**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's policy and procedure last updated and implemented on 04/01/24, entitled Enhanced Barrier Precautions read in part: under Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multi-drug-resistant organisms. Under Definitions: Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multi-drug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Under Policy Explanation and Compliance Guidelines: 2. Initiation of Enhanced Barrier Precautions (EBP): a. The facility will have the discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with a multi-drug- resistant organism (MDRO) that is not currently targeted by the Centers for Disease Control and Prevent (CDC). b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous status ulcers) and/or indwelling medical devices (e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. ii. Infection or colonization with a CDC-targeted MDRO when contact precautions do not otherwise apply. 4. High contact resident care activities include: a. Dressing b. Bathing c. Transferring d. Providing hygiene e. Changing linens f. Changing briefs or assisting with toileting g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes h. Wound care: any skin opening requiring a dressing a. Observation on 04/15/24 at 11:15 AM of Resident #57 revealed she had a gastrostomy tube for which she was receiving bolus feedings and she had a tracheostomy tube. There was no personal protective equipment (PPE) available outside her door. b. Observation on 04/15/24 at 12:07 PM of Resident #1 revealed she had an indwelling urinary catheter and an unstageable wound to her right hip area. There was no personal protective equipment (PPE) available outside her door. c. Observation on 04/15/24 at 12:30 PM of Resident #26 revealed he had an indwelling urinary catheter. There was no personal protective equipment (PPE) available outside his door. d. Observation on 04/15/24 at 2:36 PM of Resident #19 revealed he had a stage III pressure ulcer on his left buttock. There was no personal protective equipment (PPE) available outside his door. e. Observation on 04/16/24 at 4:00 PM of Resident #20 revealed she had chest catheter access for dialysis with a dressing on the catheter site. There was no personal protective equipment (PPE) available outside her door. Interview on 04/18/24 at 2:55 PM with the Director of Nursing (DON) who was also the Infection Preventionist (IP) revealed she was aware of the new guidelines for placing residents with wounds and internal medical devices such as urinary catheters, gastrostomy tubes and tracheostomy tubes on Enhanced Barrier Precautions (EBP) effective 04/01/24. She stated they had not yet educated their staff on the procedures and had placed an order for caddies but had not received them and she had not implemented the guidelines. The DON/IP stated she was aware that it was supposed to be implemented effective 04/01/24 but she had not implemented the new guidelines at the facility and admitted the staff were not aware they needed to be wearing PPE during high contact resident care for residents with wounds, urinary catheters, feeding tubes, tracheostomy tubes and central catheters. She further stated that she should have already implemented the procedure at the facility effective 04/01/24. 3. Review of the facility's policy and procedure implemented on 11/01/20, entitled Hand Hygiene read in part: under Policy Explanation and Compliance Guidelines: 3. Alcohol-based hand rub is the preferred method for cleaning hands in most clinical situations. 6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves. Hand Hygiene Table - use either soap and water or alcohol-based hand rub (ABHR is preferred) After handling contaminated objects When, during resident care, moving from a contaminated body site to a clean body site After assistance with personal body functions (e.g., elimination, hair grooming, smoking) When in doubt. Observation on 04/15/24 at 11:27 AM revealed Nurse Aide (NA) #5 preparing to provide incontinence care to Resident #35. NA #5 donned her gloves and prepared wash cloths and wipes and proceeded to clean the resident on the front side from urine and then turned him on his right side and cleaned his back side and in between his buttocks from smears of stool. Once he was cleaned, with the same gloves on she placed a clean brief under the resident, opened his bedside drawer and removed a tube of barrier cream from the drawer, squirted it on her gloved hand and proceeded to rub the barrier cream on his buttocks. NA #5 then fastened his brief on the left side, turned him on his back and fastened the brief on the right side and adjusted his linens. NA #5 then doffed her gloves, sanitized her hands, and proceeded out of the room with a trash bag in her hand. Telephone interview on 04/18/24 at 2:44 PM with NA #5 revealed she recalled caring for Resident #35 on 04/15/24. She stated she was nervous about being observed during resident care and forgot to doff her gloves after cleaning the resident and before applying barrier cream to his buttocks. She stated she knew the proper procedure for changing gloves when moving from a dirty to clean procedure but said she just forgot to do it because she was nervous about being watched. Interview on 04/18/24 at 2:58 PM with the Director of Nursing (DON) who was also the Infection Preventionist (IP) revealed NA #5 should have doffed her gloves after cleaning the resident, sanitized her hands and donned clean gloves prior to touching the resident's bedside table and applying barrier cream to his buttocks. She stated she would provide additional education to NA #5 regarding hand hygiene. Based on observations, record review, picture, manufacturer's instructions, resident, family member #5, staff, consultant pharmacist, and Medical Director interviews the facility failed to ensure that single resident insulin pens were not shared between residents. On 07/10/23 Nurse #10 administered insulin to Resident #171 using Resident #172's insulin pen. Insulin pens are designed to be used multiple times by a single resident only and must never be shared. Regurgitation (emission) of blood into the insulin cartridge after injection will create a risk of bloodborne pathogen transmission if the pen is used for more than one resident, even when the needle is changed. This has the high likelihood to spread bloodborne pathogens such as human immunodeficiency virus (HIV), Hepatitis B and Hepatitis C. This affected 1 of 3 residents reviewed for infection control. The facility also failed to initiate Enhanced Barrier Precautions (EBP) for residents with medical devices and non-chronic wounds such as indwelling catheters and tracheostomies for 4 of 4 residents reviewed with medical devices and wounds (Resident #1, Resident #19, Resident #26, and Resident #57). The facility further failed to change gloves during incontinent care and before touching the resident's environment (Resident #35). Immediate Jeopardy began on 07/10/23 when Nurse #10 administered insulin to Resident #171 using a pen that belonged to Resident #172. Immediate jeopardy was removed on 04/19/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal The facility will remain out of compliance at a lower scope and severity of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of education and monitoring system are in place. Example #2 and #3 are being cited at a lower scope and severity of an E. The findings included: 1. Review of an article published on the National Library of Medicine website January 2008 read in part, the most common method of open loop insulin delivery is the subcutaneous insulin injection. In addition to the basal requirements the patient will inject insulin into subcutaneous tissue prior to meals. To provide rapid insulin during this situation a fast-acting insulin such as insulin aspart or insulin lispro is used. Review of a facility policy dated 11/01/20 read in part, Insulin Pen: insulin pens contain multiple doses of insulin but are used for single residents only. Review of manufacturer's instructions for Lispro insulin revised in July 2023 read in part, do not share your insulin Lispro (insulin in a pen form that has a reservoir that holds the insulin and a rubber end that is punctured when the small needle is applied to administer the insulin) pen with other people even if the needle has been changed. You may give other people a serious infection or get a serious infection from them. Resident #171 was admitted to the facility on [DATE] and was discharged on 09/06/23. Resident #171's diagnoses included diabetes mellitus. Resident #171 resided on the 200 hall at the time of the incident. Review of a physician's order dated 06/24/23 read, Admelog (Lispro insulin fast acting) for blood sugar 151-200=2 units, 201-250=4 units, 251-300=6 units, 301-350=8 units, 351-400=10 units, 401-450=12 units give subcutaneously three times a day for diabetes at 8:00 AM, 12:00 PM, and 4:00 PM. An admission Minimum Data Set (MDS) dated [DATE] indicated Resident #171 was cognitively intact. Review of the Medication Administration Record (MAR) dated July 2023 revealed that on 07/10/23 Nurse #10 administered Admelog insulin at 8:00 AM, 12:00 PM, and 4:00 PM. Review of a progress note for Resident #171 written by Nurse #11 dated 07/11/23 at 11:13 AM read; new insulin Lispro opened from e-kit. Reordered insulin Lispro from pharmacy. Will update as needed. Resident #171 was interviewed via phone on 04/15/24 at 4:31 PM. She stated that she resided at the facility for a few months. Resident #171 stated that on 07/10/23 at 6:06 PM (time on her cell phone) Nurse #10 came into her room to give her an insulin shot. Resident #171 could not recall what her blood sugar was but stated that after Nurse #10 had checked her sugar, she required several units of insulin. She stated Nurse #10 had laid the cap to the insulin pen that she used to administer her insulin on her bedside table and after she had given the insulin shot to Resident #171, she (Resident #171) noted that the label that was on the insulin pen cap had Resident #172's name on it. Resident #171 stated she asked Nurse #10 about it, and she stated that it was left at the facility by another resident and was ok to use. Resident #10 stated that she reported the incident to Nurse #11 the next morning on 07/11/23 and to family member #5. She added she had no ill effects from receiving Resident #172's insulin A cell phone picture provided by Resident #171 on 04/15/24 revealed an insulin pen with the red connector to the lower insulin reservoir noted with a label that contained Resident #172's name, room number, type of insulin, prescription number and fill date on the pens cap. The type of insulin was Lispro insulin (fast acting insulin). Observations made on 04/17/24 at 2:38 PM of the medication carts revealed Lispro insulin pens for other residents that all contained the label and instructions on the cap of the pen. Each pen had a red connector that was attached to the pen reservoir and when removed the pen cap did not contain the red connector. Family member #5 was interviewed via phone on 04/16/24 at 5:03 PM. The family member stated that Resident #171 had called her and told her a nurse had used another resident's insulin pen to administer insulin to her (Resident #171) and had sent her a picture of the insulin pen. The family member stated she reported the issue to the Director of Nursing (DON) in July 2023 after the incident occurred but had not heard anything back from her. The DON told the family member she would address it. Resident #172 was admitted to the facility on [DATE] and was discharged on 08/09/23. Resident #172's diagnoses included diabetes mellitus. Resident #172 resided on the 300 hall at the time of the incident. A physician's order dated 05/29/23 read, Lispro insulin for blood sugars 200-250=2 units, 251-300=4 units, 301-350=6 units, and 351-400= units subcutaneously before meals. Nurse #10 