**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The MDS assessment dated [DATE] revealed Resident #53 BIMS score 12 out of 15 indicating a moderate cognitive impairment. The MDS revealed the resident dependent with chair/bed to chair transfers and used a wheelchair. The MDS revealed a diagnosis of hemiplegia, unspecified affecting left dominant side. The Care Plan revealed a focus area dated 4/17/24 for ADL (Activities of Daily Living) self-care performance deficit for left-sided hemiplegia. The interventions dated 5/14/24 revealed transfers with an assist of 2 with a mechanical lift and use of a green sling. The EHR (Electronic Health Record) revealed the following Physician Orders: a. Start date 7/2/24- monitor left forearm skin tear and bruising until healed every shift for skin tear and bruising b. Start date 7/2/24- left forearm: gently cleanse ST (skin tears) with NS (normal saline), apply house stock moisturizer or A&D ointment daily u/h (until healed). May cover if needed every day shift for Skin tear During an interview on 7/1/24 at 11:49 AM, Resident #53 stated she transferred with an mechanical lift, but she had an accident with a non mechanical lift. She stated she ended up scraping and bruising her left arm. The Resident stated they helped her stand up and she didn't have any control of her left arm and her arm dangled and when the girls stood her up, her arm scraped against a screw on the non mechanical lift. During an observation on 7/1/24 at 12:00 PM, Resident #53 had a large band-aid on her left forearm. She peeled the band-aid back and a large purple bruise with skin tears observed underneath. During an interview on 7/2/24 at 11:20 AM, the Administrator stated she didn't know of any recent incidents that occurred with Resident #53 and she would need to look into it. The Investigation Notes on July 2nd, 2024 revealed on 6/28/24 nursing staff (Staff D, CMA (Certified Nurse Aide), Staff B, CNA (Certified Nurse Aide), and Staff H, CNA) used a non-mechanical stand-aid with a gait-belt to stand resident up. While using non-mechanical stand-aid, resident's flaccid left arm came into contact with the side of non-mechanical stand-aid while sitting back down into her wheelchair, causing skin tears. The nurse evaluated the resident's skin and initial treatment to left arm was performed. [name redacted] ARNP (Advanced Registered Nurse Practitioner) was made aware of the incident. a. An investigation initiated with the following completed 1. ARNP notified 2. Interviewed Resident #53 3. Interviewed Resident #53 roommate 4. Interviewed Staff: Staff D, Staff B, Staff H, and Staff E, LPN (Licensed Practical Nurse) b. Upon completion of the investigation the facility was able to determine the injury occurred when Resident #53 left flaccid arm came into contact with the non-mechanical stand aid. Interventions implemented to prevent further occurrences. As a result of the investigation the following interventions have been put in place: 1. Education opportunity for staff identified of monitoring all limbs when transferring residents. 2. Maintenance evaluated non-mechanical sit-stand to ensure equipment is in proper working order; no faulty equipment noted or reported. 3. Care plan and Kardex reviewed, all interventions and current plan of care remains appropriate at this time. 4. Treatment Administration Record (TAR) updated to include skin monitoring until site resolved. The Care Plan revealed a focus area dated 7/2/24 for a skin tear of the left forearm. The interventions dated 7/2/24 revealed identify potential causative factors and eliminate/resolve when possible; inform/instruct staff of causative factors and measures to prevent skin tears; and use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. The Progress Note dated 6/28/2024 19:20 (late entry created on 7/3/24 at 6:21 AM) revealed CNA's reported to this nurse they were trying to put res to bed when they noticed that res did not have a mechanical lift sling on. PT (Physical Therapy) used non-mechanical sit to stand and sling was not placed under resident after transfer. 3 CNA's used the non-mechanical sit to stand to aid resident in standing to place sling back under resident to transfer resident with a mechanical lift. When resident stood, her left arm hit the lift. 3 skin tears were noted. ARNP [name redacted] notified and new orders received for xeroform and mepilex until healed. The Weekly Wound Observation dated 7/2/24 at 12:27 PM revealed the following information: a. Location: left forearm b. Date acquired: 6/28/24 c. Type: other- skin tear d. Overall impression: improving e. Comments: skin flaps intact and adhered f. Wound measurements 1. 2.5 cm (centimeters) in length; 2.1 cm in width; and 0 cm in depth g. Peri-wound tissue: intact with bruising h. Wound edges defined i: Treatment plan: apply house stock moisturizer daily j. Evaluation of wound progress: skin flap intact and adhered The Progress Note dated 6/28/24 at 8:20 PM (late entry dated on 7/2/24 at 2:23 PM) revealed this provider was notified by on duty nurse of skin tears to left elbow while using the non-mechanical stand aide. Skin well approximated. Area cleaned covered with zero form and mepilex dressing applied. During an interview on 7/2/24 at 4:39 PM, Staff B stated Resident #53 used a mechanical lift for transfers and she didn't have a sling under her in the wheelchair and wanted to get back in bed. Staff B thought PT changed her status so she went and asked Staff D and she said the resident needed a sling under her. Staff B stated she took Staff H in with her to help get Resident #53 stood up to get a sling under her and they couldn't do it, so Staff B asked Staff D to assist them. Staff B stated Staff D came in and they put a gait belt on Resident #53 and Staff D and Staff H used the non mechanical lift with Resident #53 and as the resident held onto the bar with her right hand Staff D and Staff H pulled the resident up with the gait belt as she put the sling under her in the wheelchair. Staff B stated they noticed the bleeding when they sat her back down. Staff B stated she thought the resident hit her arm on the nut on the side of the non mechanical lift bar. Staff B stated the resident didn't say anything when it happened and the left side was the resident's bad side. Staff B stated that was the first time they used a non mechanical lift with the resident, because the resident used a mechanical lift. Staff B stated therapy worked with the resident that day and forgot to put the sling back in the wheelchair. During an interview on 7/2/24 at 5:44 PM, Staff D stated she recalled the incident with Resident #53. She stated a CNA came and got her and didn't know how to get the sling under Resident #53. Staff D stated therapy didn't put the sling under her after they worked with the resident. Staff D stated she suggested using the non mechanical lift and a gait belt. Staff D stated she went under the good arm and Resident #53 used her good arm on the bar and when the resident sat back down, they noticed she was bleeding and went and told Staff E and she took care of the rest. Staff D stated she didn't know how else to get her up because she used a full body sling and her wheelchair didn't have much wiggle room. Staff D stated this situation never occurred before and it shouldn't of been an issue because therapy should put the slings back in the wheelchair. During an interview on 7/2/24 at 6:17 PM, Staff H stated he was training with another CNA and Staff B stated she needed help getting Resident #53 up. Staff H stated therapy used a non mechanical lift with the resident and we didn't feel comfortable doing that so they asked Staff D to come in and help them put a sling under her with the non mechanical lift. Staff H stated Resident #53 only had mobility on one side. Staff D stated when they put the sling under the resident, her bad arm got caught on the bolt. Staff D stated the resident tried to help but her left arm was like dead weight and not movable. Staff D stated the resident tried to pull herself up with her right hand on the non mechanical lift bar. During an observation 7/3/24 at 8:56 AM, Staff F, LPN performed wound care on Resident #53 left arm. Resident #53 had dark purple bruising with 3 skin tears to the left lower arm. The skin flaps adhered to the skin. During an interview on 7/3/24 at 9:12 AM, Staff F stated she just found out about the wound yesterday and did the wound measurements then. During an interview on 7/3/24 at 10:10 AM, Staff E stated she knew about the incident with Resident #53. She stated Resident #53 didn't have a sling under her and they used the non mechanical lift to stand her up and they didn't hang onto Resident #53 arm and she got a skin tear from the non mechanical lift. Staff