**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews with staff, physician and laboratory customer service staff, the facility failed to notify the physician when Resident #6 experienced a change of condition. Resident #6 received a positive result from a urinalysis (UA) and culture and sensitivity (C&S), which indicated the resident had a urinary tract infection (UTI) with extended-spectrum beta-lactamase (ESBL, an enzyme produced by some bacteria that makes them resistant to many antibiotics) in her urine and failed to notify the physician of the C&S results after the report was received from the facility. These deficient practices affected 1 of 4 residents reviewed for a experiencing a change of condition related to a UTI (Resident #6). Resident #6 was sent to the emergency department on 6/22/24 after being found with seizure-like symptoms, requiring hospital admission for acute metabolic encephalopathy (an alteration in consciousness caused by large-scale brain dysfunction from impaired cerebral metabolism) caused by the UTI with ESBL. The resident's antibiotics were changed due to the results of the hospital C&S, noting the antibiotic started in the facility was ineffective, and the resident began to improve in the hospital. The resident readmitted to the facility on [DATE]. The immediate jeopardy began on 6/10/24 when the results of the urine C&S results were not communicated to Resident #6's physician. The immediate jeopardy was removed on 8/15/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity D (no actual harm with potential for more than minimal harm) to ensure monitoring systems put into place are effective. The findings included: Resident #6 was admitted to the facility on [DATE] with diagnoses including renal (kidney) insufficiency Review of Resident #6 nursing progress notes dated 06/06/2024 written by the Assistant Director of Nursing (ADON) revealed it was reported from the floor nurses and nursing aides (NA) resident had become increasingly more agitated and combative with staff. The ADON assessed the resident and noted that resident was not acting as she normally did. The ADON contacted the physician, who ordered laboratory tests including a UA and C&S. Review of preliminary laboratory results dated [DATE] revealed Resident #6's urine sample was collected on 06/07/2024 and positive for 1+ bacteria (normal range was none). The preliminary report indicated identification of the bacteria and sensitivity results would be on a following report. The physician reviewed and signed the results on 06/12/24. Review of Resident #6's C&S results dated 06/10/2024 revealed the bacteria identified was Escherichia coli (E. coli), which was positive for ESBL. There was no evidence the physician was notified of the results when the results became available. In an interview on 8/12/24 at 6:03 pm, the Customer Representative for the facility contracted laboratory stated the final results of the UA were uploaded to the communication portal on 06/07/2024 and the finalized C&S results were uploaded to the portal on 6/10/24 at 10:38 am and would have been available to the facility at those times. The facility used the communication portal to obtain results directly instead of waiting for a faxed copy. Review of Resident #6's nursing progress notes dated 06/11/2024 written by Nurse #12 revealed the resident's UA results were received. The physician was notified and said to wait for the C&S report. There was no indication the C&S results were reviewed with the physician. In an interview on 8/13/24 at 10:04 am, Nurse #12 said she did not remember any additional information about Resident #6's UTI or reporting the results to the physician. Review of Resident #6's nursing progress notes dated 6/17/24 by the ADON revealed the C&S results dated 6/10/24 were reviewed with the physician, who ordered the antibiotic levofloxacin 500 mg every day for 7 days entered. In an interview on 8/12/24 at 2:45 pm, the ADON said she went out of town the week of 6/11through 6/17/24. When she came back to work on 6/17/24, she reviewed the laboratory results in the laboratory portal from the week she was out and found the C&S had not been reported to the physician, so she called him with the results. The physician ordered levofloxacin 500 mg every day for 7 as a result of the C&S report. She was not sure why the results had not been reported to the physician earlier. She said not obtaining orders delayed the treatment of the UTI. Continued review of Resident #6's C&S results dated 6/10/24 revealed the bacteria was resistant to the effects of the antibiotic levofloxacin. In an interview on 8/12/24 at 3:53 pm, Nurse #13 said if he called and gave C&S results to the physician or if he noted the physician had ordered an antibiotic that the microorganism was resistant to, he was supposed to call the physician and get clarification of the order because the antibiotic would not actually kill the bacteria. In an interview on 8/12/24 at 4:20 pm, the ADON said she didn't know how she didn't catch that the bacteria was resistant to the antibiotic. She said both her and the physician reviewed the results together and the physician signed off on the order. She did not know why neither of them caught the error. She said that giving an antibiotic that the bacteria was resistant to delayed the effective treatment of the UTI. In an interview on 8/13/24 at 10:01 am, Nurse #4 said she was passing breakfast trays on 6/22/24 on Resident #6's hallway but didn't normally work on that hall. She brought Resident #6 her breakfast tray and set it up. Resident #6 began eating and then her roommate requested assistance with being moved in bed. While Nurse #4 was assisting Resident #6's roommate, she heard Resident #6 make an unusual noise. Nurse #4 said she turned and saw the resident was having a seizure Review of Resident #6's nursing Situation, Background, Appearance, and Review (SBAR) Communication Form to the provider dated 6/22/24 completed by Nurse #12 noted she was unresponsive after a seizure. Review of the EMS Patient Care Record dated 6/22/24 revealed EMS was called to the facility for Resident #6 due to being unresponsive after a seizure. When they arrived, they found Resident #6 sitting upright in bed with an oxygen mask on. The oxygen was set at 15 liters per minute (lpm). Staff reported to EMS that Resident #6 was eating breakfast and started to seize. Her body went rigid. EMS noted she was awake but not oriented to person, place, or time. She was breathing on her own and started to try to verbalize and move her extremities. She had a weak pulse in both wrists. EMS transferred her to the hospital Review of Resident #6's hospital ER evaluation dated 6/22/24 revealed her symptoms were consistent with an acute UTI complicated by acute metabolic encephalopathy. The provider did not believe the resident suffered a seizure but instead experienced rigors (sweats and uncontrollable shivering attacks due to a severe infection). The emergency room (ER) provider noted she had altered mental status, was recently diagnosed with UTI, and had been taking Keflex (levofloxacin). When she arrived to ER she was noted to be bradycardic (low heart rate) with tachypnea (rapid, shallow breathing that is faster than normal for a person's age and physiological condition). The provider noted that given the resident's urine, it appeared Keflex was not treating the UTI adequately and it had progressed causing encephalopathy. Review of Resident #6' hospital Discharge summary dated [DATE] revealed she was placed on meropenem intravenous (IV) antibiotics in the hospital. The resident was noted to be alert, eating, drinking, voiding, improved, and stable at discharge. Resident #6 discharged with orders for meropenem 1 gram in 100 milliliters of normal saline IV every 12 hours until 6/29/24. In an interview on 8/12/24 at 3:22 PM, the Director of Nurses (DON) said Resident #6's UA and C&S results should have been reported to the physician sooner. The DON said the expected procedures were for the charge nurses to check the laboratory portal and report the results to the physician that shift. The DON said she knew of several instances when the procedures weren't followed because the floor nurses were used to the nurse managers reviewing them. The nurse managers would then review the laboratory results the next day. If the resident' UTI was not treated and resolved, the resident would experience further complications. In an interview on 8/20/24 at 1:00 pm, Resident #6' physician said he expected to be notified of UA and C&S results the same day they were reported to the facility from the laboratory. He expected the nurse to review the C&S and what antibiotics the C&S indicated would be effective with him so he could make an informed decision. If he ordered an antibiotic that was noted in the C&S to be resistant and ineffective, he expected the nurse to let him know and review options of what antibiotic would be effective so the UTI could be effectively treated. If a UTI was not treated, the resident could develop sepsis, which may cause further inflammation, metabolic encephalopathy, seizures, and other complications. The Administrator was notified of an immediate jeopardy on 8/13/24 at 2:09 pm. The facility provided the following credible allegation of immediate jeopardy removal plan. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. 6/6/24: A UA C & S was ordered by nursing for Resident #6 with the UA results received on 6/7/24 positive for a Urinary Tract Infection (UTI). 6/10/24: C & S results were received for Resident #6. 6/11/24: Positive results for the Urinalysis (UA) were reported to the physician. Nursing staff did not identify that the Culture & Sensitivity test (C & S) results had also been received with the UA. Nursing staff did not communicate the C & S results to the physician. The physician indicated waiting for the C & S results before initiating treatment orders. 6/17/24: The Assistant Director of Nursing (ADON) identified that the physician had not been made aware of the C & S results and communicated with the physician the lab results. The physician ordered an antibiotic that the organism was resistant to. 6/22/24: Nursing staff noted Resident #6 with seizure-like activity and she was sent to the hospital for further evaluation. The hospital record indicates that Resident #6 was bradycardic and tachypneic upon arrival. The hospital record indicates that the antibiotic was not treating the UTI causing encephalopathy. Resident #6 was transitioned to a new type of antibiotic via intravenous (IV). 6/26/24: Resident #6 returned to the facility. readmission diagnoses included acute metabolic encephalopathy and UTI secondary to Escherichia coli (ESBL E. coli). 8/13/24: The Director of Nursing (DON) and ADON began reviewing all resident ' s UA C&S results obtained since June 10, 2024 to ensure results were communicated to the provider and an appropriate antibiotic was ordered. Completed by 8/14/24. Any identified problems will be addressed immediately by the DON/ADON to include communication with the physician. All residents had the potential to be affected as a result of noncompliance with provision of necessary care and services to treat infection. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. 8/13/24: The Quality Assurance and Performance Improvement team met to discuss the failure and initiate a plan of correction. 8/13/24: Implementation of integrated laboratory services was completed. With the integration services, all licensed nursing staff will have the ability to transcribe laboratory test orders and have the ability to view test results from the electronic medical record. 8/13/24: The Assistant Director of Nursing/ Human Resources Director initiated education for all licensed nurses on the process for obtaining and following up on test results. Charge Nurses will be responsible for communication of all test results to the physician. Nursing staff will be notified of lab results on the electronic medical record dashboard alert screen which is the first screen nurses see upon logging into the medical record. Education included how to transcribe laboratory orders correctly to utilize the integration system effectively, the process for obtaining results, as well as reporting procedures including provider notification and required documentation of physician and responsible party notification of test results. The Human Resources Director provided education to all licensed nursing via the facility broadcast text communication through the time and attendance system. The Assistant Director of Nursing initiated education for all licensed nurses in house, including completion of Lab and Diagnostic Results Reporting Competency. All licensed nurses will complete education on the test results reporting procedures prior to the start of their next shift. Nursing staff was reeducated as a part of the new integrated system that it is their responsibility to address lab results as results come in during their work shift and to ensure the appropriate treatment is started for the identified diagnosis. The ADON is leading the education and will be tracking for competency and completion on 8/14/24. 