**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews with staff, Psychiatric Nurse Practitioner, Responsible Party (RP), and the Police Detective, the facility failed to protect the right of two cognitively impaired residents (Residents # 1 and # 7) to be free from abuse. On the evening of 2/6/25 Resident # 2 returned from an outing and was observed by staff to show signs of being inebriated. That evening he was also observed at the bedside of Resident # 1, who was cognitively impaired and who did not have the ability to invite him into her room. After his removal from Resident # 1's room by staff, Resident # 2 was observed in Resident # 1's room a second time with the curtain pulled so that he and Resident # 1 were out of view. During this second incident, Nurse Aide # 1 and Nurse # 1 entered the room and walked around the curtain and witnessed Resident # 2 with his hand under Resident # 1's right leg lifting it up while Resident # 1's brief was open on the right side exposing part of her private area. Resident # 2 was seated in his wheelchair at Resident # 1's bedside at the time with his hand between Resident # 1's thighs to the point that only above his wrist was visible. Resident # 1 was in her bed clenching her brief which was unfastened on the right side and with part of her private area exposed. Resident # 1 was saying No, no, no. Resident # 1's RP reported during interview that if Resident # 1 could have spoken about what had occurred to her, it would have made her sad and cry, and furthermore Resident # 1 would have called out to God asking why it had happened to her in her old age after she had lived through hard times. In addition, Resident # 6, who had a history of aggressive and volatile behaviors, was observed by staff standing over her cognitively impaired roommate (Resident # 7) and pulling her hair. At the time, Resident # 7 was observed screaming and crying. A reasonable person would expect to be safe from abuse in their home and could experience trauma, fear and anxiety. This was for two (Residents # 1 and # 7) of two sampled residents reviewed for abuse. Example #2 was cited at a lower scope and severity of G. The findings included: Resident # 2 was admitted to the facility on [DATE]. The resident's diagnoses included muscle weakness and right leg below knee amputation. Resident # 2's annual MDS (Minimum Data Set) assessment, dated 1/28/25, coded the resident as cognitively intact. The resident was also coded as totally independent with bathing, dressing, and transfers. The resident was assessed to be able to walk 150 feet with supervision. The resident's age was less than [AGE] years of age. On 2/6/25 at 1:12 PM a nurse documented in a progress note that Resident # 2 signed out with a friend for a leave of absence at 1:10 PM. He left the facility in stable condition. On 2/6/25 at 7:29 PM the DON (Director of nursing) entered the following information in a progress note. At 6:15 PM Resident # 2 had been noted to be in a female resident's room and her brief was undone. Resident # 2 was removed from the room and placed on one on supervision. Appropriate staff, family, police, and physician were notified. Investigation with the police and detectives resulted in Resident # 2 being arrested. A review of the facility's investigative file revealed Resident # 1 was the resident whose brief was undone when Resident # 2 was found in the room. A review of Resident # 1's record revealed the following information. Resident # 1 had been admitted to the facility on [DATE] and was elderly. Resident # 1's diagnoses in part included a history of stroke, hemiplegia, hemiparesis, anxiety, and heart disease. Resident # 1's 1/21/25 quarterly MDS assessment coded the resident as severely cognitively impaired and as being totally dependent on staff for her dressing and hygiene needs. She was also assessed to need substantial to maximum assistance to turn in bed and was dependent on staff for transfers. Resident # 1's care plan, updated on 1/31/25, included the information that the resident was dependent on staff for intellectual; physical, and emotional needs secondary to her hemiparesis, hemiplegia, and a language barrier. Review of physician orders revealed a hospice consultation was ordered for Resident # 1 on 2/3/25. Further review of Resident # 1's record revealed the DON made a nursing entry on 2/6/25 at 8:42 PM that was entered as a late entry. The DON documented the following information within the entry. At 6:15 PM a male resident was noted going in Resident # 1's room and upon nursing staff entering the room Resident # 1's brief was found open on the right side and the male resident was observed touching the resident. All appropriate parties were notified. The police were notified for investigation. The family members were notified, and Resident # 1 was sent to the hospital for evaluation. Review of 2/6/25 hospital ED (emergency department) notes revealed the following notations by the ED physician. Resident # 1 was assessed for possible sexual assault and found to have no overt signs of trauma. The resident had advanced dementia and had no recall of the event. The physician talked to the family who declined sexual disease testing and declined to send off testing and to pursue sexual assault nursing examination. Resident # 1's family member reported the resident was starting hospice and she just wanted to focus on her being kept comfortable. Review of the facility's investigative file revealed typed statements the DON had obtained from Nurse Aide (NA) # 1 and Nurse # 1 during the facility's investigation. NA # 1's statement read as typed, [Resident # 2] had returned from being out with friends/family, he appeared to have been drinking, as we were passing dinner trays noticed he went into [Resident # 1's] room. Myself and the nurse removed him from the room and redirected him to his room across the hall. As we were continuing to pass trays, we saw him enter her room again and we went down the hall to get him again. As we entered the room, we noticed that she was uncovered, and his right hand was under her leg with her brief undone. The nurse yelled at him to stop, and we immediately removed him from the room back to his room, reported it to supervisor. NA # 1 was interviewed on 2/24/25 at 4:55 PM and reported the following information about the incident. She had not often cared for Resident # 2 before 2/6/25. Resident # 2 had returned to the facility around 6:00 PM or 6:30 PM on 2/6/25 after being out to celebrate his birthday. When he returned, she could smell fumes on him and he appeared to be drunk. While the staff were passing out trays he sat in the hall and was not going to eat. She went to check on Resident # 1 after Resident # 1 had already been served her tray. When she went to Resident # 1's room to check on her, she found Resident # 2 in Resident # 1's room. He was seated in his wheelchair. Resident # 1 was in her bed. Resident # 2 was messing with her tray and at the same time he was pulling down her gown. At the time she (NA # 1) first saw Resident # 2 pulling Resident # 1's gown down, the gown was above Resident # 1's waist. Resident # 1's brief was on and intact. At the time, the privacy curtain was open. Resident # 1's covers were down, but that was not unusual because she did not always like the covers on her. She (NA #1) told Nurse # 1, who told Resident # 2 to leave the room. Nurse # 1 also told the supervisor about the situation. Resident # 2 did leave the room and went into the hallway. She (NA # 1) continued to take up trays, but she kept an eye on Resident # 2. As she was taking up dinner trays, she noticed that Resident # 2 had disappeared. She went and got Nurse # 1 and informed her. They went back to Resident # 1's room. At that time the door was open and the curtain was closed where you could not see Resident # 1 in her bed. They entered and rounded the curtain together. She (NA # 1) saw Resident # 2 in his wheelchair and Resident # 1 was in her bed. Resident # 2 had his hand under Resident # 1's right leg lifting it up. Resident # 1's brief was open on the right side to the point that part of her private area was exposed. Nurse # 1 yelled for Resident # 2 to get out of the room. He stopped lifting Resident # 1's leg and left the room. Nurse # 1 sent Resident # 2 to his room and notified the supervisor again, who called the DON. At the time when Resident # 2 was found in Resident # 1's room the second time, she was moaning in a way that she usually moaned. She (NA # 1) stood guard over Resident # 1 to protect her after the second incident, and another person was stationed to stand guard over Resident # 2's room where he was. Prior to the incident, no one had mentioned to her, and she was not aware of any incidents in which Resident # 2 allegedly was touching any other resident inappropriately. During an interview with the Administrator on 2/28/25 at 10:11 AM, the Administrator reported that no staff member had reported during their immediate interviews following the incident that Resident # 2 was touching Resident # 1 in anyway during the first incident on 2/6/25 when Resident # 2 was found in Resident # 1's room. The surveyor agreed to interview NA # 1 again for clarification. A second interview with NA # 1 on 2/28/25 at 11:11 AM was conducted with the Administrator per a three- way telephone call. NA # 1 reported the following information. In recalling the events weeks after the initial event had occurred, she may have been recalling the touching of the gown incorrectly when she first spoke to the surveyor. The touching of the gown was possibly during the second incident. She could recall for certainty that in the first incident she was surprised to see Resident # 2 in Resident # 1's room and he had been eating something off the resident's tray at the time. He had been removed from the room. NA # 1 further reported Resident # 1 could move and slide down in bed and that at times her gown would ride up from her movement in the bed. Review of the statement from Nurse # 1 as typed by the DON read as follows: [Resident # 2] appeared to be drunk when returned from LOA (leave of absence) with family as he went down the hall, he went into [Resident # 1's] room and myself and a CNA (certified nursing assistant) removed him to his room and told him that we would help her. We went on about passing trays and about 10 minutes later saw him go into the room again. We immediately went down the hall and into the room, I yelled for him to get out. He was sitting in his wheelchair beside the bed, her brief was undone, and his right hand was under her leg and unable to see where it was at. We immediately removed him and placed him in his room with someone watching him 1:1 per supervisor. Nurse # 1 was interviewed on 2/25/25 at 11:27 AM and reported the following information. She usually worked throughout the facility and did not care for Resident # 1 and Resident # 2 all the time. On the date of the incident, she had been at the desk when Resident # 2 had returned from an outing. He walked in with a walker and had a prosthesis on at the time. By looking at his eyes and his walk, it appeared he was inebriated when he returned. He went to his room. Later dinner trays came out on the hall. At that time, she recalled Resident # 2 being in his wheelchair without his prosthesis. While dinner trays were on the hall, NA # 1 got her to go to Resident # 1's room because Resident # 2 was in the room. When she entered the room, Resident # 1 was looking at the television. Resident # 2 was seated in his wheelchair in her room. Resident # 1's bedside table was between Resident # 2 and Resident # 1 at the time. Resident # 2 was eating dessert in Resident # 1's room and said he was talking to her. She informed Resident # 2 that the resident did not speak his language, he was not to help feed her, and he needed to leave the room. Resident # 2 did leave. She (Nurse # 1) informed Nurse # 3 (the supervisor for that evening) and she (Nurse # 1) then continued to help with tasks on the hall. Approximately ten minutes later she and NA # 1 met in the hall and went back to check on Resident # 1. At the time, the privacy curtain was pulled where you could not see Resident # 1 from the doorway. They could hear Resident # 1 saying very softly and not loud enough to hear down the hallway, No, no, no. They rounded the curtain. Resident # 1 was in her bed clenching her brief which was unfastened on the right side. Part of her private area was exposed. Resident # 2 was in his wheelchair and closer to her bed than previously. His hand was between her thighs to the point that only above his wrist was visible, and therefore she could not see exactly where his hand was touching. She told him to get out of the room right then and put him in his room. She ran to tell Nurse # 3. One on one was placed with both residents. Prior to the incident, she had only been working in that section of the facility about every two weeks and therefore was not often assigned to care for Resident # 2. She knew Resident # 2 had fresh tendencies and he would say he had multiple girlfriends, but she had never witnessed him touching another resident inappropriately. She did not recall anything in report about any special monitoring Resident #2 needed around other residents. There was no statement from Nurse # 3 (the nursing supervisor) in the investigation file. Nurse # 3 was interviewed on 2/24/25 at 4:02 PM and reported the following information. She had not witnessed either incident. She did know that Resident # 2 had returned that evening and appeared to be inebriated. That evening NA # 1 had told Nurse # 1 about an incident in which Resident # 2 was in Resident # 1's room with his hand under her covers. Nurse # 1 had relayed this to her (Nurse # 3). Resident # 2 and Resident # 1 had immediately been separated and Nurse # 1 had reported it to her (Nurse # 3). She (Nurse # 3) immediately went to a private area to call the DON about the incident. At that time, the DON had already left work and was planning to return to the facility. Immediately after she got off the phone and was returning to the unit, she saw Nurse # 1 and NA # 1 power walking-running to her. They reported there was a second incident in which Resident # 2 was found in Resident # 1's room and this time it was her understanding that Resident # 2 had been in Resident # 1's bed. She (Nurse # 3) was told that Resident # 2 had been on top of Resident # 1 and Resident # 2 was violating her while Resident # 1 was saying, no, no, no. Resident # 2 had been removed by them and put back in his room before Nurse # 1 and NA # 1 came to her. Nurse # 3 stated it had seemed like a minute since the first report and all she had done was go call the DON before the second incident with Resident #1 and Resident #2 was reported to her. She immediately called the DON back again after the second incident, and the DON was on her way. The Administrator called and talked to her (Nurse #3) and told her to call the police which was done. She checked Resident # 1's blankets to make sure she was not bleeding but she did not tamper with her brief until emergency services and the police could arrive. Staff did stay one on one with Resident # 2 and Resident # 1. The DON, who was the person to record Nurse # 1 and NA # 1's statements, was interviewed on 2/24/25 at 12:00 PM, 1:30 PM, and again on 5:10 PM and reported the following information. Resident # 1 had appeared to be drinking when he returned to the facility on 2/6/25. NA # 1 and Nurse # 1 were his assigned caregivers. Nurse # 3 was the supervisor that evening. Nurse # 3 was not the witness to the actual events. Resident # 2 had never been in bed with Resident # 1, and as in the recorded statements, Resident # 2 was found seated in his wheelchair beside Resident #1. He had his hand underneath her leg. The staff could not tell exactly where Resident # 2 had been touching Resident # 1 with his hand. Resident # 1 had been sent out to the hospital and found to have no trauma or penetration. NA # 3 was interviewed on 2/25/25 at 11:40 AM and reported the following information. She routinely cared for Resident # 1 and Resident # 2. Resident # 2 was usually in his room or the dining room when she was assigned to him. She had not seen him in other residents' rooms. In taking care of Resident # 1, Resident # 1 did not use her call bell to call for assistance. Resident # 1 had communication problems. The Administrator was interviewed on 2/26/25 at 3:30 PM and again on 2/28/25 at 10:11 AM and reported the following information. On 2/6/25 Resident # 2 returned from his outing and appeared inebriated. Staff did find him in Resident # 1's room one time prior to the actual incident and he should not have been in her room. Resident # 2 was not touching Resident # 1 or her clothing in any way during the first incident. He was removed from Resident #1's room. A short time later when the curtain was observed pulled, two staff members entered