Every finding on record at Vero Health & Rehab of Sylva

Based on record review and staff interviews, the facility failed to submit accurate payroll data on the Payroll Based Journal (PBJ) report to the Centers for Medicare and Medicaid Services (CMS) related to Registered Nurse (RN) and licensed nursing coverage 24 hours per day for 1 of 1 Federal Fiscal Year quarter reviewed for sufficient nurse staffing (Quarter 2: January 1 - March 31, 2025).The findings included: The PBJ report for the Federal Fiscal Year Quarter 2 2025 (January 1 through March 31) revealed there were no Registered Nurse (RN) hours for 01/09/25, 02/21/25, 02/22/25, 02/23/25, 02/24/25, 02/25/25, 02/26/25, 02/27/25, 02/28/25, and the entire month of March 2025. The PBJ report also noted the facility failed to have licensed nursing coverage 24-hours a day for 02/21/25, 02/22/25, 02/23/25, 02/24/25, 02/25/25, 02/26/25, 02/27/25, 02/28/25, and the entire month of March 2025. Review of the daily staff schedule for 01/09/25 revealed there was no RN onsite. Review of the daily staff schedules and associated time clock detailed reports for 02/21/25, 02/22/25, 02/23/25, 02/24/25, 02/25/25, 02/26/25, 02/27/25, 02/28/25, and the entire month of March 2025 revealed there was a RN onsite for at least 8 hours a day every 24 hours and there was licensed nursing coverage at the facility 24 hours a day.During an interview on 08/13/25 at 2:15 PM, the Human Resources (HR) Director revealed she was responsible for submitting PBJ data to CMS and had done so since the first of the year (2025). The HR Director confirmed she submitted the PBJ data for the CMS Federal Fiscal Quarter 2 (January 1-March 31, 2025) and was not sure why the dates triggered for no RN or licensed nursing coverage. She stated for the triggered date of 01/09/25, the Director of Nursing (DON) would have been in the building; however, the DON was a salaried position and her hours would not show on a time clock punch report. The HR Director explained the process was to upload the data directly from the payroll system, review for accuracy and then submit to CMS. She stated they had started the process of changing payroll systems toward the end of February 2025 and the payroll data submitted to CMS was coming from 2 separate payroll systems which she could only assume was part of the reason the dates in question triggered for no RN and no licensed nursing coverage. The HR Director stated when she submitted the payroll data to CMS for January 1-March 31, 2025, she received notification that the data was received and did not recall getting any error messages. She stated the only thing she could recall that was done differently was that the payroll data was not reviewed for accuracy prior to submitting to CMS. She explained because of the change in payroll systems, they were running out of time to get the PBJ data submitted and they felt it was more important to have the information submitted to CMS on time. During interviews on 08/13/25 at 9:30 AM and 08/14/25 at 8:30 AM, the Corporate Nurse Consultant revealed for overall staffing, there was always a RN for at least 8 hours per day and typically 4 Nurses, one for each unit, every shift. She stated for the date of Thursday 01/09/25, the former Director of Nursing had worked onsite but did not clock in/out because her position was salaried. The Corporate Nurse Consultant explained around March 2025, they switched to a new payroll system which she felt contributed to the PBJ information not being accurate since no RN and no licensed nursing coverage triggered.

Based on observations, record review and interviews with staff and residents, the facility failed to keep a pull cord for the light above the bed within reach for 2 of 2 residents reviewed for accommodation of needs (Residents #92 and #41).a. Resident #92 was originally admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #92 had moderate cognitive impairment and had no impairment of her upper extremities. On 8/11/25 at 10:10 AM an observation and interview were conducted with Resident #92. It was observed in her room that her bed was moved towards the center of the room with the headboard up against the wall and the pull cord for the light above her bed hung against the wall on her right side. The pull cord was approximately 15 inches long and was not within reach of Resident #92 when she was in the bed. Resident #92 was asked about the light and if she would like to be able to turn the light on and off herself, and she stated she wanted to but couldn't reach the pull cord. Resident #92 was unsure when she last used the pull cord since it had not been in her reach for some time. b. Resident #41 was admitted to the facility on [DATE]. The quarterly MDS assessment dated [DATE] revealed that Resident #41 had moderate cognitive impairment and had no impairment of her upper extremities. On 8/13/25 at 3:15 PM an observation and interview were conducted with Resident #41. It was observed that the pull cord for Resident #41's light above her bed hung against the wall on the right side of the bed and was out of reach. When interviewed Resident #41 stated that she liked to be able to use the pull cord for the light, but she couldn't reach it. On 8/13/25 at 2:02 PM an interview was conducted with the Maintenance Director. He stated that the facility had a computer system the staff used to enter any maintenance issues. He reviewed the computer system daily and prioritized what needed to be fixed. The Maintenance Director was shown the pull cord for Resident #92. He agreed that the pull cord did not reach Resident #92's bed. He stated that he had recently started employment at the facility and prior to his employment, an audit on the pull cords had been conducted and pull cord extensions and clips had been ordered and received. Additionally, the Maintenance Director was unaware Resident #41 was unable to reach her pull cord from the bed. On 8/14/25 at 1:58 AM an interview was conducted with the Corporate Nurse Consultant. She agreed that if a resident wanted and was able to use a pull cord for a light that the cord should be within their reach to be used.

Based on record review and staff interviews, the facility failed to ensure code status information was accurate throughout the medical record for 1 of 1 resident reviewed for advance directives (Resident #12).The findings included:Resident #12 was admitted to the facility on [DATE].Resident #12's advance directive care plan, initiated on [DATE], indicated she was a full code. Interventions included to perform cardiopulmonary resuscitation (CPR) if the resident's heart stopped beating and the medical record would indicate the resident's wishes.The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #12 with moderate impairment in cognition. Review of Resident #12's electronic health record (EHR) revealed a physician's order dated [DATE] for a code status of Do Not Resuscitate (DNR). The profile section of Resident #12's EHR also indicated a code status of DNR.Review of the Code Status binder kept at the nurses' station revealed Resident #12 had a DNR form signed by the physician with an effective date of [DATE].During an interview on [DATE] at 10:40 AM, the Social Worker (SW) revealed she reviewed advance directives with the resident and/or Responsible Party. The SW stated either she or the MDS Nurse were responsible for updating a resident's advance directive care plan when their code status had changed. The SW confirmed Resident #12 had a code status of DNR and was not sure why the care plan still had her listed as a full code. The SW recalled during a care plan meeting on [DATE] with Resident #12's family member, advance directives was reviewed and the family member requested a code status of DNR for Resident #12. The SW did not recall Resident #12's advance directives paperwork coming back to her once the form(s) were signed by the family member which was why the care plan did not get updated.During an interview on [DATE] at 10:55 AM, the MDS Nurse explained upon admission, all residents were listed as a full code until advance directives were reviewed with the resident and/or family and the paperwork signed. The MDS Nurse stated when there was a change in a resident's code status, the advance directives paperwork was returned to the SW who would then update the care plan.During an interview on [DATE] at 4:40 PM, the Director of Nursing (DON) revealed the SW was responsible for reviewing advance directives with the resident and/or family and maintaining the code status binders. The DON stated a resident's code status on the care plan should match the code status listed in the resident's EHR and code status binder. The DON stated she would expect for care plans to be updated as needed and the SW was responsible for updating a resident's care plan when there was a change to a resident's code status. The Administrator was out of the facility during the survey and unavailable for an interview.

Based on record review, resident and staff interviews, the facility failed to offer, administer, or document the Pneumococcal vaccine for 1 of 5 residents reviewed for immunizations (Resident #15).The facility policy for Pneumococcal Vaccine revised October 2019 read prior to upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Resident #15 was admitted to the facility on [DATE]. The 5-day Minimum Data Set, dated [DATE] indicated he was cognitively intact. The pneumococcal vaccine section was coded as offered and declined. Review of Resident #15's electronic health record revealed no signed consent, administration, or refusal documentation for the Pneumococcal vaccine. An interview on 8/14/25 at 12:52 PM with Resident #15 revealed he usually kept his immunizations up to date and had not been offered the pneumococcal vaccine since his admission to the facility. An interview on 08/13/2025 at 9:29AM with the Director of Nursing (DON) revealed she was the facility Infection Preventionist. She stated she had been at the facility a few weeks and was unable state if Resident #15 had received or been offered the pneumococcal vaccine. She was also unable to locate any documentation for Resident #15's pneumococcal vaccine status in the paper records located in the DON office, medical records or the electronic health records. An interview on 8/14/25 at 11:49 AM with the Corporate Nurse Consultant revealed there was no reason that Resident #15's pneumococcal vaccine had not been given or documented. She stated she believed it had been completed, and the documentation was unavailable. She stated she was aware there were some areas for improvement in the immunization process but had not yet had time to initiate a new process.

Based on record review and staff interviews, the facility failed to determine the status of Resident #15's Covid-19 vaccination to determine if Resident #15 was eligible to receive a dose of the Covid-19 vaccine for 1 of 5 residents reviewed for immunizations (Resident #15).Resident #15 was admitted to the facility on [DATE]. The 5-day Minimum Data Set assessment dated [DATE] indicated Resident #15 was cognitively intact. The Covid-19 vaccine section was coded as the resident was not up to date. Review of Resident #15's electronic health record revealed no signed informed consent, record of administration, or documentation of refusal for the Covid-19 vaccine. The medical record also contained no evidence of past Covid-19 vaccinations that had been administered. An interview on 8/14/25 at 12:52 PM with Resident #15 revealed he usually kept his immunizations up to date and had received prior Covid-19 vaccines. He also revealed he had not been offered the Covid-19 vaccine since his admission to the facility. Resident #15 could not say if he was up to date with the Covid-19 vaccine. An interview on 08/13/2025 at 9:29AM with the Director of Nursing (DON) revealed she was the facility Infection Preventionist. She stated she had been at the facility a few weeks and was unable state if Resident #15 had received or been offered the Covid-19 vaccine. She was also unable to locate any documentation for Resident #15's Covid-19 vaccine status in the paper records located in the DON office, medical records or the electronic health records. An interview on 8/14/25 at 11:49 AM with the Corporate Nurse Consultant revealed there was no reason that Resident #15's Covid-19 vaccine had not been given or documented. She stated she believed it had been completed, and the documentation was unavailable. She stated she was aware there were some areas for improvement in the immunization process but had not yet had time to initiate a new process.

Based on record review and staff interviews, the facility failed to provide a surety bond that covered the total account balance for 55 of 55 residents with funds deposited in the resident trust fund account.The findings included:Review of the Resident Fund Management Service document provided by the Business Office Manager revealed the total balance in the Resident Trust Fund Account was $63,647.25 as of [DATE].Review of the facility's Surety Bond Continuation Certificate provided by the Corporate Nurse Consultant on [DATE] revealed the amount of the bond was for $90,000 and was effective starting on [DATE] and terminated at midnight on [DATE]. During an interview on [DATE] at 2:58 PM, the Business Office Manager revealed the corporate office handled the renewal of the surety bond and she was not sure why the surety bond had expired or what had happened. During an interview on [DATE] at 2:26 PM, the Corporate Nurse Consultant revealed there were 55 residents who had funds deposited in the Resident Trust Fund account. The Corporate Nurse Consultant stated she was unaware that the facility's surety bond had expired and now that they were aware, they were actively working on getting a surety bond in place.The Administrator was out of the facility during the survey and unavailable for an interview.

Based on observations, staff and resident interviews the facility failed to post survey results in a location accessible to all residents. This deficient practice occurred for 3 out of 4 days of the recertification survey.The findings included:Observations made on 8/12/25 at 4:40 PM, 8/13/25 at 7:55 AM and 8/14/25 at 8:24 AM revealed the survey results located in the first-floor lobby of the facility in a binder placed in a wall file pocket. The wall file pocket with the binder was located approximately five feet high on the wall. All resident rooms were located on the second floor of the facility which was only accessible by a secured elevator making it difficult for residents to have access to the first floor and survey results located there. The stairwell door on the second floor was locked and required a code to unlock the door again making it difficult for residents to have access to the first floor and survey results. A Resident Council Meeting held on 8/13/25 at 11:07 AM revealed 5 of 5 residents who attended the meeting did not know where the survey results book was located (Resident #37, Resident #41, Resident #18, Resident #62 and Resident #77). After the residents were informed of the location of the survey results binder, all five residents indicated if they wanted to get to the lobby where the survey results binder was located, they would have to ask a staff member to unlock the elevator and accompany them down to the lobby. One resident in a wheelchair indicated she would not be able to reach the binder on her own. An interview with the Social Services Director on 8/14/25 at 8:53 AM revealed the only survey results binder was located in the first-floor lobby. She indicated residents were not allowed to use the elevator on their own, and she considered the location of the survey results binder not accessible to residents without having to ask for assistance. An interview with the Corporate Nurse Consultant on 8/14/25 at 1:07 PM revealed the survey results binder observed in the first-floor lobby was the only survey results binder in the facility. She indicated it was not accessible to the residents due to the locked elevator and because of the height of the file holder on the wall.

Based on record review, observations, and interviews with staff, Nurse Practitioner, Medical Director, and urology office staff the facility failed to follow up with the Urologist for Resident #49 who was hospitalized for obstructing ureteral stones (kidney stones that get stuck in tubes composed of smooth muscle that transport the urine from the kidneys to the bladder) with hydronephrosis (swelling of one or both kidneys due to urine build up), urinary tract infection (UTI), pyelonephritis (an infection of the kidneys) and (a serious condition in which the body responds improperly to an infection). The Resident had a stent (a small tube placed in the ureter that allows the urine to drain) placed for renal stone obstruction on 4/23/24 and returned to the facility on [DATE] with a urinary catheter. The discharge summary specified further assessment by Urology next week and also included an order for antibiotics for a UTI. Resident #49 experienced and was treated for two UTIs, urinary pain and a yeast infection due to the antibiotics while waiting to see the urologist. The second UTI diagnosed on [DATE] showed the growth of two organisms which had a greater resistance to antibiotics. The presence of the urinary catheter and the stent both increased the risk of bacterial growth, UTIs and sepsis. In addition, the facility failed to obtain physician orders for use of an indwelling catheter and failed to use a securement device to anchor urinary catheter tubing (Resident #80) and ensure the urine collection bag remained below the level of the resident's bladder (Resident #11). These deficient practices affected 3 of 4 residents reviewed for urinary catheter or urinary tract infection (Resident #49, Resident #80 and Resident #11). Immediate jeopardy began on 5/3/24 when the facility failed to not follow up with urology for Resident #49. Immediate jeopardy was removed on 7/26/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. Example #2 and #3 were cited at a S/S of D. Findings included: 1. Review of nurses noted dated 4/22/24 revealed Resident #49's was complaining of stomach pain, nausea and chills. Resident #49 was noted to be shivering and had a temperature of 100.2 and oxygen saturation of 86%, resident placed on 2 liters via nasal canula. The doctor was notified and gave the order to send the resident to the emergency room (ER) for evaluation. Review of Resident #49's hospital discharge summary dated 4/26/24 revealed she had been hospitalized from 4/23/24 to 4/26/24 for obstructing ureteral stones with hydronephrosis, UTI, pyelonephritis due in part to obstructing ureteral stones, and sepsis. Diagnostics showed she had a 5millimeter (mm) stone in the juncture where the kidney meets the ureter and a 4 mm stone in the juncture where the ureter meets the bladder as well as multiple other non-obstructing stones in both kidneys. Urology was consulted during her hospitalization to provide intervention for her urinary obstruction. She was taken to the operating room on 4/23/24 by the urologist and a stent was placed in her left ureter. Her blood culture and urine cultures grew out the organism Klebsiella. Her discharge summary read in part, per infectious disease recommendations will treat with Ciprofloxacin (antibiotic) 500 milligrams (mg) twice daily with end of treatment on 5/2/24, return to the facility today, follow-up with urology next week, urinary catheter to stay in place and be further assessed by urology next week. Resident #49 was readmitted to the facility on [DATE] with diagnoses including renal and ureteral calculous (kidney stones) obstruction with hydronephrosis, urinary tract infection (UTI), acute pyelonephritis (sudden and severe inflammation of the kidney due to a bacterial infection), sepsis, chronic kidney disease, and encounter for surgical aftercare following surgery on the genitourinary system. Review of Resident #49's Medication Administration Record (MAR) for April 2024 and May 2024 revealed an order dated 4/26/24 that read: Ciprofloxacin 500 milligrams (mg) one tablet by mouth every 12 hours for infection until 5/2/24. The MAR revealed all doses of Ciprofloxacin were documented as administered until 5/2/24. There was not a record of a urology appointment that had been scheduled for May 2024 in Resident #49's electronic medical record. Review of Resident #49's electronic medical record revealed there was an order dated 4/26/24 that read: follow up with urology next week. The order was discontinued by the Director of Nursing on 6/6/24. An interview was conducted on 7/12/24 at 11:27 AM with the Director of Nursing (DON). The DON said she had discontinued the order for Resident #49 from 4/26/24 that read follow up with urology next week. The DON said she had been removing old orders on all residents from the electronic computer system and had discontinued the order because it had been old. The DON said she did not check to see if Resident #49 had been to the urologist for follow up prior to discontinuing the order. The DON indicated she thought it had been an old order and had already been taken care of. A History and Physical (H&P) was completed on 5/2/24 by the Medical Director (MD). Under history of present illness, the note read in part: [AGE] year-old female seen at bedside for readmission H&P. Patient recently admitted to the hospital for sepsis and UTI secondary to obstructive stone in the left ureter. The patient underwent several days of IV antibiotics. After appropriate treatment, the patient was sent back to facility for continued rehabilitation. Under the section past surgical history, it read: recent left ureter stent placement. Under the note section labeled physical exam there was not a genitourinary assessment/exam included. The note did not mention Resident #49 needing to follow up with the urologist or her indwelling urinary catheter. The significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was cognitively intact. She was coded for an indwelling catheter. The MDS revealed she was also coded for receiving antibiotics and septicemia (disease caused by the spread of bacteria and their toxins in the blood stream). Review of Resident #49's care plan revised on 5/9/24 revealed she had a care plan in place for an indwelling catheter due to ureter obstruction, pyelonephritis, hydronephrosis, and UTI. The care plan goal was to not have any complications from the indwelling catheter, will not develop a UTI. The care plan interventions included: to follow up urology as recommended, monitor for signs/ symptoms of infection, and catheter care every shift. Further Review of Resident #49's electronic medical record revealed: A medical provider progress note dated 5/29/24 that read in part: Nurse reports that patient has bladder pain on and off. Urinalysis (UA) (a lab used test for an infection in the urine) with Culture and Sensitivity (C&S) (a report used to determine which antibiotic to use to treat an infection) ordered. Lab results showed Resident #49 had a UA completed on 5/30/24. The urine C&S report dated 6/1/24 showed the growth of the organism morganella morganii (bacteria) with a colony count of greater than 100,000 (cultures with greater than 100,000 colony count usually indicate infection). The organism was resistant to multiple antibiotics listed on the urine culture sensitivity report. An order entered by the Medical Director (MD) dated 5/30/24 read: Cephalexin (antibiotic) 500 mg tablet give one tablet by mouth three times a day for infection for 7 days. The order was discontinued on 6/3/24. Review of Resident #49's MAR for May 2024 and June 2024 revealed Cephalexin was given as ordered. A medical provider telehealth visit note dated 6/3/24 read in part: I gave an order to administer Ceftriaxone (antibiotic) 1 gram (gm) intramuscular once daily for 7 days. Patient was ordered Cephalexin prior, started 5/30/2024 until 6/6/2024. I discontinued cephalexin at this time. The note did not indicate why Cephalexin had been discontinued and a new antibiotic had been ordered. An order dated 6/3/24 for Ceftriaxone (antibiotic) 1 gm intramuscularly every 24 hours for infection for 7 days. Review of Resident #49's June 2024 MAR revealed Ceftriaxone was given as ordered. A medical provider progress note dated 6/4/24 read: nurse reports patient complaining of pain 10/10 even after pain medication given. Patient states pain is in groin related to UTI. Order given for Pyridium (a medication used to treat urinary pain) 200 milligram (mg) three times daily as needed for two days. A review of Resident #49's active physician orders revealed an order dated 6/4/24 given by the Medical Director (MD) that had been entered by the Minimum Data Assessment (MDS) Nurse that read: Urology consult/ follow up diagnosis pyelonephritis status post stent placement. A progress note from NP #1 dated 6/27/24 read in part: Being seen today for follow up regarding urinary pain and not feeling well. Nurses report patient states she is not feeling well and having discomfort with urination. Patient reporting discomfort with urination, even though she has an indwelling urinary catheter. Under the section labeled assessment and plans it read: Dysuria: UA and C&S. A progress note from NP #1 dated 6/29/24 read in part: Patient seen today for discomfort with urination and low-grade temp. Will start on antibiotics while awaiting lab results. Urinary tract infection: Previous 5/30/24 sensitivity noted to Ceftriaxone (Rocephin-antibiotic). Orders to give Ceftriaxone 1 gram (gm) give every 24 hours for 7 days intramuscular. Awaiting results from UA C&S. Follow up as soon as possible (ASAP) with urologist regarding indwelling placement status post left ureter stent placement. An order to follow up with the urologist as soon as possible was not located in Resident #49's physician orders. An order dated 6/29/24 that read: Ceftriaxone sodium solution reconstituted 1 gm inject 1 gm intramuscularly every 24 hours for infection related to urinary tract infection for 7 days. The order was discontinued on 7/5/24 the reason for discontinuation read due to sensitivity report shows resistance; antibiotic changed. Review of Resident #49's June 2024 and July 2024 MAR revealed Ceftriaxone had been given as ordered. Lab results showed Resident #49 had a UA that was completed on 7/1/24. The urine C&S report dated 7/4/24 showed the growth of two different organisms, Provedencia Stuartii (bacteria) and Acinetobacter baumannii complex (bacteria) The two organisms were not sensitive to the same antibiotic. Both organisms were resistant to multiple antibiotics listed on the urine culture and sensitivity report. An order dated 7/4/24 that read: Ciprofloxacin 250 mg tablet give one tablet by mouth twice daily related to UTI for 7 days. An order dated 7/5/24 that read: Bactrim (an antibiotic) oral tablet 400-80 mg tablet give one tablet by mouth twice daily for 3 days related to UTI, do not give at the same time as Cipro. A progress note from NP #1 dated 7/8/24 read in part: Urine culture is not sensitive to Rocephin this has been discontinued. There are two bacteria isolation in urine culture: one is sensitive to Cipro (antibiotic); and the other sensitive to Bactrim (antibiotic); patient can take both safely. A medical provider progress note dated 7/11/24 read: Nursing reports resident with severe, yeast infection. Previously on antibiotic for UTI, Diflucan (a medication used to treat fungal infections) 150 mg one dose ordered. An interview was conducted on 7/10/24 at 8:04 AM with the Transportation Aide. The Transportation Aide explained he primarily scheduled the facility resident appointments but that the receptionist helped schedule appointments if he was out on transport. The Transportation Aide said he had scheduled Resident #49's 5/17/24 urology appointment. He said 5/17/24 had been the date the urologist office had been able to get Resident #49 in to be seen. The Transportation Aide said he thought that Resident #49 had refused to go to the urology appointment that had been scheduled for her in May but was not sure. He stated Resident #49's urology appointment in June had been cancelled because another resident had an urgent appointment they needed to go to. The Transportation Aide stated he had been out on transport and that the Receptionist moved and rescheduled Resident #49's 6/14/24 appointment. He said Resident #49 had an upcoming urology appointment scheduled at the end of July on 7/31/24. He explained he looked at appointments when they needed to be moved and decided if appointments were okay to be moved. The Transportation Aide indicated the facility had a new DON and that now he discussed medical appointments that needed to be changed or moved with the DON to make sure it was clinically okay. He was unsure if the receptionist had spoken to anyone to make sure it was okay to move her appointment. He said the receptionist was currently out on medical leave. The Receptionist was unavailable to be interviewed. A telephone interview was conducted on 7/9/24 at 9:05 AM with the Urology Office Appointment Scheduler. The Scheduler stated that Resident #49's original urology appointment had been scheduled for 5/17/24. She said the office had received a call from the facility to cancel /reschedule the appointment, and that the appointment had been rescheduled to 6/14/24. She stated there was not a note as to why the appointment on 5/17/24 had been cancelled and moved. The Scheduler further stated the facility called again on 6/13/24 and had cancelled the appointment for 6/14/24 and rescheduled it for 7/31/24. She said there was a note attached to the appointment re-scheduled for 7/31/24 that said it was the only time and date they had available for a driver to take her. The Scheduler explained the turnaround time for appointments depended on the reason why someone needed to be seen. She said if the needed appointment was related to kidney stones or post-op the office would usually get them in within 2 weeks or sooner. If an initial hospital follow-up appointment had been cancelled the office would not re-schedule the appointment for a month out, she said the office would be able to get them in to be seen sooner. A telephone interview was conducted on 7/9/24 at 10:51 AM with the Urology Office Clinical Coordinator Nurse. She reviewed Resident #49's notes and confirmed she was supposed to follow up with the urology office a week after her hospital discharge on 4/26/24. The Urology Office Clinical Coordinator Nurse indicated she thought the reason Resident #49 had not been seen was due to transportation issues with the facility. The Clinical Coordinator stated that if the physician had wanted to Resident #49 her for a follow-up in a week, then ideally Resident #49 should had been seen. She said typically at the one week follow up appointment the office would check to ensure the UTI causing her sepsis had resolved and schedule for surgery to bust the renal stone up. The Clinical Coordinator stated if the stent was in place, it would allow the urine to drain and keep the ureter from becoming blocked again. She said Resident #49 could become septic again if her ureter became blocked again. The Clinical Coordinator was unable to speak to if Resident #49 would have been able to pass the renal stones on her own without having the surgical procedure to break up the stones. She said if the plan was for Resident #49 to come back in a week for follow up, then at the follow up appointment they would have made sure her infection was resolving and set up for surgery to deal with the stones that had caused the urinary blockage and sepsis. She said that Resident #49 had a urology appointment scheduled for 7/31/24 and there was a note on the appointment that stated it was the only date and time the facility had a driver. The Clinical Coordinator explained that some patients kept urinary stents in place for months and some patients had to have them replaced quarterly if the stent was due to a chronic issue. She said a stent did not usually stay in place for a renal stone obstruction. The office was not aware Resident #49 had been treated with antibiotics for two additional UTIs since her hospitalization . She explained a urinary stent could cause urinary irritation and bacteria would accumulate around the device. The Clinical Coordinator stated the stent could cause the urine to have traces of blood in it and would cause the patient to feel uncomfortable because a urinary stent was not comfortable. She said the ureter was opened with the stent and the next step would be to bust up the stones. The Clinical Coordinator further explained after the stones were busted up, the old stent would be removed, and a new stent placed while in the operating room. The Clinical Coordinator stated that the new stent would remain in place for a certain amount of time, then it would be removed, and the ureter assessed for stricture. She could not say if or how long Resident #49's catheter would need to be in place or if the catheter would have been removed at the follow up appointment. She said kidney stones tended to hide infection and that with Resident #49 already having had urosepsis and having a catheter she was at a huge risk of further infection. An interview was conducted on 7/10/24 at 8:15 AM with Resident #49. Resident #49 did not remember anyone coming to talk to her about a urology appointment in May and that she did not remember refusing to go a urology appointment in May. Resident #49 stated she did not remember being told by anyone in June that they needed to change/ reschedule her urology appointment. Resident #49 said she knew she had was supposed to go see the urologist after being in the hospital but was not sure why she had not been. Resident #49 thought she had been doing okay, until she had gotten another infection in her urine. Resident #49 stated she had pain in her bladder and stomach when she had the infections in her urine but said she did not currently have any discomfort. Resident #49 stated she did not have a urinary catheter before she had gone to the hospital and that she would rather have it out than in and if the catheter was able to be removed, she wanted it to be removed An interview was conducted on 7/10/24 at 3:59 PM with the MDS Nurse. The MDS Nurse stated that Resident #49's indwelling catheter had been brought up during a clinical meeting. The MDS said she was unsure which meeting it had come up in, but that it was around the same date (6/4/24) that she had entered the order from the MD for Resident #49 to follow up with the urologist. The MDS Nurse said that she had heard Resident #49 had asked about her indwelling catheter and wanted to know when or if it would be able to come out. The MDS Nurse was unsure who had told her Resident #49 had asked about her indwelling catheter. The MDS nurse stated she had asked the Medical Director (MD) about Resident #49's indwelling catheter regarding if the plan was to keep the catheter in place long term, the diagnosis, and if it was necessary. She said the MD gave her the order to have Resident #49 follow up with urology for her indwelling catheter, pyelonephritis, and the urinary stent. The MDS Nurse had not been aware that when Resident #49 returned to the facility from the hospital on 4/26/24 she was supposed to follow up with urology in a week. She said it was after the MD had given her the order for the urology follow up on 6/4/24 that she realized that Resident #49 had not followed up with urology when she returned to facility as specified on the hospital discharge summary. The MDS Nurse stated the urology appointment for Resident #49 had been made for 6/14/24 but that she was not sure what had come of that appointment. A telephone interview was conducted with NP #1 on 7/10/24 at 12:03 PM. NP #1 said when she saw Resident #49 on 6/29/24 and had placed in her progress note she needed to be seen by urology ASAP, she had also entered the order for a urology referral into the electronic computer system. NP #1 stated she had also verbally let the staff know. NP #1 was certain she had discussed Resident #49 needing to be seen by the urologist for follow up with Unit Manager (UM) #1 and the Director of Nursing (DON). NP #1 indicated she had also told UM #3. NP #1 stated she had not given a time frame that Resident #49 needed to be seen, but that she expected that Resident #49 to be seen as soon as the urology office could get her in. NP #1 stated she had wanted Resident #49 to be seen ASAP for follow up of the stent and evaluation of the urinary catheter because Resident #49 had another UTI, and the current UTI had a greater resistance pattern to antibiotics. NP #1 was concerned if Resident #49 developed another UTI in between her completion of the antibiotic for her current UTI and her going to the urologist it could have a higher antibiotic resistance and required Resident #49 to go back to the hospital to be treated. NP #1 did not know that Resident #49 had missed her other urology appointments but that the appointments for follow up being scheduled a month later was too long. NP #1 stated she did not usually see the urology office being booked out and unable to fit someone in for an appointment. An interview was conducted on 7/10/24 at 12:16 PM with Unit Manager (UM) #1. UM #1 did not remember the NP #1 speaking to her about Resident #49's indwelling catheter, urinary stent, UTTs, or needing to be seen by urology for follow up as soon as possible. UM #1 had not been aware of NP #1's note from 6/29/24 that specified Resident #49 needed to be seen by urology ASAP. UM #1 explained appointments listed on the hospital discharge summary were given to the Transportation Aide and that the Transportation Aide scheduled the appointments. UM #1 said in-house appointment referrals were entered into the electronic computer system by the provider. She said the UMs would go through orders each morning and if there was an order for an appointment/ referral they printed it out and would give it to the Transportation Aide to schedule. UM #1 said the appointment date/ time was not entered into the electronic computer system. UM #1 explained appointment dates/ times were in the appointment book kept at the reception desk. She said the Transportation Aide made a copy of appointments for the week and put the list out at the nurse's station for the current week. She stated the only way to know when a resident had an appointment would be for someone to look at the weekly list of appointments for the current week located at the nurse's station or to call the Transportation Aide. UM #1 explained the facility MD/ NP would not know when a resident had a specialty appointment scheduled unless it was on the current weeks appointment list at the nursing station, because it did not show up in the electronic computer system anywhere that they could see. UM #1 said the Transportation Aide was not clinical and would not know if an appointment was medically necessary versus a routine appointment. She did say the Transportation Aide asked for clinical decision-making support from nursing management when he was unsure. UM #1 stated if a residents appointment needed to be moved because another resident had an urgent appointment need, the Transportation Aide should call that day and re-schedule the appointment for as soon as possible. UM #1 said she thought a cancelled appointment would need to be re-scheduled for within a week if possible. UM #1 stated she had started working at the facility on June 10th and was unaware that Resident #49 was supposed to follow up with urology in a week after her hospital discharge on 4/26/24 and had not been seen. An Interview was conducted with UM # 2 on 7/10/14 at 12:38 PM. UM #2 indicated she had never been approached by the Transportation Aide about an appointment that needed to be moved or changed. UM #2 said she did not always review the providers notes after they had seen a resident because they did not put the notes into the electronic computer system right away. UM #2 did not remember why Resident #49 did not go to her urology appointment scheduled on 5/17/24. UM #2 said she did not know that Resident #49's appointment on 6/14/24 had to be moved because another resident had an urgent appointment need. UM #2 stated she remembered a patient that needed to have an urgent appointment but that she did not tell the Transportation Aide to bump or move Resident #49's urology appointment to take the other resident. UM #2 said she would tell the Transportation Aide if a resident needed to be seen urgently but that the Transportation Aide did not ask her whose appointment to move or bump to fit in the appointment. She stated if the Transportation Aide had asked her, she would have asked the MD/NP which appointment could be moved or bumped to a later date if that needed to happen. UM #2 did not remember NP #1 discussing Resident #49's urinary issues with her or that Resident #49 needed to be seen by the urologist as soon as possible. UM #2 had not been aware of the NP #1's note on 6/29/24 indicating Resident #49 needed to be seen by urology ASAP. UM #2 indicated Resident #49 needing to be seen by the urologist had been discussed during a clinical meeting but that she did not remember the date of the meeting. UM #2 had known the urology appointment for Resident #49 had been scheduled but had not known that the date had been changed, and that the appointment had been pushed out so far to the end of July. UM #2 had known Resident #49 had received antibiotics for treatment of UTIs but had not attributed that to be a concern. She could not say if Resident #49's UTIs could have been prevented if she had followed up with the urologist sooner. An interview was conducted with UM #3 on 7/10/24 at 1:09 PM. UM #3 stated she had worked at the facility for 6 weeks. UM #3 did not remember NP #1 speaking to her about Resident #49's indwelling catheter, urinary issues, or that she needed to be seen by urology as soon as possible. She said orders and appointments that were needed were discussed in the morning stand up meetings but that she did not remember Resident #49 being discussed. UM #3 stated there was not a good communication flow at the facility about when appointments were scheduled. An interview was conducted with the NP #1 on 7/10/24 at 8:18 AM. NP #1 stated she had been working at the facility for approximately 5 weeks. She said Resident #49 had her indwelling catheter placed when the urinary stent was placed during her hospitalization in April. NP #1 explained she had seen Resident #49 last week and had been trying to find an appropriate diagnosis or medical need to keep the indwelling catheter in place. NP #1 stated she had wanted to remove Resident #49's indwelling catheter due to her having another UTI but wanted to check with urology first. NP #1 explained she had entered a referral for Resident #49 to be seen by urology for follow up of the indwelling catheter and urinary stent. NP #1 stated she had not been aware that Resident #49's hospital discharge summary from 4/26/24 had included for her to follow up with urology in a week. NP #1 explained she knew Resident #49 needed to be seen by urology because she had a stent placed. NP #1 did not know why Resident #49 had not gone to the urologist but knew she needed to be seen. NP #1 stated she felt Resident #49's most current UA with C&S that had a colony count of 30,000-40,000 needed to be treated with antibiotics because of her history of pyelonephritis with sepsis. NP #1 said Resident #49 should have been seen by urology for follow up the week after her hospital discharge. NP #1 stated it was hard to say if her following up with urology when she was supposed to would have prevented her from developing the 2 additional UTI's. She said Resident #49's urinary catheter was an indwelling device and because it was invasive it increased the risk of bacteria growth. NP #1 stated she did not know if Resident #49 needed the surgical procedure to break up her renal stones. NP #1 stated that if Resident #49 had been seen by urology when she was supposed to be seen they could have done the surgical procedure to break up the renal stones sooner if she needed it. NP #1 said Resident #49 should be seen by urology sooner than 7/31/24. NP #1 was worried that when Resident #49's current antibiotics ended that she could potentially develop another UTI that was resistant to everything because Resident #49's most recent UTI showed the growth of two organisms which had a greater resistance to antibiotics. She said Resident #49 needed to be sooner, preferably by next week because Resident #49 would be at high risk of developing another UTI between the time, she completed her current ordered antibiotics and the appointment scheduled on 7/31/24. NP #1 said that it would put Resident #49 at high risk for sepsis or returning to the hospital if she developed another UTI. A telephone interview was conducted on 7/9/24 at 4:45 PM with the MD. He stated Resident #49 should have been seen the week after her hospital discharge by urology for follow up. The MD thought she was doing okay and that there was not a negative impact to Resident #49, but that she should be seen soon for follow up by the urologist. The MD said Resident #49 should be seen sooner than 7/31/24 and it would be preferable to move the appointment up. An interview with the MD on 7/10/24 at 4:30 PM revealed he did not specifically remember giving the order dated 6/4/24 for Resident #49 to follow up with urology. An interview was conducted with the Director of Nursing (DON) on 7/10/24 at 1:55 PM. She stated that appointments were given to the Transportation Aide to schedule. She said once the Transportation Aide made an appointment, he put the appointment date/ time into the appointment book. The DON explained a weekly list of appointments was distributed to the nursing stations and administrative staff. She said if someone wanted to know when an appointment was scheduled further out than the current week, then they would have to look in the appointment book. She said the appointment book was located downstairs at the reception desk. The DON was unsure if everyone knew where the appointment book was located. The DON said she had been at the facility for 6 weeks and was not sure why Resident #49 had been hospitalized in April or why she had an indwelling catheter. The DON stated she was aware that Resident #49 had been treated for two UTIs since she returned from the hospital. The DON did not know that Resident #49 was supposed to have followed up with the urologist in a week when she returned from the hospital on 4/26/24. The DON only recalled one urology appointment in June that had to be rescheduled because another resident needed to go to an appointment. The DON stated no one had approached her to ask if it was medically appropriate to move Resident #49's urology appointment in June. The DON did not remember NP #1 speaking to her about Resident #49's urinary issues or telling her that she needed to be seen by urology ASAP. The DON said that they reviewed physician orders and appointments during the morning meetings and did not remember discussing Resident #49 during the morning meetings. She stated that if the urology office had an appointment that was earlier than 7/31/24 then Resident #49's appointment should have been scheduled sooner. She stated Resident #49 not following up with urology when she was supposed to, could have contributed to her infections. She said Resident #49 should have followed up with the Urologist within a week after her hospital discharge if possible. The DON was unsure where the break in the appointment process was that caused Resident #49's urology appointment to be pushed out so far to the end of July. A follow up telephone interview was conducted with the MD on 7/10/24 at 4:30 PM. The MD was not sure if Resident #49 would have followed up with

