10:00 pm) , 9/10/2024 (6:00 am, 2:00 pm, and 10:00 pm), 9/11/2024 (6:00 am, 2:00 pm, and 10:00 pm), 9/12/2024 (6:00 am, 2:00 pm, and 10:00 pm), 9/13/2024 (6:00 am, 2:00 pm, and 10:00 pm), 9/14/2024 (6:00 am, 2:00 pm, and 10:00 pm), 9/15/2024 (6:00 am, 2:00 pm, and 10:00 pm), 9/16/2024 (6:00 am, 2:00 pm, and 10:00 pm), and 9/17/2024 (6:00 am) and ciprofloxacin on 9/9/2024 (9:00 am), 9/10/2024 (9:00 am and 6:00 pm), 9/11/2024 (9:00 am and 6:00 pm), 9/12/2024 (9:00 am and 6:00 pm), 9/13/2024 (9:00 am and 6:00 pm), 9/14/2024 (9:00 am and 6:00 pm), 9/15/2024 (9:00 am and 6:00 pm), 9/16/2024 (9:00 am and 6:00 pm), and 9/17/2024 (9:00 am). An observation was conducted on 9/16/2024 at 10:43 am of Resident #96. Resident #96 was observed lying in bed. Resident #96 had a tracheostomy and was on the ventilator. Ventilator settings were the following: oxygen at 5 liters per minute, respiration rate of 18 breaths per minute, Resident #96 was able to open his eyes and mouthed that he was hot. The Surveyor notified Nurse Aide (NA) #3. Resident #96's ventilator was set on Assist Control/Volume Control (AC/VC, the ventilator produces a fixed tidal volume, the amount of air that moves in and out of the lungs with each breath, that is delivered at set time intervals or when the individual initiates a breath). A review of vital signs on 9/16/2024 at 11:18 pm revealed Resident #96 had a temperature of 100.4 degrees (normal temperature is 98.6 degrees), heart rate of 116 beats per minute (normal heart rate is 60-100 beats per minute, respiration rate of 24 breaths per minute (normal respiration rate is 12-20 breaths per minute), a blood pressure of 113/62, and an oxygen saturation of 96% (normal is greater than 92%). The vital signs were documented by Nurse #1 and were not reported to the physician. An interview was conducted on 9/18/2024 at 4:49 pm with Nurse #1. Nurse #1 stated she had worked on the ventilator unit on 9/16/24 from 7:00 pm until 9/17/2024 at 7:00 am and was assigned Resident #96. Nurse #1 stated Resident #96 had a low-grade fever of 100.4 degrees Fahrenheit when she checked his vital signs close to the start of her shift somewhere between 8:00 pm and 9:00 pm. Nurse #1 stated she had not thought to re-check it until she had been informed around 7:00 am while giving report to Nurse #2, that Resident #96 had a temperature of 103 degrees. Nurse #1 stated Resident #96 met criteria for the Sepsis Protocol during her shift but stated she usually did not initiate the protocol if a resident was already on antibiotics. Nurse #1 stated Resident #96 met sepsis criteria because he had high heart rate of 116 beats per minute and an elevated respiratory rate of 24 breaths per minute. Nurse #1 stated the nurse could implement the Sepsis Protocol if a resident met two or more criteria, however, she was not sure how that worked since Resident #96 was on antibiotics. Nurse #1 stated staff typically only checked vital signs once a shift. Nurse #1 stated did not notify the provider because Resident #96 was already on antibiotics. A review of vital signs on 9/17/2024 at 6:30 am revealed Resident #96 had a temperature of 103 degrees F, heart rate of 121 beats per minute, respiratory rate of 22 breaths per minute, and a blood pressure of 106/63. The vital signs were documented on a vital sign report sheet completed by NA #1. An interview was conducted on 9/17/2024 at 10:35 am with Nurse Aide (NA) #1. NA #1 stated she was assigned Resident #96 and had arrived on shift at 6:00 am on 9/17/2024. NA #1 stated shortly after she arrived, she obtained Resident #96's vital signs and recalled Resident #96 having an elevated temperature. NA #1 stated she wrote down Resident #96's vital signs and gave them to Nurse #1. NA #1 documented Resident #96's vital signs on a vital sign report sheet. An interview was conducted on 9/17/2024 at 10:45 am with Nurse #2. Nurse #2 stated she was assigned Resident #96 and arrived on shift at 7:00 am. Nurse #2 stated she was told in report that Resident #96 had a temperature of 103 degrees Fahrenheit, heart rate of 121 beats per minute, respiration rate of 22, and a blood pressure of 106/63. Nurse #2 stated she had just received orders for Acetaminophen and Ibuprofen but had not given them yet. Nurse #2 had no response for why Acetaminophen and Ibuprofen had not been administered earlier. Nurse #2 stated she was not sure if the facility had a Sepsis Protocol and was unsure where the standing orders were. A physician's order dated 9/17/2024 at 8:45 am revealed Resident #96 was ordered ibuprofen 400 mg via gastrostomy tube one time only for hyperthermia (increased body temperature). A physician's order dated 9/17/2024 at 9:00 am revealed Resident #96 was ordered prednisone (steroid used to decrease inflammation) 60 mg via gastrostomy tube once a day for seven days for ventilator associated pneumonia. An observation was conducted on 9/17/2024 at 9:07 am of Resident #96. Resident #96 would not make eye contact or mouth any words. Resident #96's lips were dry and cracked. Ventilator settings were the following: oxygen at 10 liters per minute, respiration rate of 18 breaths per minute. An interview was conducted on 9/17/2024 at 10:45 am with Nurse #2. Nurse #2 stated she was assigned Resident #96 and arrived on shift at 7:00 am. Nurse #2 stated she was told in report that Resident #96 had a temperature of 103 degrees Fahrenheit, heart rate of 121 beats per minute, respiration rate of 22, and a blood pressure of 106/63. Nurse #2 stated she had just received orders for Acetaminophen and Ibuprofen but had not given them yet. Nurse #2 had no response for why Acetaminophen and Ibuprofen had not been administered earlier. Nurse #2 stated she was not sure if the facility had a Sepsis Protocol and was unsure where the standing orders were. An interview was conducted on 9/18/2024 at 5:19 pm with Wound Care Nurse #2. Wound Care Nurse #2 stated she had changed Resident #96's dressing around lunch time on 9/17/2024. Wound Care Nurse #2 stated at that time Resident #96's skin felt warm, and she told Nurse #2, and was told by Nurse #2 she was going to give him acetaminophen. An interview was conducted on 9/18/2024 at 5:01 pm with the Wound Care Nurse #1. Wound Care Nurse #1 stated she had been told by Wound Care Nurse #2 that Resident #96 had a fever, because he felt warm, when she had changed his dressings on 9/17/2024 around lunchtime. Wound Care Nurse #1 stated she had walked to Resident #96's room to check on him around 3:30 pm at which time he appeared terrible and grayish blue in color. Wound Care Nurse #1 stated RT #1 was in the room with Resident #96 at that time giving him a nebulizer treatment and she left the room to inform the DON. An interview was conducted on 9/17/2024 at 2:47 pm with Respiratory Therapist (RT) #1. RT #1 stated Resident #96 had been on antibiotics for pneumonia and was ventilator dependent. RT #1 stated Resident #96 had his oxygen level desaturate (get lower) on 9/16/2024 and had to have his oxygen requirements increased from 5 liters to 10 liters. RT #1 stated that was not uncommon for Resident #96. RT #1 stated nursing staff had not made him aware that Resident #96 had an elevated temperature and heart rate and stated that could be an indication of sepsis. A physician's order dated 9/17/2024 at 3:20 pm revealed Resident #96 was ordered a sputum culture one time only for a fever, a urinalysis with culture and sensitivity one time only for a fever, and blood cultures/comprehensive blood count (CBC, used to evaluate for infection)/platelets (help blood to clot). A sputum sample was documented as collected on 9/17/2024 at 3:29 pm. A physician's order dated 9/17/2024 at 3:37 pm revealed Resident #96 was ordered Ibuprofen 400 mg via gastrostomy tube one time only for hyperthermia (fever). A physician's order dated 9/17/2024 at 3:45 pm revealed Resident #96 was ordered tobramycin nebulizer treatments 300 mg via tracheostomy two times a day for pneumonia for 13 administrations to be nebulized with oxygen and 150 mg via tracheostomy one time for hyperthermia for one day. A physician's order dated 9/17/2024 at 4:00 pm revealed Resident #96 was ordered meropenem (antibiotic) 1 gram/100 milliliters (ml) every 8 hours for hyperthermia for 7 days. An interview was conducted on 9/17/2024 at 3:41 pm with the Unit Manager. The Unit Manager stated the ventilator unit utilized a Sepsis Protocol. The Unit Manager stated that the sepsis protocol typically applied to residents that were not currently on antibiotics and had experienced brand new sepsis symptoms. The Unit Manager stated she had not initiated the Sepsis Protocol for Resident #96 earlier in the shift because he was already on two different antibiotics. The Unit Manager stated she had contacted the NP earlier in the shift around 8:30 am and received orders to administer acetaminophen and ibuprofen at the same time. The Unit Manager stated she had to go to the store to get ibuprofen and when she returned, she gave it to Nurse #2 and told her to administer it with the acetaminophen. The Unit Manager stated she asked Nurse #2 around 3:00 pm what Resident #96's temperature was, at which time she had not checked it. Resident #96's temperature was 102.3 degrees Fahrenheit at that time. The Unit Manager stated that a temperature was typically rechecked between 30 minutes and 1 hour after the administration of medication for a fever. The Unit Manager stated she was unsure why Nurse #2 had not rechecked Resident #96's temperature sooner stated she contacted the NP at 3:20 pm and was told to alternate Acetaminophen and Ibuprofen and initiate the Sepsis Protocol. A review of a physician's order dated 9/17/2024 at 4:05 pm revealed Resident #96 was to be transferred to the hospital for evaluation and treatment for respiratory distress and fever. Review of an Emergency Medical Services (EMS) report dated 9/17/2024 at 4:04 pm revealed that EMS had been dispatched to the facility in reference to Resident #96 having a fever. Upon arrival documentation revealed Resident #96 presented with septic shock. Facility staff had stated Resident #96's mental status was abnormal. Resident #96's skin was warm and diaphoretic. Resident #96's initial vital signs were a blood pressure of 94/60, heart rate of 118 beats per minute, and an oxygen saturation level of 100% on the ventilator. Resident #96 was given a normal saline fluid bolus (fluid administered through the vein to increase blood pressure) of 500 ml enroute to the hospital. Review of an emergency room note dated 9/17/2024 at 5:48 pm revealed Resident #96 presented to the ER with a concern for sepsis (life-threatening infection). Resident #96's initial blood pressure was 83/58, heart rate of 101 beats per minute, respiration rate of 18, an oxygen saturation level of 97%, and a temperature of 98.4 degrees Fahrenheit. Resident #96 had extremely dry mucous membranes and a large, stage 3 sacral wound that was foul-smelling. Resident #96 went into ventricular tachycardia (irregular heart rate that can be life-threatening) and required an amiodarone (medication used to treat ventricular tachycardia) drip and continued to have worsening blood pressures which required a dose of epinephrine and initiation of a norepinephrine (medication used to increase blood pressure) drip. Resident #96 was admitted to the Critical Care Unit and remained in the hospital. An interview was conducted on 9/17/2024 at 12:05 pm with the Pharmacist. The Pharmacist stated Resident #96 was on ciprofloxacin for a gram-negative bacterium, pseudomonas, and was also on ceftazidime, a third-generation cephalosporin, that was broader spectrum. The Pharmacist stated Resident #96 had been on antibiotics for several days and stated if Resident #96 had a fever of 103 degrees the facility should reinitiate the Sepsis Protocol to determine which bacteria was causing the elevation and adjust antibiotics as necessary. An interview was conducted on 9/18/2024 at 2:16 pm with the Medical Director (MD). The MD stated the Sepsis Protocol was developed by the NP. The MD stated the Sepsis Protocol had to be initiated by himself, the Pulmonologist, or the NP, not the nursing staff. The MD stated the nursing staff at the facility should call the MD when a resident experienced signs or symptoms of sepsis before initiating the Sepsis Protocol. The MD stated Resident #96 had pneumonia in the past and had been on a couple of broad-spectrum antibiotics. The MD stated Resident #96 was on antibiotics which would typically start working within 3 to 5 days. The MD stated he would not be concerned about a fever of 103 degrees Fahrenheit not being treated unless the resident experienced symptoms of discomfort. The MD stated a fever was only dangerous when it reached 105 degrees, which could cause seizures. An interview was conducted on 9/18/2024 at 4:11 pm with the Director of Nursing (DON). The DON stated on 9/17/2024 around 3:30 pm that she was approached by the Wound Care Nurse that Resident #96 did not look good, at which time she and the ADON started to the ventilator unit. The DON stated she stopped by the Unit Manager's office and asked how Resident #96 had been doing and was told he had been running a fever and orders had been obtained from the NP to initiate the Sepsis Protocol. The DON stated when she entered the room Resident #96 looked malaise, was warm to the touch, had a bounding heart rate, and looked like he needed to be transferred. The DON stated acetaminophen should have been administered by Nurse #2 per standing order when Resident #96 had a fever of 103 degrees, and stated she was unsure why there was a long delay in the administration of acetaminophen and ibuprofen. The DON was unsure why the Sepsis Protocol was also not initiated when Resident #96 had an elevated temperature and heart rate at the beginning of shift and agreed it should have been. The DON also reported Nurse #1 should not have waited multiple hours to recheck a temperature after the administration of antipyretics (fever-reducing medications). An interview was conducted on 9/19/2024 at 10:04 am with the NP. The NP stated that she had created the Ventilator Unit Sepsis Protocol specifically for residents in the ventilator unit to prevent frequent hospitalization s. The NP stated that any nurse in the facility could initiate the Sepsis Protocol, and the nursing staff would inform her when she was in the building the next day. An interview was conducted on 9/18/2024 at 5:37 pm with the Administrator. The Administrator stated that she had been informed that Resident #96 had a fever of 103 degrees and that the Unit Manager had went to the store to get ibuprofen. The Administrator stated she was under the impression that Nurse #2 had given Resident #96 ibuprofen and acetaminophen. The Administrator stated the Sepsis Protocol could be initiated by any hall nurse and that the nurse did not have to call the MD or NP prior to initiating it. The Administrator reported Nurse #2 should have performed continuous assessments, including vital sign checks, until the resident had stabilized or was transferred to a higher level of care. The Administrator was notified of Immediate Jeopardy on 9/18/2024 at 6:06 pm. The facility provided the following credible allegation of Immediate Jeopardy Removal: Identify those recipients who have suffered and those who are likely to suffer a serious adverse outcome as result of the noncompliance: Beginning on 9/16/24 on 3-11 shift, resident # 96 met criteria to implement the center's sepsis protocol. Facility failed to implement the sepsis protocol and failed to reassess resident timely after administration of acetaminophen and ibuprofen on 9/17/24. On 9/18/2024 at approximately 7:00 p.m. the Director of Nursing (DON) and Nursing Leadership team which includes the Assistant Director of Nursing (ADON), Unit Managers, and Wound Nurse obtained vital signs, to include temperature, respirations, pulse, oxygen saturations and blood pressure, of all current residents in the center to ensure that no other resident was experiencing an acute change in condition. No other residents were identified as having abnormal vital signs. 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 9/18/2024 at approximately 7:00 p.m. the Staff Development Coordinator (SDC) initiated education for all licensed nurses and Respiratory Therapists on the Facility Sepsis Protocol (Sepsis Protocol to be initiated when the patient exhibits two or more symptoms), Assessing and Responding to Changes in Condition to include abnormal vital signs, notifying the provider and re-assessment for efficacy after initial intervention (residents should be reassessed one hour after intervention). Licensed nurses also educated at this time to new process for monitoring vital sign exception report at end of every shift and that nurses are to enter their vital signs every shift as ordered (The Vital Signs Exception Report is a report that is ran from the electronic health record that shows any vital signs that are abnormal) The Nurses' Aides were educated on Vital Signs and reporting abnormal results immediately to the charge nurse. This education includes Full-Time, Part Time, PRN and Agency Staff. No licensed staff shall work until they have received this education. Director of Nursing is responsible for making sure all receive the above education. Director of Nursing informed the Staff Development Coordinator on 9/18/2024 that she would be responsible for new hire and new agency education on the above. Education will be included in new hire orientation and new agency orientation via in person review or a written education packet by a member of the Nurse Management Team (DON, ADON, SDC, Unit Managers, Shift Supervisors). No Licensed Nurses, Respiratory Therapists or Nurses Aides shall work until they have received the above education. On 9/18/24 at 7:00 p.m. a new process implemented by the Director of Nursing that begins having the Director of Nursing, Assistant Director of Nursing, Unit Manager, or charge nurse monitor resident vital signs exception report at end of shift daily to ensure that abnormal vital signs were addressed timely. The Unit Managers will round on their residents daily to ensure that there is no evidence of change in condition, to include abnormal vital signs, for any resident. If Unit Manager is not present the ADON, DON or Shift Supervisor will complete the rounds on that unit. Alleged date of IJ removal: 9/19/24. A validation of IJ removal was conducted on 09/24/24. A review of the initial audit completed on 09/18/24 revealed all resident vital signs were obtained to ensure no other change in condition was identified. Staff interviews revealed that they had received the education on identifying a change in condition, abnormal vital signs, and initiating the Sepsis protocol. The nursing staff were also able to verbalize the new process of running a vital sign exception report at the end of their shift to ensure that all abnormal vital signs had been acted upon appropriately and nothing had been missed. Interviews with the Unit Manager/Charge Nurse revealed that they rounded daily on their units to look for any change in condition and ensuring that none were missed or overlooked including reviewing vital signs for the shift. The IJ removal date of 09/19/24 was validated.