8/13/24: The DON provided education to the ADON and Unit Managers on the process for reviewing UA C&S test results and verifying an appropriate antibiotic including organism susceptibility to the medication being ordered during the morning clinical meeting. The medication is reviewed for appropriateness by the Charge Nurse when received, 7 days a week. The DON, ADON and Unit Managers will audit antibiotic orders Monday through Friday during the morning clinical meeting. Completed 8/13/24. All new hires will be educated on the process for lab results and physician communication during the department orientation led by the ADON. Alleged date of immediate jeopardy removal is 8/15/24. The validation process for the IJ removal plan was completed on 8/15/2024. Licensed nursing staff who worked different shifts were interviewed and verified receiving training on entering laboratory test and reviewing laboratory results in the facility ' s electric health record system and documenting in the progress notes notification of the physician of laboratory test results. The licensed nursing staff also demonstrated using the facility ' s electronic health record system to enter and review laboratory test ordered. The facility provided a list of all licensed nursing staff and in-service training sheets that included verbalization and demonstration on entering, reviewing and documenting notification of the physician of laboratory tests were reviewed for all licensed staff randomly interviewed. There were no new hired licensed nursing staff and licensed nursing staff (medical leave, vacation) will not be able to work until receiving the education training on entering, reviewing and documenting notification of the physician of laboratory test in the facility 's electronic health record system. The immediate jeopardy removal date of 08/15/24 was validated

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed protect a resident's right to be free from abuse when a moderately cognitively impaired resident (Resident #29) punched severely cognitively impaired resident (Resident #231) in the face. Resident #231 was prescribed and received a blood thinner daily. Resident #231 sustained bruising and swelling to the left side of his face. Resident #231 stated he was scared and did not want to be near Resident #29. Resident #29 and Resident #231 were immediately separated. Resident #29 was moved to another room by himself. Resident #231 requested to be sent to emergency room for evaluation and did not return to the facility. Resident #231 transferred from the hospital to a different facility. Resident #231's family member stated Resident #231 had never emotionally recovered from the incident and still does not want to be in a room with someone else. This deficient practice affected 1 of 3 residents reviewed for abuse. The findings included: Resident #231 was re-admitted to the facility on [DATE]. Resident #231 diagnoses included hemiplegia (complete paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) following cerebral infarction (stroke) affecting the left non-dominant side, vascular dementia, psychotic disturbance, and anxiety. Resident #231's care plan dated 11/23/23 revealed he was care planned for at risk for bleeding, bruising, abnormal labs related to receiving blood thinning medication. The interventions included avoid activities that could result in injury and handle gently during hands-on care. Resident #231 was care planned for difficulty communicating with interventions which included approach resident from the front and use gestures and simple sentences. Resident #231 also cared planned for left side hemiplegia/hemiparesis related to stroke. Review of Resident #231's physician orders dated 12/18/23 revealed an order for Warfarin Sodium Oral Tablet (blood thinner) 5 mg by mouth once daily. Resident #231's 5-day Minimum Data assessment dated [DATE] revealed Resident #231 was severely cognitively impaired. Resident #231 had impairment on the left side of upper and lower extremities, totally dependent upon staff for activities of daily living (ADL) and transfers. Resident #29 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, hypertension, cardiac arrest, and malignant neoplasm of larynx. Resident #29's care plan dated 12/11/23 revealed he was care planned for physical aggressive behavior with other residents. The interventions included 4/9/23 resident on one-to-one observation related to an altercation with another resident, resident removed from current roommate situation and placed on every 15-minute checks for 72 hours to ensure new room does not become triggered by room situation or roommate and keep all sharp objects including butter knife out of patient's room. Resident #29's quarterly Minimum Data Assessment (MDS) dated [DATE] revealed Resident #29 was moderately cognitive impaired. Resident #29 was independent with all activities of daily living (ADL's), independent with transfers and independent ambulation with a walker. Nurse Aide (NA) #13's written statement with no date revealed NA #13 checked on Resident #231 around 2:00 am and gave him some water. NA #13 reported he emptied Resident #231's urinary catheter bag. NA #13 reported he returned to the nurses' station to chart. NA #13 reported he returned to Resident #231's room about 3:00 am to give him some more water. Resident #231 started telling NA #13 that Resident #29 punched him in his eye. NA #13 reported he talked to Resident #231 and Resident #29 for about 30 minutes. NA #13 indicated Resident #29 admitted to punching Resident #231. NA #13 went to the nurses' station and reported the situation to Nurse #7. Nurse #7 began procedures according to facility protocol. NA #13 explained he did not hear or see the altercation. Attempts were made to interview NA #13 via phone on 8/9/24 and 8/12/24 and were unsuccessful. NA #13's phone would not accept messages with each attempt. Nurse #7's written statement dated 12/28/23 revealed he was called down to Resident #231's room after an altercation at around 2:00 am. Nurse #7 stated when he entered the room with NA #13 both residents were laying in their beds. Resident #231 stated he was struck by Resident #29. Resident #29 stated he heard Resident #231 calling out for help. Resident #29 went to the door to find help and Resident #231 asked Resident #29 to get him some water. Resident #29 further stated while Resident #231 was drinking he grabbed Resident #29's arm and kicked him in the side. Resident #29 reported he punched Resident #231 in the face. Resident #231 had redness to his face with no complaints of pain. Resident #29 had no signs of injury or bruises. Resident #231 and Resident #29 calmed down. Resident #29 stated he would not help Resident #231 or go over to Resident #231's side of the room. Nurse #7 explained approximately 30 minutes later Resident #231 indicated he felt unsafe and wanted to go to the hospital. Nurse #7 called the on-call supervisor. Nurse #7 stated he was told to wait to hear from the Administrator for decisions. Nurse #7 revealed Resident #29 was moved to another room around 3:20 am. Resident #231 was taken to the hospital. Nurse #7 stated both Resident #231 and Resident #29 were questioned by the police around 3:45 am. Nurse #7 indicated the police would issue a summons to Resident #29 in the morning and did not need to arrest Resident #29. Review of a progress note written by Nurse #7 on 12/28/23 at 4:13 am revealed redness to Resident #231's face due to altercation with roommate. Medical Doctor (MD) was notified via phone. Orders received to send Resident #231 to emergency room (ER) for evaluation and treatment. Resident #231 was informed of transfer to hospital and Resident Representative (RR)/family informed of Resident #231's transfer via phone. In a phone interview with Nurse #7 on 8/9/24 at 5:00 pm, he recalled the incident on 12/28/23 between Resident #29 and Resident #231. He stated Nursing Aide (NA) #13 was called to Resident #231's room by Resident #231. Resident #231 reported to NA #13 that he was hit by his roommate (Resident #29). NA #13 reported to Nurse #7. Nurse #7 went to Resident #231's room with NA #13. Resident #231 reported to him that Resident #29 jumped on him and started hitting him. Nurse #7 stated Resident #231 had swelling and bruising noted on the left side of his face. He further stated Resident #231 was scared and wanted Resident #29 out of the room. Nurse #7 described Resident #231 as bed bound and required total care. Nurse #7 indicated he questioned whether Resident #231 could have kicked Resident #29 due to his medical condition of left-sided hemiplegia (complete paralysis on one side of the body) and left-sided hemiparesis (partial weakness on one side of the body). Resident #231 was in the A bed (on the right side of the room) by the door with the foot of the bed facing towards the bathroom. Resident #29 was in the B bed (on the left side of the room) by the window with the foot of the bed facing towards the wall. He indicated Resident #29 had a previous history of physical aggressive behavior. Nurse #15's written statement dated 12/28/23 at 3:23 am revealed she received a call from Nurse #7. Nurse #7 reported an altercation between Resident #231 and Resident #29. Resident #29 had hit Resident #231 in the face. Nurse #15 asked had the residents been separated and Nurse #7 confirmed they had been separated. Nurse #15 asked when this incident happened, and Nurse #7 reported approximately 30 minutes ago. Nurse #15 then asked was Resident #231 okay and Nurse #7 responded Resident #231's face had some swelling. Nurse #15 instructed Nurse #7 to start neurological checks (assessing mental status and level of consciousness, and pupil response), and skin checks. Nurse #15 then called the Administrator at 3:28 am and reported the incident which was reported to her. Nurse #15 went to the facility to assist with protocol and begin education. An interview with Nurse #15 via phone on 8/9/24 at 10:38 am, she indicated she was the on-call clinical staff for the night of the incident on 12/28/23. She stated Nurse #7 called her and reported the resident-to-resident altercation. She called the previous Administrator, and she was enroute to the facility. Nurse #15 stated she honestly did not know what happened. NA #13 reported Resident #231 had called out and NA #13 responded to his call. NA #13 further reported to her that Resident #231 stated Resident #29 had hit him. Resident #231 and Resident #29 were separated immediately. Resident #231 was sent to the emergency room for evaluation and never returned to the facility. Nurse #15 was told Resident #29 had a history with physical aggressive behavior, but she had never witnessed this behavior. During a phone interview with the previous Social Worker on 8/9/24 at 4:06 pm, stated she recalled Resident #29 struck Resident #231. Resident #231 was sent to the emergency room. Resident # 231 did not return to the facility. Resident #29 was placed on one-to-one observation (1:1). Review of an email sent to the previous Administrator from the previous Social Worker on 12/28/23 revealed the previous Social Worker interviewed Resident #29 on 12/28/23 at 10:50 am. Resident #29 could not recall what happened with Resident #231. Resident #29 stated he was asleep when he heard Resident #231 say Hey. Resident #29 further stated he remembered Resident #231 being taken out of the room. Resident #29 indicated he went back to sleep. Resident #29 explained he had no remembrance of any physical altercation with Resident #231. Resident #29 stated he had not assisted Resident #231. A progress note completed by the previous Administrator on 12/28/23 revealed the previous Administrator spoke with Resident #29's Resident Representative (RP). The RP was informed of the resident-to-resident altercation which happened that morning. The previous Administrator explained to Resident #29's RP that Law Enforcement had been notified along with Adult Protective Services. The previous Administrator further explained Law Enforcement would be returning to the facility potentially providing Resident #29 a summons. RP was informed Resident #29 would have a room change on 12/28/23. In a phone interview with the previous Administrator on 8/9/24 at 3:12 pm, she stated she recalled the incident on 12/28/23 which involved Resident #29 and Resident #231. She recalled it was reported to her that Resident #29 went to give Resident #231 some water and Resident #29 punched Resident #231 in the face. The residents were separated. Resident #29 was placed on one to one (1:1) supervision. Law Enforcement and APS (Adult Protective Services) were notified. Resident #231 was sent to hospital emergency department (ED) for evaluation. Resident #231 did not return to the facility. She further stated Resident #29 had a history of physical aggressive behavior. She explained the Interdisciplinary Team (IDT) would talk about new admissions in the morning meetings. The team would discuss any concerns about the residents and which room to place them. She also added they would do room changes if necessary. The police report was completed on 12/28/23 at 3:42 am. Resident #231 was listed as the victim with minor apparent injury due to a simple assault. A review of the Emergency Medical Services (EMS) report dated 12/28/23 revealed [AGE] year-old male patient with chief complaint of eye and face injury. The patient had gotten into a fight with another resident at the nursing home and was punched several times in the face. There was swelling and tenderness on both sides of his face but no significant injury. Patient was alert and oriented, patent airway, and warm dry skin. Patient wanted to be transported to hospital for evaluation and he did not feel safe at the nursing home. Patient noted he was not in any pain. Arrived at hospital 