at the same time. As they rounded the corner of the pulled curtain, one of the staff members had a phone and obtained a photograph of Resident # 2 touching Resident # 1. The photograph was not taken to disrespect or slow the removal of Resident # 2 from Resident # 1. It was taken quickly to provide evidence so that the police could arrest Resident # 2 and remove Resident # 2 from the facility. As one staff member took the photograph, the other staff member was pulling the resident away. Resident # 2 had never been on top of Resident # 1. At the time, as shown in the photographic evidence, he was in a wheelchair beside her. He did not have his prosthesis on and it would have been impossible for him to have been in Resident #1's bed. The Administrator was also interviewed regarding the difference in some of the statements given by the staff to the surveyor. The Administrator reported the following information regarding this. Statements had been obtained that night directly following the incident at a time when things were fresh in his staff members' mind. The two witnesses were Nurse # 1 and NA # 1, and their recall at the time was that the resident [Resident #2] had not been touching the resident [Resident #1] or the resident's clothing in anyway during the first incident. Nurse # 3 had not witnessed either incident and Nurse # 3 had been very shaken up about things and there had been a lot of discussion about what had occurred. The Administrator felt like the details had become conflated over time and was not sure why Nurse # 3's interview about what occurred was different than what Nurse #1 and Nurse Aide #1 reported at the time of the incidents. On 2/26/25 the Administrator provided a copy of the photograph that had been provided to the police on 2/6/25. Review of the photograph revealed the following observation. Due to the angle of the photograph, it did not depict any of Resident # 1's private area or Resident # 1's brief. The photograph was taken from the perspective of someone at the foot of the bed. Resident # 2 was seated in his wheelchair with his wheelchair parallel and right next to Resident # 1's bed. His wheelchair was positioned so that he was seated facing Resident #1. Resident # 1 was in bed with the head of the bed slightly elevated and the majority of her right thigh was exposed. The majority of Resident # 2's right forearm was under Resident # 1's right thigh pointed in the direction of her private area. The exact placement of Resident #2's hand was not visible in the photograph. The police detective, who was investigating the assault, was interviewed on 2/27/25 at 3:51 PM and reported the following information. The call came into the police at 6:53 PM and they arrived at 7:17 PM. The police detective confirmed Resident # 2 was in his room and under surveillance by facility staff when police arrived. Staff reported that Resident # 2 did not normally associate with Resident # 1 and on that evening Resident # 2 had reported to staff that Resident # 1 was wanting her dinner tray removed. On the evening of 2/6/25 Resident #2 was removed from the facility and jailed. Resident # 1's RP (Responsible Party) was interviewed on 2/24/25 at 12:38 PM and again on 2/28/25 at 9:20 AM and reported the following information. Resident # 1 had recently been placed on hospice before the incident of 2/6/25. She (the RP) had received a voice mail on 2/6/25 around 8:00 PM from the DON and returned it around 8:15 PM. The DON informed her that Resident # 1 had been assaulted by another resident. The DON further told her Resident # 1 was fine, and as a precaution the facility was sending Resident # 1 to the hospital to be checked. She had been told that staff had entered Resident # 1's room and the resident, who had assaulted Resident # 1, had been in a wheelchair at the time. Family members had been very involved in Resident # 1's care and would visit regularly. Family had noted a male resident sitting in the hallway near doorways and looking into rooms when they visited. She and the family were not aware of any incidents prior to 2/6/25 where anyone had entered Resident # 1's room and touched her inappropriately before 2/6/25. The RP reported Resident # 1 had lived through the hard times during the depression years and through war times. Due to the resident's medical status, she could not speak up for herself regarding what had happened. If the resident could have spoken up for herself and understood what had happened to her, the RP reported Resident # 1 would have been sad, cried, and prayed a lot. The RP further reported Resident # 1 would have asked God, At my old age why did this happen? Why God, why me? The Administrator was informed of immediate jeopardy on 2/27/25 at 11:00 AM and presented the following corrective action plan. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. At approximately 6:15 PM on 02/06/2025, Resident #2 was found to have his hand under the gown and between the legs of Resident #1 in Resident #1 room which was the B bed (closer to window) with privacy curtain pulled. Resident #1 brief was unfastened and hospital gown she was wearing was around her waist but witness statements do not state that Resident #1 was exposed and was covered by hospital gown. Resident #2 was immediately removed from Resident #1 room and placed on 1:1 supervision. Police were contacted and arrived on scene to conduct investigation. Resident #2 was placed under arrest for 2nd degree felony sexual offense and misdemeanor sexual battery. Resident #2 was formally discharged from the facility due to action and arrest with notification to family to collect his personal belongings. As of 02/27/2025, Resident #2 continues incarceration with $10,000.00 jail bond per detective assigned to this case. This was the first incident with Resident #2 being noted to have any touching of Resident #1 or having any contact with Resident #1's clothing per immediate interview with on-site clinical team of Certified Nursing Assistant (CNA) and Licensed Practical Nurse (LPN) who were assigned to both Resident #1 and Resident #2. Based on those immediate interviews, we were not aware of any inappropriate touching and Resident #2 was immediately placed on 1:1 observation when touching was identified. Resident #1 was monitored for psycho-social needs with no concerns identified during bathing and/or incontinent care. Resident #1 did not present with any recall of the adverse event and did not present with any facial grimacing or signs of fear or distress at any time after the event occurred. Resident #1 was relocated to a private room on 02/12/2025 which was when a private room became available. The Medical Director was notified. Both resident's Responsible Parties were notified. A physical exam to include a skin assessment was conducted by assigned staff LPN for Resident #1 following the adverse event on 02/06/2025. No signs of bruising or trauma were indicated. As an additional precaution, the facility sent Resident #1 to the hospital emergency department for an additional exam. The resident's daughter declined extensive testing as she wished Resident #1 to return to the facility and wanted to keep Resident #1 comfortable. Resident #1 returned at approximately 3:45 AM on 02/07/2025 and no signs of trauma or penetration were identified. Adult Protective Services (APS) was contacted and determined that a formal investigation was not warranted as Resident #2 was no longer a potential threat to Resident #1. Allegation of abuse was submitted to North Carolina Division of Healthcare Service Regulation (NCDHSR) at 7:38 PM on 02/06/2025. Address how corrective action will be accomplished for those residents having the potential to be affected by the same deficient practice. On 02/06/2025, nursing managers completed skin assessments on residents with a brief interview of mental status (BIMS) of 8 or below and abuse questionnaires for residents with a BIMS of 9 or greater. Abuse and neglect education was provided to staff on 02/06/2025 by the Director of Nursing. A Resident Council meeting was held on 02/07/2025 to ensure residents understood sexual abuse and to report any allegation of sexual abuse. Signage was discussed during the meeting and then posted in all common areas on 02/07/2025 as a reminder to Residents and Staff and vendors IF YOU SEE SOMETHING, SAY SOMETHING. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur On 02/06/2025, the Facility Administrator and Director of Nursing re-educated current staff (including contracted services) on Abuse/Neglect policy and procedures with emphasis on signs and symptoms of sexual abuse and ways to prevent sexual abuse. This also included timely reporting for Administrator and/or Director of Nursing to provide formal notification to NCDHSR within the required 2-hour window. Education included examples of what to look for including inappropriate touching or unwanted advances. This included covering unwanted intimate touching of any kind especially of breast or perineal area, all types of sexual assault, forced observation of masturbation and/or pornography, taking sexually explicit photographs and/or audio/video recordings of a resident and maintaining or distributing them. Residents should be monitored for bruises or grip marks, dismissive attitude about any injuries, uncommunicative or unresponsive, unreasonably fearful or suspicious, lack of interest in social contact, unexplained changes in behavior Education forms were signed by trained staff for the verbal education that was provided. Existing staff who were not present on the evening of 02/06/2025 or on 02/07/2025 were required to undergo abuse and neglect training prior to their return to work. This subset of staff were directed to contact unit managers prior to return to work and a list of all employees was cross-referenced and checked off as education was completed. All new hire staff are required to undergo abuse and neglect training during new-hire orientation. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained Facility Administrator and Director of Nursing determined on 02/06/2025 to monitor facility performance in an ongoing pursuit of quality control. The Social Worker will interview five residents with a brief interview of mental status (BIMS) of eight or greater per week for twelve weeks to inquire if they have felt abused or have witnessed or suspected abuse or neglect. Skin audits will be conducted by Director of Nursing or designee for 5 randomly selected residents with a BIMS of 8 or below. Immediate action to be taken for any positive findings. Results of these audits/interviews will be brought before the Quality Assurance Performance Improvement (QAPI) Committee monthly with the QAPI Committee responsible for ongoing compliance. Facility Administrator and Director of Nursing conducted an Ad hoc QAPI on 02/07/2025 with the Interdisciplinary Team (IDT) which includes Executive Director, Director of Nursing, Medical Director, Social Services Director, Activities Director, Dining/Nutrition Supervisor, Minimum Data Set (MDS) Team of RN and LPN, Rehabilitation Director, Housekeeping/Laundry Supervisor, Maintenance Supervisor, LPN Unit Manager, Business Office Director and Human Resources Director to review the event and conduct a root cause analysis for group discussion. Resident #2 was known to be very social and outgoing and friendly with all residents and staff. The root cause was determined to be that although staff did not have any reasonable expectation that this event had the likelihood to occur, it is possible for anyone at any time to make a poor decision with little to no consideration of consequence. In the monthly Quality Assurance and Performance Improvement (QAPI) Meeting, the Interdisciplinary Team (IDT) will review all resident to resident abuse allegations to ensure appropriate interventions are in place and the individualized resident-specific Plan of Care is updated for 8 weeks. The Administrator will report the results of the monitoring to the QAPI committee to review audits and make recommendations to assure compliance is maintained on an ongoing basis. The QAPI Committee will determine the need for further intervention and auditing beyond three months to ensure compliance is sustained on an ongoing basis. Compliance Date - 02/08/2025 Alleged date of IJ removal date: 02/08/2025 2. Resident # 6 was admitted to the facility on [DATE] with diagnoses of dementia, restlessness, agitation, hypertension, depressive disorder, anxiety, insomnia, muscle weakness, and cognitively communication problems. A review of Resident # 6's care plan, updated on 11/21/24 and which was in place until her final discharge on [DATE], revealed the following information. Resident # 6 independently bathed, toileted, and transferred herself. She was continent. She had exit seeking behaviors. She displayed inappropriate behaviors which included agitation, screaming, inappropriate language, and resistance to care. She had the potential to be verbally and physically aggressive. Resident # 6's care plan directed staff to monitor, document, and report when a resident posed a danger to others. The care plan also indicated a psychiatric consult would be done as indicated. According to the care plan, Resident # 6 had been on psychoactive medications since 3/20/24. Review of progress notes revealed a notation by the Social Worker on 11/25/24 at 2:17 PM noting that Resident # 6 had returned to the facility on [DATE] after being at the hospital for aggressive and combative behaviors. The Social Worker noted she was continuing to look for appropriate long- term placement in a secured memory care unit. On 11/25/24 the Psychiatric NP noted she visited the resident, and the resident was calm at the time. The Psychiatric NP noted there had been an issue with noncompliance with the resident taking her medication. The psychiatric NP also noted that because of the resident's history of aggression and the potential for future volatility plans were underway to transfer her to a psychiatric facility for a higher level of care. On 11/27/24 at 1:15 PM Nurse # 2 documented the following information in a nursing entry. Resident # 6 was being sent to the ED (emergency department) for combative behavior. Both the NP (Nurse Practitioner) and management had been advised with orders to send the resident out. The family was also notified. There were no specific details in the nursing note about what had occurred. Review of EMS (Emergency Medical Services) records, dated 11/27/24, revealed the following information by the paramedic. Facility staff stated the pt. (patient) refused to take any of her medications since being discharged from [name of hospital] for the same behavior several days ago. They stated she was striking her roommate and facility

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, family member, Physician Assistant, and Medical Director interviews the facility failed to notify the physician of a significant change in condition when staff were unable to obtain a urine sample on 3 instances (10/31/24 at approximately 5:00 AM and 9:00 PM and 11/1/24 at approximately 5:30 AM) for a resident identified with complaints of burning urination and decreased fluid intake. Resident #294 was first identified with decreased nutritional and fluid intake on 10/29/24 requiring staff to push fluids (deliberately drink beyond what thirst dictates to avoid dehydration) through 11/1/24. On 10/30/24 the resident complained of burning urination (dysuria) and was ordered a urinalysis (used to detect abnormalities such as blood, protein, glucose, and indirect indicators of bacterial infection) and urine culture and sensitivity (used to diagnose a urinary tract infection and determine the best treatment). Resident #294 exhibited signs and symptoms of dehydration on 10/31/24 at approximately 9:00 PM and 11/1/24 at approximately 5:30 AM as evidenced by the inability to collect urine via an in and out catheter (inserting a thin, hollow tube into the bladder) when the resident had no recent episodes of urination. The first notification to a medical provider was made to the Physician Assistant when she arrived at the facility on 11/1/24 at approximately 10/10:30 AM. During this time, nursing staff continued to administer the resident's Lasix (diuretic) 20 milligrams once daily at 9:00 AM despite signs and symptoms of dehydration and did not contact the physician regarding the diuretic administration. On 11/1/24 Resident #294's family member requested the resident be sent to the hospital. Emergency Medical Services (EMS) were contacted at 3:42 PM and Resident #294 was transferred to the emergency room where he was identified with altered mental status, tachypnea (rapid and shallow breathing), poor perfusion (occurs when there is inadequate blood circulation to organs and tissues and can be an early sign of circulatory or heart problems and can lead to life-threatening conditions), hypothermia (a medical emergency that occurs when the