Based on record reviews, observations, and interviews with residents and staff, the facility failed to treat residents in a dignified manner when staff did not allow Resident #51, Resident # 77 and Resident # 8 to leave their rooms due to the facility running out of oxygen tanks for 3 days. Resident # 51 stated she was very upset because she was unable to leave her room to go to church or do any of her daily routine and it made her feel very depressed. She stated that she felt like a caged animal having to stay in her room and felt anxiety over it. Resident #77 stated he had to stay in his room for all those days and was very bored and upset and did not feel it was right for the facility to not have portable tanks so he could do his daily business. Resident #8 stated he had to stay in his room for all those days and was very bored and upset and did not feel it was right for the facility to not have portable tanks so he could do his daily business. In addition, the facility failed to treat Resident #34 in a dignified manner by standing over them while assisting with eating. The reasonable person concept was applied to this example as individuals have expectations of being treated with dignity while dining. This deficient practice affected 4 of 4 residents reviewed for dignity. The findings included: 1. Resident #51 was admitted to the facility on [DATE] with the following diagnoses: chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD). Resident #51 had a physician order 3/17/24 stating the resident should be administered oxygen at 3 liters per minute via nasal cannula continuously. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #51 was cognitively intact. She used a walker or a wheelchair for mobility. She did show signs of shortness of breath with exertion, when sitting and lying flat. She was on oxygen therapy. On 7/08/24 at 3:13 PM an interview with Resident #51 stated about one month ago, on a Friday, she needed a new portable oxygen tank and one of the staff took her to the oxygen tank room to get a new tank. Resident # 51 could not remember who the staff was. The staff person went into the room to get a tank and came out saying there wasn't any. She stated the facility was out of the portable tanks until Tuesday at 3pm. Resident #51 stated that this had never happened before. She stated she was very upset because she was unable to leave her room to go to church or do any of her daily routine and it made her feel very depressed. She stated that she felt like a caged animal having to stay in her room for so many days. She also stated she had anxiety over it. On 7/08/24 at 11:30 AM an interview with Nurse #3 was conducted. Nurse #3 stated that she started working at the facility 6 weeks ago. Nurse #3 stated that she was alerted by a resident on her first day working at the facility that the facility had run out of portable oxygen for about 5 days. Nurse #3 checked the room which holds the portable oxygen tanks and found there were no portable oxygen tanks. She remembers that later that same day there was a delivery of portable oxygen tanks. Nurse #3 stated that this was the only time she knew that the facility ran out of portable tanks. Nurse #3 remembers that Resident #51was upset that day. Nurse #3 stated that Resident #51 needed to always be on oxygen, so she had to stay in her room using the concentrator. On 7/8/24 at 3:29 PM an interview was held with central supply staff. She stated that she took over the position at the end of March. She keeps an inventory of all office supplies and facility supplies. She has a list hanging in her office to write down supplies needed. The portable oxygen tanks are kept in a room off the 100 hall. There is an order placed with vendor every other Tuesday to get more tanks. The staff person stated the facility has never run out of portable oxygen tanks. She stated that the facility did have a power outage and the staff did use more of the portable tanks, but they did not run out. She stated that she has slips for all the deliveries. The delivery receipts were reviewed and showed that 40 tanks were delivered on 4/9/24, 40 tanks delivered on 4/23/24, 110 tanks delivered on 5/7/24, 110 tanks delivered on 5/10/24, 129 tanks delivered on 6/4/24, 78 tanks delivered on 6/18/24 and 119 tanks delivered on 7/2/24 On 7/10/24 at 2:45 PM an interview was conducted with the Director of Nursing (DON). The DON stated that central supply usually orders the oxygen for the facility and had the tank delivery on a schedule and if for some reason the facility runs out before the next scheduled delivery, central supply can call for more tanks to be delivered. The DON states that if staff notices that they need more tanks they can text the central supply staff and sometimes the central supply staff work on the weekends. The DON's understanding was that the facility did not run out of tanks, but only had 2 tanks left. The residents could use their concentrators and still have oxygen needed, but daily activity would be disrupted. On 7/10/24 at 4:54 PM an interview was held with the Administrator. The administrator stated that central supply handles and maintains the portable oxygen tanks. Central supply orders them and returns the empty tanks. Central supply staff keep a log and check to see how many tanks the facility had. The administrator is not aware of the facility running out of portable tanks. The administrator stated she had recently spoken to central supply about making an extra order of tanks to ensure the facility doesn't run out. The administrator stated that there would be no reason to run out of tanks for 3 or 4 days because the staff at the facility can call and get them delivered. 2. Resident #77 was admitted to the facility on [DATE] with diagnoses of acute and chronic respiratory failure with hypoxia (lack of enough oxygen in the tissues to sustain bodily functions) and pulmonary fibrosis (chronic lung disease causing scarring of the lungs making it difficult to breath). Resident #77 had a physician order dated 4/17/24 stating to administer oxygen at 6 liter per minute via nasal cannula continuously and monitor for shortness of breath or oxygen saturation less than 90%. The Admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #77 was cognitively intact. He was independent with his mobility. He did show signs of shortness of breath with exertion, when sitting and lying flat. He was on oxygen therapy. On 7/9/24 at 12:30 PM an interview was conducted with Resident #77. Resident #77 stated that he needs to be on continuous oxygen. He stated about 5 weeks ago the facility ran out of portable oxygen tanks. He stated that it was a Friday when the facility ran out of tanks and the facility did not get more until Tuesday. Resident #77 had to stay in his room for all those days and was very bored and upset and did not feel it was right for the facility to not have portable tanks so he could do his daily business. On 7/08/24 at 11:30 AM an interview with nurse #3 was conducted. Nurse #3 stated that she started working at the facility 6 weeks ago. Nurse #3 stated that she was alerted by a resident on her first day working at the facility that the facility had run out of portable oxygen for about 5 days. Nurse #3 checked the room which holds the portable oxygen tanks and found there were no portable oxygen tanks. She remembers that later that same day there was a delivery of portable oxygen tanks. Nurse #3 stated that this was the only time she knew that the facility ran out of portable tanks. Nurse #3 remembered that Resident #77 were upset that day as well. Nurse #3 stated that he needs to always be on oxygen continuously, so he had to stay in his room using the concentrator. On 7/8/24 at 3:29 PM an interview was held with central supply staff. She stated that she took over the position at the end of March. She keeps an inventory of all office supplies and facility supplies. She has a list hanging in her office to write down supplies needed. The portable oxygen tanks are kept in a room off the 100 hall. There is an order placed with vendor every other Tuesday to get more tanks. The staff person stated the facility has never run out of portable oxygen tanks. She stated that the facility did have a power outage and the staff did use more of the portable tanks, but they did not run out. She stated that she has slips for all the deliveries. The delivery receipts were reviewed and showed that 40 tanks were delivered on 4/9/24, 40 tanks delivered on 4/23/24, 110 tanks delivered on 5/7/24, 110 tanks delivered on 5/10/24, 129 tanks delivered on 6/4/24, 78 tanks delivered on 6/18/24 and 119 tanks delivered on 7/2/24. On 7/10/24 at 2:45 PM an interview was conducted with the Director of Nursing (DON). The DON stated that central supply usually orders the oxygen for the facility and had the tank delivery on a schedule and if for some reason the facility runs out before the next scheduled delivery, central supply can call for more tanks to be delivered. The DON states that if staff notices that they need more tanks they can text the central supply staff and sometimes the central supply staff work on the weekends. The DON's understanding was that the facility did not run out of tanks, but only had 2 tanks left. The residents could use their concentrators and still have oxygen needed, but daily activity would be disrupted. On 7/10/24 at 4:54 PM an interview was held with the Administrator. The administrator stated that central supply handles and maintains the portable oxygen tanks. Central supply orders them and returns the empty tanks. Central supply staff keep a log and check to see how many tanks the facility had. The administrator is not aware of the facility running out of portable tanks. The administrator stated she had recently spoken to central supply about making an extra order of tanks to ensure the facility doesn't run out. The administrator stated that there would be no reason to run out of tanks for 3 or 4 days because the staff at the facility can call and get them delivered. 3. Resident #8 was admitted to the facility on [DATE] with the diagnosis of chronic obstructive pulmonary disease. He had a physician order 4/10/24 for oxygen at 2 liter per minute via nasal cannula as needed for shortness of breath. The quarterly MDS dated [DATE] revealed that Resident #8 was cognitively intact and used a wheelchair for mobility. He did not have shortness of breath. On 7/08/24 at 11:30 AM an interview with nurse #3 was conducted. Nurse #3 stated that she started working at the facility 6 weeks ago. Nurse #3 stated that she was alerted by a resident on her first day working at the facility that the facility had run out of portable oxygen for about 5 days. Nurse #3 checked the room which holds the portable oxygen tanks and found there were no portable oxygen tanks. She remembers that later that same day there was a delivery of portable oxygen tanks. Nurse #3 stated that this was the only time she knew that the facility ran out of portable tanks. On 7/9/24 at 12:30 PM an interview was conducted with Resident #8. Resident #8 shared a room with Resident #77 and stated he was also affected by the facility running out of oxygen tanks. Resident #8 stated that he needed to be on oxygen. He stated that about 5 weeks ago the facility ran out of portable oxygen tanks. He stated that it was a Friday when the facility ran out of tanks and the facility did not get more until Tuesday. Resident #8 had to stay in his room for all those days and was very bored and upset and did not feel it was right for the facility to not have portable tanks so he could do his daily business. On 7/8/24 at 3:29 PM an interview was held with central supply staff. She stated that she took over the position at the end of March. She keeps an inventory of all office supplies and facility supplies. She has a list hanging in her office to write down supplies needed. The portable oxygen tanks are kept in a room off the 100 hall. There is an order placed with vendor every other Tuesday to get more tanks. The staff person stated the facility has never run out of portable oxygen tanks. She stated that the facility did have a power outage and the staff did use more of the portable tanks, but they did not run out. She stated that she has slips for all the deliveries. The delivery receipts were reviewed and showed that 40 tanks were delivered on 4/9/24, 40 tanks delivered on 4/23/24, 110 tanks delivered on 5/7/24, 110 tanks delivered on 5/10/24, 129 tanks delivered on 6/4/24, 78 tanks delivered on 6/18/24 and 119 tanks delivered on 7/2/24. On 7/10/24 at 2:45 PM an interview was conducted with the Director of Nursing (DON). The DON stated that central supply usually orders the oxygen for the facility and had the tank delivery on a schedule and if for some reason the facility runs out before the next scheduled delivery, central supply can call for more tanks to be delivered. The DON states that if staff notices that they need more tanks they can text the central supply staff and sometimes the central supply staff work on the weekends. The DON's understanding was that the facility did not run out of tanks, but only had 2 tanks left. The residents could use their concentrators and still have oxygen needed, but daily activity would be disrupted. On 7/10/24 at 4:54 PM an interview was held with the Administrator. The administrator stated that central supply handles and maintains the portable oxygen tanks. Central supply orders them and returns the empty tanks. Central supply staff keep a log and check to see how many tanks the facility had. The administrator is not aware of the facility running out of portable tanks. The administrator stated she had recently spoken to central supply about making an extra order of tanks to ensure the facility doesn't run out. The administrator stated that there would be no reason to run out of tanks for 3 or 4 days because the staff at the facility can call and get them delivered. 50046 4. Resident # 34 was readmitted to the facility on [DATE] with diagnoses including dementia, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #34 was cognitively impaired and required substantial/ maximum assistance with eating. Review of Resident #34's care plan dated 1/26/21 and last reviewed 4/16/24 revealed she had a care plan in place for needing assistance with activities of daily living (ADLs) due to cerebral vascular accident (CVA/stroke) and impaired cognition. The care plan interventions included to assist with eating. She had an additional care plan in place for nutritional problems or potential nutritional problems related to the need for mechanically altered pureed foods and nectar thickened liquids, poor dentition, and impaired cognition. The care plan interventions included to provide feeding assistance when she did not feed herself, and that sometimes she needed staff to provide total assistance with meal. A continuous dining observation was performed on 7/8/24 from 12:22 PM through 12:44 PM. At 12:22PM Resident #34 was observed in the dining room. She was sitting in a specialty wheelchair. The chair was pushed up to the dining table. There were 3 other residents seated at the table. The meal tray for Resident #34 was positioned in front of her on the table. NA #3 was observed to be standing beside Resident #34 while she was feeding her. At 12:26 PM an observation of the dining room revealed there were multiple empty extra chairs located throughout the dining room At 12:28 PM NA #3 was observed briefly to sit on her knees on the floor beside Resident #34 as she continued to feed her. At 12:29 PM NA #3 was observed to stand again as she continued to feed Resident #34. At 12:35 PM NA #3 covered the meal plate with the lid. She kneeled beside Resident #34 to give her fluids from a cup and then stood again. NA #3 proceeded to feed resident #34 the ice cream and pudding that was on her meal tray while standing. The NA #3 remained standing for the remainder of the time while feeding Resident #34. At 12:44 PM The NA #3 stopped feeding Resident #34 and she was assisted from the dining room by another staff member. An interview was conducted on 7/8/24 at 12:56 PM with NA #3. She said that there was usually an extra empty chair located at the table for her to sit in while providing feeding assistance. NA #3 said that today the table had been full with 4 residents seated at the table. She said she could have pulled an empty chair over to the table to sit in. NA #3 said since she had already been at Resident #34's table she had not wanted her to be delayed in eating and thought it would be okay to feed her standing up. NA #3 said she had never been told she could not or should not stand to feed a resident. NA #3 said it would make her feel a little bit inferior if someone stood over her while assisting her with eating. An interview was conducted on 7/9/24 at 11:23 AM with Nurse # 3. She said Resident #34 did not feed herself and was dependent on staff to eat. Nurse #3 said NA #3 should have sat beside Resident #34 when she was feeding her. She said you should be at eye level with residents and not hover or stand over them while providing feeding assistance. Nurse #3 said it was a dignity issue if an NA stood while feeding a resident. An interview was conducted on 7/10/24 at 1:55 PM with the Director of Nursing (DON). She said NA #3 should have sat beside Resident #34 while providing feeding assistance. The DON stated it would make her feel rushed if someone was standing while assisting her with eating. An interview was conducted on 7/10/24 at 4:55 PM with the Administrator. She said staff should sit while feeding a resident during meals. The Administrator said this was a dignity issue and that the staff member should be at eye level with the resident when providing meal assistance. The Administrator stated she felt the outcomes from feeding and meal consumption were improved with that approach. She said this also provided a better view of the residents chewing process to ensure safety and swallowing of food.

Based on observations, record review, and interviews with resident and staff the facility failed to maintain the wall and ceiling in sanitary condition at 1 of 2 nursing stations (nursing station #1). The facility failed to manage outside water drainage to prevent outside storm water from flooding into 1 of 4 hallways (Hallway #2), 1 of 1 dining room, and 2 of 2 resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]). Furthermore, the facility failed to clean ceiling air vents located over the food prep and food service area that had a large amount of dark black substance visible on the outside of 3 of 6 vents. The facility also failed to maintain a footboard in good repair for 1 of 1 bed (Resident #37's bed) and failed to maintain a wheelchair in good repair for 1 of 1 resident (Resident #6) reviewed for a safe, clean, comfortable and homelike environment. These deficient practices had the potential to affect all residents residing in the facility. Findings included: 1. An observation on 7/7/24 at 2:40 PM of the common area at nursing station #1 revealed an area on the wall and an area on the ceiling that had a dark black substance visible. The wallpaper was off the wall. Each area was approximately one foot in diameter. The dark black substance had a circular and dotted growth pattern with scattered small areas of gray colored fuzz. There was a brown/orange colored drip line that was moist and extended from the black substance on the ceiling down the wall. Subsequent observation on 7/8/24 at 3:30 PM revealed the conditions remained unchanged. An interview was conducted on 7/8/24 at 4:16 PM with the Maintenance Director. He stated he had been at the facility in his current role for a little over three months. He stated that the black substance on the wall and ceiling had been there since he had started and had not changed. He said he had checked the area previously and thought the area was glue because it had been tacky feeling and that it did not scrape off the wall. He was unsure why the wallpaper had been removed from that area. An interview and observation was completed on 7/8/24 at 4:34 PM of the black substance on the wall and ceiling with the Maintenance Director. He touched the black substance on the wall and ceiling with two of his fingers. When he brought his fingers away from the wall/ ceiling a black residue was visible on his fingers. He touched along the seam of the wall and ceiling and stated the area was moist/ wet. He acknowledged there was a visible drip line from the ceiling extending down the wall. He said he thought the black substance on the wall and ceiling was mold. He stated he thought the area was mold because the area was moist and because of the way the black residue came off onto his fingers when he touched the area. A follow up observation on 7/9/24 10:05 AM of the area revealed the black substance had been cleaned off the ceiling and wall. A follow up interview was conducted with the Maintenance Director on 7/10/24 at 3:14 PM. He said he had cleaned the black substance off the wall and ceiling with a bleach wipe. He said he had looked in the ceiling above the area and that there were pipes that ran above the area but that he had not seen anything leaking. He said there had been condensation and moisture in that area and that he had called a plumbing company to come out and check the pipes in that area. An interview was conducted with the Administrator on 7/10/24 at 4:55 PM. She said she was unsure how long the black substance had been on the ceiling and wall. She stated she had not noticed the black substance on the wall and ceiling. She said if she had noticed the black substance on the wall and ceiling, she would have asked maintenance to check the area and clean it. 2. a. An observation on 7/7/24 at 1:41 PM revealed water flooded and pooled across the bathroom and room floor in rooms [ROOM NUMBERS]. A moisture mark that extended out from the wall approximately 3 feet was observed on the carpet in hallway #2 along the wall outside of room [ROOM NUMBER]. The moisture mark on the carpet extended the length of approximately 8 feet of hallway #2 along the wall. The carpet was wet to touch. Subsequent observation on 7/8/24 at 11:26 AM revealed the carpet in hallway #2 continued to have a moisture mark extending from the wall and was moist to touch. There was a damp/ wet smell present. There was no water observed on the floor in room [ROOM NUMBER] or 217. 2. b. An observation on 7/7/24 at 2:23 PM of the dining room revealed water on the floor in front of the entrance door. The carpet in front of the dining room entrance door had a water moisture mark extending approximately 6 feet out on the carpet. The carpet was wet to touch. Subsequent observation on 7/8/24 at 12:08 PM revealed the carpet in front of the dining room remained wet to touch. A wet/ moist smell was noted. An interview was conducted on 7/8/24 at 4:16 PM with the Maintenance Director. He stated he had been at the facility in his current role for a little over three months. He stated that since he had been at the facility the dining room had flooded 3-4 times. He stated it had flooded into rooms [ROOM NUMBERS] one other time that he was aware of. He stated the flooding was from an issue with the drain located outside of the dining room at the exterior wall of rooms [ROOM NUMBERS]. He said the fooding occurred when it rained. The Maintenance Director stated he had tried things to correct the issue the other times that water had flooded from outside into the building, but that what he had tried had not fixed the issue with the drain. He said he thought that the drainpipe needed to be brought down to ground level so it would drain. He said there was gravel along the exterior building wall at rooms [ROOM NUMBERS]. The Maintenance Director stated he thought the flooding into the resident rooms and hallway had occurred because there was plastic under the gravel and water was getting under the plastic and going into the foundation. He said the gravel and plastic would need to be removed and the ground graded to prevent the rooms from flooding again. A follow up interview was conducted with the Maintenance Director on 7/10/24 at 3:14 PM. He stated that they had cleaned the carpet that had been flooded a few times with the carpet cleaning machine. He said he had placed fans to blow and help the carpet dry. An interview was conducted with the Administrator on 7/10/24 at 4:55 PM. She said she was aware that the dining room had flooded on Sunday during a storm. She said since Sunday she had heard comments that the flooding happened frequently but that she had not been aware before then that the flooding had happened frequently. She said the water coming into the building and resident rooms from the outside was being addressed by Maintenance. 3. An observation of the kitchen on 7/9/24 at 12:35 PM was completed with the Dietary Manager (DM) and revealed 3 out of 6 air vents located over the food preparation and service area had a large amount of black substance with a circular and dotted growth pattern visible on the outside of the vents. An interview with Dietary Manager (DM) was conducted on 7/9/24 at 12:40 PM. She said she was not sure what the black substance on the vents was. She stated that the vents needing to be cleaned had been identified by the health department during the kitchen inspection in October of 2023. She said the health department did not say what the black substance on the vents was but that the vents needed to be cleaned or replaced. The DM said she had told maintenance about the vents needing to be cleaned or replaced when it had come up on the kitchen inspection in October. The DM said she had also mentioned that the vents needed to be cleaned or replaced to the new Maintenance Director. She said each time she had been told by Maintenance they would take care of the vents but that nothing had been done. An interview was conducted with the Health Department Inspector on 7/9/24 at 2:33 PM. She said that the facility kitchen inspection was completed in October 2023 and that the inspection said the outside of the vents in the kitchen needed to be cleaned. She said this was a repeated issue from the facility's previous kitchen inspection. An interview was conducted with the Maintenance Director on 7/10/24 at 3:14 PM. He stated he had not been aware that the kitchen vents needed to be cleaned. He said that the vents needing to be cleaned had not been mentioned to him. The Maintenance Director said he had been under the assumption that the kitchen staff were supposed to clean the stuff in the kitchen. He said he was not aware that the vents needed to be cleaned and that it had been an issue during the last kitchen inspection and had not been addressed. The Maintenance Director said the health department had come to the building yesterday and had looked at the vents in the kitchen. He said the health department inspector said the black substance on the kitchen vents could be mold and had told him to clean them with bleach water. He said the health department had said some of the vents also had dust that needed to be cleaned off. He stated that the kitchen vents would have to be cleaned after hours and that he had set up for the vents to be cleaned on Friday 7/12/24. The Maintenance Director said there had been a couple of spots on the bottom of the walls in two resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) that recently had to be replaced because of mold. He said he had taken the baseboard off in rooms [ROOM NUMBERS] because it had been peeling away from the wall. The Maintenance Director said that when he had removed the baseboard, he could see the mold behind it. He said had cut out the area and replaced it. An interview was conducted on 7/10/24 at 4:55 PM with the Administrator. She stated she did not remember if the kitchen vents needing to be cleaned had been an issue during the facility's last kitchen inspection in October 2023. She said she did not remember if the kitchen vents needing to be cleaned had been brought up by the DM previously. The Administrator stated she was not sure why the kitchen vents had not been cleaned. She did not mention if there had been other areas located in the building that had to be repaired due to the growth of black substance. The Administrator stated that the health department had come to the facility yesterday (7/9/24) and they had mentioned that the kitchen vents needed to be cleaned. She said that maintenance was going to clean them. 41069 4. During an interview with Resident #37 on 7/7/24 at 10:28 AM, his footboard was observed coming off his bed on one side when he backed into it with his wheelchair. Resident #37 stated that his footboard needed to be fixed because the screw had come loose. He stated that the footboard had been broken like this for two months, but he was not sure if the Maintenance Director knew about it. A follow-up observation on 7/8/24 at 8:24 AM revealed Resident #37's footboard was missing a screw and was not attached tightly to the bed frame. An interview with Nurse Aide (NA) #2 on 7/10/24 at 8:43 AM revealed she had known about Resident #37's broken footboard a couple of weeks ago, and had told Unit Manager #2 about it because she did not know where the work orders were located. An interview with Unit Manager (UM) #2 on 7/10/24 at 10:16 AM revealed she did not know about Resident #37's footboard needing repair, and that she did not remember NA #2 telling her about the broken footboard. UM #2 stated that if she had known about it, she would have texted the Maintenance Director right away to get it taken care of. She also stated that she did not know that NA #2 did not know where the work orders were located. An observation and interview with the Maintenance Director on 7/9/24 at 2:50 PM revealed staff should fill out a work order or tell him verbally if something needed to be repaired inside a resident's room. The Maintenance Director stated that he did a walk through once a month, but he did not know about Resident #37's broken footboard. He looked at Resident #37's footboard and when he moved it, the footboard came off the bed frame. He stated that he needed to replace the screw, but that he was not aware that it had been broken. An interview with the Administrator on 7/10/24 at 5:07 PM revealed that all department managers did daily rounds, and each had room assignments where they should be looking for equipment that needed repair. The Administrator stated that they had to change Resident #37's foot board a number of times, and the common way to notify the Maintenance Director of needed repairs was verbally. 36217 5. Resident #6 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] coded Resident #6 with severe impairment in cognition. The MDS indicated she had impairment for one side of her upper and lower extremities and utilized a wheelchair as the main mobility device for locomotion. Review of the weekly skin assessment from 05/01/24 through 07/08/24 revealed Resident #6's skin was intact without any issues. During an observation conducted on 07/07/24 at 11:21 AM, Resident #6 was seen sitting in her wheelchair outside of her room in the hallway. The armrest for both sides of the wheelchair were observed with multiple spots that were torn, cracked, and ripped with sharp edges approximately 2.5 inches in diameter. Resident #6 was wearing a short sleeves shirt while sitting in the wheelchair with both arms contacting the broken armrests during the observation. An interview was conducted with Resident #6 on 07/07/24 at 11:24 AM. She could not recall how long the armrests for her wheelchair had been in disrepair. She stated she wore a short sleeve shirt most of the time, and the broken armrests had caused skin irritation at times. During a subsequent observation conducted on 07/08/24 at 11:41 AM, Resident #6 was seen sitting in her wheelchair wearing a short sleeve shirt pedaling in the hallway. The armrests remained in disrepair. A joint observation was conducted on 07/09/24 at 12:24 PM with Nurse Aide (NA) #5 and Nurse #5. Resident #6 was seen sitting in her wheelchair wearing a short sleeve shirt in the activity room in 400 halls. The armrests remained in disrepair. An interview was conducted with Nurse Aide (NA) #5 on 07/09/24 at 12:26 PM. She stated she had provided care for Resident #6 in the past few months, but she did not notice the armrests were in disrepair. She added Resident #6 wore a short sleeve shirt frequently and explained the broken portion of the armrests were covered by Resident #6's arms most of the time to make it harder to identify repair needs. During an interview conducted with Nurse #5 on 07/09/24 at 12:28 PM. She stated she had provided care for Resident #6 in the past few months, but she did not notice the armrests for the wheelchair were broken. She acknowledged that it needed to be fixed immediately as it could cause skin irritation. She added the rehab department was responsible for checking the wheelchair routinely and fixing it as needed. An interview was conducted with the Rehab Director on 07/09/24 at 12:34 PM. She stated Resident #6 was under rehab department's caseload, she was responsible to check her wheelchair at least once per month. She could not explain why she missed Resident #6's wheelchair during the monthly audit. For residents who were not under rehab department's caseload, the maintenance department was responsible to check the wheelchair to ensure they were in good repair. She added the rehab department also depended on nursing staff to report repair needs. She acknowledged that the armrests for Resident #6's wheelchair were in disrepair, and it needed to be fixed immediately. During an interview conducted on 07/09/24 at 2:51 PM, the Maintenance Director stated the maintenance department did not check repair needs for wheelchairs on a regular basis. Nursing staff or rehab staff would notify him whenever they identified repair needs for wheelchairs. He did not know Resident #6's wheelchair armrests were broken and acknowledged that they should be fixed immediately. An interview was conducted with the Director of Nursing (DON) on 07/09/24 at 4:31 PM. She expected the staff to be more attentive to resident's mobility devices, and to report all the repair needs to the maintenance department or rehab department in a timely manner. It was her expectation for all the mobility devices to be in good repair at all the times. During an interview conducted on 07/10/24 at 5:06 PM, the Administrator expected the staff to pay attention to the condition of residents' mobility devices and report repair needs in a timely manner. It was her expectation for residents' mobility devices to be in good repair while in the facility.

