**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to comprehensively assess and implement pressure ulcer interventions for 1 of 3 residents (R1) who was admitted to the facility without pressure ulcers. The facility failed to provide ongoing comprehensive skin assessments, monitor for signs of infection/deterioration and ensure R1 was seen at the wound clinic per physician orders. As a result, R1 had a life threatening infection that required an above the knee amputation resulting in an immediate jeopardy. The IJ began on 12/20/22, when R1 was transferred to hospital-B for left above knee amputation related to diagnoses of osteomyelitis (bone infection) and calcaneus sepsis (life threatening bone infection that has spread through the body) from R1's pressure ulcer. The director of nursing (DON), assistant director of nursing (ADON), and social worker (SW)-A were notified of the IJ on 1/30/23, at 3:55 p.m. The IJ was removed on 2/2/23, at 1:51 p.m. Noncompliance remained at the lower scope and severity level of D-isolated indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Pressure Ulcer/Injury (PU/PI); localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin or open ulcer. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Soft tissue damage related to pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 2 Pressure Ulcer: partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. Unstageable Pressure Ulcer: full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar should only be removed after careful clinical consideration and consultation with the resident's physician. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. Debridement: the removal of devitalized/necrotic tissue and foreign matter from a wound to improve or facilitate the healing process. Eschar: is dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound. R1's Face sheet printed 1/30/23, identified a diagnoses of Diabetes and morbid obesity. R1's admission Minimum Data Set (MDS), dated [DATE], identified R1 did not have cognitive impairment. R1 required limited assistance from one staff for hygiene, dressing, and toileting and required extensive assist from one staff for bed mobility and transfers. In addition, R1 was at risk for pressure ulcers, did not have skin concerns, and utilized a pressure reducing device for his bed. R1's skin care plan 8/18/22, indicated R1 was at risk for delayed healing and additional skin break down due to immobility and diabetes. Corresponding interventions included treat skin issues/wounds per MD orders. Record location, size (length, width, depth), color, surrounding skin, presence/absence of drainage/pain/signs of healing. Avoid shearing resident's skin during positioning, transferring, and turning. R1's East Nurse Aide Shift Report document, dated 8/19/22, evening shift, identified that R1's left heel has a pressure ulcer-the nurse knows. R1's record lacked a comprehensive assessment that included description, measurements, interventions to improve and/or prevent further deterioration. Further, it was not evident the physician was notified upon identification. R1's care plan 8/1/22 did not include interventions to treat R1's pressure ulcers once they developed. Additionally, review of physician orders identified delay in treatment and intervention. Physician order dated 8/21/22, directed staff not to put R1's shoes on and physician order dated 8/23/22 directed staff to change left heel dressing every 3 days and as needed: cleanse with wound cleanser, foam heel dressing and secure with Kerlix (roll gauze). Check twice a day for placement, keep dry and intact. This order remained until 10/6/22 even though there had been physician ordered treatment change on 9/7/22. R1's progress note dated 8/23/22, indicated R1's Mepilex (absorbent antimicrobial foam dressing) dressing was changed to his left heel with a moderate amount of serosanguinous drainage (composed of red blood cells and blood serum, typically thin and watery with light red or pink hue). Area measured 8 centimeters (cm) x 8.5 cm. Wound appeared to be a drained open blister, top skin is intact, pink, and whitish overall. New dry foam heel dressing applied with Kerlix, blue boots on and left heel floated while in bed. The note did not identify the stage of the ulcer, and the care plan was not revised to identify the aforementioned interventions. R1's progress note dated 8/24/23, indicated R1's left heel large blister is now open, Xerofoam (medicated dressing) applied, Vaseline gauze, ABD pad (an absorbent pad) and wrapped with ace bandage. R1's physician orders did not identify a signed order to change/add the medicated gauze wound treatment from the ordered treatment on 8/23/22, that directed to clean wound with wound cleanser, apply heel dressing, and secure with Kerlix every three days. In review of R1's record it could not be determined the duration of how long Xeroform was used. R1's significant change MDS dated [DATE], identified R1 had one stage 2 pressure ulcer. However, R1's skin assessment dated [DATE], i identified a stage 2 pressure ulcer on his left heel and had wounds to left buttock. No further assessment was identified, however R1 would be referred to the wound clinic. R1's Nurse Practitioner visit, dated 9/7/2022, indicated R1 has developed a pressure ulcer to the plantar (sole) of his left heel that had been found a few days ago. The ulcer was fairly large, reddened area that encompassed most of the plantar aspect of his heel, two inch diameter eschar in the center of the wound. Nurses think it might be slightly improving. New treatment included, cleanse the wound with wound cleanser, apply Medi honey (an antibacterial wound gel), foam heel dressing, and secure with Kerlix, change dressing