body's temperature drops below 95°F), severe lactic acidosis (occurs when the body produces too much lactic acid and the liver can't metabolize it fast enough), and new vasopressor requirements (vasopressors are a medication that are used to treat people with low blood pressure) most consistent with septic shock (a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection) with end organ dysfunction. Resident #294 died at 8:26 PM on 11/1/24. This deficient practice occurred for 1 of 3 residents (Resident #294) reviewed for notification of significant changes. Immediate jeopardy began on 10/31/24 when staff failed to notify the physician of a significant change in condition when Resident #294 exhibited signs and symptoms of dehydration and staff were unable to obtain a urine specimen via an in and out catheter when the resident had no recent episodes of urination. Immediate jeopardy was removed on 11/21/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems put into place and are effective. The findings included: Resident #294 was admitted to the facility on [DATE]. His diagnoses included dementia, type 2 diabetes, adult failure to thrive, generalized muscle weakness, chronic kidney disease, and congestive heart failure. A physician order dated 10/7/24 indicated give Lasix oral tablet 20 milligram by mouth one time a day for edema (swelling from fluid retention). Lasix is a diuretic used to treat fluid retention that can result from congestive heart failure, kidney disease or other medical conditions. (Lasix increases the flow of urine and can lead to dehydration.) Resident #294's admission Minimum Data Set (MDS) assessment dated [DATE] coded Resident #294 as cognitively intact. He required supervision or touching assistance with toileting. He required setup or clean up assistance with eating. He was coded as frequently incontinent of bowel and bladder and was also coded as taking a diuretic. Resident #294's overall discharge goal was to return to the community. He was not coded for hospice care. A facility 24-hour condition report completed by Nurse #5 dated 10/29/24 indicated Resident #294 had poor oral intake on day shift. The facility's 24-hour condition report is a form that nurses document the status of all the residents during or at the end of their shift to communicate any pertinent information to the next shift and nursing management. (Breakfast and lunch meals are served during the day shift which starts at 7:00 AM and ends at 3:00 PM.) During an interview with Nurse #5 on 11/18/24 at 2:45 PM, she stated that she had cared for Resident #294 on 10/29/24 from 7:00 AM to 7:00 PM. Nurse #5 indicated that normally Resident # 294 consumed more than 25% of his tray food and drinks but on 10/29/24 he had eaten and drank less than 25% during breakfast, lunch and dinner and she documented it in the 24 hour report and informed the oncoming night shift nurse (Nurse # 4). A facility 24-hour condition report completed by Nurse #4 dated 10/30/24 indicated Resident #294 was complaining of burning with urination on night shift (10/29/24 11:00 PM to 10/30/29 7:00 AM shift). During an interview on 11/19/24 at 3:53 PM with Nurse #4, she stated that she was assigned to care for Resident #294 on 10/29/24 at 7:00 PM to 10/30/24 at 7:00 AM. Nurse #4 stated that during shift change Nurse #5 had informed her and documented in the 24-hour condition report that Resident #294 had a decreased oral intake with food and drinks. Nurse #4 verbalized that Resident #294 complained of burning with urination during her shift and she left a note for the Provider in the physician book, noted it in the 24-hour condition report and informed the oncoming day shift nurse (Nurse #1). Nurse #4 stated that Resident #294 was stable and the only concern during her shift was complaints of burning with urination which she noted in the physician's book and she pushed fluids while Resident #294 was awake because she thought it was a sign of urinary tract infection. Resident #294's medication administration record indicated Lasix 20 mg was administered on 10/30/24 at 9:00 AM by Nurse #1. A Physician telephone order dated 10/30/2024 at 11:59 AM ordered by Physician Assistant (PA) #2 indicated urinalysis (UA), urine culture and sensitivity (C & S) for a diagnosis of dysuria. A facility 24-hour condition report dated 10/30/24 on day shift (7:00 AM to 3:00 PM) completed by Nurse #1 and evening shift (3:00 PM to 11:00 PM) completed by Nurse #6 indicated the need for a UA/C&S for Resident #294 in the morning (10/31/24). During an interview on 11/19/24 at 10:20 AM with Nurse #1, she indicated that she had cared for Resident #294 on 10/30/24. Nurse #1 stated that when she came to work on 10/30/24 at around 7:00 AM she was informed by the off going night shift nurse (Nurse #4) that Resident #294 had complained of pain with urination during the night shift (10/29/24 at 7:00 PM to 10/30/24 at 7:00 AM). Nurse #1 verbalized that a UA/C&S to rule out a urinary tract infection was ordered during her shift (10/30/24 7:00 AM- 7:00 PM) but she did not attempt to obtain a urine sample since it would not have been picked up until around 6:00 AM the following morning. Nurse #1stated that Resident #294 was less talkative than usual on 10/30/24. An interview was conducted on 11/20/24 at 1:40 PM with Nurse #6. He stated that he had filled in for four hours and cared for Resident #294 on 10/30/24 from 7:00 PM to 11:00 PM and he was aware that Resident #294 required a urine sample but he did not obtain it because it wouldn't have been picked up until the morning around 6:00 AM. He notified the third shift nurse (Nurse #2) to collect the urine specimen when she took over at 11:00 PM. Nurse #6 explained that the laboratory specimens were picked up by laboratory staff in the morning at approximately 6:00 AM. A facility 24-hour condition report dated 10/31/24 on night shift (10/30/24 11:00 PM to 10/31/24 7:00 AM) completed by Nurse #2 and day shift (10/31/24 7:00 AM to 3:00 PM) completed by Nurse #1 indicated the need for a UA and C&S for Resident #294. During an interview on 11/20/24 at 3:38 PM with Nurse #2, she stated that she had cared for Resident #294 on night shift (10/30/24 at 11:00 PM to 10/31/24 at 7:00 AM). Nurse #2 stated that when she took over the assignment that night, she was notified by the off going nurse (Nurse #6) that a urine sample was needed for Resident #294. She indicated that when she came on shift Resident # 294 was asleep and she did not recall waking him up to give him any fluids. Nurse #2 indicated that Resident #294 slept throughout her shift, and she attempted to obtain the urine specimen via an in and out catheter at around 5:00 AM on 10/31/24 but was unsuccessful and she notified the oncoming day shift nurse (Nurse #1). Nurse #2 indicated Resident #294's incontinence brief was wet during the in and out catheter attempt. Nurse #2 also indicated that she was not Resident #294's regular nurse and she was not familiar with his baseline. She verified that she did not notify the physician that she was unable to obtain the ordered urine specimen. An interview was conducted on 11/20/24 at 2:12 PM with NA #2 who had cared for Resident #294 on 10/30/24 and 10/31/24 on night shift. NA #2 stated that Resident #294 took only a few sips of water during her shifts and when she changed his incontinence brief there was very little urine. NA #2 stated that Nurse #3 was aware of Resident's condition from the beginning of her shift when she had told NA #2 to offer and encourage the Resident to drink water when she went to check on him. Resident #294's medication administration record indicated Lasix 20 mg was administered on 10/31/24 at 9:00 AM by Nurse #1. During an interview with Nurse #1 on 11/19/24 at 10:20 AM she stated that when she came back to work on 10/31/24 at around 7:00 AM she was informed by the off going night shift Nurse (Nurse #2) that a urine sample was still needed for Resident #294 since she had not been able to obtain the urine during the night shift. Nurse #1 stated that she did not attempt to obtain the urine sample on 10/31/24 day shift. She indicated that Resident #294 was more like he was the previous day when she had noted he was not at his baseline. He was less talkative than usual and not eating/drinking as usual and she continued to push fluids. Nurse #1 stated that Resident #294 normally ate and drank most of what was on his tray, and he also drank most of the water she gave him during medication administration, but on 10/31/24 he took only sips with the medication. She further stated that Resident #294 consumed 0 out of 120 milliliters of his med pass (nutritional supplementation) on 10/31/24 at approximately 9:00 AM and 5:00 PM whereas previously he consumed 100 % of the supplementation. Nurse #1 verified that she did not notify the physician of Resident #294's change of condition from baseline. A facility 24-hour condition report completed by Nurse #3 dated 11/1/24 on night shift (10/31/24 7:00 PM to 11/1/24 7:00 AM) indicated the nurse attempted twice to collect urine unsuccessfully. A late entry nursing progress note written by Nurse #3 dated 11/1/2024 at 6:13 AM indicated report was given to the nurse that a UA/C&S was needed. The nurse attempted to push fluids, however, resident would only take small sips. The first attempt to obtain the UA/C&S was around 9:00 PM on 10/31/24 and she was unable to collect as not enough urine came out. The writer continued to push fluids throughout the shift, again, only getting small sips. The first attempt to collect the urine was reported to the supervisor. The second attempt to obtain the UA/C&S was at 5:33 AM on 11/1/24 and was again unsuccessful. Oncoming nurse (Nurse #1) and the Unit Manager were made aware of the attempts and that the resident was still in need of a specimen or the medical doctor may need to be called to get further orders. Nursing progress note written by Nurse #3 dated 11/1/2024 at 6:31 AM indicated writer attempted to collect urine twice, however, was unsuccessful and Nurse #3 would report off to oncoming nurse (Nurse #1). An interview was conducted on 11/20/24 at 1:54 PM with the Nurse #3 who was assigned to care for Resident #294 on 10/31/24 at 7:00 PM through 11/1/24 at 7:00 AM. Nurse #3 stated she had received report from the off going day shift nurse (Nurse #1) that a urine specimen was needed for Resident #294 and she attempted to obtain the specimen at around 9:00 PM on 10/31/24 and at approximately 5:30 AM on 11/1/24 via an in and out catheter both times but was unsuccessful. She stated that there was barely any urine and it was too thick to be processed. She stated that Resident #294's incontinence brief was dry during both attempts, and she was pushing fluids but Resident #294 was only taking small sips and could not get in much. Nurse #3 reported to the oncoming day shift nurse (Nurse #1) that she had been unsuccessful in obtaining the urine specimen via an in and out catheter. Nurse #3 stated that Resident #294's vital signs were completed on day shift and were stable. She stated that she could not recall if she had obtained any vital signs during her shift and if she did, she would have documented them if they were outside parameters. Nurse #3 stated that Resident #294 did not seem different than other nights she had cared for him, he was verbal and did not seem to be in any acute distress otherwise she would have informed the physician to send him out. She verified she did not notify the physician. During an interview on 11/19/24 at 3:05 PM with Nursing Assistant (NA) #1 she stated that she had cared for Resident #294 on 10/30/24 through 11/1/24 during the 7:00 AM to 3:00 PM shift. NA #1 stated that during those 3 days she noticed that Resident #294 was eating and drinking less than usual, and he had become incontinent whereas previously he was using the urinal. She also stated that previously he could feed himself, but she had to feed him and offer drinks on 10/31/24 and 11/1/24 but he did not eat or drink as he usually did. NA #1 also stated that when she changed Resident #294's briefs there was minimal urine. NA #1 further stated that when she was giving Resident #294 a shower on 11/1/24 he was not as responsive as usual, he was quiet and not shouting like he would normally do during showers. She verbalized that Nurse #1 was aware of Resident #294's condition and had told NA #1 to encourage Resident #294 to drink his fluids and also to give him a shower because he kept pulling off his clothes. Resident #294's medication administration record indicated Lasix 20 mg was administered on 11/1/24 at 9:00 AM by Nurse #1. A Physician order dated 11/1/24 at 10:15 AM ordered by PA #1 indicated obtain peripheral intravenous (PIV) access (small catheter inserted into a superficial vein [a vein located close to the surface of the skin]). If unable to obtain, obtain a midline (a long flexible tube that is inserted into a vein in the upper arm to deliver fluids or medication into the blood stream). A Physician order dated 11/1/24 ordered by PA #1 indicated Sodium Chloride Intravenous Solution 0.9 %. Use 2 liters intravenously in the morning for poor oral intake for 3 Days. Administer 2 liters intravenous fluids normal saline at 100 milliliters per hour for 3 days. (Sodium Chloride is used to replenish lost water and salt in the body.) During an interview with Nurse #1 on 11/19/20 at 10:20 AM, Nurse #1 stated that when she came to work on 11/1/24 at around 7:00 AM she was informed by the off going night shift nurse (Nurse #3) that a urine sample was still needed. She indicated the resident drank only sips of water during medication administration on 11/1/24. Nurse #1 revealed that she had administered Resident #294's Lasix on 10/30/24, 10/31/24 and 11/1/24 at approximately 9:00 AM despite the resident's decreased oral food and fluid intake and that she did not think to hold it or ask the provider about it. She stated Resident #294 seemed more confused than the previous 2 days, and she notified Physician Assistant (PA) #1 when she came to the facility between 10:00 AM and 11:00 AM on 11/1/24. She stated that she knew the PA would come to the facility that morning and she would let the PA know that they had not been able to obtain the urine specimen and the resident was not drinking much which was probably a sign of dehydration. PA #1 went to examine Resident #294 and ordered a midline and IV fluids. Nurse #1 stated she did not attempt to insert a peripheral line because Resident #294 was dehydrated and she could not find a visible vein. She stated that she did not notify the PA regarding the PIV because the PA had ordered a midline if a PIV was not obtained. She called the vascular team (a contracted entity that is specialized in inserting intravenous catheters) to come and insert a midline and also called Resident #294's family member to obtain consent for the midline insertion. The family member did not answer the phone, and she left a message for her. The family member arrived at the facility at around 3:00 PM and the Nurse informed her that the vascular team were enroute to the facility to insert the midline. The family member wanted Resident #294 to be sent to the Emergency Department (ED) due to the worsening condition and Nurse #1 stated she agreed. She informed the Unit Manager and the facility Provider and called emergency medical services (EMS) who came to transfer Resident #294 to the hospital. A Physician Assistant (PA) progress note written by PA #1dated 11/1/24 at 11:52 AM indicated Resident #294 was seen by PA at the request of nursing for evaluation of change in condition. The resident was minimally responsive. This was a noted change from usually being agitated and interactive per nursing/therapy. The roommate reported that he had not seen Resident #294 eat over the past 3 days. Nursing attempted to obtain UA/C&S, unable to provide adequate sample even with catheter. The progress note also indicated the resident had a change in condition, altered mental status, decreased oral intake, and was clinically dehydrated. An order was provided to obtain a PIV on 11/1/24 and ordered IVF 2 liters for 3 days (11/1/24 to 11/4/24). The progress note indicated staff were unable to obtain UA/C&S given dehydration. During an interview on 11/19/24 at 4:30 PM with Physician Assistant #1 (PA #1) she stated that she was notified by Nurse #1 when she came to the facility at around 10:30 AM on 11/1/24 that Resident #294 had a change in condition, and they had not been able to obtain a urine sample for a UA and C&S. The PA explained that when she went to assess Resident #294, he seemed dehydrated but was responsive to questions. She gave an order to insert a peripheral intravenous (PIV) line and if unable to obtain PIV access to obtain a midline so that they could administer IV fluids. The PA stated she normally put the two orders (PIV and midline) on the same order so that if they could not obtain a PIV they could go ahead and obtain the