4:45 am. A review of the Emergency Room's (ER) report dated 12/28/23 revealed Resident #231 was brought in by ambulance at 4:45 am after being involved in a fight with another resident. Resident #231 had some redness on bilateral eyes and slight bruising around the left eye. Computed Tomography (CT) scan of the Spine (which is a procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures of spine) was completed with no acute fracture noted. CT scan of the head was completed which showed no skull fracture. Clinical Impression: closed [NAME] injury, assault, and old cerebrovascular accident (CVA). The police returned to the facility on [DATE] at 11:36 pm with a Criminal Summons for Misdemeanor Assault and Battery and was served to Resident #29 which indicated a court date of 2/9/24. Several attempts to interview the investigating officer via phone were unsuccessful on 8/12/24 and 8/13/24. The Sheriff's Office Dispatch operator stated the officer was on vacation. During an interview with Resident #29 on 8/5/24 at 11:06 am, he was able to communicate verbally that he did not remember the incident on 12/28/23 which involved his former roommate. Resident #231 was not able to be interviewed. A phone interview with Resident #231's family on 8/8/24 at 7:44 pm, revealed the family member stated that Resident #231 could not defend himself. Resident #231's family member stated, that man beat the hell out of my daddy. Family member indicated Resident #231 previously had 2 strokes. Resident #231's family member further stated Resident #231 had never emotionally recovered from the incident on 12/28/23. Resident #231 still does not want to be in a room with someone else. A phone interview was conducted with the Admissions/Marketing Director on 8/9/24 at 1:37 pm. The Admissions/Marketing Director stated she was not sure why Resident #231 was not placed in his previous room after hospitalization in early December 2023. She explained the process of how room placement with new admissions and/or readmissions were determined. She indicated fall history and medical conditions were determining factors in room placement. If a resident was considered high risk room placement would be near the nurses' station. The Admission/Marketing Director indicated she thought the incident on 12/28/23 was determined to be a mutual incident with Resident #231 and Resident #29. The Admission/Marketing Director stated she was not aware of Resident #29's history of physical aggressive behaviors. She indicated this was Resident #29's first roommate since 11/20/23. She further explained if a resident had a history of physical aggressive behavior, they would not place a resident in the room with that resident. A phone interview with Nurse #8 on 8/9/24 at 4:05 pm, stated she was not in the facility at the time of the incident on 12/28/23. Nurse #8 stated she had heard about the incident on 12/28/23. She further stated she was aware Resident #29 had a history of physical aggressive behaviors. She recalled another incident in April 2023 where Resident #29 hit another resident with an open hand on the back of his neck. Resident #29 was transferred to a room with no roommate. Attempts to interview the Medical Doctor via phone were unsuccessful on 8/9/24 and 8/10/24. During a phone interview with the Director of Nursing (DON) on 8/14/24 at 1:25 pm, she stated she had been in her position since May 2023. She remembered the incident on 12/28/23 between Resident #231 and Resident #29. She stated Resident # 29 had struck Resident # 231. Resident #29 was immediately removed from the room and placed on one-to-one (1:1) observation. She further stated she was aware of Resident #29's physical aggressive behavior but had never witnessed. The Administrator was notified of Immediate Jeopardy on 8/12/24 at 4:45 pm. The facility provided the following corrective action plan with a completion of 12/31/23. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: The facility failed to prevent resident from physical abuse on 12/28/23 at approximately 2:00 am Nurse #7 was notified by NA #13 that Resident #231 reported Resident #29 punched him in the face. Resident #29 was immediately removed from Resident #231's room and moved to a private room where he was placed on 1:1 staff supervision to ensure all residents safety. Timely notifications made to the Administrator who ensured appropriate reporting requirements were made to the North Carolina Department of Health and Human Services (NC DHHS), local police department, and Adult Protective Services (APS). On 12/28/23 Resident #231 and Resident #29 were immediately separated by nursing staff on the unit. Law Enforcement, Adult Protective Services (APS), physician, responsible parties and facility abuse coordinator were notified Nurse #7. On 12/28/23 Resident #231 was assessed by Nurse #7 redness to his face was noted. He was sent to the emergency room for evaluation by the same nurse. Resident #29 was assessed by Nurse #7 and no injury was noted. On 12/28/23 immediately after staff was notified of the altercation, Resident #29 was removed from the room for both resident's safety. Resident #231 was sent to the hospital for further evaluation. Resident #29 was returned to the same room by himself, with no roommate. Resident #29 has remained in the facility but has had no roommate since 12/28/23. Resident #231 did not return to the facility from the hospital on [DATE]. This decision was made by the resident and his resident representative. On 12/28/23 Resident #29 was placed on one-to-one monitoring for behavior by the DON until reassessed by the physician and interdisciplinary team. Resident #29 would remain on one-to-one monitoring with decreasing frequency as long as the resident did not exhibit any aggressive or abusive behaviors. One to one monitoring would continue until he consistently demonstrated appropriate behaviors and interactions as determined by the interdisciplinary team. Resident #29 was under psychiatry care. The DON emailed Psychiatry Provider requesting an additional visit. This visit was scheduled for 1/9/24. On 12/29/23 Physician Provider saw Resident #29. No acute issues reported, vital signs were stable, and the physician indicated to continue current plan of care with no new orders. Address how the facility will identify other residents having the potential to be affected by the same deficient practice: 12/28/23: Skin checks were completed on cognitively impaired residents with no negative findings by the DON/designee. 12/28/23: Resident interviews were conducted with no reports of residents experiencing abuse or neglect by the Social Worker/designee. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: 12/28/23 thru 12/30/23: 100% of Staff received education on abuse identification, types of abuse and reporting procedures and de-escalation techniques by the DON/designee. New staff are educated by the DON/designee during initial orientation and prior to department assignments. For new admissions to the facility, the medical records are screened by the Admissions Coordinator for indications of a history of negative behaviors. If there is any indication of possible aggressive or abusive behaviors during the referral process, the resident is reviewed with the interdisciplinary team in our morning meeting to determine appropriate placement within the facility. Due to the incident on 12/28/23, the facility began putting existing residents with behaviors, new admissions with behaviors or readmissions with behaviors into a private room until resident demonstrates consistent positive interaction with other residents. The Admissions Coordinator was educated on 12/29/23 as a part of all staff education. Admissions serves on the interdisciplinary team as available. Effective 12/28/23, all current residents and readmitted residents with known behaviors that increase the risk for physical aggression are reviewed by the interdisciplinary team to determine if they should reside in a private room. The interdisciplinary team was educated by the DON/designee on this process and de-escalation techniques on 12/28/23 through 12/30/23. Any residents with an indication of a change in behavior, such as increased aggression, are reviewed during the interdisciplinary weekly meeting to identify trends and triggers of behaviors and implement interventions to decrease or eliminate those behaviors. The interdisciplinary team consists of the Administrator, DON, Assistant DON, Social Worker, Clinical Managers with input from Psychiatrist and/or physician, and at times Dietary, Activities or Therapy. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. 12/28/23: The Administrator scheduled an ad hoc Quality Assurance and Performance Improvement meeting following the incident. The interdisciplinary team, consisting of the Administrator, DON, Assistant DON, Medical Director, Social Worker and Clinical Managers, decided to initiate reviews of residents demonstrating similar behaviors for at least 12 weeks. 12/28/23: The interdisciplinary team reviewed residents with known aggressive behaviors via progress notes or care plan updates initially for 12 weeks. Their care plans and interventions were reviewed for effectiveness. Care plans were revised as appropriate. The interdisciplinary team continues to review residents with behaviors during the weekly clinical meeting and proper placement in private rooms are made as deemed appropriate. 12/28/23 thru 3/13/24: Social worker/designee conducted five random resident interviews per week for 12 weeks. The interviews included questions to determine if the residents had witnessed or experienced any form of abuse or felt unsafe in their environment. 12/28/23 thru 3/13/24: DON/designee conducted skin assessments on five non-interviewable residents for 12 weeks to ensure there were no signs of abuse. The alleged date of immediate jeopardy removal and date of compliance was 12/31/23. On 8/14/24 the facility's corrective action plan was validated by the following: Staff interviews revealed they had received education on the facility's Abuse policy and procedure which included the types of abuse, recognizing and understanding behavioral symptoms, and de-escalation techniques, residents' right to be free from abuse, and to immediately report any concerns of abuse to their immediate supervisor, DON, and/or Administrator. Review of the attendance sign-in sheets revealed education was completed on 12/28/23. New staff will be educated by the DON/designee during initial orientation. New admissions to the facility, the medical records will be screened by the Admissions Coordinator for indications of a history of negative behaviors. If any indication of possible aggressive and/or abusive behavior was identified during the referral process, the interdisciplinary team will review and determine appropriate placement within the facility. Current residents and readmitted residents with known behaviors that increased the risk for physical aggression were reviewed by the interdisciplinary team to determine if that resident would reside in a private room. Education provided to the interdisciplinary team by the DON/designee on this process and de-escalation techniques on 12/28/23 through 12/30/23. Residents with a change in behavior such as increased aggression were reviewed in interdisciplinary weekly meetings and implemented interventions to decrease or eliminate the behaviors. The Administrator scheduled an ad hoc Quality Assurance and Performance Improvement meeting following the incident on 12/28/23. The interdisciplinary team reviewed residents which demonstrated similar behaviors for 12 weeks. Care plans and interventions were revised as necessary. Skin assessments were completed on all cognitively impaired residents with no concerns identified. Alert and oriented residents were interviewed who all reported they felt safe in the facility, were aware of their rights to be free from abuse and knew how and who to report any concerns. One-to-one observation sheets were reviewed. The IJ removal date of 12/31/23 was validated. The compliance date was validated as 12/31/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews with staff and the physician, the facility failed to ensure Resident #6 received necessary care and services for a urinary tract infection (UTI) when she experienced signs and symptoms of a change in condition. The facility failed to follow up on results of urinalysis, failed to effectively respond to a positive urinalysis (UA) report, failed to follow up on results of urine culture and sensitivity, effectively respond to urine culture and sensitivity results (C&S), and administer an antibiotic that was sensitive to the microorganism listed on the C&S report. These deficient practices affected 1 of 4 residents reviewed for UTI (Resident #6). Resident #6 was sent to the emergency department on 6/22/24 due to being found with seizure-like symptoms, requiring hospital admission for acute metabolic encephalopathy (an alteration in consciousness caused by large-scale brain dysfunction from impaired cerebral metabolism) due to a UTI with extended-spectrum beta-lactamase (ESBL, an enzyme produced by some bacteria that makes them resistant to many antibiotics). The resident's antibiotics were changed due to the results of the C&S, noting the antibiotic started in the facility was ineffective, and the resident began to improve. The immediate jeopardy began on 6/10/24 when the facility did not effectively respond to the results of the C&S. The immediate