every 3 days and as needed. Further indicated a provider from wound clinic would be coming to visit R1 for wound care yet this week. We will continue to monitor R1 on a routine and as needed basis. Diagnosis of pressure injury of skin of left heel, unspecified injury stage. R1's wound assessment dated [DATE], indicated R1's medical record identified R1 developed a pressure ulcer to his left heel that measured 5 centimeters (cm) x 6.5 cm with a heavy amount of serosanguinous drainage. The record lacked staging of the pressure ulcer. R1's skin care plan was revised on 9/21/22, identified the left heel pressure area and had pressure areas on the tops of his right toes. Additional interventions included; air mattress on bed, followed by podiatry, determine if R1's feet are desensitized to pain/pressure, discourage R1 from using anything sharp/abrasive /drying to feet or nails. R1's progress note dated 9/26/23, indicated R1's wound changed in appearance; wound bed about 98% necrotic tissue. R1's wound note dated 9/28/22, left heel measured 5 cm x 5.7 cm, necrotic, declining. R1's Nurse Practitioner visit, dated 9/28/2022, indicated R1 was being seen today for his left heel, this started out as a blister approximately 8/23/22. The nursing staff have been trying to keep pressure off of it and have been treating it, but it has progressed. R1 has a very large black spot on the bottom/back of his left heel, with slight foul odor. Diagnosis: pressure injury of skin of left heel, unspecified injury stage. Referral to the wound clinic was completed. R1's Wound Care Clinic After Visit Summary (AVS) dated 10/6/22, indicated a new order placed for an ultrasound of the lower left extremities. Culture taken of unstageable left heel pressure ulcer. Will need wound care follow-up on 10/20/22. Included orders to start antibiotic medications. Wound dressing orders included: carefully remove all prior wraps and dressings and rinse all open areas with saline. Soak gauze in Dakin's 1/4 solution (a strong topical antiseptic to clean infected ulcers) and apply to heel for 15 minutes with dressing change daily, apply Iodosorb (wound gel that cleanse the wound by absorbing fluids and removing exudate) to the left posterior heel, place absorbent pad. If dressing becomes soiled, saturated, displaced, please remove, and replace. 100% non-weightbearing to the left lower extremity-PRAFO boot provided for wound offloading of left posterior heel, toe touch as needed for transfers. Use a tubigrip or stockinette to his left lower extremity. R1's culture results dated 10/11/23, identified methicillin resistant staphylococcus aureus (MRSA) was found in left heel wound and antibiotics were changed. R1's Medication Administration Record (MAR) identified the Iodosorb was not transcribed or implemented until 10/26/26. 20 days after the order was to be initiated. Further, R1's MAR identified on 10/8/22, 10/9/22, and 10/10/22, dressing was not changed with Dakin's solution, due to item unavailable. On 10/20/22 not completed as R1 was unavailable. R1's wound note dated 10/18/22, indicated left heel measured 5.0 cm x 6.5 cm, necrotic, declining. R1's Doctor of Podiatric Medicine (DPM) wound clinic visit, dated 10/20/22, indicated R1 was last seen on 8/19/22. The nursing facility applied the foam dressing to the left heel without removing the plastic covering, this was applied incorrectly so this caused maceration of the pressure injury. Post debridement measurements were 7.6 cm x 6.9 cm x 0.2 cm. New orders to apply Iodosorb, calmoseptime (an ointment that forms a barrier on the skin to protect it from irritants) and ABD pad applied to left heel ulceration. R1's vascular ultrasound scheduled for 11/7/22. Physician orders dated 10/21/22 identified the aforementioned order from the podiatrist, however, did not include the directive to apply the calmoseptime. Corresponding MAR identified the dressing was completed without the calmoseptime from 10/21/22 to 10/26/22. R1's Wound Clinic AVS dated 10/27/22, indicated R1 has an appointment on 11/7/22 at 9:00 am to have an ultrasound completed of his lower extremities, and wound care follow up on 11/10/22. According to R1's record, R1 was not seen for vascular ultrasound as ordered. R1's Physician assistant (PA) advanced wound healing visit and orders, dated 10/27/22, indicated R1's wound was very macerated and has worsened since his last visit. Radiographs of his left heel unstageable pressure ulcer, revealed no osteomyelitis. Wound was debrided; post debridement measurements were 5.5 cm x 9.1 cm x 0.4 cm. Advised R1 to increase protein intake via diet supplementation to accelerate wound healing. Return in 2 weeks for re-evaluation. New orders included, discontinue previous order. start daily dressing changes; cleanse wound with saline and gauze, soak the wound using gauze soaked in Dakin's ¼ strength for 10 -15 minutes. Apply Santyl (an ointment used to remove dead tissue from a wound) to the left posterior wound bed (nickel thick), cover with ABD pad. R1's PA advanced wound healing visit, dated 11/10/22, indicated that R1 stated during his visit that his dressing does not get changed every day. R1 further stated he has significant pain in the region of the ulcer edges, failed to complete his vascular ultrasound appointment and R1 reported the transportation never arrived, and was rescheduled today. R1 left heel unstageable pressure ulcer was debrided, post debridement measurements were 4.2 cm x 8.1 cm x 0.6 cm. Return to clinic in 1 week. According to R1's record it was not evident R1 returned to the wound clinic within one week as ordered. R1's NP Visit note, dated 11/30/22, indicated R1 was seen due to concerns with right heel, identified right heel as an unstageable pressure