midline without needing a second order. The PA stated she did not know Resident #294's baseline since she was not the primary care provider for Resident #294. She also stated that she could not recall if the facility contacted her to let her know that they had not obtained an IV access. She indicated she would not have expected to be notified if they did not obtain the PIV since the order explicitly stated to obtain the midline if PIV access was unable to be obtained. PA #1 stated the timeline to contact a provider was a case-by-case basis based on Resident's status. She further stated that if the Resident was declining and they could not get an IV access then they would contact the Provider if they needed the Resident to be sent to the hospital. An interview was conducted with the Unit Manager (UM) on 11/19/24 at 10:40 AM. The UM stated that she was notified by Nurse #1 on 11/1/24 at approximately 3:00 PM that Resident #294's family member was in the facility to see the resident and wanted him to be sent to the hospital due to altered mental status and she told Nurse #1 to go ahead and send the Resident out to the hospital per family request. The UM verbalized she was not aware if the Provider was notified about the inability to obtain the urine sample and change in condition until 11/1/24 when the Provider came to the facility between 10:00 AM and 11:00 AM. An interview was conducted with Resident #294's Emergency Contact #1 (Family Member) on 11/18/24 at 3:02 PM. The family member stated that she received a voice message from Nurse #1 on 11/1/24 at approximately 1:30 PM indicating that Resident #294 was doing okay and that she wanted to give her an update. The family member decided to come to the facility to check what was going on when she tried to call back the facility and was put on hold. When she arrived at the facility around 3:00 PM she found the Resident naked and disoriented, his mouth was dry and crusty and she attempted to give him a drink and he drank it. The family member stated Nurse #1 told her she was waiting for vascular team to come and insert an intravenous line and she informed Nurse #1 that she wanted the Resident to be sent to the hospital because he was in distress and Nurse #1 called 911. An EMS report dated 11/1/24 indicated that EMS was contacted at 3:42 PM for a non-emergent transportation due to family choice. EMS arrived at the facility at 4:02 PM and primary impression was altered mental status and secondary impression was sepsis. The chief complaint was altered mental status with onset of 10/30/24. An electrocardiogram (ECG) at 4:05 PM indicated atrial fibrillation (irregular heart rhythm characterized by rapid and irregular heartbeat). Vital signs obtained by EMS at 4:17 PM were noted as blood pressure: 103/72, pulse: 65, respirations: 8, oxygen saturation: 94 % and level of consciousness was responds to painful stimulation on the AVPU (alert, voice, pain, unresponsive scale used to measure patient's level of consciousness). EMS obtained a telephone order at 4:22 PM to administer IV fluids due to Resident #294 meeting the criteria for sepsis. IV fluids were not administered due to inability to establish an IV access. EMS departed facility at 4:39 PM with Resident #294 and notified the receiving hospital of sepsis indication at 5:00 PM. EMS assessment at 5:05 PM indicated Resident #294 was lethargic, non-verbal with minimal alertness, he had rapid mouth breathing, his skin was cold and dry, lung sounds were clear with increased respiratory rate and oxygen saturation readings were inconsistent due to the resident having cold hands. Resident #294 arrived at the ED at 5:41 PM. An ED progress note dated 11/1/24 indicated that Resident #294's vital signs were noted as follows: blood pressure: 72/58, heart rate: 138, and respirations 29 at 5:45 PM and oxygen saturation: 33 %, and temperature: 93.4 degrees Fahrenheit at 6:23 pm. The progress note indicated Resident #294 presented critically ill, obtunded (reduced level of alertness and consciousness), breathing on his own with cold distal extremities with dilated pupils without response bilaterally and no response to painful stimuli. Facility stated that he had not been eating or drinking anything for 3 days, and today he was found naked by his family and encouraged the nurse to take his vital signs who then emergently called for 911. Resident #294 was found to be in metabolic acidosis (a condition in which too much acid accumulates in the body). Because of his cold extremities, they were unable to reliably obtain a pulse oximeter reading. Discussion with family revealed patient had voiced wishes to have everything done to sustain his life. After discussion regarding his goals of his care, family wanted the patient to continue to be full code. They understood that he was critically ill at that moment. The ED note indicated that Resident's presentation with altered mental status, tachypnea, poor perfusion, hypothermia, severe lactic acidosis, and new vasopressor requirements, consistent with septic shock with end organ dysfunction as cause of death. Resident #294 died at 8:26 PM on 11/1/24. During an interview on 11/20/24 at 3:07 PM with PA #2 she stated that she was the primary care provider for Resident #2 and that she had given the telephone order on 10/30/24 for the UA/C&S due to dysuria per nursing reports. PA #2 stated that she could not recall the facility notifying her that they had not obtained the urine sample or that the Resident's condition was declining. She also stated the timeline to contact a provider was a case-by-case basis based on Resident's status. An interview was conducted with the facility Medical Director (MD) on 11/19/24 at 4:37 PM. The MD stated he was aware of Resident #294's condition and the facility did what they were supposed to do to manage the Resident's condition. He indicated that when the Resident showed signs of a UTI, a UA was ordered and when they could not obtain a urine sample, they ordered an IV access for hydration, but the Resident was sent out before the IV access was obtained. The MD also stated that if the Resident had been sent out earlier the outcome would not have been any different. He also stated that if the UA had been obtained on 11/1/24 and was positive for a UTI they would have started the Resident on oral antibiotics and the outcome would have probably been the same. When the MD was asked if the facility staff should have notified him when they could not obtain the urine on 10/31/24 with the resident not drinking adequately as well as with continued Lasix administration, the MD stated the facility did everything right. When asked if the facility staff should have notified him when they didn't obtain PIV access, he stated that the vascular team had been contacted and they were on the way when the resident was sent out to the hospital. An interview was conducted on 11/20/24 at 4:30 PM with the Director of Nursing (DON). The DON stated that if nurses were not able to obtain the urine specimen on 10/31/24 at 5:00 AM, 10/31/24 at 9:00 PM and 11/1/24 at 5:30 AM with decreased oral intake nurses should have contacted the on call provider if there was no provider in the facility. She also stated nurses should have notified the PA on 10/31/24 when they were in the building that they had not obtained the ordered urine sample and inquired about the Lasix administration due to decreased oral intake and inability to obtain the urine specimen. The DON indicated she did not expect the staff to notify the physician/PA when the PIV access was unable to be obtained as the order specifically stated that if staff were unable to obtain PIV access that they were to obtain a midline via the vascular team. The Administrator was notified of immediate jeopardy on 11/20/24 at 6:04 PM. The facility provided the following credible allegation of immediate jeopardy removal: 1) Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Resident #294 no longer resides in the facility. Resident was transferred to the local hospital on [DATE] due to altered mental status. The center recognizes that all residents have the potential to be affected from the noncompliance of notifying the physician as it relates to obtaining a urine sample for residents identified with complaints of burning urination and decreased fluid intake, including signs and symptoms of dehydration as evidenced by the inability to collect urine via an in and out catheter when the resident had a dry brief. A review of Resident #294's electronic medical record revealed an order for UA w/ reflex, Urine Culture and Sensitivity with Diagnosis of Dysuria was ordered on 10/30/2024. The facility staff attempted to push fluids and obtain urine sample on 10/31/2024 at approximately 5:00 AM and 9:00 PM, 11/01/2024 at approximately 5:30 AM and was unable to collect urine sample. A review of Resident #294 orders indicated resident was prescribed Lasix 20mg daily to be administered daily per physicians' orders. A quality review of current residents with an order for UA/C&S between 10/20/2024 through 11/20/2024 were audited by the Director of Clinical Services and Unit Managers on 11/20/2024 to ensure urine sample was obtained. Nine (9) residents with orders for UA/C&S and eight (8) with no further change in condition that required notification to physician. No discrepancies were noted. Twenty-three (23) residents identified as having a physician order to administer diuretics were audited by the Director of Nursing and Unit Managers to ensure no signs and symptoms of dehydration as evidenced by the inability to collect urine. No resident was identified with signs and symptoms of dehydration as evidenced by the inability to collect urine, therefore notification to the physician was not warranted. On 11/20/2024, a root cause analysis was completed by the Director of Clinical Services and the Executive Director regarding notifying the physician for Resident #294 when staff were unable to obtain a urine sample. It was determined through the root cause analysis that the facility failed to follow policy and procedures to notify the physician regarding change in condition as it relates to decreased fluid intake for Resident #294 receiving Lasix and unable to obtain urine sample. 2) Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete The Director of Clinical Services and Nurse Managers re-educated licensed nurses on notifying physician for residents identified as having a change in condition via Situation, Background, Assessment and Recommendation (SBAR) as it relates to assessing residents with signs and symptoms of dehydration on 11/20/2024. The licensed nurse is to assess the resident, including vitals, complete the SBAR and notify the attending physician when there is a change in the status or condition of the resident. The Director of Nursing and Unit Managers re-educated licensed nurses on recognizing signs and symptoms of dehydration to ensure prompt physician notification for change in condition on 11/20/2024. Staff (licensed nurses/ Certified Nurse Assistants) not educated on 11/20/2024, will be educated by the Director of Nursing and or Unit Manager prior to working the floor. Newly hired staff will be educated during orientation by the Director or Nursing or Unit Manager on notifying physician for residents identified as having a change in condition via SBAR as it relates to assessing residents with signs and symptoms of dehydration. The Director of Clinical Services and Nurse Managers re-educated licensed nurses on notifying physician via change in condition (SBAR) for residents with an order for UA/C&S and unable to obtain urine sample on 11/20/2024. The licensed nurse is to assess the resident, including vitals, complete the SBAR and notify the attending physician when there is a change in the status or condition of the resident. The Director of Clinical Services and Nurse Managers re-educated certified nursing assistants on signs and symptoms of dehydration and immediately report the change in condition to the licensed nurse on 11/20/2024. Newly hired staff will be educated during orientation by the Director of Clinical Service and or Unit Managers. Staff (licensed nurses/ Certified Nurse Assistance) not educated on 11/20/2024, will be educated by the Director of Nursing and or Unit Manager prior to worki[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, family member, Physician Assistant, and Medical Director interviews, the facility staff failed to recognize the seriousness of a significant change in condition, the importance of and identify the need for urgent medical attention to address an emergent situation. On 10/29/24 a sudden decrease in food and fluid intake was observed by staff. Resident #294 reported burning with urination to the night shift nurse (10/29/24 at 11:00 PM through 10/30/24 at 7:00 AM) and an order for a urinalysis (UA) and urine culture and sensitivity (C & S) was obtained from Physician Assistant #2 on 10/30/24. No attempts were made to collect the urine specimen for the UA until 10/31/24 at around 5:00 AM and the nurse was not successful. Another nurse attempted to obtain the urine specimen the evening of 10/31/24 and the morning of 11/1/24 but was not successful. Resident #294 was administered his diuretic daily 10/29/24 through 11/1/24 despite decreased intake. The poor intake continued and by 10/31/24 Resident #294 had become incontinent of urine, there was minimal urine noted when his brief was changed, and staff had to feed him. The morning of 11/1/24 staff requested PA #1 to evaluate Resident #294 who noted the resident had a change in condition, altered mental status, decreased oral intake, and was clinically dehydrated. PA #1 ordered intravenous (IV) fluids for 3 days, but the nurse did not attempt to insert a peripheral line because Resident #294 was dehydrated, and she could not find a visible vein. The nurse contacted the vascular team to obtain IV access. On 11/1/24 Resident #294's family member arrived at the facility at approximately 3:00 PM and requested the resident be sent to the hospital and the facility requested non emergent transport. The specimen for the urinalysis had still not been collected and the IV fluids had not been initiated. EMS arrived at the facility at 4:02 PM and the primary impression was altered mental status and secondary impression was sepsis. The chief complaint was altered mental status with onset of 10/30/24. Resident #294 was transferred to the emergency department (ED) where the progress note indicated Resident #294 presented critically ill, obtunded (reduced level of alertness and consciousness), breathing on his own, with cold distal extremities, with dilated pupils without response bilaterally, and no response to painful stimuli. He was identified with altered mental status, tachypnea (rapid and shallow breathing), poor perfusion (occurs when there is inadequate blood circulation to organs and tissues and can be an early sign of circulatory or heart problems and can lead to life-threatening conditions), hypothermia (a medical emergency that occurs when the body's temperature drops below 95°F), severe lactic acidosis (occurs when the body produces too much lactic acid and the liver can't metabolize it fast enough), and new vasopressor requirements (vasopressors are a medication that are used to treat people with low blood pressure) most consistent with septic shock (a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection) with end organ dysfunction. Resident #294 died at 8:26 PM on 11/1/24. This deficient practice occurred for 1 of 3 residents (Resident #294) reviewed for professional standards of care. Immediate jeopardy began on 10/31/24 when staff failed to recognize the seriousness of Resident #294's change in condition and obtain necessary emergent medical attention. Immediate jeopardy was removed on 11/21/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems put into place and are effective. The findings included: Resident #294 was initially admitted to the facility on [DATE] with the last readmission to the facility on [DATE]. His diagnoses included fracture of right femur (thigh bone between hip and knee), dementia, type 2 diabetes, adult failure to thrive, generalized muscle weakness, chronic kidney disease, and congestive heart failure. He was admitted to the facility for rehabilitation therapy services after hospitalization following the femur fracture. A hospital Discharge summary dated [DATE] indicated Resident #294 was admitted to the hospital from [DATE] to 10/7/24 due to inability to care for himself at home after he was discharged home from SNF on 7/23/24 and readmitted to the hospital on [DATE]. He had an unwitnessed ground-level fall early morning on 9/25/2024 at the hospital when he thought he smelled smoke in his room and got up to investigate. Plain films revealed right femoral neck fracture. Resident #294 underwent a right hip hemiarthroplasty on 9/28/2024 and was discharged to SNF on 10/7/24 with physical and