was interviewed via phone on 04/16/24 at 5:10 PM. Nurse #10 confirmed she no longer worked at the facility. She stated when she did work at the facility, via an agency, she was a hall nurse and administered medications including insulin. Nurse #10 stated I have seen them share insulin pens there (at facility), but I have not done it because it messes up when they can get a refill. Nurse #10 stated she had never had to do that in this building referring to sharing insulin pens. Nurse #10 recalled Resident #171 but stated she did not recall giving her insulin from another resident's insulin pen. She added that the facility had availability issues with medications because the staff were not reordering them like they should. Nurse #11 was interviewed via phone on 04/17/24 at 11:59 AM. Nurse #11 confirmed she no longer worked at the facility. Nurse #11 recalled that on 07/11/23 Resident #171 had reported to her that the cap from the insulin pen that was used the previous night was left at bedside and it was not her insulin. Nurse #11 stated she reported the issue to the DON. After she reported the incident to the DON, she was asked by the DON to educate all the nursing staff about insulin pens and how to use them, how to reorder them, and how to store them. Nurse #11 stated that was the only incident she heard about of staff sharing insulin pens and she was aware that you were not supposed to share insulin pens. The Consultant Pharmacist was interviewed on 04/16/24 at 3:09 PM. The Pharmacist stated staff should not be sharing insulin pens, they are designed to be used multiple times by one resident only. She explained that when insulin pens first came out, they marketed the insulin pens as they could be used on multiple residents as long as you changed the needle between residents but then they discovered that those residents who shared insulin pens had Hepatitis C and the guidance was changed that you could not share the pens even if you changed the needle. The DON was interviewed on 04/16/24 at 3:59 PM and again on 04/18/24 at 2:45 PM. The DON stated it was reported to her that there was an insulin pen cap found in Resident #171's room that did not belong to her. She stated she interviewed Resident #171 on 07/11/23, and she stated that the cap to the insulin pen that was used on her last evening had another resident's name on it. She also interviewed Nurse #10 who was certain that she had not shared the insulin pen. However, the DON stated on 07/11/23 she went through and made sure that each resident who was prescribed insulin had a supply of their prescribed insulin either on the medication cart or in the refrigerator. During the initial audit of the insulin, they discovered that some residents did not have a supply of insulin but Resident #171 was not one of those residents. The DON stated that she was instructed by the Administrator to replace everyone's insulin pen despite the high cost and all nursing staff were educated on the usage of insulin pens, how to reorder them and how to store them. The DON again stated she could not confirm that the insulin was given from another resident's pen, but they decided to put together a plan to correct any issue that they had. The DON was asked to run a report from July 2023 to October 2023 of residents that had diagnoses of bloodborne disease, and she stated she unable to do so. The Administrator was interviewed on 04/18/24 at 11:54 AM, she stated she was aware of the insulin pen issue. From what she understood, it was just a cap that was discovered but she asked the DON to cover all the bases, and everyone got new insulin pens from the pharmacy. The Administrator stated she did not want any of her staff to share insulin pens as it is never appropriate to share the pens. She stated that the MD had stated to her that the insulin pens were a closed system as long as the needle was removed, and a new one put on. The Medical Director (MD) was interviewed via phone on 04/17/24 at 4:20 PM. The MD stated that Lispro insulin and Admelog insulin were very similar and were in the same category of insulin and that there was no adverse effects from giving one or the other. The MD stated, it is not ideal to share insulin pens, but it can be done in certain circumstances because they are changing the needles, but it is better if you don't share them. The MD stated he had never heard of anyone at the facility sharing insulin pens and he only been the MD since October of 2023. The Administrator was notified of Immediate Jeopardy on 04/18/24 at 11:09 AM. The facility provided the following credible allegation of immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to ensure that a single resident insulin pen was used for one resident (Resident #171). On 7/10/23 Nurse #10 used Resident #172's insulin pen to give short acting insulin to Resident #171 Nurse #10 is no longer employed at the facility. The Director of Nursing notified the Medical Director and the Physician on 7/11/2023. There were no new orders. The Director of Nursing initiated an investigation and collected statements. On 7/11/2023 the Director of Nursing notified the pharmacy of Resident #172's insulin pen used for Resident #171. The Director of Nursing ordered new insulin pens for all residents with a physician order for insulin. The Insulin pen for Resident #172 was discarded, and new ones were ordered on 7/11/2023. Resident #172 did not receive insulin from the reused insulin pen. Resident #172 was discharged [DATE] and no longer resides in the facility. Resident #171 notified the facility of deficient practice on July 11,2023. On 7/11/2023, new insulin pens were reordered, and the previously used pens were discarded. The Resident was assessed by the physician on 7/28/2023 with no new orders. The Resident was discharged from the facility on 9/6/2023. The Director of Nursing reviewed residents who receive insulin via pen in July 2023. The Director of Nursing conducted an audit of all residents currently prescribed insulin to determine that all residents who receive insulin had a pen specific to the prescribed medication and dosage. On July 12 2023 All Residents who receive insulin via pen, received a new pen, labeled with their name, drug and dosage. 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: On July 12,2023 Nurse #10 who was employed through agency contract was terminated. On July 11, 2023, the Director of Nursing and Assistant Director of Nursing conducted an in person verbal in-service for 100% of nursing staff, including LPNs, RNs, and Medication Aides. The lesson plan covered the following topics: -Insulin pens are Resident specific. -Nurses may not exchange insulin pens for use with that of a different resident. -If a resident does not have the required pen notify the supervisor, physician and pharmacy and medical director. On July 11, 2023 all staff who received the in-service verbalized understanding. The infection control policy was reviewed by the Director of Nursing and the Regional Nurse Consultant on July 11, 2023, to ensure it includes bloodborne pathogens and the use of insulin pens. No revisions were necessary. On 7/11/2023, the Director of Nursing notified the Assistant Director of Nursing (who is responsible for staff education) to provide education on the policy prior to the start date for all new nursing hires (LPN, RN, Medication Aids). On 4/17/24 the Director of Nursing notified the Health Department that on 7/11/2023 it was reported by Resident #171 that Nurse #10 administered insulin using a pen belonging to Resident #172 Immediate jeopardy removal date is 4/19/24 A validation of immediate jeopardy removal was conducted on 04/23/24. Interviews with nursing staff revealed they were aware to never share insulin pens, how to reorder them, how to store them, and how to utilize the backup medication system if a resident was out of their prescribed insulin. A medication pass was completed that included insulin administration with no issues noted and a medication error rate of 0%. The initial audit of all residents' insulin was reviewed as was the order form and confirmation from the pharmacy indicating that they had received the order for insulin pens for the residents that were in the building. Education sign in sheets were reviewed with no concerns noted. The DON verbally confirmed that the education was included in the new hire orientation program and that she had contact the health department to notify them of the reported incident. Attempts to notify the local health department of the incident were made on 04/17/24 and 04/18/24. The facility's removal date of 04/19/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff, responsible person (RP) and Medical Director (MD) interviews, the facility failed to notify the MD when multiple doses of significant morning medications (seizure medication, insulin, depression medication, and chronic kidney and heart failure medication) were not administered due to Resident #20 being out of facility for dialysis treatment and not administered her morning medications. There was a high likelihood of failure to administer these medications could have resulted in non-therapeutic levels resulting in seizure activity, high blood sugars which could lead to diabetic coma, and increased blood pressure and heart rate which could lead to stroke and cardiac complications. Additionally, the facility failed to notify the Responsible Person (RP) for Resident #66 when Resident #66 who was severely cognitively impaired with a history of wandering was observed by Nursing Assistant (NA) #6 attempting to cut her cast off her left arm using a long ridged knife with handle. This deficient practice affected two of three sampled residents reviewed for notification (Resident #20 and #66). Immediate jeopardy began on 4/02/24 when the facility failed to notify the physician when medications scheduled for morning administration (a seizure medication, insulin, a depression medication, and a chronic kidney and heart failure medication) were not administered on multiple occasions to Resident #20. Immediate jeopardy was removed on 4/28/24 when the facility implemented an acceptable credible allegations of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of E no actual harm with potential for more than minimal harm that is not immediate jeopardy to ensure monitoring systems and staff education put into place are effective. Example #2 for Resident #66 was cited at a scope and severity of D. Findings included: 1. Resident #20 was admitted to the facility on [DATE] with diagnoses to include renal dialysis dependence, heart failure, seizure disorder, depression, and diabetes. Resident #20 also received scheduled dialysis treatments outside of the facility on Tuesday, Thursday, and Saturday and would leave the facility for these treatments at 5:30 AM and return to the facility at 10:30 AM. Review of physician orders for significant medication for Resident #20 are as follows: Escitalopram 20 milligrams (MG), give 1 tablet by mouth one time a day related to depression; Keppra 24 hour extended release 500 MG, give 1 tablet by mouth one time a day related to epilepsy; Ozempic 1 MG solution pen-injector, inject subcutaneously (beneath the skin) 1 time a day every Thursday related to type 2 diabetes; Carvedilol 25 MG, give 1 tablet by mouth 2x's daily for hypertensive heart disease and chronic kidney disease with heart failure; and Humalog 100-unit/ milliliter (ML) solution pen- injector, inject subcutaneously per sliding scale before meals and at bedtime related to type 2 diabetes. Review of the Medication Administration Record (MAR) dated April 2024 revealed dates of Resident #20 not receiving significant morning medications due to being out of the facility for scheduled dialysis treatments. Per Resident #20's April 2024 MAR, missed doses of scheduled significant morning medication are as follows: Escitalopram (9 AM) - Tuesday 4/02, Thursday 4/11, Tuesday 4/16 Keppra (8 AM) - Tuesday 4/02, Tuesday 