injury, referral in place for the wound clinic for his right heel. The visit note did not include further description of the left and right heel pressure ulcers. R1's quarterly MDS, dated [DATE], identified R1 had 2 unstageable pressure ulcers, however R1's record (aside from MDS) did not identify the presence of a second unstageable ulcer. R1's progress note, dated 12/6/22, indicated that social worker (SW)-A escorted R1 to his wound clinic appointment. R1 was sent to the emergency department from the wound clinic for further evaluation due to R1's elevated INR (a blood test that measures the time for blood to clot), pale complexion, lethargy and possible cellulitis of wound and was admitted to the hospital. In review of R1's medical record, it was not evident an assessment was completed to determine the tissue tolerance over bony areas to pressure in accordance with facility policy. Not evident on-going monitoring was completed. Further not evident weekly comprehensive assessments were completed for all of R1's pressure ulcers that included risk factors, size, depth, stage, wound bed characteristics, drainage, and pain. There was no indication the facility reassessed PU prevention modalities and treatment strategies for effectiveness every 14 days or sooner to ensure appropriateness for healing and/or prevent infection and further deterioration. During a continuous observation on 1/26/23, from 9:35 a.m. to 10:51 a.m. R1 was observed to be lying on his back in bed. R1 was observed to have an above the knee amputation on his left leg and had a wound vac that was attached to the stump that was running. R1's right lower extremity had a blue PRAFO boot (a device worn on the calf and foot that is used to prevent pressure ulcers to the back of the heel) on. R1 stated he had not eaten breakfast yet. During an interview on 1/26/23, at 10:38 a.m. nursing assistant (NA)-A stated she had been the one who had first identified the pressure ulcer on R1's left heel that had resulted in left leg amputation because of infection. R1 was hospitalized for about a month. NA-A explained NAs did not document toileting/reposition in the electronic health record (EHR); they would use paper care sheets with time slots of 6 am, 8 am, 10 am, 12 pm. We just put a check mark if we toileted or repositioned them. If the care plan changed the sheets would be updated by the nurse so that the NA's knew what to do. Most of the sheets don't direct us to offload heels for for people who need it, NA-A did not think that staff would offload heels if it was not on the care sheet. NA-A stated she could not get residents toileted and repositioned on time per their care plan because there was not enough staff. NA-A stated she had not had time to reposition R1 yet, because she had been busy with other residents. At 10:56 a.m. R1 was transferred via full body lift to his wheelchair. During an interview on 1/26/23, at 2:01 p.m. registered nurse (RN)-A changed R1's right heel dressing; reported the scabbed area measured 2.4 cm x 1.0 cm which would not be stageable. RN-A indicated the ulcer looked like it was getting better. During an observation and interview on 1/26/23, at 2:15 p.m. unit clinical manager (CM)-A stated, the floor nurses should be doing weekly wound assessments, this is typically done on Saturdays and should be documented in the nursing notes. CM-A stated R1 had pressure ulcers to his buttocks and was not sure how long they have been there. At 2:27 p.m. RN-A removed the sacral Mepilex dressing from R1's coccyx area; dressing had pinkish drainage on it. RN-A stated there was a moderate amount of serosanguinous drainage on the dressing. Four open areas were observed on R1's coccyx area. RN-A stated they were all stage 2 pressure ulcers. RN-A measured the areas and started to cleanse the areas with wound cleanser. R1 clenched his buttocks during the cleansing and stated, Ow! Ow! Ow! Wound beds all were red. Measurements were as follows: middle coccyx area measured 3.1 cm x 1.0 cm, ulcer directly below measured 0.5 cm x 0.5 cm. Right middle buttock ulcer was 1.5 cm x 0.5 cm and right lateral area was 0.7 cm x 0.7 cm. RN-A cut pieces of Aquacel and placed in each wound bed. RN-A stated they did not have any sacral Mepilex so instead she used a square 4 x 4 Mepilex and placed it in the middle of R1's coccyx area. R1 was then repositioned to his left side. During an interview on 1/26/23, at 3:04 p.m. CM-A stated the facility did not have a designated nurse to oversee wound care right now; the wound care system that had been in place just kind of fell apart. After a wound was identified a comprehensive assessment should be completed that included measurements, staging (if pressure ulcer), wound bed appearance, drainage and surrounding skin area. Assessments were to be completed weekly because if it started to worsen, the provider would be notified for possible change in treatments. The dressing should be changed per the MD order. During an interview on 1/26/23, at 5:17 p.m. CM-A thought R1's left heel wound started as a stage 2 pressure ulcer. CM-A was not sure when the ulcer became unstageable because the weekly wound assessments were not done. CM-A reported she was responsible for tracking the wound clinic appointments and communicating with SW-A to set up transport services; R1's follow-up appointment after the 11/10/22 was missed. On 11/30/22, R1 had developed a blister on his right heel. We obtained a referral to wound clinic, the appointment was made for 12/6/22, when he was transferred to the emergency room. He was admitted to hospital with osteomyelitis (bone infection) that resulted in a left above the knee amputation. During an interview on 1/26/23 at 4:49 p.m. SW-A, stated she was the one who set up transportation