occupational therapy recommendations. A physician skilled nursing facility (SNF) admission note indicated Resident #294 was seen on 10/8/24 and reason for admission was debility. The symptoms had begun 11 weeks ago and the symptoms were reported as being moderate. The note indicated that the resident had a history of type 2 diabetes, coronary artery disease and suspected major neurocognitive disorder and had presented to the hospital for failure to thrive in adult. Resident #294 was admitted to the hospital on [DATE] through 7/2/24 for difficulty caring for self. He was discharged from the hospital on 7/2/24 and admitted to a skilled nursing facility and was discharged from the SNF to the community on 7/23/24 but he was unable to care for self at home and was readmitted to the hospital on [DATE]. He was living in a trailer without access to running water or sewer and likely not consistently taking his medications. He was known to only be able to feed and dress himself but not to perform other activities of daily living (ADL) or instrumental activities of daily living (IADLs) independently, including unable to bathe himself or use toilet, often using water jugs as commodes instead. Per review of prior records, Resident had demonstrated inability to follow-up with medical providers (was lost to Cardiology follow-up for 3 years despite significant cardiac history) and was paranoid about medications, such as self-discontinuing enalapril (medication used to treat high blood pressure) because he did not trust new pill color, demonstrating inability to make rational decisions regarding his health. The plan on the admission note indicated Resident #294 had a set of conditions, syndromes and functional impairments that would likely require frequent medication changes, other treatment changes and re-evaluations. Resident was at significant risk of worsening medical (including behavioral) status and was at significant risk for readmission to a hospital and these multiple morbidities required intensive management. Resident #294's care plan last revised on 10/8/24 had a care focus area that indicated Resident had potential for fluid deficit related to diuretic use with the goals for Resident to be free of symptoms of dehydration. Interventions included: monitor and document intake and output as per facility policy; monitor vital signs as ordered/per protocol and record; notify physician of significant abnormalities; monitor/document/report as needed any signs/symptoms of dehydration; obtain and monitor lab/diagnostic work as ordered and report results to physician and follow up as indicated. A physician order dated 10/7/24 indicated full code. A physician order dated 10/7/24 indicated give Lasix oral tablet 20 milligram by mouth one time a day for edema (swelling from fluid retention). Lasix is a diuretic used to treat fluid retention that can result from congestive heart failure, kidney disease or other medical conditions. Lasix increases urine output and can lead to dehydration. Resident #294's admission Minimum Data Set (MDS) assessment dated [DATE] coded Resident #294 as cognitively intact. He had no behaviors or rejection of care. He required supervision or touching assistance with toileting. He required setup or clean up assistance with eating. He was coded as frequently incontinent of bowel and bladder and was also coded as taking a diuretic. His weight was 137 pounds, and his height was 68 inches. Resident #294's overall discharge goal was to return to the community. He was not coded for hospice care. A 24-hour facility condition report completed by Nurse #5 dated 10/29/24 indicated Resident #294 had poor oral intake on day shift (7:00 AM to 7:00 PM). The facility's 24-hour condition report is a form that nurses document the status of all the residents during or at the end of their shift to communicate any pertinent information to the next shift and nursing management. During an interview with Nurse #5 on 11/18/24 at 2:45 PM, she stated that she had cared for Resident #294 on 10/29/24 from 7:00 AM to 7:00 PM. Nurse #5 indicated that normally Resident # 294 consumed more than 25% of his tray food and drinks but on 10/29/24 he had eaten and drank less than 25% during the three meals on her shift and she documented it in the 24 hour report and informed the oncoming night shift nurse (Nurse # 4). Vital signs documented on 10/29/24 at 1:43 PM by Nurse #5 were blood pressure (BP): 110/61, pulse:79, oxygen saturations: 96% and temperature: 98°F. Phone interviews were attempted with Nursing Assistant (NA) #3, the NA who worked with Resident #294 during the first shift (7:00 AM to 3:00 PM) on 10/29/24, and were unsuccessful. A 24-hour facility condition report completed by Nurse #4 dated 10/30/24 indicated Resident #294 was complaining of burning with urination on night shift (10/29/24 11:00 PM to 10/30/29 7:00 AM shift). During an interview on 11/19/24 at 3:53 PM with Nurse #4, she stated that she was assigned to care for Resident #294 on 10/29/24 at 7:00 PM to 10/30/24 at 7:00 AM. Nurse #4 stated that during shift change Nurse #5 had informed her and documented in the 24-hour condition report that Resident #294 had a decreased oral intake with food and drinks. Nurse #4 verbalized that Resident #294 complained of burning with urination during her shift and she left a note for the Provider in the physician book, noted it in the 24-hour condition report and informed the oncoming day shift nurse (Nurse #1). Nurse #4 stated that Resident #294 was stable and the only concern during her shift was complaints of burning with urination which she noted in the physician's book, and she pushed fluids while Resident #294 was awake because she thought it was a sign of urinary tract infection. Resident #294's medication administration record indicated Lasix 20 mg was administered on 10/30/24 at 9:00 AM by Nurse #1. A Physician telephone order dated 10/30/2024 at 11:59 AM ordered by Physician Assistant (PA) #2 indicated urinalysis (UA), urine culture and sensitivity (C & S) for a diagnosis of dysuria. During an interview on 11/19/24 at 10:20 AM with Nurse #1, she indicated that she had cared for Resident #294 on 10/30/24. Nurse #1 stated that when she came to work on 10/30/24 at around 7:00 AM she was informed by the off going night shift nurse (Nurse #4) that Resident #294 had complained of pain with urination during the night shift (10/29/24 at 7:00 PM to 10/30/24 at 7:00 AM). Nurse #1 verbalized that a UA/CS to rule out a urinary tract infection was ordered during her shift (10/30/24 7:00 AM- 7:00 PM) but she did not attempt to obtain a urine sample since it would not have been picked up until around 6:00 AM the following morning. She stated that she was pushing fluids and Resident #294's vital signs were stable. Nurse #1 stated she did not obtain urine specimen and put in the refrigerator because it was normally collected on night shift to be sent out in the morning. Vital signs documented on 10/30/24 at 3:13 PM by Nurse #1 were BP: 128/60, pulse:65, oxygen saturations: 94% and temperature: 97.5°F. A 24-hour facility condition report dated 10/30/24 on day shift (7:00 AM to 3:00 PM) completed by Nurse #1 and evening shift (3:00 PM to 11:00 PM) completed by Nurse #6 indicated the need for a UA/CS for Resident #294 in the morning (10/31/24). An interview was conducted on 11/20/24 at 1:40 PM with Nurse #6. He stated that he had filled in for four hours and cared for Resident #294 on 10/30/24 from 7:00 PM to 11:00 PM and he was aware that Resident #294 required a urine sample, but he did not obtain it because it wouldn't have been picked up until around 6:00 AM in the morning. He notified the third shift nurse (Nurse #2) to collect the urine specimen when she took over at 11:00 PM. Nurse #6 explained that the laboratory specimens were picked up by laboratory staff in the morning at approximately 6:00 AM. Nurse #2 stated that Resident #294 was stable and carried on conversation with him when he went to administer his 9:00 PM medications, he was in no pain and he took his medications with no concerns. Nurse #6 stated he did not collect the urine specimen and refrigerate it during his shift since a sample collected by third shift would have been fresher when it was sent out in the morning. A 24-hour facility condition report dated 10/31/24 on night shift (10/30/24 11:00 PM to 10/31/24 7:00 AM) completed by Nurse #2 and day shift (10/31/24 7:00 AM to 3:00 PM) completed by Nurse #1 indicated the need for a UA and C&S for Resident #294. During an interview on 11/20/24 at 3:38 PM with Nurse #2, she stated that she had cared for Resident #294 on the night shift (10/30/24 at 11:00 PM to 10/31/24 at 7:00 AM). Nurse #2 stated that when she took over the assignment that night, she was notified by the off going nurse (Nurse #6) that a urine sample was needed for Resident #294. She indicated that when she came on shift Resident # 294 was asleep and she did not recall waking him up to give him any fluids. Nurse #2 indicated that Resident #294 slept throughout her shift, and she attempted to obtain the urine specimen via an in and out catheter at around 5:00 AM on 10/31/24 but was unsuccessful and she notified the oncoming day shift nurse (Nurse #1). Nurse #2 indicated Resident #294's incontinence brief was wet during the in and out catheter attempt. Nurse #2 also indicated that she was not Resident #294's regular nurse and she was not familiar with his baseline. She further stated that his vital signs were obtained on day shift, but she would have obtained a set of vital signs that night if the Resident was in acute distress. An interview was conducted on 11/20/24 at 2:12 PM with NA #2 who had cared for Resident #294 on 10/30/24 and 10/31/24 on night shift. NA #2 stated that Resident #294 took only a few sips of water during her shifts and when she changed his incontinence brief there was very little urine. NA #2 stated she worked with Nurse #3 (10/31/24 at 11:00 PM through 11/1/24 at 7:00 AM) and Nurse #3 was aware of Resident's condition from the beginning of her shift when she had told NA #2 to offer and encourage the Resident to drink water when she went to check on him because they needed to obtain urine. NA #2 stated she could not recall if she had reported any information about Resident #294 to Nurse #2 on 10/30/24 night shift. Resident #294's medication administration record indicated Lasix 20 mg was administered on 10/31/24 at 9:00 AM by Nurse #1. During an interview on 11/19/24 at 10:20 AM with Nurse #1, she stated that when she came back to work on 10/31/24 at around 7:00 AM she was informed by the off going night shift Nurse (Nurse #2) that a urine sample was still needed for Resident #294 since she had not been able to obtain the urine during the night shift. Nurse #1 stated that she did not attempt to obtain the urine sample on 10/31/24 day shift since it would wait until the following morning at around 6:00 AM to be picked up. She indicated that Resident #294 was still not at baseline; he was less talkative than usual and not eating/drinking as usual and she continued to push fluids. Nurse #1 stated that Resident #294 normally ate and drank most of what was on his tray, and he also drank most of the water she gave him during medication administration, but on 10/31/24 he took only sips with the medication. She further stated that Resident #294 consumed 0 out of 120 milliliters of his med pass (nutritional supplementation) on 10/31/24 at approximately 9:00 AM and 5:00 PM whereas previously he consumed 100 % of the supplementation. Nurse #1 stated she recognized the resident was not at his baseline and was not eating and drinking as he usually did. The UA had been ordered the day before and Nurse #2 had not been able to obtain the specimen the previous shift. Nurse #1 stated she did not think of obtaining the urine during her shift to be sent to the lab and she left it for the next shift so it could be sent out the following day because it was normally collected on night shift and sent out in the morning. Vital signs documented on 10/31/24 at 3:43 PM by Nurse #1 were BP: 101/66, pulse:58, oxygen saturations: 94% and temperature: 97.2°F. A 24-hour facility condition report completed by Nurse #3 dated 11/1/24 on night shift (10/31/24 7:00 PM to 11/1/24 7:00 AM) indicated the nurse attempted twice to collect urine unsuccessfully. A late entry nursing progress note written by Nurse #3 dated 11/1/2024 at 6:13 AM indicated report was given to the nurse that a UA/C&S was needed. The nurse attempted to push fluids, however, resident would only take small sips. The first attempt to obtain the UA/CS was around 9:00 PM on 10/31/24 and she was unable to collect as not enough urine came out. The writer continued to push fluids throughout the shift, again, only getting small sips. The first attempt to collect the urine was reported to the supervisor. The second attempt to obtain the UA/C&S was at 5:33 AM on 11/1/24 and was again unsuccessful. Oncoming nurse (Nurse #1) and the Unit Manager were made aware of the attempts and that patient is still in need of a specimen or the medical doctor may need to be called to get further orders. Nursing progress note written by Nurse #3 dated 11/1/2024 at 6:31 AM indicated writer attempted to collect urine twice, however, was unsuccessful and Nurse #3 would report off to oncoming nurse (Nurse #1). An interview was conducted on 11/20/24 at 1:54 PM with the Nurse #3 who was assigned to care for Resident #294 on 10/31/24 at 7:00 PM through 11/1/24 at 7:00 AM. Nurse #3 stated she had received report from the off going day shift nurse (Nurse #1) that a urine specimen was needed for Resident #294 and she attempted to obtain the specimen at around 9:00 PM on 10/31/24 and at approximately 5:30 AM on 11/1/24 via an in and out catheter both times but was unsuccessful. She stated that there was barely any urine, and it was too thick to be processed. She stated that Resident #294's incontinence brief was dry during both attempts, and she was pushing fluids but Resident #294 was only taking small sips and could not get in much. Nurse #3 reported to the oncoming day shift nurse (Nurse #1) that she had been unsuccessful in obtaining the urine specimen via an in and out catheter. Nurse #3 stated that Resident #294's vital signs were completed on day shift on 10/31/24 and were stable. She stated that she could not recall if she had obtained any vital signs during her shift and if she did, she would have documented them if they were outside parameters. Nurse #3 stated that Resident #294 was verbal and did not seem to be in any acute distress otherwise she would have informed the physician to send him out. During an interview on 11/19/24 at 3:05 PM with Nursing Assistant (NA) #1 she stated that she had cared for Resident #294 on 10/30/24 through 11/1/24 during the 7:00 AM to 3:00 PM shift. NA #1 stated that during those 3 days she noticed that Resident #294 was eating and drinking less than usual, and he had become incontinent whereas previously he was using the urinal. She also stated that previously he could feed himself, but she had to feed him and offer drinks on 10/31/24 and 11/1/24 but he did not eat or drink as he usually did. NA #1 also stated that when she changed Resident #294's briefs there was minimal urine. NA #1 further stated that when she was giving Resident #294 a shower on 11/1/24 he was not as responsive as usual, he was quiet and not shouting like he would normally do during showers. She verbalized that Nurse #1 was aware that Resident #294 was not drinking and eating as he normally did and had told NA #1 to encourage Resident #294 to drink his fluids and also to give him a shower because he kept pulling off his clothes. NA #1 indicated Resident #294 was not alert and oriented when she completed her shift, and they were getting ready to transfer the Resident to the hospital. Resident #294's medication administration record indicated Lasix 20 mg was administered on 11/1/24 at 9:00 AM by Nurse #1. A Physician Assistant (PA) progress note written by PA #1dated 11/1/24 at 11:52 AM indicated Resident #294 was seen by PA at the request of nursing for evaluation of change in condition. The resident was minimally responsive. This was a noted change from usually being agitated and interactive per nursing/therapy. The roommate reported that he had not seen Resident #294 eat over the past 3 days. Nursing attempted to obtain UA/CS, unable to provide adequate sample even with catheter. The progress note also indicated the resident had a change in condition, altered mental status, decreased oral intake, and was clinically dehydrated. An order was provided to obtain a PIV on 11/1/24 and ordered IVF (intravenous fluids) 2 liters for 3 days (11/1/24 to 11/4/24). PA #1 progress note indicated she confirmed hold parameters for insulins with decreased oral intake, although blood sugar was in 300s (normal range between 70 and 100 milligrams per deciliter). The progress note also indicated unable to obtain