E stated she notified the ARNP and cleaned the resident's arm up, but forgot to chart it on the day it happened. During an observation on 7/3/24 at 10:23 AM, a blue colored non mechanical lift in the PT room. Bolts on the lateral side of the horizontal bars. During an interview on 7/3/24 at 10:28 AM, Staff I, PT Assistant stated she remembered doing a non mechanical transfer with her. Staff I stated she didn't put the sling back in the chair because she forgot. Staff I stated she can practice with Resident #53 with the non mechanical lift but the CNA should not use it. Staff I stated Resident #53 took a moderate to a maximum of 2 staff because she didn't have much function to her left and no functioning in her left arm. Staff I stated once she got her to stand, Resident #53 stood really good on her left leg. Staff I stated the staff could of pushed the sling down her back. Staff I stated it wouldn't of been easy, but it could be done. Staff I stated she wouldn't say the CNA should use the non mechanical lift, but she should of remembered to put the sling back in the chair. During an interview on 7/3/24 at 1:29 PM, the Director of Nursing (DON) stated she thought the staff were trying to transfer the resident the safest way possible. The DON queried if she would of recommended a different approach and she stated she couldn't say because she never transferred the resident before. The DON stated it was a possibility to tuck the sling under her, other ways to get the sling under her. During an interview on 7/3/24 at 3:01 PM, the DON stated she wanted to clarify the staff didn't transfer the resident, they used the non mechanical lift to stand her up to place the sling under to transfer the resident in the mechanical lift. The DON stated the resident used the full body sling and not the criss cross between the legs sling. The Facility Sit to Stand Lift Transfer dated 10/25/22 revealed the following information: a. Instruct the resident to hold onto the grab bars of the lift with both hands. Based on observation, interview, facility investigation review, and facility policy review the facility failed to ensure a severely cognitively impaired resident identified at risk for elopement, with wandering behaviors free from elopement on 4/30/24. The resident went through a set of double doors into a common area by the beauty salon, went through a door into the unoccupied assisted living portion of the facility when the keypad was disengaged, and exited through a third door present on the unoccupied assisted living portion of the facility which lead directly to the outside of the facility. The third door the resident exited from, present on the unoccupied assisted living section of the facility, did not alarm to the nursing home section of the facility for 1 of 1 resident reviewed for elopement (Resident #25). This deficient practice resulted in an Immediate Jeopardy (IJ) to the health and safety of residents who resided at the facility. The facility also failed to adhere to the plan of care when a resident dependent on a mechanical lift was raised up off of a wheelchair via the assistance of a non-mechanical lift, resulting in skin tears and bruising to the left lower arm for 1 of 4 residents reviewed for accidents (Resident #53). The State Agency informed the facility of IJ that began as of April 30, 2024 on July 2,2024 at 12:25 PM. The Facility Staff removed the Immediate Jeopardy on July 2, 2024 through the following actions: a. 100% Headcount of all Residents on 4/30/24 b. 100% Elopement Risk assessment completed on all residents on 4/30/24 c. 100% Care plan audit for all residents determined to be at risk for elopement on 4/30/24 d. Facility conducted 100% audit of all external doors to ensure they are in proper working order on 4/30/24 e. Door lock changed on 4/30/24 to assisted living interior door f. Facility conducted elopement drills x 3 shifts 4/30-5/1/24 g. Facility conducted Ad Hoc QAPI to address this alleged deficient practice on 4/30/24 h. Elopement binder updated on 4/30/24 i. Staff in-service on Elopement Policy on 4/30/24 The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 55 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #25 scored 3 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated severely impaired cognition. Per this assessment, the resident had inattention and disorganized thinking which fluctuated, had delusions, and wandered daily. Review of Medical Diagnoses for Resident #25 revealed, in part, paranoid personality disorder, schizophrenia, and vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The Care Plan dated 1/30/24, revised and canceled on 5/3/24, revealed the following: History/potential for behavior problem. Resident is no longer allowed to smoke as he is at high risk for elopement. Interventions per the Care Plan included the following: a. (Initiated 1/30/24, revised/canceled 5/3/24): Administer medications as ordered. Monitor/document for side effects and effectiveness. b. (Initiated 1/30/24, revised/canceled 5/3/24): Anticipate and attempt to meet needs. c. (Initiated 1/30/24, revised/canceled 5/03/24): Explain all procedures before starting and allow time to adjust to d. (Initiated 1/30/24, revised/canceled 5/03/24): Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. e. (Initiated 1/30/24, revised/canceled 5/3/24):Observe behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. f. (Initiated 2/2/24, revised/canceled 5/03/24): Wander Guard in Place The Care Plan dated 1/30/24 revealed, the resident has depression and insomnia with diagnosis of schizophrenia. The Elopement Risk Evaluation V 2.0 dated 1/29/24 and 4/2/24 revealed the resident at risk for elopement, and the resident scored 4 on both assessments. It was noted a score of greater than one indicated at risk for elopement. Review of Progress Notes prior to Resident #25's exit from the building on 4/30/24 revealed the following: Review of Hospital Records from a visit dated 1/27/24 revealed, during time of his ED (emergency department) evaluation, patient had evaded our staff members when he was utilizing the bathroom, eloping from our facility as search was performed including contacting local law enforcement. Patient identified at gas station where [Hospital Name Redacted] EMS (Emergency Medical Services) identified him as well as patient voluntarily returned to our ED via EMS. Review of a Behavior Note dated 3/23/24 at 4:49 AM revealed, Resident has been pacing the halls constantly this shift, going in to other resident's rooms, and is short tempered with staff, especially when we attempt to redirect him from going into other resident's rooms. Message left with [Name Redacted, ARNP (Advanced Registered Nurse Practitioner)] awaiting response. The Risk Note dated 3/28/24 at 1:16 PM revealed, Risk IDT (interdisciplinary team) met to discuss residents more frequent wandering and agitation. Resident is not agitated with staff or residents almost seems as if he is agitated with himself or overwhelmed in this environment. Talked to SS (Social Services) about talking to [family member] to get him placed in a locked unit with less stimulus, will have her make prog [progress] note when she talks to [family member]. The Social Services Note dated 3/28/24 at 4:29 PM revealed, Contacted residents [family member, name Redacted] about potentially moving resident to a location that has less stimuli and calmer environment such as a locked dementia unit. The Behavior Note dated 3/31/24 at 3:46 AM revealed, Resident continues to have episodes of pacing, fidgeting with anything that is around him, and going in to other residents' rooms. Resident did settle down and has been sleeping in his bed since 9pm. The Nurses Note dated 4/1/24 at 11:26 AM revealed, Observed resident wandering up and down halls, noted to have layered clothing (a couple shirts) the top polo was on backwards. The Risk Note dated 4/5/24 at 1:52 PM revealed, Risk management held today to discuss residents behaviors. Resident continues to wander into other residents room and up and down hallways. Resident is easily redirected. Review of a Psychiatric Services Provider Clinical Note dated 4/9/24 revealed, Facilitator shared patient is wandering more and this is related to his dementia. She is working on a referral for him to move to a facility with a dementia unit that will be closer to family. The Nurses Note dated 4/12/24 at 3:46 PM revealed, Resident continues to wander throughout the facility on foot. No new behaviors observed or reported. The Behavior Note dated 4/14/24 at 12:49 AM revealed, Resident has been wandering all shift so far this shift. Going in to other resident's rooms, taking things off the med carts, trying to drink everyone's drink. Resident has yet to settle down and is