Based on observations, record review, and interviews with staff the facility failed to establish an infection control policy for or implement Enhanced Barrier Precaution (EBP) precautions when Nurse #4 was observed providing care to a resident with a feeding tube (Resident #43) and nursing assistant (NA) #1 failed to wear a gown while performing urinary catheter care and failed to change gloves or perform hand hygiene following catheter care and prior to replacing and touching clean bedding (Resident #80). The facility also failed to implement their hand hygiene policy when they did not provide hand hygiene for a resident who was dependent on staff for hand hygiene prior to eating (Resident #45). This deficient practice occurred for 3 of 3 residents reviewed for infection control. Findings included: 1. a. Review of the facility's infection control policy and procedures revealed no policy for enhanced barrier precautions (EBP). An interview on 7/08/24 at 1:45 PM with the Corporate Nurse revealed she was aware of the EBP requirement and that there was no facility EBP policy. She stated the prior DON and Infection Preventionist had not established or implemented the requirement and could not say why. b. An observation on 7/09/24 at 9:50 AM of Nurse #4 revealed she entered Resident #43's room, and donned gloves. She then opened the resident's abdominal binder at his feeding tube site. She touched the tube feeding dressing gauze. She then leaned over the resident and turned him to reposition him toward her in the bed to check the skin on his side and back for integrity under the binder. Her clothing was noted to be touching the resident's bed and linens. An interview on 7/09/24 at 10:00 AM with Nurse #4 revealed she had heard of EBP. She stated it was for residents who have catheters, wounds, feeding tubes and staff were supposed to wear a gown and gloves when providing direct care. She stated she should have worn a gown along with her gloves when opening his abdominal binder but did not explain why she had not. Nurse #4 stated that she had not seen the facility staff observing EBP before today and was not sure why not. An interview on 7/08/24 at 1:30 PM with the Director of Nursing (DON) and Infection Preventionist revealed they were both aware of the EBP requirements but had not yet implemented the protocols at the facility. The DON stated that she had not had time to provide staff training. c. The facility Urinary Catheter Care policy dated 2017 read in part to ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. It continued to read to put on gloves and wash the resident's peri area thoroughly, rinse and dry. Discard the soiled linen, remove gloves, wash and dry hands thoroughly. Reposition the bed covers. Resident #80 was observed on 7/10/24 at 9:32 AM as Nursing Assistant (NA) #1 provided urinary catheter care wearing a gown and gloves. Then while wearing the same gloves and without performing hand hygiene, NA#1 removed the top bed sheet and replaced it with a clean bed sheet and a clean blanket. Then she used the bed control to adjust the bed for the resident. An interview on 7/10/24 at 9:55 AM with NA #1 revealed she had worn the same gloves to perform catheter care and change the sheet and blanket. She stated that she got nervous and forgot to remove her gloves and perform hand hygiene. An interview on 7/10/24 at 10:30 AM with the Director of Nursing revealed that NA #1 should have changed her gloves and performed hand hygiene to minimize infection control risks. An interview on 7/08/24 at 1:30 PM with the Director of Nursing (DON) and Infection Preventionist revealed they were both aware of the EBP requirements but had not yet implemented the protocols at the facility. The DON stated that she had not had time to provide staff training. 50046 2. An observation was completed on 7/8/24 at 12:20 PM of Resident #45 eating in the dining room. Resident #45 was observed sitting at a table in the dining room eating with his hands. His fingernails were long with a dark substance visible under all his nails. He was observed to dip his fingers into his food and lick the food off of his fingers. He was further observed to scoop food up from his plate with his fingers and place it into his mouth An interview was conducted with NA #3 on 7/8/24 at 12:59 PM. NA #3 said she wiped Resident #45's hands off after meals but that she did not typically do hand hygiene with him before meals. NA #3 said she was Resident #45's assigned NA and that she did not assist him with hand-hygiene before he came to the dining room or while he was in the dining room. NA #3 said she thought hand-hygiene before meals would be important for Resident #45 because he ate with his hands. She said she did not think to do hand-hygiene with Resident #45 because it was not something that they had done before at the facility. An interview was conducted on 7/9/24 at 11:33 AM with Nurse #3. She said that NAs should provide residents with hand-hygiene before meals and check that their nails were clean. An interview was conducted on 7/10/24 at 1:55 PM with the Director of Nursing (DON). The DON said staff should have assisted Resident #45 with hand-hygiene and checked his nails for cleanliness before he ate. An interview was conducted with the Administrator on 7/10/24 at 4:55 PM. She said staff should have assisted Resident #45 with hand- hygiene before his meal and checked his nails for cleanliness.

Based on observations and staff interviews, the facility failed to ensure ready-for-use metal pans and cooking pots were clean and not stacked wet. This occurred for 1 of 2 kitchen observations. They failed to discard opened food items ready for use within 7 days of opening and failed to discard spoiled produce with white growth in 1 of 1 walk in refrigerators in the kitchen. They also failed to discard 2 loaves of bread with green growth in 1 of 1 dry storage rooms. These practices had the potential to affect food served to residents. The findings included: 1. An initial tour of the kitchen occurred on [DATE] at 10:30 AM with the Cook. The initial observation of the dishware storage area, cold food storage, and dry food storage revealed the following: a. Dishware that was ready for use was put away and stacked wet (wet-nested). - 4 out of 7 small square metal pans - 2 out of 5 large rectangle metal pans - 3 out of 3 deep small rectangle metal pans - 2 out of 3 deep small square metal pans b. Dishware that was ready for use was put away and/or stacked dirty. - 2 out of 3 large deep cook pots dirty - 3 out of 5 large rectangle metal pans dirty - 3 out of 3 small deep rectangle metal pans dirty c. The cold food storage had 3 out of 20 cucumbers that were spoiled. The cucumbers were soft, squishy, and had spots of white fuzzy growth. A plastic storage container, the top of the container was covered with clear plastic wrap. The top of the plastic wrap was dated ,d+[DATE]. d. The dry storage area had 2 out of 6 loaves of bread with visible green and white growth visible on the bread. There was not a date on the bread. An interview was performed with the [NAME] on [DATE] at 11:10 AM. She stated that the bread came in a box from the supply company and the date was on the box. She said the bread should have been labeled with a date when it had been removed from the box. She stated the Dietary Manager checked the bread but that no one was assigned to check the bread on a routine schedule for spoilage. The [NAME] said the produce and food stored in the cold storage was supposed to be checked daily. She did not say if someone had checked the items in the cold storage today. She said she was not sure how the mushroom soup and spoiled produce had been missed. She said no one had been served the mushroom soup. An interview was conducted with the Dietary Manager (DM) on [DATE] at 3:10 PM. She said the pots and pans should have been allowed to air dry before they were put away. She said the pots and pans should have been checked for cleanliness and that they were dry before they had been put away for next use. She said staff needed to be re-educated. She stated that the produce should have been checked daily for spoilage and that the cold storage should have been checked daily for items that were beyond the date of use. She said once a food item had been opened, it should be dated, and should be used within three days. She said food items that were opened and not used should be discarded after three days. The DM said that there was not someone who was specifically assigned who checked the cold food storage for food items past the date of use or who checked the produce daily, but that it should be checked daily by the staff working. The DM said she checked the dry storage room for expired and spoiled food. She stated she checked the bread daily and that she had checked the bread on Friday. The DM stated that she usually dated the bread when she took it out of the delivery box. She said she had missed dating the bread when she had taken it out of the box on Friday. An interview was conducted on [DATE] at 4:55 PM with the Administrator. She stated that the kitchen should have checked for expired and spoiled food. She stated that the pots and pans should have been checked to ensure that they were clean and dry before they were put away.

Based on record review, and interviews with resident and staff, the facility failed to invite residents and/or their resident representative to participate and provide input in care planning for 2 of 4 residents reviewed for care planning (Resident #27 and Resident #37). The findings included: 1. Resident #27 was admitted to the facility on [DATE]. A review of Resident #27's medical record revealed her last care plan meeting was held on 3/14/24. Resident #27's care plan was last revised on 5/16/24. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #27 was cognitively intact. An interview with Resident #27 on 7/7/24 at 10:38 AM revealed she had not been to a care plan meeting recently. An interview with the Social Worker (SW) on 7/9/24 at 8:21 AM revealed she was responsible for scheduling the care plan meetings. The SW stated that when she started working at the facility in June 2024, she was given a list of residents whose care plan meetings needed to be done because a staff member had quit doing them before she came onboard. The SW stated that she scheduled the care plan meetings right after the MDS was updated and it looked like Resident #27 should have had a care plan meeting done around May 2024 or June 2024 since her last care plan meeting was done on 3/14/24. The SW shared that the late care plan meetings would take time to get done. An interview with the Administrator on 7/10/24 at 5:07 PM revealed that there was a week in May 2024 when they had to reschedule some of the care plan meetings due to a state survey at the facility. 2. Resident #37 was admitted to the facility on [DATE]. A review of Resident #37's medical record revealed his last care plan meeting was held on 3/26/24. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #37 was cognitively intact. Resident #37's care plan was last revised on 6/10/24. An interview with Resident #37 on 7/7/24 at 10:28 AM revealed he had not been to a care plan meeting in a while. An interview with the Social Worker (SW) on 7/9/24 at 8:21 AM revealed she was responsible for scheduling the care plan meetings. The SW stated that when she started working at the facility in June 2024, she was given a list of residents whose care plan meetings needed to be done because a staff member had quit doing them before she came onboard. The SW stated that she scheduled the care plan meetings right after the MDS was updated and it looked like Resident #37 should have had a care plan meeting done around June 2024 since his last care plan meeting was done on 3/26/24. The SW shared that the late care plan meetings would take time to get done. An interview with the Administrator on 7/10/24 at 5:07 PM revealed that there was a week in May 2024 when they had to reschedule some of the care plan meetings due to a state survey at the facility.

Based on observation, record review, and interviews with resident and staff, the facility failed to ensure a dependent resident could access a light switch located behind her bed for 1 of 1 resident reviewed for accommodation of needs (Resident #60). Resident #60 was admitted to the facility on [DATE]. Review of Resident #60's medical records revealed she had moved to her current room on 08/07/23. The annual Minimum Data Set (MDS) dated [DATE] coded Resident #60 with intact cognition. The MDS indicated Resident #60 with impairment for both sides of her lower extremities and walking between locations inside the room for more than 10 feet did not occur during the assessment period. During an observation conducted on 07/07/24 at 10:50 AM, the switch for the light fixture behind Resident #60's bed on the wall approximately 5 feet from the floor and 6 feet from the bed was attached with a cord approximately 4 inches in length. Resident #60 was unable to reach the switch cord from the bed if needed. An interview was conducted with Resident #60 on 07/07/24 at 10:52 AM. She stated she had osteoarthritis and was non-ambulatory. She did not have any control of the light fixture behind her bed as she could hardly stand up to reach the broken switch cord on the wall from her bed. She had to rely on nursing staff to control the light fixture for her and it was very inconvenient. Resident #60 added the switch cord was broken since she moved into this room last August. She had never brought up her concern to any staff so far. However, she wanted the maintenance staff to fix the switch cord to accommodate her needs as soon as possible. Subsequent observation conducted on 07/08/24 at 11:12 AM revealed the switch cord for the light fixture behind Resident #60's bed remained inaccessible. During a joint observation conducted with Nurse Aide (NA) #5 and Nurse #5 on 07/09/24 at 12:07 PM, the switch cord for the light fixture behind Resident #60's bed remained inaccessible from her bed. Both nursing staff acknowledged that the switch cord needed to be fixed immediately. An interview was conducted with NA #5 on 07/09/24 at 12:18 PM. She stated that she worked in 300 halls frequently and had provided care for Resident #60 on a regular basis. She did not notice that the switch cord for the light fixture behind Resident #60's bed was broken and inaccessible from her bed. NA #5 explained Resident #60 never voiced accessibility concerns for the light fixture behind her bed when receiving care so far. She stated the light fixture behind Resident #60's bed should always be accessible. During an interview conducted with Nurse #5 on 07/09/24 at 12:20 PM, she confirmed she had provided care for Resident #60 frequently, but she did not notice that the switch cord for the light fixture behind Resident #60's bed was broken and inaccessible from her bed. She added Resident #60 was bed bound and it was important for her to have accessibility to the light fixture behind the bed all the time. An interview was conducted with the Maintenance Director on 07/09/24 at 2:51 PM. He stated that he did not notice the switch cord for Resident #60's light fixture behind her bed was broken and acknowledged that it needed to be fixed as soon as possible. He performed weekly walk throughs for the facility to identify repair needs. Once a month, he would conduct a more detailed walk through that included the interior of residents' rooms and bathrooms. In most cases, he depended on the staff to report repair needs via work orders or verbal notifications. He checked the work order box outside of his office door at least twice daily to ensure all repair needs being addressed in a timely manner. He could not explain why he missed the switch cord for Resident #60 and acknowledged that it had to be fixed immediately. During an interview conducted on 07/09/24 at 4:31 PM, the Director of Nursing (DON) expected the staff to be more attentive to residents' living environment, and to report repair needs to the maintenance department in a timely manner to accommodate residents' needs. An interview was conducted on 07/10/24 at 5:06 PM with the Administrator. She expected nursing staff to pay attention to residents' homes and reported repair needs to the maintenance department in a timely manner. It was her expectation for all the dependent residents to have full accessibility and control of the light fixture behind the bed all the time.

Based on record reviews, resident, and staff interviews, the facility put a resident that had been assessed to be a safe smoker on a supervised smoking schedule for 1 of 2 residents (Resident #83) reviewed for choices. The findings included: The facility's smoking policy dated 5/2024 stated on page 2 under designated smoking times that the facility had designated up to four (4) smoking times daily. Smoking times are posted near the designated smoking area lasting up to thirty (30) minutes. Designated smoking times are subject to change in response to inclement weather or other unforeseen events. Changes in the designated smoking times shall be communicated with residents who smoke. The policy also listed smoking rules and resident policy on violation enforcement. Resident #83 was admitted to the facility on [DATE]. A smoking assessment was completed on Resident #83 on 5/29/24. The assessment found him to be a safe smoker. The quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #83 was cognitively intact. He used a wheelchair for mobility and had full range of motion of both upper extremities and on one side of his lower extremity. Resident #83 had an admission care plan dated 6/10/24 that stated that Resident #83 was a smoker and needed to be supervised when smoking. The care plan had the following interventions: all smoking materials were kept at the nurses' station and the resident will ask staff to get the materials before going outside to smoke. The resident was informed of the facility smoking policy. The resident will need staff to accompany him to the designated smoking area and will need staff to stay until the resident had finished smoking. Staff were to ensure the resident was dressed appropriately to go outside to smoke. On 7/7/24 at 10:55 AM an interview was held with Resident #83. He stated that the facility currently allowed residents to smoke 3 times a day, at 9:30 am, 1:30 pm and 4:00 pm. Resident #83 would like the facility to allow him or any other resident a fourth time to smoke. Resident #83 would like the fourth time to be after dinner. Resident #83 stated that he would like to have a cigarette after each meal. Resident #83 understood that the staff would first need to finish with dinner trays before supervising a fourth smoke session. On 7/10/24 at 10:04 AM an interview was held with Activity Aide. He stated that when he was working, he usually supervised the 3 smoking times, which are 9:30 am, 1:30 pm and 4:00 pm. He stated that since he had worked at the facility there had only been 3 times during a 24 hour period to smoke. The Activity Aide was aware that a few residents would like a fourth time to smoke after dinner. He stated that Resident #83 has made it known that he wishes for a fourth smoking break after dinner. Recently at a resident council meeting the fourth smoking time was discussed and the Administrative Assistant told the council that the facility was unable to do a fourth smoke session. The Activity Aide stated he didn't remember if there was a reason why a fourth smoke session could not happen. On 7/10/24 at 2:49 PM an interview was held with the Director Of Nursing (DON). She stated that the facility had conducted education to the staff on supervising residents with smoking and vaping. The DON stated she was not aware of any residents wanting another smoking time. She stated she could not think of a reason not to look into the facility having a fourth smoke break. On 7/10/24 at 10:15 AM an interview was held with the Administrator. The smoking policy was reviewed, and she stated that the policy stated that smoking would be allowed up to 4 times a day which meant the facility could have smoking sessions up to 4 times but not necessarily. The Administrator is aware that a fourth smoke break had been requested by some residents. The Administrator stated the facility had considered a smoke session after dinner and it had been talked about at departmental meetings and at resident council, but currently the facility didn't know who would be available to supervise smoking after dinner.

Based on record review and staff interview, the facility failed to submit an Initial Allegation Report to the State Agency for 1 of 1 resident reviewed for neglect (Resident #238). The findings included: The facility's policy Abuse Investigations, dated 2017 indicated all reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. The facility's policy Reporting Abuse to State Agencies and Other Entities/Individuals, dated 2017 indicated: Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse be reported, the facility Administrator or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident, including law enforcement officials. During a complaint investigation survey on 4/22/24 through 5/22/24, the facility was cited for neglect for Resident #238 when Nurse Aide (NA) #18 neglected to provide incontinence care to Resident #238. Review of the state agency records revealed the facility did not submit an initial report to the State Agency following the notification of neglect through the CMS-2567. An interview with the Administrator on 7/10/24 at 5:07 PM revealed that she was not made aware of neglect while the surveyors were onsite during the complaint investigation survey which ended on 5/22/24. The Administrator stated she found out about neglect on Resident #238 which involved NA #18 when she received the CMS-2567. The Administrator explained that NA #18 was uncomfortable with taking care of Resident #238 and requested to be re-assigned and spoke with the nurse. The nurse was aware that NA #18 was uncomfortable and had agreed to provide personal care for Resident #238. The Administrator stated that she did not file an initial report on NA #18 for neglect to the State Agency because she felt like she thoroughly investigated the issue, and she did not know that NA #18 was neglectful of Resident #238. According to the CMS-2567 from 5/22/24, the Administrator was notified of neglect when she was notified of immediate jeopardy on 5/11/24 at 10:37 AM.

Based on record reviews and staff interviews, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) application for a resident with a new psychiatric diagnosis for 1 of 3 residents (Resident #41) reviewed for PASRR. The findings included: When Resident #41 was admitted to the facility he came with a level 1 PASRR number dated 12/8/2020. Resident #41 was admitted to the facility on [DATE] with the following diagnoses: delusional disorder, dementia with other behavioral disturbances and psychosis not due to a substance or known physiological condition. Resident #41 was prescribed the following medications: On 10/18/23 he was prescribed Risperidone (an anti-psychotic medication) 3 milligrams (mg) given twice a day for mood related to delusional disorder and on 10/26/23 Resident #41 was prescribed Trazodone (an anti-depressant medication) 50mg given at bedtime for insomnia and depression related to delusional disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #41 was cognitively intact and no behaviors were exhibited. A physician order dated 6/18/24 revealed behavioral monitoring every shift for paranoia, confabulation (creating false or distorted memories about oneself or the world), exit seeking and depression. The medical record revealed a PASRR application was not completed to determine if a level II PASRR referral (the purpose of the Level II screening is to assure that individuals with serious mental illness entering or residing in Medicaid certified nursing facilities receive appropriate placement and services) was needed due to new psychiatric diagnoses. On 7/09/24 at 9:33 AM an interview was conducted with the Social Worker (SW). She stated she was new to working at the facility and the previous SW was doing the PASRR applications. She stated that a new application for PASRR for Resident #41 had not been done when he was admitted from the hospital with psychiatric diagnoses. On 7/09/24 at 11:54 AM an interview was held with the Administrative Assistant. She stated that she knew a level I PASRR was completed for Resident #41. She did not know that the level I PASRR was dated 12/8/2020, almost 3 years before Resident #41 entered the facility. The Administrative Assistant stated she had not asked the hospital to complete a new PASRR application prior to admission. She also stated that the facility had not completed a new PASRR application for Resident #41. On 7/10/24 at 4:59 PM an interview was conducted with the Administrator. The Administrator stated she knew Resident #41, and he was admitted from the hospital with dementia. The Administrator stated that if he did not have a level II PASRR then he should have. The Administrator said a new PASRR application was needed for a new psychiatric diagnosis or if one was being treated for a qualifying diagnosis. The Administrator did not think Resident #41 had a new diagnosis.

Based on record review, observation, and staff interviews, the facility failed to provide nail care and meal assistance to a resident dependent on staff. This occurred for 1 of 3 residents (Resident #45) reviewed for activities of daily living (ADL) care. The findings included: Resident # 45 was admitted to the facility on [DATE] with diagnoses including dementia, lack of coordination, and sequelae of cerebral infarction (stroke). The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #45 had severe cognitive impairment and required substantial/ maximum assistance with eating and personal hygiene. He had no behaviors or rejection of care documented. Review of Resident #45's care plan last reviewed on 6/18/24 revealed he had a care plan in place for ADL self-care performance deficit related to dementia. The care plan interventions included to check nail length and trim and clean on bath day and as necessary. Further care plan interventions included for staff to provide assistance with bathing, personal hygiene, and eating. A continuous dining observation was conducted on 7/8/24 from 12:20 PM- 1:00 PM and revealed the following: At 12:20 PM Resident #45 was observed sitting at a table in the dining room eating with his hands. His fingernails were long with a dark substance visible under all his nails. His thumb nail was noted to extend over the edge of his fingertip by approximately half an inch. He had his meal tray sitting in front of him on the table. His tray included a plate with the meal being served, an empty clear cup with handles, silverware, a single serve cup of ice cream, and a nutritional milk shake in a carton. The carton and ice cream cup were unopened. Resident #45 was observed attempting to open the milk shake carton but was unable to do so. After attempting to open the carton he sat it on top of his plate. He was observed dipping his fingers into his food and licking the food off of his fingers. He was further observed to scoop food up from his plate with his fingers and place it into his mouth. Nurse Aide (NA) #3 was observed feeding a resident at the table behind Resident #45. Hospitality Aide #1 was also observed assisting with the meal activities in the dining room. Resident #45 was not approached by any of the staff members in the dining room to provide assistance with the items on his tray or to provide meal assistance. At 12:42 PM Hospitality Aide #1 approached Resident #45 and asked him was it good? She said, here use your spoon and handed him the spoon on his tray. The hospitality aide brought Resident #45 a cup of tea and left the table. Resident #45 was observed to place the spoon down and started eating with his hands. At 12:49 PM NA #3 approached Resident #45 and handed him his spoon again and verbally cued him to use the spoon. NA #3 left the table. Resident #45 was observed to put down his spoon and started eating with his hands again. He was observed trying to lift the top off the ice cream cup but was unsuccessful. At 12:53 PM NA #3 approached Resident #45 again at the table and poured his tea into the cup with handles but did not open the milk shake carton, ice cream cup, or assist him with his meal. The milk shake carton remained sitting on the top of his plate. At 12:59 PM NA #3 opened the milk shake carton and ice cream cup. At 1:00 PM the dining observation of Resident #45 ended. He was still seated at the table in the dining room, drinking his milk shake. He had eaten approximately 75 % of his meal. An interview was conducted with NA #3 on 7/8/24 at 12:59 PM. NA #3 said she was Resident #45's assigned NA today. NA #3 said she usually provided meal setup for Resident #45. She said meal setup included cutting up food if needed, opening condiments, and cartons that were on the meal tray. NA #3 said it was not unusual for Resident #45 to eat with his hands and that he ate with his hands often. She said that he used his silverware when staff cued him but went back and used his hands once staff were not with him to provide cues. NA #3 said Resident #45 held the spoon but thought he ate with his hands because it was easier for him. NA #3 confirmed Resident #45's fingernails were long with a brown substance visible underneath the nails. NA #3 shared the condition of Resident #45's fingernails was unhygienic, especially when he ate with his hands. NA #3 said Resident #45 was unable to open cartons and that she should have opened the milk shake carton and ice cream cup for Resident #45 but that it got missed. A follow up interview was conducted with NA #3 on 7/8/24 at 5:49 PM. NA #3 said resident nails should be checked every shift for cleanliness and trimmed during showers. She said nails should also be checked every shift between showers and trimmed if needed. NA #3 said that checking for nail cleanliness was important for Resident #45 because he ate with his hands. NA #3 said Resident #45's nail care had been missed and that his nails needed to be trimmed and cleaned. An interview was conducted on 7/9/24 at 11:33 AM with Nurse #3. She said resident nails should be checked during showers and that they should be trimmed and cleaned if needed. She said if a resident ate with their hands staff were supposed to check that their nails were cleaned and trimmed before meals, but added residents should not be eating with their hands. She said NA #3 should assist residents with their meals and provide feeding assistance and cueing for meals. She said staff working in the dining room should open cartons on the meal tray and provide tray setup for the residents. She did not say how much meal assistance Resident #45 needed. An interview was conducted with Occupational Therapy Assistant (OTA) #1 on 7/9/24 at 4:14 PM. She stated Resident #45 had received occupational therapy services and that the services had ended on 7/4/24. She said occupational therapy had worked with him on feeding because he liked to eat with his hands. OTA #1 said Resident #45 needed supervision, spoon loaded, and cues for eating. She said he needed supervision and encouragement to keep using his utensils. OTA #1 said Resident #45 needed someone to keep cueing him to use his spoon but that once he was cued, he would usually use his spoon if someone was there to supervise and re-cue him if needed. An interview was conducted on 7/10/24 at 1:55 PM with the Director of Nursing (DON). The DON said the staff in the dining room should have opened Resident #45's drink cartons and should have sat with him and cued him to use his spoon or provided feeding assistance if needed. She said that NA's checked nails during showers and trimmed them if needed. The DON said that NA's should be checking under nails for cleanliness daily and before meals, especially for Resident #45 since he used his hands to eat. An interview was conducted with the Administrator on 7/10/24 at 4:55 PM. She said staff in the dining room should have assisted Resident #45 with his meals. She said staff should have sat with him to assist with the meal, provided cues, and opened the items on his tray. The Administrator said nail care should occur as needed. The Administrator said a resident's nails should be trimmed and checked for cleanliness

Based on record review, observations, staff and Nurse Practitioner (NP) interviews the facility failed to apply a hand splint to a resident (Resident #43) for management of a contracture. This deficient practice occurred for 1of 3 residents reviewed for positioning and mobility. Findings included: Resident # 43 was readmitted to the facility on [DATE] with diagnosis including hemiplegia and hemiparesis following cerebral infarction (stroke) affecting right dominant side and contracture of muscle. The annual minimum data set (MDS) assessment dated [DATE] revealed Resident #43 was cognitively impaired. He was not documented for behaviors or rejection of care. The MDS assessment revealed he was dependent for activities of daily living (ADL). Review of Resident #43's electronic medical record revealed he had a care plan which was last reviewed on 5/30/24 for impaired physical mobility. The care plan interventions included wearing right hand-based splint 4-6 hours a day on by 9:00 AM off by 2:00 PM for contracture management and prevention. Review of Resident #43's active physician orders for July 2024 revealed an order dated 2/6/24 that read: Effective 7/1/23 clarification: patient to wear right hand-based splint 4-6 hours a day, every day-on-day shift, on by 9am, off by 2pm for contracture management and prevention. The order was not present on Resident #43's July 2024 medication administration record (MAR) or treatment administration record (TAR). An observation of Resident #43 and his room was completed on 7/7/24 at 2:05 PM. He was observed resting in bed. His right hand was noted to be tight with his 3rd, 4th, and 5th digits drawn inward toward his palm. He did not have a splint in place on his right hand. There was not a splint visible in his room. Additional observations were completed of Resident #43 and his room -on 7/8/24 at 9:16 AM he was observed, and he did not have a splint on his right hand. There was not a splint that was visible in his room. -on 7/8/24 at 11:53 AM he was observed and did not have a splint on his right hand An interview was conducted with Occupational Therapy Assistant (OTA) #1 on 7/9/24 at 9:50 AM. She stated that occupational therapy (OT) had been working with Resident #43 for splint management and that he needed the splint due to a contracture of his right hand. She stated Resident #43's right hand splint was supposed to be worn daily. She looked at Resident #43's therapy record and stated Resident #43 had started OT services on 6/11/24 and had been seen by OT three times a week but that he had been discharged from occupational therapy services on 7/3/24. OTA #1 stated she was not aware that Resident #43 had been discharged from OT on 7/3/24 until today. She explained that Resident #43's original splint had been lost and that OT had ordered a new splint. OTA #1 stated that they had been using the new splint for a couple of weeks and stated he had been tolerating the new splint. OTA #1 stated that Resident #43 did not have a splint in his room because his splint was kept in the therapy closet. She stated the splint was kept in the therapy closet because OT applied/ removed the splint as part of his therapy. OTA #1 stated she had still applied Resident #43's splint on the days he was not scheduled for therapy but that it would not be documented because he was not on therapy caseload those days. OTA #1 stated that she had worked on 7/4/24 and 7/5/24 and had applied Resident #43's right hand splint on those days. She stated she did not work on Saturday 7/6/24 or Sunday 7/7/24 but that the OTA who worked on Saturday would have known to apply the splint for Resident #43 on Saturday. OTA #1 could not say how the OTA who worked on Saturday would have known to apply the splint since he had been discharged from OT service and was no longer on case load. OTA #1 stated she had not applied Resident #43's splint on Monday 7/8/24. She explained that Resident #43 would not have had his splint applied on Sunday 7/7/24 because there had not been a therapist scheduled for Sunday. OTA #1 explained that therapy typically educated nursing on a resident's splint and turned the management of the splint over to nursing before a resident was discharged from therapy. OTA #1 stated that Resident #43's splint had not been turned over to nursing to manage yet and that nursing had not yet been educated on Resident #43's splint. She stated this had not been done because she had not known Resident #43 was going to be discharged from OT on 7/3/24. A telephone interview was conducted on 7/11/24 at 5:36 PM with OTA #3. She stated she had worked on Saturday 7/6/24. OTA #3 stated she did not work with Resident #43 on Saturday and did not apply his splint. OTA #3 stated Resident #43 was not on her schedule to see on Saturday. OTA #3 stated she did not apply splints for residents when they were not on her schedule or on the days she did not see a resident. OTA #3 stated she had not been aware Resident #43 had splint that needed to be applied because he had not been on her schedule. An interview was conducted on 7/9/24 at 10:00 AM with Nurse #4. She stated she was Resident #43's assigned nurse today. Nurse #4 stated that Resident #43 had a right-hand contracture. She stated that Resident #43 did not have a splint for his right hand that nursing applied. A telephone interview was conducted on 7/10/24 with Nurse #2. She stated she had worked the 7AM- 7PM day shift on Sunday 7/7/24 and had been Resident #43's assigned nurse. Nurse #2 stated that Resident #43 did not have a splint for his right hand that he was supposed to wear that she knew of. An interview was conducted with the Nurse Practitioner (NP) #1 on 7/10/24 at 9:58 AM. NP #1 stated that Resident #43 should have had his right-hand splint on every day to help prevent further contracture. She stated if therapy had discharged Resident #43 then they should have turned his splint management over to nursing and educated nursing on applying his splint. An interview was conducted with the Director of Nursing (DON) on 7/10/24 at 1:55 PM. The DON stated Resident #43 should have had his splint applied to prevent his right-hand contracture from worsening. She did not say why it had not been applied or why the order did not show up on the MAR or TAR. An interview was conducted with the Administrator on 7/10/24 at 4:55 PM. She stated Resident #43 should have had his splint in place and that the splint was needed to prevent issues with his contracture.

Based on record review, observation, and staff interviews, the facility failed to safely transfer a resident from bed to wheelchair using a total mechanical lift when staff did not lock the wheels of the lift prior to lifting Resident #69 from bed and lowering to his wheelchair. This deficient practice had the potential to cause an injury during transfers using a total mechanical lift for 1 of 6 residents reviewed for accidents (Resident #69). The findings included: Resident #69 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis that affects one side of the body) and hemiparesis (muscle weakness) following cerebral infarction (stroke) affecting left non-dominant side. Resident #69's care plan dated 11/13/23 indicated he needed extensive/dependent assistance with activities of daily living due to left hemiparesis, and poor posture/positioning. Interventions included Resident #69 needed a total mechanical lift for transfers. The quarterly Minimum Data Set assessment dated [DATE] indicated Resident #69 was cognitively intact, had range of motion impairment on one side of both upper and lower extremities, and was dependent for chair/bed-to-chair transfer. An observation was made on 7/7/24 at 1:50 PM of Resident #69 being transferred from bed to wheelchair using a total mechanical lift by Nurse #1 and Nurse Aide (NA) #1. Nurse #1 brought a green sling into the room, and it was placed underneath Resident #69 while in bed. NA #1 suggested that they crisscross the sling under Resident #69's thighs before securing it to the lift. Nurse #1 positioned the total mechanical lift so that the base was underneath Resident #69's bed frame. Nurse #1 asked NA #1 how to spread the lift's legs and NA #1 instructed Nurse #1 to move the lever from left to right. Nurse #1 moved the lever from left to right and this caused the lift's legs to spread wide. Both staff members secured the sling on the bottom loop onto the total mechanical lift. Without locking the wheels on the total mechanical lift, Nurse #1 proceeded to lift Resident #69 off the bed, moved the lift to where Resident #69 was positioned over his wheelchair and started lowering Resident #69 to his wheelchair without locking the wheels on the lift. While Nurse #1 lowered Resident #69 onto his wheelchair, the lift was observed to be unstable as it kept on moving while Resident #69 was being moved. An interview with Nurse #1 on 7/7/24 at 2:02 PM revealed he had never assisted before in lifting a resident with a total mechanical lift. He stated that he thought he had locked the wheels on the lift prior to moving Resident #69. He stated that he realized that he should have locked the wheels on the lift. An interview with the Rehabilitation Manager (RM) on 7/10/24 at 8:26 AM revealed that while using a total mechanical lift, staff should make sure the lift's legs were spread out so that there was a wide base, and this would cause the lift to less likely tip over during the transfer. The RM stated that staff should make sure that the wheels on the lift were locked as locking the wheels would make it more stable, and prevent the lift from rolling out while the resident was being lifted or lowered with the lift. An interview with the Director of Nursing (DON) on 7/10/24 at 1:56 PM revealed staff should make sure that they were locking the wheels on the lift while using them on a resident.