UA/CS given dehydration. During an interview on 11/19/24 at 4:30 PM with Physician Assistant #1 (PA #1) she stated that she was notified by Nurse #1 when she came to the facility at around 10:30 AM on 11/1/24 that Resident #294 had a change in condition, and they had not been able to obtain a urine sample for a UA and CS. The PA explained that when she went to assess Resident #294, he seemed dehydrated but was responsive to questions. She gave an order to insert a peripheral intravenous (PIV) line and if unable to obtain PIV access to obtain a midline so that they could administer IV fluids. The PA stated she did not know Resident #294's baseline since she was not the primary care provider for Resident #294. She also stated that she could not recall if the facility contacted her to let her know that they had not obtained an IV (intravenous) access. A Physician order dated 11/1/24 at 10:15 AM ordered by PA #1 indicated to obtain peripheral intravenous (PIV) access (small catheter inserted into a superficial vein [a vein located close to the surface of the skin]). If unable to obtain, obtain a midline (a long flexible tube that is inserted into a vein in the upper arm to deliver fluids or medication into the blood stream). A Physician order dated 11/1/24 ordered by PA #1 indicated Sodium Chloride Intravenous Solution 0.9 %. Use 2 liters intravenously in the morning for poor oral intake for 3 Days. Administer 2 liters intravenous fluids normal saline at 100 milliliters per hour for 3 days. (Sodium Chloride is used to replenish lost water and salt in the body.) During an interview with Nurse #1 on 11/19/24 at 10:20 AM, Nurse #1 stated that when she came to work on 11/1/24 at around 7:00 AM she was informed by the off going night shift nurse (Nurse #3) that a urine sample was still needed. Nurse #1 stated she checked on Resident #294 several times that morning and she had administered his morning medications at around 9:00 AM which he took with 25% of his med pass nutritional supplementation. Nurse #1 revealed that she had administered Resident #294's Lasix on 10/30/24, 10/31/24 and 11/1/24 at approximately 9:00 AM despite the resident's decreased oral food and fluid intake and that she did not think to hold it or ask the provider about it. She stated Resident #294 seemed more confused than the previous 2 days, and she notified Physician Assistant (PA) #1 when she came to the facility between 10:00 AM and 11:00 AM on 11/1/24. PA #1 went to examine Resident #294 and ordered a midline and IV fluids. Nurse #1 stated she did not attempt to insert a peripheral line because Resident #294 was dehydrated and she could not find a visible vein. She called the vascular team (a contracted entity that is specialized in inserting intravenous catheters) between 10:00 AM and 11:00 AM to come and insert a midline and also called Resident #294's family member to obtain consent for the midline insertion. The family member did not answer the phone, and she left a message for her. The family member arrived at the facility at around 3:00 PM and the Nurse informed her that the vascular team was enroute to the facility to insert the midline. Nurse #1 indicated Resident #249 was quieter around 3:00 PM compared to earlier in the day. The family member wanted Resident #294 to be sent to the Emergency Department (ED) due to the worsening condition and Nurse #1 stated she agreed. She informed the Unit Manager and the facility Provider and called emergency medical services (EMS) who came to transfer Resident #294 to the hospital. An interview was conducted with the Unit Manager (UM) on 11/19/24 at 10:40 AM. The UM stated that she was notified by Nurse #1 on 11/1/24 at approximately 3:00 PM that Resident #294's family member was in the facility to see the resident and wanted him to be sent to the hospital due to altered mental status and she told Nurse #1 to go ahead and send the Resident out to the hospital per family request. The UM verbalized she was not aware if the Provider was notified about the inability to obtain the urine sample and change in condition until 11/1/24 when the Provider came to the facility between 10:00 AM and 11:00 AM. The UM stated that Resident #294 was being provided treatment at the facility, but the family member was the one that wanted the Resident to be sent out. During the interview the UM initially told the surveyor that intravenous access had been obtained and fluids administered but when she further looked in Resident #294's medical records she stated that she thought the fluids had been administered but they were not. An interview was conducted with Resident #294's Emergency Contact #1 (Family Member) on 11/18/24 at 3:02 PM. The family member stated that she received a voice message from Nurse #1 on 11/1/24 at approximately 1:30 PM indicating that Resident #294 was doing okay and that she wanted to give her an update. The family member decided to come to the facility to check what was going on when she tried to call back the facility and was put on hold. When she arrived at the facility at around 3:00 PM she found the Resident naked and disoriented, his mouth was dry and crusty, and she attempted to give him a drink and he drank it. The family member stated Nurse #1 told her she was waiting for vascular team to come and insert an intravenous line and she informed Nurse #1 that she wanted the Resident to be sent to the hospital because he was in distress and Nurse #1 called 911. The family member also stated that Nurse #1 checked the Resident's vital signs during their conversation in the room and Nurse #1 immediately administered oxygen to the Resident after she checked the oxygen saturations. During an interview on 11/19/24 at 10:20 AM with Nurse #1 she stated that she had checked Resident #294's vital signs before he was transferred to the ED but she could not recall what they were, all she could remember was that oxygen saturation was below 90 % and she administered oxygen. Emergency medical services (EMS) report dated 11/1/24 indicated that EMS was contacted at 3:42 PM for a non-emergent transportation due to family choice. EMS arrived at the facility at 4:02 PM and primary impression was altered mental status and secondary impression was sepsis. The chief complaint was altered mental status with onset of 10/30/24. An electrocardiogram (ECG) at 4:05 PM indicated atrial fibrillation (irregular heart rhythm characterized by rapid and irregular heartbeat). Vital signs obtained by EMS at 4:17 PM were noted as blood pressure: 103/72, pulse: 65, respirations: 8, oxygen saturation: 94 % and level of consciousness was responds to painful stimulation on the AVPU (alert, voice, pain, unresponsive scale used to measure patient's level of consciousness). EMS obtained a telephone order at 4:22 PM to administer IV fluids due to Resident #294 meeting the criteria for sepsis. IV fluids were not administered due to inability to establish IV access. EMS departed facility at 4:39 PM with Resident #294 and notified the receiving hospital of sepsis indication at 5:00 PM. EMS assessment at 5:05 PM indicated Resident #294 was lethargic, non-verbal with minimal alertness, he had rapid mouth breathing, his skin was cold and dry, lung sounds were clear with increased respiratory rate and oxygen saturation readings were inconsistent due to the resident having cold hands. Resident #294 arrived at the ED at 5:41 PM. Emergency department (ED) progress note dated 11/1/24 indicated that Resident #294's vital signs were noted as follows: blood pressure: 72/58, heart rate: 138, and respirations 29 at 5:45 PM and oxygen saturation: 33 %, and temperature: 93.4 degrees Fahrenheit at 6:23 pm. The progress note indicated Resident #294 presented critically ill, obtunded (reduced level of alertness and consciousness), breathing on his own with cold distal extremities with dilated pupils without response bilaterally and no response to painful stimuli. Facility stated that he had not been eating or drinking anything for 3 days, and today he was found naked by his family and encouraged the nurse to take his vital signs who then emergently called for 911. Resident #294 was found to be in metabolic acidosis (a condition in which too much acid accumulates in the body). Because of his cold extremities, they were unable to reliably obtain a pulse oximeter reading. Discussion with family revealed patient had voiced wishes to have everything done to sustain his life. After discussion regarding his goals of his care, family wanted the patient to continue to be full code. They understood that he was critically ill at that moment. The ED note indicated that Resident's presentation with altered mental status, tachypnea (rapid and shallow breathing), poor perfusion (occurs when there is inadequate blood circulation to organs and tissues and can be an early sign of circulatory or heart problems and can lead to life-threatening conditions), hypothermia (a medical emergency that occurs when the body's temperature drops below 95°F), severe lactic acidosis (occurs when the body produces too much lactic acid and the liver can't metabolize it fast enough), and new vasopressor requirements (vasopressors are a medication that are used to treat people with low blood pressure) most consistent with septic shock (a life-threatening condition that happens when the blood pressure drops to a dangerously low level after an infection) with end organ dysfunction as cause of death. Resident #294 died at 8:26 PM on 11/1/24. An interview was conducted with the facility Medical Director (MD) on 11/19/24 at 4:37 PM. The MD stated he was aware of Resident #294's condition and the facility did what they were supposed to do to manage the Resident's condition. He indicated that when the Resident showed signs of a UTI, a UA was ordered and when they could not obtain a urine sample, they ordered an IV access for hydration, but the Resident was sent out before the IV access was obtained. The MD also stated that if the Resident had been sent out earlier that day on 11/1/24 the outcome would not have been any different. He also stated that if the UA had been obtained[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, family member, Physician Assistant (PA), and Medical Director interviews the facility failed to ensure staff recognized the seriousness of signs and symptoms of dehydration for a resident receiving a diuretic (Lasix 20 mg daily) and who had decreased fluid intake. Resident #294 was first identified with decreased nutritional and fluid intake on 10/29/24 requiring staff to push fluids (deliberately drink beyond what thirst dictates to avoid dehydration) through 11/1/24. Resident #294 exhibited signs and symptoms of dehydration on 10/31/24 at approximately 9:00 PM and 11/1/24 at approximately 5:30 AM as evidenced by the inability to collect urine via an in and out catheter (inserting a thin, hollow tube into the bladder) when the resident had no recent episodes of urination. During this time, nursing staff continued to administer the resident's Lasix (diuretic) 20 milligrams once daily at 9:00 AM despite signs and symptoms of dehydration. On 11/1/24 at 10:15 AM the PA ordered a peripheral intravenous (PIV) access (small catheter inserted into a superficial vein [a vein located close to the surface of the skin]) to provide intravenous fluids to the resident and staff did not attempt to insert the PIV due to the inability to find a visible vein (dehydration can cause veins to be difficult to locate). That afternoon, Resident #294's family member requested the resident be sent to the hospital. Emergency Medical Services (EMS) were contacted at 3:42 PM and Resident #294 was transferred to the emergency room where he was identified with altered mental status, tachypnea (rapid and shallow breathing), poor perfusion (occurs when there is inadequate blood circulation to organs and tissues and can be an early sign of circulatory or heart problems and can lead to life-threatening conditions), hypothermia (a medical emergency that occurs when the body's temperature drops below 95°F), severe lactic acidosis (occurs when the body produces too much lactic acid and the liver can't metabolize it fast enough), and new vasopressor requirements (vasopressors are a medication that are used to treat people with low blood pressure) most consistent with septic shock (a life-threatening condition that happens when your blood pressure drops to a dangerously low level after an infection) with end organ dysfunction. Resident #294 died at 8:26 PM on 11/1/24. This deficient practice occurred for 1 of 3 residents (Resident #294) reviewed for dehydration. Immediate jeopardy began on 10/31/24 when staff failed to recognize the seriousness of signs and symptoms of dehydration for Resident #294 when staff were unable to collect urine via an in and out catheter when the resident had no recent episodes of urination and decreased fluid intake. Immediate jeopardy was removed on 11/21/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems put into place and are effective. The findings included: Resident #294 was admitted to the facility on [DATE]. His diagnoses included fracture of right femur (thigh bone between hip and knee), dementia, type 2 diabetes, adult failure to thrive, generalized muscle weakness, chronic kidney disease, and congestive heart failure. He was admitted to the facility for rehabilitation therapy services after hospitalization following the femur fracture. Resident #294's care plan last revised on 10/7/24 had a care focus area that indicated Resident had potential for fluid deficit related to diuretic use with the goals for Resident to be free of symptoms of dehydration. Interventions included: monitor and document intake and output as per facility policy; monitor vital signs as ordered/per protocol and record; notify physician of significant abnormalities; monitor/document/report as needed any signs/symptoms of dehydration; obtain and monitor lab/diagnostic work as ordered and report results to physician and follow up as indicated. A physician order dated 10/7/24 indicated give Lasix oral tablet 20 milligram by mouth one time a day for edema (swelling from fluid retention). Lasix is a diuretic used to treat fluid retention that can result from congestive heart failure, kidney disease or other medical conditions. (Lasix increases the flow of urine and can lead to dehydration.) Resident #294's admission Minimum Data Set (MDS) assessment dated [DATE] coded Resident #294 as cognitively intact. He was coded as frequently incontinent of bowel and bladder and was also coded as taking a diuretic. Resident #294's overall discharge goal was to return to the community. He was not coded for hospice care. A facility 24-hour condition report completed by Nurse #5 dated 10/29/24 indicated Resident #294 had poor oral intake on day shift. The facility's 24-hour condition report is a form that nurses document the status of all the residents during or at the end of their shift to communicate any pertinent information to the next shift and nursing management. During an interview with Nurse #5 on 11/18/24 at 2:45 PM, she stated that she had cared for Resident #294 on 10/29/24 from 7:00 AM to 7:00 PM. Nurse #5 indicated that normally Resident # 294 consumed more than 25% of his tray food and drinks but on 10/29/24 he had eaten and drank less than 25% during breakfast, lunch and dinner and she documented it in the 24 hour report and informed the oncoming night shift nurse (Nurse # 4). During an interview on 11/19/24 at 3:53 PM with Nurse #4, she stated that she was assigned to care for Resident #294 on 10/29/24 at 7:00 PM to 10/30/24 at 7:00 AM. Nurse #4 stated that during shift change Nurse #5 had informed her and documented in the 24-hour condition report that Resident #294 had a decreased oral intake with food and drinks. Nurse #4 stated that Resident #294 was stable and the only concern during her shift was complaints of burning with urination which she noted in the physician's book and she pushed fluids while Resident #294 was awake because she thought it was a sign of urinary tract infection. Nurse #4 stated that Resident #294 did not drink much fluids because it was at night and he slept most of the night. A Physician telephone order dated 10/30/2024 at 11:59 AM ordered by Physician Assistant (PA) #2 indicated urinalysis (UA), urine culture and sensitivity (C & S) for a diagnosis of dysuria. Resident #294's medication administration record indicated Lasix 20 mg was administered on 10/30/24 at 9:00 AM by Nurse #1. During an interview on 11/19/24 at 10:20 AM with Nurse #1, she indicated that she had cared for Resident #294 on 10/30/24. She stated that she was pushing fluids because Resident #294 had complained of burning with urination and that could have been a sign of a urinary tract infection. Nurse #1stated that Resident #294 was less talkative than usual on 10/30/24. During an interview on 11/20/24 at 3:38 PM with Nurse #2, she stated that she had cared for Resident #294 