still wandering and getting in to everything. The Behavior Note dated 4/15/24 at 2:49 AM revealed, Resident has been wandering all shift again this shift. Going into other resident's rooms, redirection has been mostly unsuccessful. At this time resident has finally went to his room and is laying in bed at this time. The Behavior Note dated 4/21/24 at 1:41 PM revealed, Resident continues to roam the halls. Called and spoke to [family member]. No other behaviors noted at this time. The Risk Note dated 4/25/24 at 1:39 PM revealed, Risk IDT met to discuss behaviors. Resident continues to wander daily. No new behaviors. The Nurses Note dated 4/25/24 at 6:46 PM revealed, Resident wondering facility. Not exit seeking. Redirected out of other residents room but resident continues to go into other residents rooms after aid redirected. Resident taken to his own room where he stood at door way opening and closing door. The Behavior Note dated 4/27/24 at 12:03 PM revealed, Resident continues to wander facility and into other residents rooms. Resident talked to [family member] this morning. He has been taking objects off of medication carts such as pens and markers. Very redirectable today. The Behavior Note dated 4/28/24 at 9:53 PM revealed, Resident noted to be sleeping in bed [Room number redacted, not resident's room]. Resident woke up and redirected back to his own bed where he laid down and has been asleep since. Review of a Psychiatric Subsequent assessment dated [DATE] revealed the resident was referred due to depression, anxiety, worrying, paranoia, hallucinations delusions, confusion, elopement, sleep disturbance, and paranoia. Review of Resident #25's clinical record and facility self report investigation regarding the resident's elopement on 4/30/24 revealed the following: The Facility Investigation for Resident #25 dated 4/30/24 revealed, On 4/30/24 at approximately 5:10am [Resident #25] was observed by staff standing on the east door sidewalk approximately 6-10 feet from the building, on facility property .Upon completion of the investigation, it was determined that [Resident #25] exited the facility through a door leading to the Assisted Living portion of the community which had a manual push button lock what was noted to disengage and exit through the door .[Resident #25] was last observed by CNA (Certified Nursing Assistant), during rounds at 4:40 am standing in his doorway to his room with no signs of distress noted and no signs or symptoms of exit seeking behavior demonstrated. Resident observed going back into room and shutting door at that time. Staff member [name redacted] reports that after seeing the resident at 4:40 am, she went to the area by the nursing station and returned to the hall to complete rounding at approximately 4:45 am in which she could not locate [Resident #25]. Nurse immediately notified and search initiated. During the resident interview, [Resident #25] reported he was sleepwalking and remembered last being in his room. Review of the Self Report for Resident #25 revealed approximate date/time event occurred as 4/30/24 at 5:05 AM. The Incident Summary per the Self Report documented, in part, Resident was standing in his doorway at approximately 4:45 AM, visually seen by CNA, as she exited room across hallway. CNA went towards nurses station to use restroom and after using restroom returned to hall. CNA went to [Resident #25's] room at approximately 5:05 as he was no longer in hall. [Resident #25] was not in his room, CNA made nurse aware and they began looking for him. No alarms were sounding. Nurse state she went outside and was hollering his name and seen him standing in grass approximately 15-20 feet from building. When he heard his name he turned around and when she got to him he willingly returned inside with her. Review of staff statements included as part of the facility investigation revealed the following: a. Verbal statement from [Staff N, CNA] 04/30/24: I did rounds on resident throughout the night and resident was asleep in his bed until I saw resident standing in his doorway at 0430. Went into [another room number, redacted] to check and change resident. I needed supplies and came out of the room and saw resident at 0440 in his doorway again, when resident went back into room and shut his door. After rounding I used the rest room and went back down to check on resident when I noticed he was not in his room. Let [Staff K]RN (Registered Nurse) know that he was not in his room and staff started checking the building for resident as there had been no alarm sounding. At approximately 0510, resident was found outside at the east end of the building by [Staff K] RN. b. Verbal statement from [Staff M, CNA] 04/30/24: At approximately 0435 (4:35 AM), I witnessed resident in hallway, attempting to go into other residents rooms and get into the linen closet. I took resident back to his room and I did not see him after that time. After being told that resident was not in his room, I checked north hallway for resident and he was not in any room, bathroom, or closet. c. Verbal statement from [Staff J,CNA] 04/30/24: I went down east hall to help [Staff N] check and change [another room number, redacted] at approximately 0430 (4:30 AM). I saw resident standing in his doorway at that time. We finished checking resident and I went down west hall to do rounds when I was told that resident was no longer in his room. Checked the rooms, bathrooms, and closets down west and resident was not in any of the rooms. d. Verbal statement from [Staff K, RN] 4/30/24: I was alerted at approximately 0445 (4:45 AM) that resident was not in his room. Did a search of the building, in all rooms, bathrooms, and closets and resident could not be located. Called DON (Director of Nursing), [name redacted] and let her know that resident could not be located. No alarms were sounding. Could not locate resident in the building. At approximately 0510 (5:10 AM), I went outside and saw resident at the east side of the building in the grass, with no shoes on. Resident came back into facility with no incidents. Skin and pain assessment completed. No signs or symptoms of trauma noted. VSS (vital signs stable). Review of the Nurses Note dated 4/30/24 at 5:15 AM revealed, Resident was last seen inside his doorway at approx 440 am when the CNAs (Certified Nursing Assistants) had come out of a room across the hallway. Resident was then seen outside on east side of building in the grass. Resident came back inside facility without incident and one on one care was <sic> initiated. The Social Services Note dated 4/30/24 at 11:39 AM revealed, I met with resident concerning this morning behavior. I asked resident if he was looking for something or wanting/needing something. Resident stated, I don't know what I was doing. My memory is bad. Maybe I was looking for some money I dropped (resident began to laugh). No, I am just joking. I don't know what I was doing. Observations and interviews conducted onsite during the time of the survey revealed the following: On 7/2/24 at 9:35 AM, a voicemail message was left for the State Climatologist. Information as to the weather in [Location where facility located redacted] requested for 4:40 AM to 5:10 AM. On 7/2/24 at 11:05 AM, the State Climatologist provided the following observations: Temperature: 46 degrees F (Fahrenheit), relative humidity: 93%, winds calm to [NAME] at 3 mph (miles per hour), wind chill: 45 degrees F, and fair conditions with no precipitation detected. On 7/1/24 at approximately 11:00 AM, the Administrator queried about camera locations at the facility, explained which areas had cameras, and the response provided did not include the area of the facility where the resident had exited the facility. A walk through was conducted of the doors the resident would have traveled through with the facility's Administrator. Observation revealed first was a set of double doors which went into a common area where the beauty salon was located, referred to by staff as the East day area. It was explained if the door was cracked [ajar], the door would not alarm. The second door was a door from the East day room into the unoccupied assisted living (AL) portion of the facility, and it was explained the lock on the door to the AL had not reengaged. Upon entry to the hallway of the unoccupied AL portion of the facility, a door (exterior door) observed to the right. It was explained the alarm to the door, noted to be third door in travel path, was not hooked to the main section of the facility. Observations of the double doors which lead from the end of 300 hallway into the East day area revealed no alarm sounded at the following times the door was opened by staff and/or surveyor: a.7/2/24 at 9:56 AM b. 7/2/24 at 9:59 AM c. 7/2/24 at 