Based on observation, record reviews and visitor, family, staff, and Medical Director interviews, the facility failed to enforce their smoking policy, monitor a resident who had a history of non-compliance with the smoking policy for storage of smoking materials, and implement interventions to prevent a resident from vaping in his room with his oxygen on and while his roommate (Resident #6) was in the room. Resident #8, who was on oxygen, was found to have a vape pen in his possession on 2/2/24, 2/16/24, and 3/1/24, and was observed vaping while on oxygen on 3/1/24. An electronic cigarette or vape pen (vaporizer) is a device that simulates tobacco smoking. It contains a heating element which reaches high temperatures and can ignite nasal cannula with oxygen flowing. Vaping while on oxygen placed Resident #8 and Resident #6 at increased risk for fire and combustion. This posed a high likelihood of serious injury to all residents. The facility also failed to prevent a resident with moderate cognitive impairment, a history of wandering and exit seeking behaviors, delusional behavior, and delusions from exiting the facility unsupervised and without staff knowledge (Resident #1). Staff interviews revealed an emergency exit door alarm in hallway of the 200 unit sounded around shift change (7:00 AM) on 2/20/24 and staff disarmed the alarm without initiating a Code [NAME] (the facility elopement protocol), without conducting a full resident head count to ensure all residents were in the facility at the time, and without conducting a thorough search of the area which was accessible from the exit. Between 7:05 AM and 7:10 AM, a visitor arrived at the facility and found Resident #1 outside, unsupervised, wearing a thin night gown and socks on her feet, without shoes, and holding multiple pieces of mail. The resident was discovered at the front of the facility approximately 120 yards from the 200 hall exit door. The visitor indicated Resident #1 appeared cold, so he had the resident sit in his car with the heat on until the transportation aide arrived at the facility to open the facility door around 7:30 AM. There was a high likelihood of serious injury from falls and hypothermia as temperatures were recorded at 23 degrees Fahrenheit at the approximate time Resident #1 was found outside. In addition, the facility failed to protect a resident from exposure to an illegal substance. As a result, Resident #6 was found to have experienced altered mental status, impaired physical mobility, and slurred speech. The drug screening test conducted by Nurse #2 confirmed Resident #6 was positive for tetrahydrocannabinol (THC- a compound found in cannabis/marijuana plants). These deficient practices affected 3 of 5 residents reviewed for risk for accidents. Immediate jeopardy began on 2/20/24 for Resident #1 when Resident #1 exited the facility and wandered approximately 120 yards from the exit door in temperatures below freezing (approximately 23 degrees Fahrenheit) outside. Immediate jeopardy began on 3/1/24 for Resident #8 when Resident #8 was observed vaping while on oxygen in the room and the facility failed to have a monitoring system in place for unsecured smoking material. Immediate jeopardy was removed on 5/18/24 when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility will remain out of compliance at a scope and severity of G (actual harm that is not immediate jeopardy) for example # 3. The findings included: 1. The facility's smoking policy with the revision date of 2/2023 indicated it is the policy of the facility to allow residents to smoke tobacco-based products in the designated smoking area under staff supervision only. Smoking is allowed only during designated hours and monitored by staff during these times. The designated smoking area is the outside patio. For safety reasons, residents may not possess smoking paraphernalia (including, but not limited to tobacco products which include cigarettes, cigars, pipes along with, electronic cigarettes, lighters, matches, or other smoking material). The aforementioned items must be turned over to facility staff so they may safely store them. Any resident observed not following smoking policies may have their smoking privileges revoked. Resident #8 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure. A review of Resident #8's Smoking Evaluations in his medical record dated 1/11/23, 1/18/23, 5/5/23, and 2/8/24 indicated Resident #8 was a supervised smoker. The smoking assessments were completed by nurses. A physician's order dated 1/26/24 in Resident #8's medical record indicated oxygen via nasal cannula at 2 liters per minute continuously. Resident #8's Treatment Administration Record for February and March 2024 indicated he received oxygen via nasal cannula at 2 liters per minute continuously for COPD. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #8 was cognitively intact, had no behaviors, had range of motion impairment to one side of the lower extremities, and used a wheelchair. He required supervision to partial/moderate assistance with all activities of daily living. The MDS further indicated that Resident #8 had shortness of breath or trouble breathing with exertion, when sitting at rest, and when lying flat. Resident #8 used tobacco and received oxygen therapy. A review of Resident #8's medical record indicated no smoking contracts signed prior to 2/5/24. A smoking contract was signed on 2/5/24 by Resident #8 and the former Social Worker and on 2/17/24 by Resident #8, the former Social Worker and Nurse #3. Resident #8's care plan last reviewed on 2/20/24 indicated the resident had COPD related to history of smoking, had chronic and acute respiratory failure, (non-invasive ventilation) at night for obstructive sleep apnea, and oxygen via nasal cannula. Interventions included to monitor for difficulty breathing on exertion, signs and symptoms of acute respiratory insufficiency, and anxiety. Resident #8's care plan last reviewed on 2/20/24 indicated Resident #8 smoked and needed to be supervised when he smoked. Interventions included that all smoking materials be kept at the nurses' station and that he would ask to get them before he went outside to smoke. Resident #8 had been informed of the facility smoking policy and staff to remind him as indicated. He needed staff to accompany him to the designated smoking area and staff needed to stay with Resident #8 until he was done smoking and then accompany him back to his unit. The care plan indicated oxygen should be removed before smoking. A Social Services note in Resident #8's medical record dated 2/4/24 indicated on Friday, (2/2/24), at 12:00 PM, the Social Worker (SW) was notified Nurse #3 that Resident #8 had a vape in his room. The Social Worker and Nurse #3 went in and removed it. A phone interview with the former Social Worker (SW) on 5/9/24 at 10:15 AM revealed Resident #8 was non-compliant with the facility's smoking policy. Resident #8 was observed with a vape pen in his room on 2/2/24, but she couldn't remember if he was observed using it. Nurse #3 removed the vape pen from Resident #8's room. The former SW reported Resident #8 had been educated on the facility's smoking policy and she was responsible for completing the smoking contracts. The former SW stated she did not know why there wasn't a smoking contract in his medical record prior to 2/5/24. She also stated that she did not know where the resident was getting his vape pens from. A phone interview with Nurse #3 on 5/6/24 at 2:37 PM revealed on 2/2/24, she observed a vape pen on Resident #8's bedside table. She notified the former SW and they both removed it from the room. Nurse #3 stated she did not observe Resident #8 vaping in his room with his oxygen on, but he was educated that he could not keep his vape pen in the room. Nurse #3 stated Resident #8 would not tell them how he obtained the vape pen. Nurse #3 further stated that Resident #8 had vape pens removed from his room many times after 2/2/24, and he also had cigarettes that he kept in his room which he smoked outside in the patio. Nurse #3 stated she did not know how Resident #8 was obtaining the vape pens and the cigarettes. Nurse #3 stated that she notified the former SW after all the times she removed vape pens from Resident #8's room. She shared that a staff member was supposed to be outside when the residents were smoking but unfortunately, they had to pass out three cigarettes for each smoker and a lot of times, there was approximately 20 residents out there at a time. So therefore, they were not able to keep an eye on the residents to ensure they were not smoking things or takings things they were not supposed to be sharing. A review of a Smoking Policy/Contract signed by Resident #8 and the former Social Worker on 2/5/24 indicated the following information under Violation: Resident Policy Enforcement - 1. First Resident Infraction: Immediate notification of the Administrator and the Director of Nursing (DON) of any suspected/known smoking policy infraction, completion of an incident form with witness statements and full investigation of the infraction, prompt meeting with the resident by members of the Interdisciplinary Team (IDT) to review the smoking policy violation and the smoking policy once again, re-performance of the smoking assessment and individualized safe smoking plan for comprehensiveness, and a written witnessed warning regarding the infraction. 2. Second Resident Infraction: Immediate notification of the Administrator and the DON of any suspected/known smoking policy infraction, completion of an incident form with witness statements and full investigation of the infraction, prompt meeting with the resident by member of the IDT to review the smoking policy violation and the smoking policy once again, re-performance of the smoking assessment and individualized safe smoking plan for comprehensiveness, and revocation of smoking privileges for up to two weeks. 3. Third Resident Infraction: Immediate notification of the Administrator and the DON of any suspected/known smoking policy infraction, completion of an incident form with witness statements and full investigation of the infraction, prompt meeting with the resident by members of the IDT to review the smoking policy violation and a discussion regarding a discharge plan which may include thirty day discharge notice and plan, revocation of smoking privileges, and coordinate a resident discharge plan with the resident/resident representative to a setting that may be more suitable to his/her goals. A progress note dated 2/16/24 at 11:00 PM documented by Nurse #2 in Resident #8's medical record indicated that she removed vapes that were on Resident #8's bedside table. Nurse #2 notified the SW. A phone interview with Nurse #2 on 5/7/24 at 4:54 PM revealed she observed two vape pens on Resident #8's bedside table on 2/16/24, and confiscated them right away. Nurse #2 stated that Resident #8 was yelling loudly and would not stop that night. He wanted his vape pens back and was mad because he could not have them. He was short of breath, and had oxygen in place. Resident #8 argued with Nurse #2 about not having his vape pens and he was upset because Nurse #2 would not give them back to him. Resident #8 even went on to say that Nurse #2 was to ignore his vapes and let him have them. Nurse #2 stated she notified the former SW about the vape pens which were at the bedside. A phone interview with Nurse Aide (NA) #3 on 5/9/24 at 4:05 PM revealed she had caught Resident #8 with vape pens in his room in the past, and she reported this to the nurse who would confiscate the vape pen. NA #3 stated there was one time in February 2024, but she couldn't remember the exact date when she observed Resident #8 sitting up in his bed and he requested to have his urinal emptied. NA #3 stated that as she entered the room, she observed Resident #8 holding a vape pen in his hand while he had his oxygen on, and when she confronted him about it, he denied having the vape pen. Resident #8's roommate was also in the room at that time. NA #3 explained that she observed Resident #8 holding the vape pen, but he was not vaping at that time, and she reported this to Nurse #2. NA #3 stated that Nurse #2 confiscated the vape pen and then the former Social Worker talked to Resident #8 first thing the next morning. NA #3 stated that she knew other staff members had observed a vape pen laid out in Resident #8's bedside table, and they had told the Administrator about this concern, but nothing was done about it. NA #3 stated that she knew the residents were not supposed to have vape pens in their rooms, and that Resident #8 was not supposed to be vaping with his oxygen on. A Social Services Note dated 2/17/24 at 4:59 PM indicated Resident #8 was caught the night of 2/16/24 with two vape pens. The SW met with him this morning and informed him that this was his third time with smoking items in his room. Resident #8 signed his third smoking agreement. He asked if he could have a smoking patch and it was ordered for him. A follow-up phone interview with the former SW on 5/10/24 at 11:18 AM revealed she talked to Resident #8 on 2/17/24 about the two vape pens that were found in his room on 2/16/24. Resident #8 would not tell her where he obtained the vape pens. The former SW stated that Resident #8 signed his third smoking agreement on 2/17/24. She further stated that it was hard to enforce Resident #8's smoking contract, and they were unable to follow the consequences after each infraction because she did not have support from the interdisciplinary team. The former SW stated all she could do was meet with Resident #8 and have him sign another smoking contract. Resident #8 agreed to quit smoking at that time, and he wanted to be started on a smoking patch. The former SW shared that after a few days, the smoking patch did not work because Resident #8 started refusing to have it on, and he wanted to go back to vaping and smoking. A progress note documented by Nurse #2 on 2/19/24 at 6:42 AM indicated Resident #8 had been very anxious this entire shift. He was short of breath with exertion off and on. Resident #8 had bragged about smoking again and refused the Nicotine patch. He also bragged about having someone bring him in a new vape and cigarettes. SW aware. Another progress note documented by Nurse #2 on 3/2/24 at 3:01 AM indicated Resident #8 continued to vape as desired then he wanted staff to fix his breathing. Staff unable to reason with this resident. A phone interview with Nurse #2 on 5/7/24 at 4:54 PM revealed when she took care of Resident #8 on the night of 2/19/24, he was easily short of breath more than usual, and he was very anxious. He bragged about having someone bring him in a new vape pen and cigarettes, and that he had started smoking and vaping again. Nurse #2 stated she did not observe a vape pen in Resident #8's room on 2/19/24, but she went ahead and notified the former SW about what Resident #8 said to her. Nurse #2 also stated that she worked with Resident #8 on the night of 3/1/24, and he wanted his medications given frequently. Nurse #2 stated that she gave Resident #8's medications as often as possible, but they did not seem to help his air hunger and he was very anxious. She also stated that occasionally he rested but then would wake up with breathing problems and would quickly be in a panic. Nurse #2 further stated that Resident #8 continued to vape in his room even with his oxygen on, and he refused to hand over the vape pen to her that night. Nurse #2 stated that Resident #8's roommate was in the room at that time. Nurse #2 said that she reported this to the former SW that evening through a text message. Nurse #2 stated the former SW came in the next morning and removed the vape pen from Resident #8's room. Nurse #2 stated she was aware that Resident #8 should not be vaping with his oxygen on, but he refused to give it to her, and there was nothing else she could do. A phone interview with NA #22 on 5/9/24 at 6:52 PM revealed she had seen Resident #8 on the night of 3/1/24, and he was vaping in his room with an oxygen on while his roommate, Resident #6, was inside the room. Resident #8 refused to give the vape pen to Nurse #2. NA #22 stated she knew the weekend supervisor talked to Resident #8 the next day about not vaping in the room. NA #22 stated she knew Resident #8 should not vape with his oxygen on, but he refused to hand it over to them that night. A Social Services Note dated 3/2/24 at 1:19 PM indicated the SW was informed by Nurse #2 that Resident #8 had been using a vape during the night but would not give them to the nurse. The SW and Unit Manager went in and talked with the resident, and he gave them his vape, but he would not tell where he got it. A phone interview with the former SW on 5/20/24 at 4:09 PM revealed Nurse #2 had sent her a text message, but she did not receive it until in the morning of 3/2/24 while she was on her way to the facility. The former SW explained that she did not get good phone service at her place, and did not often receive text messages until she was closer to the facility. The former SW stated that as soon as she saw Nurse #2's text message about Resident #8 refusing to turn in his vape pen, she went to Resident #8's room and talked to him about not having vape pens in his room. The former SW stated that she confiscated four vape pens from Resident #8's room that morning. She added that she tried to call the Administrator on 3/2/24, but she could not get her on the phone. A phone interview with NA #20 on 5/7/24 at 9:22 AM revealed Resident #8 wore oxygen and was a supervised smoker in the outside patio, but NA #20 often found vape pens in his room. NA #20 stated that whenever he found Resident #8 smoking a vape pen in his room with his oxygen on, he would tell Nurse #2 or the Social Worker who would confiscate the vape pens. NA #20 said he could not remember the specific dates he had observed Resident #8 smoking a vape pen with his oxygen on, but he knew that he was not supposed to be doing that. NA #20 stated that he knew that according to the smoking contract, Resident #8 was supposed to lose his smoking privileges, but he never did. An interview with Nurse #14 on 5/10/24 at 8:32 AM who was the weekend supervisor revealed she always observed Resident #8 vaping in his room with his oxygen on. Nurse #14 stated that she would often smell the vape, and she would confiscate it from Resident #8. Nurse #14 stated that she had no idea where Resident #8 was getting his vape pens from, but she always reported this to the former SW to whom she turned in the confiscated vape pens. Nurse #14 confirmed that she removed the vape pen from Resident #8's room on the morning of 3/2/24, along with the former SW. Resident #6, roommate of Resident #8, was admitted to the facility on [DATE]. The quarterly MDS assessment dated [DATE] indicated that Resident #6's cognition was intact. An interview with Resident #6 on 5/22/24 at 2:45 PM revealed he never saw Resident #8 use a vape pen while he was using his oxygen. Resident #6 stated that Resident #8 never gave him a vape pen, and he never asked him for one. A phone interview with the former Social Worker (SW) on 5/9/24 at 10:15 AM revealed when vape pens were found in Resident #8's room, she would re-educate him and let him sign a new smoking agreement. The former SW stated that the Administrator would not let them revoke Resident #8's smoking privileges or issue a discharge notice even when he had repeated violations of the smoking contract. The former SW stated that she placed the confiscated vape pens in the bottom drawer in a filing cabinet in her office which she always kept locked. During a joint interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 5/10/24 at 2:34 PM, the DON stated that the Social Worker handled the smoking contracts while nursing handled the smoking assessments. When a resident violated their smoking contract, this was dealt with by the Social Worker and the Administrator. The DON stated that she did not know enough about vape pens, and that she did not know whether it was unsafe if a resident vaped while he was on oxygen. The ADON stated this would have been dealt with immediately, but she had not seen this happen. The DON stated that the nurse could take the vape pen away if they felt that it was a safety hazard, and that they would have to contact the Social Worker. The ADON stated that she was aware that staff saw vape pens in Resident #8's room, but she was not sure whether they belonged to him or his roommate. The DON stated that the residents were allowed to vape in the designated smoking area but not inside their rooms. The DON stated the vape pens and cigarettes were supposed to be locked up, and the residents were not supposed to have them in their person. The ADON added that they had a lot of smokers at the facility, and it was hard to control them. An interview with the Administrator on 5/10/24 at 4:34 PM revealed she was aware of staff finding vape pens in Resident #8's room but she couldn't tell when they first found them. The Administrator stated it happened on more than one occasion. Staff told the former SW that Resident #8 had a vape pen in his room, and she went in to talk to him, but she didn't know what she had explained to Resident #8. The Administrator shared that she talked to Resident #8 shortly after he signed his third smoking contract, and she told him that he could vape, but the vaping materials would need to be locked up. The Administrator said that they had multiple discussions and reviews of the smoking policy with Resident #8, but she could not enforce the smoking policy and issue him a discharge notice because they could not find an appropriate place for him. The Administrator stated that when it came down to it, they needed to go through the proper discharge. She added that most of their residents would breach the smoking policy, and all they could do was to continually monitor and observe, and ask for their cooperation. A follow-up interview with the Administrator on 5/22/24 at 4:35 PM revealed she was aware of an event where the nurse aides observed or suspected Resident #8 of vaping while he was on oxygen, and the nurse aides notified the former SW. The former SW interviewed Resident #8 about vaping with his oxygen on, but he would not give up his vape pens. Resident #8 said he should be able to vape when he wanted to, and he did not think vaping was in the same category as smoking. The former SW told the Administrator about this the following week right around the same time he was sent out to the hospital. The Administrator further stated that when Resident #8 came back from the hospital in February 2024, he asked her if he could vape, and she told him that he could, but he would have to go outside and follow the smoking policy, and he could not keep the smoking/vaping materials in his room. The Administrator said she did not know that Resident #8 had vape pens until the nurse aides and the former SW observed him with them, and he did not want to give them up until the former SW talked to him. The Administrator also stated that there was not a point where she thought about revoking Resident #8's smoking privileges because he had been compliant and honest with her. The Administrator was notified of immediate jeopardy on 5/15/24 at 10:54 AM. The facility submitted the following immediate jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to enforce their smoking policy and implement interventions to prevent a resident (Resident #8) from vaping in his room with his oxygen on and while with a roommate in the room. Electronic cigarettes or vape pens contain a heating element which reaches high temperatures and can ignite nasal cannula with oxygen flowing. Vaping while on oxygen placed Resident #8 and his roommate at increased risk for fire and combustion. This had a high likelihood of serious injury to all residents. 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 facility needs to have effective systems in place to supervise residents while smoking, enforce their smoking policy, and prevent residents from keeping smoking paraphernalia in the rooms. The facility needs to have monitoring systems in place for unsecured smoking material. * The list of resident smokers, including those who vape, was updated on 5/15/24 by social services. This updated smoking list included the current residents who also vape. The intent of this list is to provide a tool for the staff assigned to supervise the smokers to be able to be a check and balance for any changes. * An audit was completed on 5/15/24 by the Nurse Consultant to ensure that the smokers' smoking assessments were completed. The audit denoted that 23 smoking assessments required updating. Assessments, which included the safe use of oxygen, were completed on 5/16/24. * The Administrator sent out to families/guardians a letter/text message via Cliniconex/Point Click Care (PCC) on 5/15/24 regarding the purchase of cigarettes, lighting materials, and vapes. Families/guardians are to give smoking items to the nurse or activities so they can be secured. * The smoking policy was revised on 5/16/24, to include that if a resident who is on oxygen and there is suspicion of not complying with the smoking policy and refuses a room search, the facility (Administrator and/or DNS) will notify the police or fire safety of the unsafe situation. * The staff were educated on 5/16/2024 on the revised smoking policy which included that residents cannot have cigarettes, lighting material, and vape pens on their person, or in their rooms. Education was provided by the Director of Nursing/Assistant Director of Nursing/Unit Managers/Supervisors. All staff including contract staff, have been educated as to the policy expectations for following steps for ensuring enforcement of this policy. This information was provided by the Administrator and the Director of Nursing. The Administrator educated the Director of Human Resources on 5/17/24 of the updated policy and procedures addressing staff's conduct if and when they engage in any personal smoking procedures. This includes the disciplinary procedures that will occur in the event these policy expectations aren't followed. Staff smoking policy expectations was added to the employee onboarding checklist to document that this policy has been reviewed and understood. * Residents who smoke and utilize oxygen were educated on removal of oxygen prior to going outside to smoke or vape by the Director of Nursing/Assistant Director of Nursing/Unit Managers/Supervisors on 5/16/24. Reminders will be given upon each designated smoking time to all smoking and vaping residents by the assigned staff members providing supervision. * Education was provided to the smokers by social service on 5/16/24 on the smoking policy and the policy and procedures of failure to abide by safety requirements. The alleged date of immediate jeopardy removal is 5/18/24. The credible allegation for the immediate jeopardy removal was validated on 5/22/24 with a removal date of 5/18/24. A review of in-service education records dated 5/16/24 revealed education was provided to staff on the revised smoking policy which included for residents not being able to have cigarettes, lighting material, and vape pens on their person, or in their rooms. Interviews with the staff including contract staff revealed they had been educated on the policy expectations for following steps for ensuring enforcement of the smoking policy, especially for residents who used oxygen. Interviewed staff verbalized understanding that residents who used oxygen should never smoke or vape at the same time, and that oxygen should be removed prior to smoking or vaping. A review of the smoking policy revised on 5/16/24 indicated if the resident is on oxygen therapy and refuses to allow the facility to conduct a room search, the police will be notified of the unsafe situation. An observation of smoking on 5/22/24 at 1:37 PM revealed there were 18 residents in the smoking porch. There was a container by the door to the smoking area for oxygen storage, but no oxygen tanks were present. Two staff members were observed assisting the smokers with applying smoking aprons, and providing cigarettes and lighting them for the residents. No resident was observed smoking while on oxygen, and none were observed vaping. All lit cigarettes were disposed of in the appropriate containers in the outside patio at the end of the session. Interviews with residents who smoked and/or vaped revealed they were educated on the smoking policy and about not keeping smoking items such as cigarettes, vapes, and lighters in their person and in their rooms. They also stated understanding regarding the importance of not smoking or vaping while on oxygen or while in close proximity to another resident on oxygen. A review of the audits completed on 5/15/24 indicated the smoking list was updated to include residents who also used vape pens. Smoking assessments were completed on 5/16/24. A review of medical records of residents who smoked and/or vaped revealed the residents and family members were advised not to bring smoking materials including vape pens to the residents in the building, and instead, to turn them in to the nurse or start an account with the business office who would purchase smoking materials for them. They were also reminded that the residents were not allowed to have any smoking material including vape pens on them or in the rooms, and that all smoking materials must be given to the nurse or activities so that they could be safely stored. The facility's date of immediate jeopardy removal of 5/18/24 was validated. 42090 2. Resident #1 was admitted to the facility on [DATE] with diagnoses that included dementia with agitation, bipolar disorder, anxiety disorder, insomnia, history of falling, difficulty walking, unsteadiness on feet, muscle weakness, panic disorder, schizoaffective disorder, and cognitive communication deficit. A review of the facility floor plan revealed Resident #1 resided on the 200 hall unit near the 100/200 hall nurses station and approximately 7 resident rooms from the 200 hall emergency exit door. An elopement risk assessment was completed on the following dates prior to her recent readmission: 8/1/23 and 11/26/23. Resident #1 was determined to be at risk for elopement on both assessments. A review of Resident #1's Admission/Readmission nursing assessment dated [DATE] revealed she had risk alerts for falls and may attempt to exit with wandering listed under mood and behaviors. A review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had moderate cognitive impairment. Resident #2 was not coded with wandering behaviors during the 7-day lookback and required supervision for ambulating 50 feet and make 2 turns. A review of Resident #1's care plan revealed the care plan was initiated on 7/19/23. She was care planned for exit seeking behaviors and elopements and read in part; It is unsafe for me to leave this facility; however, I may attempt to do so. 8/1/23-trying codes on exit doors and the following interventions implemented: 1) When you find me trying to leave, please check to see if I am looking for a specific place or thing. If appropriate, help me to find it. If it is not appropriate, distract me. 2) Perform an elopement assessment on me quarterly and as needed should my cognitive or physical situation change 3) Make sure that my picture is in the e [TRUNCATED]

Based on record reviews, and interviews with resident, staff and the Medical Director, the facility failed to notify a medical provider of significant changes in a resident's condition (Resident #8) who was observed to be unresponsive to painful stimuli, having low oxygen saturation level and pupil constriction. Nurse #14 suspected drug overdose and administered one dose of Naloxone, also known as Narcan (a medication used to rapidly reverse opioid overdose in an emergency situation) on [DATE] at 9:34 AM and an additional dose at 9:54 AM without notifying a medical provider. Resident #8 responded temporarily to the Narcan doses but at 3:50 PM, he was observed with no heart rate or respiratory rate and was pronounced dead. In addition, the facility failed to notify the Guardian after a resident (Resident #6) tested positive for tetrahydrocannabinol (THC - a compound found in cannabis/marijuana plants). This deficient practice affected 2 of 3 residents reviewed for notification of changes (Resident #8). Immediate jeopardy began on [DATE] when the facility failed to notify a medical provider of significant changes in Resident #8's condition suggestive of a possible drug overdose. The immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. Example #2 is out of compliance at a level of D. The findings included: 1. Resident #8 was admitted to the facility on [DATE]. A progress note dated [DATE] at 9:36 AM by Nurse #14 in Resident #8's medical record indicated: Resident #8 was given Narcan per order. Oxygen saturation 68% (normal value 95% or higher), resident not responding to painful stimuli, pupils constricted. Narcan given in each nostril. Resident now 95% on oxygen. Blood pressure ,d+[DATE] (normal value less than ,d+[DATE]), heart rate 84 (normal value 60 to 100 beats per minute), respirations 18 (normal value 12 to 18 breaths per minute) and regular. Another progress note dated [DATE] at 9:47 AM by Nurse #14 in Resident #8's medical record indicated: Resident #8 now resting with eyes closed. Oxygen saturation 98%. No signs/symptoms of pain or shortness of breath. A phone interview with Nurse #14 on [DATE] at 10:56 AM revealed she was working as the weekend supervisor on [DATE] when Agency Nurse #20 alerted her. Nurse #20 told her that she had no idea what to do about Resident #8. When Nurse #14 came into Resident #8's room, he was very sweaty and was not responding. Resident #8 was sitting in his wheelchair at his bedside, and he was slumped over. Nurse #14 stated that she was afraid Resident #8 might fall forward off his wheelchair, so Nurse Aide (NA) #20 helped her put him back in bed. Nurse #14 stated that she administered two doses of Narcan to Resident #8 to try to get him to wake up because she suspected that he might have overdosed from medications he took by himself. Nurse #14 further stated after she gave Resident #8 the two doses of Narcan, he perked up. Nurse #14 said she thought Nurse #20 spoke with the on-call provider while she was busy taking care of Resident #8. Nurse #14 also stated that she did not think to call 911 because it seemed like the two doses of Narcan worked, and she noted on the physician's order that she could give another dose after 10 minutes if the first one did not work. After Nurse #14 administered the second dose, she observed that Resident #8's oxygen saturation was within normal limits, and he was talking to her although he said that he was tired and just wanted to lay there in the bed. Nurse #14 stated that Nurse #20 told her that she had called the doctor, and she thought that Nurse #20 had also called 911. Nurse #14 stated that she knew this was Nurse #20's first day working at the facility. A progress note dated [DATE] at 10:00 AM by Nurse #20 in Resident #8's medical record indicated: Resident #8 was sitting up in wheelchair, very difficult to arouse. Oxygen saturation was 71% on oxygen via nasal cannula. Resident #8 was placed back to bed with head of bed elevated. Somewhat more responsive but continued to nod off. Oxygen saturation increased to the low 80% with deep breaths. Narcan administered by Nurse #14. Narcan somewhat effective, more alert and verbal. Morning medications held. A second progress note dated [DATE] at 12:58 PM by Nurse #20 in Resident #8's medical record indicated: Resident #8 difficult to arouse at this time. Responds to sternal rub (application of painful stimulus with the knuckles of closed fist to the center chest of a patient who is not alert and does not respond to verbal stimuli) with mumbles. Oxygen on per order via nasal cannula. BiPAP (bilevel positive airway pressure which is a form of non-invasive ventilation therapy used to help you breathe) placed on. More verbal and alert at this time. A third progress note dated [DATE] at 3:50 PM by Nurse #20 in Resident #8's medical record indicated: Upon observation, no heart rate or respiratory rate noted. Responsible party aware. Nurse Practitioner aware, order to release body to the funeral home received and noted. Funeral home contacted per family request. A phone interview with Nurse #20 on [DATE] at 12:26 PM revealed NA #21 alerted her that Resident #8 was lethargic. When Nurse #20 checked Resident #8's oxygen saturation, it was dropping so she asked Nurse #14 for help. Resident #8 woke up somewhat after he received the two doses of Narcan. Nurse #20 explained that [DATE] was her very first day working at the facility as an agency nurse and she did not have access at the time to the clinical messaging platform that the facility used to contact the on-call providers. Nurse #20 stated that she did not think about calling the on-call provider because she thought that Nurse #14 took over Resident #8's care when she gave him the Narcan. Nurse #20 explained that during this incident, she was still trying to get her medication pass done, and she thought Nurse #14 was going to take care of Resident #8. Nurse #14 stated she did not recall telling Nurse #14 whether she called the provider or not because she thought Nurse #20 was going to do it. A phone interview with the former Social Worker (SW) on [DATE] at 12:45 PM revealed she was the manager on duty on [DATE]. The former SW stated that when she came in that morning around 9:30 AM, Nurse #14 told her that Resident #8's pupils were pinpoint, and that they needed help to put him back into bed. The former SW stated she observed Resident #8 slumped over in his wheelchair and she thought he was going to die right there. Resident #8's eyes were pinpoint, and she watched Nurse #14 give Resident #8 two doses of Narcan. The former SW further stated that she told Nurse #14 that the facility's policy was to immediately call EMS, call the doctor and send the resident to the hospital after the resident was given Narcan. The former SW stated that she told Nurse #14 to call EMS right after Nurse #14 administered the Narcan to Resident #8. A joint interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on [DATE] at 1:11 PM. The ADON stated that she did not know if Nurse #14 notified the provider, but said she would have called the doctor if she was at the facility. An interview with the Medical Director (MD) on [DATE] at 10:21 AM revealed he last saw Resident #8 on [DATE] when he visited him after he had just gotten back from the hospital for COPD and CHF, and he seemed to be doing fine during the visit. The MD stated that he was not notified when Resident #8 died but he found out about it the next day he visited the facility. The MD stated that he did not know that they administered Narcan to Resident #8, and he was not familiar with the facility policy for Narcan. The MD stated that if the policy indicated for staff to notify EMS when administering Narcan, then they should have followed that. The MD confirmed that low oxygen saturation and pupil constriction were signs of overdose, and that Resident #8 should have been sent out to the hospital on [DATE]. The MD added that if an on-call provider was notified about the Narcan doses, then there would be a note in Resident #8's chart and they would have ordered to send him out to the hospital. The Administrator was notified of immediate jeopardy on [DATE] at 2:50 PM. The facility provided the following immediate jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to notify the medical provider of the suspected drug overdose of Resident #8 who was observed unresponsive to painful stimuli, had low oxygen saturation, and pupil constriction, and received 2 doses of Narcan on [DATE] at 9:34 AM and 9:54 AM. The guidelines for notifying physicians of clinical problems to ensure 1) medical care problems are communicated to the medical staff in a timely, efficient, and effective manner and 2) all significant changes in resident status are assessed and documented in the medical record was not followed in the administration to Resident #8 by Nurse #14. The facility notified the medical provider of the suspected drug overdose of Resident #8 who was observed unresponsive to painful stimuli, low oxygen saturation, and pupil constriction receiving 2 doses of Narcan on [DATE] at 9:34 AM and 9:54 AM on [DATE] by the Director of Nursing Services (DNS). A facility look-back audit of 30 days was completed by the Nurse Consultant on [DATE] to ensure that for any resident that was administered Narcan, the medical provider was notified. The audit did not identify any other residents who were administered Narcan. An audit will be completed by [DATE] by the Nurse Consultant on the number of residents who use opioids, which will include residents that have a diagnosis of opioid abuse disorder that do not have a scheduled or prn opioids. The audit identified 3 residents who have a diagnosis of opioid dependence, one resident has scheduled pain management, and two residents have prn pain management per physician order. 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 specific actions the facility will take to alter the system failure to prevent a serious outcome from reoccurring are: * Re-education to licensed nursing staff, including agency nurses on ensuring the medical provider has been notified of any resident receiving Narcan and activating EMS per physician orders by the Director of Nursing Services/Assistant Director of Nursing (designee) by [DATE]. Licensed nursing staff that are not available on or before [DATE] will not be scheduled until the education has been completed. * Facility wide audit completed by Nurse Consultant by [DATE] to determine if for any resident who received Narcan, the medical provider has been notified. The audit identified 3 residents who have a diagnosis of opioid dependence, one resident has scheduled pain management, and two residents have prn pain management per physician order. * The actions the facility will take to ensure the nurses notify the medical provider of administration of Narcan by the DNS reviewing the 24-hour report on a daily basis for appropriate notification documentation in the Electronic Medical Record (EMR). Agency licensed nurses working at the facility will receive education on notification to the medical provider on administration of Narcan for a suspected overdose by the Director of Nursing Services and/or the Assistant Director of Nursing Services, Unit Managers, and Supervisors. * If the Director of Nursing Services is unavailable the Assistant Director of Nursing will assume this responsibility of reviewing the 24-hour report. * Agency licensed nurses working at the facility will receive education on notification to the medical provider on administration of Narcan for a suspected overdose prior to working their first shift by the DNS/Assistant Director of Nursing (designee). The alleged date of immediate jeopardy removal is [DATE]. The credible allegation for the immediate jeopardy removal was validated on [DATE] with a removal date of [DATE]. A review of in-service education records dated [DATE] indicated education was provided to nurses including agency nurses on ensuring the medical provider has been notified of any resident receiving Narcan and activating EMS per physician orders. Interviews with the nursing staff including agency nurses revealed they had been educated on notifying the medical provider of any resident who receives Narcan for suspected overdose. The audit completed by the Nurse Consultant on [DATE] was reviewed. All residents identified as having orders for Narcan administration had notification of medical providers added to the Narcan order. The facility's date of immediate jeopardy removal of [DATE] was validated. 36217 2. Resident #6 was admitted to the facility on [DATE]. The nurse's progress notes dated [DATE] revealed Resident #6 was found to have slurred speech and unable to sit, stand, or keep his eyes opened at around 8:45 PM. He could not answer questions from the staff but was making the comment I feel good and high. Around 9:00 PM, a urine specimen was obtained per the on-call provider's order for a drug screening. On [DATE] at 1:30 AM, the results from the urine drug screening were obtained and faxed to the on-call provider. A review of medical records indicated Resident #6 had a 12-Panel urine drug screening conducted on [DATE] and was positive for THC. A review of medication administration records (MARs) from [DATE] through [DATE] revealed Resident #6 was not ordered to receive any medications containing THC. During an interview conducted on [DATE] at 3:30 PM, Resident #6 stated he would not take drugs from anyone except nurses in the facility. He attributed the incident to the medications he received from the nurses in the facility prior to the incident. A phone interview was conducted with Nurse #2 on [DATE] at 4:15 PM. She stated she worked second shift from 7 PM to 7 AM on [DATE] evening and was providing care for Resident #6 in 300 Hall. At around 8:45 PM, Resident #6 was brought to her by a staff member from the rehab department with altered mental status, impaired movements, and slurred speech. She contacted the on-call provider immediately and was told to monitor Resident #6's vital signs and collect urine specimen for a drug screening. After obtaining Resident #6's urine specimen, she ordered one of her nurse aides (NA) to bring it to the local hospital immediately and waited for the results. At around 1:30 AM, the results from the urine drug screening confirmed Resident #6 was positive for THC. She faxed the results to the on-call provider immediately and was ordered to report the results to the Director of Nursing (DON). She did not notify Resident #6's Guardian after she received the drug screening results as it was late and non-urgent. She explained after she notified DON and Unit Manager (UM) #2 in the morning, she assumed either one of them would notify the Guardian. During an interview conducted on [DATE] at 10:30 AM, Resident #6's Guardian stated he did not know that Resident #6 was tested positive for THC on [DATE] morning and confirmed none of the staff in the facility had notified him about the drug screening results after the incident. It was his expectation for the facility to notify him within 24 hours after the incident occurred. During an interview conducted on [DATE] at 11:52 AM, UM #2 stated Nurse #2 reported the incident to her on [DATE] in the morning. However, she did not specifically ask her to notify Resident #6's Guardian before leaving for the shift, and she assumed the notification had been made. An interview was conducted with the DON on [DATE] at 12:54 PM. She stated the hall nurse (Nurse #2) was responsible for notifying the Guardian after Resident #6 was tested positive for THC. The UM would be the back-up if the hall nurse was unable to do it. It was her expectation for the hall nurse and the UM to communicate with each other to ensure the Guardian was notified as soon as possible. An interview was conducted with the MD on [DATE] at 1:53 PM. He stated he was being notified of the incident on [DATE] in the morning and expected the Guardian to be notified in a timely manner as well. During an interview conducted on [DATE] at 3:28 PM, the Administrator stated it was her expectation for the facility to notify Resident #6's Guardian regarding the incident in a timely manner.