Based on observation, record review and staff interviews the facility failed to ensure that a nurse was competent in responding to medical emergencies and activating emergency procedures with emergency medical services (EMS). Resident #103 was a Full Code and experienced sudden cardiac arrest on [DATE]. Nurse #3 was unable to locate the crash cart, the automated external defibrillator and did not immediately call 911. Resident #103 was pronounced deceased by EMS on [DATE] at 7:50 pm. The deficient practice was identified for 1 of 5 nurses (Nurse #3) reviewed for competency and had the high likelihood for causing serious harm to other residents. Immediate jeopardy began on [DATE] when Nurse #3 did not demonstrate competency in responding to a medical emergency. Immediate jeopardy was removed on [DATE] when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems put into place are effective. The findings included: This tag is cross referred to: F678: Based on record review, observation, crash cart checklist, staff, Respiratory Therapist, and Medical Director (MD) interviews the facility failed to immediately initiate Cardiopulmonary Resuscitation (CPR) when Resident #103, who was a full code had agonal breathing (a state of breathing of gasping for air due to the brain receiving insufficient oxygen) and went pulseless, failed to immediately utilize the overhead paging system to call staff to Resident #103's room (code blue), and failed to immediately active Emergency Medical [NAME] (EMS). Once the Respiratory Therapy recognized the need for CPR, they failed to implement the use of the Automated External Defibrillator (AED), failed to have available or use an oral airway, and the regulator on the emergency oxygen tank on the crash cart only went to 10 liters. Resident #103 was pronounced deceased and resuscitative efforts were stopped. This affected 1 of 1 resident reviewed for CPR. A review of Nurse #3's Nurse Orientation Checklist dated [DATE] revealed Nurse #3 had knowledge of the location of the crash cart and emergency procedures. The Checklist was signed as completed by Nurse #3 and the Staff Development Coordinator (SDC). The Checklist ensured that staff members knew where the crash cart and emergency procedures were located. A review of a Termination/Discipline Notice dated [DATE] revealed Nurse #3 was terminated for not adequately responding to a resident with a change in condition. The notice was signed by the Administrator and Human Resources (HR) Director. Nurse #3 was not available for an interview. An interview was conducted on [DATE] at 4:39 pm with the Staff Development Coordinator (SDC). The SDC stated all staff were required to attend in-person orientation which lasts several hours. The SDC stated during orientation all staff were given a facility tour and shown the location of the crash carts. The SDC stated there were three crash carts in the facility, and each crash cart contained an AED. The SDC stated she did not open crash carts to go over the components and location of supplies and stated that there was a list on top of the cart that explained where to find needed items because the cart was locked with a plastic tag. The SDC stated all nursing staff in the facility were required to be CPR certified and should have received training on the usage of an AED during their certification course. The SDC stated Nurse #3 received a facility tour, was shown the location of the crash cart, and where to find the on-call provider contact information at the nurse's station. The SDC stated she was unsure why Nurse #3 could not locate the crash cart, find information to notify the on-call provider, or what to do when Resident #103 experienced sudden cardiac arrest on [DATE]. An interview was conducted on [DATE] at 9:37 am with the Director of Nursing (DON). The DON stated there were concerns after the Code Blue on [DATE] that involved Resident #103 and Nurse #3 not acting sooner and recognizing things. The DON stated [DATE] was the last shift that Nurse #3 worked at the facility and stated staff received education on [DATE] regarding notification and to respond when a change in condition occurred to prevent a Code Blue situation. An interview was conducted on [DATE] at 2:21 pm with the Administrator. The Administrator stated she had not been previously made aware of Nurse #3 not knowing where the crash cart was, when to initiate CPR, or when to activate 911 during the Code Blue event involving Resident #103. The Administrator stated she would have expected Nurse #3 to remain with Resident #103, perform ongoing assessments/vital signs, call 911, and initiate CPR if the resident did not have a pulse. The Administration was notified of Immediate Jeopardy on [DATE] at 3:33 pm. The facility provided the following credible allegation of Immediate Jeopardy Removal: Identify those recipients who have suffered and those who are likely to suffer a serious adverse outcome as result of the noncompliance: Nurse # 3 was hired as a full time RN to the center on [DATE]. She completed the center's orientation process on [DATE], which included location of crash cart. Nurse # 3 did not have training on emergency process. Nurse # 3 failed to follow process and stated she did not know where crash cart was located on [DATE]. Nurse # 3 failed to respond appropriately in an emergency for resident # 103. Nurse # 3 failed to locate the emergency equipment and did not know how/when to respond in an emergency. On [DATE] the Regional Nurse reviewed new hire and new agency staff orientation from [DATE] to current for validation of training and location on emergency equipment, procedures, and how to respond in case of emergency with attestation provided on [DATE] by staff development coordinator that all new and agency hires were trained on emergency equipment, crash cart location, emergency procedures and how to respond to emergencies at the time of orientation. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On [DATE] the center Administrator notified the Director of Nursing of immediate implementation of Mock Code Drills increasing from Quarterly to Monthly. Mock Code Drills are conducted by the DON or ADON. Agency staff receive an abbreviated orientation that includes location of crash carts and emergency process. The center orientation process includes emergency equipment location and emergency process. On [DATE] the Director of Nursing informed the Staff Development Coordinator that it is her responsibility to orient new hires and new agency staff. On [DATE] at approximately 5:00 p.m. the Director of Nursing and Nursing Leadership Team which includes ADON, Unit Managers, Wound Nurse, initiated education for all licensed nurses and Respiratory Therapy on Assessing and Responding to Changes in Condition to include abnormal vital signs. Education was completed for all staff on how and when to call a Code Blue, Calling 911, and the Location of Crash Carts/Emergency Supplies. This education includes Full-Time, Part Time, PRN and Agency Staff. On [DATE] at approximately 5:00 pm the Regional Nurse initiated education with all staff to include Administrative Staff, Maintenance, Dietary, Laundry, Housekeeping, Nurses' Aides and Therapy Staff on the Location of the Crash Carts/Emergency Supplies, how to call Code Blue. No staff shall work until they have received this education. The Director of Nursing is responsible for making sure all receive the above education. Director of Nursing informed the Staff Development Coordinator on [DATE] that she would be responsible for new hire and new agency education on the above, as well as responsible for verifying competencies and understanding of training. Education will be included in new hire orientation and new agency orientation via in person review by a member of the Nurse Management Team (DON, ADON, SDC, Unit Managers, Shift Supervisors). No Licensed Nurses, Respiratory Therapists shall work until they have received the above education. SDC will verify the competency and understanding of emergency procedures and emergency procedures and their role in an emergency. On [DATE] at 6:00 p.m. a new process was implemented by the Director of Nursing that will include validation of new hire and new agency staff orientation to emergency procedures, crash cart locations, and procedures for calling Code Blue and 911 via a post test administered following orientation. Alleged date of IJ removal: [DATE]. A validation of IJ removal was conducted on [DATE]. The initial audit of staff hired since [DATE] was reviewed to ensure that they had received the necessary orientation including location of emergency supplies and crash carts, how to activate EMS, when to initiate CPR and how to respond in a Code Blue situation. The facility conducted a mock Code Blue drill on [DATE] which was also observed without concerns. The nursing staff secured the crash cart, notified emergency personnel, and all staff including the RT responded and began emulating CPR on the victim. Nursing staff interviews revealed that they had received the education on CPR, responding to emergencies, location of crash carts, calling EMS services and the overhead page of Code Blue when an emergency was identified. Interviews with non-nursing departments revealed that they were aware of their role during an emergency and were able to verbalize tasks that they could do in the event of a Code Blue. The IJ removal date of [DATE] was validated.

Based on observations, record reviews, and staff interviews, the facility failed to: 1) dispose of loose and unidentified tablets of various shapes and sizes from medication cart (300 Hall Bottom), 2) discard expired medications from medication cart (600 Hall), 3) store medications in accordance with the manufacturer's storage instructions (300 Hall Bottom and 100 Hall), and 4) properly store and date a open vial of Tuberculin Purified Protein Derivative (PPD) (600 hall) for 3 of 8 medication carts reviewed for medication storage. The findings included: 1. On 09/20/24 at 9:20 AM an observation was made of the 300 Hall Bottom medication cart accompanied by Medication Aide (MA) #1. The observation yielded 5 loose and unsecured tablets of varying shapes and sizes in the bottom of the middle drawer. When the MA was asked about the loose tablets, she replied she did not work the 300 hall Bottom medication cart often, but it was the third shift nurses' responsibility to clean the medication carts. The MA could not identify the loose tablets. 2a. The manufacturer's storage instructions printed on the box of 0.5 milligrams (mg) / 3 mg ipratropium bromide / albuterol sulfate inhalation solution read in capital letters: Store in pouch until time of use. On 09/20/24 at 9:20 AM an observation was made of the 300 Hall Bottom medication cart accompanied by MA #1. The observation yielded 2 boxes of open foil pouches of ipratropium bromide / albuterol sulfate inhalation solution that were available for use. One box had one vial not stored in the foil pouch and one box of 2 vials not stored in the foil pouch. When the MA was asked about how the ipratropium bromide / albuterol sulfate inhalation solution should be stored the MA stated she did not know and explained it was the third shift nurses' responsibility to clean and organize the medication carts. 2b. On 09/20/24 at 9:40 AM an observation was made of the 100 Hall medication cart accompanied by MA #2. The observation yielded 1 open box of ipratropium bromide / albuterol sulfate inhalation solution that was available for use. The box had 5 vials of the ipratropium bromide / albuterol sulfate inhalation solution lying loose in the bottom of the box and not stored in the foil pouch. The MA was asked about how the ipratropium bromide / albuterol sulfate inhalation solution should be stored and the MA stated she was unsure, but it was every nurses' responsibility to keep the medication cart clean and organized. At 3:30 PM on 09/20/24 an interview was conducted with both the Director of Nursing (DON) and the Assistant Administrator. The DON explained she educated the staff just that week on cleaning and organizing the medication carts. She indicated she would need to do more education. 35789 3. A document provided by the facility with no date revealed that Tuberculin PPD was to be stored in the refrigerator and should be discarded thirty days after opening. An observation of the 600-hall medication cart with Nurse #5 on 09/18/24 at 4:37 PM revealed the following expired medications in the medication cart and available for use: *Opened bottle of Divalproex 500 milligrams (mg) that indicated the medication should be discarded after 01/17/24. *Opened bottle of Atorvastatin 80 mg that indicated the medication should be discarded after 08/27/24. * Opened bottle of Ascorbic Acid 250 mg that indicated the medication should be discarded after 11/30/22. *Opened bottle of Donepezil 10 mg that indicted the medication should be discarded after 04/27/22. * Opened bottle of Venlafaxine 75 mg that indicated the medication should be discarded after 11/02/23. * Opened and undated vial of Tuberculin Purified Protein Derivative (PPD). Nurse #5 was interviewed on 09/18/24 at 4:50 PM revealed that the medications in the bottom drawer of her medication cart were brought from home because the resident was there for respite care (period of rest). She explained that they were not able to order any of those medications from the pharmacy and had to use the medications from home but stated she had not realized that some of those medications were expired. She stated that she would sort through the bag to administer the resident's ordered medication but did not check the expiration dates on them. Nurse #5 stated she had noticed the Tuberculin PPD vial in her cart earlier that morning and should have thrown it away because she knew that it was supposed to be kept in the refrigerator. The Unit Manager (UM) was interviewed on 09/18/24 at 4:58 PM. The UM stated that the resident came from home with respite care, so they were unable to order any medications from their pharmacy and had to use what the family had supplied. She stated that the admission nurse should have gone through the bag of medications supplied by the family and ensured all were within date and not expired. The UM added that the Tuberculin PPD serum should be stored in the refrigerator and discarded thirty days after being opened. The Consultant Pharmacist was interviewed via phone on 09/19/24 at 9:43 AM. The Pharmacist stated that she visited the facility monthly and went through the medication carts usually every other month and sometimes every month just depended on the time constraints she had. The Pharmacist further explained that sometimes she would review each medication cart and sometimes she would review a sample of them and added that it was a big building and that she tried to sample each medication cart every other month so that she saw each cart at least every 3 months. Her medication cart review included looking for expired medications. She stated that she usually did not have issues with expired medications. The Pharmacist stated that the vial of Tuberculin PPD should be stored in the refrigerator and discarded after thirty days of opening. Nurse #6 was interviewed via phone on 09/19/24 at 12:05 PM. Nurse #6 stated she worked at the facility via an agency and stated that she had never done an admission until 09/14/24 when she unexpectedly readmitted a resident to the facility from home. Nurse #6 stated she had no idea what the admission process was as she had not received any orientation to the facility. She stated she did a portion of the admission process as directed by other staff members and she took the bag of medication that the resident's family brought in with him and put them in the medication cart. Nurse #6 stated she did not review or look at the medication. She just put the bag on the medication cart until it was time to administer his medications then she went through the bag and got the medications she needed out of the bag. Nurse #6 stated she was unaware that there was expired medication in the bag. The Director of Nursing (DON) was interviewed on 09/20/24 at 10:43 AM who stated that the nurses should be going through their medication carts daily to take out expired medications or anything that had been discontinued. She added that the pharmacy staff was there earlier in the week and did a cart audit of some of the medication carts and she did not believe that any issues were identified.