jeopardy was removed on 8/15/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity D (no actual harm with potential for more than minimal harm) to ensure monitoring systems are put into place are effective. The findings included: Resident #6 was admitted to the facility on [DATE] with diagnoses including renal (kidney) insufficiency and congestive heart failure (CHF). Resident #6's Minimum Data Set (MDS) assessment dated [DATE] revealed she had moderate cognitive impairment, had not displayed any combative or aggressive behaviors, was always incontinent of bowel and bladder, was dependent on staff for assistance with activities of daily living (ADL). The assessment indicated the resident did not have a UTI and was not taking antibiotics in the past 7 days. Resident #6's comprehensive care plan dated 5/30/24 revealed the resident was incontinent, needed assistance with toileting and had CHF. Interventions included to monitor and report to physician changes in mental condition like lethargy, confusion, disorientation, and anxiety. Review of Resident #6 nursing progress notes dated 06/06/2024 written by the Assistant Director of Nursing (ADON) revealed it was reported from the floor nurses and nursing aides (NA) resident had become increasingly more agitated and combative with staff. The ADON assessed the resident and noted that resident was not acting as she normally did. The ADON contacted the physician, who ordered laboratory tests including a UA and C&S. Review of preliminary laboratory results dated [DATE] revealed Resident #6's urine sample was collected on 6/7/24 and the results were positive for 1+ bacteria (normal range was none). The preliminary report indicated identification of the bacteria and sensitivity results would be on a following report. The physician reviewed and signed the results on 6/12/24. Review of Resident #6's C&S results dated 6/10/24 revealed the bacteria identified was Escherichia coli (E. coli) which was positive for ESBL. Continued review of Resident #6's C&S results dated 6/10/24 revealed the bacteria was resistant to the effects of the antibiotic levofloxacin. The physician reviewed and signed the results on 6/19/24. In an interview on 8/12/24 at 3:53 pm, Nurse #13 said laboratory results would be in the communication portal in the computer or come via fax. The laboratory would call the facility directly only if there are critical results to follow up on immediately. He said the nurse managers check the laboratory results, so he didn't usually check the portal. In an interview on 8/12/24 at 6:03 pm, the customer representative for the facility contracted laboratory stated the final results of Resident #6's UA were uploaded to the communication portal on 6/7/24 and the finalized C&S results were uploaded to the portal on 6/10/24 at 10:38 am and would have been available to the facility at those times. The facility used the communication portal to obtain results directly instead of waiting for a faxed copy. Review of Resident #6's nursing progress notes dated 06/11/2024 written by Nurse #12 revealed the resident's UA results were received. The physician was notified and said to wait for the C&S report. There was no indication the C&S results were reviewed with the physician at this time. In an interview on 8/13/24 at 10:04 am, Nurse #12 said she did not remember any additional information about Resident #6's UTI or reporting the results to the physician. Review of Resident #6's nursing progress notes dated 6/17/2024 by the ADON revealed the C&S results were reviewed with the physician, who ordered the antibiotic levofloxacin 500 milligrams (mg) every day for 7 days. Review of Resident #6's physician order dated 6/17/24 revealed the physician ordered levofloxacin 500 mg every day for 7 days for a UTI to start on 6/18/24. The order was entered into the record by the ADON. Review of Resident #6's Medication Administration Record for June 2024 indicated she received the medication daily from 6/18/24 through 6/21/24. In an interview on 8/12/24 at 2:45 pm, the ADON said she went out of town the week of 6/11-6/17/24. When she came back to work, she saw the C&S had not been reported to the physician, so she called him with the results. She was not sure why the results had not been reported to the physician earlier. She said she was the unit manager on that hallway and would normally check the results of the laboratory tests, but it appeared to her that no one had done so while she was out. In an interview on 8/12/24 at 4:20 pm, the ADON said she didn't know how she didn't see that the bacteria was resistant to the antibiotic ordered for Resident #6. She said she reviewed the results with the physician by phone and the physician reviewed and signed the order on his subsequent facility visit. She did not know why neither of them caught the error. She said that giving an antibiotic that the bacteria was resistant to delayed the effective treatment of the UTI. In an interview on 8/13/24 at 10:01 am, Nurse #4 said she was passing breakfast trays on 6/22/24 on Resident #6's hallway but didn't normally work on that hall. She brought Resident #6 her breakfast tray and set it up. Resident #6 began eating and then her roommate requested assistance with being moved in bed. While Nurse #4 was assisting Resident #6's roommate, she heard Resident #6 make an unusual noise. Nurse #4 said she turned and saw the resident was having a seizure. Review of the EMS Patient Care Record dated 6/22/24 revealed EMS was called to the facility for Resident #6. When they arrived, they found Resident #6 sitting upright in bed with an oxygen mask on. The oxygen was set at 15 liters per minute (lpm). Staff reported to EMS that Resident #6 was eating breakfast and started to seize. Her body went rigid. EMS noted she was awake but not oriented to person, place, or time. She was breathing on her own and started to try to verbalize and move extremities. She had a weak pulse in both wrists. EMS transferred her to the hospital. Review of Resident #6's hospital ER evaluation dated 6/22/24 revealed her symptoms were consistent with acute UTI complicated by acute metabolic encephalopathy. The ER provider indicated resident's symptoms did not indicate sepsis at that time. Resident was given intravenous (IV) fluids due to a low blood pressure of 80/40 and the resident responded well. The ER provider initiated IV ceftriaxone (an antibiotic). The provider did not believe the resident suffered a seizure but instead experienced rigors (sweats and uncontrollable shivering attacks due to a severe infection). The provider noted the resident's family stated she had no history of seizures but would have episodes of involuntary shaking at times. The provider noted the resident's laboratory results related to her diagnosis of chronic kidney disease (CKD) were very elevated. The provider noted that the appearance of her urine indicated Keflex (another name for the antibiotic levofloxacin) was not treating UTI adequately and the UTI had progressed causing encephalitis. Resident #6's vital signs did not indicate she had a fever when she arrived at the ER. The hospital C&S results confirmed resistance to levofloxacin, as well as the ceftriaxone started in the ER. Review of Resident #6's hospital Discharge summary dated [DATE] revealed her antibiotics were changed due to the C&S results in the hospital to meropenem through an IV. The resident was noted to be alert, eating, drinking, voiding, improved, and stable at discharge. Resident #6 discharged with orders for meropenem 1 gram in 100 milliliters of normal saline IV every 12 hours until 6/29/24. In an interview on 8/12/24 at 3:22 PM, the Director of Nurses (DON) said Resident #6's UA and C&S results should have been reported to the physician sooner. The DON reviewed Resident #6's C&S results and confirmed the bacteria was resistant to the ordered antibiotic. The DON said the expected procedures were for the charge nurses to check the laboratory portal and report the results to the physician that shift. The DON said she knew of several instances when the procedures weren't followed because they were used to the nurse managers reviewing them. The nurse managers would then review the laboratory results the next day. She said when obtaining an order for an antibiotic, the nurse was responsible to compare the C&S results and the antibiotic ordered and to get clarification from the physician if microorganism was resistant to the ordered antibiotic. If the resident received the wrong antibiotic, the UTI would not be treated and resolved, causing further complications. In an interview on 8/20/24 at 1:00 pm, Resident #6's physician said he expected to be notified of UA and C&S results the same day they were reported from the laboratory. He expected the nurse to review the C&S and what antibiotics the C&S indicated would be effective with him so he could make an informed decision since he would only review the results on his next visit to the facility. If he ordered an antibiotic that was noted in the C&S to be resistant and ineffective, he expected the nurse to let him know and review options of what antibiotic would be effective so the UTI could be effectively treated. If a UTI was not treated, the resident could develop sepsis, which may cause further inflammation, metabolic encephalopathy, seizures, and other complications. The Administrator was notified of an immediate jeopardy on 8/13/24 at 2:09 pm. The facility provided the following credible allegation of immediate jeopardy removal plan. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. 6/6/24: A UA C & S was ordered by nursing for Resident #6 with the UA results received on 6/7/24 positive for a Urinary Tract Infection (UTI). 6/10/24: C & S results were received for Resident #6. 6/11/24: Positive results for the Urinalysis (UA) were reported to the physician. Nursing staff did not identify that the Culture & Sensitivity test (C & S) results had also been received with the UA. Nursing staff did not communicate the C & S results to the physician. The physician indicated waiting for the C & S results before initiating treatment orders. 6/17/24: The Assistant Director of Nursing (ADON) identified that the physician had not been made aware of the C & S results and communicated with the physician the lab results. The physician ordered an antibiotic that the organism was resistant to. 6/22/24: Nursing staff noted Resident #6 with seizure-like activity and she was sent to the hospital for further evaluation. The hospital record indicates that Resident #6 was bradycardic and tachypneic upon arrival. The hospital record indicates that the antibiotic was not treating the UTI causing encephalopathy. Resident #6 was transitioned to a new type of antibiotic via intravenous (IV). 6/26/24: Resident #6 returned to the facility. readmission diagnoses included acute metabolic encephalopathy and UTI secondary to Escherichia coli (ESBL E. coli). 8/13/24: The Director of Nursing (DON) and ADON began reviewing all resident's UA C&S results obtained since June 10, 2024 to ensure results were communicated to the provider and an appropriate antibiotic was ordered. Completed by 8/14/24. Any identified problems will be addressed immediately by the DON/ADON to include communication with the physician. All residents had the potential to be affected as a result of noncompliance with provision of necessary care and services to treat infection. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. 8/13/24: The Quality Assurance and Performance Improvement team met to discuss the failure and initiate a plan of correction. 8/13/24: Implementation of integrated laboratory services was completed. With the integration services, all licensed nursing staff will have the ability to transcribe laboratory test orders and have the ability to view test results from the electronic medical record. 8/13/24: The Assistant Director of Nursing/ Human Resources Director initiated education for all licensed nurses on the process for obtaining and following up on test results. Charge Nurses will be responsible for communication of all test results to the physician. Nursing staff will be notified of lab results on the electronic medical record dashboard alert screen which is the first screen nurses see upon logging into the medical record. Education included how to transcribe laboratory orders correctly to utilize the integration system effectively, the process for obtaining results, as well as reporting procedures including provider notification and required documentation of physician and responsible party notification of test results. The Human Resources Director provided education to all licensed nursing via the facility broadcast text communication through the time and attendance system. The Assistant Director of Nursing initiated education for all licensed nurses in house, including completion of Lab and Diagnostic Results Reporting Competency. All licensed nurses will complete education on the test results reporting procedures prior to the start of their next shift. Nursing staff was reeducated as a part of the new integrated system that it is their responsibility to address lab results as results come in during their work shift and to ensure the appropriate treatment is started for the identified diagnosis. The ADON is leading the education and will be tracking for competency and completion on 8/14/24. 