Based on record reviews, and interviews with staff and the Medical Director, the facility failed to protect a resident's right to be free from neglect when they failed to provide care and services to a resident experiencing a medical emergency. The facility failed to activate emergency response for Resident #8 who was observed to be unresponsive to painful stimuli, having low oxygen saturation level and pupil constriction. Nurse #14 administered two doses of Naloxone, also known as Narcan (a medication used to rapidly reverse opioid overdose in an emergency situation) on [DATE] at 9:34 AM and 9:54 AM, with positive response, for suspicion of drug overdose. At 3:50 PM, Resident #8 was observed with no heart rate or respiratory rate and was pronounced dead. In addtion, on [DATE] the facility neglected to provide incontinence care to Resident #8 who was cognitively intact but experienced mental status changes with new onset of hallucination and confusion and required increased assistance with toileting. Resident #8 had a fall on [DATE] while attempting to go to the bathroom without assistance. Resident #8 was hospitalized with a left hip fracture requiring surgical repair and a four centimeter laceration to the left upper extremity which required two-layer suture repair. This deficient practice affected 1 of 4 residents reviewed for abuse and neglect (Resident #8). Immediate jeopardy began on [DATE] when staff found Resident #8 slumped over, non-responsive with constricted pupils and impaired respiration and administered two doses of Narcan for suspected drug overdose, was not provided emergency medical services, and subsequently died . Immediate jeopardy was removed on [DATE] when the facility implemented a credible allegation of immediate jeopardy removal. Example #2 is out of compliance at a level of G. The findings included: 1. The first example for this tag is cross-referred to: F580 - Based on record reviews, and interviews with resident, staff and the Medical Director, the facility failed to notify a medical provider of significant changes in a resident's condition (Resident #8) who was observed to be unresponsive to painful stimuli, having low oxygen saturation level and pupil constriction. Nurse #14 suspected drug overdose and administered one dose of Naloxone, also known as Narcan (a medication used to rapidly reverse opioid overdose in an emergency situation) on [DATE] at 9:34 AM and an additional dose at 9:54 AM without notifying a medical provider. Resident #8 responded temporarily to the Narcan doses but at 3:50 PM, he was observed with no heart rate or respiratory rate and was pronounced dead. In addition, the facility failed to notify the Guardian after a resident (Resident #6) tested positive for tetrahydrocannabinol (THC - a compound found in cannabis/marijuana plants). This deficient practice affected 2 of 3 residents reviewed for notification of changes. F684 - Based on record reviews, and interviews with staff and the Medical Director, the facility failed to initiate emergency medical services for symptoms of a drug overdose. Resident #8 was slumped over, non-responsive with constricted pupils and impaired respiration. Resident #8 was observed by a facility staff member with no heart rate or respiratory rate and was pronounced dead on [DATE] at 3:50 PM. This deficient practice affected 1 of 3 residents reviewed for quality of care. F726 - Based on record reviews, and staff interviews, the facility failed to ensure nursing staff were trained and competent with responding to medical emergencies, activating emergency procedures with emergency medical services, and notifying medical providers for 1 of 4 residents (Resident #8) reviewed for neglect. Nursing staff failed to notify a medical provider of significant changes in a resident's condition who was observed to be unresponsive to painful stimuli, having low oxygen saturation level and pupil constriction, and failed to immediately initiate emergency procedures with 911. Resident #8 expired on [DATE]. This was for 2 of 2 staff members reviewed for competency (Nurse #20 and Nurse #14). The Administrator was notified of immediate jeopardy on [DATE] at 10:37 AM. The facility provided the following immediate jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility neglected to activate emergency response for Resident #8 after Nurse #14 administered Narcan on [DATE] at 9:34 [NAME], again at 9:54 AM with positive response for suspicion of drug overdose. In addition, the nurse supervisor did not activate emergency response. All residents who use opioid medications are at risk of overdose and may be subject to the need for Narcan administration and emergency response. An audit will be completed by [DATE] by the Nurse Consultant on the number of residents who are prescribed opioid medication, which will include residents that have a diagnosis of opioid abuse disorder that do not have a scheduled or prn opioids. 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 specific actions the facility will take to alter the system failure to prevent a serious outcome from reoccurring are: * The licensed nursing staff who neglected to activate emergency response were Nurse #14 and Nurse #20. * The facility has filed a report of the neglect to the health care personnel registry on [DATE]. * Education on the facility policy for Abuse and Neglect Prevention was presented to all facility staff beginning [DATE] by the Administrator, Director of Nursing and Assistant Director of Nursing. This educational in-service included the policy and implementation of procedures to prevent abuse and neglect. Included in this education was a review of staff training expectations on preventing, identifying, reporting abuse and neglect. * The facility has filed a report of the neglect to the licensing agency on [DATE]. * The facility has re-educated the licensed nursing staff on the use of Narcan and activation of the emergency response per physician orders by [DATE]. * The actions the facility will take to ensure the nurses have activated the emergency response as indicated in the physician's orders on the administration of Narcan is the DNS will review the 24-hour report on a daily basis for appropriate activation of the emergency response. Feedback will be provided by the DNS addressing any challenges or barriers. * Agency licensed nurses working at the facility will receive education on notification to the medical provider on administration of Narcan for a suspected overdose by the DNS/ Assistant Director of Nursing (designee). * The nurse who responds to the suspected overdose will direct another staff member to activate the emergency response system which is denoted in the revised Narcan Administration Policy [DATE]. The alleged date of immediate jeopardy removal is [DATE]. The credible allegation for the immediate jeopardy removal was validated on [DATE] with a removal date of [DATE]. A review of in-service education records dated [DATE] to [DATE] indicated education was provided to all facility staff including contract staff on the policy for Abuse and Neglect Prevention which included staff training expectations on preventing, identifying, and reporting abuse and neglect. Education was also provided to nurses including agency nurses on the activation of emergency response upon administration of Narcan, and ensuring the medical provider has been notified of any resident receiving Narcan and activating EMS per physician orders. Interviews with staff revealed they had been educated on the facility policy for preventing abuse and neglect. Interviews with the nursing staff including agency nurses revealed they had been educated on activating EMS and notifying the medical provider of any resident who receives Narcan for suspected overdose. The nurses including agency nurses stated they received education on medical emergencies and activation of the emergency response. A review of the revised Narcan administration policy dated [DATE] indicated the nurse who responds to the suspected overdose will direct another staff member to activate EMS. The facility's date of immediate jeopardy removal of [DATE] was validated. 42090 2. Resident #8 was admitted to the facility on [DATE] with diagnosis that included chronic obstructive pulmonary disease (COPD), acute respiratory failure, shortness of breath and anxiety. A review of Resident #8's comprehensive care plan revealed an activities of daily living plan of care dated [DATE] which included the following interventions: - The resident requires assistance by staff with personal hygiene. - The resident requires assistance by staff with toileting. - The resident requires assistance by staff to move between surfaces. An Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact and was independent for transfers and hygiene. The assessment indicated Resident #8 was independent and continent of bowel and bladder, had no behaviors or rejection of care. A review of Resident #8's physician's order revealed the following: - [DATE] consult for Hospice services for end stage COPD. - [DATE] Morphine Sulfate (concentrate) 20 mg (milligrams)/ mL (milliliter)- administer 0.4 ml every 2 hours for pain or shortness of breath (SOB); hold if sedation. - [DATE] Morphine Sulfate (concentrate) 20 mg (milligrams)/ mL (milliliter)- administer 0.5 ml every 2 hours for pain or shortness of breath (SOB); hold if sedation. - [DATE] Morphine Sulfate (concentrate) 20 mg (milligrams)/ mL (milliliter)- administer 0.75 ml every 2 hours for pain or shortness of breath (SOB); hold if sedation. - [DATE] Morphine Sulfate (concentrate) 20 mg (milligrams)/ mL (milliliter)- administer 1.0 ml every 2 hours for pain or shortness of breath (SOB); hold if sedation. A nurse progress note written on [DATE] at 4:00 AM by Nurse #2 read as follows: Resident is noted to be very busy. He is constantly messing with anything in reach. Objects have been removed for his safety. He is not keeping his O2 (oxygen) in place. Easily anxious with neb (nebulizer) treatments and removes from face. Needs supervision to maintain his O2 placement. Not wanting to take scheduled and routine meds but then easily upset if meds are not given. See MARS (medication administration records) for med administration. Hallucinations off and on. Asking to wear a brief (adult incontinence product) to assist with no movement due to exertion and SOB (shortness of breath). Drinking well. Frequent rounds made. Resident will use call bell at times then he yells out! Call bell is in reach. An interview with Nurse #2 on [DATE] at 4:54 PM revealed she was assigned to care for Resident #8 on night shift from 7:00 PM on [DATE] until 7:00 AM on [DATE]. Nurse #2 indicated Resident #8 was very anxious on that night and she recalled him hallucinating which she assessed to be related to his recent increase in opioid medications. Nurse #2 said although Resident #8 was at baseline continent of bowel and bladder and independent to supervision assistance with toileting, he was more confused that night and staff had convinced him to wear a brief to help him with comfort and to conserve his exertion of him having to get up and down from the bed causing him increase shortness of breath. Nurse #2 stated Resident #8 remained anxious during her shift and she reported these changes to the oncoming nurse at 7:00 AM who she believed to be Nurse #3. A nurse progress note written on [DATE] at 11:47 AM by Nurse #3 read as follows: Res (Resident) is up on side of bed unable to eat lunch due to confusion as well as hallucinations res had a hard time this am with taking breathing treatments writer had to sit with res and hold res hand as well as hold the mask to talk with res due to res felt as if the breathing treatment was suffocating res. Res is crying and tearful due to seeing cats and cars, Res is also wearing a brief at this time due to decline in health status res has made a choice to be comfort measures staff have checked in on resident multiple times this shift. Res is digging through draws (drawers) and making room in disarray as staff walk in throughout checks res is unsure of what he is doing res has had one dose of Morphine (opioid medication used to control pain and aid in breathing during air hunger) this shift as well as morning medications. Staff will continue to check on resident throughout shift. An additional progress note written on [DATE] at 4:43 PM by Nurse #3 read as follows: Res was noted to be laying on the bedroom floor res has a gash noted to the left upper arm res also has pain and discomfort noted to the left hip and femur res is unable to move leg or hip area res is in pain and discomfort res on call provider is notified as well as POA (power of attorney) is notified res is sent to ER (emergency room ) for treatment and evaluation at this time. DON (Director of Nursing) is notified for the fall. A review of Resident#8's hospital emergency room report dated [DATE] indicated Resident #8 arrived at the hospital via ambulance status post an unwitnessed fall with complaints of pain to his left hip. Resident #8 was comfort care with some confusion noted but expressed desire to have his hip fixed due to worsening pain when he moved. The report includes a radiological report from a left hip and pelvis x-ray which resulted in a foreshortened subcapital left femoral neck fracture (most common fracture in the elderly population where the fracture line extends through the junction of the head and neck of the femur) and 4 cm (centimeter) laceration to his left upper arm which required 2 layered repair with sutures. The ER report further detailed he had an increase in lethargy (sluggish) and hypoxia (low levels of oxygen in the blood) in the emergency department and as a result was admitted to the intensive care unit. Resident #8 was readmitted to the facility on [DATE] with diagnoses that included an unspecified intracapsular left hip fracture and chronic respiratory failure with hypoxia. An interview with Nurse #3 on [DATE] at 12:19 PM revealed she was assigned to care for Resident #8 on day shift on [DATE] from 7:00 AM to 7:00 PM. Nurse #3 indicated she recalled Resident #8 being very agitated and anxious in the first portion of the shift. Nurse #3 said staff had convinced him to allow assistance to get back in the bed and allow assistance for incontinence by use of wearing a brief to decrease exertion from increase movement and fidgeting. Nurse #3 said she provided him with his medications during the shift but had not provided any incontinence care during her shift. Nurse #3 stated Nurse Aide #18 was assigned to Resident #8 and would have provided him with incontinence care. Nurse #3 said she was standing at her medication cart sometime after her afternoon medication pass was completed and was alerted by Resident #6 (Resident #8's roommate) that she needed to come to the room because Resident #8 had fallen to the floor. Nurse #3 explained she rushed down to Resident #8's room to find him lying on the floor on his side and face facing towards the floor, a heavily soiled brief located around his knees and lying in a puddle of urine. Nurse #3 said he had multiple cuts and gashes on his body, and he was complaining of severe pain in his left hip. Nurse #3 said she recognized the hip was fractured and immediately initiated calling the emergency medical services [DATE] line for transport for evaluation and treatment. Nurse #3 stated she sent Resident #8 to the hospital; she was not aware NA #18 had not provided him with incontinence care and she had not assigned his care to another nurse aide on the unit. An interview with Nurse Aide (NA) #18 on [DATE] at 3:38 PM revealed she was assigned to Resident #8 on [DATE] during day shift (7:00 AM to 7:00 PM). NA #18 stated she had gone in to see Resident #18 at approximately 9:00 AM for incontinence care. NA #18 indicated during that care, Resident #8 became very upset and had threatened her to say he would beat her a**. NA #18 said after completing the incontinence care she left the room and told Nurse #3 about the interaction and that she had concerns about providing him with further care. NA #18 stated Nurse #3 gently reminded her that the behaviors Resident #8 was currently exhibiting were not his morning baseline and if he were himself, he would apologize for what he said that he didn't mean any of it. NA #18 indicated this had not reassured her since his threat had caused her to have flashbacks from personal traumas of her past and therefore, she did not provide any further incontinence care to Resident #8 that day. NA #18 stated she periodically stepped in the room to verify that he was breathing until she was called to his room by Nurse #3 stating he had fallen, and she needed assistance. NA #18 said when she arrived at Resident #18's doorway, she saw Resident #8 on the floor with blood on him and the floor, his soiled brief halfway down his legs around his knees and laying in a puddle of urine with his wheelchair resting upon him. NA #18 said this made her feel guilty that she had not provided him with incontinence care, and he had attempted to go by himself as a result. NA #18 said she did not tell Nurse #3 at the time she had not provided him with incontinence care after 9:00 AM that morning. An interview with Nurse Aide (NA) #20 on [DATE] at 9:22 AM revealed that he was not assigned to Resident #8 on that morning ([DATE]) but had gone in to provide him his breakfast tray about 8:00 AM and retrieved a pitcher of tea, a pitcher of water, and a pitcher of ice for Resident #8 upon request at the time of the breakfast delivery. NA #20 said he did not return to Resident #8's room until he was summoned by Nurse #3 shortly after 4:00 PM that afternoon when he was alerted that Resident #8 had fallen. NA #20 indicated he approached Resident #8's room to find him lying on the floor on his side with his brief which was visibly saturated located around his knees and a puddle of urine surrounding him on the floor. NA #20 said Resident #8 was complaining of terrible pain and after initial assessment was sent to the emergency room for evaluation. NA #20 said he was not asked to provide assistance with incontinence care to Resident #8 on [DATE]. An interview with the Director of Nursing on [DATE] at 12:03 PM revealed she had not been aware NA #18 had not provided incontinence care to Resident #8 on [DATE] from 9:00 AM until he fell around 4:00 PM. The DON stated incontinence care should be provided to Resident #8.

Based on record reviews, and interviews with staff and the Medical Director, the facility failed to initiate emergency medical services for symptoms of a drug overdose. Resident #8 was slumped over, non-responsive with constricted pupils and impaired respirations. Resident #8 was observed by a facility staff member with no heart rate or respiratory rate and was pronounced dead on [DATE] at 3:50 PM. This deficient practice affected 1 of 3 residents reviewed for quality of care (Resident #8). Immediate jeopardy began on [DATE] when the facility failed to initiate emergency medical services. 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 of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. The findings included: Resident #8 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure, congestive heart failure (CHF), obstructive sleep apnea, anxiety disorder, and panic disorder. Effective [DATE] per physician's order, Resident #8's code status was Do Not Resuscitate (DNR). Resident #8's care plan initiated on [DATE] indicated the resident had COPD related to history of smoking, had chronic and acute respiratory failure, BiPAP (non-invasive ventilation) at night for obstructive sleep apnea, and oxygen via nasal cannula. Interventions included to monitor for difficulty breathing on exertion, signs and symptoms of acute respiratory insufficiency, and anxiety, and oxygen as ordered. Resident #8 also had a care plan initiated on [DATE] that he was on pain medication therapy related to chronic pain, COPD, and severe breathing problems. Interventions included to administer analgesic medications as ordered by physician, monitor/document side effects and effectiveness every shift, monitor for respiratory depression and for increased risk of falls. There was no mention of opioid or Narcan use in Resident #8's care plans. Resident #8 did not have an end of life care plan. A review of the physician's orders in Resident #8's medical record indicated an order for BiPAP with mode/settings: Inspiratory positive airway pressure (IPAP) 22, Expiratory positive airway pressure (EPAP) 18 - Apply at bedtime and remove in morning upon awakening for obstructive sleep apnea. This order started on [DATE] and was discontinued to [DATE] per recommendations from a pulmonologist as Resident #8 could not tolerate it and the resident wanted to be comfortable. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #8 was cognitively intact, had no behaviors, had range of motion impairment to one side of the lower extremities, and used a wheelchair. He required supervision to partial/moderate assistance with all activities of daily living (ADL). The MDS further indicated that Resident #8 received both scheduled and prn (as needed) pain medications for complaints of frequent pain at a level of 8 (on a scale of ,d+[DATE] with 1 being minimal pain and 10 being severe pain). He had shortness of breath or trouble breathing with exertion, when sitting at rest, and when lying flat, and used tobacco. He received anti-anxiety, antidepressant, antibiotic, diuretic, and opioid medications. He also received oxygen therapy but was not coded for receiving hospice care. A physician's order dated [DATE] in Resident #8's medical record indicated Naloxone (also known as Narcan) liquid 4 milligrams (mg)/0.1 milliliter (ml) 0.1 ml in nostril every 24 hours as needed for opioid depression/suspected opioid depression (overdose). CALL 911 TO ACTIVATE EMERGENCY RESPONSE. Naloxone liquid 4 mg/0.1 ml in alternate nostril from first dose if no response from first dose. Validate 911 emergency response activated. Nasal Narcan order - Call 911- May repeat dose every 10 minutes as needed for opioid depression/suspected opioid depression (overdose). A history and physical note documented by the Medical Director on [DATE] in Resident #8's medical record indicated Resident #8 was a long-term care resident who mobilized with wheelchair and was sitting in the hallway. Resident #8 endorsed no complaints of anxiety at this time. He recently was admitted to the hospital for treatment of COPD/CHF exacerbation, and stated he was feeling better after returning to the facility. Review of systems was negative except for cough and shortness of breath. Assessment and plan included COPD - improved since admission to hospital, and CHF - plan to give (diuretic) twice a day for 10 days. A review of Resident #8's Medication Administration Record for [DATE] indicated he received the following medications: * Buspirone (anxiolytic) 5 milligrams (mg) on [DATE] at 8:00 PM by Nurse #2 * Trazodone (antidepressant and sedative) 25 mg on [DATE] at 9:00 PM by Nurse #2 * Alprazolam (sedative use to treat anxiety and panic disorder) 1 mg on [DATE] at 9:00 PM by Nurse #2 * Hydroxyzine (antihistamine used to treat anxiety) 25 mg intramuscularly on [DATE] at 9:29 PM by Nurse #2 and [DATE] at 3:37 AM by Nurse #2 * Oxycodone-Acetaminophen (narcotic used to treat moderate to severe pain) ,d+[DATE] mg on [DATE] at 9:26 PM by Nurse #2 and [DATE] at 6:28 AM by Nurse #2 * Lorazepam (sedative) 1 mg on [DATE] at 9:25 PM by Nurse #2 and [DATE] at 6:29 AM by Nurse #2 * Naloxone liquid 4 mg in nostril on [DATE] at 9:34 AM and 9:54 AM by Nurse #14 A progress note dated [DATE] at 3:01 AM by Nurse #2 in Resident #8's medical record indicated: Resident #8 had been restless just about the entire shift. He wanted to argue about everything. He was so easily exerted with just movement. He was wearing oxygen via nasal cannula. He would not rest in the bed, and sat up on the side of the bed with feet hanging off. Both lower legs and feet were noted to be very edematous. Resident #8 was non-compliant with care. Staff not able to reason with this resident. He was using call bell constantly. See Medication Administration Record for all prn medications and scheduled medications given. A phone interview with Nurse #2 on [DATE] at 4:54 PM revealed she worked with Resident #8 on the night before he died . Nurse #2 stated that he rested occasionally but then he would wake up with breathing problems and would quickly be in a panic. Resident #8 had chronic breathing problems, and he wanted his medications given frequently. Nurse #2 shared that she gave all his medications that she could give that night, but nothing seemed to help his air hunger and he was very anxious. Resident #8 was independent with ADL and was able to go in and out of bed by himself. A phone interview with Nurse Aide (NA) #24 on [DATE] at 3:22 PM revealed she worked with Resident #8 on the night before he passed away. NA #24 stated that Resident #8 had increased shortness of breath that night, and he was very anxious. Resident #8 came to the nurses' station that night and then eventually went back to bed in the early morning. A progress note dated [DATE] at 9:36 AM by Nurse #14 in Resident #8's medical record indicated: Resident #8 was given Narcan per order. Oxygen saturation 68% (normal value 95% or higher), resident not responding to painful stimuli, pupils constricted. (Small pupils or constricted pupils are common symptoms of opioid overdose.) Narcan given in nostril. Resident now 95% on oxygen. Blood pressure ,d+[DATE] (normal value less than ,d+[DATE]), heart rate 84 (normal value 60 to 100 beats per minute), respirations 18 (normal value 12 to 18 breaths per minute) and regular. Another progress note dated [DATE] at 9:47 AM by Nurse #14 in Resident #8's medical record indicated: Resident #8 now resting with eyes closed. Oxygen saturation 98%. No signs/symptoms of pain or shortness of breath. A phone interview with Nurse #14 on [DATE] at 10:56 AM revealed she was working as the weekend supervisor on [DATE] when Agency Nurse #20 alerted her. Nurse #20 told her that she had no idea what to do about Resident #8. When Nurse #14 came into Resident #8's room, he was very sweaty and was not responding. Resident #8 was sitting in his wheelchair at his bedside, and he was slumped over. Nurse #14 stated that she was afraid Resident #8 might fall forward off his wheelchair, so NA #20 helped her put him back in bed. Nurse #14 stated that she administered two doses of Narcan to Resident #8 to try to get him to wake up because she suspected that he might have overdosed from medications. Nurse #14 further stated she gave him the two doses of Narcan which perked him up. Nurse #14 said she thought Nurse #20 spoke with the on-call provider while she was busy taking care of Resident #8. Nurse #14 also stated that she did not think to call 911 because it seemed like the two doses of Narcan worked, and she noted on the physician's order that she could give another dose after 10 minutes if the first one did not work. After Nurse #14 administered the second dose, she observed that Resident #8's oxygen saturation was within normal limits, and he was talking to her although he said that he was tired and just wanted to lay there in the bed. Nurse #14 stated that Nurse #20 told her that she had called the doctor, and she thought that Nurse #20 had also called 911. Nurse #14 commented that she thought Nurse #20 was going to call 911 because Resident #8 was Nurse #20's resident, and after giving Resident #8 the two doses of Narcan, Nurse #14 went back to the other side of the building. Nurse #14 stated that she knew this was Nurse #20's first day working at the facility. She denied having been told by the Social Worker to call EMS after she gave him Narcan. Nurse #14 stated she did not think she needed to call 911 because Resident #8 responded to the Narcan doses, and he was DNR. Nurse #14 further stated that she was not familiar with the facility's policy for Narcan administration and had not received training on how to administer Narcan. She found out later around 2:00 PM that Resident #8 took a turn for the worse but because the ADON told her that morning after she gave him Narcan that Resident #8 was DNR, and that he was dying, she didn't think there was anything else she should have done. A progress note dated [DATE] at 10:00 AM by Agency Nurse #20 in Resident #8's medical record indicated: Resident #8 was sitting up in wheelchair, very difficult to arouse. Oxygen saturation was 71% on oxygen via nasal cannula. Resident #8 was placed back to bed with head of bed elevated. Somewhat more responsive but continued to nod off. Oxygen saturation increased to the low 80% with deep breaths. Narcan administered by Nurse #14. Narcan somewhat effective, more alert and verbal. Morning medications held. A second progress note dated [DATE] at 12:58 PM by Nurse #20 in Resident #8's medical record indicated: Resident #8 difficult to arouse at this time. Responded to sternal rub (application of painful stimulus with the knuckles of closed fist to the center chest of a patient who is not alert and does not respond to verbal stimuli) with mumbles. Oxygen on per order via nasal cannula. BiPAP (bilevel positive airway pressure which is a form of non-invasive ventilation therapy used to help you breathe) placed on. More verbal and alert at this time. A third progress note dated [DATE] at 3:50 PM by Nurse #20 in Resident #8's medical record indicated: Upon observation, no heart rate or respiratory rate noted. Responsible party aware. Nurse Practitioner aware, order to release body to the funeral home received and noted. Funeral home contacted per family request. A phone interview with Nurse #20 on [DATE] at 12:52 PM revealed she took care of Resident #8 on the day he died . Nurse #20 stated Resident #8 was not alert and was unresponsive, so she got Nurse #14 to come in his room to see him and they took his vital signs which were the same vital signs recorded by Nurse #14 in her 9:36 AM progress note. Nurse #20 stated that Resident #8's oxygen saturation level was very low. She could not recall the exact numbers, but she remembered it being in the 70s. Nurse #20 said that Nurse #14 administered Narcan to Resident #20. Nurse #20 further stated she was not sure why EMS (Emergency Medical Services) was not notified, and she did not know at the time that EMS was supposed to be notified when Narcan was administered. Nurse #20 shared that she did not look at the order for Narcan because she was not the one who administered it to Resident #8. Nurse #20 recalled Resident #8's pupils being very pinpoint, and he was very lethargic on the day that he died but because Nurse #14 told her that Resident #8 was DNR and that there was nothing else they could do for him, she did not think about calling EMS. Nurse #20 stated she was not familiar with Narcan and had never given it before. She also did not receive training on Narcan administration at the facility prior to her working there. A follow-up phone interview with Nurse #20 on [DATE] at 12:26 PM revealed NA #21 alerted her that Resident #8 was lethargic. When Nurse #20 checked Resident #8's oxygen saturation, it was dropping so she asked Nurse #14 for help. Resident #8 woke up somewhat after he received the two doses of Narcan. During the interview, Nurse #20 stated that she was very nervous because she thought that she might be in trouble. Nurse #20 explained that [DATE] was her very first day working at the facility as an agency nurse and she did not have access at the time to the clinical messaging platform that the facility used to contact the on-call providers. Nurse #20 stated that she did not think about calling the on-call provider because she thought that Nurse #14 took over Resident #8's care when she gave him the Narcan. Nurse #20 explained that during this incident, she was still trying to get her medication pass done, and she thought Nurse #14 was going to take care of Resident #8. Nurse #20 further shared that she asked Nurse #14 if they needed to send Resident #8 to the hospital, but Nurse #14 told her no, and that they were not going to do anything for Resident #8 because he was DNR. Nurse #20 clarified that the progress note she documented in Resident #8's chart at 10:00 AM was entered late and that she referred to this note about what happened to Resident #8 before receiving the two Narcan doses. Nurse #20 confirmed that Resident #8 was somewhat more responsive after the two doses of Narcan, but she was not familiar with him because this was her first time taking care of Resident #8, so she did not know what was normal for him. Resident #8 stayed in bed asleep, and his oxygen saturation went up a little, but he got worse in the afternoon when he became lethargic and unresponsive with no heart rate and no breathing. She notified Nurse #14 but again Nurse #14 told her there was nothing they could do for Resident #8. Nurse #20 stated she could not remember why she did not send Resident #8 to the hospital after he received the two doses of Narcan. She did not think of administering the Narcan again and did not think about calling 911. She further shared that she had never administered Narcan before which was why she asked for help from Nurse #14. A phone interview with Nurse Aide (NA) #21 on [DATE] at 11:03 AM revealed on the day that Resident #8 passed away, he was very lethargic, and she told Nurse #20 that he was unresponsive. NA #21 stated that this was not normal for Resident #8 because he was usually up and about and could get around by himself. NA #21 stated that they tried to wake him up multiple times, but he had extremely low oxygen saturation level according to what Nurse #14 and Nurse #20 told her. He was wheezing and although she could not recall the exact oxygen saturation, she stated that it was in the 70s based on what she remembered Nurse #20 telling her. NA #21 further stated that they tried to sit him up but over the next few hours, he did not get any better. NA #21 shared that Resident #8 briefly opened his eyes after receiving the Narcan doses but within 20 to 30 minutes he was back to being lethargic. Resident #8 was able to answer questions, but he acted tired and went back to sleep. He continued to have wheezing and a few hours later he was actively dying based on what Nurse #14 told her. She reported this to Nurse #20, and she placed Resident #8 on BiPAP which was at the bedside. NA #21 stated she went on to take care of the other residents on the hall so NA #20 could sit with Resident #8. Then they provided postmortem care to Resident #8. A phone interview with NA #20 on [DATE] at 9:22 AM revealed he took care of Resident #8 when he died . NA #20 stated that it was the most horrific experience he had ever had. Resident #8 sat in his wheelchair and had his head down on the rolling table. Resident #8 was slumped over, and he was jerking in and out of consciousness, so they put him back into bed. NA #20 stated that Resident #8 was not able to speak that day. He was very short of breath. NA #20 reported that Resident #8 usually complained of shortness of breath, but he was always alert and oriented, and he was able to move around in his room by himself. NA #20 said that he told Nurse #14 that Resident #8 was not responding and was lethargic. After Nurse #14 gave Resident #8 the Narcan, he woke up for a few minutes and then after a brief period he was back to being unresponsive. NA #20 added that he continued to tell Nurse #20 and Nurse #14 that something was not right with him because his eyes were pinpoint and glazed over even when his head was laid on the pillow. His head was floppy, and his limbs were flaccid. NA #20 further shared that Resident #8 had severe edema in his lower extremities which was worse than usual. He said he attempted to check a pedal pulse on Resident #8 because his legs were so swollen, but he was unable to obtain a pedal pulse for the remainder of the day. He stated that he did not check a pulse anywhere else on Resident #8's body. NA #20 stated that Nurse #14 told him that Resident #8 was actively dying and that there was nothing to be done because he was DNR. NA #20 stated that he stayed with Resident #8 holding his hand because he had known previously that he was afraid of dying alone, and then Resident #8 got quiet and then NA #20 realized that he had passed away. NA #20 hollered for Nurse #20 at approximately 3:50 PM and they came to check on Resident #8 who was pronounced dead. NA #20 provided postmortem care with NA #21 before the funeral director got Resident #8's body. A phone interview with the former Social Worker (SW) on [DATE] at 12:45 PM revealed she was the manager on duty which meant she was in charge of the facility in the absence of the Administrator on [DATE]. The former SW stated that when she came in that morning around 9:30 AM, Nurse #14 told her that Resident #8's pupils were pinpoint, and that they needed help to put him back into bed. The former SW stated she observed Resident #8 slumped over in his wheelchair and she thought he was going to die right there. Resident #8's pupils were pinpoint, and she watched Nurse #14 give Resident #8 two doses of Narcan. The former SW further stated that she told Nurse #14 that the facility's policy was to immediately call EMS, call the doctor and send the resident to the hospital after the resident was given Narcan. The former SW explained that she was training an activity staff member that day, so she left the room after Resident #8 received the two doses of Narcan and she said she thought Nurse #14 was going to send Resident #8 out to the hospital afterwards, but she did not. Later that day, around 2:00 PM, Nurse #14 reported to her that Resident #8 took a turn for the worse, so the former SW asked Nurse #14 if she was going to send Resident #8 out. Nurse #14 did not answer her and just looked at her. The former SW stated that she thought Nurse #14 should know what she was supposed to do because she was the nurse. The former SW stated that she did not want to interfere with nursing because she worked in another department, and she could not tell them what they were supposed to do. The former SW stated that she tried to call the Administrator to alert her as to what was happening in the facility, but she could not get her on the phone. An initial joint interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on [DATE] at 1:11 PM. The DON stated that she was not at the facility when Resident #8 died so she did not remember anything that went on that day. The DON stated that she would have to look back at the notes, but she knew that the former Social Worker and Nurse #14 were at the facility on [DATE]. The ADON stated that she knew Resident #8 passed away, but it was expected that he was going to die because he had end-stage COPD and respiratory failure. The ADON stated that from what she remembered, Resident #8 was found unresponsive, but she denied knowing any details regarding Resident #8 receiving Narcan. The ADON shared that each resident had a standby order for Narcan especially if they had opioid medications in cases of opioid overdose, but she was not sure whether the order indicated that they were supposed to call 911 when administering Narcan. The DON stated that if it was specified on the Narcan order to call EMS, the nurses should have followed what was specified on the order. A follow-up interview with Nurse #14 on [DATE] at 8:32 AM revealed she talked to the ADON after she gave two doses of Narcan to Resident #8 and the ADON told her that it was fine, and that she didn't have to do anything else because Resident #8's code status was DNR. Nurse #14 further stated that if the ADON had told her to call 911, she would have called 911, but because he was DNR, the ADON told her they did not need to do anything. Nurse #14 also shared that around 2:00 PM on [DATE] when Resident #8's condition was getting worse, she asked the former Social Worker if she needed to send him out to the hospital. Nurse #14 claimed that the former Social Worker told her that she didn't have to send him out to the hospital because he was DNR. Nurse #14 further shared that Resident #8 had improved after the first dose of Narcan, but she did not know the reason for the persistent lethargy even while he was in bed, so she gave her another dose of Narcan. A follow-up phone interview with the former SW on [DATE] at 11:18 AM revealed she did not say to Nurse #14 not to send Resident #8 to the hospital because he was DNR. The former SW stated that it was not her call. She added that Nurse #14 was the nurse on the floor, and she should have taken care of Resident #8. A follow-up interview with the ADON in the presence of the DON on [DATE] at 3:29 PM revealed that the ADON could vaguely remember if she called or texted Nurse #14 on [DATE] after Nurse #14 gave the two Narcan doses to Resident #8. The ADON stated that she couldn't remember when her conversation with Nurse #14 was and what time, but that the ADON was not surprised that Resident #8 had died but she was surprised that Nurse #14 had given him Narcan. The ADON stated she questioned Nurse #14 why she gave Resident #8 Narcan when he was expected to die. The ADON explained that she was doing verbal education to the staff to help them understand how sick he was. Whenever Resident #8 had issues with his breathing, he wanted to go to the hospital where they would just give him a rescue BiPAP and intravenous diuretics, and then send him back to the facility. The ADON stated she did not remember her exact response to Nurse #14 about the two Narcan doses, but she recalled Nurse #14 telling her that Resident #8 responded a little bit to the Narcan dose. The ADON further explained that she remembered telling Nurse #14 that Resident #8 was unresponsive because he was actively dying. The ADON recalled Nurse #14 told her Resident #8 responded a little bit after she gave him Narcan. An interview with the Medical Director (MD) on [DATE] at 10:21 AM revealed he last saw Resident #8 on [DATE] when he visited him after he had just gotten back from the hospital for COPD and CHF, and he seemed to be doing fine during the visit. The MD stated that Resident #8 was a long-term care resident and his plan of care included providing assistive care and managing his chronic medical issues. The MD stated that he was not notified when Resident #8 died but he found out about it the next day he visited the facility. The MD stated that he did not know that they administered Narcan to Resident #8, and he was not familiar with the facility policy for Narcan. The MD stated that if the policy indicated for staff to notify EMS when administering Narcan, then they should have followed that. The MD confirmed that low oxygen saturation and pupil constriction were signs of overdose, and that Resident #8 should have been sent out to the hospital on [DATE]. The MD added that if an on-call provider was notified about the Narcan doses, then there would be a note in Resident #8's chart and they would have ordered to send him out to the hospital. Resident #8's death certificate indicated date of death was [DATE] and the immediate cause of death was myocardial infarction (heart attack) with the following diagnoses listed as underlying causes: coronary artery disease and congestive heart failure. A follow-up phone interview with the MD on [DATE] at 11:39 AM revealed he put myocardial infarction (MI) on Resident #8's death certificate because that was the most likely cause of his death but if he had known that the nurses had to give him Narcan, he probably would not have put MI without doing further investigation into the cause of his death. The MD stated that he could not put possible overdose on Resident #8's death certificate, and that he would need to have a toxicology report done but this was rarely done unless the family member requested for one to be done. The MD stated that a toxicology report could verify the cause of death but since they did not do this anymore, he said he didn't know what he would have put as the cause of death without investigating further. The MD explained that Narcan was just a temporary fix, and it did not fix or correct the cause of the lethargy. Narcan also had a tendency to wear off quickly which was why it could be given every 10 minutes or so, but it would be nice to have EMS around in case the resident went back into depression. The MD added that Narcan was only used in cases of emergency and any resident who received it needed to be observed and monitored closely. The MD further explained that a positive response from Narcan meant that the Narcan was working in terms of reversing whatever caused the unresponsiveness, but it was only effective up to a certain extent. A phone interview with the Administrator on [DATE] at 11:55 AM revealed she was not aware of Resident #8's passing until the Monday when she came in. The Administrator stated Resident #8 had been having repeated respiratory issues, and she knew that he had been advancing with his COPD and that he was end-stage which meant there was not a lot they could do for him. She stated that she knew Resident #8 had just been through two previous hospitalization s for respiratory distress where he received treatment. The Administrator stated that she did not know the specific date that she found out about Resident #8 having been given Narcan without guessing. She could not say whether Resident #8 should have received emergency treatment after receiving the two Narcan doses. The Administrator was notified of immediate jeopardy on [DATE] at 12:00 PM. The facility provided the following immediate jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to activate emergency response for Resident #8 after Nurse #14 administered two doses of Narcan on [DATE] at 9:34 AM and 9:54 AM with positive response for suspicion of drug overdose. The facility has re-educated the licensed nursing staff on the use of Narcan and activation of the emergency response per physician orders by [DATE]. Licensed nursing staff that are not available on or before [DATE] will not be scheduled until the education has been completed. The actions the facility will take to ensure the nurses have activated the emergency response as indicated in the physician's orders on the administration of Narcan is the DNS will review the 24-hour report on a daily basis for appropriate activation of the emergency response. Feedback will be provided by the DNS to the licensed nurse addressing any challenges or barriers in the use of Narcan and/or the activation of the emergency response. Re-education was provided to licensed nursing staff about the activation of the emergency response when Narcan is administered. * Agency licensed nurses working at the facility will receive education on activating emergency response when administration of Narcan for a suspected overdose by the DNS/ Assistant Director of Nursing (designee). 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 specific actions the facility will take to alter the system failure to prevent a serious outcome from reoccurring are: * The facility has re-educated the licensed nursing staff on the use of Narcan and activation of the emergency response per physician orders by [DATE]. * The actions the facility will take to ensure the nurses have activated the emergency response as indicated in the physician's orders on the administration of Narcan is the DNS will review the 24-hour report on a daily basis for appropriate activation of the emergency response. Feedback will be provided by the DNS addressing any challenges or barriers. * Agency licensed nurses working at the facility will receive education on notification to the medical provider on administration of Narcan for a suspected overdose by the DNS/ Assistant Director of Nursing (designee). * The nurse who responds to the suspected overdose will direct another staff member to activate the emergency response system, which is denoted in the revised Narcan Administration Policy [DATE]. The alleged date of immediate jeopardy removal is [DATE]. The credible allegation for the immediate jeopardy removal was validated on [DATE] with a removal date of [DATE]. A review of in-service education records dated [DATE] revealed education was provided to nurses including agency nurses on the activation of emergency response upon administration of Narcan, and ensuring the medical provider has been notified of any resident receiving Narcan and activating EMS per physician orders. Interviews with the nursing staff including agency nurses revealed they had been educated on activating EMS and notifying the medical provider of any resident who receives Narcan for suspected overdose, and the revised Narcan administration policy. A review of the revised Narcan administration policy dated [DATE] indicated the nurse who responds to the suspected overdose will direct another staff member to activate EMS. The facility's date of immediate jeopardy removal of [DATE] was validated.