Based on observations, record reviews, and resident and staff interviews, the facility failed to keep an accurate account of controlled substances (Resident #90 and Resident #110), failed to remove discontinued controlled substances from the medication cart (Resident #90), and administered medications to Resident #113 from a bottle that was labeled for another person. This affected 3 of 3 residents reviewed for pharmacy services. The findings included: 1. Resident #90 was admitted to the facility on [DATE] with diagnosis that included pain. A physician order dated 03/18/24 read, hydrocodone/acetaminophen (controlled pain medication) 5/325 milligrams (mg) by mouth every 6 hours as needed for pain for 5 days. The Medication Administration Record (MAR) dated March 2024 revealed the order was present from 03/18/24 through 03/23/24 and Resident #90 had received none of the hydrocodone/acetaminophen during those 5 days. The control drug record dated 03/18/24 contained a label with Resident #90's name and dosing instructions for the hydrocodone/acetaminophen and revealed that 20 tablets were sent to the facility. The declining count went down from #20 tablets but skipped #12 and went from #13 to #11. The card of tablets in the medication cart had 11 tablets of the hydrocodone/acetaminophen and all doses administered were accompanied by a staff signature. The quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #90 was moderately cognitively impaired and received no scheduled or as needed pain medication. No pain was reported during the assessment reference period. An observation and interview were conducted with Resident #90 on 09/20/24 at 11:16 AM. Resident #90 was up in his wheelchair in the day room appropriately dressed and well groomed. Resident #90 stated he was waiting on lunch; he denied any pain and stated, I only have an occasional headache. The Consultant Pharmacist was interviewed via phone on 09/19/24 at 9:43 AM. The Pharmacist stated that she visited the facility monthly and went through the medication carts usually every other month and sometimes every month just depended on the time constraints she had. The Pharmacist further explained that sometimes she would review each medication cart and sometimes she would review a sample of them and added that it was a big building and that she tried to sample each medication cart every other month so that she saw each cart at least every 3 months. Her medication cart review included reviewing the controlled drug records and she will scan a sample of several different records to ensure that the math and count were correct. The Pharmacist explained that her review included looking for any signs of diversion and she encouraged the staff to be diligent in what they put down on the controlled drug record. The Pharmacist was not aware of any controlled drug record discrepancies but stated that the Director of Nursing (DON) may need to talk to the nurses and educate them on documenting on the controlled drug record. Nurse #4 was interviewed on 09/19/24 at 10:56 AM who confirmed that she was responsible for Resident #90 and his controlled medications. Nurse #4 also confirmed that she had counted all the controlled substances in her medication cart at the beginning of her shift with the off going nurse that day and all were correct. Nurse #4 was questioned about the declining control drug record and why #12 was skipped on the record. Nurse #4 replied, I am agency staff and none of those are my signatures and threw her hands up in the air. Nurse #4 stated that when she counted the controlled substances earlier that morning, she did not look at the controlled drug record (off going nurse did) she was counting the actual medications in the cart and could not explain the discrepancy on the control drug record again stating she was agency staff. Nurse #4 was asked what she was supposed to do if she had a discrepancy with her controlled medication and she stated to report to the DON. Nurse #4 was asked to please alert the DON of the discrepancy. The DON was interviewed on 09/19/24 at 11:15 AM. The DON observed the control drug record for Resident #90 and could not explain the discrepancy on the record. She stated she would have to look into the situation. A follow up interview was conducted with the DON on 09/20/24 at 10:43 AM. The DON stated that she needed to do some re-education with the staff because the nurses should be going through their medication carts and removing any discontinued controlled substances so that they were not remaining on the medication carts for months and months. The DON stated that there was no reason why the medication remained on the medication cart 6 months after it had been discontinued and added she was not aware of the issue until brought to her attention by the surveyor. The DON stated she knew that Resident #90 did not take pain medication, and she would have to open an investigation to see where the medication went. 2. Resident #110 was admitted to the facility on [DATE] with diagnosis that included pain. A physician order dated 09/12/24 read, Tramadol (controlled substance) 50 milligrams (mg) by mouth every 6 hours as needed for pain. The control drug record dated 09/13/24 revealed that the pharmacy sent 30 tablets. The declining count went down from 30 tablets, 29, 28, 27 then repeated 28, 27, 26, 25, and so on. The record indicated that Resident #110 had received 7 doses from the card of 30 which should leave 23 tablets, but the card contained 25 tablets. Nurse #5 was interviewed on 09/18/24 at 4:50 PM who confirmed that she was working with Resident #110. Nurse #5 also confirmed that she had counted her controlled substances at the beginning of her shift that day. She explained that when she counted the controlled substances she was standing at the cart and then compared the number of medications to the controlled drug record that the off-going nurse was calling out to her and ensured that they matched. Nurse #5 stated she had not noticed the discrepancy on the controlled drug record. Nurse #5 notified the Unit Manager (UM) of the discrepancy. The UM was interviewed on 09/18/24 at 4:58 PM. The UM was unable to explain the discrepancy on Resident #110's-controlled drug record and stated she would have to report it to the Director of Nursing (DON). The Consultant Pharmacist was interviewed via phone on 09/19/24 at 9:43 AM. The Pharmacist stated that she visited the facility monthly and went through the medication carts usually every other month and sometimes every month just depended on the time constraints she had. The Pharmacist further explained that sometimes she would review each medication cart and sometimes she would review a sample of them and added that it was a big building and that she tried to sample each medication cart every other month so that she saw each cart at least every 3 months. Her medication cart review included reviewing the controlled drug records and she will scan a sample of several different records to ensure that the math and count were correct. The Pharmacist explained that her review included looking for any signs of diversion and she encouraged the staff to be diligent in what they put down on the controlled drug record. The Pharmacist was not aware of any controlled drug record discrepancies but stated that DON may need to talk to the nurses and educate them on documenting on the controlled drug record. A follow up interview was conducted with the UM on 09/19/24 t 11:19 AM who stated that she went through the controlled drug records and looked for any discrepancies weekly but had not noticed the discrepancy with Resident #110. The DON was interviewed on 09/20/24 at 10:43 AM reviewed the controlled drug record and was unable to explain the discrepancy and stated she would have to do some education with the nurses on signing out controlled drugs correctly. She further explained that the controlled medications were counted with the off-going and on-coming nurses at every shift change or when a change in staff was necessary. If there was any discrepancies noted during the shift to shift count they were to immediately report them to the DON. 3. Resident #113 was readmitted to the facility on [DATE] with diagnosis of vascular dementia. A physician order dated 08/18/24 read; Donepezil 10 milligrams (mg) by mouth one time a day related to vascular dementia. No Minimum Data Set (MDS) information was available for Resident #113. An observation of Resident #113's medication was made on 09/18/24 at 4:50 PM along with Nurse #5. The observation revealed a large bag containing bottles of medications prescribed for Resident #113. In the bag of medication, the bottle that was labeled Donepezil 10 mg had a different person's name on the bottle. Nurse #5 explained that Resident #113 had recently admitted from home with respite (a period of rest) care and so his family brought his medication from home in a bag, and they had been administering the medications Resident #113 had an order for from that bag. Nurse #5 stated that the name on the bottle of Donepezil 10 mg was not a resident at the facility and she had no idea who it was but stated that Resident #113 did have an order for Donepezil, but she had not noticed the medication was labeled for someone else when she administered it earlier on her shift. Nurse #6 was interviewed via phone on 09/19/24 at 12:05 PM. Nurse #6 stated she worked at the facility via an agency and stated that she had never done an admission until 09/14/24 when Resident #113 unexpectedly readmitted to the facility from home. Nurse #6 stated she had no idea what the admission process was as she had not received any orientation to the facility. She stated she did a portion of the admission process as directed by other staff members and she took the bag of medication that Resident #113's family brought in with him and put them in the medication cart. Nurse #6 stated she did not review or look at the medication she just put the bag on the medication cart until it was time to administer his medications then she went through the bag and got the medications she needed out of the bag. Nurse #6 stated she was unaware that there was a bottle of medication in the bag that was not labeled for Resident #113. The Unit Manager (UM) was interviewed on 09/18/24 at 4:58 PM. The UM stated that Resident #113 came from home with respite care, so they were unable to order any medications from their pharmacy and had to use what the family had supplied. She stated that the admission nurse should have gone through the bag of medications supplied by the family and ensured all were correctly labelled for Resident #113 and not someone else. The UM stated that the name on the bottle of Donepezil was not the name of anyone that had been a resident at the facility before so it must have been someone in Resident #113's family. The Consultant Pharmacist was interviewed via phone on 09/19/24 at 9:43 AM. The Pharmacist stated that she assumed the nurses would be ensuring that Resident #113's medications were present if brought in from the family so there would be no availability issues. She added the nurses should be looking at the orders on the medication administration record and verify that they were giving the correct dose of medication to the correct resident. The Pharmacist stated that the staff should not be using someone else's medication to medicate Resident #113 but if the Resident had an order for the medication, then she was less concerned. The Director of Nursing (DON) was interviewed on 09/20/24 at 10:43 AM who confirmed that the admission Nurse should have ensured the medications that the family brought in matched the orders for Resident #113 and ensured that they were properly labeled for Resident #113 and not someone else.

Based on record reviews and staff interviews the facility failed to follow their Abuse, Neglect, and Exploitation policy by failing to screen a new employee and initiate protective measures to safeguard residents from potential abuse and neglect when they hired Dietary Aide (DA) #1 with one pending allegation of Abuse of a Resident on the North Carolina Nurse Aide Registry for 1 of 5 employees reviewed for screening of employees (DA#1). The facility also failed to implement their abuse policy and procedures in the areas of reporting by not submitting an initial allegation report to the Division of Health Service Regulation (DHSR) within 2 hours of the facility being made aware of an allegation of abuse (Resident #81) and not notifying local law enforcement of an allegation of neglect (Resident #225) for 2 of 3 sampled residents reviewed for abuse. The findings included: Review of the facility's Abuse, Neglect, Exploitation, and Misappropriation Prevention Program policy reviewed on 3/28/2023 revealed the facility should conduct background checks and not knowingly employee or otherwise engage any individual who has a) been found guilty of abuse, neglect, misappropriation of property, or mistreatment by a court of law; b) had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or c) a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property. Review of Dietary Aide #1's employee file revealed he was hired on 9/6/2024 and was terminated on 9/12/2024. A background check had been completed and there were no criminal charges. A report from the North Carolina Nurse Aide Registry dated 9/6/2024 revealed Dietary Aide #1 had one pending allegation of Abuse of a Resident. A review of a September 2024 timecard revealed Dietary Aide #1 worked on 9/6/2024 for 3.75 hours, on 9/8/2024 for 3.25 hours, and on 9/10/2024 for 8 hours. An interview was conducted on 9/17/2024 at 12:49 pm with the Human Resources (HR) Director. The HR Director stated the Director of Nursing (DON) had brought Dietary Aide #1 to her office and introduced Dietary Aide #1 as her son. The HR Director stated the DON and Dietary Aide #1 never mentioned having a pending charges or allegations. She stated that she had printed a report from the North Carolina Nurse Aide Registry on Dietary Aide #1 prior to hiring him. The HR Director stated she had not thoroughly looked over the document from the Registry because it was the DON's son. The HR Director stated if she would have seen the pending allegation, she would not have allowed Dietary Aide #1 to work at the facility. The HR Director stated she was made aware by the Administrator on 9/12/2024 that Dietary Aide #1 had 1 pending allegation of abuse on the North Carolina Nurse Aide Registry. The HR Director stated after she was made aware of the pending allegation, Dietary Aide #1 was immediately terminated. The HR Director stated Dietary Aide #1 had not had any resident contact in the facility, had one day of classroom orientation, and two shifts with another Dietary Aide in the kitchen. The HR Director stated she was responsible for reviewing the registry information prior to employment was offered An interview was conducted on 9/17/2024 at 1:58 pm with the Administrator. The Administrator stated she was contacted by someone outside of the facility on 9/12/2024 and informed that Dietary Aide #1 had pending abuse allegations on the North Carolina Nurse Aide Registry. The Administrator stated she immediately went to the HR Director and had her retrieve Dietary Aide #1's employee file. The Administrator stated in the file was a copy of the report from the North Carolina Nurse Aide Registry that stated Dietary Aide #1 had a pending allegation of abuse. The Administrator stated she immediately terminated Dietary Aide #1 and spoke with the DON. The Administrator stated she was told by the DON that Dietary Aide #1 had received a letter in the mail that stated the abuse allegation had been cleared. The Administrator stated if she would have known about the pending abuse allegation on his certification, she would not have allowed Dietary Aide #1 to work at the facility. The Administrator stated their system had failed and they had not followed their policies and procedures. 37014 2. The facility policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating with a revised date of September 2022, revealed in part: Policy Statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Policy Interpretation and Implementation: 1) If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the Administrator and to other officials according to state law. 3) Immediately is defined as a) within two hours of an allegation involving abuse or result in serious bodily injury or b) within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. Resident #81 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #81 with intact cognition. Review of the initial allegation report submitted by the facility to DHSR via fax transmission on 08/11/24 at 9:33 PM noted an allegation type of resident abuse that the facility was made aware of on 08/09/24 at 4:35 PM. Resident #81 alleged that a young, male staff member had exposed his genitalia to her during care. Law enforcement was notified of the allegation on 08/10/24 at 4:00 PM. Review of the 5-day investigative report submitted by the facility to DHSR via fax transmission on 08/14/24 at 3:53 PM noted Adult Protective Services (APS) was notified of the allegation on 08/10/24 and an onsite visit by APS was conducted on 08/12/24. Further review revealed the allegation of resident abuse was unsubstantiated. During an interview on 09/20/24 at 8:51 AM, the Administrator confirmed that she was notified of the abuse allegation reported by Resident #81 the evening of 08/09/24 and an investigation was immediately initiated. The Administrator confirmed that she had not submitted the initial allegation report to DHSR until 08/11/24 and explained she was trying to get statements along with further details of the alleged incident and time just slipped away from her. 37280 3. A review of the facility's Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating policy revised September 2022 revealed: Policy Statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Policy Interpretation and Implementation: Reporting Allegations to the Administrator and Authorities: 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: 3. Law enforcement officials. Resident #225 was admitted to the facility on [DATE]. A review of the facility's Initial 24-hour Report dated 07/12/24 at 8:50 AM revealed the facility was notified on 07/12/24 by the local county of department of social services (DSS) and adult protective services (APS) of the confirmation of neglect of Resident #225. The report indicated the Resident was currently in the facility and with no harm noted and no concerns noted upon nurse assessment. The Resident remained at baseline with normal psychosocial affect and an investigation was underway. The Report did not indicate the local law enforcement was notified of the allegation. The Report was completed by the Assistant Administrator on 07/13/24. A review of the Investigation Report dated 07/17/24 and completed by the Administrator revealed the local law enforcement was not notified of the allegation of neglect of Resident #225. During an interview with the Assistant Administrator on 09/17/24 at 2:02 PM the Assistant Administrator explained that on 07/12/24 the facility was notified by an APS investigator that they were substantiating an allegation of neglect secondary to two omissions of documentation of wound treatments in May 2024. She continued to explain that she completed the Initial Report as Resident Neglect as advised by their corporation but failed to inform the local law enforcement of the allegation. An interview was conducted with the Administrator on 09/17/24 at 2:42 PM. The Administrator explained that she was informed by an APS investigator on 07/17/24 that they were substantiating an allegation of neglect of Resident #225 based on one or two omissions of documentation of treatments of pressure ulcers and stated, if they were not documented, they were not done. The Administrator indicated she was not aware that the reports were submitted to the state agency as Resident Neglect and remarked the local law enforcement should have been notified as well.