8/13/24: The DON provided education to the ADON and Unit Managers on the process for reviewing UA C&S test results and verifying an appropriate antibiotic including organism susceptibility to the medication being ordered during the morning clinical meeting. The medication is reviewed for appropriateness by the Charge Nurse when received, 7 days a week. The DON, ADON and Unit Managers will audit antibiotic orders Monday through Friday during the morning clinical meeting. Completed 8/13/24. All new hires will be educated on the process for lab results and physician communication during the department orientation led by the ADON. Alleged date of immediate jeopardy removal is 8/15/24. The validation process for the IJ removal plan was completed on 8/15/2024. Licensed nursing staff who worked different shifts were interviewed and verified receiving training on entering laboratory test and reviewing laboratory results in the facility's electric health record system and documenting in the progress notes notification of the physician of laboratory test results. The licensed nursing staff also demonstrated using the facility's electronic health record system to enter and review laboratory test ordered. The facility provided a list of all licensed nursing staff and in-service training sheets that included verbalization and demonstration on entering, reviewing and documenting notification of the physician of laboratory tests were reviewed for all licensed staff randomly interviewed. There were no new hired licensed nursing staff and licensed nursing staff (medical leave, vacation) will not be able to work until receiving the education training on entering, reviewing and documenting notification of the physician of laboratory test in the facility's electronic health record system. The immediate jeopardy removal date of 08/15/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews with Division of Health Service Regulation (DHSR) Life Safety Surveyor, resident, physician and staff, the facility failed to provide the necessary supervision to ensure residents were safe while smoking when Resident #31 was found smoking in the presence of a supplemental oxygen device, to implement their smoking policy and effective interventions to address the resident's repeated non-compliance with safe smoking practices both inside and outside of the facility, and to monitor the resident to prevent further incidents of unsafe smoking. Resident #31 was assessed on admission as a non-smoker at the facility. On 1/31/24 Resident #31 was observed smoking outside in the designated smoking area and he had smoking materials in his possession in violation of the smoking policy. On 6/27/24 Resident #31 was observed smoking outside in a non-designated smoking area with his portable oxygen tank on his wheelchair. On 7/9/24 Resident #31 was observed lying in bed smoking a cigar with oxygen on via nasal cannula. On 7/20/24 staff found a cigarette in Resident #31's toilet in his bathroom, ashes on the floor, and in the trash can. Resident #31 admitted to smoking a cigarette in his bathroom. An oxygen concentrator was present in his room. On 8/4/24 Resident #31 was observed in the designated smoking area with a portable oxygen tank on his wheelchair smoking a cigarette. He remained an unsupervised/independent smoker until 8/5/24 at which time he refused to sign his updated smoking contract and indicated he would quit smoking. On 8/14/24 Resident #31 was observed in the designated smoking area smoking without supervision. Supplemental oxygen devices produce enriched oxygen which accelerates combustion. Smoking near oxygen devices, even when turned off, is a fire hazard and has a high likelihood of resulting in serious harm to all residents nearby from fire and/or an explosion. This deficient practice was for 1 of 6 residents reviewed for smoking. Immediate jeopardy began on 6/27/24 when nursing did not extinguish the cigarette when Resident # 31 was observed with his oxygen tubing in his lap, nursing was unaware of the hazard and did not do a new smoking assessment. The immediate jeopardy was removed on 8/15/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level E (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service training. The findings included: Review of the user's manual intended use for Resident #31's portable oxygen tank revealed the portable oxygen tank supplied a high concentration of oxygen and is used with a nasal cannula to channel oxygen from the concentrator to the patient. General precautions included a warning which stated this device produces enriched oxygen gas which accelerates combustion. Do not allow smoking or open flames within 10 feet of this device while in use. Review of the facility smoking policy last revised 12/20/2022 titled, Resident Smoking Policy revealed the following: Residents who smoke or desire to smoke will be required to sign a Safe Smoking Contract and agree to abide by the rules regarding safe smoking or they will forfeit their smoking privileges. Residents may only smoke on premises in designated location(s). Those requiring supervision will only smoke at designated times. Independent smokers may smoke in designated location(s) at any time but need to sign out so that the staff know where the resident is. No resident will maintain or store smoking materials on their person or in their rooms. Resident smoking materials will be retained by the facility staff and distributed to the residents or supervising staff at designated smoking times. No smoking may occur near oxygen or other combustible materials. Failure to adhere to the provisions outlined in this smoking protocol (such as resident having smoking materials in his/her possession; found smoking in his/her room or any non-designated area, or smoking at any non-designated time) will result in: a. A reassessment of the resident utilizing the smoking safety assessment. b. Counseling of the resident by Social Services/designee using the Behavior Contract for Smoking Violations. c. Notification of the resident representative and/or guardian or POA of the incident by Social Services/designee. Depending on the severity of the violation, the following may occur at the discretion of the Administrator or his/her designee: a. Social Services/designee will notify resident due to violation he/she will forfeit smoking privileges for a period to be determined. b. A resident room search for smoking and lighting materials. c. Issuance of a discharge notice. Resident #31 was admitted to the facility on [DATE] with diagnosis which included chronic obstructive pulmonary disease (COPD). Review of Resident #31's physician's order dated 1/27/24 included an order for continuous oxygen at 3 LPM (liters per minute) via nasal canula. Resident #31's Smoking assessment dated [DATE] indicated he was non-smoker or intended not to smoke. a) The nursing progress note dated 1/31/24 documented by Nurse #2 stated Resident #31 was going outside to smoke and taking his nasal cannula off before lighting the cigarette. In an interview with Nurse #2 on 8/5/24 at 3:24 pm, she stated Resident #31 traveled outside to smoke via his motorized wheelchair. Nurse #2 stated she observed Resident #31 take his oxygen tubing off and place it in his lap before lighting the cigarette on 1/31/24. She further stated Resident #31's portable oxygen tank was not on his wheelchair. Nurse #2 indicated Resident #31 was assessed as a non-smoker on 1/27/24 and was unaware he had his smoking materials in his room at the time of this incident. Nurse #2 indicated she did not complete a new smoking assessment on Resident #31 after she observed him smoking on 1/31/24. Nurse #2 stated she reported to the oncoming shift on 1/31/24 but was unable to recall exactly who she reported the incident to. The physician was made aware the next day when he came to the facility. Resident #31's smoking materials were taken away from him by Nurse #2 after this incident and stored on the nurses' medication cart. Resident #31 had to ask the nurse on the medication cart for his smoking materials when he wanted to go smoke. Resident #31's Electronic Medical Record (EMR) revealed no evidence a smoking assessment was completed after the incident on 1/31/24. There was no documentation of counseling for the resident using the Behavior Contract for Smoking Violations for violating the smoking policy by having smoking materials in his possession as indicated in the smoking policy. No physician notes were documented related to the incident on 1/31/24. Resident #31 did not sign the Safe Smoking Contract as stated in the facility's Smoking Policy. Resident #31's admission Minimum Data Set (MDS) dated [DATE] revealed he had moderate cognitive impairment and was on oxygen therapy. The Current Tobacco use section was marked No. Resident #31 was independent with ambulation and transfers. Resident #31 had a walker and a motorized wheelchair for mobility. Resident #31's care plan dated 2/3/24 revealed a focus for oxygen therapy with an intervention of a portable oxygen tank provided for ambulatory residents. Resident #31's care plan dated 2/3/24 did not address his smoking. A nursing progress note completed by Nurse #8 on 3/15/24 stated Resident #31 asked for a nicotine patch to quit smoking. Physician notified and a new order for nicotine patches started on 3/16/24. A phone interview on 8/9/24 at 4:05 pm with Nurse #8 revealed Resident #31 came to her on 3/15/24 and asked for the nicotine patch to quit smoking. Resident #31's physician's order dated 3/16/24 included an order for nicotine patch 21 milligrams (mg)/24 hour to be applied daily at 9:00 am. Resident #31's March 2024 Medication Administration Record (MAR) revealed the nicotine patch was placed on 3/16/24, 3/17/24, 3/18/24 and refused on 3/19/24. The MAR further revealed this order was discontinued on 3/20/24. Resident #31's physician's order dated 4/14/24 included an order for nicotine patch 21 mg/24 hour to be applied daily at 9:00 am. There was no documentation that corresponded to this 4/14/24 order for the nicotine patch. Resident #31's quarterly Smoking Assessment completed by Nurse #14 on 4/18/24 indicated he was a safe smoker with a score of 1. The Smoking Assessment was a questionnaire, and the score was based on the answers to the questions for Observation Details - Including Smokes in Unauthorized Areas, Careless with Smoking Materials (Drops cigarette/cigar butts or matches on floor, furniture, self, or others; burns finger tips; smokes near oxygen) and for Capability to Follow Facility Safe Smoking Policy. Scoring on the smoking assessment gave points for answers defined as: No Problem (0 points), Minimal Problem (1 point), Moderate Problem (2 points), and Severe Problem (3 points). Resident #31's smoking assessment scored revealed a minimal problem (1 point) for Careless with Smoking Materials. The Smoking Interpretation Risk is scored as follows: o Score 0 to 9 = Safe Smoker o Score 10 to 18 = Potentially Unsafe Smoker o Score 19 to 27 = Unsafe Smoker Resident #31's April 2024 MAR indicated Resident #31 refused the nicotine patch on 4/14/24 and 4/19/24. The nicotine patch was discontinued on 4/28/24. There was no documentation that corresponded to this 4/28/24 discontinuation of the nicotine patch. A discharge MDS dated [DATE] indicated Resident #31 was discharged to the hospital. A hospital Discharge summary dated [DATE] indicated Resident #31 was readmitted to the facility on [DATE]. The expected medication list at discharge included the nicotine patch. Resident #31's physician's order dated 6/20/24 included an order for nicotine patch 21 mg/24 hour to be applied daily at 11:00 am and to hold the patch if smoking. Resident #31's June 2024 MAR indicated Resident #31 had the nicotine patch placed on 6/20/24 through 6/27/24. b) A nursing progress note completed on 6/27/24 by Nurse #1 indicated Resident #31 was sitting outside of the 400-hall door. Resident #31 was wearing a nicotine patch and noted to be smoking in an area not designated for smoking. Resident #31's oxygen tubing was off and laying in his lap. Nurse #1 did not know if Resident #31's portable oxygen tank was on or off. During an interview with Nurse #1 on 8/5/24 at 8:41 am, she stated on 6/27/24 it was brought to her attention, unable to recall by who, that Resident #31 was sitting outside of the facility in his motorized wheelchair at the 400-hall exit door and was observed through the window on the door to be smoking. Nurse #1 stated she walked down the 400 hall to the exit door and observed Resident #31 smoking. Resident #31's oxygen tubing with nasal cannula was off and laying in his lap. His portable oxygen tank was sitting in his lap. She was unsure if it was on or off. Nurse #1 did not ask Resident #31 to extinguish the cigarette but immediately reported this to Nurse #6 who was the charge nurse on 6/27/24. She was not aware of where he got the smoking materials. Nurse #1 also stated Resident #31 had been smoking for years. Nurse #1 indicated Resident #31 was not a supervised smoker. She did not complete a new smoking assessment on 6/27/24. Nurse #1 was not sure if the physician was made aware of this incident. In an interview with Nurse #6 on 8/5/24 at 9:09 am, she stated Nurse #1 reported to her on 6/27/24 that Resident #31 was outside smoking at the end of the 400-hall exit door in his motorized wheelchair. Nurse #6 went outside where Resident #31 was and educated him on the dangers of smoking with oxygen and wearing a nicotine patch. Resident #31 was observed by Nurse #6 to have his portable oxygen tank on his motorized wheelchair, but she was unsure if it was on