4/09, Thursday 4/11, Tuesday 4/16 Ozempic (9 AM) - Thursday 4/11 Carvedilol (7:30 AM) - Tuesday 4/02, Tuesday 4/09, Thursday 4/11, Tuesday 4/16 Humalog and blood sugars (7:30 AM) - Tuesday 4/02, Tuesday 4/09, Thursday 4/11, Saturday 4/13, Tuesday 4/16 Per the manufacturer label warnings, failure to administer these medications could have resulted in non-therapeutic levels resulting in seizure activity, high blood sugars which could lead to diabetic coma, increased blood pressure and heart rate which could lead to stroke and cardiac complications, anxiety, and irritability. Review of Resident #20's April 2024 nursing progress notes revealed no documentation of the MD being notified of the missed medications. A telephone interview was conducted with the MD on 04/17/24 at 4:24 PM. The MD revealed that he had not been made aware of Resident #20 not receiving her morning medications on the days she received dialysis. He stated all dialysis residents should be administered any medications missed while at dialysis upon their return. The MD also stated that he would have expected the facility to notify him if a resident's dialysis treatments were conflicting with when a medication was ordered to be administered so he could adjust the medications and their times to be administered. Due to having no knowledge of Resident #20 not being administered morning medications on days where she had received dialysis treatments, he was not able to comment on any outcome it caused or could have caused and whether those would have been significant or not. An interview was conducted with the Administrator and Director of Nursing (DON) on 04/18/24 at 12:20 PM revealed they were not aware Resident #20 had missed her medications. The Administrator stated nursing staff had been educated that anytime a medication is not administered to a resident for whatever reason they were to notify the physician, the supervisor and document. The DON revealed all dialysis residents should be administered their scheduled medications upon their return to the facility and any issues with not being able to administer those medications should be reported immediately to the physician for recommendations on how to proceed, the nursing supervisor and documented. The Administrator was notified of immediate jeopardy on 04/26/24 at 1:07 PM. The facility provided the following plan for IJ removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The facility failed to notify the Medical Director of missed/omitted significant medications prescribed for Resident #20 to treat diabetes, epilepsy and hypertensive heart disease and chronic kidney disease with heart failure, and depression. Nurse #13 and Nurse #15 did not notify the medical provider of the missed/omitted significant medications. On 4/18/24 Nurse #13 received verbal 1 on 1 education by Director of Nursing (DON) on policy regarding notification of provider and resident representative promptly upon any resident change in condition, clinical complications, or need to alter treatment significantly. Education also included notifying the medical provider regarding missed significant medications when a resident is out of the facility when these medications are due to be administered. Nurse #13 verbalized understanding of re-education. On 4/18/24 facility Medical Director (MD) was notified by DON of Resident #20's identified medication omissions. An order was obtained from MD to administer all prescribed medications upon return from dialysis for all residents in the facility who receive dialysis treatment. The DON completed an audit on 4/18/24 of all residents receiving dialysis services back 4/1/24 to ensure no other significant medication errors. Any errors identified were reported to MD. On 4/27/24 DON completed an audit of all residents' Medication Administration Records back to 4/1/24 for med errors/omissions and reviewed incident reports to ensure notification of responsible party/family and MD was completed. The Director of Nursing reviewed electronic health care record dashboard back to 4/1/24, which reflects resident's changes in conditions, new medication orders, omitted medications as well as risk management dashboard for incidents and accidents to ensure notification to resident's responsible party and the medical practitioner. 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. 4/24/24 Quality Assurance Performance Improvement (QAPI) meeting was held by Administrator (LNHA) with all department heads on policy regarding notification of provider and resident representative promptly upon any resident change in condition, clinical complications, or need to alter treatment significantly and MD via phone. Notification Policy was reviewed during QAPI. Education/audits/monitoring were discussed. MD and Department Heads verbalized understanding. The Notification Policy did not require revisions at this time. On 4/24/24 in person education began with all licensed nurses (including Nurse #15) and medication aides including agency nurses and medication aides by DON/ Assistant DON (ADON)/Nurse Managers on policy regarding notification of medical provider and resident representative promptly upon any resident change in condition, clinical complications, or need to alter treatment significantly, including medications missed/omitted. Education also included notification to medical provider for all missed or omitted medications for residents out of the facility and/or on leave of absence. All staff verbalized understanding. Education to all remaining licensed nurses and medication aides was completed by DON on 4/24/24 via phone and/or in person. All staff not educated on 4/24/24 will be educated by DON/ADON/Nurse Manger prior to the start of their next shift. The DON will be responsible for maintaining an employee tracking log to identify staff that still require education. All newly hired nurses and medication aides, including agency nurses and medication aides, will receive this education from the DON/ADON during the orientation process. The Nurse Manager on duty will provide verbal education to any agency staff member that works after 4/24/24 prior to accepting shift assignment. DON/ADON/Nurse Managers were made aware of this responsibility by the Administrator on 4/24/24. The DON will notify the Nurse Managers when there is a new agency nurse or medication aide that requires the education. Alleged date of immediate jeopardy removal: 4/28/24 A validation of immediate jeopardy removal was conducted on 05/07/24. The audit of all dialysis residents was reviewed and verified that each resident that received dialysis had an ordered entered into their medical record that indicated all prescribed medications were to be given upon return from dialysis treatment. Each resident's care plan was also updated and verified as a part of the removal verification process. Staff in-service records and interviews with nursing staff confirmed they were educated on the requirement of notification to the medical provider and responsible party when medications were missed or omitted. The facility's QA committee met on 04/24/24 and reviewed the policy on notification which did not require any revisions. The QA verbalized understanding of the policy and requirement. Audits completed from 04/28/24 through 05/06/24 were reviewed with no new issues identified. The facility's removal date of 04/28/24 was validated. 2. Resident #66 was admitted to the facility on [DATE] with diagnosis that included a left arm fracture and dementia. An interview with Nursing Assistant (NA) #6 on 4/17/24 at 9:00 AM revealed she had been employed at the facility since August 2023 and was familiar with Resident #66. She stated on 2/21/24 she was walking up the resident 200 hall and observed Resident #66 standing right outside of the maintenance room (located at the top of the 200 hall between the utility room and beauty parlor), the door was unlocked and cracked open. Resident #66 had a long ridged knife with a handle in her right hand and using a back-and-forth motion was attempting to cut off the cast located on her left arm. The NA stated she assumed Resident #66 had gotten the knife from inside the maintenance room since that was where she was standing. NA #6 revealed she asked Resident #66 to hand her the knife, which she did with no issues and placed it back inside the maintenance room and shut the door. She assessed Resident #66's body for any injuries, and walked her back to her room where she assessed her again for any injuries and did not observe any visible injuries and Resident #66 had no complaints of pain. NA #6 stated she did not recall if she informed any of the nurses on the hall but did report the incident to the DON. She revealed Resident #66 had a history of wandering all the halls in the facility and would stop at each room and try and turn all the door handles to see if they would open. She stated she had no knowledge of what occurred after she notified the DON of the incident, and she did not lock the maintenance door back and was not aware if anyone else locked the maintenance door after the incident or why the maintenance door had been unlocked in the first place. Review of Resident #66 progress notes from February 2024 to present revealed no documentation of incident or notification of incident to Resident #66's Responsible Party (RP) or the Medical Director. An interview with Resident #66's RP on 04/17/24 at 10:45 AM revealed she had not been notified of the incident with Resident #66 standing outside of the unlocked maintenance room attempting to cut the cast off of her left arm with a ridged knife on 2/21/24. She stated she would have liked to have been notified of the incident so that she could have come to the facility to assess Resident #66 herself, address any issues and make sure that Resident #66 was safe and unharmed. A telephone interview was conducted with the MD on 04/17/24 at 4:24 PM. The MD revealed that he had not been made aware of the incident with Resident #66 that occurred on 2/21/24 and would have preferred the facility to notify him or the nurse practitioner about the incident so they could have discussed any change in behavior or condition, possible treatments, or medication changes. An interview with the Administrator and Director of Nursing (DON) on 04/18/24 at 12:20 PM revealed the Administrator had not been made aware of the incident and the DON did not recall being notified of the incident with Resident #66. The Administrator stated anytime an event such as a behavioral incident or accident occurs with a resident, nursing staff should notify their supervisors immediately and document the event so they can investigate the incident properly, provide notifications to the residents' RP and family, and make sure the correct precautions or treatment are put into place. The Administrator and DON revealed Resident #66's RP should have been notified of the incident when it occurred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and staff interviews the facility failed to maintain an environment free of accident hazards for 1 of 5 residents (Resident #66) reviewed for supervision to prevent accidents. On 2/21/24, Resident #66 who was severely cognitively impaired with a history of wandering was observed by Nursing Assistant (NA) #6 attempting to cut her cast off her left arm using a long ridged knife with a handle. Resident #66 was unattended in the hallway outside of the maintenance room, the door was unlocked and partially open. NA #6 asked Resident #66 to hand her the long ridged knife with handle which she did with no issues, placed the knife back inside the maintenance room and shut the door without locking the door. The maintenance room was observed on 4/17/24 to be unlocked. This practice has a high likelihood that residents could access materials that could cause serious harm or injury. Immediate Jeopardy began on 2/21/24 when Resident #66 accessed a long rigid knife with a handle and was attempting to use it