Based on record review, staff interviews, the facility failed to ensure a staff member had no pending or substantiated allegations of Resident Abuse or Neglect on the North Carolina Nurse Aide Registry for 1 of 5 employees (Dietary Aide #1) reviewed for resident abuse. The findings included: Review of Dietary Aide #1's employee file revealed he was hired on 9/6/2024 and was terminated on 9/12/2024. A background check had been completed, and there were no criminal charges. A report from the North Carolina Nurse Aide Registry revealed Dietary Aide #1 had one pending allegation of Abuse of a Resident. An interview was conducted on 9/17/2024 at 12:49 pm with the Human Resources (HR) Director. The HR Director stated when a person was hired, she completed a background check to ensure there were no criminal charges. The HR Director stated she also searched each new hire employee's name on the North Carolina Nurse Aide Registry to ensure there were no allegations of abuse or neglect. The HR Director stated if either the criminal background check or North Carolina Nurse Aide Registry reports had any charges or allegations, the individual would not be eligible for employment at the facility. The HR Director stated she was made aware by the Administrator on 9/12/2024 that Dietary Aide #1 had 1 pending allegation of abuse on the North Carolina Nurse Aide Registry. The HR Director stated she had not thoroughly looked over the document from the Registry because Dietary Aide #1 was the DON's son. The HR Director stated if she would have seen the pending allegation, she would not have allowed Dietary Aide #1 to work at the facility. The HR Director stated Dietary Aide #1 had not had any resident contact in the facility, had one day of classroom orientation, and two shifts with another Dietary Aide in the kitchen. An interview was conducted on 9/17/2024 at 1:13 pm with the Director of Nursing (DON). The DON stated any individual can apply to work at the facility by walking in and completing an application. The DON stated whenever someone was being considered for employment, she obtained a copy of their driver's license and current certifications. The DON stated she would then give the copies to the HR Director who completed a criminal background check and set up orientation. The DON stated that Dietary Aide #1 was her son. The DON stated she was aware that her son had pending allegations on the North Carolina Nurse Aide Registry, which is why he was not employed at the facility as a Nurse Aide (NA). An interview was conducted on 9/17/2024 at 1:27 pm with the Dietary Manager. The Dietary Manager stated Dietary Aide #1 went through one day of in-person general orientation in the front conference room at the entrance of the facility and worked two days alongside another Dietary Aide in the kitchen. The Dietary Manager stated Dietary Aide #1 never had any contact with any residents during his time of employment and only trained on the dishwasher. An interview was conducted on 9/17/2024 at 1:58 pm with the Administrator. The Administrator stated that anyone can apply for a job at the facility by completing an application in person or over the internet. The Administrator stated after an application was received it was forwarded to the appropriate department manager for employment consideration and to schedule an interview. The Administrator stated if a department manager wished to hire an individual, they would notify the HR Director. The Administrator stated the HR Director completed a criminal background check, would run a report on the North Carolina Nurse Aide Registry, and would schedule/set up orientation. The Administrator stated she was contacted by someone outside of the facility on 9/12/2024 that Dietary Aide #1 had pending abuse allegations on the North Carolina Nurse Aide Registry. The Administrator stated she immediately went to the HR Director and had her retrieve Dietary Aide #1's employee file. The Administrator stated in the file was a copy of the report from the North Carolina Nurse Aide Registry that stated Dietary Aide #1 had a pending allegation of abuse. The Administrator stated she immediately terminated Dietary Aide #1. The Administrator stated if she would have known about the pending abuse allegation on his certification, she would not have allowed Dietary Aide #1 to work at the facility.

Based on record review and staff, family member, and regional ombudsman interviews, the facility failed to notify the Regional Ombudsman of a facility initiated discharge for 1 of 4 residents reviewed for dischage (Resident #308). The findings included: Resident #308 was admitted to the facility on [DATE] with diagnoses that included dementia. A review of Resident #308's discharge Minimum Data Set assessment dated [DATE] revealed resident was moderately cognitively impaired. Resident #308 was discharged home on 08/14/24. An interview with Resident #308's Family Member on 10/07/24 at 4:56 PM revealed Resident #308 had been admitted to the facility for a short-term respite period while Resident #308's spouse was having a medical procedure. The Family Member stated he was contacted on 08/14/24 by the Admissions Coordinator and notified that Resident #308 had eloped from the facility. During that phone call, he was notified that the facility could not meet the care needs of Resident #308 but would assist in finding him a secure unit. Resident #308's Family Member reported he came to the facility and picked up Resident #308 and took him home with him while the facility continued to locate a more appropriate placement for Resident #308. Resident #308's family member reported Resident #308 respite care stay was scheduled to be over on 08/15/24. During an interview with the Admissions Coordinator on 10/07/24 at 2:35 PM revealed after Resident #308 was brought back into the facility from his elopement, she was notified by the Administrator to contact Resident #308's family and notify them of the elopement and ask them to come get Resident #308 as the facility could not meet Resident #308's needs and keep him safe. The Admissions Coordinator reported she typically did not have anything to do with discharging of residents and that discharges were handled by the Social Worker. The Admissions Coordinator reported she did not notify the Regional Ombudsman of the discharge. During an interview with the Social Worker on 10/07/24 at 3:09 PM revealed she was on vacation during the time that Resident #308 was admitted to the facility and stated while she was away, the Business Office Manager covered her duties. The Social Worker stated that they should have been notified along with the Regional Ombudsman. She reported she did not know if the facility had notified the Regional Ombudsman. During an interview with the Business Office Manager on 10/07/24 at 3:13 PM revealed she had nothing to do with Resident #308's discharge process. An interview with the Regional Ombudsman via phone on 10/07/24 at 4:20 PM revealed she was not notified of Resident #308's facility-initiated discharge. She stated she would like to be notified of any facility-initiated discharges so she could reach out to the resident and or family to see if they would like for her to advocate for the discharging resident. During an interview with the Assistant Administrator on 10/07/24 at 4:40 PM she stated Resident #308 was admitted to the facility for a very short-term respite care stay and while he was admitted , Resident #308 eloped from the facility. She stated after the elopement, the Admissions Coordinator was instructed to contact his family and notify them of the elopement and to tell them that the facility could not meet the care needs of Resident #308 but would assist the family in locating a facility that had a secured dementia-care unit. The Assistant Administrator reported Resident #308's respite care stay was scheduled to end on 08/15/24. She also revealed the facility did not provide any discharge planning or notify the Regional Ombudsman of the facility-initiated discharge of Resident #308. She reported because Resident #308 admitted under respite care, and the facility was only providing room, board, and nursing services, she was under the impression that they did not need to provide notification to the Regional Ombudsman.

Based on record review and staff interviews, the facility failed to have a nurse assess Resident #19 after the resident fell from the bed to the floor. Resident #19 was on life support and connected to a ventilator. Before reporting the fall to a nurse, staff transferred Resident #19 from the floor to the bed, then from the bed to a shower stretcher, provided a shower and then transferred the resident from the shower stretcher to her bed. Nurse #1 was made aware of the fall after Resident #19 had been transferred three times and showered. Nurse #1 performed a head-to-toe assessment and determined that Resident #19 had abrasions to her abdomen and right arm. Resident #19 was sent to the emergency room and was determined to have acute right tibia and fibula fractures. This deficient practice affected 1 of 1 resident reviewed for falls (Resident #19). The immediate jeopardy began on 10/31/21 when Resident #19 who was on a ventilator for life support and received an anticoagulant fell from her bed and was transferred three times before a nurse was notified and assessed the resident. The immediate jeopardy was removed on 02/17/22 when the facility provided and implemented a credible allegation of immediate jeopardy removal. The facility remained out of compliance at a lower scope and severity of a D (an isolated situation with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education was in place and monitoring systems put into place were effective. Findings included: Resident #19 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #19 had a urinary catheter, special respiratory treatments including oxygen therapy, suctioning, [CONDITION(S)] care and ventilator and received an anticoagulant. A review of a document written by Nurse Aide (NA) #1 dated 10/31/21 read, in part, while I was changing [Resident #19], she started coughing and bouncing. I couldn't catch her before she rolled off the bed. [Respiratory Therapist (RT)/NA #2] and I put a bed pad under her and lifted her back into bed. We then took her to the bath. This document did not provide any details after Resident #19 was taken to the shower. Three attempts were made to contact NA #1 were unsuccessful. A review of a document written by RT/NA #2 dated 10/31/21 read, in part, walking past resident's room. C.N.A (NA#1) asked for assistance getting resident in bed. Assisted C.N.A. in getting into bed. Resident covered in BM (bowel movement). C.N.A took resident to shower. An additional typed witness statement signed by RT/NA #2 on 10/31/21 read, in part, Resident #19 was sitting on the floor/leaned up against bed in between the bed and the wall air conditioner. Resident #19 was covered in BM; BM was all over the floor and Resident #19's fully inflated catheter was lying on the floor under Resident #19. NA #1 stated he just needed help getting Resident #19 back in the bed. RT/NA #2 believed NA #1 had already reported to the nurse and NA #1 just needed help to transfer Resident #19 back to bed. After Resident #19 returned from the shower, NA #1 commented to RT/NA #2 and NA #3 that the catheter needed to be replaced. RT/NA #2 wrote after this conversation, he alerted the nurse about what he had observed and notified her that the catheter needed to be replaced. At that time, he learned she was unaware of the fall. An interview with RT/NA #2 on 02/15/22 at 3:53 PM revealed he did not notify the nurse that Resident #19 was on the floor prior to assisting NA #1 to move her from the floor to bed. RT/NA #2 stated that he assumed NA #1 had already reported the fall to Nurse #1 but stated he told her about it on his way back to his unit. He stated it was five to ten minutes after he had assisted NA #1 to transfer Resident #19 back to the bed. There were no written statements written by NA #3 provided by the facility. An interview with NA #3 on 02/16/22 at 7:15 PM revealed she was familiar with Resident #19 and was working on the 500 Hall on the night of 10/31/21. NA #3 indicated she was approached and asked for assistance by NA #1 when he was enroute to retrieve a shower stretcher for Resident #19 after she had a large BM and needed to be bathed. NA #3 said RT/NA #2 performed [CONDITION(S)] care and ensured Resident #19 was properly attached to the ventilator before he left the room to alert the nurse and let her know the catheter needed to be replaced. NA #3 stated she did not know that Nurse #1 was not made aware of the fall immediately by NA #1 and did not alert Nurse #1 herself. An incident report dated 10/31/21 at 5:50 AM written by Nurse #1 read, in part, I assessed resident for injuries and noted abrasions on right forearm and left lower abdomen. Also, right lower leg swelling just below the knee and some discoloration noted. I was not informed of fall until after she was back in bed and taken to shower and put in bed again. C.N.A. (NA#1) said he was changing her, and she rolled off bed into floor. A nurses' note written by Nurse #1 on 10/31/21 at 7:00 AM indicated Resident #19 had noted swelling to her right lower extremity. An interview with Nurse #1 on 2/15/21 at 1:42PM revealed she cared for Resident #19 on the night of 10/30/21 (7:00 PM to 7:00 AM). Nurse #1 indicated she was made aware that Resident #19 had fallen earlier in her shift while Resident #19 was being provided incontinence care by NA #1. Nurse #1 recalled RT/NA #2 making her aware Resident #19's catheter needed to be replaced, but as she recalled she thought NA #1 told her about the fall when she went to the room about the catheter. Nurse #1 explained NA #1 reported that Resident #19 began coughing and jerking after she was rolled on her side during incontinence care. Resident #19 came out of bed because NA #1 was unable to catch her before she came off the bed and landed on the floor. Nurse #1 found Resident #19 bathed and back in bed when she arrived at the room to assess her. She had abrasions to her abdomen and right forearm as well as swelling in her right lower extremity. Nurse #1 described Resident #19's right lower extremity to be more flexible and different. Nurse #1 stated she did not notify the provider at the time of her assessment but passed the abnormalities along to the oncoming day shift nurse (Nurse #2). Nurse #1 indicated she was busy finishing her shift duties and planned to notify the provider at the end of her shift because she did not assess Resident #19 to have sustained major injuries. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview with Nurse #2 on 2/15/21 at 4:45 PM revealed he arrived to work on 10/31/21 at approximately 6:45 AM. He stated Nurse #1 reported to him that Resident #19 had fallen out of the bed earlier on the shift and the staff had not reported the fall to her until after she was placed back in the bed. Nurse #2 explained that he and Nurse #1 went to Resident #19's room to assess her. He stated that her right leg was positioned differently and was very flexible at the top, near her knee, which was abnormal for Resident #19. Nurse #2 stated that during the assessment and thereafter Resident #19 remained at her baseline with no visible facial grimacing or nonverbal signs of pain that he could recall. He stated that he returned to the nurse's station and notified the physician and obtained new orders. He said later in the shift the portable x-rays were obtained and resulted in fractures to her tibia and fibula on her right side. A review of x-ray reports from both the contracted in -house company and the hospital dated 10/31/21 confirmed acute fractures to the right tibia and fibula. According to an emergency room (ER) report dated 10/31/21, Resident #19 was transported to the ER after a traumatic injury of the right lower leg. Per the report, it was unable to determine if Resident #19 fell during incontinence care or if she was dropped during a transfer from the bed to the shower stretcher. Resident #19 was splinted because she was not a surgical candidate and ordered to be non-weight bearing and subsequently discharged back to the facility on [DATE]. During an interview with the Director of Nursing (DON) on 2/15/22 at 5:00 PM, additional documentation titled Fall Investigation-Resident #19-10/31/21 5:50 AM signed by the DON on 11/2/21 was provided which indicated in an abundance of caution and concern for our resident safety, all facility nurses and NAs were reeducated on positioning a resident in lateral position. The DON reported that following any fall in the facility, when a resident was found to be on the floor, a staff member should immediately notify a nurse prior to moving a resident. She also explained she determined Resident #19 had received a shower before assessed for injury by Nurse #1. The DON stated she did not think NA #1 did anything wrong related to the fall but was an accident. An interview with the DON, Assistant Administrator, and Administrator on 2/16/22 at 12:00 PM revealed each expected all staff to notify the nurse if a resident had a fall and a nurse should assess the resident for injury before the resident is moved to ensure safety. An interview with the Physician on 2/17/22 at 2:01 PM revealed he expected to be contacted with all changes in conditions to include a fall. The Physician stated he thought this occurrence was an accident. The Administrator was notified of the Immediate Jeopardy on 2/16/22 at 12:11 PM. The facility provided the following IJ removal plan. o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the noncompliance. Resident # 19 slid off the bed to the floor during incontinent care at approximately 5:50a. Nurse Aide (NA) #1 requested help from Respiratory Therapist/Nurse Aide #2 and they placed a pad under the resident's buttocks, lifted and transferred her back to the bed. Respiratory Therapist/NA#2 ensured that the resident's airway was patent, ventilator circuit and [CONDITION(S)] tube were connected, and patient was being ventilated appropriately before leaving the room. Nurse Aide #1 and Nurse Aide #3 then transferred Resident #19 to the shower stretcher and took her to the shower room and Nurse Aide #1 completed a shower because she had a large amount of bowel on her. Respiratory Therapist/NA#2 notified Nurse # 1 after resident #19 had been transferred back to the bed. Nurse #1 performed a head-to-toe assessment of Resident #19 after she was made aware of the fall. Nurse #1 noticed that the resident had an abrasion to her abdomen and her right forearm and that her right leg was positioned differently and was very flexible at the top near her knee. Then at approximately 6:45am Nurse #2 came on shift and he and Nurse #1 assessed the resident together. The Physician on call was notified at 6:59am and gave new orders for an X-ray of right leg. Nurse #2 stated that during the assessment and thereafter, Resident #19 remained at her baseline, no facial grimacing, or nonverbal signs of pain were observed. Nurse #2 immobilized the resident's leg while awaiting the x-ray report. X-ray report received indicating fractures of right tibia and fibula. Nurse #2 reported the X-ray results to the Physician and the order was received for Resident #19 to be sent to the CVMC emergency room . EMS arrived at approximately 6:00pm on 10/31/2021 to transport. Resident returned to this facility at 00:15 on 11/1/21. The facility Nurse Practitioner assessed and evaluated this resident on the morning of 11/1/21. On 11/1/2021 the DON suspended NA#1 while an incident investigation was conducted. NA#1 was subsequently terminated from employment on 11/3/2021 due to not immediately notifying the nurse of the fall and for moving the resident prior to her being assessed by the Nurse. To identify any other resident who may have been affected; beginning on 11/21/2021, the DON began reviewing and monitoring all fall incidents. All fall incidents are monitored to ensure immediate nurse notification and assessment before the resident was moved. As of 2/16/22 all falls incidents have been in compliance with nurse notification and assessment. -Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete On 11/01/21 the DON provided in-service training for all Certified Nursing Assistants on immediately notifying a Nurse upon observation of any resident experiencing a fall and that the nurse is to assess the resident before the resident is moved. On 11/1/21 the DON began reviewing all falls that occur to determine if a nurse was notified immediately of the fall and the nurse performed an assessment prior to the resident being moved. All fall incidents have been in compliance with requirement of immediate nurse notification and nurse assessment of the resident. On 2/16/22, the DON implemented facility wide in-service training for all staff (dietary, housekeeping, activities, maintenance, Social Workers, Therapy staff, office staff, Licensed nursing staff and Certified Nursing Assistance including all agency staff on the Fall Protocol that includes: Notifying a Licensed Nurse immediately before moving the resident. Before the resident is moved, the Licensed Nurse shall perform an assessment of the resident to determine if any injury has occurred. If no obvious injury is present, the resident should be assisted back to the bed, chair, or wheelchair using the appropriate transfer device. The Director of Nursing informed Nursing Supervisors of their responsibility to continue this education / re-education on all shifts for all staff. The Director of Nursing and / or her designee will track which staff has been educated by comparing educational roster to the employee work schedule. Any Staff not working on 2/16/22 are required to receive this education on their next scheduled workday. Staff will not be allowed to work until this education is completed. New educational material has been added to the New Hire Orientation packet, new CNA clinical check off list, and the facility information that is provided to Nursing Agency staff. Alleged IJ removal date: 2/17/22 A credible allegation validation for quality of care was conducted in the facility on 02/17/22. Record review included Resident #19's Kardex and care plan. Notable revisions were as follows: Resident #19's transfer status has been updated to 2- person draw sheet on both the Kardex and care plan which are available to all nursing staff. The in-service training records reflected all staff to include nursing, housekeeping, maintenance, dietary, activities, and administrative staff were in serviced on notification of a nurse with any changes in a resident's condition to include a fall and staff were not to move a resident without a nurses' assessment and direction to do so. The facility's IJ removal date of 2/17/22 was validated.