Based on record reviews, and staff interviews, the facility failed to ensure nursing staff were trained and competent with responding to medical emergencies, activating emergency procedures with emergency medical services, and notifying medical providers for 1 of 4 residents (Resident #8) reviewed for neglect. Nursing staff failed to notify a medical provider of significant changes in a resident's condition who was observed to be unresponsive to painful stimuli, having low oxygen saturation level and pupil constriction, and failed to immediately initiate emergency procedures with 911. Resident #8 expired on [DATE]. This was for 2 of 2 staff members reviewed for competency (Nurse #20 and Nurse #14). Immediate jeopardy began on [DATE] when nursing staff did not demonstrate competency in responding to a medical emergency. The immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective for ensuring all staff are trained and competent before caring for residents in the facility. The findings included: A review of the employee file for Nurse #20 indicated verification of an active license to practice in the state, and a checklist entitled, Agency Staff Facility Orientation. The checklist was initialed and signed by Nurse #20 on [DATE]. Included in the checklist were emergency codes, Narcan, and code blue. A review of the employee file for Nurse #14 indicated she was hired on [DATE] as a charge nurse. A new-hire orientation checklist was completed on [DATE] and verification of an active license to practice in the state was done. The checklist dated [DATE] indicated Nurse #14 was checked off on the location of fire alarms, location and operation of emergency exits, location of fire extinguishers, fire plan, evacuation procedure, emergency telephone numbers, door alarms, and emergency generators. The Nurse Supervisor job description was signed by Nurse #14 and the Director of Nursing on [DATE]. Included in the job description were to assist the charge nurse in monitoring seriously ill patients, and to notify the attending physician and next-of-kin when there is a change in the resident's condition. A progress note dated [DATE] at 9:36 AM by Nurse #14 in Resident #8's medical record indicated: Resident #8 was given Narcan per order. Oxygen saturation 68% (normal value 95% or higher), resident not responding to painful stimuli, pupils constricted. (Small pupils or constricted pupils are common symptoms of opioid overdose.) Narcan given in nostril. Resident now 95% on oxygen. Blood pressure ,d+[DATE] (normal value less than ,d+[DATE]), heart rate 84 (normal value 60 to 100 beats per minute), respirations 18 (normal value 12 to 18 breaths per minute) and regular. Another progress note dated [DATE] at 9:47 AM by Nurse #14 in Resident #8's medical record indicated: Resident #8 now resting with eyes closed. Oxygen saturation 98%. No signs/symptoms of pain or shortness of breath. A progress note dated [DATE] at 10:00 AM by Agency Nurse #20 in Resident #8's medical record indicated: Resident #8 was sitting up in wheelchair, very difficult to arouse. Oxygen saturation was 71% on oxygen via nasal cannula. Resident #8 was placed back to bed with head of bed elevated. Somewhat more responsive but continued to nod off. Oxygen saturation increased to the low 80% with deep breaths. Narcan administered by Nurse #14. Narcan somewhat effective, more alert and verbal. Morning medications held. A second progress note dated [DATE] at 12:58 PM by Nurse #20 in Resident #8's medical record indicated: Resident #8 difficult to arouse at this time. Responds to sternal rub (application of painful stimulus with the knuckles of closed fist to the center chest of a patient who is not alert and does not respond to verbal stimuli) with mumbles. Oxygen on per order via nasal cannula. BiPAP (bilevel positive airway pressure which is a form of non-invasive ventilation therapy used to help you breathe) placed on. More verbal and alert at this time. A phone interview with Nurse #20 on [DATE] at 12:52 PM revealed she took care of Resident #8 on the day he died . Nurse #20 stated Resident #8 was not alert and was unresponsive, so she got Nurse #14 to come in his room to see him and they took his vital signs which were the same vital signs recorded by Nurse #14 in her 9:36 AM progress note. Nurse #20 stated that Resident #8's oxygen saturation level was very low. She could not recall the exact numbers, but she remembered it being in the 70s. Nurse #20 said that Nurse #14 administered Narcan to Resident #20. Nurse #20 further stated she was not sure why EMS (Emergency Medical Services) was not notified, and she did not know at the time that EMS was supposed to be notified when Narcan was administered. Nurse #20 shared that she did not look at the order for Narcan because she was not the one who administered it to Resident #8. Nurse #20 recalled Resident #8's pupils being very pinpoint, and he was very lethargic on the day that he died but because Nurse #14 told her that Resident #8 was DNR (Do Not Resuscitate) and that there was nothing else they could do for him, she did not think about calling EMS. Nurse #20 stated she was not familiar with Narcan and had never given it before. She also did not receive training on Narcan administration at the facility prior to her working there. A follow-up phone interview with Nurse #20 on [DATE] at 12:26 PM revealed that [DATE] was her very first day working at the facility as an agency nurse and she did not have access at the time to the clinical messaging platform that the facility used to contact the on-call providers. Nurse #20 stated that she did not think about calling the on-call provider because she thought that Nurse #14 took over Resident #8's care when she gave him the Narcan. Nurse #20 explained that during this incident, she was still trying to get her medication pass done, and she thought Nurse #14 was going to take care of Resident #8. Nurse #20 further shared that she asked Nurse #14 if they needed to send Resident #8 to the hospital, but Nurse #14 told her no, and that they were not going to do anything for Resident #8 because he was DNR. Nurse #20 confirmed that Resident #8 was somewhat more responsive after the two doses of Narcan, but she was not familiar with him because this was her first time taking care of Resident #8, so she did not know what was normal for him. Resident #8 stayed in bed asleep, and his oxygen saturation went up a little, but he got worse in the afternoon when he became lethargic and unresponsive with no heart rate and no breathing. She notified Nurse #14 but again Nurse #14 told her there was nothing they could do for Resident #8. Nurse #20 stated she could not remember why she did not send Resident #8 to the hospital after he received the two doses of Narcan. She did not think of administering the Narcan again and did not think about calling 911. She further shared that she had never administered Narcan before which was why she asked for help from Nurse #14. The interview further revealed that Nurse #20 started as an agency nurse on [DATE] and later signed a contract with the facility. Nurse #20 stated she received no orientation prior to working at the facility because agency staff did not receive orientation. Nurse #20 stated that she was only given an orientation packet and was asked to sign a checklist, but she did not have time to read over the material before she started working on the floor on [DATE]. Nurse #20 also stated she was not familiar with the facility's policy regarding the administration of Narcan. She further stated that she was not sure how to notify an on-call provider for the facility if needed during a medical emergency. Nurse #20 explained that she did not receive any training from the facility regarding emergency procedures. A phone interview with Nurse #14 on [DATE] at 10:56 AM revealed she was working as the weekend supervisor on [DATE] when Nurse #20 alerted her about Resident #8 being unresponsive. Nurse #14 stated that she administered two doses of Narcan to Resident #8 to try to get him to wake up because she suspected that he might have overdosed from medications. Nurse #14 said she thought Nurse #20 spoke with the on-call provider while she was busy taking care of Resident #8. Nurse #14 further stated that Nurse #20 told her that she had called the doctor, and she thought that Nurse #20 had also called 911. Nurse #14 commented that she thought Nurse #20 had called 911 because Resident #8 was Nurse #20's resident, and after giving Resident #8 the two doses of Narcan, Nurse #14 went back to the other side of the building. Nurse #14 stated that she knew this was Nurse #20's first day working at the facility, and that she was supposed to monitor Nurse #20, but she was also busy on another hall. Nurse #14 stated she did not think she needed to call 911 because Resident #8 responded to the Narcan doses, and he was DNR. Nurse #14 further stated that she was not familiar with the facility's policy for Narcan administration, and had not received training on how to administer Narcan. She found out later around 2:00 PM that Resident #8 took a turn for the worse but because the Assistant Director of Nursing (ADON) told her that morning after she gave him Narcan that Resident #8 was DNR, and that he was dying, she didn't think there was anything else she should have done. During a follow-up interview with Nurse #14 on [DATE] at 8:32 AM, Nurse #14 stated she started as the weekend supervisor on [DATE], but she did not get orientation on her job responsibilities. Nurse #14 stated she remembered signing a job description, but she did not receive formal training on what she needed to do as the weekend supervisor. Nurse #14 also stated that she was the nurse who had been at the facility the longest and she had worked previously as a supervisor nine years ago. A joint interview with the Director of Nursing (DON) and the ADON on [DATE] at 2:34 PM revealed agency nurses who worked per diem received an orientation packet while agency nurses who signed a contract with the facility received at least one shift of orientation while working with another nurse. The DON stated Nurse #20 started as a per diem agency nurse so she would not have gotten a shift orientation before she worked on the floor. The Human Resources Director usually reviewed the packet with agency nurses prior to them working, but Nurse #14 should have monitored Nurse #20 since it was her first day working at the facility, and it was on a weekend. The ADON further stated that Nurse #14 did not get training as a supervisor, and they were not sure whether she used to be supervisor. The DON stated Nurse #14 was expected to read her job description and that they went over her responsibilities with her as a team. An interview with the Administrator on [DATE] at 4:34 PM revealed they put agency nurses through an onboarding list. Nursing went over with them the review of the medication carts. The Administrator stated that typically when agency nurses started, they came in with the knowledge on how to do their job while receiving monitoring from administrative staff. Nurse #14 had worked as a charge nurse, as a Unit Manager, and as the Director of Nursing before at the facility. The Administrator was notified of immediate jeopardy on [DATE] at 10:54 AM. The facility provided the following immediate jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to ensure nursing staff were trained and competent in responding to medical emergencies, activating emergency response, and notifying medical providers for Resident #8 who received two doses of Narcan on [DATE] at 9:34 AM and 9:54 AM, with positive response, for suspicion of drug overdose. All residents who use opioid medications are at risk of overdose and may be subject to the need for Narcan administration and emergency response. 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 facility needs to have a system in place to provide training and verify competencies for nurses related to responding to medical emergencies, medical provider notification and activation of emergency response. The facility continues to employ agency nurses without providing orientation and training prior to providing care to the residents. * An audit was completed by [DATE] by the Nurse Consultant on the number of residents who are prescribed opioid medication, which will include residents that have a diagnosis of opioid abuse disorder that do not have a scheduled or prn opioids. * The Director of Nursing/Assistant Director of Nursing (designee) has re-educated the licensed nursing staff on medical emergencies and emergency activation response per physician orders on [DATE]. * The actions the Director of Nursing/ Assistant Director of Nursing (designee) will take to ensure the nurses have activated the emergency response as indicated in the physician's orders on the administration of Narcan is the DNS will review the 24-hour report on a daily basis for appropriate activation of the emergency response. Feedback will be provided by the DNS addressing any challenges or barriers, which can require re-education if needed. * Agency licensed nurses working at the facility will receive education on medical emergencies and activation of the emergency response by the DNS/Assistant Director of Nursing (designee). * Licensed nursing staff, including agency staff that are not available on or before [DATE] will not be scheduled until the education has been completed. The Director of Nursing/Assistant Director of Nursing (designee) will provide education on medical emergencies, medical provider notification, and activation of emergency response for the nursing staff unavailable after [DATE] before they start the shift. * The nurse who responds to the suspected overdose will direct another staff member to activate the emergency response system which is denoted in the revised Narcan Administration Policy [DATE]. * The facility will initiate Mock Medical Emergencies Drills on each shift weekly x 4 weeks, and then ongoing monthly upon completion of the licensed nursing education. The first drill took place [DATE]. The DNS and/or the ADNS will critique the drill denoting areas in need of improvement. The alleged date of immediate jeopardy removal is [DATE]. The credible allegation for the immediate jeopardy removal was validated on [DATE] with a removal date of [DATE]. A review of in-service education records dated [DATE] revealed education was provided to nurses including agency nurses on the activation of emergency response upon administration of Narcan, and ensuring the medical provider has been notified of any resident receiving Narcan and activating EMS per physician orders. Interviews with the nursing staff including agency nurses revealed they had been educated on activating EMS and notifying the medical provider of any resident who receives Narcan for suspected overdose. The nurses including agency nurses stated they received education on medical emergencies and activation of the emergency response. Interviews with staff confirmed a mock medical emergency drill was conducted on [DATE] and [DATE] where the nursing staff initiated emergency response and notified the doctor of a suspected drug overdose. The audit completed by the Nurse Consultant on [DATE] was reviewed. All residents identified as having orders for Narcan administration had notification of medical providers added to the Narcan order. A review of the revised policy for Narcan Administration dated [DATE] indicated that the nurse who responds to the suspected overdose will direct another staff member to activate the emergency response system. The facility's date of immediate jeopardy removal of [DATE] was validated.

Based on record reviews, staff, family, Pharmacist and Medical Director interviews the facility failed to obtain an antianxiety medication from the pharmacy which caused a resident to miss 3 doses of antianxiety medication for 1 of 5 residents (Resident #7) reviewed for medication errors. This failure resulted in Resident #7 experiencing feelings of panic, sweatiness, crying, shaking and asking for assistance from family to calm down. The findings included: Resident #7 was admitted to the facility on [DATE] with diagnoses including anxiety disorder. Review of Resident #7's physician orders revealed an order dated 04/30/23 for lorazepam one milligram (mg) every twelve hours as needed for anxiety and an order dated 05/01/23 for lorazepam one mg by mouth three times a day for anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact, had unclear speech, was usually able to make himself understood, and was able to understand others. The MDS also indicated Resident #7 received antianxiety medication during the lookback period. Resident #7's Medication Administration Record (MAR) for April 2024 revealed the doses of lorazepam one mg scheduled for 8:00 AM, 2:00 PM, and 9:00 PM on 04/25/24 were not initialed as administered. An interview with Nurse #17 on 05/08/24 at 1:58 PM revealed she was assigned to care for Resident #7 on 04/25/24 on the 7:00 AM to 11:00 PM shift and was notified in report the morning of 04/25/24 that Resident #7 was out of his scheduled lorazepam 1 mg. Nurse #17 stated Resident #7 had a physician order for prn (meaning as needed) lorazepam one mg every twelve hours, but he was out of that medication also and there was none in the emergency back-up medication dispenser. Nurse #17 explained when she completed her 8:00 AM medication pass, she called pharmacy to ask when Resident #17's lorazepam would be available and was told Resident #17 needed a new prescription for the medication. She stated she notified the ADON and DON that Resident #17 was out of lorazepam one mg, had missed two scheduled doses of lorazepam on 04/25/24, and needed a new prescription to be sent to the pharmacy. Nurse #17 stated she was notified by the ADON that Resident #17's lorazepam would arrive from the pharmacy in the night delivery. She stated the lorazepam did not arrive from pharmacy before she left the night of 04/25/24. An interview with NA #7 on 05/10/24 at 8:10 AM revealed she cared for Resident #7 on 04/25/24 on the 7:00 AM to 7:00 PM shift. She stated Resident #7 did not receive his lorazepam that day and was anxious all day. NA #7 explained Resident #7 repeatedly rang his call light to request his lorazepam, was sweating and shaking, and requested she text his mom and ask her to come to the facility on [DATE]. She stated she texted Resident #7's mom as he requested and tried to reassure Resident #7 that Nurse #17 was working on getting his medication throughout her shift. A telephone interview with Resident #7's mother on 05/06/24 at 11:02 AM revealed 2 nurse aides (NAs) called her on 04/25/24 from Resident #7's cell phone per his request (she was unsure of the exact time of the call) because he had not received his lorazepam. She stated the NAs informed her Resident #7 was in a panic and he wanted her to come to the facility to help him calm down. Resident #7's mother stated she came to the facility to check on Resident #7 and he was panicky and did not want her to leave. She stated she spoke with Nurse #17 on 04/25/24 and the nurse confirmed Resident #7 was out of lorazepam and she was trying to get the medication from pharmacy. Resident #7's mother stated she later found out Resident #7 did not receive any doses of lorazepam on 04/25/24. A telephone interview with the Medical Director on 05/07/24 at 3:06 PM revealed when residents ran out of medication, the on-call Nurse Practitioner (NP) was notified of the need for a prescription refill and a temporary prescription was issued until the regular delivery shipment of medications was received from the pharmacy. He stated he was not notified Resident #7 missed 3 scheduled doses of lorazepam on 04/25/24 and confirmed missing the medication doses would result in an increase in anxiety. A joint interview with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) on 05/08/24 at 1:12 PM revealed Nurse #17 notified the ADON on 04/25/24 that Resident #7 was out of his scheduled lorazepam and needed a new prescription. The ADON explained she logged onto the online forum the facility used to communicate with providers and saw multiple prescription refill requests for Resident #7's lorazepam had been requested and the providers responded that the prescription had been sent to pharmacy electronically. The ADON stated she called the pharmacy and asked for Resident #7's lorazepam to be sent to the facility stat (immediately) and she understood the medication would arrive as soon as possible. The ADON stated stat orders did not mean the same thing in long term care as in acute care, but she thought the medication would arrive sooner than the scheduled pharmacy delivery that occurred nightly between 10:30 PM and midnight. When the ADON and DON were asked why they did not request a prescription be sent electronically by the provider to a local pharmacy and picked up on 04/25/24, they explained they were new to their roles and did not know that was an option. They stated in hindsight, they would have asked the provider to send an electronic prescription for the lorazepam to a local pharmacy and staff would pick it up rather than waiting on the medication to arrive from the facility pharmacy located in Hickory, NC. An interview with the Pharmacist on 05/08/24 at 5:18 PM revealed the last refill request from the facility for lorazepam one mg for Resident #7 prior to 04/25/24 was on 03/15/24. She stated on 03/17/24 sixty lorazepam one mg tablets were delivered to the facility for Resident #7. The Pharmacist confirmed she had no record of a stat request for lorazepam tablets from the facility on 04/25/24 for Resident #7. An interview with the Administrator on 05/10/24 at 4:15 PM revealed it was her understanding that nursing staff had a difficult time getting Resident #7's prescription refilled for lorazepam and when the prescription was obtained and sent to pharmacy, the medication did not arrive in the pharmacy delivery (she could not recall the date). She confirmed Resident #7 missed 3 scheduled doses of lorazepam on the day in question. The Administrator stated in hindsight the Medical Director should have been contacted and a prescription for lorazepam called in to a local pharmacy and picked up, so the resident did not have to miss multiple doses of scheduled medication.

Based on record review and staff, Medical Director, and family interviews the facility failed to ensure a resident was free of significant medication errors due to failing to administer three scheduled lorazepam (antianxiety medication) doses. The deficient practice was for 1 of 5 residents reviewed for medication errors (Resident #7). This failure resulted in Resident #7 experiencing feelings of panic, sweatiness, crying, shaking and asking for assistance from family to calm down. The findings included: Resident #7 was admitted to the facility on [DATE] with diagnoses including anxiety disorder. Review of Resident #7's physician orders revealed an order dated 04/30/23 for lorazepam one milligram (mg) every twelve hours as needed for anxiety and an order dated 05/01/23 for lorazepam one mg by mouth three times a day for anxiety. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively intact, had unclear speech, was usually able to make himself understood, and was able to understand others. Resident #7's care plan last updated 03/19/24 revealed he used antianxiety medications related to anxiety disorder. Interventions included administering antianxiety medications as ordered by the physician, and monitoring/recording the occurrence of target symptoms. Resident #7's Medication Administration Record (MAR) for April 2024 revealed the doses of lorazepam one mg scheduled for 8:00 AM, 2:00 PM, and 9:00 PM on 04/25/24 were not initialed as administered. An interview with Nurse #17 on 05/08/24 at 1:58 PM revealed she was assigned to care for Resident #7 on 04/25/24 on the 7:00 AM to 11:00 PM shift and was notified in report the morning of 04/25/24 that Resident #7 was out of his scheduled lorazepam 1 mg. Nurse #17 stated Resident #7 had a physician order for prn (meaning as needed) lorazepam one mg every twelve hours, but he was out of that medication also and there was none in the emergency back-up medication dispenser. Nurse #17 explained when she completed her 8:00 AM medication pass, she called pharmacy to ask when Resident #17's lorazepam would be available and was told Resident #17 needed a new prescription for the medication. She stated she notified the ADON and DON that Resident #17 was out of lorazepam one mg, had missed two scheduled doses of lorazepam on 04/25/24, and needed a new prescription to be sent to the pharmacy. Nurse #17 stated she was notified by the ADON that Resident #17's lorazepam would arrive from the pharmacy in the night delivery. She stated the lorazepam did not arrive from pharmacy before she left the night of 04/25/24. Nurse #17 confirmed Resident #7 was tense all day on 04/25/24, had episodes of crying throughout the day, repeatedly requested his lorazepam, and asked Nurse Aide (NA) #7 to call his mom multiple times throughout the day. She stated she reassured Resident #7 throughout her shift that she was working on obtaining the medication from pharmacy. An interview with NA #7 on 05/10/24 at 8:10 AM revealed she cared for Resident #7 on 04/25/24 on the 7:00 AM to 7:00 PM shift. She stated Resident #7 did not receive his lorazepam that day and was anxious all day. NA #7 explained Resident #7 repeatedly rang his call light to request his lorazepam, was sweating and shaking, and requested she text his mom and ask her to come to the facility on [DATE]. She stated she texted Resident #7's mom as he requested and tried to reassure Resident #7 that Nurse #17 was working on getting his medication throughout her shift. A telephone interview with Resident #7's mother on 05/06/24 at 11:02 AM revealed 2 nurse aides (NAs) called her on 04/25/24 from Resident #7's cell phone per his request (she was unsure of the exact time of the call) because he had not received his lorazepam. She stated the NAs informed her Resident #7 was in a panic and he wanted her to come to the facility to help him calm down. Resident #7's mother stated she came to the facility to check on Resident #7 and he was panicky and did not want her to leave. She stated she spoke with Nurse #17 on 04/25/24 and the nurse confirmed Resident #7 was out of lorazepam and she was trying to get the medication from pharmacy. Resident #7's mother stated she later found out Resident #7 did not receive any doses of lorazepam on 04/25/24. A telephone interview with the Medical Director on 05/07/24 at 3:06 PM revealed when residents ran out of medication, the on-call Nurse Practitioner (NP) was notified of the need for a prescription refill and a temporary prescription was issued until the regular delivery shipment of medications was received from the pharmacy. He stated he was not notified Resident #7 missed 3 scheduled doses of lorazepam on 04/25/24 and confirmed that would be a significant medication error for Resident #7 and would result in an increase in anxiety. A joint interview with the Assistant Director of Nursing (ADON) and Director of Nursing (DON) on 05/08/24 at 1:12 PM revealed Nurse #17 notified the ADON on 04/25/24 that Resident #7 was out of his scheduled lorazepam and needed a new prescription. They stated in hindsight, they would have asked the provider to send an electronic prescription for the lorazepam to a local pharmacy and staff would pick it up rather than waiting on the medication to arrive from the facility pharmacy located in Hickory, NC. An interview with the Administrator on 05/10/24 at 4:15 PM revealed it was her understanding that nursing staff had a difficult time getting Resident #7's prescription refilled for lorazepam and when the prescription was obtained and sent to pharmacy, the medication did not arrive in the pharmacy delivery (she could not recall the date). She confirmed Resident #7 missed 3 scheduled doses of lorazepam on the day in question. The Administrator stated in hindsight the Medical Director should have been contacted and a prescription for lorazepam called in to a local pharmacy and picked up, so the resident did not have to miss multiple doses of scheduled medication.