10:12 AM d. 7/2/24 at 2:56 PM. Observation revealed although the right side of the door had an alarm that sounded, the left side of the set of double doors could be opened without an alarm sounding. On 7/2/24 at 3:06 PM, observation conducted of the surrounding area of the facility revealed the facility was located on a two lane road with speed limit of 25 miles per hour. Observation of the area outside of the door where the resident exited the facility (from the assisted living section) revealed a concrete pad, then sidewalk which extended right towards the parking lot in front of the facility. The sidewalk did not have handrails present, and a gap of approximately three inches existed in places between the edge of the sidewalk and the grass. Outside of the door where Resident #25 exited the facility, there was a grass strip of approximately 10 to 15 feet wide between the facility and the parking lot of the neighboring business. On 7/2/24 at 5:56 PM, Resident #25 observed walking down the hall. The resident held a staff member's hand, and observed with tennis shoes to his feet. Observation on 7/2/24 at 6:25 PM revealed Resident #25 walked independently with tennis shoes to his feet. The resident stood upright and walked near a chair to the front common area/television area at the front of the facility. The resident held onto another chair while he attempted to sit in a stationary chair, and then sat down. On 7/3/24, observation of Resident #25 revealed the resident in his room with the wrong tennis shoe (left shoe) on his right foot, and wanderguard present to the resident's left ankle. Staff assisted the resident with his shoes. When queried if he (Resident #25) ever went out of the facility real early in the morning, the resident responded no. Observation revealed the resident again put the wrong shoe on his right foot. On 7/2/24 at 9:13 AM, Staff M, CNA, who worked the night the resident got out of the facility, explained the following about Resident #25: The previous night the resident was up and down, tried to feed him and he would eat a little bit and get back up. The resident said he wanted to go to bed, and a few minutes later was back up. Per Staff M, some nights the resident slept all night. When queried if she worked the night the resident got out, Staff M responded she was. Per Staff M, she was down North hall, and usually had an aide each hall. Per Staff M, the other girl said Resident #25 was missing. Staff M explained room to room checks and closet check done, Staff M said she could not find the resident. Per Staff M, the alarm must have been going off. When queried if alarms had been going off, Staff M responded she didn't hear any. Per Staff M, she thought the resident needed to be in a locked unit where he could roam free, explained sometimes at night may be in with a resident in another hall and may not see Resident #25 or notice him being gone. Staff M explained for the resident's safety, would be best if he could be in a locked unit. On 7/2/24 at 9:37 AM, interview conducted with Staff J, CNA, who worked when Resident #25 exited the building. Per Staff J, herself and another CNA went down East hall, and went down to answer a call light. Staff J explained the first time, she saw Resident #25 out of his room standing in his doorway. The second time, the door was cracked and she could tell Resident #25 wasn't in there, and Staff J had a feeling the resident was not in there. Staff J explained she went fully in the room and looked and the resident was not in there. Staff J further explained she and the CNA started looking all around all the hallways, looked everywhere, looked in the day area where the double doors were, and never thought to look at [AL name] as it was supposed to be locked. Per Staff J, she and the CNA told the nurse the resident was not in his room, and the resident was in there 20 minutes ago. Staff J explained they looked and looked and looked, and finally had to stop because pharmacy came. Per Staff J, the resident was outside the church's parking lot. Staff J further explained there had been three CNAs and one nurse, and all started looking, looked outside the back and the resident wasn't out there, pharmacy came, the nurse went out, and the resident was in the church parking lot. When queried if pharmacy found the resident, Staff J responded no, and said after pharmacy came looked again, and the resident was in the church parking lot in between the grass and the church. Staff J explained they did not hear alarms, the resident did not have a wanderguard on, and was supposed to as at risk for wandering. Per Staff J, the alarm to the double door was on , but they did not hear that go off at all, and thought it malfunctioned. Staff J further explained she found out later the resident went out that way to the [AL name redacted], call lights in the [AL] were going off, that is how figured out he was out there (fig[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #18 scored 15 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS documented resident used indwelling catheter and received an antibiotic for 6 out of 7 days. The MDS revealed diagnoses of amputation; complete traumatic amputation at the level between knee and ankle, right lower leg, sequela; completed traumatic amputation at level between knee and ankle, left lower leg, sequela; neurogenic bladder; Paraplegia; Depression (other than bipolar); pressure ulcer of other site, Stage 4. The Baseline Care Plan dated 8/1/23 documented resident took antibiotics and did not check the box for nurse monitoring. The Care Plan with revision date 8/16/23 revealed a focus area of required catheterization of a suprapubic catheter due to a diagnosis of neurogenic bladder. The interventions with initiated date 8/3/23 directed staff as follows; monitor and document intake and output per facility policy; and monitor, record, report signs and symptoms of Urinary Tract Infection (UTI) to the provider such as pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse,increased temp,urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. The Care Plan dated 8/16/23 revealed a focus problem of antibiotic therapy. The interventions dated 8/8/23 directed staff as follows: Administer antibiotic medications as ordered by physician; monitor and document side effects and effectiveness every shift; monitor/document/report as needed (PRN) adverse reactions to antibiotic therapy: diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions (rashes, welts, hives, swelling face/throat); and monitor/document/report PRN signs and symptoms of secondary infection related to antibiotic therapy such as oral thrush (white coating in mouth, tongue), persistent diarrhea, and vaginitis/itchy perineum/whitish discharge/coating of the vulva/anus. The Physician Orders revealed the following orders: a. ordered 8/1/23- Macrobid capsule 100 mg (microgram) - give 100 mg by mouth two times a day for UTI for 10 Days- prescription ended on 8/12/23 b. ordered 8/1/23 and started 8/2/23- Amoxicillin oral capsule 500 mg - give 500 mg by mouth every 12 hours for UTI for 7 Days- prescription ended 8/9/23 c. ordered 8/13/23 at 3:48 AM- Send to [Name Redacted] Emergency Department The Weights and Vitals Summary revealed the following vitals: a. 8/1/2023 at 3:01 PM: 97.6 °F Temperature; 8/1/2023; 95 bpm (beats per minute) Pulse; 142/86 BP (blood pressure) b. 8/13/2023 at 3:43 AM: 67 bpm- Pulse c. 8/13/2023 at 3:42 AM: 68/42 BP The Electronic Medical Record (EMR) lacked documentation of vitals for the all the other dates not shown between 8/1/23 and 8/12/23. The EMR failed to include documentation of catheter care and urinary catheter output completed. The Progress Note dated 8/7/23 at 3:35 AM revealed resident continued antibiotic therapy related to UTI. No side effects noted. Suprapubic catheter intact, patent, and drained well. Fluids encouraged & provided. Call light within reach. Will continue to monitor. The EMR failed to include documentation of Progress Notes of for catheter care/output or resident's presentation for effectiveness of antibiotic therapy or signs and symptoms of UTI. The August MAR revealed the resident refused his HS (bedtime) medications of mirtazapine, pregabalin, sennosides, baclofen, L-arginine, oxybutynin, and phenazopyridine on 8/12/23 for the 8:00 PM doses. The Progress Note dated 8/12/23 at 12:17 PM revealed a late entry of the resident had 3 loose stools this shift. Resident received suppository for morning bowel program. The resident stated that that suppository definitely did its job. The Progress Note dated 8/13/23 at 4:39 AM revealed at 3:30 AM this nurse called to resident room for resident unresponsive during CNA (certified nurse assistant) check and change. It was communicated to