for outside appointments. R1 did not go to his vascular ultrasound appointment. The follow-up wound clinic appointment from the 11/10/22 visit was missed because nursing had not informed her of R1's need for appointment or transportation. R1 did not have another wound clinic appointment until 12/6/22, that she escorted him to. When we got to the clinic, R1 looked very white and pale looking. Clinic staff took him back for examination and came back out and told her they were sending him to the emergency room because he had an elevated INR, he was pale, and had possible cellulitis (skin infection). During an interview on 1/26/23, at 3:24 p.m. assistant director of nursing (ADON) stated the facility did not have anyone in charge of wounds currently. Anyone with a wound should be comprehensively assessed at least weekly. With any worsening the provider would need to be called to ensure appropriate treatment was in place. The resident's wound clinic physicians have been the ones doing the measurements. During an interview on 1/30/23 at 12:59 a.m. director of nursing (DON) stated, when R1 was admitted he had no pressure ulcers. DON stated R1 did not have weekly skin assessments performed as he should have to include pressure ulcer staging, measurement of ulcer, wound bed characteristics, surrounding skin area. Assessment needed to be done weekly to ensure the current treatment was working. DON stated on 11/10/22, R1 was supposed to have a follow-up appointment with the wound specialist within a week and the MD orders were not followed. R1 did not get to the wound specialist until 12/6/22. At the appointment R1 was immediately hospitalized with sepsis and ultimate left leg above the knee leg amputation. DON stated the floor nurses should be doing weekly bath audits which would be where the comprehensive skin assessments should go. During a phone interview on 1/30/23, at 1:57 p.m. NP-A explained she had seen R1 in September (2022) for his left heel unstageable ulcer so depth could not be determined. NP-A referred R1 to the wound clinic. Then on 11/30/22, NP-A wrote another referral for R1's right heel unstageable ulcer. The missed appointments and lack of assessments resulted in an unstageable pressure ulcer, sepsis, and ultimate loss of his left leg. NP-A stated she had recently seen R1 for his pressure ulcers on his buttocks, she had cultured the wounds, results were MRSA. We will be starting antibiotics. During a phone interview on 1/31/23, at 4:34 p.m. physician assistant wound specialist (PAWS)-A stated R1's left heel unstageable pressure ulcer was being managed by the wound clinic. We saw R1 on 10/20/22, at that time the left heel was just a big eschar cap. On 11/10/22, the eschar cap had softened and was macerated because the facility had applied the dressing incorrectly by not taking the plastic off. R1 was supposed to come back in a week for follow-up however, did not come back until 12/6/22. When he presented on 12/6/22 for that appointment he was really sick, pale, weak, cognition was blunted, his INR was high, he was just way off from his baseline. and that they sent him right over to the ER. He further stated he, the podiatrist, and ortho looked at his left heel, it was all open and wet, eschar stringy tissue, it looked terrible. R1 was diagnosed at the hospital with osteomyelitis and calcaneus sepsis. On 12/20/22, R1 transferred to another hospital where he had an above the knee amputation as a direct result from the infection in the pressure ulcer. Had R1 came back for his follow-up visit as ordered, could have prevented amputation of his leg. Facility policy entitled, Pressure Sores Protocol, revised 8/3/18, indicated a purpose to identify residents at risk for developing pressure sores. To assure residents are receiving necessary treatment and services to prompt healing, prevent infection and prevent new sores from developing. 1. Identifying at-risk individuals needing prevention and specific factors placing them at risk will be done in the initial comprehensive nursing assessment and in on-going assessments by the nursing staff. 5. Protection of residents from external mechanical forces such as friction, pressure, and shearing will be done as follows: a. positioning devices, such as pillows or foam wedges, should be used to keep boy prominence's from direct contact with one another, according to a written plan of care. B. individuals in bed who are completely immobile should have a care plan that includes the use of devices that totally relieves pressure on heels. The heels should be raised off the bed. F. Any individual assessed to be at risk for developing pressure areas should be placed on a pressure reducing device such as an air mattress, RoHo or gel cushions. The resident should be repositioned, shifting the points of pressure at least every hour. Resident capable of being taught should be instructed to shift weight every 15 minutes while sitting. Facility policy, entitled, Tissue Tolerance Audit Policy and Procedure, revised 8/3/18, included: 1. Tissue tolerance is the skin and its supporting structures ability to endure the effects of pressure without adverse effects. Each resident who is dependent on bed and/or chair mobility, will be monitored for tissue tolerance while lying and sitting: a. upon admission, readmission; and b. with a change in condition 2. Once an individualized turning and repositioning schedule is determined a daily skin inspection by the nursing assistant and a weekly skin inspection by the licensed nurse will be done to ensure that there are no adverse effects to the skin and its supporting structures, ensuring that the determined intervals are still appropriate. Facility policy entitled, Pressure Sore Monitoring, revised 8/3/18, identified a purpose to assure assessment and reassessment completion of all open area and appropriateness of treatment. 