to cut her cast off. The immediate jeopardy was removed on 4/28/24 when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of an E (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and monitoring systems put into place are effective. The findings included: Resident #66 was admitted to the facility on [DATE]. Her admission diagnoses included fracture of left arm and dementia. Review of admission nursing progress note dated 02/16/24 read in part, Resident #66 history of dementia, alert and oriented to person, pleasantly confused and forgetful. Hospital diagnosis included fall with left wrist fracture with cast in place. Resident #66's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was severely cognitively impaired. Resident #66 was also assessed as being ambulatory with assistance of a walker or wheelchair, wandering with the significant risk of getting to a potentially dangerous place. Review of admission care plan dated 2/22/24 revealed Resident #66 had an approach for wandering with a goal to reduce exit seeking behaviors. Interventions included wandering alarm bracelet located on Resident #66 left ankle, check wandering alarm bracelet every evening to ensure working properly, anticipate and meet resident needs in a prompt manner, notify MD and family of any changes in behavior, and monitor/ document/ report each shift and as needed any exit seeking behaviors or changes in behaviors. Review of facility incident report log for February 2024 revealed no incident reports for Resident #66. An interview with Nursing Assistant (NA) #6 on 4/17/24 at 9:00 AM revealed she had been employed at the facility since August 2023 and was familiar with Resident #66. She stated on 2/21/24 she was walking up the resident 200 hall and observed Resident #66 standing right outside of the maintenance room (located at the top of the 200 hall between the utility room and beauty parlor), the door was unlocked and cracked open with a long ridged knife with a handle in her right hand and using a back and forth motion was attempting to cut off the cast located on her left arm. The NA stated she assumed Resident #66 had gotten the knife from inside the maintenance room since that was where she was standing. She revealed she asked Resident #66 to hand her the knife which she did with no issues, placed it back inside the maintenance room and shut the door, assessed Resident #66 body for any injuries, and walked her back to her room where she assessed her again for any injuries and did not observe any visible injuries and Resident #66 had no complaints of pain. NA #6 stated she did not recall if she informed any of the nurses on the hall but did report the incident to the DON. She revealed Resident #66 had a history of wandering all the halls in the facility and would stop at each room and try and turn all the door handles to see if they would open. She stated she had no knowledge of what occurred after she notified the DON of the incident, and she did not lock the maintenance door back and was not aware if anyone else locked the maintenance door after the incident or why the maintenance door had been unlocked in the first place. An observation on 04/17/24 at 9:45 AM revealed a room door at the beginning of the resident 200 hall with no signage. The room was located between the utility room and the beauty salon. The door handle to the room had a keyhole on the front and lock on the back. After knocking on the door with no answer, the surveyor placed hand on the door handle to check if the door was locked and the door easily opened without the handle having to be turned. An observation of the inside of the room revealed access to tools such as a hammer, sharp screw drivers, screws and nails lying on the desk and in the floor, filing cabinets, computer system on the desk, a television propped against wall at the door, and papers lying on top of the desk and in the floor. The Regional Nursing Educator Consultant approached surveyor as the observation of maintenance room was being made from doorway and when asked about the incident stated she had no knowledge of the incident but that the door should be locked at all times to prevent residents from entering. An interview was conducted with the Regional Maintenance Director on 04/17/24 at 10:40 AM revealed the previous Maintenance Director had left at the end of February 2024 and he had been filling the role since the first of March. He also revealed no knowledge of the incident with Resident #66 but stated the door to the room maintenance room should always be locked due to the tools and materials kept inside. He stated the maintenance room was used to store maintenance tools and equipment and to send and receive work orders from the computer located in the room. When asked if he was aware that the maintenance room door was currently unlocked, he stated he was not aware and that he had not been in the room on this date or the day prior and was not aware of how long the door had been unlocked. He revealed he had a key to the maintenance room door but was not aware of who else in the facility had access to the room and could have left it unlocked. A telephone interview with the previous Maintenance Director on 4/17/24 at 11:47 AM revealed he had previously been employed with the facility in different roles but had worked as the Maintenance Director for several months prior to leaving at the end of February 2024. He stated he had no knowledge of the incident involving Resident #66 but was sure there had been times the maintenance room door could have been left unlocked and therefore residents could have had access to items in the room used for maintenance work such as knives or sharp tools. He revealed when he originally started as the Maintenance Director the room had a keypad lock but he would sometimes forget the code to unlock it so he changed the door lock to a regular door handle like the ones located on resident's rooms that could be locked from the inside and would require a key to open. The previous Maintenance Director stated he had a key to the lock but could not recall who else in the facility had a key and that the maintenance room door should have been locked at all times to prevent residents from entering the room. An interview with the Administrator and DON on 4/18/24 at 12:20 PM revealed the Administrator had no knowledge of the incident with Resident #66 until yesterday and the DON stated she did not recall being informed by NA #6 of the incident either. They both revealed the maintenance door should have been locked at all times to prevent residents and other staff from having access to the room and staff should have reported the incident immediately and documented the details of the incident. The Administrator was notified of immediate jeopardy on 4/26/24 at 11:02 AM. The facility provided the following plan for immediate jeopardy (IJ) removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The facility failed to maintain an environment free of accident hazards for vulnerable residents by not maintaining locked maintenance office door, located in hall of resident, enabling her to enter and obtain the knife. On 2/21/24 Resident #66 was observed by Nurse Aide (NA) #6 to have a ridged knife in her hand attempting to cut off her cast. NA #6 removed knife from resident, secured maintenance door. NA #6 did not note any injuries or cuts on the cast. Administration was not aware of the incident with Resident #66 that occurred on 2/21/24 until 4/17/24. The physician or family wasn't made aware of the incident that occurred with Resident #66 on 2/21/24. Resident #66 cast was removed on 3/20/24. Resident #66 discharged from the facility on 4/23/24. On 4/17/24 the maintenance office door was observed unlocked by a member of the survey team and notified the Regional Nurse. The Regional Nurse immediately notified the Administrator that the door was unlocked. The Administrator immediately informed the Maintenance Director who changed the lock out for a keypad security lock which allows door to lock automatically when shut on 4/17/24. The root cause analysis determined that the Maintenance Director failed to manually lock the maintenance office door with a key upon exit on 2/21/24 and 4/17/24. On 4/17/2024 the Administrator provided Maintenance Director with one-on-one education on the requirement for the facility to maintain an environment that is free of accident hazards by keeping all areas of the facility secure including housekeeping storage, kitchen entrance, and all other high-risk areas that residents have the potential to enter. All residents residing in the facility can be affected by the deficient practice. On 4/17/24 an audit of all doors to high-risk areas including kitchen entrance, shower rooms, housekeeping storage rooms was completed by the Administrator to ensure all had keypad security locks in place. On 4/17/24 administrative staff were instructed by the Administrator to monitor and ensure all high-risk areas of entry are secured and halls are free of clutter. Any issues identified will be corrected and reported to the Administrator immediately. On 4/27/24 the Administrator, DON and the Maintenance Director met to identify any high-risk areas in the facility and reviewed accidents/incidents including resident falls, injuries, and resident transportation back to April 1, 2024, to determine if there were any that were avoidable accidents or incidents. The review of the accidents/incidents did not determine the need for further analysis, education, or monitoring. 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. On 4/23/24, a QAPI meeting was held with all facility department heads at which time all were educated on potential accidents and hazards related to residents accessing hazardous materials and requirement for these items to be secure at all times by the Administrator. On 4/24/24 in person education began with all staff, including agency staff, by Director of Nursing (DON) on maintaining an environment free of accidents, hazards and that each resident receives adequate supervision and assistive devices to prevent accidents. Education included ensuring high risk areas of entry are secured at all times, halls are free of clutter. All staff not educated on 4/24/24 will be educated by DON or Assistant Director of Nursing (ADON prior to the start of their next shift. The Administrator will be responsible for maintaining employee log to identify staff that may still require education. Upon review of staff log, the Administrator will notify DON/ADON of any staff requiring education. All new hires, including maintenance staff and agency staff will be educated during the orientation process by DON/ ADON. The DON and ADON were made aware of this responsibility on 4/24/24 by the Administrator. Alleged date of immediate jeopardy removal: date 4/28/24 A validation of immediate jeopardy removal was conducted on 05/07/24. The maintenance office door was noted to be closed, locked, and secured on 05/07/24 along with the other doors in the facility that potentially had hazardous chemicals or equipment in them. The doors include the spa doors located on each hallway, the maintenance office door, the kitchen doors, the supply room, the oxygen storage room, the housekeeping closet, and any other ancillary room that was identified by the facility, all were locked and secured. Interviews with administrative staff revealed that they had been educated on the need for continued monitoring of the doors to ensure that they were locked and secured to ensure resident safety. In-service records and interviews with all staff across all departments revealed that they had been educated on ensuring resident safety by keeping hallways clutter free and ensuring doors to potentially hazardous areas, chemicals, and equipment were always secure and if not to ensure no resident was in the area, secure the area and notify the administrator. The facility's QA committee met on 04/23/24 and conducted a root cause analysis which was reviewed as part of the removal process. Audits conducted daily from 04/17/24 through 05/07/24 were reviewed with no issues. The facility's removal date of 04/28/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, staff, and Medical Doctor (MD) interview the facility failed to prevent a significant medication error by failing to administer morning medications for a dialysis resident (Resident #20) for 1 of 3 residents reviewed for assuring the facility was free of medication errors. Resident #20 attended dialysis treatments on Tuesday, Thursday, and Saturday from 5:30 AM to 10:30 AM and was not administered her significant morning medications. Per the manufacturer label warnings, failure to administer these medications could have resulted in non-therapeutic levels resulting in seizure activity, high blood sugars which could lead to diabetic coma, and increased blood pressure and heart rate which could lead to stroke and cardiac complications. Immediate jeopardy began on 04/02/24 when the facility failed to administer Resident #20's morning medications. Immediate jeopardy was removed on 04/27/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of E no actual harm with potential for more than minimal harm that is not immediate jeopardy to ensure monitoring systems and staff education put into place are effective. The findings included: Resident #20 was admitted to the facility on [DATE]. Resident #20's diagnoses included dependence on renal dialysis, seizures, type 2 diabetes, depression, chronic kidney and heart failure. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #20 was cognitively intact and was assessed for receiving dialysis treatments. Review of current physician order revealed Resident #20 was to receive scheduled dialysis treatments outside of facility every Tuesday, Thursday, and Saturday. Pick up time at 5:30 AM from the facility. Review of physician orders for significant medication for Resident #20 are as follows: Escitalopram Oxalate Tablet 20 milligrams (MG), give 1 tablet by mouth one time a day for depression related to MAJOR DEPRESSIVE DISORDER Keppra XR Oral Tablet Extended Release 24 Hour 500 MG (Levetiracetam), give 1 tablet by mouth one time a day related to EPILEPSY Ozempic (1 MG/DOSE) Subcutaneous Solution Pen-injector 4 MG/3 milliliter (ML) (Semaglutide) Inject 1 mg subcutaneously (beneath skin) one time a day every Thu related to TYPE 2 DIABETES Carvedilol Oral Tablet 25 MG (Carvedilol), give 1 tablet by mouth two times a day related to HYPERTENSIVE HEART AND CHRONIC KIDNEY DISEASE WITH HEART FAILURE HumaLOG KwikPen 100 UNIT/ML Solution pen-injector Inject as per sliding scale: if 0 - 150 = 0 Units Notify Provider if less than 60; 151 - 200 = 2 Units; 201 - 250 = 4 Units; 251 - 300 = 6 Units; 301 - 350 = 8 Units; 351 - 400 = 10 Units; 401+ = 12 Units Notify provider if greater than 401, subcutaneously before meals and at bedtime related to TYPE 2 DIABETES MELLITUS WITH HYPERGLYCEMIA (high blood sugars). Review of Medication Administration Record dated April 2024 revealed dates of Resident #20 not receiving significant morning medications due to being out of the facility for scheduled dialysis treatments. Nursing staff coded reason for not administering medications as #3 (resident on leave of absence). Per Resident #20 April 2024 MAR, missed doses of scheduled significant morning medication are as follows: Escitalopram (9 AM) - Tuesday 4/02 (Nurse #13), Thursday 4/11 (Nurse #13), Tuesday 4/16 (Nurse #15) Keppra (8 AM) - Tuesday 4/02 (Nurse #13), Tuesday 4/09 (Nurse #13), Thursday 4/11 (Nurse #13), Tuesday 4/16 (Nurse #15) Ozempic (9 AM) - Thursday 4/11 (Nurse #13) Carvedilol (7:30 AM) - Tuesday 4/02 (Nurse #13), Tuesday 4/09 (Nurse #13), Thursday 4/11 (Nurse #13), Tuesday 4/16 (Nurse #15) Humalog and blood sugars (7:30 AM) - Tuesday 4/02 (Nurse #13), Tuesday 4/09 (Nurse #13), Thursday 4/11 (Nurse #13), Tuesday 4/16 (Nurse #15) Review of Resident #20 progress notes for April 2024 revealed blood pressure and blood sugar were within normal limits. An interview was conducted with Resident #20 on 04/16/24 at 4:54 PM revealed she had missed her morning medications on several occasions and although she could not recall the exact dates of when they were missed, she stated it usually occurred on the days she received her dialysis treatments. She stated to her knowledge she had not had any issues with her blood sugars or seizures from missing the medications but would like to receive her medications as ordered so that doesn't happen. She revealed she attends her dialysis treatments 3 days a week and leaves the facility at 5:30 AM and returns at 10:30 AM and sometimes nursing staff will give her medications to her with food when she returns and other times they don't. Resident #20 stated she had asked about not receiving her medications before and staff would tell her they could only be given at their scheduled time. She revealed she had not told anyone such as the Administrator or Director of Nursing (DON) about the missing medications. A telephone interview was conducted with Nurse #15 on 04/18/24 at 12:20 PM revealed for the past several months she had worked both 1st and 2nd shift at the facility as an agency nurse and was typically assigned to work the medication carts on the resident halls. She stated she believed Resident #20 received dialysis treatments and on the days she received treatments she would leave the facility around 5 AM and return around 10:30 AM. Nurse #15 verified her initials listed for the MAR, the dates that she worked the medication cart for Resident #20 hall and on the dates Resident #20 had been at dialysis she was not able to administer her morning medications and did not administer them when she returned. She stated she was not aware that she was supposed to hold resident medications and wait to administer when they arrived back from dialysis and had coded the reason for not administering the medications as resident leave of absence because she did not know what other code to use for a resident out of facility for a treatment. She revealed she did not recall if Resident #20 asked about not receiving her medications. An interview was conducted with Nurse #13 on 4/18/24 at 2:35 PM revealed for the past several months she had worked 1st shift at the facility as an agency nurse and was typically assigned to work the medication carts on resident halls. She stated she was familiar with Resident #20 and had administered her medications on several occasions. She also stated that Resident #20 received dialysis treatments 3x's a week and was usually gone for her treatments before she came into work and would return from them around 10:30 AM. Nurse #13 verified her initials listed for the MAR, the dates that she had worked the medication cart for Resident #20 hall. She admitted she had not administered Resident #20 her morning medications on the dates she had coded as resident leave of absence and was not aware that she was supposed to administer those medications when Resident #20 arrived back from treatments. She revealed she did not recall if Resident #20 asked about not receiving her medications. A telephone interview was conducted with the MD on 04/17/24 at 4:24 PM. The MD revealed that he had not been made aware of Resident #20 not receiving her morning medications on the days she received dialysis. He stated all dialysis residents should be administered any medications missed while at dialysis upon their return. The MD also stated that he would expect to notify him if resident dialysis treatments were conflicting with when a medication was ordered to be administered so he could adjust the medications and their times to be administered. Due to having no knowledge of Resident #20 not being administered morning medications on days where she had received dialysis treatments, he was not able to comment on any outcome it caused or could have caused and whether those would have been significant or not. An interview was conducted with the Administrator and Director of Nursing (DON) on 04/18/24 at 12:20 PM revealed they were not aware Resident #20 had missed her medications. The Administrator stated nursing staff had been educated that anytime a medication is not administered to a resident for whatever reason they were to notify the supervisor and document. The Administrator and DON revealed all dialysis residents should be administered their scheduled medications and any issues with not being able to administer those medications should be reported to the nursing supervisor immediately, the MD, and documented. The Administrator was notified of immediate jeopardy on 04/26/24 at 1:07 PM. The facility provided the following plan for IJ removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The facility failed to prevent significant medication errors when Resident #20 was not administered medications as ordered by the physician prescribed to treat diabetes, epilepsy and hypertensive heart disease and chronic kidney disease with heart failure, and depression. Nurse #13 and Nurse #15 did not administer Resident #20 her morning medications when she returned to the facility from her dialysis treatments. On 4/18/24 facility Medical Director (MD) was notified by the Director of Nursing (DON) of Resident #20's identified medication errors. An order was obtained from the MD to administer all prescribed medications upon return from dialysis for all residents in the facility who receive dialysis services. These orders were added to each resident's Medication Administration Record by Assistant Director of Nursing (ADON) on 4/18/24. On 4/18/24 Dialysis residents care plans were updated MDS Coordinator. Nurse Practitioner assessed Resident #20 on 4/18/24. No new orders were received. On 4/18/24 Nurse #13 received verbal 1 on 1 education by Director of Nursing (DON) on 6 rights of medication administration, potential adverse effects of missed medications, documentation requirements regarding omissions, significant medication errors, and administering medications upon resident return from dialysis. Nurse #13 verbalized understanding of re-education. 4/26/24 DON audited all current residents' Medication Administration Records back to 4/1/24 for any potential significant medication errors including missed/omitted medications or those marked as leave of absence. No additional significant medication errors were noted. 