Based on record review and staff interview, the facility failed to provide incontinence care according to an established plan to Resident #19 who was on a ventilator and in a persistent vegetative state. Nurse Aide #1 (NA #1) lost control of Resident #19 when he was in the process of providing incontinent care to Resident #19 who began to cough and bounce on the air mattress. NA #1 was unable to prevent Resident #19 from falling out of bed. NA#1 did not immediately report to a nurse. Prior to a nursing assessment to check for injury, nurse aides transferred Resident #19 three times, from the floor to the bed, from the bed to the shower stretcher and then from the shower stretcher to her bed. These transfers were performed by two staff without the use of the mechanical lift. This deficient practice affected 1 of 1 resident reviewed for falls (Resident #19). Resident #19 was sent to the emergency room and diagnosed with acute right tibia and fibula fractures. The immediate jeopardy began on 10/31/21 when Resident #19 fell from her bed during incontinence care and sustained acute fractures. The immediate jeopardy was removed on 02/17/22 when the facility provided and implemented a credible allegation of immediate jeopardy removal. The facility remained out of compliance at a lower scope and severity of a D (an isolated situation with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education was in place and monitoring systems put into place were effective. Findings included: Resident #19 was admitted to the facility on [DATE] with diagnoses that included a persistent vegetative state with chronic ventilator usage and severe [CONDITION(S)]. A physician's order dated 8/1/19 indicated Resident #1 was to receive [MEDICATION(S)] (an anticoagulant- blood thinner) 20mg (milligram) daily at bedtime. A quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #19 required physical assistance from two or more persons with bed mobility, transfers, and toileting. She had a urinary catheter and was always incontinent of bowel. She received special respiratory treatments including oxygen, suctioning, [CONDITION(S)] care and was on a ventilator. She also received tube feeding for nutrition and anticoagulant medication. A self-care deficit care plan revised on 1/24/22 indicated Resident #19 was dependent for transfers and incontinence care with rounds and as needed. The care plan did not indicate how many staff should provide incontinence care or how to transfer the resident. According to the DON, on 2/15/22 at 5:00 PM, most ventilator residents in a vegetative state are transferred using a mechanical lift which required the assistance of 2 staff members. NA #1's statement read, while I was changing Resident #19, she started coughing and bouncing. I couldn't catch her before she rolled off the bed. RT/NA #2 and I put a bed pad under her and lifted her back into bed. We then took her to the bath. Multiple attempts to contact NA #1 were made without success. A review of a document written by RT/NA #2 dated 10/31/21 read, in part, walking past resident's room. C.N.A (NA #1) asked for assistance getting resident in bed. Assisted C.N.A. in getting into bed. Resident covered in BM (bowel movement). C.N.A took resident to shower. An additional typed witness statement signed by RT/NA #2 on 10/31/21 read, in part, Resident #1 was sitting on the floor/leaned up against bed in between the bed and the wall air conditioner. Resident #19 was covered in BM. Resident #19's fully inflated catheter was lying on the floor under Resident #19. NA #1 stated he just needed help getting Resident #19 back in the bed. RT/NA #2 indicated NA #1 had already conversed with the nurse and NA #1 just needed help to transfer Resident #19 back to bed. NA #3 ' s assistance was requested to help clean Resident #19 and she was taken to the shower room for bathing. RT/NA #2 wrote after this conversation, he alerted the nurse, shared what he had observed and notified her that the catheter needed to be replaced. At this time, he learned she was unaware of the fall. An interview with RT/NA #2 on 02/15/22 at 3:53 PM revealed he recalled the events surrounding the fall sustained by Resident #19 on 10/31/21. RT/NA #2 stated he was walking by Resident #19's room and NA #1 was in the hallway and asked for help to transfer Resident #19 from the floor to the bed. He noticed Resident #19 lying on the floor on her right side with her catheter no longer intact. RT/NA #2 explained that he and NA #1 placed a cloth incontinence pad under Resident #19 then lifted her up to the bed. RT/NA #2 indicated before NA #1 left the room to retrieve the shower stretcher, NA #1 stated he would need to reinsert Resident #19's catheter because it had come out during the fall. When NA #1 returned to the room with the shower stretcher, NA#3 entered the room and she assisted NA #1 to slide Resident #19 from the bed to the shower stretcher using the cloth bed pad used to lift her from the floor. RT/NA #2 stated he left the room to go back to the unit and he stopped and told Nurse #1 about the incident because he knew the catheter was no longer intact. RT/NA #2 stated normally Resident #19 was transferred using a mechanical lift and two-person physical assistance. He stated for some reason they were just in a hurry and did not use the lift. RT/NA #2 stated that he assumed NA #1 had already reported the fall to Nurse #1 but stated he told her about it on his way back to his unit which he stated was five to ten minutes after he had assisted NA #1 to transfer Resident #19 back to the bed. There were no written statements written by NA #3 provided by the facility. An interview with NA #3 on 02/16/22 at 7:15 PM revealed she was familiar with Resident #19 and was working on the 500 Hall on the night of 10/31/21. NA #3 indicated she was approached and asked for assistance by NA #1 when he was enroute to retrieve a shower stretcher for Resident #19 after she had a large BM and needed to be bathed. NA #3 reported she followed NA #3 back to Resident #19's room where she found Resident #19 lying in the bed with her catheter lying on the floor near the bed. NA #3 indicated she and NA #1 transferred Resident #19 from the resident ' s bed to the shower stretcher using a cloth incontinence pad and NA #1 took Resident #19 to the shower room independently. Approximately 20-30 minutes later, when NA #1 returned with Resident #19 from the shower room, she assisted NA #1 to transfer Resident #19 from shower stretcher to the resident ' s bed via a clean cloth incontinence pad. NA #3 vocalized she was aware Resident #19's transfer status was a mechanical lift with 2-person physical assistance, but stated staff never transferred Resident #19 using a mechanical lift and always used a cloth incontinence pad for transfers. An interview with NA #4 on 2/17/22 at 11:00 AM revealed she was familiar with Resident #19 and cared for her often. NA #4 indicated she tried to have 2-person assist for incontinence care, bed mobility, but there were times when they must provide incontinence care and bed mobility with only one person if other staff were busy helping other residents. An interview with Nurse #3 on 2/17/22 at 11:00 AM indicated staff were required to provide 2-person physical assistance for transfers of Resident #19 and make attempts to provide 2-person physical assistance for bed mobility and toileting. An incident report dated 10/31/21 at 5:50 AM written by Nurse #1 read, in part, I assessed resident for injuries and noted abrasions on right forearm and left lower abdomen. Also, right lower leg swelling just below the knee and some discoloration noted. I was not informed of fall until after she was back in bed and taken to shower and put in bed again. C.N.A. said he was changing her, and she rolled off bed into floor. A nurses' note written by Nurse #1 on 10/31/21 at 7:00 AM indicated Resident #19 had noted swelling to her right lower extremity. An interview with Nurse #1 on 2/15/21 at 1:42PM revealed she cared for Resident #1 on the night of 10/30/21 (7:00 PM to 7:00 AM). Nurse #1 indicated she was made aware that Resident #19 had fallen earlier in her shift while Resident #19 was being provided incontinence care by NA #1. Nurse #1 explained NA #1 reported Resident #19 began coughing and jerking after she was rolled on her side during incontinence care. She subsequently fell out of bed because NA #1 was unable to catch her before she came off the bed and landed on the floor. According to Nurse #1, Resident was found bathed and back in bed when she assessed Resident #19. She found her to have abrasions to her abdomen and right forearm as well as swelling in her right lower extremity. Nurse #1 described Resident #19's right lower extremity appeared to be more flexible and different. Nurse #1 indicated Resident #19 was dependent for transfers using the mechanical lift. Nurse #1 did not feel Resident #19 was injured and did not feel contacting the physician before the end of her shift which was approximately 1 hour later was warranted. A physician's order written by Nurse #2 and dated 10/31/21 at 6:59 AM indicated Resident #19 was to have an anterior/posterior (AP) and lateral x-ray of the right lower extremity. An interview with Nurse #2 on 2/15/22 at 4:45 PM revealed he arrived to work on 10/31/21 at approximately 6:45 AM. Nurse #2 explained that he and Nurse #1 went to Resident #19's room to assess her. He stated that her right leg was positioned differently and was very flexible at the top, near her knee, which was abnormal for Resident #19. Nurse #2 stated that during the assessment and thereafter Resident #19 remained at her baseline with no visible facial grimacing or nonverbal signs of pain that he could recall. Nurse #2 stated Resident #19 was dependent for transfers using a total body mechanical lift and 2 staff physical assistance for safety. He elaborated Resident #19 should not have been lifted using an incontinence pad after she fell from her bed. A review of x-ray reports from both the contracted in -house company and the hospital dated 10/31/21 confirmed acute fractures to the right tibia and fibula. According to an emergency room (ER) report dated 10/31/21, Resident #19 was transported to the ER after a traumatic injury of the right lower leg. Per the report, it was unable to determine if Resident #19 fell during incontinence care or if she was dropped during a transfer from the bed to the shower stretcher. Resident #19 was splinted and ordered to be non-weight bearing and subsequently discharged back to the facility on [DATE]. During an interview with the Director of Nursing (DON) on 2/15/22 at 5:00 PM, additional documentation titled, Fall Investigation- [Resident #19] 10/31/21 5:50 AM, signed by the DON on 11/2/21, was provided which indicated the DON investigated and determined that the NAs involved in the incident surrounding Resident #19's fall did no wrong and the root cause of the fall was due to the air mattress' slick surface and the resident's coughing. The document further indicated in an abundance of caution and concern for our resident safety, all facility nurses and NAs were reeducated on positioning a resident in lateral position. The DON reported that following any fall in the facility, when a resident was found to be on the floor, a staff member should immediately notify a nurse prior to moving a resident. Once the resident was assessed not to have an injury, the resident may be transferred based on their current transfer method Once the resident is transferred and safety established, the physician, responsible party, and the DON should be notified immediately for further orders and investigation. The DON verbalized she discovered during her investigation Resident #19 was transferred incorrectly using the incorrect transfer method. An interview with the DON, Assistant Administrator, and Administrator on 2/16/22 at 12:00 PM revealed each expected all staff to notify the nurse if a resident had a fall. They stated they did not believe the mechanical lift wouldn't fit on that side of the bed where Resident #19 fell , but later acknowledged the bed was able to have been moved to allow for transfer using the mechanical lift. The Administrator was notified of the Immediate Jeopardy on 2/16/22 at 12:11 PM. The facility provided the following IJ removal plan. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Resident #19 was provided incontinence care by a Certified Nursing Assistant (CNA) on 10/31/21. During the care the resident had a coughing spell and began bouncing around on the bed. Before the Certified Nursing Assistant #1 could reach the resident, she rolled from the bed. MDS indicated resident required 2 assist to provide incontinence care 1 time in the 7 day look back period. Information the resident required 2 assists when providing incontinence care was not available on the Kardex file. It is unknown if the side rail on the opposite side was up or down. Per CNA Resident #19 was rolled away from him. Resident #19 requires 2 person assist for incontinence care. Kardex and Care Plan was updated to 2 person assist for incontinence care on 2/16/2022. Transfer status for Resident #19 was evaluated by the Physical Therapist Doctor of Physical Therapy for patient safety and mobility 2/17/2022. Therapist determined resident is dependent on functional mobility and would benefit utilizing a draw sheet for lateral transfers with total assistance from 2+ staff. This deficient practice has the potential to affect all residents residing within the facility who are incontinent and require assistance with care. On November 1, 2021 Director of Nursing implemented in-service training for all Nursing staff on Safe Positioning of Resident when Turning and Providing Incontinence Care Independently. In service covered positioning a resident in lateral position, using proper body mechanics, assure residents face is not obstructed. Use supporting devices. This education is covered in orientation and was used as a refresher to remind the nursing staff to be cognizant of residents position on the bed during incontinent care and required no additional steps for implementation. On February 16, 2022, Director of Nursing, MDS RNS and Nursing Supervisors reviewed all other resident's residing in the facility to determine those who needed two person assistance with incontinence care and those residents who required a mechanical lift for transfers. The MDS nurses then reviewed each Resident's Kardex (tool used in the electronic health record to inform staff of care requirements) and made changes where necessary to provide information to staff on amount of assistance needed for safe transfer of resident, the mobility status of a resident and the required number of staff to provide safe toileting/incontinence care to a resident while in bed. This was completed on 2/16/2022. · Transfer Status · Mobility Status · Toileting Status Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. All resident falls are reviewed in Morning Standup meetings. The Director of Nursing presents the review of falls to the clinical team. Clinical team consists of DON, MDS Nurse, Wound Care Nurse, Nursing Supervisors, Administration, Director of Rehab, Social Worker, Director of Respiratory Therapy, Root cause of why the fall occurred is investigated by the DON and shared with all disciplines participating in the review. Interventions are put in place to keep the resident from having a recurring fall. MDS Nurse adds interventions to the care plan which populates the Kardex. Nursing Supervisors inform hall staff of any updates in plan of care. Previous implemented interventions are reviewed at our monthly At Risk meetings to determine effectiveness. If the intervention does not work and a resident has a repeat fall, root cause is evaluated again and additional interventions put in place or previous interventions removed. Interventions are updated in the care plan immediately after the meeting and staff notified by Nursing Supervisors. CNA's have access to both the care plan and the Kardex. On February 16, 2022 the Director of Nursing implemented in-services for all Nursing Staff including Agency on Locating Required Staff Assistance for Toileting and Incontinence Care. Any nursing staff or agency nursing staff reporting to work after this date will receive this in-service prior to working. · Locating information in electronic Kardex which indicates residents need for number of staff required to provide safe toileting/incontinence care . · Use the correct number of staff when providing care. · Informing supervisor if additional staff is needed to provide incontinence care to resident safely. · Use correct equipment/assistance devices for lifting and/or transfers according to the assessment and care plan of the resident. · Reviewed location of Care Plan and Kardex within the Electronic Records. New educational material has been added to the New Hire Orientation packet for Nursing and Nurse Aide staff as well as the Clinical version . · Kardex Information · Care Plan Information Alleged IJ removal date: Requested for February 17, 2022 A credible allegation validation for supervision to prevent accidents was conducted in the facility on 02/17/22. Record review included Resident #19's Kardex and care plan. Notable revisions were as follows: Resident #19's transfer status has been updated to 2- person draw sheet on both the Kardex and care plan which are available to all nursing staff. The in-service training records reflected all staff to include nursing, housekeeping, maintenance, dietary, activities, and administrative staff were in-serviced on notification of a nurse with any changes in a resident's condition to include a fall and staff were not to move a resident without a nurses' assessment and direction to do so. Staff were observed to perform incontinence care using the appropriate turning education provided as well as residents were transferred using 2 person physical assistance when using the mechanical lift. The facility's IJ removal date of 2/17/22 was validated.