1. Staff nurse will assess all open areas on each resident on his/her wing weekly. 2. Staff will document on the skin and wound assessment and record sheet the stage of each area and present treatment. 3. Report of open areas and treatment will be given to the Quality Assurance Nurse. 4. Quality Assurance Nurse will do random assessments of open areas on each unit on an ongoing basis. %. Copies of weekly assessments of open areas will be available to the dietician for her review at her next visit. Residents with significant open areas will be reviewed by the dietician and recommendations made. Scheduled reviews with dietician will be coordinated by the dietary manager. 6. Assessment information will be utilized to assure on-going individual care plan approaches are current and specific for each resident. The immediate Jeopardy that began on 12/20/22, was removed on 2/2/23 at 1:51 p.m. when it was verified through interview and document review the facility implemented the following: -immediately review/revise/develop their pressure ulcer program policies and protocols. -Provided education to licensed staff on completing comprehensive pressure ulcer assessments and care plan interventions for pressure ulcers. -Comprehensively assess all residents who have any stage pressure ulcers. Evaluated and review/revise care plan for appropriateness of treatment and services to reduce the risk of pressure ulcer development and/or further deterioration of pressure ulcers and infection with notification to the physician as appropriate. -Provided education to direct care staff on pressure ulcer prevention modalities in accordance with the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure residents were free from neglect when they allowed two nursing assistants (NA)-A, NA-B, who were suspected of chemical impairment to work in the facility. NA-A and NA-B both tested positive for illicit drugs. 3 of 3 residents (R2, R3, R4) sustained falls that resulted in injuries when NA-A and NA-B did not follow the care plan. This resulted in an immediate jeopardy (IJ) for resident health and safety when NA-A and NA-B provided care. The IJ began on 1/18/23, when the facility failed to ensure residents were free from neglect when they allowed two nursing assistants who tested positive of chemical impairment to work in the facility. The administrator and the director of nursing (DON) were notified of the IJ on 1/25/23, at 5:28 p.m. The IJ was removed on 1/27/23, at 5:30 p.m. but scope and severity remained at a level D, no actual harm with potential for more than minimal harm. Findings include: NA-A's employee file dated 1/31/22, included a self-reported history of alcoholism. On 2/1/22, the facility implemented a plan to breathalyzer NA-A at beginning and middle of her shift while employed. On 2/20/22, NA-A reported to work at 6:30 a.m. and had a breathalyzer test (A breath alcohol test determines how much alcohol is in your blood) of 0.13 (0.08 is considered legally intoxicated in the state on Minnesota.) NA-A was sent home before starting her shift. The facility did not complete any breathalyzer testing after 5/10/22. NA-A's employee file contained NA-A's Escreen (an online portal that enables individuals to schedule and pay for drug screening and testing services and receive the online results.) Specimen Result Certificate dated 1/18/23, at 9:31 a.m., showed positive presence of amphetamines (a synthetic, addictive, mood-altering drug, used illegally as a stimulant). The report indicated the laboratory confirmation cutoff for a positive test of amphetamines as being 500 (nanograms/milliliter) ng/ml and this specimen indicated NA-A's result of over 1000 ng/ml. The result disposition of this specimen indicated NA-A's specimen as being positive for amphetamines. NA-B's employee file contained NA-B's Escreen Specimen Results Certificate dated 4/11/22, at 8:36 a.m. Employee file identified on her pre-employment drug screen sent to Escreen on 4/5/22, at 2:00 p.m. showed a positive presence of marijuana. The report indicated the laboratory confirmation cutoff for a positive test of marijuana as being 15ng/ml and this specimen indicated NA-B's result of over 50ng/ml. The result disposition of this specimen indicated NA-B's specimen as being positive for marijuana. On 1/19/23, at 1:09 p.m. an interview was conducted with NA-C. NA-C stated she had reported concerns to registered nurse (RN)-A about NA-A smelling of alcohol and sneaking out the window to drink in NA-A's truck during a shift. NA-C also stated on a shift in November (unknown date), NA-A had ran into a parked car in the parking lot and come into work smelling of alcohol. NA-C stated she did not feel NA-A was safe to continue to work at the facility as residents continued to fall on NA-A's shifts. NA-C stated she felt management was aware of her concerns because NA-C had told management she refused to work at the same time as NA-A, because N-A came to work impaired, and NA-C didn't want to work with someone you could not rely on. On 1/19/23, at 1:48 p.m. an interview was conducted with RN-A. RN-A stated she was aware that both NA-A and NA-B were supposed to be in recovery. RN-A stated she had heard about NA-A and NA-B coming to work chemically impaired in the past, and had heard about NA-A drinking at work last week. RN-A stated she had gotten calls from staff with concerns of NA-A and NA-B being at work impaired, and she told the staff to send them home. RN-A stated the last time she had told someone to send one of them home was a few months ago. RN-A stated she has had to do some coaching and re-education with NA-A when she had completed a transfer