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. On 4/24/24 a Quality Assurance Performance Improvement (QAPI) meeting was held by the Administrator (LNHA) with all department heads and MD via phone regarding identification of the significant medication error. Education/audits/monitoring were discussed. Department Heads and MD verbalized understanding of education, audits and ongoing monitoring. On 4/24/24 in person education began with all licensed nurses (including Nurse #15) and medication aides, including agency nurses or med aides, by DON/ Assistant Director of Nursing (ADON)/Nurse Managers on 6 rights of medication administration, potential adverse effects of missed medications, documentation requirements regarding omissions, significant medication errors, and administering medications upon resident return from dialysis or leave of absence. All staff verbalized understanding. Education to all remaining licensed nurses and medication aides was completed by DON on 4/26/24 via phone and/or in person. All newly hired nurses and medication aides, including agency nurses and medication aides, will receive this education from the DON/ADON during the orientation process. Nurse Manager on duty will provide verbal education to any agency staff member that works after 4/26/24 prior to accepting shift assignment. The Nurse Managers were notified of this responsibility on 4/24/24. The DON will notify the Nurse Managers when there is a new agency nurse or medication aide that requires the education. Alleged date of immediate jeopardy removal: 4/27/24 A validation of immediate jeopardy removal was conducted on 05/07/24. The audit of all dialysis residents was reviewed and verified that each resident that received dialysis had an ordered entered into their medical record that indicated all prescribed medications were to be given upon return from dialysis treatment. Each resident's care plan was also updated and verified as a part of the removal verification process. Staff in-service records and interviews with nursing staff confirmed they were educated on the requirement of notification to the medical provider and responsible party when medications were missed or omitted. The facility's QA committee met on 04/24/24 and reviewed the policy on notification which did not require any revisions. The QA verbalized understanding of the policy and requirement. Audits completed from 04/28/24 through 05/06/24 were reviewed with no new issues identified. The facility's removal date of 04/27/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff, resident, Registered Dietitian, and Food Service Provider Representative interviews the facility failed to ensure that fried chicken was completely cooked before serving to residents on lunch trays by 1 of 2 cooks (Cook #1). Undercooked fried chicken was served to 15 of 69 residents and 5 of 15 residents consumed the undercooked fried chicken. Resident #54, Resident #21, Resident #37, Resident #51, and Resident #45 were noted as having consumed the undercooked fried chicken. This unsafe food handling practice had a high likelihood for food borne illness for residents. In addition, the facility failed to have food items labeled with a use by or expiration date and discard food items by the use by date in the dry storage room. Food items were left open to air in 1 of 1 walk-in freezer and a food item was not discarded by the use by date in the reach in refrigerator. Immediate Jeopardy began on 04/16/24 when residents were served undercooked fried chicken for lunch. The immediate jeopardy was removed on 04/19/24 when the facility implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity level of an E (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and monitoring systems put into place are effective. Example #2 is cited at a lower scope and severity of a D. The findings included: 1. An interview was conducted on 04/17/24 9:30 AM with Nursing Assistant (NA) #6 revealed she was present during lunchtime in the dining room yesterday (4/16/24) and had observed the undercooked chicken served to residents. She stated she was assisting Resident #54 and when she cut further into the resident's chicken towards the bone the chicken was pink, bloody, and appeared undercooked. When NA #6 looked at the plate further, she observed blood on the plate underneath the chicken. NA #6 stated she immediately picked up Resident #54's plate and took it into the kitchen and showed it to the Dietary Manager (DM) #1 and informed her the chicken was undercooked. NA #6 stated Dietary Manager #1 took Resident #54's plate with a look of shock on her face and stated the chicken was not cooked. NA #6 explained after that they were told by the Administrator and DM #1 to pull all the residents trays out of the dining room and off the halls and they would provide them with all new trays. She stated she observed other residents in the dining room had eaten some of the chicken on their plates prior to them pulling them and she just informed them that they would be bringing them a fresh tray shortly. On 04/16/24 at 12:15 PM an observation was conducted of the 200 halls during the lunch meal. Staff were observed passing trays to 4 residents. Staff were observed immediately removing two of the trays from (Resident #5 and Resident #6). The other two residents on the hall had received a mechanical soft diet with precooked chopped chicken and their meals were left in the rooms. The Administrator was observed pushing the meal cart back towards the kitchen. A continuous observation of the kitchen that included interviews occurred on 04/16/24 from 12:10 PM until 1:45 PM. The door to the kitchen was propped open by a meal cart with several other meal carts in the kitchen, all with resident trays. DM #1, Clinical Nutrition Manager, Dietary Aide (DA) #1 and [NAME] #1 were observed looking at a piece of fried chicken that had been cut in to and the meat was pink and red colored juices on the plate. DM #1 was asked what was going on and she replied they were having to pull all the fried chicken because it was undercooked and bloody. DM #1 explained the Administrator made the decision to remove all the fried chicken from the residents for safety reasons and a different meal had to be prepared. Dietary Aide (DA) #1 and DA #2 were removing trays from tray carts, and dumping the food into the trash can. Two other dietary aids were running all plates, silverware, plate warmers, lids, and trays through the dishwasher. [NAME] #1 was clearing all the food off the serving line and then began preparing new side items. It was confirmed by DM #1 that 5 of the 15 residents that had been served the undercook chicken had eaten part of the chicken provided to them. The fried chicken that was being discarded into the trash can included breasts, wings, thighs, and legs and some of the chicken pieces had been partially consumed and others had not been touched. During the continuous observation pieces of the fried chicken that were sent back to the kitchen were cut into by [NAME] #1. The fried chicken was observed to be pink and undercooked in the middle and close to the bone and had red colored juices flowing from the chicken onto the meal plate. There was an observation of plates that had red colored juices on the plate that had seeped into the vegetables and sides on the plates on the counter tops in the kitchen. According to DM #1 all carts had been sent out and returned to the kitchen. Then [NAME] #1 removed an additional tray of fried chicken from the oven and temped chicken with a thermometer that was given to him by DM #2 and the temperature was 137 degrees Fahrenheit. This fried chicken was discarded. It was observed that the temperature on the oven was set at 170 degrees Fahrenheit. The Administrator was observed bringing fried chicken from a local fast-food restaurant and placing it on the kitchen counter. Dietary staff were then observed preparing new meal trays for residents that had their meal trays pulled. Review of the food temperature sheet revealed a temperature of 168 degrees Fahrenheit was entered for the fried chicken on 4/16/24. An interview on 04/16/24 at 2:40 PM with [NAME] #1 revealed this was only his second day working at the facility. [NAME] #1 stated that when he had questions about cooking fried chicken, that DM #2 showed him the recipe for fried chicken, and he followed the instructions. [NAME] #1 revealed that he had chicken breast, thighs, legs, and wings to prepare for the lunch meal. [NAME] #1 revealed that Dietary Manager #2 was working on the sides while he worked on preparing the chicken. [NAME] #1 reported that the chicken was cooked for 15 minutes in the [NAME], but then moved it to the oven because he felt the grease was old and dark and did not want the chicken to become too dark, so the chicken was placed in the oven to finish cooking. [NAME] #1 also reported he did not have a 2-inch pan, so he had to put all the chicken in a 4-inch pan instead, so the chicken pieces were piled on top of each other. He explained using a 2-inch pan would have allowed the chicken to be spread out and not sitting on top of each other so it would have cooked better in the oven. [NAME] #1 stated he believed since the chicken was piled on top of each other was why the top layer of chicken pieces were cooked but the chicken in the middle and lower layers was not cooked. He reported that the first time he pulled the chicken out of the oven it was not done, and he asked DA #1 who told him the chicken was not done after she cut into it and told him to put it back into the oven. [NAME] #1 indicated he failed to take the temperature of the chicken the second time it was taken out of the oven and reported he knew better and should have checked the temperature of the fried chicken pieces before sending food out. [NAME] #1 also stated he knew better than to leave the oven at 170 degrees Fahrenheit knowing that would not cook the chicken, but only keep it warm. The food temperature sheet was reviewed during the interview and [NAME] #1 confirmed there was an entry for the fried chicken on 4/16/24 of 168 degrees Fahrenheit but [NAME] #1 stated he did not write that temperature down. An interview on 04/16/24 at 02:05 PM with DM #1 revealed the menu being served that day for lunch included fried chicken. The Dietary Manager explained the chicken had been thawed the prior evening, marinated and was dredged in flour and fried that morning prior to being served. When asked to clarify the type of chicken that had been prepared and served, she stated it was frozen, raw chicken that had been thawed. DM #1 also stated that this was a common recipe she had seen used at several of the facilities she had worked at prior. DM #1 indicated DA#1 reported to her the fried chicken was returned to the oven because it was not fully cooked the first time it was removed from the oven. DM #1 stated that a temperature of 168 had been documented on the food temperature sheet for the fried chicken but she did not know who had written that temperature down and [NAME] #1 denied writing it down. DM #1 revealed that [NAME] #1 stated he did not check the temperature of the fried chicken the second time the chicken was removed from the oven. DM #1 indicated [NAME] #1 was responsible for checking the temperature of the food before it was served to the residents on 4/16/24. Dietary Manager #1 reported she became aware of the fried chicken not being fully cooked when NA #6 came to the kitchen door and told them a resident had raw chicken. DM #1 then notified the Administrator of the issue with the fried chicken not being [NAME] cooked. DM #1 further stated that she was going to adjust dinner time since lunch was not served until 1:30 PM. DM #1 also stated that all new sides were prepared, and the Registered Dietician had approved all changes to the menu. She indicated she had only been working at the facility for a month and was always short-staffed. Dietary Manager #1 stated she thought Dietary Manager #2, who was from another facility, and [NAME] #1 were working together. An interview was conducted with DM #2 on 04/16/2024 at 3:00 PM. DM #2 stated she was from another facility and had been called in to help due to the facility not having enough kitchen staff. DM #2 stated she was asked to come and support DM #1 since she was new and was short staffed. DM#2 revealed that [NAME] #1 asked her about the chicken and DM #2 reported getting him the recipe for cooking fried chicken and told him to follow the recipe. DM #2 stated she was not with [NAME] #1 when he checked the temperature of the fried chicken, and she was not aware that the first time it was taken out of the oven it was not cooked all the way. DM #2 further added that if she had known the chicken was not cooked thoroughly, she would have provided [NAME] #1 with more assistance. DM #2 also revealed she was helping the best she could, but she felt like the kitchen was in chaos when she arrived at the facility, and she felt bad for the new employee (Cook #1). DM #2 also stated that when she started looking into the chicken situation, she noted that [NAME] #1 had turned the temperature on the oven to 170 degrees, so it was too low to cook the chicken. A review of the recipe for fried chicken provided by Dietary Manager #2 revealed: 1. Wash and drain the raw chicken, and season with salt and pepper. 2. Combine eggs and milk in large mixing bowl and dip chicken in milk mixture. 3. Season flour with salt and paprika, and dredge chicken in season flour. 