Based on observations, staff and resident interviews and record review the facility failed to safely transfer a resident and the resident fell fracturing her left tibia and fibula and failed to provide supervision during toileting for a resident who was at risk for falls for 2 of 4 sampled residents (Residents #9 and #7). The findings included: 1. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #9's care plan dated 07/01/15 for impaired physical mobility specified the resident was to be transferred with 2 persons. The admission Minimum Data Set ((MDS) dated [DATE] specified the resident had moderately impaired cognitive skills and required extensive assistance with activities of daily living, and two person assistance with transfers. Review of Resident #9's medical record revealed a nurses' entry 09/21/14 and made by nurse #1 read in part, Resident observed in floor of shower room screaming in pain from left knee. Nurse Aide #1 attempted to put a shower chair under the resident. A physician's orders [REDACTED]. On 09/21/15 the resident was sent to the Emergency Department for evaluation of pain after a fall and was admitted to the hospital. Hospital records were reviewed and revealed an x-ray dated 09/21/15 revealed Resident #9 fractured her left tibia and fibula. Further review revealed Resident #9 was admitted to the hospital and discharged on [DATE]to the facility. On 10/06/15 at 2:40 PM Resident #9 was observed in her bed wearing a brace to her left leg. Resident #9 was interviewed and explained that after she had a stroke it took two people to transfer her. She added that on 09/21/15 two nurse aides assisted her to the shower and one of the nurse aides left leaving her alone with nurse aide #1. Resident #9 stated, I told her she better get help before trying to move me but she said she could do it. Resident #9 added that NA #1 asked the resident to stand up and hold on to the whirlpool bathtub and walked away from the resident. While standing there, the Resident reported that her legs gave way and she fell . On 10/06/15 at 3:00 PM NA #1 was interviewed and reported that she was new to the facility but was instructed to use a transfer lift sheet as a reference to know what type of transfer assistance a resident required. NA #1 added that on 09/21/15 she was assigned to give Resident #9 a shower. She explained that she and another NA transferred Resident #9 into the shower room and from her wheelchair to the shower chair and then the other NA (name not provided) left the shower room. NA #1 stated that she proceeded to bathe the resident and rather than calling for assistance, she attempted to transfer the resident from the shower chair to the wheelchair but the Resident fell . NA #1 stated that she had not referenced her transfer lift sheet to see what type of assistance Resident #9 needed for transfers but added that she should have known and it was her fault. On 10/07/15 at 8:10 AM nurse #1 was interviewed on the telephone and reported she was the nurse assigned to Resident #9 on 09/21/15. The nurse explained that she heard a scream and went to the shower room and observed NA #1 coming out of the shower room and Resident #9 in the floor in pain. Nurse #1 stated she asked what happened and NA #1 reported that she was attempting to put a chair (unsure if it was shower chair or wheelchair) under the resident and her legs gave out and she fell . Nurse #1 stated that Resident #9 required 2 persons for transfers and that NA #1 was new and apparently didn't know to use two people. On 10/07/15 at 9:15 AM the Director of Nursing (DON) was interviewed and reported that she had investigated the fall and determined that NA #1 did not get assistance to transfer Resident #9. The DON stated that NA #1 should have known that Resident #9 required 2 person assistance with transfers because two people had transferred the resident to the shower chair and NA #1 had her transfer lift sheet in her pocket at the time of the fall. The DON stated she expected staff to transfer residents in accordance with their plan of care. 2. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent quarterly Minimum Data Set ((MDS) dated [DATE] indicated Resident #7 was cognitively intact for daily decision making and required extensive assistance by staff for toileting. The MDS also indicated Resident #7 was frequently incontinent of bladder and bowel. A review of a care plan with a problem statement for impaired mobility dated 05/08/15 revealed a goal that staff would anticipate and meet all daily care needs. The approaches indicated to assist with toileting and incontinence care with rounds and as needed and 2 person assist for transfers and assist with positioning as necessary or as requested by resident. A review of physician's orders [REDACTED]. A review of a nurse's note dated 09/19/15 indicated in part at 9:30 AM Resident #7 was observed in the floor in the bathroom. The note documented by Nurse #1 revealed she had assisted Nurse Aide (NA) #4 to transfer Resident #7 to the toilet then stepped out to continue working on her medication pass. The notes further revealed about 2 minutes later Nurse #1 heard a loud noise and went in Resident #7's room to check on her and she was in the floor. The notes indicated Resident #7 stated she was trying to clean herself and lost her balance. The notes further indicated Nurse #1 assessed Resident #7 and she was alert and oriented but she had a skin tear to the left elbow, a skin tear and raised area approximately 1 inch above left eye, swelling around left eye, a bruise to left shoulder with a raised area and she applied a non stick antiseptic mesh gauze and dressings to Resident #7's left elbow and above her left eye. A review of a facility document titled Resident Incident Reports dated 09/19/15 at 9:31 AM revealed Resident #7 had a non-witnessed fall in the bathroom with a skin tear, abrasion, hematoma and bruise. The report indicated Nurse #1 assisted NA #4 and placed Resident #7 on the toilet and left the room to continue with a medication pass. The report further indicated Nurse #1 heard a crash and went into Resident #7's bathroom and saw the resident on the floor in front of the toilet. The report revealed Resident #7 stated she was trying to clean herself and lost her balance. The report further revealed Resident #7 had swelling above her left eye, a skin tear to her left elbow and a bruise on her left shoulder. The report indicated Nurse #1 applied a non stick antiseptic mesh gauze and dressings above Resident #7's left eye and to her left elbow. A review of a therapy note dated 09/19/15 at 11:01 AM indicated Resident #7 was seated in wheel chair in room with bump and blood on left side of face above eye and left elbow due to falling off toilet while trying to complete hygiene with no assistance. During an observation and interview on 10/06/15 at 10:02 AM Resident #7 was seated in a wheelchair next to her bed and had bruising above her left eye and on both cheeks of her face. She explained she was paralyzed on her left side and could not use her left arm because of a stroke and confirmed she recently had a fall in her bathroom when she was trying to clean herself and fell forward off the toilet and hit her face and left arm. She stated 2 staff had assisted her to the toilet and they left her in the bathroom with the door almost closed except for a narrow opening. She further stated she thought 2 staff were waiting outside the door until she finished so she attempted to clean herself and when she did she fell forward off the toilet and hit her face and left arm on the wall in front of the toilet. She stated she did not ring the call bell because it happened so quickly and after she fell in the floor she could not reach the call bell. She explained she then realized there were no staff outside the door because it took several minutes before staff came into the bathroom and helped her up into her wheelchair. During an interview on 10/06/15 at 3:02 PM with Nurse #2 she verified Resident #7 required 2 staff assist for transfers and they tried not to leave Resident #7 in the bathroom unattended but if there was only 1 NA on the hall and another resident rang a call bell they left her to go attend to the other resident. She stated during breaks and lunch sometimes there was only 1 NA on hall and she was usually passing medications to residents and if she was in a resident room she couldn't hear if a resident called. During an interview on 10/06/15 at 2:38 PM with NA #4 she verified she was the NA assigned to Resident #7 on 09/19/15 when she fell in the bathroom. She stated staff were aware Resident #7 was at risk for falls because she had fallen since she had been in the facility. NA #4 explained Nurse #1 helped her transfer Resident #7 onto the raised toilet seat that was positioned over the toilet in her bathroom and they told the resident to ring the call bell when she finished and she left the bathroom door barely open to give the resident privacy. She further explained Nurse #1 went back to her medication cart and then a call bell rang in the central bath on the hall so she left Resident #7's room and went to the central bath. She confirmed when she left Resident #7's room there were no other staff in the room with Resident #7. She stated while she was still in the central bath another NA came in and told her Resident #7 had fallen in her bathroom. She explained she went to Resident #7's room and saw her lying in the floor in front of the toilet with her head against the wall and was bleeding from above her left eye and left elbow. She further explained she left Resident #7's room to answer the call light in the central bath because she thought another NA who was also assigned to work on the hall would respond if Resident #7 rang her call bell but later found out the other NA had left the hall and had not told her. During an interview on 10/07/15 at 8:15 AM with Nurse #1 she confirmed she was the nurse assigned to Resident #7 on 09/19/15. She stated she was giving medications to residents when Resident #7 rang her call bell and said she needed to go to the toilet right away. She explained she stopped giving medications when NA #4 asked for her help and they transferred Resident #7 onto a raised toilet seat in her bathroom because she required 2 staff assist for transfers. She stated Resident #7 was incontinent before they could get her transferred to the toilet so she told NA #4 to clean her and she went back to passing medications to residents. She stated she thought NA #4 had stayed with Resident #7 but a few minutes later she heard a loud noise and went to Resident #7's bathroom to check on her and she was in the floor. She explained Resident #7 was bleeding so after she determined she did not have any broken bones she and other staff who had come to the room moved her and got her into a wheelchair. She stated Resident #7 was bleeding from her head and left elbow and the skin above her left eye was sheared off and she had bruising and swelling over the area. She explained she got the bleeding stopped and checked her vital signs and they were within normal limits. She further explained Resident #7 wanted to be independent and care for herself but she was not physically capable of being independent. During an interview on 10/07/15 at 9:31 AM the Director of Nursing confirmed Resident #7 had a fall in her bathroom on 09/19/15. She explained Resident #7 needed staff assistance with transfers and toileting because she was paralyzed on her left side. She further explained Resident #7 wanted to be independent with her care but was not capable of taking care or herself and was modest with personal care. She stated it was her expectation for staff to respect her privacy but not leave her unattended during toileting.

Based on observation, record review, and staff interviews, the facility failed to have interventions in place to prevent 1 of 3 cognitively impaired residents with wandering behavior from exiting, unsupervised from the facility. On 5/12/2015 Resident #191 was seen attempting to leave the facility through a non-alarmed door and 5/21/2015 the resident was found outside by a staff member, approximately 300 feet from the same, non-alarmed exit door. Immediate Jeopardy began on 5/21/2015 and the Administrator was notified on 7/22/2015 at 6:50 PM. Immediate Jeopardy was removed on 7/24/2015 at 5:11 PM when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy (D), to ensure monitoring of systems put in place and 100% of employee training. Findings included: The facility Policy Statement, titled Elopements (revised February 2014), included: 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. Resident #191 was admitted to the facility 4/28/2015 with [DIAGNOSES REDACTED]. The admission comprehensive Minimum Data Set ((MDS) dated [DATE] indicated the resident was severely cognitively impaired but had not exhibited wandering during the assessment period, The MDS also indicated the resident's walking balance was not steady and he required extensive assistance of two staff members for locomotion on and off the unit. The Plan of Care (originally dated 5/11/2015) indicated the resident had short and long term memory problems due to Alzheimer's disease, received medications for anxiety and depression and was at risk for falls. Review of the facility 24 Hour Report Sheet dated 5/12/2015 revealed a note by Resident #191's name which read, opened patio door on second shift but did not indicate a time for the incident. Review of the clinical record revealed that on 5/12/2015 resident #191 was observed in his wheelchair, propelling himself into the patio dining room. The nursing documentation note included, resident stood up and opened patio door and tryed (sic) to go out unassisted, another nurse assisted resident back into w/c (wheelchair), resident stated he was leaving and very determined to get out any door in facility, will monitor closely, call light within reach. The note did not indicate the time of the incident. The facility did not provide an incident report for the attempted elopement on 5/12/2015. A physician order [REDACTED].#191 was given a bracelet that with the facility magnetic door lock system, would alarm if he attempted to leave through an alarmed door. The order also indicated a pad alarm was to be placed in the resident's bed and wheelchair to alert staff if the resident attempted to rise off of the pad. Resident #191's Plan of Care was updated on 5/14/2015 to indicate a wander guard bracelet was in place to prevent elopement. A note in the clinical record dated 5/20/2015 at 5:28 PM read, Resident attempting to leave facility this afternoon. Redirection attempts by staff unsuccessful SW (Social Worker) asked resident why he was trying to leave, resident indicated he was going home. The record also indicated the Nurse Practitioner was informed and the resident was given a one-time dose of Ativan 1 milligram, intramuscularly for agitation. Further review of the clinical record revealed the resident succeeded in exiting the facility without staff knowledge on 5/21/2015. A note by the SW dated 5/21/2015 at 6:58 PM included, Resident went out patio door in dayroom, locked his wheelchair breaks, climbed over the short brick wall on the patio, ambulated around the facility and was walking down the 600 hall driveway, when staff were alerted to resident being outside. Resident redirected back into the facility. Review of the facility investigation included a description of the incident, written by the Director of Nursing (DON) on 5/25/2015. The description included, On 5/21/2015, at approximately 4:30 PM, resident was observed by staff through a resident's window outside on the grounds. Resident was walking alongside the building independently. Staff immediately went to resident and resident was cooperative and allowed staff to lead him back inside the building. The patio dining room door was observed on 7/21/2015 at 11:50 AM and again at 2:22 PM. There was a sign on the door which read, KEEP THIS DOOR LOCKED AT ALL TIMES Approximately 24 inches above the doorknob was a deadbolt lock. The door was locked. The door was able to be unlocked by turning the deadbolt to the left and no alarm sounded. Outside the door was a 15 foot square patio surrounded by a brick wall that was approximately 26 inches high. A second brick wall surrounded the first wall, separated by a space of approximately 8 inches. The space between the brick walls was filled with dirt which formed a garden where tomato plants were growing. Beyond the patio was a large grassy area with trees and bushes. Beyond the grassy area was a driveway which ran behind the facility and then a chain-link fence and a downward sloping area that was heavily wooded. The driveway behind the facility went around to the side of the building where there was a parking lot and then further around to the front parking lot. Nurse #1 was interviewed on 7/22/2015 at 3:16 PM. She stated she was working on 5/12/2015 (attempted elopement through patio door) and also on 5/21/2015 when Resident #191 was found outside the 600 hall wing. When asked about the incident on 5/12/2015, Nurse #1 said the resident was observed to stand up from his wheelchair, unlock the patio door and was going to step outside when he was stopped by another nurse who brought him back into the building. Nurse #1 indicated that between 5/12/2015 and the time of his discharge on 5/25/2015, the resident would go to all the doors and try to get out. She said after he was admitted , His meds were decreased and when he started to wake up is when it started. He would go to the 600 door or patio door and try to go out. The nurse added that she had questioned why the patio door was not alarmed and was told the door could not have the wander guard lock on it. The nurse said, The sign, 'This door must be locked at all times' was already posted at that door but he saw activity staff unlock the door and go out with residents to do activities on the patio, I guess. Nurse #1 said she made sure the attempted elopement was documented, passed on in report and was on the 24 hour Report Sheet. During the same interview Nurse #1 described the events on 5/21/2015 when the resident was successful in leaving the building unsupervised. Nurse #1 said she had spoken to the resident 10-15 minutes earlier and the resident's family member was looking for him too when Resident #191 was observed through the 100 hall window, moving through the backyard. Nurse #1 sent staff to get him while she went around to the closest door on the 600 hall with a wheelchair to meet them and the resident's family member, was right behind me. My question was this an elopement or just an incident because he wasn't off the grounds. The DON said she would take care of the documentation and notifying the appropriate people and I could just go back to what I was doing. Nurse #1 clarified that Nursing Assistant (NA) #2 had told her the resident was outside and the nurse was also aware a NA on 600 hall saw the resident through another resident's window on 600 hall. The Assistant Administrator was interviewed on 7/22/2015 at 4:24 PM. The Assistant Administrator said a wander guard alarm system was in place and all exit doors were alarmed except this one. There was no electricity to this patio door so it could not be alarmed with the system so they put up a sign that said to keep door locked. The Assistant Administrator said after the investigation on 5/25/2015 of the elopement on 5/21/2015, the facility attached a personal body alarm to the patio door. The Assistant Administrator said she had noticed someone had removed the personal body alarm from the patio door so she placed one on the door again just prior to the interview. She did not know how long it had been gone from the door. NA #1 was working