Based on record review, observation, and interviews with resident, staff, and the Medical Director, the facility failed to use a mechanical lift to transfer a non-ambulatory resident (Resident #1) for 1 of 3 residents reviewed for accidents. Resident #1 sustained a distal femoral periprosthetic (structure in close relation to an implant) fracture of the left knee after Nurse Aide #1 attempted to transfer her from bed to wheelchair by putting his hands on her and supporting her by holding the back of her pants after her knees buckled as soon as she stood up. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (stroke), generalized muscle weakness, and cognitive communication deficit. Resident #1's care plan initiated on 7/18/23 indicated Resident #1 had an activities of daily living self-care performance deficit related to stroke. She did not stand or ambulate. She preferred to remain in bed much of the time. Resident #1 required mechanical lift with staff assistance for transfers. Resident #1's care plan further indicated that she was at risk for further injury from falls related to impaired cognition. She believed that she could walk but she had not ambulated in over three years per her family member. Interventions included mechanical lift for transfers and no ambulation. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was severely cognitively impaired and required extensive assistance by one person physical assist with bed mobility. Transfer occurred only once or twice during the assessment period, and she required extensive physical assistance. She also required substantial/maximal assistance with lying on her back to sitting on the side of her bed. An untitled and undated report sheet listed all the residents on 200 hall with their shower information, assistance needed, transfer and continence status. Included in this list was Resident #1 and it indicated that she required total assistance and used a mechanical lift for transfers. An incident report dated 11/7/23 at 8:30 AM for Resident #1 indicated that at approximately 8:30 AM, the nurse aide (Nurse Aide #1) was getting Resident #1 up for breakfast when the nurse (Nurse #1) informed him that the resident did not get up for breakfast. Nurse #1 continued with her medication pass when Nurse Aide (NA) #1 came out of Resident #1's room and stated that she was on the floor and asked if she would help him get her back into bed. Nurse #1 asked what happened and was told that her legs gave out while transferring her to the wheelchair from the bed, and that he assisted her to the floor to get help. Nurse #1 walked into the room and Resident #1 was sitting on the floor. She performed a head to toe assessment and took her vital signs. Resident #1 denied hitting her head or having any pain other than left knee pain. Vital signs were within normal limits and two nurse aides (NA #1 and NA #2), and Nurse #1 helped Resident #1 back into bed. Nurse #1 medicated the resident for pain and notified the Physician Assistant (PA) who was in house at the time of the fall. The PA assessed Resident #1 and ordered x-rays. Resident #1's family member came to visit and was notified. A typed statement of NA #1 taken via phone by the Interim Director of Nursing on 11/10/23 indicated that on 11/7/23 early morning, Resident #1 was trying to get out of bed. The resident said she could walk. NA #1 said let's try. Resident #1 slid to the floor and landed on her knees. There was no one else in the room at the time. NA #1 called for assistance. Nurse #1 and NA #2 helped NA #1 pick her up to put her back in bed. NA #1 told Resident #1's family member what happened when she came to the nursing station later day. An initial phone interview with NA #1 on 11/28/23 at 4:15 PM revealed during the fall incident on 11/7/23, Resident #1 slipped and fell to the floor from her bed. NA #1 stated that right before the incident, he asked her if he needed to use a mechanical lift on her and she told him no. Resident #1 had stated she was able to walk and get up by herself and that she had been working with therapy. She tried to get up and slid to the floor while he tried to ease her to the floor. A follow-up phone interview with NA #1 on 11/29/23 at 10:39 AM revealed when he was assigned to care for Resident #1 on 11/7/23, he was not familiar with Resident #1 but when he went into her room, she was anxious, and she was trying to get up. Her upper body was up but her legs were still on the bed. NA #1 stated that this was the first time he saw Resident #1 moving in her bed and she usually stayed in her bed. NA #1 stated that he told her to slow down, hold on and wait but he couldn't stop her from getting on her feet. NA #1 stated that he was not aware of Resident #1's transfer status and he did not receive report from the outgoing shift. NA #1 denied being told by Nurse #1 not to get up Resident #1 for breakfast. NA #1 further revealed that he usually asked his residents if they wanted to get up or not, and whether he needed to use a mechanical lift or not. He stated he did not know anything about a report sheet or a Kardex and that the facility did not have a system of communicating the transfer status of each resident to the nurse aides especially to the agency aides. NA #1 stated that he was an agency aide, and he was used to this practice at any facility he worked. He emphasized that Resident #1's fall was not his fault and that it was Resident #1's fault because she told him that she could stand up and she even said to him to get out of her way. Then she slid down to the floor from a sitting position on the side of her bed. NA #1 shared that Resident #1 was not able to stand up on her legs when her legs gave out, so he supported her by holding the back of her pants through the waist. Resident #1's buttocks hit the floor first with her legs straight out in front of her. NA #1 alerted Nurse #1 who came to the room to assess Resident #1. NA #1, NA #2 and Nurse #1 assisted Resident #1 off the floor back to her bed by manually lifting her up as directed by Nurse #1. NA #1 and NA #2 lifted Resident #1 by holding her under each arm while Nurse #1 held Resident #1's ankles. A typed statement signed by Nurse #1 on 11/12/23 indicated that on 11/7/23 at approximately 8:30 AM, NA #1 was getting Resident #1 up for breakfast. Nurse #1 informed him that Resident #1 did not get up for breakfast. Nurse #1 continued with her medication pass. NA #1 came out of Resident #1's room and stated that she was on the floor and asked if she would help him get her up and back to bed. Nurse #1 asked him what happened. NA #1 told Nurse #1 that as he was transferring her from the bed to the wheelchair, she had weakness in both legs, and he assisted her to the floor. Nurse #1 walked in the room and did a head-to-toe assessment and took her vital signs. Resident #1 was complaining of left knee pain. Two nurse aides and Nurse #1 assisted her off the floor to bed. Nurse #1 medicated her for pain, notified the PA who was in-house at the time of her fall. The PA assessed Resident #1 and ordered x-rays. Resident #1's family member came in to visit and was notified. A phone interview with Nurse #1 on 11/29/23 at 10:28 AM revealed on the morning of 11/7/23, NA #1 was getting the residents up for breakfast and he went into Resident #1's room to get her up. Nurse #1 stated that she told NA #1 that Resident #1 usually stayed in bed for breakfast, but NA #1 stated that Resident #1 was on his list of residents to get up, so he was going to get her up. Nurse #1 stated that she proceeded with her medication pass when she heard NA #1 asking for help in Resident #1's room. NA #1 told her that he was transferring Resident #1 from the bed to her wheelchair and both of her legs gave out. NA #1 assisted Resident #1 to the floor. Nurse #1 shared that she obtained Resident #1's vital signs and assessed her for any signs of injuries. She asked Resident #1 if she was having any pain and Resident #1 complained of pain of the left knee. After she assessed that Resident #1 was safe to be moved off the floor, NA #1 and NA #2 both grabbed under each arm while Nurse #1 held both ankles. Nurse #1 stated that Resident #1's legs were straight out, and she tried to move her legs as little as possible, so she grabbed her by both ankles. Nurse #1 further revealed that Resident #1 complained of pain the whole time they moved her from the floor to the bed. She stated that Resident #1 usually favored her left side and she tended to lean towards the left and when she was back in the bed, she complained of pain to the whole left lower extremity from the hip to the ankle. Nurse #1 propped Resident #1's left leg on a pillow and when she palpated over her left knee, Resident #1 complained of pain. Resident #1 was not able to give a pain rating, but she was crying and grimacing. Nurse #1 did not observe any obvious deformities. She medicated Resident #1 for pain with Acetaminophen and notified the PA who was at the facility at that time. The PA ordered an x-ray and then she notified Resident #1's family member. Nurse #1 further shared that she was not entirely sure about Resident #1's transfer status and that she would have to look it up, but she knew that the nurse aides had a report sheet that indicated the residents' transfer status. Nurse #1 stated that since being back from the hospital, Resident #1 had not been eating much and she stayed asleep all the time because they kept her medicated for pain. Nurse #1 said that she asked Resident #1 frequently about her pain level and she received pain medications as needed. Resident #1 did not get up out of the bed anymore and had refused to get up due to pain on her left knee. Nurse #1 stated that prior to the fall, Resident #1 was not able to get herself to a sitting position on the side of the bed. She required total assistance from staff to do this. Resident #1's November 2023 Medication Administration Record (MAR) indicated Resident #1 was monitored for pain every shift. On 11/7/23, she had a pain level of 7 out of 10 (0 being no pain and 10 being severe pain) on the day shift after the fall and she received Acetaminophen 650 milligrams (mg) at 9:00 AM. During the evening shift on 11/7/23, she was assessed as having pain level of 3 out of 10 but she did not receive any pain medication. On 11/8/23, Resident #1 had a pain level at 8 out of 10 and was given Acetaminophen 650 mg at 2:07 PM. An interview with NA #2 on 11/29/23 at 2:28 PM revealed she was the other nurse aide who worked with NA #1 on 11/7/23 but she was assigned to the other side of the hall. NA #2 stated that Nurse #1 alerted her and told her that she needed assistance with a fall. When she entered Resident #1's room, NA #1 was in the room with Resident #1 who was sitting up on the floor. NA #2 stated she grabbed the mechanical lift to get Resident #1 off the floor, but the mechanical lift would not lower all the way down to the floor. NA #1 stated the battery probably needed to be charged so they couldn't use the lift. Nurse #1 instructed NA #1 and NA #2 to grab Resident #1 under both arms while Nurse #1 grabbed her ankles. NA #2 stated that she had not taken care of Resident #1 before the fall incident and was not familiar about what her transfer status was at that time. NA #2 shared that the residents' transfer status information could be found in a report sheet at each of the nurses' station and copies were kept in a folder. NA #2 stated that these sheets were given to the nurse aides especially the agency aides and they used them as reference so they would know how to take care of each resident. A progress note dated 11/7/23 by the Physician Assistant (PA) indicated Resident #1 reported sliding out of chair to the floor, landing on her bottom and pain going all the way from her left hip to left knee, difficulty moving her leg. She did not believe she had lower back pain but did land on her tailbone. She denied numbness or tingling in extremity but reported left hip and left knee pain. She recently took Acetaminophen and Ibuprofen with some pain relief, but still hurting. She denied hitting her head. No loss of consciousness. No chest pain or shortness of breath. Resident #1's family member present during exam. No erythematous (red) or bruised joints noted. No joint tenderness over left ankle. Significant knee joint line tenderness on exam and painful range of motion. Mild diffuse left hip discomfort and hip range of motion. Unable to examine the patient's coccyx as she was unable to turn due to left leg discomfort. Sensation in extremities grossly intact and capillary refill normal in toes. Pedal pulses present bilaterally. Lower extremities of equal length, without rotation. Plan: Concerned with patient joint pain, significant weight, and history of injury. Ordering left hip and left knee x-ray as well as sacrum/coccyx x-ray. Non-weightbearing until x-ray results are in. Putting on hold order to change position every 2 hours due to concern of possible fracture. No evidence of neurovascular compromise on exam. Continue monitoring. Acetaminophen as needed for pain. Nursing to report if pain not well-controlled. A review of the physician's orders dated 11/7/23 in Resident #1's medical record indicated the following: coccyx x-ray 2 views, left hip x-ray 2 views, left knee x-ray 2 views to rule out fractures, no weight-bearing until x-ray results are in. A progress noted dated 11/8/23 by the Medical Director (MD) indicated Resident #1 continues with pain at left knee today. X-ray was ordered, results arrived at noon on 11/8/23 and showed fracture of the distal medial condyle of left femur (inner part of the upper expanded section of the thighbone) with prosthesis noted. She was placed on non-weightbearing status and hold on every two hour positioning order yesterday. Patient is at higher risk for fracture at this site due to prosthesis, female and age over [AGE] years old. Suspect osteopenia (condition that occurs when the body doesn't make new bone as quickly as it reabsorbs old bone) due to her limited mobility and postmenopausal status. Immediately following review of the results, emergency medical services (EMS) was contacted, and resident transported to emergency department (ED). Resident #1's hospital discharge summary dated 11/10/23 indicated she was transferred to the hospital on 11/8/23 after presenting for left knee pain after a reported fall at the nursing facility where she resided. Radiographic imaging of the knee demonstrated complex fracture. Computed tomography of left knee showed mildly impacted distal femoral periprosthetic fracture. She was admitted to orthopedic surgery with hospital medicine consulting. Initially, they had planned for surgery but ultimately (the Orthopedist) opted for non-operative conservative care due to the patient's underlying medical conditions and baseline mobility limitations. Per family, she was bedbound at baseline and had been for the last three years. Because of her baseline status and the fact that she had no operative needs, she was discharged back to her living facility. May take Ibuprofen and Acetaminophen for pain, as well as ice and elevation for pain and swelling. Non-weightbearing left lower extremity. Wear hinged knee brace on left lower extremity. Resident #1's November 2023 MAR further indicated that on 11/11/23, she was started on Gabapentin 300 mg by mouth two times a day for pain and on 11/16/23, she received a new medication order for Hydrocodone-Acetaminophen 5-325 mg 2 tablets by mouth every 6 hours as needed for moderate pain. An interview with Resident #1 on 11/28/23 at 10:41 AM revealed she did not remember what happened, but she remembered having fallen off the bed. Resident #1 stated that she broke her leg, but she was not sure which one. Resident #1 stated her leg hurt whenever they moved her, but she couldn't rate her pain level. She also stated that she was currently working with therapy but did not know how often therapy worked with her. During the interview, Resident #1 kept dozing off after each question. An observation of personal care on Resident #1 was made on 11/28/23 at 10:53 AM. Resident #1 was lying in bed asleep with her left leg elevated on a pillow with a knee immobilizer in place. Resident #1 had soft boots in place on both feet. Although Resident #1 was given a pain medication prior to care, she complained of intermittent pain whenever she was turned and moved in bed. She was observed grimacing and would say ow, that hurt. She was unable to rate her pain level. An interview with the Rehabilitation Manager (RM) revealed therapy worked with Resident #1 from July to August 2023 but she only worked with Occupational Therapy (OT) and Speech Therapy. The RM stated that Resident #1 refused an evaluation with Physical Therapy (PT). She stated that Resident #1 was admitted to the facility with a history of a left knee fracture for which she had a prosthesis, so she did not like therapy and did not receive an evaluation from PT because she refused to get up and be moved off her bed. The RM stated that since Resident #1 did not receive a PT screen upon admission to the facility, her transfer status would be obtained from her past medical history. During the interview, the RM pulled up Resident #1's discharge summary from another facility from which she came and noted that Resident #1 was listed as non-ambulatory. The RM stated that using a mechanical lift would be the safest way to transfer Resident #1. She shared that this information was in Resident #1's medical record but she would have to look it up. The RM stated that she found out about Resident #1's fall wherein she obtained a leg fracture, and she did not know how it could have happened. She said that she found out later that a staff member had attempted to transfer Resident #1 without using a mechanical lift. The RM stated that if Resident #1 was attempting to get up from the bed unassisted and she witnessed this, she would have called for help from another staff member and educated Resident #1 to stay in bed until they could get a lift because it was not safe to move her without using a mechanical lift. The RM further shared that after Resident #1 came back from the hospital, PT and OT had started working with her, but she had refused three out of five treatments from PT and said that it was painful, and she was not participating. She was not able to state whether she would have had the ability to get herself to sitting position on the side of the bed prior to the incident because PT never worked with her, and they never got her up out of the bed. An interview with the Medical Director (MD) on 11/29/23 at 12:27 PM revealed the PA was informed that Resident #1 had slid out of chair to the floor, but the MD stated that she did not know that a staff member had attempted to transfer her without using a mechanical lift. The MD stated attempting to let Resident #1 ambulate and stand up possibly led to the fracture on her left leg and this could have been avoided if they had used a mechanical lift on her. An interview with the Interim Director of Nursing (DON) on 11/29/23 at 11:17 AM revealed during her clinical review on 11/8/23, she noted that Resident #1 had been complaining of pain, so she placed her on the doctor's list to be seen for management of pain. The Interim DON stated clinical review included reading the 24-hour report. Resident #1 was noted to have a fracture on her left knee near her prosthesis, so this was reported to the Administrator, and they started an investigation. The Interim DON stated she only found out about the fall incident when Resident #10 was coming back from the hospital on 11/10/23. The Interim DON stated she interviewed the nurse on 11/12/23 and found out that Resident #1 had a fall that was not reported to her, but it was reported to the PA. The Interim DON stated that she was not satisfied with the care approach by NA #1 and when she interviewed him, he stated to her that he didn't know how to care for the resident. He said he did not ask other staff members and attempted to get Resident #1 up without using a mechanical lift. He told her that Resident #1 slid down to her knees when she fell , and he also told her that he didn't know how to transfer Resident #1. The Interim DON stated she had educated NA #1 about where to find information regarding transfer status, but he wasn't receptive, and he would not take responsibility for Resident #1's fall. The Interim DON stated this education was just verbal and she didn't document this anywhere, but she did it before he took his first assignment. The Interim DON stated Resident #1 should have been transferred using a mechanical lift with two staff members assisting. She added that she did not believe that Resident #1 was trying to get out of bed on her own because she did not have trunk control and in order to sit up on the edge of her bed, he must have assisted her to do that. The Interim DON stated the nurse should have filled out an incident report and documented the fall incident in Resident #1's medical record. After she found out about the fall, the Interim DON asked Nurse #1 to fill out an incident report for Resident #1's fall on 11/7/23. An interview with the Administrator on 11/30/23 at 5:05 PM revealed she learned of Resident #1's fall on 11/7/23 when it was reported at the clinical team meeting. Her initial understanding was that it was an injury of unknown origin, and they did not know how the injury occurred. The Interim DON started an investigation which involved talking to the staff members who were involved, and other staff members were working that day. Resident #1 was immediately assessed but she could not say anything about the fall. An x-ray was obtained which revealed a fracture. The Administrator stated when she talked to NA #1, he stated that he had just walked in to the building, and he happened to walk by the room. He immediately tried to assist Resident #1 to the floor. NA #1 told her that he learned from Resident #1's family member that Resident #1 tried to get up all the time, thinking that she could walk. The Administrator stated that NA #1 presented the situation as if he had assisted her from falling on her face and he just intervened. After the Interim DON talked to him, they decided to place him on Do Not Return status on 11/9/23.

Based on observations, record review, staff, friend, Physician Assistant (PA), and Medical Director (MD) interviews, the facility failed to prevent a resident with severe cognitive impairment and a history of wandering and exit seeking behaviors, from exiting the facility unsupervised and without staff knowledge for 1 of 3 sampled residents (Resident #2). During the evening hours on 08/11/23, the Business Office Manager observed Resident #2 approximately 150 yards from the facility walking in the direction of a two-lane main road approximately 100 yards away. The Business Office Manager was able to intercept and escort Resident #2 back to the facility before he reached the two-lane main road which was located on a blind curve and directly across the two-lane road was a wooded area. The posted speed limit sign on the main road was 35 miles per hour (mph) and in the blind curve the posted speed limit was 25 mph. Immediate jeopardy began on 08/11/23 when Resident #2 exited the facility unattended and wandered approximately 150 yards from the facility exit door. Immediate jeopardy was removed on 09/08/23 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place and the completion of staff education. The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses that included early onset Alzheimer's disease, non-Alzheimer's dementia, and depression. A review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had severe cognitive impairment. Resident #2 was not coded with wandering behaviors during the 7-day lookback but indicated he ambulated in his room and in the corridor. Review of Resident #2's care plan revealed he was care planned for wandering and read in part; It is unsafe for me to leave this facility; however, I may attempt to do so. I wander without purpose. I sometimes wander into others' rooms or will attempt to get on the elevator. 8/11/23- exited facility, 8/14/23- trying exit doors two times, 8/23/23-Trying exit door. The care plan was initiated on 07/24/2023 and last updated 08/23/23. An Elopement Evaluation was completed dated 07/20/23, Resident #2 scored not at risk for elopement. Two separate Elopement Evaluations forms dated 08/02/23 were started for Resident #2 but were incomplete. Review of a nurse's progress noted dated 08/3/23 at 6:06 PM, read the patient continues with wandering, urinating / defecating in inappropriate places. He has wandered today and has been exit seeking. Patient redirected as able. Will continue to observe and note behaviors as they occur. Will redirect patient as able during times of these behaviors and provide hygiene and safety measures as necessary. The note was written by Nurse #4. Review of a nurse's progress note dated 08/9/23 at 12:37 AM read, wandering, urinating /defecating in inappropriate places. Resident resting in bed with eyes closed. Wandering on and off unit, not in any inappropriate areas noted so far this shift. The note was written Nurse #6. Review of a nurse's progress note dated 08/11/23 at 12:00 PM, read patient has been wandering hallways per usual. The resident had no abnormal urination or defecation and was not noted to be in places he should not be. However, he does have bladder incontinence then walks through the hallways. Staff redirects the patient to toilet, then incontinence care. No complaints or complications noted. No exit seeking behaviors currently. The progress note was written by Nurse #4. Review of an Incident Report dated 08/11/23 at 6:33 PM, revealed that Resident #2 was found outside of the building, and he was returned to the building and assessed. No other information or details were provided about the elopement. The incident report was completed by the Unit Manager. Review of the recorded weather on 08/11/23 for the facility revealed at 6:00 PM, it was 80 degrees Fahrenheit with fair skies and winds at 3 miles per hour. Source - weatherunderground.com. On 08/24/23 at 9:00 AM an observation of the area where Resident #2 eloped on 08/11/22 was located revealed a gravel/dirt path that descended towards the main road. This path was also used as the ambulance/emergency pick-up location. From the top of the path where the hallway 400 doors open, was approximately 250 yards to the two-lane main road which was located on a blind curve and directly across the street was all a large, wooded area. The posted speed limit sign on the main road was 35 miles per hour (mph) and on the blind curve the posted speed limit was 25 mph. A continuous observation on 08/23/23 from 10:44 AM to 10:59 AM of Resident #2 was made and revealed he was walking around all the hallways alone and stopped at various exit doors to look outside. Resident #2 appeared to be inspecting the door and would bend down to look at the door jam and various structures associated with the exit door. In an interview on 08/24/23 at 9:42 AM with the Business Office Manager, he reported that since April 2023, when he started working at the facility, Resident #2 had been a wanderer but hadn't tried to get outside until about 2 weeks ago and was becoming more aggressive in his attempts to exit the building. He stated he recalled that on 08/11/23 it was a hot day and around 6:00 PM - 6:01 PM and he was getting into his car to go home. He stated he saw Resident #2 walking down the gravel/dirt pathway on the 400-hall side of the building. He stated Resident #2 was approximately 150 yards from the exit doors and approximately 100 yards from the main road when he called out to Resident#2 and had to move quickly to intercept Resident#2 as he was a fast walker. He stated there were no staff members following behind him. He stated Resident #2 was wearing pants, t-shirt, tennis shoes, and carrying a coffee cup. He stated he was at the bottom of the pathway, and he yelled out to Resident #2 asking him where he was going. He stated Resident #2 pointed towards the main road, which was about 100 yards away and he kept walking at a fast pace towards the road. The Business Office Manager stated he went to Resident #2 and was able to re-direct him and walked him back into the main entrance and took him up the elevator back to the 200 hallway and he notified the nursing staff. An interview on 08/23/23 at 2:33 PM with Nurse #4, she stated she worked on the 100-200 hallway and took care of Resident #2 almost every day. She stated she was Resident #2's nurse and worked on 08/11/23 when he eloped. She recalled the Business Office Manager brought Resident #2 back to the 200 - hallway from outside and told everyone at the nurses' desk where he found Resident #2. She stated they did not know Resident #2 had gotten out of the building until the Business Office Manager brought him back to the floor. The Director of Nursing and Unit Manager came to the desk and were told about the elopement. The Director of Nursing and Unit Manager stated Resident #2 would be a 1:1 for a while. She stated nothing seemed different about his behavior that day before he exited the building. In an interview on 08/23/23 at 3:40 PM with Nurse Aide (NA) #1, she stated they discussed the residents who were elopement risks in report before their shifts started. She stated she worked the day Resident #2 exited the building on 08/11/23. She stated she didn't know how he got outside without being seen. She stated the permanent NAs knew the residents well but not all the agency NAs knew the residents as well. She stated she tried her best to keep an eye on the at-risk residents, but it was hard because she was so busy completing her patient care duties. An interview with the Unit Manager on 08/23/23 at 1:15 PM revealed Resident #2 had been wandering for a long time, but just started trying to get outside about 2 months ago and he was getting worse. She stated he roamed all day/night, and all the staff knew to watch out for him. She stated they had started him on new medications less than a week ago and hoped it would help with his wandering and agitation behaviors. She stated the elevator and stairwell, that led down to the lobby were next to the 300 nurses' station and were secured. She stated the elevator was key controlled and the key was kept in a drawer on the 300 nurses' station. The Unit Manager stated the stairwell was code pad controlled and they had to push 2 numbers at one time and then a single number which made it harder to manipulate. She stated all their exit/emergency doors that led outside had a regular alarm and an extra loud screamer alarm. She stated if anyone pushed the door push bar the first alarm would go off, and if the door was pushed open the screamer alarm would go off. She stated their Social Worker was trying to find Resident #2 placement at a facility with a locked unit. The Unit Manager stated Resident #2 had gotten out of the building on 08/11/23, and he left the building through the 400 exit/emergency door which was on the same floor as his room. She stated after Resident #2 exited through the 400-hallway door he walked down a gravel path when the Business Office Manager saw Resident #2 walking down the path. She stated they had an elopement book at each nurse's station, and all the departments discussed at the beginning of each shift which residents were elopement risks, so everyone knew who to keep an eye on. She stated after Resident #2 got outside on 08/11/23, they put him on 1:1 supervision and they continued that until his behaviors were under control and then they started every 15-minute safety checks. The exit/emergency door alarm went off, but the screamer alarms were not in place until after he eloped. An interview with Resident #2's friend on 08/23/23 at 2:31 PM explained that Resident #2 was an avid hiker/walker and had been his whole life. He was very agile and walked or hiked frequently before coming to the facility and loved being in the woods. An interview with the facility's Social Worker on 08/23/23 at 2:49 PM stated that Resident #2 was an avid hiker and walked constantly. She stated that she had been looking for alternate placement for Resident #2 on a locked unit but had been unsuccessful at this time. An interview was conducted on 08/23/23 at 12:52 PM with Nurse #3 who stated she usually worked the day shift on the 100-200 hallway and cared for Resident #2 frequently. She stated Resident #2 was known for always walking around in the halls, but the exiting behaviors had just started recently. She stated the permanent staff knew him well and watched him closely. An observation was made on 08/23/23 at 3:27 PM when the Social Worker and a nurse started running to the 400 hallway to see why the alarms for the exit/emergency doors at the end of the 400 hallway were going off. The Activities Assistant came out of the activity room which was directly next to the exit doors and told the Social Worker and nurse that she heard the alarm and came out of the activity room and found Resident #2 standing at the 400 hallway doors pushing the door push bar which sounded the alarm. She stated the doors never opened and he never went outside. She stated she had re-directed Resident #2, and he went back down the hall in the opposite direction. In an interview with the Director of Nursing on 08/24/23 at 1:43 PM, she stated although she had not been working at the facility for very long, she was familiar with Resident #2. The Director of Nursing stated he was a wanderer and exit seeking resident. She stated she was aware he had gotten out of the facility a few weeks ago and knew they placed him on 1:1 supervision until the exit seeking behaviors ceased which she thought was a for a few days. The Director of Nursing stated his behaviors of going to the exit doors or standing by the elevator, had slowed down so now he was on every 15-minute safety checks. She stated she was not aware he pushed the 400-hallway exit/emergency doors push bar yesterday (08/23/23), and she did not hear the alarms. She stated they had realized that many of the staff members did not know about Resident #2's exit seeking behaviors as well as some other at-risk for elopement residents. She stated she has started elopement in-services today that would be presented to all departments. In an interview on 08/23/23 at 3:35 PM with Nurse #2, she stated she was working on the hallway 300-400 medication cart. She stated they had discussed residents who were elopement risks in morning report, and she was aware Resident #2 was an elopement risk. She stated she tried to keep her eye on him, however, she was passing medications throughout the day and did not see him go to the 400 hallway doors today and hit the push bar. She stated they did have a good view of the 400 exit doors from the nurse's station, but she was not usually at desk. She stated she must have been doing something else when Resident #2 went to the 400 hallway doors. She stated the NA # 2 who was working with her had also been very busy taking care of residents. She stated it was difficult to manage a patient care assignment and watch wandering residents as well. In an interview on 08/24/23 at 11:38 AM with the Central Supply-Maintenance Manager, he stated all the exit/emergency doors had their own alarms. He stated when the door push bars were pushed on all exit/emergency doors the regular alarms would sound at 15 seconds and the regular alarm were not very loud. He stated after Resident #2 exited the 400 hallways exit/emergency doors, he suggested they add screamer alarms, in addition to the regular alarms, to all the exit/emergency doors. He stated the screamer alarms had now been put into place on all the exit/emergency doors and they were loud at 120 decibels (sounded like a siren on an emergency vehicle), and they would sound off the minute the door opened. Observation on 08/23/24 at 11:50 AM with the Central Supply-Maintenance Manager, revealed the regular alarm on hallway 400 exit/emergency doors worked after 15 seconds of pushing the door push bar, but when the door was opened the screamer alarm did not work. The Central Supply-Maintenance Manager noticed that the screamer alarm was not set. The Central Supply-Maintenance Manager then re-set the alarm so it would sound off if the doors were opened. The Central Supply-Maintenance Manager was unable to state when the door alarm was last checked because daily logs were not kept. He stated the batteries and alarms were to be checked by the Manager on Duty on the weekends, after any elopement, and a minimum of once a week. He stated he just developed and initiated a log for the alarm checks to be documented. He stated education about checking the screamers and how to set them to the ready to activate had been by word of mouth, but he was going to put together some formal education. During an interview on 08/23/23 at 3:52 PM with the Activities Assistant, she revealed that she knew a few of their residents were elopement risks but could not recall their names or describe them. She stated she was not aware there was an elopement notebook with pictures of the residents who were at risk for elopement. She stated she really didn't know exactly what she was personally supposed to do when an alarm went off, but she knew they would have to figure out if a resident got outside and then find them. Observation on 08/24/23 at 11:30 AM revealed Resident #2 was standing around the elevator and stairwell area next to the 300-400 nurse's station. The elevator key which was attached to a large rectangular piece of brown wood was unsecured on the top corner of the nurses' station counter corner closest to the elevator. An observation on 08/23/23 at 2:50 PM of Resident #2, revealed he was walking to the end of the 300 hallway, when he got to the exit/emergency doors he stopped, stared, and lightly touched the doors for approximately 3 minutes. Resident #2 then turned and walked away and went down the main facility hallway. The staff at the 300 nurse's station desk, Nurse # 2, and Nurse Aide # 2, were not watching him as they were busy with tasks. In a phone interview on 08/28/23 at 9:30 AM with the lobby receptionist, she reported she would watch when people came off the elevator or out of stairwell to ensure no residents were coming down to the lobby unattended. She stated she had an elopement notebook with pictures of the residents who were at high risk of eloping at her desk. She stated she knew they had some residents who would try to escape out of the building, and she was able to name several residents including Resident #2. She stated she recalled Resident #2 came down the elevator about 3 months ago with family members of another resident. She stated she received a call from someone upstairs, she thought it might have been their previous Director of Nursing and was told Resident #2 had gotten on the elevator before they could stop him, and he was on his way down. She stated she was ready and met him and re-directed so he didn't go outside. She stated she could not remember who came down and took Resident #2 back upstairs. She stated all the Administration and Nursing staff were aware of the incident because everyone was talking about it. She thinks the Administrator came out to the lobby when Resident #2 was there, but she was not sure. A phone interview was conducted on 08/28/23 at 4:23 PM with the previous Director of Nursing and she stated that in early June 2023, Resident #2 absolutely did get on the elevator with family members of another resident and got down to the lobby unattended. She stated she could not remember the exact time, but it was after lunch and before 3:00 PM. She stated all the Administration team, and all the department heads, were aware of the event because they discussed it on the same day of the event during their 3:00 PM stand-down daily meeting. She stated no one saw Resident #2 get on the elevator, but he must have been hanging around the elevator and slipped on when another resident's family got on the elevator. She stated he made it down to the lobby. The previous Director of Nursing stated the receptionist in the lobby called up to the floor and reported that Resident #2 was in the lobby. She stated she did not think he made it outside and could not recall who brought Resident #2 back up to the floor. She stated this event must have occurred between June 1, when the Administrator started working at the facility, and June 8, the last day she worked in the facility. She stated there were no changes or interventions put in place after Resident #2 made it down to the lobby. She stated they were not allowed to have enough staff, especially Nurse Aides, and could not have possibly watched all the wanderers adequately to ensure their safety. In a phone interview with a previous Social Worker on 08/28/23 at 4:55 PM, she confirmed that Resident #2 did get in the elevator and made it to the lobby unattended in early June 2023. The former Social Worker also reported Resident #2 had done the same thing in January 2023 when she first started working at the facility. She stated she could not recall much about the January 2023 occurrence because she had just started her job, but she knew Resident #2 had gotten on the elevator and made it to the lobby on his own. She stated the first time he got to the lobby via elevator she thinks the other Social Worker went to the lobby and brought Resident #2 back to the floor, and the second time the receptionist brought him back to the floor. She recalled on the second occurrence, someone from the lobby called up to the floor and said Resident #2 had come down the elevator and was in the lobby. She stated she was concerned about several of their wanderers and worried that they would elope because they did not have enough staff to watch those residents as closely as they needed to be watched. She stated she recalled after the second occurrence of Resident #2 getting down to the lobby, it was discussed on that same day in their stand-down meeting with the Administrator, Director of Nursing, and all other department heads. She stated it was a big discussion but does not recall any plans or interventions put in place for Resident #2's safety. In an interview with the administrator on 08/28/23 at 5:45 PM, she stated she had no recollection or knowledge of Resident #2 ever getting on the elevator and making it down to the lobby on his own. She stated Resident #2 had tried to get on the elevator at times, but he had never been successful which was why they started using an elevator key 2 years ago. In a phone interview on 08/25/23 at 5:15 PM with Physician Assistant #2, she stated she did not recall being notified that Resident #2 had eloped. She stated she had no documentation of his elopement in her notes, and she felt confident that she would have written a note and/or remembered if he had eloped. She stated Resident #2 was not safe to be outside unattended because he had progressive dementia and would not know how to get back to the facility if he wandered off. She stated if he wandered away, he would be in danger because he would not have his medications, someone may hurt him or take advantage of him, he could get hit by a car on the main road which was very close to the building, and there were many other bad things that could have happened to him. She stated she would like to see the staff watch him more closely and perhaps move him to a room furthest from the exits and closest to the nurse's station. Additionally, Physician Assistant #2 stated she felt Resident #2 needed 1:1 supervision. She stated she was going to review his medication for any adjustments that could possibly help. She stated she was going to reach out to the Medical Director on Monday for more assistance. She said she wished they could keep only permanent staff because agency staff came and went so frequently, and they didn't know the residents and that brought so much risk with no continuity of care. A phone interview was conducted on 08/28/23 at 5:41 PM with the Medical Director. She stated that the day after the elopement, the Director of Nursing had called her to report the elopement and they discussed changing medications and possible care plan interventions. The Medical Director stated Resident #2 would not be safe outside unattended as he could be injured or much worse, and an elopement was no small thing. The Administrator was notified of Immediate Jeopardy on 11/13/23 at 4:26 PM. The facility provided the following immediate jeopardy removal plan: The entity's removal plan must: o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; On 8-11/23 upon reentering the facility, the charge nurse completed a clinical assessment of Resident#2 to ensure that there were no injuries. None were noted. The Director of Nursing, (DON), initiated a head count of all residents to assure all residents were present in the facility. All residents were present. This action was completed on 8-11-23 by the clinical nursing staff, certified nursing assistants, the Unit Nurse Manager, and the Director of Nursing. Notifications were made to the facility Medical Director, (MD) and the responsible party of the event involving Resident #2. The Administrator notified the Social Worker on 8/11/23 of the responsibility for updating the elopement binders with any new admissions that are identified as elopement risk and to remove information for discharged residents from the elopement binders on a weekly basis this was completed on 09/08/23. The Clinical nursing staff began providing 15-minute checks upon Resident#2's reentry into the building on 8-11-2023 to 08/14/23. Then due to the continued exit seeking behavior of Resident #2, the clinical nursing staff were directed to assign 1:1 staffing with Resident #2 from 08/15/23-08/17/23 to ensure that this resident received constant supervision to ensure safety. 15 minutes were resumed on 08/18/23 and continue. This action was initiated on 8-11-23 after observation of continued exit seeking was noted by the clinical nursing staff. The Administrator also directed the Director of Maintenance to complete a facility door audit to ensure that all facility doors were functioning as designed. An audit was conducted on 8-11-2023. All exit doors were found to be in proper working order. In addition, the Director of Maintenance installed screamer alarms to the facility exit doors. The screamer alarms were placed on the exit doors on 8-11-2023 by the Maintenance Director. The Maintenance Director and Assistant Maintenance Director confirmed proper functioning of the screamer alarms on 8/11/23 at the time of installation. The residents care plan was reviewed and modified by the Minimum Data Set (MDS) Nurse on 8/14/23 to include additional interventions to ensure the resident's safety. Interventions implemented: 1) 1:1 supervision, 2) Divert me to an activity, 3) Offer me snacks. The Nurse Unit Manager notified the direct care staff of the modified care plan on 8-11-2023. The facility acknowledges that all residents that are cognitively impaired are at risk of this alleged deficient practice. On 8/11/23 the Nursing Unit Manager reviewed all resident's elopement risk assessments and made a list of those residents who were determined to be at risk for elopement. The list was shared with the Director of Social Work who then confirmed that each of those residents' information (resident face sheet and photograph) was current and in the Elopement Risk binder. This was started on 08/11/23 and completed on 09/08/23. The elopement books were placed at each nursing station by the Social Worker. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete The Administrator notified the Nurse Unit Manager on 8/11/23 of the need to provide education of the facility's elopement policy and procedures and the staff expectations for any exit seeking resident. On 8/11/23 the Administrator notified the Nurse Unit Manager and Director of Nursing of the need began in-services for all facility staff including (full time, part time, and contract agency staff) by the Nurse Unit Manager, Director of Nursing and Administrator on 8-11-2023. The education was provided by various methods including one on one, verbally through phone calls as well as group in-services. The educational in-service covered the content of increasing the awareness and knowledge of the staffing expectations and techniques when intervening with residents that are exhibiting exit seeking behaviors as well as the purpose of the elopement binders, where they are located (each nursing station and reception areas), the placement of screamers/alarms on the exit doors and how to operate them. The in-services were completed on 08/30/23. The educational material used included: 1) Elopement book protocol, 2) Code [NAME]/Elopement Protocol, 3) Emergency Door and Screamer Alarms. Validation of understanding was confirmed verbally during the in servicing, 4) Elopement Policy/Procedure. The Nurse Unit Manager and Director of Nursing were notified on 8/11/23 of the need to provide this education by the Administrator. The Nurse Unit Manager developed the educational material, and the in-services were provided by both the Unit Manager and Director of Nursing and Administrator. The Nurse Unit Manager, Director of Nursing and Administrator provided in-services to the night shift staff as they reported for duty for their 7:00 pm to 7:00 am shift. Weekend staff were educated by the Nurse Unit Manager while she was in the facility performing her Weekend Nurse Supervisor duties. On 8-11-23 the Administrator notified the Corporate Nurse Consultant to add the educational material described above to the new hire orientation packet. The Director of Human Resources tracked to see what employees had been educated by running an employee listing and as each of them in-serviced the staff, they checked those staff members off the list. Any staff that did not receive the education by 8/11/23 will not be allowed to work until they receive the education. The following process for identifying residents at risk for elopement is outlined below. The nursing staff were educated by the Nurse Unit Manager and Administrator on this process as part of the educational and in-services that began on 8/11/23. Elopement risk assessments are completed on admission by the licensed nurses on admission, quarterly and if a significant change in residents occurs. If the resident is assessed as an elopement risk, this information is communicated to the Leadership Team (Administrator, Director of Nursing, MDS Nurse, Social Worker) during daily clinical meetings. The Social Worker then completes the process of placing the information in the elopement book. The information is also included in the resident care plan by the MDS Nurse, who also updates the Kardex (care guide for staff). The Nurse Unit Manager and Administrator monitored and tracked the nursing staff to cross reference the scheduled staff that received in-services and compared to the staff that were not scheduled. The Nurse Unit Manager maintained a list of staff that required education prior to reporting to work. The Nurse Unit Manager was notified of this task on 8-11-2023 by the Administrator. The Elopement Policy and Procedure was added to the new hire orientation packets by the Administrator on 8-11-2023. The Administrator notified the Social Worker on 8/11/23 of the responsibility for updating the elopement binders with any new admissions that are identified as elopement risk and to remove information for discharged residents from the elopement binders on a weekly basis. The Social Worker will also review the information in the elopement books at that time to ensure the information and pictures are up to date. On 8/11/23 The Administrator reiterated to the Minimum Data Set (MDS) nurse the need to ensure that all residents identified as an elopement risk has a proper care plan initiated with the proper interventions noted and kept current and any significant changes will reflect the accurate interventions as it related to interventions to prevent any potential elopements. To ensure any agency staff that did not receive the in-service/education above, the Unit Manager notified the Charge Nurses on 8/11/23 of their responsibility to ask the Agency staff when they report for duty if they have received the education related to (expectations and techniques when intervening with residents that are exhibiting exit seeking behaviors as well as the purpose of the elopement binders, where they are located (each nursing station and reception areas), the placement of screamers/alarms on the exit doors and how to operate them prior to beginning work). If they report no, then the staff person will be educated prior to beginning work. Direct care staff and basic supervision of residents at risk is achieved through care delivery daily by staff using the process outlined above. On 2-21-2023 and 8-14-2023 the Social Worker began contacting other long term care facilities with secured units for possible placement of Resident # 2. IJ removal date is 09/08/23 Validation of the facility's credible allegation of IJ removal for supervision to prevent accidents was conducted on 11/21/23. The initial assessment of Resident #2 was reviewed, as was his care plan that was updated after his elopement on 08/11/23. Resident #2 was placed on every 15-minute check but his exit seeking behavior worsened so he was placed on 1:1 supervision until the exit seeking behaviors decreased. The 1:1 supervision and every 15-minute check logs were reviewed with no issues noted. Each exit door was observed with its own alar [TRUNCATED]