4. Melt shortening in a large skillet or pan and place chicken in hot grease and cook until golden brown on both sides and the internal temperature is reached. Hazard Analysis and Critical Control Point (HACCP). [NAME] to an internal temperature of 165 degrees Fahrenheit. And HACCP: hold food at 135 degrees Fahrenheit. Interview on 04/16/24 at 3:15 PM with [NAME] #2 revealed she usually cooked for the facility, but they were short of staff today, so she was not cooking but working as a dietary aide on the serving line. [NAME] #2 stated since she was not cooking, she had not been responsible for temping the food and had not temped any of the food that was prepared. She further stated when [NAME] #1 had removed the chicken from the fryer after 15 minutes he asked her to check the chicken to see if it was done. [NAME] #2 said she cut into the chicken and told [NAME] #1 that it was not done so he had put the chicken into the oven to finish cooking. She indicated when the trays started coming back into the kitchen due to the undercooked chicken, she and the other dietary aide began tearing everything down, discarding all the food items and washing and sanitizing everything that had encountered the undercooked chicken. An interview on 04/16/24 at 02:00 PM with DA #1 revealed she was not involved with the cooking process on 04/16/24 and [NAME] #1 was responsible for checking and writing down temperatures for the fried chicken. DA #1 further stated she had not temped any of the food during the meal preparation and she was not sure who had checked the temperature of the fried chicken prior to it being served to the residents. DA #1 recalled she did not know there was a problem with the fried chicken being undercooked until trays started being returned to the kitchen. She indicated once the issue was identified she began cleaning and washing all the service items that had been returned so they could prepare new trays for the residents. An interview conducted with Resident #5 and Resident #6 on 04/16/24 at 12:20 PM revealed they had been told the chicken they received that day was undercooked. The interview revealed neither of the residents had time to remove the lid of the plate before staff came and removed the tray from the room. An interview was conducted on 04/16/24 4:20 PM with Resident #54. Her most recent Minimum Data Set Assessment noted she had intact cognition. She stated she had been eating lunch around noon in the dining room and was served a fried chicken thigh on her plate. She revealed she had begun eating her chicken and the closer she got to the bone of the chicken she noticed the chicken appeared pink and bloody and there was blood on her plate underneath the chicken. Resident #54 stated NA #6 who was also in the dining room saw her chicken and the blood on her plate and immediately removed the plate from her and took the plate into the kitchen and informed her they would bring her a new tray shortly. An interview was conducted with Resident #21 on 04/16/24 at 04:23 PM. His most recent Minimum Data Set Assessment (MDS) noted he had intact cognition. Resident #21 revealed he had eaten the top half of the fried chicken provided to him in his room on 04/16/24 at lunch time and staff returned to the room and removed the rest of his chicken telling him there was a problem, and he would get a different tray shortly. Resident #21 stated he was upset because the first half of the fried chicken he had eaten tasted good, and their chicken is usually not good at all. An interview was conducted with Resident #37 on 04/16/24 at 04:41 PM. Her most recent MDS noted she had intact cognition. Resident #37 revealed on 4/16/24 she was eating lunch in the dining room and had been served a fried chicken thigh and she first noticed the skin on the chicken was very brown and dark. The resident peeled the chicken skin back and took a few bites of the chicken and realized that it did not taste right. The chicken was chewy and appeared pink like it wasn't fully cooked. Resident #37 stated she stopped eating the chicken and NA #6 removed her tray and informed her they would bring her a fresh tray. An interview was conducted with Resident # 51 on 04/16/24 at 04:45 PM. His most recent MDS noted he had intact cognition. Resident #51 revealed he had been served two fried chicken thighs for the lunch meal (4/16/24). He stated he ate the first thigh which did not appear to be pink on the inside however the texture tasted, off. The interview revealed when he took a bite of the second chicken thigh it was red and bloody on the inside, which dripped onto his plate. He stated staff removed the plate and eventually he was provided with a new meal tray. An interview was conducted with Resident #45 on 04/16/24 at 03:37 PM. Her most recent MDS noted she had moderately impaired cognition. Resident #45 revealed on 04/16/24 she was eating in the dining room for lunch and was served fried chicken. She stated she had been served a leg piece but reported it was not good so after the first bite she did not eat the chicken anymore. Resident #45 reported that NA# 6 came and removed her tray with everyone else's and eventually brought her a new lunch tray. Interview on 04/16/24 at 3:45 PM with the Assistant Director of Nursing revealed she had been instructed to contact the Medical Director regarding the five residents who had been served the undercooked chicken. An interview on 04/16/24 at 03:20 PM with the Clinical Nutrition Manager for the food service provider revealed Dietary Manager #2 stated that staff in the dining room were the ones who discovered the undercooked fried chicken and let the kitchen know there was a problem with the chicken. The interview further revealed there were plenty of pans in the kitchen, so she had no idea why [NAME] #1 said there were not enough pans to spread the chicken out instead of piling it on top of each other. Dietary Manager #2 further stated that [NAME] #1 should have checked the temperature of the chicken right before the serving line was started and if the chicken was not done it should have been cooked longer even if lunch had to be a little late. An interview on 04/16/24 at 03:45 PM with the Registered Dietician (RD) revealed NA #6 showed her the undercooked fried chicken that day. The RD reported that she observed the piece of fried chicken that NA #6 identified as undercooked and reported she did see the red liquid on the plate. The RD stated the fried chicken was slightly bloody and it was immediately pulled from the dining room. The RD further stated all trays had been delivered to the halls, but not all had been delivered to residents when the issue with the undercooked fried chicken was identified. Then the Administrator instructed staff to pull all trays back to the kitchen. The RD indicated DM #1 had informed her that 5 residents had consumed the undercooked fried chicken. The RD denied being present during the preparation of the fried chicken and did not observe [NAME] #1 while he prepared or cooked the chicken. The RD was asked twice if the kitchen used raw chicken for its fried chicken recipe and she stated yes, both times. The RD further stated all her kitchens used raw chicken for their fried chicken recipe. Review of nursing note written by Assistant Director of Nursing (ADON) on 4/16/24 at 12:15 PM revealed Resident #54 notified of undercooked chicken. Removed tray, replaced with another meal, notified provider and power of attorney (POA/ sister). Resident education done and if experience abdominal pain, nausea/ vomiting, chills, lightheadedness, diarrhea, gas, weakness, headaches, or anything abnormal to notify staff/nurse. Resident #54 indicated understanding by nodding her head up and down. Denies any symptoms at present. No orders received by provider. (This same nursing note was placed in Resident #21, #23, and #51 electronic chart). An interview and review of a purchase order was completed on 04/18/24 at 10:58 AM with the Regional Director of Operations (RDO) for Dietary with the food service provider. The RDO stated the facility had previously used raw bone-in chicken but had just recently switched to using the frozen precooked breaded chicken and there was no way that the fried chicken on 4/16/24 could have been undercooked. She supplied a purchase order with a delivery date of 04/14/24 for precooked breaded chicken. The RDO stated that the fried chicken could not be undercooked because it was a precooked product. She reported they had just switched from frozen raw chicken to precooked frozen chicken. The RDO also stated she felt the dietary staff were confused about what they were cooking and that it was precooked chicken. When the RDO was asked about the recipe instructions for fried chicken using raw chicken, she stated she did not know why the recipe was written the way it was since they no longer ordered raw chicken, so they needed to update the recipe. The RDO stated the [NAME] #1, Dietary Manager #1, and Dietary Manager #2 had since calmed down and she reported that their stories had changed and [NAME] #1 had checked the temperature of the fried chicken the second time it was pulled from the oven and the temperature was 168 degree Fahrenheit. The RDO was asked why the Registered Dietician would have confirmed the recipe was prepared using raw chicken and by the fried chicken recipe on 4/16/24. The RDO stated they just switched to pre-cooked chicken and was not sure if there was still raw chicken in kitchen freezer, or maybe the supplier had sent the wrong product. The RDO stated she was not present in the facility on 4/16/24 and wished someone had taken a picture of the undercooked fried chicken and was unable to produce the packaging the chicken had come from. An interview on 04/18/24 at 02:38 PM with the Administrator revealed food being served to the residents should have temperature checks and be in expected ranges before it is served to the residents. The Administrator stated that DM #1 reported the undercooked fried chicken to her immediately after DM #1 became aware (on 4/16/24) and she went to the kitchen to see the undercooked chicken. The interview revealed after the Administrator observed the fried chicken, the decision was made to remove and discard all the fried chicken. The Administrator reported she was happy about how all the staff handled the situation once the issue was identified. The Administrator stated that education had been started for all dietary employees concerning correct food temperatures. A conference call on 04/18/24 at 4:10 PM with the survey team, Administrator, Clinical Educator, Director of Clinical Asset Management for the food service provider, Clinical Nutrition Manager for the food service provider, [NAME] President of Operations for the food service provider, [NAME] President of Operations for the facility, owner and Chief Executive Officer of facility, revealed the facility and the food service providers maintained the fried chicken on 4/16/24 could not have been undercooked because the product was in fact frozen precooked chicken that was prepared and served to the residents. The Director of Clinical Asset Management stated there was no raw chicken in the kitchen, only precooked chicken as indicated by the purchase order she had provided to the survey team. She also stated she had interviewed the 4 residents that were identified as having received undercooked fried chicken and they had denied being served undercooked chicken. The [NAME] President of Operations for the food service provider indicated [NAME] #1 had embellished what he had told the survey team about how he had prepared and cooked the fried chicken. The [NAME] President of Operations also stated what NA #6 had cut into in the dining room was the blood line of the chicken close to the bone and said it was always dark reddish in color. The [NAME] President of Operations further indicated the cook time for raw chicken should have been 15 to 30 minutes in the fryer per the guidelines and then held in the warmer