on 600 hall on 5/21/2015 and was interviewed on 7/22/2015 4:46 PM. NA #1 said, I was assisting a resident in room 621 and went to shut the blind and happened to look up and saw him (Resident #191). I went running out the door to go get him. NA#1 went on to say, I didn't have the code for the door nearest (room) 621 so I ran up the hall and went out the door by the 600 hall lobby and ran down the side of the building to get him. NA #1 clarified that Room 621 overlooked the facility's side parking lot and one could not see the backyard from that room. On 7/23/2015 at 10:31 AM, the Administrator and Assistant Administrator were both interviewed about the attempted elopement on 5/12/2015. Both of them stated they had been made aware of Resident#191's exit-seeking behavior but they were not aware he had attempted to leave by a non-alarmed door. On 7/23/2015 at 10:48 AM, the Director of Nursing (DON) was interviewed about the attempted elopement on 5/12/2015. She stated she was present at the Clinical Meeting on 5/13/2015 when it was discussed. The DON indicated it was she who had obtained the physician order [REDACTED]. When asked about the non-alarmed patio door where he had attempted to get out, the DON indicated the resident had also made attempts to exit the facility by alarmed doors. On 7/23/2015 at 11:25 AM, the Director of Maintenance measured the two routes the resident could have taken when he exited by the patio door on 5/21/2015. If he had climbed over the brick wall (approximately 26 inches high) and taken a direct path to the other side of the 600 hall wing, the distance was approximately 249 feet from the patio door. If the resident went over a lower portion of the brick wall that was only 12-14 inches high, which is where he had parked his wheelchair, the distance covered would have been approximately 354 feet. NA #2 was interviewed on 7/23/2015 at 4:30 PM, about where Resident #191's wheelchair was found on 5/1/2015 after the elopement. NA#2 stated that after the resident was returned to the building she went to look for his wheelchair and said, I walked around (inside) the building and found the patio door was unlocked. She indicated the wheelchair was parked right beside the patio door and next to the area of the brick wall that was just 12-14 inches high. She said, the wheels were locked and the alarm was going off. It was a pad alarm it was pretty loud. I remember as soon as I opened the door it was loud. NA#2 approximated the resident had last been seen approximately 10 minutes prior to the elopement. She stated she and another NA had last seen him on the 100 hall near his room. The Administrator was notified of the Immediate Jeopardy on 7/22/2015 at 6:50 PM. The facility presented a credible allegation of compliance on 7/24/2015 at 5:01 PM which included: This plan of correction represents Valley Nursing Center's credible Allegation of Compliance. The submission of the following combined plan of correction and allegation of compliance does not constitute an admission or agreement by the provider as to the truths of the facts as alleged or conclusions presented by survey consultants from NCDHSR relating to F323 alleged deficient practice with determination of immediate jeopardy. Please accept this corrective action as our credible Allegation of Compliance with F323: 1. Corrective actions taken for resident found to have been affected by alleged deficient practice: Resident #191 no longer resides in facility. Resident #191 exited the facility through the locked patio door, went off the bricked in patio, and was observed ambulating outside crossing the courtyard between the 200 and 600 hall. He was met by staff on the grass beside the end of the 600 hall wing. He was seated in the wheelchair and brought back inside in the presence of his (family member) and examined for injuries by the DON and his hall Nurse. There were no apparent injuries observed and the resident was in no distress other than he repeatedly stated he wanted to go home. The VA (Veteran's Administration), and the medical provider were notified of the incident. The resident's (family member) was present in the facility when the incident occurred and therefore was aware of the occurrence. On 5/21/15 it was determined Resident # 191 could return to home with his family and VA Home Care services as was the planned goal upon admission to the SNF, or if the family and VA choose, we initiate referral and would seek placement in facility with a locked unit. He was discharged with his wife on 5/25/15. 2. Corrective actions taken for other residents having the potential to be affected by alleged deficient practice: A keyed padlock was placed on the door to the bricked in patio, by the maintenance director, on 7/22/15 at 7:40pm. The door will be kept locked at all times unless staff is present to unlock it with a key and supervise residents. (Please Note: This door is NOT an emergency exit. This was approved by Life Safety). The lock will be used temporarily until a more permanent solution can be implemented. The environmental services staff that cleans the day room daily 7 days each week will be responsible to visually check, ensure, and sign off daily on the verify that patio door is locked log that is posted on the unalarmed patio door in the day room. All other facility door alarms and doors with WanderGuard monitors are checked three times weekly for functionality and documented by maintenance staff on the WanderGuard and Fire Exit Door Alarm Monitoring log. WanderGuard devices on residents are verified for placement and checked for functionality by nursing and documented each shift on the eMAR (electronic Medication Administration Record. All resident are assessed for wandering in Section E0900 Wandering- Presence and Frequency and Section E1000 - Wandering and Impact on the MDS assessment upon admission and at least quarterly. More frequent assessments are completed if change in behaviors/condition are determined. Interventions to maintain the resident in a safe environment are initiated through the Care Area Assessment (CAAs) and plan of care process by the Interdisciplinary Care Plan Team. This information is available to all nursing staff and Care Plan team via the electronic charting software. The list of residents identified as having wandering behaviors is sent out to all inside facility email recipients to be printed by department managers and posted within their department and available to all staff. The MDS Nurses are responsible to update the list as changes are made and disseminate information via email and EMR. All staff will be oriented to this process upon hire and annually thereafter. All facility staff will be educated to policies Wandering-Presence and Frequency by 07/28/15. On the night of 7/22/15 a 100% audit of all residents identified with wandering behaviors was conducted by the MDS/Care Plan nurses. Care Plans were reviewed and revised as needed, to ensure appropriateness of care plan goals and interventions to maintain resident safety. Beginning on the morning of 7/24/15 all residents assessed by Nurses using the new risk assessment tool implemented. Care Plans were reviewed and revised as needed, to ensure appropriateness of care plan goals and interventions to maintain resident safety. 3. Measures taken and systems changed to prevent repeat of alleged deficient practice: A keyed padlock was placed on the door to the bricked in patio, by the maintenance director, on 7/22/15 at 7:40pm. The door will be kept locked at all times unless staff is present to unlock it with a key and supervise residents. The key to the patio will be available from the Activity Director, Administration, Maintenance, DON, ADON, and Charge Nurse. (Please Note: This door is NOT an emergency exit.) The environmental services staff that cleans the day room daily 7 days each week will be responsible to visually check, ensure, and sign off daily on the verify that patio door is locked log that is posted on the unalarmed patio door in the day room. A policy/procedure titled Bricked in Patio was developed on 7/23/15 by Administration that describes the steps outlined above. A copy of the policy was distributed to and reviewed with the Maintenance Director, Environmental services, DON, ADON, Life Enrichment Coordinator, and Nurse Managers/Supervisors on 7/23/15 by Administration. A copy of the policy is posted on the patio door and also a list of all staff members who have a key to unlock the door to use the patio. Key will be available to unlock the door 24 hours a day. Nursing Staff including all direct care staff, CNA staff, as well as other departments within the facility was provided in-service training beginning on 7/22/15, 7/23/15, 7/24/15 by nurse management and administration on emergency Code E - missing resident procedures and the Wandering, Unsafe Resident Policy. Nurses were also instructed to immediately inform the nurse manager on duty in facility, or to call the nurse manager on call, if a resident demonstrates exit seeking behaviors and interventions currently in place are not effective in maintaining the resident in a safe environment. The nurse manager will be responsible for re-assessing the situation, implement additional interventions and measures to ensure the resident's safety is maintained. These interventions may include but are not limited to: redirection, diversional activities (recreation, music, IN2L, talking with family members) intensified visual monitoring, one-on-one with staff, initiation of wander guard, visual barriers (stop signs, ribbons) etc. Effectiveness of the interventions will be monitored and documented by the nurse. The nursing staff will report to the Nurse Manager if the new interventions implemented are not effective who will then notify the DON and Administrative on call person (Administrator or Assistant Administrator). As of 7/24/15, 155 employees out of a total of 240 (includes PRN staff) have received re-training described above. Each staff member who has not been trained will be required to receive training prior to beginning their next work shift. At this time 94% of all regular full-time staff has received training. A new assessment tool was implemented on 7/24/15 by DON to help staff identify residents at risk of wandering, presence of wandering and the impact of wandering on resident safety/disruption a new tool entitled Risk of Elopement / Wandering Review. The assessment will be completed upon admission and quarterly thereafter. More frequent assessments may be completed if change in behaviors/condition is determined. Completion Date: 7/24/15 Immediate Jeopardy was removed on 7/24/015 at 5:11 PM. Observations revealed the patio door was equipped with the padlock. Interviews with direct care staff and licensed staff confirmed they had received in-servicing on responding to residents with exit-seeking behavior. Staff were able to define the method of communication to ensure Administrative staff was made aware so appropriate measures could be put in place to ensure safe environment. Staff were also able to describe a new assessment tool entitled Risk of Elopement / Wandering Review

Based on observation, record review, and staff interviews, the facility failed to have interventions in place to prevent 1 of 3 cognitively impaired residents with wandering behavior from exiting, unsupervised from the facility. Administrative staff were not informed that Resident #191 was seen attempting to leave the facility through a non-alarmed door on 5/12/2015. The wander guard ankle bracelet intervention put in place on 5/13/2015 did not prevent the resident from exiting the building unattended on 5/21/2015 through the same, non-alarmed exit door. Immediate Jeopardy began on 05/21/2015 and the Administrator was notified on 7/22/2015 at 6:50 PM. Immediate Jeopardy was removed on 7/24/2015 at 5:11 PM when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy (D), to ensure monitoring of systems put in place and 100% of employee training. Findings included: The facility Policy Statement, titled Elopements (revised February 2014), included: 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. Resident #191 was admitted to the facility 4/28/2015 with [DIAGNOSES REDACTED]. The admission comprehensive Minimum Data Set ((MDS) dated [DATE] indicated the resident was severely cognitively impaired but had not exhibited wandering during the assessment period, The MDS also indicated the resident's walking balance was not steady and he required extensive assistance of two staff members for locomotion on and off the unit. The Plan of Care (originally dated 5/11/2015) indicated the resident had short and long term memory problems due to [MEDICAL CONDITION], received medications for anxiety and depression and was at risk for falls. Review of the facility 24 Hour Report Sheet dated 5/12/2015 revealed a note next to Resident #191's name which read, opened patio door on second shift but did not indicate a time for the incident. Review of the clinical record revealed that on 5/12/2015 resident #191 was observed in his wheelchair, propelling himself into the patio dining room. The nursing documentation note included, resident stood up and opened patio door and tryed (sic) to go out unassisted, another nurse assisted resident back into w/c (wheelchair), resident stated he was leaving and very determined to get out any door in facility, will monitor closely, call light within reach. The note did not indicate the time of the incident. A physician order [REDACTED].#191 was given a bracelet that with the facility magnetic door lock system, would alarm if he attempted to leave through an alarmed door. The order also indicated a pad alarm was to be placed in the resident ' s bed and wheelchair to alert staff if the resident attempted to rise off of the pad. Resident #191's Plan of Care was updated on 5/14/2015 to indicate a wander guard bracelet was in place to prevent elopement. A note in the clinical record dated 5/20/2015 at 5:28 PM read, Resident attempting to leave facility this afternoon. Redirection attempts by staff unsuccessful SW (Social Worker) asked resident why he was trying to leave, resident indicated he was going home. The record also indicated the Nurse Practitioner was informed and the resident was given a one-time dose of [MEDICATION NAME] 1 milligram, intramuscularly for agitation. Further review of the clinical record revealed the resident succeeded in exiting the facility without staff knowledge on 5/21/2015. A note by the SW dated 5/21/2015 at 6:58 PM included, Resident went out patio door in dayroom, locked his wheelchair breaks, climbed over the short brick wall on the patio, ambulated around the facility and was walking down the 600 hall driveway, when staff were alerted to resident being outside. Resident redirected back into the facility. Review of the facility investigation included a description of the incident, written by the Director of Nursing (DON) on 5/25/2015. The description included, On 5/21/2015, at approximately 4:30 PM, resident was observed by staff through a resident's window outside on the grounds. Resident was walking alongside the building independently. Staff immediately went to resident and resident was cooperative and allowed staff to lead him back inside the building. The patio dining room door was observed on 7/21/2015 at 11:50 AM and again at 2:22 PM. There was a sign on the door which read, KEEP THIS DOOR LOCKED AT ALL TIMES Approximately 24 inches above the doorknob was a deadbolt lock. The door was locked. The door was able to be unlocked by turning the deadbolt to the left and no alarm sounded. Outside the door was a 15 foot square patio surrounded by a brick wall that was approximately 26 inches high. A second brick wall surrounded the first wall, separated by a space of approximately 8 inches. The space between the brick walls was filled with dirt which formed a garden where tomato plants were growing. Beyond the patio was a large grassy area with trees and bushes. Beyond the grassy area was a driveway which ran behind the facility and then a chain-link fence and a downward sloping area that was heavily wooded. The driveway behind the facility went around to the side of the building where there was a parking lot and then further around to the front parking lot. Nurse #1 was interviewed on 7/22/2015 at 3:16 PM. She stated she was working on 5/12/2015 (attempted elopement through patio door) and also on 5/21/2015 when Resident #191 was found outside the 600 hall wing. When asked about the incident on 5/12/2015, Nurse #1 said the resident was observed to stand up from his wheelchair, unlock the patio door and was going to step outside when he was stopped by another nurse who brought him back into the building. Nurse #1 indicated that between 5/12/2015 and the time of his discharge on 5/25/2015, the resident would go to all the doors and try to get out. She said after he was admitted , His meds were decreased and when he started to wake up is when it started. He would go to the 600 door or patio door and try to go out. The nurse added that she had questioned why the patio door was not alarmed and was told the door could not have the wander guard lock on it. The nurse said, The sign, 'This door must be locked at all times' was already posted at that door but he saw activity staff unlock the door and go out with residents to do activities on the patio, I guess. Nurse #1 said she made sure the attempted elopement was documented, passed on in report and was on the 24 hour Report Sheet. During the same interview Nurse #1 described the events on 5/21/2015 when the resident was successful in leaving the building unsupervised. Nurse #1 said she had spoken to the resident 10-15 minutes earlier and the resident ' s family member was looking for him too when Resident #191 was observed through the 100 hall window, moving through the backyard. Nurse #1 sent staff to get him while she went around to the closest door on the 600 hall with a wheelchair to meet them. My question was this an elopement or just an incident because he wasn't off the grounds. The DON said she would take care of the documentation and notifying the appropriate people and I could just go back to what I was doing. Nurse #1 clarified that Nursing Assistant (NA) #2 had told her the resident was outside and the nurse was also aware a NA on 600 hall saw the resident through another resident's window on 600 hall. The Assistant Administrator was interviewed on 7/22/2015 at 4:24 PM. The Assistant Administrator said a wander guard alarm system was in place and all exit doors were alarmed except this one. There was no electricity to this patio door so it could not be alarmed with the system so they put up a sign that said to keep door locked. The Assistant Administrator said after the investigation on 5/25/2015 of the elopement on 5/21/2015, the facility attached a personal body alarm to the patio door. The Assistant Administrator said she had noticed someone had removed the personal body alarm from the patio door so she placed one on the door again just prior to the interview. She did not know how long it had been gone from the door. NA #1 was working on 600 hall on 5/21/2015 and was interviewed on 7/22/2015 4:46 PM. NA #1 said, I was assisting a resident in room [ROOM NUMBER] and went to shut the blind and happened to look up and saw him (Resident #191). I went running out the door to go get him. NA#1 went on to say, I didn't have the code for the door nearest (room) 621 so I ran up the hall and went out the door by the 600 hall lobby and ran down the side of the building to get him. NA #1 clarified that room [ROOM NUMBER] overlooked the facility's side parking lot and one could not see the backyard from that room. On 7/23/2015 at 10:31 AM, the Administrator and Assistant Administrator