this nurse that resident had no output from suprapubic catheter since 10:00 PM. This nurse assessed the resident who not aroused by sternal rub. This nurse attempted to wake resident and unsuccessful. Resident diaphoretic and cool to the touch. Pulse oximetry could not be obtained. Blood pressure 68/42 manually on left arm in lying position. Heart rate 67. Temperature 97 F. This nurse then called Advanced Registered Nurse Practitioner (ARNP) at 3:37 AM for further instruction. Phone orders received to send resident to Emergency Department (ED). Emergency services called and resident sent via ambulance to local hospital. Report called to ED Nurse at 4:14 AM. Director of Nursing (DON) notified of transfer to hospital. Change of Condition evaluation dated 8/13/23 at 4:48 AM revealed the following: a. signs and symptoms identified: abnormal vital signs and unresponsiveness; started in the morning b. general background information: the resident in the facility for post acute care c. mental status evaluation: unresponsive d. functional status evaluation: general weakness and had abrupt changes in status to unresponsive and weak. e. genitourinary status evaluation: yes, the genitourinary/Urine assessment relevant to the change in condition been reported, decreased urine output; abrupt decrease in urinary output, with lower abdominal distention, discomfort over bladder, or bladder volume > 400 cc f. neurological status evaluation: yes, a neurological assessment relevant to the change in condition been reported; Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse); sudden change in level of consciousness or responsiveness; and resident unresponsive to painful stimuli g. review findings and provider notifications: Things that make the condition or symptoms unchanged (or unable to determine)- Resident sent to ED (Emergency Department due to abrupt change. Resident found to be unresponsive to painful stimuli. Resident BP 68/42. Urine output decreased. The Emergency Medical Servie Run Report dated 8/13/23 revealed the dispatcher dispatched the local emergency service to the facility at 4:00 AM for a male resident who had an unresponsive episode and altered level of consciousness. Upon arrival at the scene, the resident found in his room lying supine in bed. The resident appeared to be dazed. Limited bedside report given by the facility Licensed Practical Nurse (LPN) and CNA . The resident transferred to our stretcher via a four person slide. The Chief complaint revealed altered level of consciousness. The history of present illness revealed facility staff reported that the resident had a diminishing level of consciousness for the past day or so. They reported that the resident normally alert and oriented, but hadn't been for some time now. The resident with a history of dementia, per facility staff. The Assessment revealed the resident semi conscious, unable to answer any and all questions. Glasgow Coma Score (GSC) at worse (2/2/4) 8, at best (3/2/3), The resident unable to speak or communicate effectively. The resident responded to most stimuli by screaming. The Cardiopulmonary assessment revealed the airway patent, as evidenced by ease of screaming, with some concern for compromise. The resident appeared to have intermittent apnea episodes, the resident would quickly begin to breath again in a large gasp followed by a sparse episodes. The four-lead cardiac monitor revealed NSR (normal sinus rhythm) with any abnormalities. The resident connected to the four lead cardiac monitor because the 12-lead ECG (electrocardiogram) unable to be obtained due to the patient's poor cooperation. IV (intravenous)access unable to be obtained as the patient would not allow his arm to be repositioned. The Physicians Clinical Report from the local hospital dated 8/13/23 at 4:24 AM revealed the resident's chief complaint decreased mental status. The resident described as having decreased responsiveness. This started today and still present. Resident found by nursing home staff, agitated, screaming, with decreased mental status, hypotensive. Resident had decreased urine output. Resident oriented x 3 at baseline. No know recent falls or injuries. Usually alert and oriented x 3 . (Resident with multiple chronic conditions of history of bilateral below knee amputation (BKA), paraplegia, pressure ulcer of sacral region, depression, chronic pain, hypertension (HTN), gastroesophageal reflux disease (GERD), chronic osteomyelitis, neurogenic bladder. UTIs, indwelling suprapubic Foley catheter. Resident been hospitalized several times at another hospital for sepsis. Resident took Macrobid for UTI. The progress and procedures section of documentation documented the Course of Care of resident very lethargic, hypotensive. Resident on 3 L of normal saline, blood pressure initially improved to 95/60 then dropped to 70/50. Ordered vasopressors, levophed drip. BP improved to 129/72. Blood cultures order, with IV antibiotics Zosyn/vancomycin. The resident needed transferred to hospital if indicated, may include critical care. The Physician Clinical Report from the local hospital dated 8/13/23 at 4:24 AM revealed the resident needed a higher level of care and the resident approved to transfer to another hospital with a ICU (Intensive Care Unit). The resident transferred by ground ambulance. The Physicians Clinical Report from the local hospital dated 8/13/23 at 4:24 AM documented the following information: The Clinical Impression revealed the following conditions: a. Severe sepsis with shock and acute cardiovascular failure central nervous system failure and renal failure. b. renal failure c. urinary tract infection. The CT (computerized tomography) Head without contrast completed on 8/13/23 at 4:35 AM for the clinical indication of altered mental status and dementia revealed the impression of no acute intracranial process; mild cerebral volume loss. mild chronic small vessel ischemia disease. The Nurses Clinical Report dated 8/13/23 at 4:52 AM- documented the following; a. vitals: BP 54/44, Heart rate 89; RR 12. O2 (oxygen) saturation 95%. Temp. 97.1 b. The Physical Assessment revealed an General/Neuro/Psych assessment with the following documented information: The resident pale and dehydrated, confused and combative and bedridden. He appeared older than stated age and unkempt. Decreased awareness (didn't open eyes to pain and combative). No apparent seizure activity. The resident didn't appear post-ictal. Resident's speech incoherent and loud. Resident appeared unkempt. Marked body odor. Clothes dirty. Hair uncombed. c. The Respiratory Assessment revealed decreased breath sounds in the bases bilaterally. d. GI (gastrointestinal)/GU(genitourinary): Urinary catheter in place on arrival (suprapubic) The Chest X-ray completed on 8/13/23 at 6:42 AM for hypotension and sepsis. No acute cardiopulmonary process found. The higher level of care hospital ICU [Hospital Name] dated 8/13/23 at 1:20 PM documented the following findings: a. Chief complaint: septic shock b. HPI (History of Present Illness HPI): [AGE] year old male with significant past medical history of spinal cord and resulting paraplegia, bilateral BKA (bilateral knee amputation), Hepatitis C. Self care neglect and deficits. Information primarily obtained from medical documentation from the outside facility. All 40 pages of documentation reviewed. No physician documentation. Recent evaluation at another hospital for stage 4 decubitus ulcer, which found positive for Extended Spectrum Beta-Lactamase (ESBL), Escherichia coli (E. Coli)on 7/30/23. Reported resident admitted to nursing facility at the beginning of August due to multiple episodes of self care deficits and readmission. Documentation reported patient complained of Altered Mental Status (AMS) and hypotension, worked up for sepsis at outside hospital. Received vancomycin and piperacillin-tazobactaum. Required norepinephrine, 2L IVF (Intravenous fluids) bolus given. Critical labs of procalcitonin 6.840, creatine 2.4. Resident noted confused and combative. GCS documented between 6-13. CT head/brain displayed no acute findings. The Discharge Summary from Hospital dated 8/21/23 revealed the following: a. The urine culture collected on 8/13/23 at 2:38 PM revealed gram negative rods >100,000 col/ml (colonies/milliliter) yeast b. The stool culture collected on 8/14/23 at 3:33 PM revealed a positive result for Clostridium Difficile on 8/14/23 at 5:28 AM. The Facility discharge form from the hospital dated 8/14/23 revealed hospital notes which documented chief complaint of septic shock and resident worked up for sepsis at outside hospital and received vancomycin and piperacillin -tazobactum. required norepinephrine and required a 2 litter of Intravenous fluid (IVF) bolus given. critical labs revealed