wrong and nearly dropped a resident when she wasn't using a gait belt during the transfer. RN-A stated she was unable to recall date of the coachings but stated it had been more than once On 1/19/23, at 2:23 p.m. an interview was conducted with director of nursing (DON) who stated she had heard allegations of NA-A drinking on the facility premises and sneaking out the window to avoid facility camaras on the weekend of the January 1st, 2023. The DON did not come to the facility but reviewed the camera footage on January 2nd, 2023, and stated she had not found anything concerning. The DON stated NA-A and NA-B did not have any substance abuse concerns in their employee files (despite NA-A self-reporting concerns and being breathalyzed previously at the facility). The DON stated she had NA-A and NA-B drug tested on [DATE]rd, 2023, to rule out staff suspicions of intoxication at work. The DON stated NA-A had never tested positive for alcohol at work during her breathalyzer testing contract. The DON stated NA-A's drug screen from 1/3/23, had come back positive for amphetamines (a synthetic, addictive, mood-altering drug, used illegally as a stimulant and legally as a prescription drug to treat children with ADD and adults with narcolepsy) on 1/18/23. NA-A had admitted to taking Vyvanse (a stimulant medication that is mainly used to treat attention deficit hyperactivity disorder in people over the age of five.) and continued to stay on the schedule and work pending the DON getting direction from the Escreen doctor on how to proceed on 1/23/23 when the doctor would be available for consultation. The DON stated she was not concerned about diversion related to the positive amphetamine test with NA-A, because no current residents had orders for amphetamines. The DON stated the facility was aware that NA-B had a prescription for medical marijuana and the DON had no concerns for NA-B's work performance with residents. The DON stated they had no monitoring of NA-A and NA-B's work performance related to their known chemical abuse history. On 1/19/23, at 5:13 p.m. an interview was conducted with the administrator who stated the DON had informed him on the day of the survey 1/19/23, she had a copy of NA-B's medical marijuana card in NA-B's employment file. The administrator stated he had reviewed NA-B's employment file and was unable to locate a medical marijuana card and had found a pre-employment drug test that was positive for marijuana. The administrator was unsure if staff would be able to work when using medical marijuana and would have to review the facility policy. The administrator stated nothing had been or was currently in place for monitoring impairment in NA-A or NA-B. The administrator stated he had thought both NA-A and NA-B had been removed from the schedule on 1/3/2023 pending further investigation, he was unaware NA-A and NA-B continued to be on the schedule. On 1/23/23 at 9:04 a.m. an interview was conducted with assistant director of nursing (ADON). The ADON stated he had been the person who tested NA-A with the portable breathalyzer on 2/10/22, and had sent her home. The ADON stated he was instructed by the DON to breathalyze NA-A at the beginning of her shifts back in February of 2022, but he was not sure who was supposed to breathalyzer her in the middle of her shifts. The ADON stated he had called the DON and informed her he had sent NA-A home on 2/10/22, related to the positive breathalyzer test. The ADON stated the DON informed him he had done the right thing, and she would have to meet with NA-A and have a conversation with her before NA-A's next work shift. The ADON stated staff had reported concerns of NA-A and NA-B coming to their shifts smelling of drugs and alcohol, but he had not observed this himself. The ADON stated he had usually been informed of the concerns a day or more after these occurred, so he was unable to determine the accuracy of these allegations. On 1/23/23, at 1:30 p.m. an interview was conducted with NA-D. NA-D stated she had worked with both NA-A and NA-B, and had reported her concerns to nurses on the floor as well, as the DON and administrator. NA-D stated she had reported seeing NA-A drinking in her truck at work, and being intoxicated, to her charge nurse. NA-D stated she was told by licensed practical nurse (LPN)-B, Yeah, she (NA-A) probably is. NA-D stated she personally witnessed NA-B transferring patients without her gait belt, and the residents falling and getting injured. NA-B stated she was present during at least five residents falls related to NA-B. NA-D stated she asked NA-B if she was impaired at work during one of her shifts, and NA-B had admitted she was. NA-D stated she observed NA-B transferring a resident with no gait belt, and the resident fell and hit her head on the floor causing a large goose egg on the resident's (R6) forehead. NA-D stated, Four of the residents are no longer with us. (R6) passed away last Tuesday, and I feel real bad. NA-D stated she witnessed NA-B transferring another resident without her gait belt, and NA-B let go of the resident and she fell, and NA-B put the gait belt on after the fall. NA-D stated she reported the incident to the floor nurse (LPN-A.) NA-D stated she had witnessed NA-A and NA-B always on break, and she could see them smoking out on the corner of the building. NA-D stated NA-B smoked her pen thing that smelled of marijuana, out on the corner for hours. NA-D stated NA-B had sat in NA-D's car at work one day and she witnessed NA-B rolling a white substance in white paper in NA-D's car and smoking it. NA-D stated she became upset, and had another co-worker assist her to get NA-B out of NA-D's car. NA-D stated she was so upset she went to the DON and threatened to quit after the incident, and