were both interviewed about the attempted elopement on 5/12/2015. Both of them stated they had been made aware of Resident#191's exit-seeking behavior but they were not aware he had attempted to leave by a non-alarmed door. On 7/23/2015 at 10:48 AM, the Director of Nursing (DON) was interviewed about the attempted elopement on 5/12/2015. She stated she and the Assistant Administrator were present at the Clinical Meeting on 5/13/2015 when it was discussed but the emphasis was on the exit-seeking behavior, not on which doors he had been using. The DON indicated it was she who had obtained the physician order [REDACTED]. On 7/23/2015 at 11:25 AM, the Director of Maintenance measured the two routes the resident could have taken when he exited by the patio door on 5/21/2015. If he had climbed over the brick wall (approximately 26 inches high) and taken a direct path to the other side of the 600 hall wing, the distance was approximately 249 feet from the patio door. If the resident went over a lower portion of the brick wall that was only 12-14 inches high, which is where he had parked his wheelchair, the distance covered would have been approximately 354 feet. On 7/24/2015 at 3:42 PM, the Administrator was interviewed about the attempted elopement on 5/12/2015. The Administrator indicated if she had known he had attempted to leave through a non-alarmed door, different measures could have been used. She said, For any attempt by a resident who is trying to elope, my expectation is that staff call me and we can assess what needs to be done in that particular area. It is my responsibility to keep these residents safe. The Administrator was notified of the Immediate Jeopardy on 7/22/2015 at 6:50 PM. The facility presented a credible allegation of compliance on 7/24/2015 at 5:01 PM which included: This plan of correction represents Valley Nursing Center ' s credible Allegation of Compliance. The submission of the following combined plan of correction and allegation of compliance does not constitute an admission or agreement by the provider as to the truths of the facts as alleged or conclusions presented by survey consultants from NCDHSR relating to F490 alleged deficient practice with determination of immediate jeopardy. Please accept this corrective action as our credible Allegation of Compliance with F490: 1. Corrective actions taken for resident found to have been affected by alleged deficient practice: Resident #191 no longer resides in facility. New policies developed and interventions implemented to ensure immediate notification will be made to administration if a resident is attempting to elope. When incidences of wandering and or attempted elopement are reported, a more thorough investigation and inquiry will be immediately initiated by the Administrator. Resident #191 exited the facility through the locked patio door, went off the bricked in patio, and was observed ambulating outside crossing the courtyard between the 200 and 600 hall. He was met by staff on the grass beside the end of the 600 hall wing. He was seated in the wheelchair and brought back inside in the presence of his (family member) and examined for injuries by the DON and his hall Nurse. There were no apparent injuries observed and the resident in no distress except him repeatedly stating the he wants to go home . Due to residents continued efforts to exit the facility to Go Home, it was determined on 5/21/15 that for his own safety and best interests, he could returned to home with family and VA (Veteran's Administration) Home Care services as stated as his planned goal upon admission, or be relocated to a locked facility as soon as feasibly possible. The VA, the medical provider were notified of the unwitnessed exit from the locked dayroom door onto the patio and onto facility courtyard located between the 200 hall and the 600 hall. The resident ' s wife was present in the facility when he was observed by staff outside and brought back into the building. 2. Corrective actions taken for other residents having the potential to be affected by alleged deficient practice: To ensure other residents were not at similar risk, no the night of 7/22/15 the Administrator instructed the MDS/Care Plan Nurses to complete a 100% audit of all residents identified with wandering behaviors and to review/revised resident Care Plans as needed, to ensure appropriateness of care plan goals and interventions to maintain resident safety and to ensure that none of these identified residents had attempted to elope. The results of the audit showed that there were no other noted elopement attempts made by any other resident. The Administrator and Assistant Administrator reviewed the audit results on 7/23/15. On 7/24/15 all residents were assessed by nursing using the new risk assessment tool implemented. Care Plans were reviewed and revised as needed, to ensure appropriateness of care plan goals and interventions to maintain resident safety. Residents identified with wandering behaviors are available to all nursing staff and Care Plan team via the electronic charting software. The list of residents identified as having wandering behaviors is sent out to all inside facility email recipients to be printed by department managers and posted within their department and available to all staff. The MDS Nurses are responsible to update the list as changes are made and disseminate information via email and EMR. All staff will be oriented to this process upon hire and annually thereafter. 3. Measures taken and systems changed to prevent repeat of alleged deficient practice: Systematic changes implemented by Administration include: · A keyed padlock was placed on the door to the bricked in patio, by the maintenance director, on 7/22/15 at 7:40pm. The door will be kept locked at all times unless staff is present to unlock it with a key and supervise residents. (Please Note: This door is NOT an emergency exit.) The lock will be used temporarily until a more permanent solution can be implemented. The environmental services staff that cleans the day room daily 7 days each week will be responsible to visually check, ensure, and sign off daily on the verify that patio door is locked log that is posted on the unalarmed patio door in the day room. Administrator and/or Assistant Administrator reviewed the logs on 7/22, 7/23 and 7/24 and will continue to review the logs regularly to assure continued compliance. · A policy/procedure titled Bricked in Patio was developed on 7/23/15 by Administration that describes the steps outlined above. A copy of the policy was distributed to and reviewed with the Maintenance Director, Environmental services, Life Enrichment coordinator, DON, ADON and Nurse Managers/Supervisors on 7/23/15 by Administration. Keys distributes to Admin, Nurse Admin, Charge Nurse on Duty, Life Enrichment coordinator, EVS, and Maintenance. · All other facility door alarms and doors with WanderGuard monitors are checked three times weekly for functionality and documented by maintenance staff on the WanderGuard and Fire Exit Door Alarm Monitoring log. WanderGuard devices on residents are verified for placement and checked for functionality by nursing and documented each shift on the eMAR (electronic Medication Administration Record). Administrator and/or Assistant Administrator reviewed this process and verified compliance on 7/23/15. · On the night of 7/22/15 a 100% audit of all residents identified with wandering behaviors was conducted by the MDS / Care Plan nurses. Care Plans were reviewed and revised as needed, to ensure appropriateness of care plan goals and interventions to maintain resident safety. The audit results were reviewed by the Administrator and Assistant Administrator on 7/23/15 to assure completion. · Nursing Staff including direct care staff was provided in-service training on 7/22/15, 7/23/15 and 7/24/15. Emphasis was placed on the immediate urgency to notify Administration if a resident attempts to Elope so that appropriate safeguards can be initiated. The in-services were presented by nurse management and Administration to include emergency Code E - missing resident and procedures from policy for Wandering, Unsafe Resident. Nurses were also instructed to immediately inform the nurse manager on duty in facility, or to call the nurse manager on call, if a resident demonstrates exit seeking behaviors and interventions currently in place are not effective in maintaining the resident in a safe environment. The nurse manager will be responsible for re-assessing the situation, implement additional interventions and measures to ensure the resident ' s safety is maintained. These interventions may include but are not limited to: redirection, diversional activities (recreation, music, talking, IN2L, time with family members) intensified visual monitoring, one-on-one with staff, initiation of wander guard, visual barriers (stop signs, ribbons) etc. Effectiveness of the interventions will be monitored and documented by the nurse. The nursing staff will report to the Nurse Manager if the new interventions implemented are not effective who will then immediately notify the DON and Administrator on call person (Administrator or Assistant Administrator). As of 7/24/15, 155 employees out of a total of 240 (includes PRN staff) have received re-training described above. Each staff member employed by the facility who has not been trained will be required to receive training prior to beginning their next work shift. · A new assessment tool was implemented on 7/24/15 by DON to help staff identify residents at risk of wandering, presence of wandering and the impact of wandering on resident safety/disruption (See assessment tool titled Risk of Elopement / Wandering Review). The assessment will be completed upon admission and quarterly thereafter. More frequent assessments may be completed if a change in behaviors/condition are determined. · Administrator and Assistant Administrator reviewed the Wandering, Unsafe Policy on 7/22/15 and revisions to the policy written on 7/23/15 as follows: #1. - Language added to include the use of the new Wander Data Collection Tool, #4 b - Language added to notify the Administrator, DON immediately if a resident is suspected as missing and # 5 b - Language added to contact the Administrator when the resident is returned to the facility and report findings and conditions of the resident. The content of this policy was used with the in-service training beginning 7/22/15 continuing through 7/28/15. As of today, 7/24/15, 155 of 164 full time staff have been trained. The remaining full-time, part-time, and PRN staff will be contacted and trained. Every staff member MUST be trained prior to beginning their next work shift in the facility. This training will be added to new hire orientation and added to the required annual in-services for all staff. · 7/22/15 (following the announcement of the IJ situation) the Administrator and Assistant Administrator met with the facility Management staff and all charge nurses on staff informing them of the need to contact Administrator and Assistant Administrator when residents are suspected as elopement risks. · 7/22/15 Administrator and Assistant Administrator checked each nurses station to assure their contact information (phone numbers) was readily accessible. Compliance was noted. · 7/22/15 (2nd shift) Administrator and Assistant Administrator immediately began rounding throughout the facility interviewing staff to assure they were aware of the Code E policy/procedure and inquiring about any untoward incidents/resident behavior. Rounds continued on 3rd shift until 2 a.m. Rounds resumed on 7/23/15 on first shift at 7am. · 7/23/15 8:30 - Management staff were reminded again of the need to immediately communicate potential elopement risk concerns to Administrator. Administrator and Assistant Administrator continued to round throughout the day until approximately 9:30 pm. · 7/24/15 - Assistant Administrator conducted rounds at 7am and received report from the DON who had also completed rounds prior to 7am. There were no issues reported. · Process was developed to enhance the communication between the Nursing Staff and Administrator of daily activities that occur in the facility during off hours and weekends. Off hours are defined as hours outside of the normal work scheduled times (8:00 a.m.-5:00 p.m.) The process Facility Pulse Checks was initiated 7/23/15. Completion Date: 7/24/15 Immediate Jeopardy was removed on 7/24/015 at 5:11 PM. Observations revealed the patio door was equipped with the padlock. Interviews with direct care staff and licensed staff confirmed they had received in-servicing on responding to residents with exit-seeking behavior. Staff were able to define the method of communication to ensure Administrative staff was made aware so appropriate measures could be put in place to ensure safe environment. Staff were also able to describe a new assessment tool entitled Risk of Elopement/Wandering Review

Based on staff interviews and record review the facility failed to provide toileting assistance for a resident who fell and broke his hip and failed to ensure the resident had nonskid footwear when he ambulated for 1 of 3 sampled residents (Resident #2). The findings include: Resident #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] specified the resident had moderately impaired cognition and required limited assistance with transfers and toilet use. The MDS also specified the resident was not steady with his balance and required use of a walker for mobility. According to the MDS, the resident was always continent of bowel and bladder and the resident had a history of [REDACTED]. The resident's fall care plan dated 01/15/13 specified interventions to minimize the resident's fall risk included: - encourage resident to obtain assistance with transfers and ambulation - nonskid shoes upon rising - provide assistive device as ordered for use when ambulating Resident #2 had a care plan specific to impaired mobility dated 01/16/13 that specified the resident was to be supervised for all transfers. Nurses' entries dated 01/21/13, 01/22/13 and 01/25/13 specified the resident would take himself to the bathroom and was reminded he should call for assistance. Review of physical therapy notes dated 01/23/13 specified the resident was working with physical therapy for strength and endurance with gait stability and ambulation. The progress note also specified the resident was making progress towards his goals but required minimal assistance for safe transfers, minimal assistance with gait and required frequent rest breaks with all activities. A nurses' entry dated 01/28/13 at 8:19 PM specified the resident was to receive a rectal suppository before he went to bed to help with constipation. Further review of Resident #2's medical record revealed a nurses' entry dated 01/29/13 at 4:08 AM written by Nurse #1 that specified at 3:45 AM the resident was observed on the floor in the hallway. Resident #2 had partial range of motion to his right leg and was unable to bear weight when staff attempted to assist resident off the floor. The resident's right leg was rotated outward and appeared shorter than the left leg. The on-call physician was notified and ordered the resident to be sent to the Emergency Department for evaluation. The Emergency Department report dated 01/29/13 was reviewed and revealed the resident presented to the hospital and was diagnosed with [REDACTED]. On 03/18/13 at 10:30 AM Nurse #1 was interviewed on the telephone and reported that she was notified during the shift report that Resident #2 had received a suppository and had not experienced a bowel movement. She stated that it was usual procedure to notify the nurse aides of which residents had received a suppository so the nurse aides would be aware to monitor those residents more closely and to notify the nurse when the resident had a bowel movement. Nurse #1 could not recall who the nurse aide was on the night of 01/29/13 but stated she should have told the nurse aide that Resident #2 had received a suppository and would have expected the nurse aide to monitor him closely in the event he needed to go to the bathroom to have a bowel movement. Nurse #1 also reported the resident required assistance with toileting. She added Resident #2 was more confused than usual on the night of 01/29/13. She added that around 3:45 AM she was at the nurses' station and heard a loud noise. She stated she looked down the hall and saw Resident #2 in the floor. Nurse #1 stated Resident #2 appeared to have gotten out of bed unassisted, ambulated without his walker across the hall into an empty room where he used the bathroom in the floor and then when he was walking back to his room he fell . She stated that his call light was not on and that he did not have his walker. She was unaware of what type of footwear the resident was wearing. Nurse #1 assessed the resident and noted his right leg appeared shorter than the left. She notified the on-call physician and the resident was sent to the Emergency Department for evaluation. On 03/18/13 at 10:45 AM nurse aide (NA) #1 was interviewed and reported she was assigned to care for Resident #2 on 01/29/13. She explained that each resident was listed in the computer with specific instructions how they were to be transferred and what level of assistance they needed with activities of daily living (ADL). She also added that since Resident #2 was new she had asked other nurse aides and nurses about the level of care the resident required. She stated that Resident #2 used his walker to take himself to the bathroom unassisted. She added that she was not aware the resident had received a suppository on the evening shift and added that if she had known that then she would have monitored him more frequently to check if he needed to go to the bathroom. She reported that she made rounds and checked the resident between 11 PM and midnight and did not recall having checked him again before his fall at 3:45 AM. NA #1 said she was in another resident's room when Resident #2 fell . She added that she observed the resident laying in the floor and noted he was wearing socks that were not non-skid. NA #1 explained that when she assisted residents to bed she was expected to change their footwear to non-skid socks if the resident was able to ambulate but offered no explantion why she failed to change Resident #2's socks to non-skid socks. On 03/18/13 at 12:20 PM the Director of Nursing (DON) was interviewed and stated that nurses were expected to notify nurse aides if a resident had been given a suppository so the nurse aide could monitor the resident and notify the nurse if the resident had a bowel movement. She stated she would expect the nurse aide to respond quickly to a resident's call bell request to go to the bathroom and continue to montior residents at least every 2 hours for incontinence. The DON also stated residents were to have either non-skid socks or shoes on when out of bed. She added that nurse aides were expected to monitor a resident's footwear and change any footwear that was not appropriate. The DON stated she would have expected NA #1 to have changed Resident #2's socks to non-skid when she assisted him to bed the night he fell . The DON also stated she would have expected NA #1 to have known the resident had been given a suppository and provided him with the assistance he required with transfers and toileting. The DON provided additional information from the computer system used by the nurse aides that specified on 01/29/13 at 2:09 AM NA#1 documented in the computer that she had monitored Resident #2 but had not assisted him to the bathroom. The DON also provided a nurses' entry dated 01/29/13 at 1:10 AM made by Nurse #1 that specified the nurse had obtained vital signs on Resident #2.