procalcitonin 6.840 and creatine 2.4 with resident noted combative and confused. The physical exam revealed T: 99 degrees Farenheit, heart rate: 84; blood pressure: 109/54 respiration: 23 pulse oximetry: 95% on 3 liters nasal cannula. Psych assessment: Confused and encephalopathic. Resident responded with 1-2 words. GCS 14. The assessment documented resident with septic shock secondary to unknown source, possibly UTI vs osteomyelitis and cellulitis of sacrum, present on admission and complicated by stage 4 decubitus ulcer, hypotension, and hypoxia. The plan documented resident worked up for septic shock after the patient required norepinephrine. Initially started on vancomycin and Zosyn. This has been continued following arrival to the ICU (Intensive Care Unit). Patient arrived on norepinephrine. Norepinephrine stopped for a brief moment following arrival to the ICU but needed restarted at low doses. This was apparently will be stopped for a brief moment following arrival to the ICU. Ordered 100 milliliters/hour of IV fluids to continue for continued gentle hydration. Resident urinary output from 8/12/23 at 11:01 PM to 8/13/23 11:00 PM totaled 179 milliliters. The resident received the following medications in the last 24 hours: a. ertapenem IVPB (intravenous piggy back) 1 gram(s) IVPB daily b. fluconazole IVPB 200 milligram(s) IVPB daily c. Heparin injection SQ (subcutaneouly) 5000 Unit(s) Subcutaneous every (12) twelve hours d. lactated ringers 1000 milliliter(s) Intravenous <Continuous> e. norepinephrine Infusion 4 mcg/min Intravenous <Continuous> f. pantoprazole INJ 40 milligram(s) Intravenous Push daily g. sodium chloride 0.9% flush bag 500 milliliter(s) Intravenous <Continuous> h. vancomycin 125 milligram(s) By Mouth every 6 hours i. vancomycin ADULT IVPB 1000 milligram(s) IVPB every (24) twenty-four hours The Discharge Summary from Hospital dated 8/21/23 revealed the following: a. The urine culture dated 8/14/23 at 11:20 AM revealed gram negative rods >100,000 COL/ML yeast. b. The urine culture dated 8/16/23 at 9:29 AM revealed gram negative rods >100,000 COL/ML yeast c. The urine culture dated 8/19/23 at 7:41 AM revealed pseudomonas aeruginosa with organism stenotrophomonas maltophilia 1500 col/ml The Progress Note dated 8/21/23 at 4:51 PM revealed resident arrived to facility via hospital transport with hospital transport. Resident in stable condition, A&O x 3. VSS (vitals signs stable). Resident transferred to electric wheelchair. Suprapubic catheter in place and draining. admission nursing assessment completed. The Weights and Vitals Summary revealed the following vitals: a. 8/21/2023 at 3:48 PM: 97.8 °F Temperature; 73 bpm Pulse; 116 / 78 BP b. 8/23/2023 at 3:51 PM: 98.3 °F Temperature; 84 bpm Pulse; 126 / 72 BP c. 8/27/2023 at 2:21 PM: 97.6 °F Temperature; 90 bmp Pulse; 110 / 60 BP d. 8/31/2023 at 2:30 AM: 97.4 °F Temperature; 82 bmp Pulse; 114 / 58 BP The Physician Orders revealed the following orders: a. ordered 8/21/23- vancomycin HCl (hydrochloride) oral capsule 125 mg (milligram)- give 125 mg by mouth every 6 hours related to UTI, site not specified, discontinued on 8/24/23 b. ordered 8/24/23- vancomycin HCl oral capsule 125 mg - give 125 mg by mouth every 6 hours related to UTI, site not specified until 9/05/2023 23:59 c. ordered 8/21/23- fluconazole oral tablet 100 mg- give 100 mg by mouth one time a day related to UTI, site not specified d. ordered 8/21/23- levofloxacin oral tablet 750 mg - give 750 mg by mouth one time a day related to UTI, site not specified e ordered 8/29/23- document suprapubic catheter output every shift every shift f. ordered 8/29/23 - Hot Chart: Monitor for signs and symptoms of UTI and C.Diff. (clotridoides difficile colitis) - monitor for suprapubic/flank pain, hematuria, confusion, loose stools, abdomen pain, document in a progress note and update provider with concerns and every shift for recent UTI and C. Diff until 09/13/2023 23:59 The August MAR (Medication Administration Record) revealed the following dates and times the resident did not receive his vancomycin 125 mg oral capsule medications: a. 8/23/23 at 6:00 AM- left blank on the MAR b. 8/24/23 at 12:00 PM - a 9 placed on the MAR box which meant not administered or resident asleep. c. 8/26/23 at 12:00 AM- 4 placed on the MAR indicating review in progress note d. 8/27/23 at 6:00 AM- left blank on the MAR e. 8/28/23 at 6:00 AM - left blank on the MAR f. 8/29/23 at 6:00 AM- left blank on the MAR g. 9/2/23 at 6:00 AM left blank on the MAR h. 9/4/23 at 6:00 AM left blank on the MAR. The Medication Administration Note dated 8/26/2023 at 3:10 AM revealed vancomycin HCl oral capsule 125 mg- give 125 mg by mouth every 6 hours related to UTI, not specified until 09/05/2023 23:59. Resident sleeping and despite 3 attempts to wake the resident, he would not wake up and this nurse unable to administer NOC dose. The facility lacked documentation of vitals or an assessment documented in the EMR (electronic medical record) on 8/26/23 at 3:10 am after the resident didn't wake up. During an interview on 8/28/23 at 8:22 AM, Resident #18 stated he bet in the last 2 months he been in and out of the hospital 15 times and currently had a UTI. He stated he got them all the time. During an observation on 8/28/23 at 8:53 AM, Resident #18 wore hospital gown, states prefers wanted to right now and laid in bed with the head of his head elevated eating breakfast. Legs propped on a pillow. During an interview on 8/29/23 at 11:17 AM, the Assistant Director of Nursing (ADON), LPN queried on the night Resident #18 went to the ED and she stated she went into his room because the girls said he wasn't responding. She stated she did a sternum rub and got vitals, and the BP low, and the resident would snore but wouldn't wake up, and she got an order to send him out to the local hospital and then he went to different hospital. The ADON asked about his pulse oximetry and and stated pulse oximetry was good. The Emergency Medical Technician (EMT) got a pulse oximetry it read 90%. He had sepsis when I sent him out so I don't know if he didn't perfuse enough. She stated the EMT hooked him up for EKG (electrocardiogram). She stated it happened around 2 or 3 in them morning and the ambulance arrived within approximately 15 minutes. The ADON asked how often rounds done on the residents and she stated they go in every 2 hours to turn and every 4 hours to check and change. The ADON asked how she notified of the urinary output and she stated usually the CNAs gave us the amount at the end of the shift and she was not aware at the beginning of the shift he didn't have any urinary output. The ADON queried if no output be would be a concern to CNA and she stated she would like so but they didn't have the same training as nurses. She stated if the urine an off color they would report it to the nurse. The ADON asked what protocol the facility used for loose stools and she stated they got loperamide on board. The ADON queried on why the resident placed in transmission based precautions and she stated for C-dif and she stated he went to precautions the day he came back. She confirmed Resident #18 shared a room with Resident #37 and then they moved Resident #18 to his own room because he kept talking to someone not there and it bothered his roommate. During an interview on 8/29/23 at 3:25 PM, Staff H, Registered Nurse (RN) queried if the facility documented when residents took antibiotics and she stated yes we monitor for signs and symptoms and reactions. Staff H asked where the documentation could be found and she stated it would be in the documentation under hot charting. Staff H asked if it would be documented somewhere else on the EMR and she stated no it shouldn't be. Staff H asked if Resident #18 took antibiotics when he came to the facility and she stated she not 100% he was on one when he came in. Staff H stated anyone on an antibiotic needed hot charting. Staff H asked how long hot charting scheduled for residents on antibiotics and she stated normally for like 3 days and we chart, after it is finished a final note if depending on the infection like UTI signs or symptoms of infections, same with C-dif. She stated normally the charted the whole time the resident took an antibiotic and what the DON and ADON put it in the computer for hot charting, goes on the LPN/RN MAR as an order and you can either put it in as a progress note. Staff H queried if urinary output recorded for residents with urinary catheter and she stated depended if ordered to check the output but if the CNA normally tell us and if it is under their tasks up they put in the computer as well. During an interview on 8/29/23 at 4:11 PM, Staff P, CNA queried on how often she checked Resident #18 catheter bag and she stated twice when she