or off. Resident #31 stated man you caught me. Nurse #6 explained to Resident #31 he could not smoke and wear a nicotine patch. She stated she removed the nicotine patch. Nurse #6 explained Resident #31 was hiding and smoking because this area was not designated for smoking. No education was reported related to the fire hazards of smoking in the presence of a supplemental O2 device even when the device was turned off. Nurse #6 was not aware this was a fire hazard. Nurse #6 stated Resident #31 obtained the smoking materials from another resident's family member. Nurse #6 did not know the resident's or family member's name. Resident #31's family told her this information. Nurse #6 reported this to the Director of Nursing (DON) the same day. The physician was made aware and recommended to remove the nicotine patch. Nurse #6 removed the nicotine patch on Resident #31 and discontinued the nicotine patch on 6/27/24 due to Resident #31 was caught smoking with the nicotine patch. Nurse #6 did not complete a new smoking assessment on Resident #31 on this date. During a phone interview with the NC DHSR Life Safety Surveyor on 8/12/24 at 3:46 pm, he stated smoking within 10 feet of a portable oxygen tank was a fire hazard. He further stated it did not matter if the portable oxygen tank was on or off, it still was a risk for fire and/or an explosion. Resident #31's physician's order initiated on 6/20/24 included an order for nicotine patch 21 mg/24 hour to be applied daily at 11:00 am and to hold the patch if smoking was discontinued on 6/27/24 due to Resident #31 was caught smoking with the nicotine patch. A nursing progress note completed by Nurse #6 dated 6/27/24 revealed Resident #31 was upset the nicotine patch was taken away. Nurse #6 explained to Resident #31 if he gave up his cigarettes, he could have the patch restarted. Resident #31 gave up his cigarettes. Resident #31's responsible party (RP) was notified by Nurse #6 not to provide Resident #31 with cigarettes. Nurse #6 made the physician aware, and the nicotine patch was restarted on 6/27/24. During an interview with Nurse #6 on 8/5/24 at 9:09 am she stated Resident #31 was upset because his nicotine patch was discontinued after being caught smoking a cigarette on 6/27/24. Nurse #8 further stated she explained to Resident #31 he could not smoke and wear a nicotine patch at the same time. Nurse #6 told Resident #31 if he gave up his cigarettes, he could have the patch restarted. Resident #31 gave up his cigarettes. Nurse #6 notified Resident #31's RP and asked RP not to provide Resident #31 with cigarettes. Nurse #6 made the physician aware, and the nicotine patch was restarted on 6/27/24. Resident #31's physician's order dated 6/27/24 included an order for nicotine patch 21 mg/24 hour to be applied daily at 11:00 am and to hold the patch if smoking. Resident #31's June 2024 MAR indicated Resident #31 had the nicotine patch placed on 6/28/24 and 6/29/24 A discharge MDS dated [DATE] indicated Resident #31 was discharged to the hospital. A hospital Discharge summary dated [DATE] indicated Resident #31 was readmitted to the facility on [DATE]. Resident #31's previous order for the nicotine patch (initiated on 6/27/24) was discontinued on 7/1/24 and a new order was written on 7/2/24 for nicotine patch 21 mg/24 hour to be applied daily at 9:00 am. Resident #31's July 2024 MAR indicated he had the nicotine patch placed on 7/3/24, 7/5/24, 7/6/24, and 7/7/24. Resident #31's July MAR revealed documented refusals of the nicotine patch on 7/4/24, 7/8/24, and 7/9/24. c) A nursing progress note completed by Nurse #2 on 7/9/24 documented Resident #31 was lying in his bed smoking a cigar with his oxygen tubing on via nasal cannula. Resident #31 was advised to put cigar out and Resident #31 refused to allow the nurse to extinguish his cigar. Resident #31 was advised either to extinguish the cigar or go outside with the lit cigar. Resident #31 was advised he could not smoke in the facility. Resident #31 stated he did not care if we kicked him out, he was not going to allow Nurse #2 to have the cigar. During an interview with Nurse #2 on 8/5/24 at 8:35 am, she stated Resident #31 was caught smoking a cigar in his bed on 7/9/24 with his oxygen tubing in place via nasal cannula. Resident #31's oxygen concentrator was on and was located beside his bed. Resident #31 refused to allow Nurse #2 to extinguish the cigar. Nurse #2 obtained the help of the Director of Nursing (DON) for Resident #31 to extinguish the cigar. Nurse #2 educated him (Resident #31) about the dangers of smoking with oxygen and how this was a fire hazard. She also educated him about the danger to the other residents in the facility. Nurse #2 did not know where Resident #31 got the cigar. Nurse #2 stated the facility was going to issue Resident #31 a 30-day discharge notice for continued violations of the smoking policy, evidenced by previous documented smoking incidents, but his family member did not return the phone calls. Resident #31 had been smoking since admission at the facility and did not require supervision to smoke. She was unable to explain why Resident #31 was an unsupervised smoker when he had a previous incident of violating the smoking policy. Nurse #2 did not complete a new smoking assessment after the 7/9/24. The medical record revealed no evidence a smoking assessment was completed after the incident on 7/9/24. There was no documentation of counseling for the resident using the Behavior Contract for Smoking Violations as indicated in the smoking policy. There was no care plan update related to smoking made to Resident #31's care plan after the 7/9/24 smoking incident. Resident #31's July 2024 MAR indicated he had the nicotine patch placed on 7/14/24 and refusals on 7/11/24, 7/12/24, 7/13/24, 7/15/24, 7/16/24, 7/17/24, 7/18/24, and 7/20/24. The 7/12/24 entry documented by Nurse #12 indicated Resident #31 continued to smoke. An attempt was made to contact Nurse #12 via phone with a message left on 8/13/24 at 11:12 am with no return call received. d) A nursing progress completed by Nurse #5 on 7/20/24 revealed a Nursing Assistant (NA) found a cigarette in Resident #31's toilet in his bathroom, ashes on the floor, and in the trash can. Resident #31 admitted yes I did have a cigarette early this morning in my bathroom. In an interview with NA #1 on 8/4/24 at 2:00 pm, she stated Resident #31 was non-compliant with the smoking policy. NA #1 indicated Resident #31 had a motorized wheelchair and was able to travel throughout the facility. NA #1 reported she did not know when Resident #31 was going outside to smoke due to his mobility in his motorized wheelchair. NA #1 indicated Resident #31 was an unsupervised smoker. She was unable to explain why Resident #31 was an unsupervised smoker when he had previous incidents of violations with the smoking policy. NA #1 recalled the incident with Resident #31 smoking a cigar in his bed 7/9/24. She also recalled the incident where a cigarette was found in Resident #31's toilet in his bathroom (7/20/24). NA #1 explained she was aware of the dangers of smoking with his oxygen tank/concentrator present. No education to the resident was reported related to the fire hazards of smoking in the presence of a supplemental oxygen device even when the device was turned off. NA #1 stated she reported any violations by Resident #31 to the nurse working on the hall. NA #1 further stated she knew Resident #31 was counseled about his non-compliance several times by the staff and administration. During an interview with Nurse #5 at 8/5/24 at 8:58 am, she stated she was informed by a NA #1 on 7/20/24 that a cigarette was found in Resident #31's bathroom toilet along with ashes on the floor and in the trash can. Nurse #5 indicated she went outside and talked to Resident #31 who was in the designated smoking area on 7/20/24. Resident #31 stated Yes, I did have a cigarette early this morning in my bathroom. Nurse #5 indicated she educated him about the dangers of smoking with oxygen and the danger to the other residents. Nurse #5 notified the Administrator and DON of this incident on 7/20/24. The Administrator came to the facility and confiscated his smoking materials and put them in a lockbox. Nurse #5 did not know who had the lockbox key. Nurse #5 indicated Resident #31 continued to violate the smoking policy with this incident and prior incidents. She was unable to explain why Resident #31 was an unsupervised smoker when he had previous incidents of violations with the smoking policy. Nurse #5 completed a smoking assessment on 7/20/24 after the incident and documented Resident #31 was a potentially unsafe smoker. Nurse #5 explained Resident #31 was a potentially unsafe smoker because he continued to violate the smoking policy and ignored the education provided. Nurse #5 could not explain the difference between a potentially unsafe smoker, unsupervised smoker, or a supervised smoker. Nurse #5 stated she thought Resident #31 kept his smoking materials in his room. Resident #31's Smoking Assessment completed by Nurse #5 on 7/20/24 indicated he was a potentially unsafe smoker with a score of 11. Resident #31's smoking assessment scored revealed a moderate problem (2 points) for Careless with Smoking Materials (smokes near oxygen), a moderate problem (2 points) for Begs or Steals Smoking Materials from Others, a moderate problem (2 points) for Ability to Understand the Facility Safe Smoking Policy, and a severe problem (3 points) for Capability to Following Facility Safe Smoking Policy. The medical record revealed no evidence of counseling for the resident using the Behavior Contract for Smoking Violations as indicated in the smoking policy was provided after the 7/20/24 incident. There was no care plan update related to smoking made to Resident #31's care plan after the 7/20/24 smoking incident. During an interview with the Administrator on 8/4/24 at 2:21 pm she indicated that Resident #31 was non-compliant with the smoking policy and safe smoking practices. She indicated she had talked to him multiple times regarding violating the facility's smoking policy. The Administrator stated she had confiscated his smoking materials after the incident on 7/20/24. She explained she ordered lockboxes to be placed in the lobby. She further explained the reason for the lockboxes was to keep the smoking materials out of the residents' room. All the smokers were listed as independent (unsupervised) smokers and kept the key to their lockbox. The Administrator did not have an explanation as to how the lockbox was supposed to help Resident #31 not violate the smoking policy when he had access to it and could retrieve the smoking materials without staff assistance. During a follow up phone interview with the Administrator on 8/22/24 at 1:18 pm she stated it was around the second or third week of July when she ordered lockboxes for the residents who smoked to retain their smoking materials. The lockboxes were installed and implemented around 7/29/24. It was at that time that she met with each resident who smoked and had them sign new smoking contracts. The Administrator stated Resident #31 signed a new Behavior contract at that time. The lockboxes were observed in the front lobby on 8/4/24. There were 6 lockboxes against the wall in the front lobby. On the front of each lockbox was the name of the resident who smoked. Resident #31 had a lockbox with his name on it. Resident #31's July 2024 MAR indicated he refused the nicotine patch on 7/21/24 and 7/22/24. The nicotine patch was discontinued on 7/23/24. Resident #31's record revealed no documentation for why the nicotine patch was discontinued on 7/23/24. Resident #31's care plan was revised by the Administrator on 7/29/24. A category of behavioral symptoms was created to reflect Resident #31 was a smoker. The goal created was Resident #31 would follow policies and procedures regarding smoking. The approach was Resident #31 would adhere to policies and procedures regarding smoking and would be accepting of staff redirection as indicated. Resident #31 would verbalize understanding of the risks associated with continued smoking. After surveyor entry to the facility for the recertification survey on 8/4/24, a list of residents who smoked was provided. Resident #31 was on the list, and he was identified as an independent (unsupervised) smoker. There were 5 additional residents on the list, and all were identified as independent smokers. e) On 8/4/24 at 2:15 pm an observation of residents in the designated smoking area revealed Resident #31 was sitting on the seat of his motorized wheelchair smoking a lit cigarette with a portable oxygen tank hanging on the back of his wheelchair. His oxygen tubing and nasal cannula was lying across his lap. There were 2 other residents in the designated smoking area were within 5 feet of Resident #31. No staff were observed in the designated smoking area. The designated smoking area was located at the end of the concrete sidewalk outside the front of the facility near the corner of the facility. No fire blanket, no fire extinguisher, and no sign to warn against having oxygen in the designated smoking area was observed. The designated smoking area had a self-extinguishing cigarette butt receptacle (a cylindrical container made of flame-retardant polyethylene material approximately 11 inches in diameter and 30 inches in height) On 8/4/24 at 2:21 pm this surveyor went to the Administrator's office and notified the Administrator, Director of Nursing (DON), and the Assistant