on night shift (10/30/24 at 11:00 PM to 10/31/24 at 7:00 AM). Nurse #2 stated that when she took over the assignment that night, she was notified by the off going nurse (Nurse #6) that a urine sample was needed for Resident #294. She indicated that when she came on shift Resident #294 was asleep and she did not recall waking him up to give him any fluids. Nurse #2 indicated that Resident #294 slept throughout her shift, and she attempted to obtain the urine specimen via an in and out catheter at around 5:00 AM on 10/31/24 but was unsuccessful and she notified the oncoming day shift nurse (Nurse #1). Nurse #2 indicated Resident #294's incontinence brief was wet during the in and out catheter attempt. An interview was conducted on 11/20/24 at 2:12 PM with NA #2 who had cared for Resident #294 on 10/30/24 and 10/31/24 on night shift. NA #2 stated that Resident #294 took only a few sips of water during her shifts and when she changed his incontinence brief there was very little urine. NA #2 stated that Nurse #3 was aware of Resident's condition and had told her to offer and encourage the Resident to drink water when she went to check on him. Resident #294's medication administration record indicated Lasix 20 mg was administered on 10/31/24 at 9:00 AM by Nurse #1. During an interview with Nurse #1 on 11/19/24 at 10:20 AM, she stated that when she came back to work on 10/31/24 at around 7:00 AM she was informed by the off going night shift Nurse (Nurse #2) that a urine sample was still needed for Resident #294 since she had not been able to obtain the urine during the night shift. She indicated that Resident #294 was more like he was the previous day (10/30/24) when she had noted he was not at his baseline. He was less talkative than usual and not eating/drinking as usual and she continued to push fluids and he did not drink much. Nurse #1 stated that Resident #294 normally ate and drank most of what was on his tray, and he also drank most of the water she gave him during medication administration, but on 10/31/24 he took only sips with the medication. She further stated that Resident #294 consumed 0 out of 120 milliliters of his med pass (nutritional supplementation) on 10/31/24 at approximately 9:00 AM and 5:00 PM whereas previously he consumed 100 % of the supplementation. A facility 24-hour condition report completed by Nurse #3 dated 11/1/24 on night shift (10/31/24 7:00 PM to 11/1/24 7:00 AM) indicated the nurse attempted twice to collect urine unsuccessfully. A late entry nursing progress note written by Nurse #3 dated 11/1/2024 at 6:13 AM indicated report was given to the nurse that a UA/C&S was needed. The nurse attempted to push fluids, however, resident would only take small sips. The first attempt to obtain the UA/C&S was around 9:00 PM on 10/31/24 and she was unable to collect as not enough urine came out. The writer continued to push fluids throughout the shift, again, only getting small sips. The first attempt to collect the urine was reported to the supervisor. The second attempt to obtain the UA/C&S was at 5:33 AM on 11/1/24 and was again unsuccessful. Oncoming nurse (Nurse #1) and the Unit Manager were made aware of the attempts and that the resident was still in need of a specimen or the medical doctor may need to be called to get further orders. Nursing progress note written by Nurse #3 dated 11/1/2024 at 6:31 AM indicated writer attempted to collect urine twice, however, was unsuccessful and Nurse #3 would report off to oncoming nurse (Nurse #1). An interview was conducted on 11/20/24 at 1:54 PM with the Nurse #3 who was assigned to care for Resident #294 on 10/31/24 at 7:00 PM through 11/1/24 at 7:00 AM. Nurse #3 stated she had received report from the off going day shift nurse (Nurse #1) that a urine specimen was needed for Resident #294 and she attempted to obtain the specimen at around 9:00 PM on 10/31/24 and at approximately 5:30 AM on 11/1/24 via an in and out catheter both times but was unsuccessful. She stated that there was barely any urine and it was too thick to be processed. She stated that Resident #294's incontinence brief was dry during both attempts, and she was pushing fluids but Resident #294 was only taking small sips and could not get in much. Nurse #3 reported to the oncoming day shift nurse (Nurse #1) that she had been unsuccessful in obtaining the urine specimen via an in and out catheter. Nurse #3 stated that Resident #294 was verbal and did not seem to be in any acute distress otherwise she would have informed the physician to send him out. She stated that when she did not obtain the urine specimen at 5:30 AM she notified the oncoming day shift nurse so that she could notify the PA that morning and they could probably get an order for an IV because he was not drinking much, they had not been able to obtain the urine sample and he was probably dehydrated. During an interview on 11/19/24 at 3:05 PM with Nursing Assistant (NA) #1 she stated that she had cared for Resident #294 on 10/30/24 through 11/1/24 during the 7:00 AM to 3:00 PM shift. NA #1 stated that during those 3 days she noticed that Resident #294 was eating and drinking less than usual, and he had become incontinent whereas previously he was using the urinal. She also stated that previously he could feed himself, but she had to feed him and offer drinks on 10/31/24 and 11/1/24 but he did not eat or drink as he usually did. NA #1 also stated that when she changed Resident #294's briefs there was minimal urine. NA #1 further stated that when she was giving Resident #294 a shower on 11/1/24 he was not as responsive as usual, he was quiet and not shouting like he would normally do during showers. She verbalized that Nurse #1 was aware of Resident #294's condition and had told NA #1 to encourage Resident #294 to drink his fluids and also to give him a shower because he kept pulling off his clothes. Resident #294's medication administration record indicated Lasix 20 mg was administered on 11/1/24 at 9:00 AM by Nurse #1. A Physician order dated 11/1/24 at 10:15 AM ordered by PA #1 indicated obtain PIV access and if unable to obtain, obtain a midline (a long flexible tube that is inserted into a vein in the upper arm to deliver fluids or medication into the blood stream). A Physician order dated 11/1/24 ordered by PA #1 indicated Sodium Chloride Intravenous Solution 0.9 %. Use 2 liters intravenously in the morning for poor oral intake for 3 Days. Administer 2 liters intravenous fluids normal saline at 100 milliliters per hour for 3 days. (Sodium Chloride is used to replenish lost water and salt in the body.) During an interview with Nurse #1 on 11/19/24 at 10:20 AM, Nurse #1 stated that when she came to work on 11/1/24 at around 7:00 AM she was informed by the off going night shift nurse (Nurse #3) that a urine sample was still needed. She stated that she knew the PA would come to the facility that morning and she would let the PA know that they had not been able to obtain the specimen and the resident was not drinking much which was probably a sign of dehydration. She indicated the resident drank only sips of water during medication administration on 11/1/24. Nurse #1 revealed that she had administered Resident #294's Lasix on 10/30/24, 10/31/24 and 11/1/24 at approximately 9:00 AM despite the resident's decreased oral food and fluid intake and that she did not think to hold it or ask the provider about it. Nurse #1 stated she could not say why she had administered Lasix when they had been unable to obtain the urine specimen and the Resident was not drinking much. She stated Resident #294 seemed more confused than the previous 2 days, and she notified Physician Assistant (PA) #1 when she came to the facility between 10:00 AM and 11:00 AM on 11/1/24. PA #1 went to examine Resident #294 and ordered a midline and IV fluids. Nurse #1 stated she did not attempt to insert a peripheral line because Resident #294 was dehydrated and she could not find a visible vein. She called the vascular team (a contracted entity that is specialized in inserting intravenous catheters) to come and insert a midline and also called Resident #294's family member to obtain consent for the midline insertion. The family member did not answer the phone, and she left a message for her. The family member arrived at the facility at around 3:00 PM and the Nurse informed her that the vascular team were enroute to the facility to insert the midline. The family member wanted Resident #294 to be sent to the Emergency Department (ED) due to the worsening condition and Nurse #1 stated she agreed. She informed the Unit Manager and the facility Provider and called emergency medical services (EMS) who came to transfer Resident #294 to the hospital. A PA progress note written by PA #1dated 11/1/24 at 11:52 AM indicated Resident #294 was seen by PA at the request of nursing for evaluation of change in condition. The resident was minimally responsive. This was a noted change from usually being agitated and interactive per nursing/therapy. The roommate reported that he had not seen Resident #294 eat over the past 3 days. Nursing attempted to obtain UA/C&S, unable to provide adequate sample even with catheter. The progress note also indicated the resident had a change in condition, altered mental status, decreased oral intake, and was clinically dehydrated. An order was provided to obtain a PIV on 11/1/24 and ordered IVF 2 liters for 3 days (11/1/24 to 11/4/24). The progress note also indicated staff were unable to obtain UA/C&S given dehydration. During an interview on 11/19/24 at 4:30 PM with PA #1, she stated that she was notified by Nurse #1 when she came to the facility at around 10:30 AM on 11/1/24 that Resident #294 had a change in condition, and they had not been able to obtain a urine sample for a UA and C&S. The PA explained that when she went to assess Resident #294, he seemed dehydrated but was responsive to questions. She gave an order to insert a peripheral intravenous (PIV) line and if unable to obtain PIV access to obtain a midline so that they could administer IV fluids. The PA stated she did not know Resident #294's baseline since she was not the primary care provider for Resident #294. She also stated that she could not recall if the facility contacted her to let her know that they had not obtained an IV access. An interview was conducted with the Unit Manager (UM) on 11/19/24 at 10:40 AM. The UM stated that she was notified by Nurse #1 on 11/1/24 at approximately 3:00 PM that Resident #294's family member was in the facility to see the resident and wanted him to be sent to the hospital due to altered mental status and she told Nurse #1 to go ahead and send the Resident out to the hospital per family request. The UM stated that Resident #294 was being provided treatment at the facility but the family member was the one that wanted the Resident to be sent out. During the interview, the UM initially told the surveyor that an intravenous access had been obtained and fluids administered but when she further looked in Resident #294's medical records she stated that she thought the fluids had been administered but they were not. An interview was conducted with Resident #294's Emergency Contact #1 (Family Member) on 11/18/24 at 3:02 PM. The family member stated that she received a voice message from Nurse #1 on 11/1/24 at approximately 1:30 PM indicating that Resident #294 was doing okay and that she wanted to give her an update. The family member decided to come to the facility to check what was going on when she tried to call back the facility and was put on hold. When she arrived at the facility around 3:00 PM she found the Resident naked and disoriented, his mouth was dry and crusty and she attempted to give him a drink and he drank it. The family member stated Nurse #1 told her she was waiting for vascular team to come and insert an intravenous line and she informed Nurse #1 that she wanted the Resident to be sent to the hospital because he was in distress and Nurse #1 called 911. The family member also stated that Nurse #1 checked the Resident's vital signs during their conversation in the room and Nurse #1 immediately administered oxygen to the Resident after she checked the oxygen saturations. EMS report dated 11/1/24 indicated that EMS was contacted at 3:42 PM for a non-emergent transportation due to family choice. EMS arrived at the facility at 4:02 PM and primary impression was altered mental status and secondary impression was sepsis. The chief complaint was altered mental status with onset of 10/30/24. An electrocardiogram (ECG) at 4:05 PM indicated atrial fibrillation (irregular heart rhythm characterized by rapid and irregular heartbeat). Vital signs obtained by EMS at 4:17 PM were noted as blood pressure: 103/72, pulse: 65, respirations: 8, oxygen saturation: 94 % and level of consciousness was responds to painful stimulation on the AVPU (alert, voice, pain, unresponsive scale used to measure patient's level of consciousness). EMS obtained a telephone order at 4:22 PM to administer IV fluids due to Resident #294 meeting the criteria for sepsis. IV fluids were not administered due to inability to establish an IV access. EMS departed facility at 4:39 PM with Resident #294 and notified the receiving hospital of sepsis indication at 5:00 PM. EMS assessment at 5:05 PM indicated Resident #294 was lethargic, non-verbal with minimal alertness, he had rapid mouth breathing, his skin was cold and dry, lung sounds were clear with increased respiratory rate and oxygen saturation readings were inconsistent due to the resident having cold hands. Resident #294 arrived at the ED at 5:41 PM. An ED progress note dated 11/1/24 indicated that Resident #294's vital signs were noted as follows: blood pressure: 72/58, heart rate: 138, and respirations 29 at 5:45 PM and oxygen saturation: 33 %, and temperature: 93.4 degrees Fahrenheit at 6:23 pm. The progress note indicated Resident #294 presented critically ill, obtunded (reduced level of alertness and consciousness), breathing on his own with cold distal extremities with dilated pupils without response bilaterally and no response to painful stimuli. Facility stated that he had not been eating or drinking anything for 3 days, and today he was found naked by his family and encouraged the nurse to take his vital signs who then emergently called for 911. Resident #294 was found to be in metabolic acidosis (a condition in which too much acid accumulates in the body). Because of his cold extremities, they were unable to reliably obtain a pulse oximeter reading. Discussion with family revealed patient had voiced wishes to have everything done to sustain his life. After discussion regarding his goals of his care, family wanted the patient to continue to be full code. They understood that he was critically ill at that moment. The ED note indicated that Resident's presentation with altered mental status, tachypnea, poor perfusion, hypothermia, severe lactic acidosis, and new vasopressor requirements, consistent with septic shock with end organ dysfunction as cause of death. Resident #294 died at 8:26 PM on 11/1/24. An interview was conducted with the facility Medical Director (MD) on 11/19/24 at 4:37 PM. The MD stated he was aware of Resident #294's condition and the facility did what they were supposed to do to manage the Resident's condition. He indicated that when they could not obtain a urine sample, they ordered an IV access for hydration, but the Resident was sent out before the IV access was obtained. The MD also stated that if the Resident had been sent out earlier the outcome would not have been any different. When the MD was asked if the staff should have continued administering Lasix with decreased oral intake and inability to obtain urine with no recent episodes of urination, the MD did not elaborate and he reiterated that the facility did everything right. An interview was conducted on 11/20/24 at 4:30 PM with the Director of Nursing (DON). The DON stated that if nurses were not able to obtain the urine specimen on 10/31/24 at 5:00 AM they should have notified the PA because PAs are normally in the building daily. She further stated that if nurses notice any signs of dehydration and the resident is not adequately drinking they should notify the on call provider if there is no provider in the building. The DON also stated that nurses should have had a discussion with the provider regarding Lasix administration if Resident #294 was not drinking adequately on 10/31/24 before administering the 9:00 AM Lasix since the Resident had complained of burning with urination and they had not obtained the ordered urine specimen. The Administrator was notified of immediate jeopardy on 11/20/24 at 6:04 PM. The facility provided the following credible allegation of immediate jeopardy removal: 1) Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Resident #294 no longer resides in the facility. Resident was transferred to the local hospital on [DATE] due to altered mental status. The center recognizes that all residents have the potential to be affected from the noncompliance of ensuring staff recognize significant changes in condition including signs and symptoms of dehydration. A review of Resident #294's electronic medical record revealed an order for UA w/ reflux, Urine Culture and Sensitivity with Diagnosis of Dysuria was ordered on 10/30/2024. The facility staff attempted to push fluids and obtain urine sample on 10/31/2024 at approximately 9:00 PM and 11/01/2024 at approximately 5:30 AM the resident was in a dry brief and staff was unable to collect a urine sample. A review of Resident #294 orders indicated resident was prescribed Lasix 20mg daily to be administered daily per physicians' orders. A quality review of current residents with an order for UA/C&S between 10/20/2024 through 11/20/2024 were audited by the Director of Clinical Services and Unit Managers on 11/20/2024 to ensure a urine sample was obtained. No residents were identified as having an issue with lab collection that would indicate dehydration. 