the DON stated she couldn't do anything because the DON wasn't present when the incident happened. NA-D stated she asked NA-B directly if she used chemicals at work and NA-B told NA-D she used alcohol, and meth only on her breaks and at home. NA-D stated she had gone to the administrator with her concerns, and he stated, he would look into it but he never got back to her. NA-D stated she felt her concerns were not being addressed. On 1/24/23, at 11:11 a.m. an interview was conducted with trained medication assistant (TMA)-A. TMA-A stated she had been told by NA-D of concerns of NA-A drinking at work the previous week. TMA-A stated NA-D had told the nurse on duty about NA-A appearing drunk and was told, She probably is. TMA-A stated NA-A and her schedules did not overlap because NA-A came to work late most shifts. TMA-A stated management had to be aware of NA-B's substance addictions, because NA-B talked openly about it, and the DON had to work around NA-B's treatment schedule. TMA-A reported she was aware of NA-B having frequent falls with the residents related to NA-B not using her gait belt. TMA-A stated she witnessed NA-B with R2 on the floor and putting on the gait belt after the fall. TMA-A stated R2 ended up going to the hospital and having hip problems. TMA-A stated NA-B had multiple falls with residents and had been reported under the influence to management. On 1/24/23, at 12:11 p.m., an interview was conducted with DON stated she was aware of NA-B completing her treatment. The DON stated she had never asked NA-B if she had ever used chemical substances at work or come to work impaired. The DON stated she had not received results of NA-B's Escreen. The DON stated she had not put any monitoring in place for NA-B, and was aware of NA-B had chemical dependency issues. The DON reported after being asked to call the lab for results, NA-B had texted the DON's phone and informed the DON that her Escreen was positive for cocaine and marijuana. On 1/24/23, at 2:21 p.m. an interview was conducted with LPN-A. LPN-A stated she had been present during falls with NA-A and NA-B, and had to provide education on using gait belts and transferring residents properly. LPN-A also reported an incident when a resident had fallen and had sustained a hip injury. LPN-A stated she had specifically asked NA-A and NA-B to not walk the resident, only to return later in the shift and find NA-A and NA-B were walking the same resident she had specifically asked them not to walk. LPN-A stated NA-A's appearance at work has been questionable at times, with her coming to work with red, blood shot eyes and a disheveled appearance. LPN-A stated NA-A and NA-B were known to take numerous breaks. LPN-A stated she was present when RN-A had told NA-A and NA-B they couldn't take a break yet as they had just gotten to work. LPN-A stated she could remember this had happened with in the last month but was unable to determine exact date. On 1/24/23, at 2:55 p.m. an interview was conducted with NA-E who stated she had heard of people jumping out the windows at the facility to avoid being seen by the facilities cameras. NA-E reported NA-A was aware of her breaks being tracked by the DON. NA-E stated NA-A was going out the window to make it harder for the DON to track her breaks. NA-E stated when she worked with NA-A and or NA-B, she frequently would not get her breaks because the two would be on break so much, and things needed to get done so she wouldn't take her breaks. On 1/24/23, at 4:12 p.m. an interview was conducted with RN-C who stated she had a shift that occurred in December 2022, when NA-C had come to her with concerns related to NA-A acting odd and drinking alcohol. NA-A had told RN-C she had reported her concerns to RN-D, and nothing had been done. RN-C stated she had RN-D handle the situation before the end of RN-D's shift. RN-C stated NA-A had been tested with the breathalyzer and it had been zeros indicating no alcohol, and NA-A was still sent home because she was upset and seemed out of sorts. RN-C stated one other time, two NA's had been working with NA-A, and observed her in her truck drinking and charting while she was on the clock. RN-C stated she had not been at the facility when she received the phone call and the NA's were reporting the incident had happened at work on the previous day. RN-C stated she had directed the reporting NA to write up a statement, make a copy of it, and put it under the DON's door as proof of the report. RN-C stated she herself had texted the DON on the day she received the report from the NA's. RN-C stated she may have even shoved the papers under the DON's office door herself on the Monday after the incident happened, but was not positive if she did or not. RN-C stated she later reported the text on her phone to the DON was on September 5th, 2022. On 1/25/23, at 12:14 p.m. an interview was conducted with drug testing company certified medical reviewer (CMR, who was a medical doctor). CMR reported the testing completed for NA-A and NA-B were regulated tests, and there were very strict procedures that were followed for these tests to ensure accuracy. CMR reported that NA-A's test was a confirmatory positive test for amphetamines, and that 500 was considered confirmatory, and NA-A's test was 1900. CMR stated he would consider this a positive test with no legitimate explanation for the result of four times the confirmatory sample. CMR stated he would consider her impaired if she was to work at this level of intoxication. CMR reported NA-B had informed the tester she had a medical marijuana card, but was unable to produce it for the test, and declined to provide a prescription list or medical diagnoses for the test. MD-A stated NA-B's test for cocaine was twice the cut