Director of Nursing (ADON) of the observation of Resident #31 smoking in the designated smoking area with his portable oxygen tank in his motorized wheel chair. The ADON immediately went outside to the designated smoking area and brought the portable oxygen tank in the facility. Resident #31's portable oxygen tank was off. In an interview with Nurse #4 on 8/5/24 at 8:35 am, she stated she has been employed at the facility for approximately 6 to 7 months. She indicated Resident #31 had smoked since his admission to the facility. Nurse #4 stated she had been re-educating Resident #31 about the dangers of smoking with oxygen for months. She explained Resident #31 was fully aware that he continued to violate the smoking policy. Nurse #4 stated she would remove his portable oxygen tank from him when he went to smoke and that he smoked without supervision. Nurse #4 was unaware Resident #31 was not allowed to have smoking materials in his possession per the smoking policy. After the incidents on 7/9/24 and 7/20/24 his smoking materials were kept on the nurses' medication cart. The Administrator purchased lock boxes around the end of July and placed them in the front lobby of the facility. Resident #31's smoking materials were in the lockbox. Resident #31 had the lockbox key on a chain around his neck. She was unable to explain how the lockbox would be effective for Resident #31 if he still had access to his smoking materials. Nurse #4 stated Resident #31 had been caught many times violating the smoking policy and was re-educated every time about the dangers of smoking with his portable oxygen tank and/or while on a nicotine patch. She was unable to explain why Resident #31 was an unsupervised smoker when he had previous incidents of violations with the smoking policy. On 8/5/24 at 9:01 am, an observation was made of the lockbox key on a chain around Resident #31's neck. During an interview with Resident #31 on 8/5/24 at 9:01 am, he stated he had been smoking since he was [AGE] years old. He further stated he had smoked since his admission at the facility. He indicated he kept his smoking materials when he was first admitted . He then explained his smoking materials were kept by the nursing staff because he was caught smoking a cigar in his bed on 7/9/24 and the staff had found a cigarette butt in his bathroom toilet on 7/20/24. He stated currently his smoking materials were in a lockbox located in the front lobby instead of his room. He had the key on a necklace around his neck. He indicated he went out to smoke whenever he wanted. He was told by the nursing staff not to take his portable oxygen tank when he went out to smoke. Resident #31 stated the nursing staff had educated him on the dangers of smoking with oxygen. During an interview with Nurse #2 on 8/5/24 at 3:24 pm, she revealed she was not aware that smoking with the oxygen tank present was a fire hazard even when the tank was off. A Smoking Assessment completed by the Clinical Unit Manager on 8/5/24 indicated Resident #31's score increased to 15 due to increased points on the assessment questions for General Awareness and Orientation - Including Ability to Understand the Facility Safe Smoking Policy and for Capability to Follow Facility Safe Smoking Policy. He required supervision to smoke. During an interview with the Social Worker on 8/6/24 at 1:26 pm, she indicated she had discussions with Resident #31 about the facility's smoking policy and discussed the dangers of smoking with oxygen. There was no documentation of these discussions with Resident #31. The smoking materials for Resident #31 were kept on the nurses' medication cart after 7/9/24. She verified the resident was an unsupervised smoker through 8/4/24 and was unable to explain why Resident #31 was an unsupervised smoker after multiple incidents of violations with the smoking policy. In an interview with the DON on 8/6/24 at 9:09 am, she stated she was made aware of each incident involving Resident #31's violation of the smoking policy on 1/31/24, 6/27/24, 7/9/24, 7/20/24 and 8/4/24. The DON explained she assisted the nurse on 7/9/24 to get the cigar extinguished. She further stated she had educated Resident #31 about the dangers of smoking with oxygen and smoking with a nicotine patch after each of the incidents. The dangers of smoking with a nicotine patch can include nicotine poisoning and fast, irregular, or pounding heartbeat. The DON stated she placed a call to his family member/representative on 7/10/24 to discuss Resident #31's non-compliance with the facility smoking policy and was unable to leave a voice message. The DON explained the facility had 5 residents that smoked along with Resident #31. The smoking materials were kept by the residents who smoked. She was she aware of the smoking policy that stated no residents were supposed to retain their smoking material and was unable to explain why any residents had been allowed to retain their smoking materials. Resident #31's smoking materials were located on the nurses' medication cart due to the previous incidents (7/9/24 and 7/20/24) of violating the smoking policy and non-compliance. The DON explained the Administrator purchased lockboxes in July 2024 to keep the smoking materials out of the residents' rooms. The DON stated each smoker had the key to their lockbox. She was unable to explain how the lockbox would be effective for Resident #31 if he still had access to his smoki[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews, Responsible Party (RP) interview, and Physician interview the facility failed to provide supervision of a resident with severe cognitive impairment and known exit seeking behaviors to prevent an unsupervised exit for 1 of 7 residents reviewed for accidents (Resident #56). On 1/01/23 Resident #56 exited the facility out the dining room exit doors unsupervised and without staff knowledge. An alarm sounded, however the alarm announcement was muffled and had static which made the announcement unclear, so the staff were not aware the announcement was in reference to an elopement. Staff did not respond to the alarm due to the poor quality of sound and did not initiate a search for Resident #56. Resident #56 was found by a visitor outside the facility near the dining room door. This dining room door had a one lane exit road on its left that was bordered by a brush covered area on the opposing side and to the right of the dining room door was an access road for dietary deliveries. There was a high likelihood for Resident #56 to suffer serious injury. Findings included: Resident #56 was admitted to the facility on [DATE] with a diagnosis of dementia and depressive disorder. A physician order dated 5/13/21 for wander guard alarm (a device placed on a resident's wrist or ankle when they are determined to be at risk for exit seeking which would activate an alarm announcement to notify staff when the resident was near an open exit door or tried to open an exit door) related to wandering/exit seeking behaviors. A care plan initiated on 5/13/21 revealed Resident #56 had a care plan in place for elopement risk/wanderer related to history of attempts to leave the facility unattended and impaired safety awareness. Interventions included redirection of Resident #56 from wandering by offering structured activities, frequent monitoring during periods of restlessness, and to identify a pattern of wandering to intervene as appropriate. The Nurse Aide (NA) care guide (not dated) revealed Resident #56 had a wander guard alarm related to elopement risk. The Elopement Risk Assessment completed on 5/19/22 revealed Resident #56 was a high risk for elopement related to her history of wandering within the facility and verbalized or exhibited exit seeking behaviors. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #56 had severe cognitive impairment and was coded for antidepressant medication. The wander guard/elopement alarm was used daily, and she was not coded for wandering behaviors during the 7-day lookback period. Resident #56's ambulation was coded as steady at times with supervision or cueing and she did not require an assistive device. The Interdisciplinary Team (IDT) meeting progress note dated 12/29/22 revealed Resident #56's behavior and elopement risk were reviewed. The IDT noted Resident #56 was more difficult to redirect during periods of confusion. A nursing progress note dated 12/31/22 at 7:52 pm by Nurse #2 revealed Resident #56 pushed on the 200 Hall exit door twice exhibiting exit seeking behaviors. Resident #56 did not exit the facility and was redirected back to her room. An attempt to interview Nurse #2 on 6/07/23 at 9:09 am and again on 6/08/23 at 10:30 am were unsuccessful. A nursing progress note dated 1/01/23 at 1:15 pm by Nurse #1 revealed Resident #56 was last seen by Nurse #1 at 12:45 pm walking in hallway. Nurse #1 was alerted that Resident #56 was outside of the facility at 1:10 pm. She reported she was unable to hear the door alarm due to muffled sound. Nurse #1 reported Resident #56 was brought back into the facility and no injuries were noted. The Head-to-Toe Evaluation dated 1/01/23 at 2:00 pm revealed Resident 56's vital signs were as follows: blood pressure was 120/68 mm/Hg (millimeter of mercury), pulse was 66 beats per minute, respirations were 16 breaths per minute and regular, her temperature was 98.7 degrees Fahrenheit, and the blood oxygen level was 99% on room air. Resident #56 was pleasant, had no signs or symptoms of distress, she had no complaints of pain, and her skin was normal, warm, and dry. A nursing progress note dated 1/02/23 at 12:43 by the Unit Manager revealed the physician completed a medication review for Resident #56 and a change was made to her medication regimen. An observation on 6/07/23 at 1:00 pm of the area outside the dining room revealed the dining room exit doors opened to a sidewalk at the rear of the building which was to the right of the one lane exit road and bordered by a brush covered area on the left side of the exit road of the facility. To the right of the dining room exit door was an access road for dietary department deliveries and three trash dumpsters were located approximately 200 feet away. An observation of the 200 Hall to the dining room was completed on 6/07/23 at 5:15 pm and it was found to be the corridor next to the 200 Hall. The corridor did not have any resident rooms. The corridor was observed to have a pantry, staff break room, staff bathroom, and after a bend in the corridor was the entrance to the kitchen on the left side and the kitchen delivery door to the right side of the hall prior to entering the dining room. A review of the weather conditions per Weather Underground's website (www.wunderground.com) for Barco's weather indicated the temperature on 1/01/23 was 57 degrees Fahrenheit with 87% humidity during the time Resident #56 was outside the facility. A telephone interview was conducted on 6/06/23 at 3:37 pm with Nurse #1 who revealed she was assigned to Resident #56 on 1/01/23 on the 200 Hall. She reported she observed Resident #56 walking around the 200 Hall after lunch and she was notified about 20 minutes later that Resident #56 was outside the facility unsupervised, but she was unable to recall the exact times. Nurse #1 stated she was not aware Resident #56 had exited the facility and was unable to state how long Resident #56 was outside unsupervised. She stated she heard the intercom system attempt to make an announcement, but she was unable to determine what was being reported because it sounded low and muffled. She stated it was not clear that it was a door alarm announcement, so she did not know it was the wander guard alarm. Nurse #1 She stated Resident #56 had a history of exit seeking behaviors by going to the exit door on the 200 Hall, but she had never left the facility. Nurse #1 reported Resident #56 was brought back into the facility and was assessed and found to have no injury. An interview was conducted on 6/06/23 at 3:35 pm with the Regional Director of Clinical Services who revealed she was the Director of Nursing (DON) at the time of Resident #56's elopement from the facility. She revealed Resident #56 was able to ambulate independently at the time of the elopement, she did have a history of wandering, and she had the wander guard alarm in place. She stated Resident #56 had traditionally gone toward the 200 Hall doors, but she was easily redirected by staff or her family away from the doors. The Regional Director of Clinical Services stated Resident #56 had a stuffed dog that she was very attached to and after the elopement she stated when she tried to talk to Resident #56 about why she exited she said she was taking the dog for a walk. The Regional Director of Clinical Services stated Resident #56's wander guard alarm was functioning at the time she exited the facility but stated the exit alarm was not functioning properly at the dining room doors. She stated the wander guard alarm announcement was activated at any exit door when a resident with the wander guard alarm on was at the exit door when it opened, or they tried to open an exit door. She stated an automatic announcement was broadcasted over the intercom system to check the door at the location of the wander guard alarm activation such as, please check front lobby door or please check 200 Hall exit door depending on the location of the wander guard alarm activation. The Regional Director of Clinical Services stated when the announcement was made staff were required to physically go to