worked 12 hour shifts. She stated she checked on him every 2 hours and he got frequent UTI's and confused. Staff P asked what she done when the resident appeared confused and she stated she reported it. Staff P asked about the night the resident sent to the hospital and she stated when she found him he was groggy, dead weight didn't respond that well and he was breathing fine but wouldn't open his eyes and wouldn't get up for anyone. She stated she went and got the nurse and told her that he was not right. Staff P stated she did the medication cart on 2nd shift that evening and then worked as the CNA in Resident#18 hall on 3rd shift and the resident sent out on the 3rd shift. Staff P stated she overheard the day shift the CNA on days shift told the 2nd shift CNA the resident wasn't right all day. Staff P stated Resident #18 refused his bedtime medications because he wouldn't wake up to take them so she went and told the nurse on duty he wouldn't wake up. Staff P stated she thought the nurse went in and checked on him but not sure if the nurse took vitals. Staff P stated when she went into the resident's room to check him on 3rd shift the resident felt cold, his numbs felt cold usually when she changed him and they always felt warm and he didn't respond but still breathing. She stated at this point, something needed to be done, clearly a sign something needed to happen and I went and got the nurse. During an interview on 8/29/23 at 4:42 PM, Staff Q, CNA queried if she worked on 8/12/23 and took care of Resident #18 and she stated she worked and when she checked on him he didn't act like he was with it and stated it started in the morning and slowly progressed and after 2 PM it went full force. She stated she found him laid the width of the bed and not the length of the bed like he usually during the afternoon. She stated his head laid against the wall and his stumps laid over the bed. She described it like sundowns. Staff Q stated someone saw him like that and came and got her and Staff P and the two of us went in there. Staff Q asked if she ever checked the catheter bags and she stated yes if she worked the floor. She stated the don't track output on every resident with a catheter. Staff Q looked Resident #18 on her computer and stated he didn't show a section for output. During an interview on 8/30/23 at 11:37 AM, Staff S, CNA queried if she remembered taking care of Resident #18 on 8/12/23 and she stated the day before he went to the hospital he had diarrhea and didn't feel well and felt achy. Staff S asked if the nurse knew the resident had diarrhea and she stated yes, the nurse helped clean him up once and he said he had a headache. Staff S asked when she completed vitals and she stated the nurse did the vitals. Staff S stated he told her he felt better but during report it was reported he had diarrhea. Staff S stated the resident had urinary output but she didn't recall how much and the urine looked orange colored. Staff S stated the resident normally alert and oriented but someone told her the resident made noises and she didn't remember who told her. Staff S didn't know what kind of noises he made. Staff S stated the catheter output pops up on the computer for them to automatically do. Staff S stated they didn't usually do outputs they just drained the catheters and told the nurse the output. During an interview on 8/30/23 at 12:02 PM, Staff L, CNA queried if she ever assisted Resident #18 and she stated yes either on 8/12 or 8/13. She stated the resident alert and oriented when she took care of him. Staff L asked if catheter care scheduled for a task and she stated she assumed so but she just knew it needed done. Staff L asked when the catheter bag needed drained and she stated at least once a shift. Staff I asked if they charted output and she stated she believed they did with residents with catheters but she reported to the nurse. Staff L queried if she remembered the resident's output and she stated she didn't. During an interview on 8/30/23 at 12:45 PM, Staff I, LPN queried on who did the vitals and she stated sometimes the nurses, sometimes the CMA (Certified Medication Aide) did them and once in awhile the CNAs. Staff I asked what warranted vitals and she stated skilled residents, resident didn't feel well, bad headache, or dizzy. Staff I asked if the facility had protocols for residents on antibiotics and she stated they needed to chart if they had adverse side effects from antibiotic therapy and made sure the antibiotic effective. She stated they looked to see if the resident had a temperature and they were supposed to chart for a couple of days after the antibiotic started on how the resident did with the antibiotic. Staff I stated she thought they charted every shift while on an antibiotic and they usually took a temperature every shift. Staff I queried what she considered a change of condition and she stated dizziness, vomited, diarrhea, lethargic, or just if the resident comes and told us or the CMA told us and then they did a change of condition report and they called the provider and the Power of Attorney (POA). Staff I confirmed if they assessed the resident, it was documented in progress notes. During an interview on 8/30/23 at 1:05 PM, Staff E, LPN queried on what warranted vitals and she stated skilled residents, change of condition or something that appeared different for the resident, if they took antibiotics, or a change in mental status. Staff E asked if they used protocols for residents on antibiotic therapy and she stated they documented the amount of time they took the antibiotic and they usually received an order that moved over to the progress notes. Staff E asked what she considered a change of condition and she stated a new skin issue, mental status change, and an injury. Staff E asked if the facility documented urinary outputs and she stated she didn't know, she didn't do anything with them. During an interview on 8/30/23 at 1:17 PM, Staff X, Certified Medication Technician (CMT) queried on what she considered a change of condition and she stated anything, not normal for them day to day. Staff X asked what she did when she saw a change of condition and she stated immediately notify the nurse and found out the next course of action. Staff X queried if she completed any additional information with administration of an antibiotic and she stated she put a temperature in the EMR, she stated another tab popped up on the computer. Staff X queried if she took Resident #18 temperature and she stated no, but he received scheduled vitals. Staff X asked what Resident #18 normal presentation appeared like and she stated the resident normally with it, very talkative, and if he could walk he would be independent. She stated she never noticed him confused and he woke easily. During an interview on 8/30/23 01:25 PM, the DON (Director of Nursing) queried on who performed vitals and she stated the nursing staff. The DON asked what warranted vitals and she stated they did monthly vitals on residents and obviously residents who didn't look right, and they also done assessments. The DON queried what protocols they used if a resident took antibiotic and she stated we charted on them to make sure they don't have any adverse reactions or nausea and things like that. She stated the nurses go in and chart on them at least daily. The DON asked if they completed vitals and she stated not the whole set but a temperature and vitals as needed for residents. The DON asked what she considered a change of condition and she stated anything different than the resident's baseline, if resident presented confused and not normally confused, a temperature, or a prolonged cough. The DON asked her expectation of nurses with a change of condition and she stated that the nurses filled out a change of condition and called the the responsible party and the provider. The DON asked if the facility documented the urinary output when residents used urinary catheters and she stated yes, it should be tasked and usually the CNA told the nurses and they kept track of it that way. The DON asked what she considered a low urinary output and her expectation of an intervention with a low output and she stated less than 30 ml/hr (milliliter/hour). She stated they don't check the output hourly in but if in a shift less than 30 ml/hr, it warranted a phone call. The DON asked what it meant if a the MAR appeared blank for a medication time and she stated she believed it meant the medication did not get administered. The DON asked her expectation of medications being administered and she stated she expected them administered unless the medication used for blood pressure medication and took they took the BP and the result revealed low, she expected the medication held. The DON asked