off, and she had tested positive for marijuana with 400 being the mean of what is considered a high-test, NA-B's test was at 1373. The CMR stated he felt both would be considered impaired and not safe to work with the vulnerable population on the day they were tested. On 1/25/23, at 2:57 p.m. an interview was conducted with NA-F who stated she had smelled alcohol on NA-A and reported it to RN-C after the Labor Day weekend. NA-F stated she had gone to the DON's office after that weekend and told the DON she was quitting because she was tired of dealing with NA's being impaired at work. NA-F reported that she had reported her concerns to RN-C, they had written out the letter together, and she then had gone into to the DON's office to talk to her face to face. NA-F stated she told the DON she was not going to do it anymore, that NA-A and NA-B were always outside, and work was not being done because you couldn't find them. NA-F stated nothing had changed, and the DON never got back to her after her report. On 1/25/23, at 4:19 p.m. an interview was conducted with the administrator. the administrator stated he was not aware of a history of impairment with NA-A or NA-B. The administrator stated he was not aware of the breathalyzer contract between NA-A and the DON in February of 2022. Administrator stated he did receive one call at home from RN-D one evening, and was told by RN-D the DON told her to inform him of NA-A being sent home, but her breathalyzer test had been negative. The administrator stated when it came to staff coming to work impaired or suspicion of being impaired, he would follow the facility policy. The administrator stated he would depend on his nurses to determine if a staff could work or not. The administrator stated, I did not know (NA-A) or (NA-B) worked on the day of the testing on [DATE]rd, and was not aware they had returned to work before we had received the test results. The administrator stated he would increased monitoring if there were concerns of staff using chemicals. A review of resident's incident reports indicated: -R1's fall event report dated 5/8/22, at 12:47 p.m. indicated NA-A transferred resident with one person transfer having R1 stand and ambulate to transfer causing a fall. R1's care plan dated 9/30/2021 identified R1 required a full body lift and two staff for transfers. -R2's Fall Scene Investigation Report (FSI) dated 11/18/22, at 8:00 a.m., indicated R2 fell in the bathroom during a transfer with NA-B. 5 whys completed by LPN-A indicated, Gait belt not in use. Interventions included gait belt or consider stand for all transfers. -R2's progress note dated 11/18/22, at 1:13 p.m., identified R2 had a fall earlier and had landed on her left hip. R2 reported hip was painful. physician assistant ordered R2 sent to emergency department for evaluation of left hip. -R2's progress note dated 11/18/22, at 11:29 p.m., stated R2 admitted to the hospital for bleeding into the hip. -R3 Progress note dated 12/28/22, at 4:22 p.m., stated R3 let go of white stand and had a fall while being toileted resulted in large bruising to her hand, small skin tear on right mid forearm.-R3's Care Plan approach dated 11/3/22, stated R3 was to have two staff assist her to transfer to and from chair and bed using sit to stand lift. Assess residents strength when using white stand and be aware she becomes weak, not able to maintain grip. -R3 progress note dated 12/28/22, at 7:03 p.m. stated new bruises and skin tear. -In an email received from DON dated 1/25/23, at 1:32 p.m., stated the facility had not created a fall event for R3's fall on 12/28/22, so no investigation had been completed. DON indicated NA-A had been assigned to the hall of R3 on the date and time of the fall. -R4 FSI dated 12/26/22 at 6:50 p.m., indicated R4 was rushing in bathroom with NA-B when resident lost balance and fell. FSI indicated NA-B had not used a gait belt during the transfer. Recommendations on the FSI stated,Do not rush, use transfer belt, gripper socks and use assistive device if resident appears weak. -R6 fall on 1/7/23 states resident had a fall from a wheelchair hit her head causing large goose egg. -On 1/23/23, 1:30 p.m. interview with NA-D stated she witnessed NA-B, drop R6 causing R6 to hit her head on the ground. NA-D stated NA-B doesn't follow resident care plans. NA-D stated she has observed NA-B put gait belts on after the falls. The facility policy The 3 I's Policy Intoxication, Impairment & Under the Influence dated 1/27/23, directed the facility is committed to health and safety of the facility and will work together to control impairment-related risks in the workplace. The facility's Vulnerable Adult Policy dated 11/17/20, directed each resident has a right to be free from abuse and defined abuse including Neglect as the failure of the facility, its employees or service provider to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. The immediate jeopardy that began on 1/25/23, at 5:28 p.m. was removed on 1/27/23, at 5:30 p.m. when it was verified through interview and document review the facility implemented the following: -immediately reviewed/revised policy/procedures for protecting residents from impaired staff. Including investigation on any impact of impairment to residents. -Identified and determined if any staff members were impaired and didn't allow them to work with residents. -Educated all staff on signs and symptoms of alcohol and illicit drug intoxication, and protocols for reporting to administration. -Educated the DON how to respond to concerns brought forward by staff, monitoring and supervision of staff with known chemical dependency issues, education on protecting residents when reasonable suspicion of impairment is determined and/or staff are drug tested. .