the door and check the door location for a resident to ensure no one had exited the facility and would have to reset the alarm by entering the code on the keypad at the activated door. The Regional Director of Clinical Services stated the Maintenance Director adjusted the annunciator volume of the dining room doors on 1/01/23 so the alarm was able to be heard by staff, but it was found that the volume lowered again within a few days, so he scheduled service to the system. An interview with the Maintenance Director was conducted on 6/06/23 at 4:28 pm. He revealed he was notified by nursing on 1/01/23 that Resident #56 had exited the facility and that the wander guard alarm system was not functioning properly at the dining room doors. The Maintenance Director stated when he checked the system, he found the annunciator (device that provides information regarding activation of the wander alarm) was not clear and was breaking in and out which made it unable to hear the announcement over the intercom system. The Maintenance Director adjusted the volume of the annunciator for the dining room exit doors on 1/01/23. He stated the wander guard exit alarm did not ring or buzz but was an automatic announcement that was activated by a resident that had a wander guard near the door when it was opened, and it would announce the location of the wander guard alarm activation over the intercom. He stated the announcement would continue to repeat until the door that was breached was reset with the code on the keypad at the door. The Maintenance Director stated he had not been notified prior to Resident #56's elopement of an issue with the wander guard alarm announcement in the dining room. A phone interview was conducted with NA #2 on 6/06/23 at 5:55 pm who revealed she worked on the 200 Hall on 1/01/23 but she was not assigned to Resident #56. NA #2 stated Resident #56 was sitting at the nursing station because she and NA #1 were collecting lunch trays and Resident #56 was following them into other resident rooms. NA #2 stated she did not see Resident #56 leave the area of the nurse station and did not know Resident #56 exited the facility. NA #2 reported the wander guard alarm system did not work properly that day because she was unable to hear what was being said over the intercom speaker. NA #2 stated she did not check the exit doors but stated Resident #56 was brought back into the facility by NA #1. She was unable to state what time Resident #56 went outside or how long she was outside unsupervised. NA #2 stated Resident #56 had a history of wandering, so they kept a close eye on her, but she had not known her to exit the building in the past. An interview was conducted with NA #1 on 6/06/23 at 6:02 pm who revealed she was assigned to the 200 Hall and Resident #56 on 1/01/23. NA #1 stated Resident #56 was sitting at the nursing station while she collected the lunch trays from the 200 Hall at approximately 12:45 pm -1:00 pm. NA #1 stated she did not see Resident #56 leave the nurse station. She reported she took the tray cart back to the kitchen and she saw a family member at the kitchen delivery door, and she waved her over. NA #1 stated she opened the door, and the family member notified her Resident #56 was outside, so she ran outside immediately and saw Resident #56 standing on the sidewalk at the dining room doors. NA #1 stated she brought Resident #56 back into the facility at the kitchen delivery door and took her to the nurse. She stated Resident #56 did not say how she got outside. She stated she heard something over the intercom, but she was unable to tell what was being said when she collected the lunch trays because it sounded like radio static and was very low. NA#1 stated she did not know Resident #56 was outside the facility and stated she did not check the exit doors because she was unable to determine if the wander guard alarm had been activated. She stated she knew Resident #56 was an elopement risk, but she normally did not go to this area of the facility. NA #1 reported Resident #56 was dressed on 1/01/23 with long pants, a long-sleeved shirt, socks, and shoes and possibly her sweater, as this was her normal clothing choice. An interview was conducted on 6/06/23 at 6:08 pm with NA #4 who revealed she was assigned to the 300 Hall on 1/01/23. She stated she did not know the wander guard alarm activated due to the poor quality of the announcement over the intercom and did not know Resident #56 exited the facility. NA #4 stated she was told Resident #56 had exited the facility and was she found outside by the dining room. NA #1 stated she went to help but when she got to the dining room, NA #1 was with Resident #56. During an interview on 6/06/23 at 6:16 pm Nurse #3 revealed she worked on 1/01/23 but she left prior to Resident #56's elopement. She stated she was notified of the elopement when she called to check in with the staff at the facility. Nurse #3 stated Resident #56 was confused but easily redirected and she enjoyed being with staff. Nurse #3 reported the wander guard alarm would at times go in and out during heavy storms, but she had not noticed the alarm not working properly on 1/01/23 when she was working. A telephone interview was conducted on 6/06/23 at 6:21 pm with Resident #56's Responsible Party (RP) who revealed she was notified of the elopement but was unable to recall if the facility was able to determine how she was able to exit the facility. She stated she came to the facility immediately and stated Resident #56 was calm and did not appear to be under any stress. During a telephone interview on 6/06/23 at 7:05 pm with NA #5 who revealed she worked on the 400 Hall on 1/01/23 but stated she did not hear the wander guard announcement alarm sound and she did not know Resident #56 exited the facility. NA #5 stated the information over the intercom was not clear and she was unable to determine what was being said. NA #5 stated she began to count the residents on the 400 Hall when she was notified Resident #56 was found outside the facility to make sure no other residents had exited. During an interview on 6/07/23 at 10:40 am the Unit Manager revealed she was on-call on 1/01/23 and came to the facility when she was notified by Nurse #1 that Resident #56 exited the facility. She stated when she arrived the wander guard alarm announcement was still activated and sounded like static. The Unit Manager stated she walked around the facility and confirmed the wander guard alarm was not able to be heard throughout the facility due to the static and low volume. She stated she stood on a table in the dining room to get closer to the intercom speaker and was still unable to determine what was being said. The Unit Manager stated she was unable to determine what door was activated by the announcement, so she walked to each exit door, she opened and shut each door, and then reset each exit door alarm by the keypad until the wander guard alarm silenced. The Unit Manager reported she contacted the Maintenance Director, and he came to the facility. The Unit Manager stated Resident #56 did have a history of exit seeking behaviors, but she would stay on the 200 Hall where her room was located. An interview was conducted with the Physician on 6/07/23 at 8:34 am who revealed he was notified that Resident #56 had eloped from the facility. He stated her diagnosis of dementia increased her exit seeking behaviors and he stated after the elopement he adjusted her medications. The Physician reported he was concerned that Resident #56 was out of the facility without supervision as she was not able to fully care for herself. The Administrator was notified of Immediate Jeopardy on 6/07/23 at 2:43 pm. The facility provided the following corrective action plan with a completion date of 1/07/23: 1. How corrective action will be accomplished for resident(s) found to have been affected: Resident #56 was assessed head to toe with no adverse findings. Resident #56 was assessed for reduced exit seeking behavior and was placed on one to one (1:1) observation for safety and the 1:1 observation remained in place until 1/30/23. Resident #56's RP and Physician were notified of the elopement. On 1/02/23 the Physician completed a medication review and changes were made to Resident #56's medication regimen. 2. How corrective action will be accomplished for resident(s) having potential to be affected by the same issue needing to be addressed: The facility completed a head count of residents on 1/01/23 to ensure no other residents were affected during the event. Elopement assessments were completed, and high-risk residents will be monitored for exit seeking behaviors and discussed during the weekly interdisciplinary team (IDT) meeting. The Director of Nursing (DON), the Assistant Director of Nursing (ADON), and the Unit Managers completed elopement assessments and chart reviews. Two residents were identified to have potential risk of elopement related to independent ambulation. On 1/01/23 The DON, ADON, and Unit Managers completed elopement assessments on all residents to ensure completion and accuracy and implementation of any wander alarms as indicated. On 1/01/23 the DON, ADON, and the Unit Managers completed education with all facility staff which included housekeeping, dietary, rehabilitation, administrative, and nursing staff. The education was via power point handout and verbal discussions that included the definition of elopement, the elopement policy reporting process, elopement response, identification of at-risk residents, and possible interventions. All staff working on 1/01/23 were provided with training immediately. Staff reporting to work for the next shift were educated upon arrival at the facility and before starting their work shift. All other staff were provided with education via telephone by the DON and ADON. The DON and ADON will track staff education to ensure education has been completed. The education was completed on 1/02/23. On 1/01/23 the Maintenance Director inspected all doors leading outside and noted volume issue on alarm in dining room and back conference room area. The Maintenance Director initiated elopement drills for all shifts to ensure staff compliance. 3. What measure will be put in place or systemic changes made to ensure that the identified issues does not occur in the future: The Maintenance Director completed daily door audits to ensure proper functioning. When an exit door is opened while a resident with a wander alarm is in proximity an annunciator will report via overhead intercom system the location of the door that was activated/alarmed. The Maintenance Director noted volume control issues after initial correction completed. On 1/04/23 VSC Fire & Security, Inc.(vendor) was contacted by the Maintenance Director and assessed the needs of the system and determined the system needed to be rewired. VSC rewired the system inputs 7 and 11 on 1/04/23 to correct announcements. On 1/06/23 VSC Fire & Security, Inc. returned to the facility and re-recorded door messages on 3 doors and inspected wiring and re-recording to ensure continued operation, appropriate volume control, and resolution of concern. 4. Indicate how the facility plans to monitor its performance to make sure the solutions are achieved and sustained: A Quality Assurance and Performance Improvement (QAPI) meeting was held on 1/03/23 with the QAPI Committee to review the root cause analysis of the elopement and review the facility's corrective action plan. a. The Maintenance Director conducted elopement drills on all three shifts completed 1/05/23. Beginning on 1/01/23 the Maintenance Director performed door alarm audits daily for 8 weeks. The Maintenance Director continues to perform weekly door alarm audits. Beginning on 2/01/23 the Maintenance Director/designee will conduct a monthly elopement drill for 1 shift for 4 months, then ongoing for 1 shift quarterly. The elopement drills will be reviewed in the QAPI meeting monthly ongoing. The door alarm audits continue to be reviewed in the QAPI monthly meeting. b. Beginning 1/03/23 the DON, ADON, and Unit Managers reviewed in the weekly IDT risk meeting (reviews nursing notes and behavior monitoring) to ensure interventions are appropriate and initiate changes to plan of care as identified. During the weekly IDT risk meeting those residents that are triggering high on the elopement assessment and are independently mobile are assessed for changes in behavior or exit seeking and that appropriate interventions were implemented. This is an ongoing review now included in the weekly IDT risk meeting. The DON is responsible to bring the results of the audits/drills to the monthly QAPI meeting and revised as needed for 3 months or longer as deemed necessary by the QAPI Committee. Alleged date of compliance: 1/07/23. Onsite validation was completed on 6/07/23 through 6/08/23 through record review, staff interviews, and observations of the wander guard alarm system. Staff were interviewed to validate the in-service was completed on the wander guard alarm process and elopement drills. A review was completed of the wander guard audits, and IDT risk meeting minutes. Review of the elopement drills and the door alarm audits were completed with no issues noted. Observations of the wander guard alarm system during the survey revealed clear annunciation and notification of the door location activation and staff responded to the designated door throughout the facility. The facility's corrective action plan was validated to be completed as of 1/07/23.