23 residents were identified as having a physician order to administer diuretics and were audited by the Director of Nursing and Unit Managers to ensure no signs and symptoms of dehydration as evidenced by the inability to collect urine. The Director of Nursing and or Unit Manager assessed current residents to include obtaining vital signs (blood pressure, increased heart rate, oxygen saturation, temperature), observation of dry cracked lips, poor skin turgor and or altered mental status and chart review to ensure no other residents exhibited signs and symptoms of dehydration that was not addressed and communicated to the physician on 11/20/2024. No concerns were identified during this audit. On 11/20/2024, a root cause analysis was completed by the Director of Clinical Services and the Executive Director regarding staff failure to recognize the signs and symptoms of dehydration and then to provide necessary medical services to address an emergent situation for Resident #294. The resident had decreased fluid intake and signs or symptoms of dehydration as evidenced by the inability to collect urine via an in out catheter. Nursing staff also continued to administer resident Lasix despite signs and symptoms of dehydration. It was determined through the root cause analysis that the facility staff failed to follow policy and procedures to recognize the seriousness of signs and symptoms of dehydration and notify the physician to obtain necessary medical services to address an emergency situation. 2) Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete The Director of Clinical Services and Nurse Managers re-educated all licensed nurses on how to recognize signs and symptoms of dehydration through assessing the resident, observation, and chart review to include medications, and notify the physician to obtain necessary medical services to address an emergent situation with emphasis on signs and symptoms of dehydration and continued administration of diuretics, on 11/20/2024. Staff (licensed nurses/ Certified Nurse Assistants) not educated on 11/20/2024, will be educated by the Director of Nursing and or Unit Manager prior to working the floor. Newly hired staff will be educated during orientation by the Director of Clinical Services and or Unit Managers. The Director of Clinical Services and Nurse Managers re-educated certified nursing assistants on signs and symptoms of dehydration and immediately report the change in condition to the licensed 11/20/2024. Newly hired staff will be educated during orientation by the Director of Clinical Service and or Unit Managers. Date of Immediate Jeopardy Removal 11/21/2024. On 11/22/24 the facility's immediate jeopardy removal was validated by the following: The facility provided documentation to support immediate jeopardy removal that included audits completed by the Director of Nursing/Director of Clinical Services and Unit Managers. The audits included all current residents with an order for UA/C&S from 10/20/2024 through 11/20/2024 which was revealed nine (9) residents with orders for UA/C&S with no other residents identified as having an issue with lab collection that would indicate dehydration. The audits also included all residents with orders for diuretics and 23 residents were identified as having a physician order to administer diuretics and to ensure no signs and symptoms of dehydration as evidenced by the inability to collect urine. The audits also included assessments of all current residents to include obtaining vital signs (blood pressure, increased heart rate, oxygen saturation, temperature), observation of dry cracked lips, poor skin turgor and or altered mental status and chart review to ensure no other residents exhibited signs and symptoms of dehydration that was not addressed and communicated to the physician. The facility provided documentation on the education they provided to include sign-in sheets. The education information indicated that the Director of Clinical Services and Nurse Managers re-educated all licensed nurses on 11/20/24 on how to recognize signs and symptoms of dehydration through assessing the resident, observation, and chart review to include medications, and notify the physician to obtain necessary medical services to address an emergent situation with emphasis on signs and symptoms of dehydration and continued administration of diuretics. The Director of Clinical Services and Nurse Managers re-educated licensed nursing staff and nursing assistants on 11/20/24 on signs and symptoms of dehydration (decreased urination, dry mouth, cracked lips, low blood pressure, increased heart rate, sunken eyes, altered mental status, poor skin turgor). Interviews confirmed that newly hired staff would be educated during orientation by the Director of Clinical Service and/or Unit Managers. Interviews with nursing staff verified the staff had been educated on all information as indicated in immediate jeopardy removal plan. The immediate jeopardy removal date of 11/21/24 was verified.

Based on observations, record review, and staff interviews the facility staff failed to disinfect a shared blood glucose meter between residents in accordance with the instructions provided by the manufacturer of the blood glucose meter and the disinfectant wipes used for 3 of 3 residents whose blood glucose levels were checked (Resident #6, Resident #7, and Resident #8) by 3 of 3 nurses (Nurse #1, Nurse #2, and Nurse #3). This occurred while there was a resident (Resident #9) with a known bloodborne pathogen in the facility. This deficient practice had a high likelihood of transmitting bloodborne pathogens within the facility. Immediate Jeopardy began on 6/20/2023 when Nurse #1 was observed performing a blood glucose test on Resident #6 using a shared blood glucose meter put the in the medication cart without cleaning or disinfecting per the manufacturer's instructions. Immediate Jeopardy was removed on 6/22/2023 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity E (no actual harm with more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put in place are effective. The findings included: A review of the facility's policy entitled Blood Glucose Monitoring and Disinfecting (Revised in April 2022) read in part Clean and disinfect the meter with disinfecting wipes (per manufacture guidelines). The manufacturer's guidelines for cleaning the blood glucose meter used at the facility included: a) wear appropriate protective gear such as disposable gloves. b) Open the cap of the disinfectant container and pull out 1 towelette and close the cap. c) Wipe the entire surface of the meter 3 times horizontally and 3 times vertically using one towelette to clean blood and other body fluids. d) dispose of the used towelette in a trash bin. She meter should be cleaned prior to each disinfection step. The manufacturer's guidelines for disinfecting the blood glucose meter used at the facility included: a) Pull out 1 new towelette and wipe the entire surface of the meter 3 times horizontally and 3 times vertically using a new towelette to remove blood borne pathogens. b) Dispose of the used towelette in a trash bin c) Allow exteriors to remain wet for the corresponding contact time for each disinfectant. d) After disinfection the user's gloves should be removed to be thrown away and hands washed before proceeding to the next patient. The disinfectant wipes used at the facility for blood glucose meter disinfection were approved by the EPA (Environmental Protection Agency) for cleaning and disinfecting their (brand name) blood glucose meter. The instructions on the label of the disinfection wipes stated may be used on blood glucose meters and indicated to allow surfaces to remain wet for two minutes and let air dry. The medication cart assignments on 6/20/23 during the first shift indicated 3 nurses (Nurse #1, Nurse #2, and Nurse #3) were assigned to medication carts. On 6/20/2023 at 11:24 AM an observation and interview were conducted with Nurse #1 who was a facility employee. Nurse #1 performed a glucose check on Resident #6 and when she completed the task, she disposed of the test strip and lancet, performed hand hygiene, and placed the blood glucose meter in the right top drawer of the medication cart without cleaning or disinfecting it. She revealed that to clean the blood glucose meter I just wipe it like this and she removed the blood glucose meter from the medication cart demonstrated wiping it with an unopen alcohol swab and replaced it back into the top right top drawer of the medication cart. She indicated this was her normal practice for cleaning and disinfecting the blood glucose meter. No observation was made of her cleaning and disinfecting the blood glucose meter. She further stated that the same blood glucose meter was used for all the residents requiring blood glucose monitoring on her assignment. She stated that there were residents on her assignment that required blood glucose checks, but they were not due until later in the day. No other blood glucose meters were noted in the medication cart at this time. Nurse #1 stated that she had received training on how to clean the blood glucose meters when she hired, she thought by the Director of Nursing but was not sure. On 6/20/2023 at 11:42 AM an observation and interview were conducted with Nurse #2 who was a facility employee. Nurse #2 performed a blood glucose check on Resident #7 and when she completed the task, she disposed of the test strip and lancet, stated she needed to clean the blood glucose meter, took a disinfectant wipe from the container, and wiped down the blood glucose meter one time then removed her gloves, and performed hand hygiene. She then stated she needed to let the blood glucose meter dry, and 5-10 seconds later placed the blood glucose meter in the top right-hand drawer of the medication cart. No other blood glucose meters were observed in the medication cart. Nurse #2 indicated that this was her normal practice for cleaning and disinfecting the blood glucose meter. She revealed that the same blood glucose meter was used for all the residents requiring blood glucose monitoring on her assignment. She stated that she received training when she was hired by the facility on using the blood glucose meter but could not remember if it was the Director of Nursing or the Infection Control Nurse who completed the training. On 6/20/2023 at 11:55 AM observed Nurse #3 who was a facility employee, perform a blood glucose check on Resident #8 and when she completed the task, she disposed of the test strip and lancet a, placed the blood glucose meter on the medication cart, removed her gloves, performed hand hygiene, and left the medication cart to assist a nursing assistant with patient care. Continuous observation of the medication cart for 10 minutes was conducted, and Nurse #3 did not return to the medication cart during this time. An interview with the Minimum Data Set Nurse on 6/20/23 at 1:22 PM revealed there was one current resident (Resident #9) who had a diagnosis of a blood borne pathogen. The current Director of Nursing was interviewed on 06/20/23 at 3:17 PM and stated that she had started two weeks ago. She indicated she was unable to answer any questions related to blood glucose cleaning and disinfecting. An interview was conducted with the Infection Preventionist on 6/21/23 at 9:27 AM revealed that she had recently been recently hired and could not answer questions on past training of cleaning and disinfecting the blood glucose meters. She indicated that staff were to follow the blood glucose manufacturer's instructions for cleaning and disinfection. The Administrator stated that the blood glucose meters should be cleaned and disinfected per manufacturer instructions after each resident's blood glucose was checked. She stated that she could not explain why Nurse #1, Nurse #2, and Nurse #3 did not clean and disinfect the blood glucose meters per manufacturer instructions. The facility's Administrator was informed of the immediate jeopardy on 6/20/2023 at 2:47 PM. The facility provided the following credible allegation of immediate jeopardy removal. o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; and On 6/20/23 Nurse #1, Nurse #2 and Nurse #3 failed to clean shared blood glucose meters which were used during medication administration. Nurse #1, #2 and #3 were immediately educated by the Director of Nursing on F880 following manufacturer's guidelines for cleaning and disinfection of blood glucose monitoring. Including the following education: Skills Competency Assessment of Glucometer cleaning to include direct observation and return demonstration and Storage individual resident's Glucometer in medication cart in individual bag. On 6/20/23, 89 residents have been reviewed by the Director of Nursing for use of blood glucose meters. Residents identified with orders for glucose monitoring were given individualized glucose meters, labeled and placed in bag in medication administration cart by Director of Nursing. On 6/20/23 21 residents identified to receive blood glucose monitoring were assessed by the charge nurse and no negative outcomes as related to Infection Control during medication pass glucometer cleaning were observed. On 6/20/23 all current glucometers were cleaned and placed in bag, labeled, and placed in medication cart. The local public health authority will be notified on 6/21/2023 on the improper cleaning of the shared glucometer with corrective actions taken and inquire about any immediate monitoring of residents potentially affected by the Director of Nursing. o Ths facility currently does not have any contact nursing staff however will add to the contract nursing staff orientation should we have any in the future. On 6/20/23, the Director of Nursing initiated education to the Licensed Nurses on F880 following manufacturer's guidelines for cleaning and disinfection of blood glucose monitoring. Including the following education: Skills Competency Assessment of Glucometer cleaning to include direct observation and return demonstration Storage individual resident's Glucometer in medication cart in individual bag After 6/20/23 Licensed Nurses not previously educated on glucometer cleaning with skills competency and storage of glucometer will be educated prior to working their next scheduled shift. Newly Hired Licensed Nurses will be educated during the Orientation process going forward. The Director of Nursing has been notified by the Regional Director of Clinical Services of this responsibility on 6/20/2023. Education is being provided in person and via phone. Prior to next shift nurse will complete skills competency assessment. The Executive Director is tracking who has received education. Validation of understanding has been documented on Skills Competency Assessment: Glucometer. Date of IJ Removal: 6/22/2023 The facility's credible allegation of immediate jeopardy removal was validated on 6/22/2023. The validation was evidenced by observations and interviews conducted with regards to the required infection control practices for the use of blood glucose meters. All nurses who were interviewed reported they had received the required in-service training and were made aware of the facility's policy to use individually assigned blood glucose meters for each resident requiring blood glucose monitoring. The education included review of the facility's infection control policy, manufacturer instructions related to blood glucose meter disinfection, and a return demonstration. The nurses reported each resident's individual blood glucose meter was now stored in the medication cart. Multiple observations confirmed the glucometers were stored inside a non-porous container and located in the medication carts. Multiple observations were made of nursing staff cleaning and disinfection the blood glucose meters per manufacturer's instructions. The credible allegation was validated, and the immediate jeopardy was removed on 6/22/2023.