if nurses received training in change in condition and she stated they conducted a verbal training with change of condition and they completed a formal education with the nurses on change of condition. During an interview on 8/30/23 at 2:01 PM, Staff V, RN queried on what warranted vitals and she stated multiple reasons like a change of condition. Staff V asked if they had protocols for antibiotic therapy such as vitals or assessments and she stated checked the temperature and it depended what else was going on with the resident. She stated if resident took an antibiotic she did an assessment every shift, and she tried to put in a progress note. Staff V queried if she she completed hot charting and she stated they hot charted for adverse reactions of an antibiotic, UTI symptoms such as urinary symptoms. Staff V asked what she considered a change of condition and she stated a change in mental status, anything irregular, and any new signs and symptoms of anything. Staff V queried on what she did when she saw a change of condition and she stated she completed an assessment and called the provider. During an interview on 8/30/23 at 2:50 PM, Staff Y, RN queried if she ever completed assessments on Resident #18 and she stated she completed his admission assessment. Staff Y asked if she remembered doing antibiotic therapy assessments on him and she stated she was trained antibiotic therapy goes on the hot chart list and documented daily and set up on alert through the EMR. The hot chart goes into EMR under LPN/RN and they did hot charting, vi[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, physician interview, staff interview and hospital record review, the facility failed to respond to a warning for possible interaction between an antibiotic and anticoagulant medication and failed to intervene appropriately once new bruising was observed in multiple locations, which was an indicator of an adverse side effect of an anticoagulation medication for 1 of 2 (Resident #1) residents reviewed on anticoagulant therapy. The facility reported a census of 56 residents. This 2567 had been amended on February 3, 2023. Findings include: Resident #1's admission Minimum Data Set (MDS) dated [DATE] documented an admission date of 11/30/22. The MDS documented a Brief Interview for Mental Status (BIMS) of 15, which indicated no cognitive impairment. The MDS documented the resident received an anticoagulation medication each of the last 7 days. Progress Note written on 11/30/22 at 2:56 PM documented a request sent out to the Primary Care Provider (PCP) for the next INR (lab test to measure anticoagulant) due date. Progress Note written on 11/30/22 at 6:41 PM documented the PCP ordered the INR to be drawn in 2 weeks, on December 14, 2022. Progress Note written on 12/5/22 at 6:30 PM documented the PCP was notified of the resident having an elevated temperature throughout the PM shift, nausea and dizziness. Progress Note generated by the Electronic Health Record (EHR) on 12/5/22 warned of a possible drug interaction between Jantoven (warfarin, Coumadin) 5 milligrams (mg) given daily for blood thinning and the antibiotic Keflex. The EHR identified the interaction as a moderate severity. The use of the medications together had the potential to increase the risk of bleeding complications. The Progress Notes lack notification to the PCP of the warning. The Progress Notes lack documentation of the PCPs decision and rationale for using the medications together despite the risk of interaction. Progress Note written on 12/11/22 at 8:11 PM documented turned resident to side, wound on sacrum draining large amount of foul smelling red and black substance. Appears to be blood. Dressing changed, and resident repositioned. New bruising on the resident's left shin, left upper back, and on her ribs on the left side. The bruises were purple on color. The Advanced Registered Nurse Practioner (ARNP) was made aware of bruising and other assessment findings. The Progress Note documented her response as if giving blood thinners twice a day, decrease to once a day. It was noted the resident would be having an INR drawn in 3 days. The resident's Care Plan alerted staff the resident was on an anticoagulant and it required lab monitoring. The resident was identified as not needing terminal care. The Medication Administration Record (MAR) for Resident #1 included warfarin 5 milligrams (mg) daily. It was given daily from 12/1/22 thru 12/10/22. It was not given on 12/11/22 or 12/12/22. Review of the hospital records for Resident #1 (Clinical Report dated 12/12/22 under History of Present Illness) documented that her INR was therapeutic on 11/29/22 at 2.9 (normal for this resident's use of the medication is 2.0 to 3.0). Review of the hospital records, Clinical Report dated 12/12/22 documented that when the resident arrived in the emergency room her INR was greater than 17.3 (the lab analyzer could not actually determine a level as it did not read that high). The lab results document an INR of over 10 is considered critical for a resident on warfarin therapy. During an interview on 12/14/22 at 3:29 PM the Emergency Department (ED) physician stated when the resident was admitted to the ED on 12/12/22 she had bruising on her arms, legs and trunk. Her hemoglobin (hgb- protein that carries oxygen to the tissues and organs) was low. The physician reported that the resident was found to have a gastrointestinal bleed (GI Bleed) and had lost about 4 units of blood presumably through her stools. The hospital was setting up a unit of blood to give to the resident but she passed before it was ready. During an interview on 12/15/22 at 11:52 AM the PCP stated he was notified on 12/5/22 that the resident was not feeling well. She had an elevated temperature and nausea. He stated he ordered Keflex for the elevated temperature and because she had a pressure ulcer on her sacrum. Stated he was concerned she may be developing an infection in that and so the antibiotic was for skin bacteria. He stated he requested and received a status update on 12/7/22. He ordered some blood tests. The bloodwork came back with her hgb at 11.6, she was a little anemic. He stated he did not receive notification about the possible interaction between the warfarin and the Keflex. He stated she had previously used warfarin and Keflex together successfully many times. He stated if her intakes decreased that could cause her warfarin to be more potent but did not feel the Keflex was the cause. He stated he was not notified of the resident's decreased intakes and he was not notified prior to sending her to the ED on 12/12/22. During an interview on 12/15/22 at 10:28 AM Staff A stated if she had a question about a medication dosage or interaction there was a drug book available for reference. She was unable to locate the book. She entered the Director of Nursing's (DON) office to ask about the book. After a few minutes, the surveyor entered the DON's office to see if they had found the book. The DON was on her computer and stated she was looking for it. A minute later Staff A and the DON entered the medication room to look for the book. Staff A came out of the medication room and stated there was not a book in there. The Clinical Nurse Consultant entered the nurses station and stated the medication information was in the EHR. He was unable to locate it or show staff where to find it. The DON stated there is a single desktop computer at the nurses station that has full Internet access. She stated they could either use that or their personal cell phones to Google medications if they had a question about dosages or interactions. She stated they do not issue facility phones to use for references. An Immediate Jeopardy (IJ) was identified on 12/15/22 (with the start date being noted as 12/5/22), and the facility was notified of the IJ on 12/15/22. The IJ was removed on 12/15/22 when the facility developed and implemented the following corrective action plan: -Facility Nurses were educated by the DON/Admin on 12/15/22 policies PCU56-Medication Monitoring, PCU-58Medication Discrepancies and Adverse Medication Reactions -Facility Nursing staff were educated on policy NursA.9 Notification of Change in Resident Condition by DON/Admin. -Staff educated on 12/15/22 on monitoring PCC for alerts for potential drug/drug interactions by DON -Staff educated on the importance of monitoring bruising on residents with Anticoagulant therapy on 12/15/22 for Dr. Notification by DON -Facility did a 100% audit on all residents on Coumadin to ensure appropriate routine lab in place for PT/INR. [NAME] completed this audit The scope and severity level of the IJ deficiency was lowered from a J to an G at the time of the survey after the facility completed the above removal plan.