Based on observation, record review, resident, and staff interviews, the facility failed to treat a resident in a respectful and dignified manner when the Social Worker completed a Brief Interview for Mental Status (BIMS) assessment on 1 of 3 residents (Resident #12) reviewed for dignity and respect. This occurred while he was in the therapy gym with other residents and therapists in the same area of the gym. Resident #12 stated it made him feel embarrassed, singled out, and targeted. The findings included: Resident #12 was admitted to the facility on [DATE] with diagnoses which included type II diabetes mellitus, chronic pain, low back pain, and cellulitis. A Minimum Data Set (MDS) assessment had not been completed; however, according to the initial nursing assessment completed on 10/06/23, Resident #12 was alert and oriented to person, place, time, and situation. The assessment also revealed the resident required extensive assistance with transfers and his mobility was in a wheelchair. An observation and interview on 10/18/23 at 2:46 PM with Resident #12 and his family member revealed the resident sitting in his wheelchair in his room and was fidgeting in his chair, his eyes were wide open and he was sighing. Resident #12 stated he felt like he was being targeted by the facility administrative staff because the Social Worker (SW) had asked him personal questions in the therapy gym within a distance that both therapy staff and other residents could hear the interview. Resident #12 explained the SW abruptly walked in and looked at me and said I need to ask you some questions. The resident further stated he said okay not knowing what she had to ask him. He said she proceeded with questions that he felt she was asking to test my mental capacities. Resident #12 further stated he answered her questions but was embarrassed that the therapists and other residents in the gym could hear their conversation. He further explained he felt he had been singled out because he had complained yesterday about not getting showers as he preferred and felt like the facility was retaliating against him for complaining and filing a grievance. Resident #12 went on to say that he was not sure he felt safe staying in the facility because he felt like he was being targeted by the administrative staff. An interview was conducted on 10/18/23 at 3:23 PM with the therapy staff including the Rehab Director, Occupational Therapist #1, Certified Occupational Therapy Assistant (COTA) #1, COTA #2 and Physical Therapy Assistant (PT-A) #1. The Occupational Therapist (OT) #1 assigned to work with Resident #12 on 10/18/23 revealed she had completed her session with the resident when the Social Worker (SW) came into the gym and wanted to ask the resident some questions. The OT stated it was not typical that the SW came into the gym to interview residents while receiving therapy but said she stepped back to allow the SW to question the resident. She further stated after the interview Resident #12 seemed offended and was visibly upset according to his facial expressions. The OT indicated Resident #12 said to her, I don't know why she asked me those questions in here. She said she told him she probably asked those questions to complete her assessment of him for his record. The OT further indicated there were other therapists working with other residents in the gym that could have overheard the conversation between the SW and Resident #12. The Rehab Director and COTA #1 stated it was not typical for the SW to come into the rehab gym to question residents about anything and could not remember that ever happening before while therapy was going on with residents. An interview on 10/18/23 at 4:45 PM with the Social Worker (SW) revealed around 10:00 AM or 10:30 AM she had gone into the rehab gym and completed a Brief Interview for Mental Status (BIMS) assessment on Resident #12. She stated there were other residents and therapists in the gym and she was not sure if they could hear the conversation between, she and Resident #12 and said she had not asked him if it was ok to do the interview in the gym. The SW further stated she was in a hurry to get the assessment done because she was behind on her work and had been to the resident's room several times and couldn't find him in the room so she decided to do it in the gym. The SW was aware the resident had filed a grievance about not getting his showers and she had been told by the Unit Manager that he had received 2 showers and a bed bath since admission and they had resolved the grievance with him and he had received a shower just yesterday. She said there was no retaliation about the grievance, she said she simply was behind on her work and had to get the assessment done so she did while he was in the gym. The SW indicated she should not have done the interview in the gym but should have done it in the privacy of Resident #12's room. An interview on 10/18/23 at 5:15 PM with the Administrator revealed she was aware of the conversation with the SW and Resident #12 in the rehab gym. She stated she was not aware of the feelings of the resident and was not aware he felt like they were retaliating against him regarding the grievance. The Administrator further stated she had spoken with the resident about his grievance and it had been resolved and he had been showered yesterday. She indicated there was no retaliation for the grievance the SW was simply behind on the assessment and had taken the opportunity to do the interview in the therapy gym. The Administrator further indicated the interview with the SW and Resident #12 should have taken place in the privacy of the resident's room or in the privacy of the SW's office not in the rehab gym around other therapists and residents.

Based on observations, record review, and staff and Physician Assistant (PA) #1 interviews the facility failed to administer pain medication to Resident #1 after he yelled out loudly in pain and grabbed his right hip. A mobile x-ray completed at the facility noted a right hip fracture. No pain medication was administered to Resident #1 until he was evaluated at the hospital emergency department for treatment of the right hip fracture later that day. This deficient practice occurred for 1 of 4 residents reviewed for supervision to prevent accidents (Resident #1). The findings included: Resident #1 admitted to the facility on [DATE]. He had diagnosis that included history of pulmonary embolism, dementia, acute deep vein thrombosis, anxiety, restlessness, and agitation. Review of a physician order dated 07/30/23 read; Acetaminophen (Tylenol) 325 milligram (mg) give 650 mg by mouth every four hours as needed for pain. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. The staff assessment of pain revealed no signs verbal or nonverbal reported by Resident #1 during the lookback period. Review of Resident #1's Medication Administration Record (MAR) dated August 2023 revealed that no Acetaminophen was administered to Resident #1 while he was in the facility during the month of August. Further review of the MAR revealed that Resident #1's pain was assessed every shift and was recorded as a 0 as having no pain the entire month of August that Resident #1 was in the facility. Review of a late entry nursing note dated 8/16/23 written by Nurse #1 at 5:44 PM read in part, Resident #1 was noted to be yelling and screaming with combative behaviors upon arrival on shift. Resident #1 unable to be consoled with drinks, snacks, or one on one supervision. He continues to yell for his family. Nothing effective at this time. Staff attempted to stand Resident #1 to reposition, and he yelled loudly in pain and grabbed at right hip and grimaced then immediately sat back down in his wheelchair. Therapy was asked to evaluate Resident #1 as did PA #1 and ordered a mobile X-ray of right hip, pelvis, and femur. The mobile x-ray company was in the building and was able to obtain one view that showed a right femoral fracture. No reports of fall were noted. New order obtained to send Resident #1 to the ED for evaluation. Resident #1 was transported via stretcher to the local ED (emergency department) with all appropriate paperwork. This nurse later spoke with ED nurse who confirmed right hip fracture with surgery pending. Nurse #1 was interviewed via phone on 8/23/23 at 9:00 PM and revealed that she had worked on 8/16/23 from 7:00 AM to 7:00 PM. Nurse #1 stated that Resident #1 was already up in his wheelchair with no pants on when she arrived at work at 7:00AM, while sitting at the nursing station. She stated that Resident #1 was yelling however that he yells at his baseline. Nurse #1 stated that Nurse Aide (NA) #2 assisted Resident #1 back to his room to put on his pants. However, NA #2 was only able to get his pants on to his knees because Resident #1 would not stand up on his right leg to bear weight. Nurse #1 stated that she conducted a body assessment that revealed no bruising and no nonverbal cues of pain, nor did he verbalize any pain at that time, while he continued to be in his wheelchair. Nurse #1 stated that she attempted to assist Resident #1 to go to the bathroom, offered him snacks and drinks hoping that would help calm him down due to his yelling that was different. Resident #1 did not calm down initially however he began to self-propel in his wheelchair down the hall. Nurse #1 stated that Resident #1 self-propelled around the hallway with both of his feet in his wheelchair, but she wanted the Physical Therapy Assistant (PTA) to evaluate Resident #1's right hip. Nurse #1 stated that she knew something was wrong with his right hip as he could not bear weight on his right leg. When the PTA arrived at work, she took Resident #1 to the therapy gym to evaluate him at 9:45AM. After the PTA evaluated Resident #1, she reported to Nurse #1 that he would not bear weight and had complained of pain in the right hip area. So, Nurse #1 stated she contacted PA #1 who had just arrived at the facility around 10:00 AM to 10:30 AM. PA #1 evaluated Resident #1 and ordered an X-ray of the right hip, femur, and pelvis. Nurse #1 stated that the PTA assisted Resident #1 back to bed for the X-ray and he could lay comfortably on his left side but if turned on his back or right side would scream very loud (louder than usual) and verbally say that hurts, ouch and grabbed his right hip in pain. Nurse #1 stated that 45 minutes later, the x-ray results confirmed that it was a fracture of his right hip, and she obtained an order to send Resident #1 to the ED for evaluation. Resident #1 remained in bed until EMS arrived to transfer him to the ED. Nurse #1 confirmed that she did not administer anything to Resident #1 for pain despite being aware that he was hurting. Nurse #1 could not provide a reason why she had not administered any pain medication to Resident #1 on 08/16/23. NA #2 that worked with Resident #1 on 8/16/23 from 7AM until 7PM was unavailable for an interview. Review of a therapy encounter note dated 8/16/23 read Resident #1 demonstrated inability to take a step and favoring right lower extremity. Physical therapy assistant (PTA) asked Resident #1 if he was in pain and he stated, Yes, and indicated his right hip. Upon inspection Resident #1's demonstrated slight external rotation and edema to the right lower extremity when compared to the left lower extremity and pain with passive range of motion hip flex. The note was electronically signed by the PTA. An interview with the PTA was conducted on 8/24/23 at 2:19 PM and revealed that on the morning of 8/16/23 at 9:45 AM, she was asked by Nurse #1 to evaluate Resident #1 because he was not able to stand that morning. The PTA stated she took Resident #1 in his wheelchair to the therapy gym and asked the Occupational Therapy Assistant (OTA) to assist her in the evaluation of Resident #1. She stated that they stood Resident #1 up in the parallel bars but Resident #1 would lean to the left side and not stand on his right leg. The PTA stated she asked Resident #1 to stand on his right leg and he stated that he could not because it hurt. Resident #1 was assisted back to his wheelchair and gentle attempt at passive range of motion Resident #1 would verbalize pain and point to the right hip area. She added that she asked Resident #1 several times about his pain, and he consistently reported verbally pain in the right hip area and would point to the area. Upon closer inspection the PTA stated she noted Resident #1's right lower extremity to be swollen and slightly externally rotated. The PTA stated that the information from their assessment was relayed to Nurse #1 who then obtained an order for an X-ray. An interview was conducted with the Occupational Therapist Assistant (OTA) on 08/24/23 at 9:58AM and revealed on the morning of 08/16/23 she was asked to evaluate Resident #1 because he would not stand on his right leg. The OTA stated that she and the PTA took Resident #1 to the therapy gym in his wheelchair and stood him up in the parallel bars where he would not bear weight on his right leg. The OTA stated she asked Resident #1 to stand on his right leg and he stated he could not, so he was assisted back to his wheelchair. She added that the PTA attempted to lift Resident #1's right leg off the seat of the wheelchair and Resident #1 stated ouch that hurts. The OTA stated that they noted some swelling to his right leg and that it was externally rotated. She added that they reported their findings to Nurse #1 who obtained an order for an X-ray which showed a right hip fracture. Review of a progress note dated 8/16/23 at 1:00 PM written by Physician Assistant (PA) #1 stated that the chief complaint was, inability to ambulate, right hip and leg pain. His note further stated that, Resident #1 had advanced dementia, behavior disturbance and agitation presented for evaluation due to the inability to bear weight on his right leg with hip pain. Resident #1's Nurse and PTA noted that he was not able to bear weight and seemed to be in pain today when attempting to do so. He seems to be in apparent pain when moving his right lower extremity when sitting. Patient was unable to quantify or describe pain but does seem to grimace when palpating the right hip and when extending the right leg. Review of a physician order dated 8/16/23 at 11:17AM read: Right Hip and pelvis x-ray femur, tibia, and fibula. Review of an x-ray report dated 8/16/23 at 12:50 PM read: Acute intertrochanteric right femoral fracture as noted. Review of physician order dated 8/16/23 at 2:15PM read: Send to ER for right hip break. PA #1 was interviewed via phone on 08/25/23 at 3:30 PM and stated that Resident #1 did not verbalize his pain however Resident #1 grimaced during PA #1's assessment. he explained Resident #1 had behaviors and at that point he would not have prescribed any significant pain medication. He stated the X-ray was positive for a right hip fracture so he gave an order to send him to the hospital and would let EMS handle the pain medication. Review of an EMS run report dated 08/16/23 at 2:30 PM indicated that they were called to the facility for reports that Resident #1 had hip fracture. The report stated, Staff (facility) heard Resident #1 crying out in pain and found him lying on his bed. The physical exam revealed Resident #1 had pain on palpation at site of fracture. The EMS reported stated that EMS left the facility at 3:11PM and no there was no documentation of medications administered to Resident #1. Review of hospital records dated 8/16/23 through 8/18/23 revealed per the ED note on 8/16/23 at 3:27 PM Resident #1 was sent for an evaluation after a fall and a mobile x-ray that noted a right hip fracture. The Physician documented Resident #1's pain was worse with movement, improved with rest and there was no attempted treatment prior to arrival. The ED note stated that the goal was to manage his pain. Resident #1 was prescribed Acetaminophen 650mg every six hours as needed by mouth and Morphine 2mg/1ml intravenously every four hours as needed for pain. He had noted pain control while at the hospital. X-rays completed on 8/16/23 noted a comminuted mildly displaced intertrochanteric fracture of the right femur. A CT scan of the head completed on 8/17/23 was negative. Per the Orthopedic consult report on 8/17/23 at 8:30AM, Resident #1's wife declined to have surgery and preferred hospice services as she did not want any significant aggressive interventions. On 8/18/23, he was discharged from the hospital to the local hospice house for comfort measures. The DON was interviewed on 08/25/23 at 3:26 PM via phone who stated that she became aware on 08/16/23 around 1:00 PM that Resident #1 had a hip fracture and was going to be sent to the ED. The DON she assisted Nurse #1 in getting the needed documentation together to send Resident #1 to the ED. The DON did not state if she assessed Resident #1 or if she observed him for pain or behaviors before he was sent out to the hospital. The DON indicated if a resident vocalized pain or had nonverbal cues of pain like grimacing then the nurse assigned to the resident should complete a pain assessment and medicate the resident for pain. If the resident did not have anything ordered for pain, then the medical provider should be notified for orders. The DON could not explain why Resident #1 did not receive anything for pain but stated she would be looking into it. The Administrator was interviewed via phone on 08/25/23 at 3:01 PM who stated that she felt very fortunate that PA #1 was in the facility and Nurse #1 had him assess Resident #1 so quickly. After the x-ray was ordered it was obtained quickly and so where the results. Administrator did not speak to Resident #1's pain or his lack of pain medication. The Administrator was interviewed via phone on 08/25/23 at 3:01 PM who stated that she felt very fortunate that PA #1 was in the facility and Nurse #1 had him assess Resident #1 so quickly. After the x-ray was ordered it was obtained quickly and so where the results. Administrator did not speak to Resident #1's pain or his lack of pain medication.

Based on record review and staff interviews the facility failed to notify the physician of changes in pressure ulcers for one (1) of ten (10) sampled residents. (Residents #1). The findings are: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] indicated cognition was moderately impaired and the resident required extensive staff assistance for transfers, eating, dressing and personal hygiene. The MDS specified Resident #1 was admitted to the facility with one (1) Stage II pressure ulcer and two (2) unstageable pressure ulcers with suspected deep tissue injury. A Care Area Assessment (CAA) dated 01/16/12 specified Resident #1 entered the facility with a Stage II pressure ulcer to the coccyx and blisters to both heels. The CAA continued Resident #1 was at risk for complications, further breakdown, and infection. The CAA also specified further skin breakdown would be evaluated by the physician for possible changes to the resident's care. The resident's care plan dated 01/22/12 identified skin breakdown of a Stage II coccyx pressure ulcer and blisters on both heels. The care plan goal specified the resident would be free from further pressure areas through the next three (3) months. Interventions for this care plan included initiate skin treatments as ordered and inform the physician of signs and symptoms of skin breakdown. A review of a medical progress note dated 01/30/12 revealed the Family Nurse Practitioner (FNP) examined Resident #1 on this date. The document specified the purpose of the medical visit was to evaluate the resident due to nursing concerns secondary to fever, worsening heel ulcers, and mental status change. Wound measurements for the heels were documented as follows: The left heel wound measured 4.7 x 5 centimeters (cm). The right heel wound measured 6.1 x 5 cm. Both heel wounds were described oozing brown pus-like drainage. An odor was noted with all wounds. Continued medical record review revealed a nursing note dated 01/30/12 at 1:35 PM signed by Licensed Nurse (LN) #3. The note described Resident #1 as lethargic and having a temperature of 99.5 degrees Fahrenheit. The note specified the resident was examined by the FNP and sent to an acute care facility for evaluation [MEDICAL CONDITION] related to wound status and mental status changes. A review of a wound care clinic evaluation obtained in the acute care facility and dated 01/31/12 described the wounds as follows: The left heel wound measured 3.5 x 5 x 0.2 cm. The wound was described as a pressure ulcer with necrotic tissue and blister membranes and was unable to be staged. The right heel wound measured 8 x 5 x 0.2 cm. The wound was described as a pressure ulcer with purulent drainage and unable to be staged. A review of a discharge summary from the acute care facility dated 02/03/12 revealed discharge [DIAGNOSES REDACTED]. 2. Decubitus both heels and coccyx with one wound showing bacterial infection. An interview on 03/08/12 at 11:45 AM with LN #2 revealed she worked on 01/18/12 when the blisters on both of Resident #1's heels were observed opened and stated she did not notify the physician or the FNP. An interview on 03/08/12 at 11:59 AM with the FNP revealed she was not contacted on 01/18/12. An interview on 03/08/12 at 4:30 PM with the Administrator revealed the nurse should have notified the physician or FNP on 01/18/12 when the resident's heel wounds opened. An interview on 03/08/12 at 11:44 AM with the resident's physician revealed he expected to be notified by facility staff anytime a resident's wound was getting worse.

Based on observations, record reviews and staff interviews, the facility failed to assess, monitor and treat pressure ulcers for two (2) of ten (10) sampled residents. (Residents #1 and #7). The findings are: Facility policies entitled Protocols for Wound Care and Prevention, treatment of [REDACTED]. The documents contained the following: All pressure ulcers will be reevaluated and measured weekly. Pressure ulcer documentation will include location and staging, size, description of exudate, if present, wound bed, wound edges and surrounding tissue. Residents at risk for heel ulcer formation require weekly assessments. 1. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The admission Minimum Data Set ((MDS) dated [DATE] indicated cognition was moderately impaired and extensive staff assistance was required for transfers, eating, dressing and personal hygiene. The MDS specified Resident #1 was admitted to the facility with one (1) Stage II pressure ulcer and two (2) unstageable pressure ulcers with suspected deep tissue injury. A Care Area Assessment (CAA) dated 01/16/12 specified Resident #1 entered the facility with a Stage II pressure ulcer to his coccyx measuring 2.0 x 0.1 x 0.1 centimeters (cm). The resident also had blisters to both heels. The CAA continued Resident #1 was at risk for complications, further breakdown, and infection. The resident would have routine skin audits to ensure there was no further breakdown and the areas were healing appropriately without complications. The CAA also specified further skin breakdown would be evaluated by the physician for possible changes to the resident's care. The resident's care plan dated 01/22/12 identified skin breakdown of a Stage II coccyx pressure ulcer and blisters on both heels. The care plan goal specified the resident would be free from further pressure areas through the next three (3) months. Interventions for this care plan included initiate skin treatments as ordered, skin assessment weekly, and inform the physician of signs and symptoms of skin breakdown. a. A review of Resident #1's medical record revealed a nursing note dated 01/18/12 written by Licensed Nurse (LN) #2 at 2:00 PM. The note specified open sores on both heels were noted today and painted with a prodine-iodine antiseptic, foam was applied and wrapped with gauze. No further assessment or measurements of "open sores" to the resident's heels was documented in the medical record between 01/18/12 to 01/30/12. A review of a medical progress note dated 01/30/12 revealed the Nurse Practitioner (FNP) examined Resident #1 on this date. The document specified the purpose of medical visit was to evaluate the resident due to nursing concerns secondary to fever, worsening heel ulcers, and mental status change. Wound measurements for the heels were documented as follows: The left heel wound measured 4.7 x 5 cm. The right heel wound measured 6.1 x 5 cm. Both heel wounds were described oozing brown pus-like drainage. An odor was noted with all wounds. Continued medical record review revealed a nursing note dated 01/30/12 at 1:35 PM signed by LN #3. The note described Resident #1 as lethargic and having a temperature of 99.5 degrees Fahrenheit. The note specified the resident was examined by the FNP and sent to an acute care facility for evaluation for [MEDICAL CONDITION] of wounds, early pneumonia and mental status changes. A review of a wound care clinic evaluation obtained in the acute care facility and dated 01/31/12 described the wounds as follows: The left heel wound measured 3.5 x 5 x 0.2 cm. The wound was described as a pressure ulcer with necrotic tissue and blister membranes and was unable to be staged. The right heel wound measured 8 x 5 x 0.2 cm. The wound was described as a pressure ulcer with purulent drainage and unable to be staged. A review of a discharge summary from the acute care facility dated 02/03/12 revealed discharge [DIAGNOSES REDACTED]. 2. Decubitus both heels and coccyx with one wound showing presence of bacteria. An interview on 03/06/12 at 12:31 PM with the FNP revealed she was asked by the facility wound nurse to examine Resident #1 on 01/30/12 related to altered mental status and fever. She stated foul odor was noted in the room. The wound nurse undressed the heel wounds and they appeared as described in her written report. The FNP stated this was the first time she had been asked to examine the resident's wounds. b. A review of a facility document dated 01/27/12 revealed measurements of Resident #1's coccyx wound on that date was 1 x 0.2 x 0.1 cm. No further description of the wound was provided. No other measurements or assessments of the coccyx wound were found on the medical record between the dates of 01/16/12 and 01/27/12. A review of a medical progress note dated 01/30/12 revealed the Nurse Practitioner (FNP) examined Resident #1 on this date. The document specified the purpose of medical visit was to evaluate the resident due to nursing concerns secondary to fever, worsening heel and coccyx ulcers, and mental status change. Further review of the medical progress note revealed the coccyx wound measured 8 x 8.4 cm and was described draining yellow pus and an odor was noted. Continued medical record review revealed a nursing note dated 01/30/12 at 1:35 PM signed by LN #3. The note described Resident #1 as lethargic and having a temperature of 99.5 degrees Fahrenheit. The note specified the resident was examined by the FNP and sent to an acute care facility for evaluation related to wound status and mental status changes. A review of a wound care clinic evaluation obtained in the acute care facility and dated 01/31/12 specified the coccyx wound measured 10 x 8.5 x 0.2 cm. The wound was described as a pressure ulcer with 40 percent slough, drainage, and unable to be staged. A review of a discharge summary from the acute care facility dated 02/03/12 revealed discharge [DIAGNOSES REDACTED]. 2. Decubitus both heels and coccyx with one wound showing presence of bacteria. An interview on 03/06/12 at 12:31 PM with the FNP revealed she was asked by the facility wound nurse to examine Resident #1 on 01/30/12 related to altered mental status and fever. She stated foul odor was noted upon entering the room. The wound nurse undressed the coccyx wound. The wound appeared as described in her written report. The FNP stated this was the first time she had been asked to examine the resident's wounds. An interview on 03/06/12 at 2:20 PM with LN #9 revealed he did the dressing change to the coccyx wound on 01/28/12 which was the last documented dressing change before 01/30/12. He stated the coccyx wound did not have an odor or drainage. 2. Resident #7 was admitted to the facility 07/29/11 with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set ((MDS) dated [DATE] indicated the resident was severely cognitively impaired and required extensive staff assistance with mobility, transfers, dressing, and personal hygiene. The MDS noted the resident had one (1) unhealed Stage II pressure ulcer that was present upon admission. A care plan updated 01/26/12 identified the resident was at risk for skin breakdown. The care plan goal specified the resident would experience no further skin breakdown. Interventions included treatments/dressing changes as ordered, update physician as needed, initiate skin treatments as indicated/ordered, skin assessment weekly, and inform physician of signs and symptoms of skin breakdown. Medical record review revealed the last documented wound assessment and measurement of the pressure ulcer was prior to January 2012. A review of Resident #7's medical record revealed a physician's orders [REDACTED]. A review of Resident #7's Treatment Record (TAR) revealed the hip wound treatment was initialed as completed on 02/27/12. A review of the March 2012 TAR revealed no initials to indicate the dressing was changed during this month. An observation was conducted on 03/06/12 at 4:28 PM of Unit Manager (UM) #1 performing a dressing change on Resident #7's left hip. UM #1 was observed to remove the old hip dressing. The dressing was dated 02/27/12. At that time UM #1 verified the date of 02/27/12 on the removed dressing. The old dressing contained an approximate quarter size amount of dried brown colored drainage when removed. The wound bed was observed red in color and approximately the size of a quarter with superficial depth. The skin immediately surrounding the wound was pink in color. The dressing change was completed as ordered. During an interview on 03/07/12 at 11:20 AM, UM #1 stated prior to 03/06/12 Resident #7's dressing was last changed on 02/27/12. She stated the dressing should have been changed on 03/01/12 and on 03/04/12 per physician's orders [REDACTED].