or oven at 140 degrees Fahrenheit until ready for service. During the conference call the Administrator stated she had not actually laid eyes on the fried chicken so she could not speak to what it looked like. The Administrator was notified of immediate jeopardy on 04/16/2024 at 05:25 PM. The facility provided the following credible allegation of immediate jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the noncompliance. On 4/16/2024 at about 11:30 am, a facility Certified Nursing Assistant assigned to the dining room observed undercooked chicken served to two residents in dining room at the beginning of lunch service. The Certified Nursing Assistant immediately removed trays from affected residents to prevent consumption of the undercooked chicken and informed the Nurses assigned to those residents to ensure safety. On 4/16/2024 The [NAME] President of Human Resources was in dining room during the incident and immediately notified Administrator and Director of Nursing of observed undercooked chicken being served in the dining room. The Administrator and Director of Nursing immediately notified dietary staff and went to halls in which trays were being served, where trays had been delivered to 1 out of 3 halls. Administrator and Director of Nursing assisted Certified Nursing Assistants in removal of delivered trays containing chicken and tray carts to prevent any further tray deliveries. On 4/16/2024 The Director of Nursing and Administrator identified 15 residents were served and 5 consumed the undercooked chicken. On 4/16/2024 The Director of Nursing notified the Physician and Medical Director. The physician's order was to monitor the residents and report any gastrointestinal complaints including abdominal pain, nausea, vomiting or diarrhea. On 4/16/2024, The kitchen staff discarded the chicken dinners, including fried chicken, macaroni, cheese, and spinach. The trays were cleaned using sanitizer and high temperature. An alternative meal was prepared and served to residents in accordance with the facilities' food preparation policy. The facility management bought chicken from a local fast-food restaurant and new side items were prepared in the kitchen. 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. On 4/16/2024 the Administrator notified Regional Dietary Manager of the situation and she informed administrator she was in route to the building. Dietary Manager re-educated immediately by Regional Dietary Manager on safe food handling, potential food borne illnesses and proper cooking temperatures on 4/16/2024. On 4/16/2024, The facility cook informed the Administrator and Regional Dietary Manager that temperature of 168 degrees Fahrenheit was obtained from top layer of prepared chicken prior to serving lunch service. The temperature log was also reviewed by the Administrator and confirmed the documented chicken temperature of 168 degrees Fahrenheit. On 4/17/2024, all dietary staff were re-educated verbally by Regional Dietary Manager with reference to facility policy on food safety requirements and preparation guidelines. This included proper cooking temperatures and potential for food-borne illnesses and emphasized the importance of maintaining food temperature logs. The Dietary Manager/designee will educate any dietary staff not educated on 4/17/2024 before their next scheduled shift. All newly hired dietary staff will be verbally educated upon hire by the Dietary Manager/Designee on food safety requirements and preparation guidelines, to include proper cooking temperatures and potential food borne illnesses. Employees must verbalize understanding and have required competencies including accurate thermometer readings. On 4/17/2024, all staff including newly hired staff will be verbally educated by the Dietary Manager or Designee with reference to facility policy on food safety requirements and potential for food borne illness related to consuming undercooked chicken as well as proper procedure to immediately remove and report any identified undercooked food items to Dietary/Administrator/Director of Nursing/Designee. Any staff member who did not work on 4/17/2017 will receive the education from the Dietary Manager prior to the start of their next shift. Administrator/Vice President of Dietary Operations /Designee will monitor for 100% completion. On 4/17/2024 the [NAME] President of Dietary Operations instructed dietary staff that a temperature check must be performed for at least 3 pieces of chicken per layer, followed by verification of temperature before serving. Dietary staff were also educated by Dietary Manager using approved recipe cards and food products. On 4/16/2024, The Regional Dietary Manager provided one on one re-education with the facility cook on proper use of recipe cards, food products, and appropriate food temperatures and process. Alleged date of immediate jeopardy removal: 04/19/24. The immediate jeopardy removal plan was validated on 4/23/24. Review of education sign-in sheets revealed all dietary and facility staff were educated on signs and symptoms of foodborne illnesses, identifying undercooked food, and what to do in the event of finding undercooked food. The kitchen staff were able to describe the process of checking food temperatures and having another kitchen staff member to verify the temperature, as well as testing multiple areas of the food for temperature. Observations of the kitchen on 4/23/24 revealed no concerns with food preparation, checking food temperatures before plating or tray line. An Ad Hoc QAPI was conducted on 4/17/24. During an interview the Administrator confirmed they are putting a hold on purchasing raw chicken for residents until they were certain the corrections were sustained. The immediate jeopardy removal date of 4/19/24 was validated. 2. a. A tour of the kitchen was conducted with the Dietary Manager (DM) #1 on 04/15/2024 at 11:20 AM. Observations in the dry storage room revealed a plastic bin on a shelf that contained 10 to 15 bags of instant chocolate pudding bags. A crumbly dry substance was observed on and under the bags and there was no use by or expiration date on the bags of pudding. DM #1 could not identify what the substance was, but stated she would get it cleaned up. DM #1 stated the expiration date for the instant chocolate pudding was on the box they came in but that the boxes had been thrown away. In addition, there was an open bag of dried pasta with a use by date of 03/29/24. Dietary Manager #1 took the bag of dried pasta and removed it from dry storage. b. Observation of the walk-in freezer on 04/15/2023 at 11:35 AM revealed an open box of bacon on a shelf. The plastic bag surrounding the bacon in the box was not sealed shut and the bacon was left open to air inside of the box. DM #1 was observed closing up the bacon, so it was no longer exposed. In addition, there was a package of sliced American cheese open to air with individual slices observed in other boxes on the same shelf. There was no date on the box of bacon or the package of cheese to indicate when they were opened. DM #1 took the cheese and removed it. c. Observation of the reach-in refrigerator on 04/14/2024 at 11:42 revealed an unlabeled container of dried shredded cheese which DM #1 identified as parmesan cheese. It was noted on the container that the use by date was 04/09/2024. The Dietary Manager #1removed the container from the refrigerator and threw it away. Interview with Dietary Manager #1 on 04/15/2024 at 11:50 AM revealed the cook for the day was responsible for checking dates before food was prepared. She also stated that all dietary employees were supposed to date all food items when they were opened and check products and to discard any expired food items. DM #1 stated was new to the position and is still trying to get things in order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident, staff, and physician interviews, the facility failed to ensure Resident #1 was assessed following a fall from her wheelchair in the facility van on 2/4/23. The Transportation Aide did not report the accident to the Director of Nursing until the evening of 2/5/23. Nursing staff were not made aware of the accident and therefore no assessment was completed. The Nurse Practitioner was contacted on 2/6/23 for Resident #1's complaint of right leg pain and ordered x-rays of the resident's right hip and pelvis which were negative for fractures or dislocations. When Resident #1 was informed of negative x-ray results, she requested to be sent to the emergency room for evaluation on 2/6/23 due to increased pain. Resident #1 was assessed to have lumbar spinal tenderness upon examination and the computer tomography (CT) scan resulted in moderate spinal canal stenosis at L3-L4 (L=Lumbar region of the spine) with possible right paracentral disc protrusion. (Ligaments from the spinal disc are intact but form a pouch that presses on the nerves). The document referenced needed treatment to include ongoing pain management and a referral to an orthopedic therapist for therapy. This deficient practice occurred for 1 of 1 resident reviewed for accidents. Findings included: Resident #1 was re-admitted to the facility on [DATE] with diagnoses that included end stage renal disease (ESRD) and chronic pain syndrome. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was cognitively intact, no behavioral concerns, required 1-person physical assistance with transfers, was able to self-propel her wheelchair with supervision assistance, and walked with 1-person physical assistance. The assessment further indicated that Resident #1 did not receive scheduled pain medications, but she did receive 7 days of opioid medications prescribed on an as needed frequency and she received 7 days of anticoagulant mediations. An interview with Resident #1 was conducted on 2/20/23 at 10:10 AM. Resident #1 was lying in her bed with the lights off and immediately voiced she was in pain in her lower back and right lower extremity. Resident #1 described the pain as a level 12 on a 1-10 scale (10 being the worst). Resident #1 stated she had some slipped discs in her lower back following a fall during transport in the facility van on 2/4/23 after an appointment with the local dialysis center. Resident #1 explained she was sitting in her wheelchair when the former Transportation Aide stopped which caused Resident #1 to be projected out of her wheelchair and into the aisle on the floor in the van. Resident #1 stated at the time of the fall, the wheelchair was not securely fastened to the van using the securing straps which caused the wheelchair to land on her when she fell out onto the van floor. Resident #1 explained when the Transportation Aide loaded her in the van, the straps which secure the wheelchair were not tightly strapped to the wheelchair and the shoulder harness/lap restraint portion was not in place. The Transportation Aide flagged down the firefighter for assistance to lift her back to her wheelchair. Resident #1 stated she initially had some pain; however, the intensity increased later that evening and over the next couple of days, but she was afraid to vocalized too much increase in severity to avoid getting questioned about not reporting the incident on the date of the occurrence. The Resident stated eventually her pain escalated to a level she felt needed to be treated more than with her routine PRN medication. Resident #1 explained on 2/6/23 she requested an emergency room evaluation and was sent to the ER and discovered she had suffered from a slipped disc and provided pain management and referred to the orthopedic outpatient center. An interview with the former Transportation Aide on 2/20/23 at 12:05 PM revealed she was suspended from the facility on 2/6/23 and terminated on 2/9/23 following a fall in the van involving Resident #1. The Transportation Aide stated she was scheduled to pick up Resident #1 from dialysis on 2/4/23. Upon arrival to the dialysis center around 10:30 AM, she loaded Resident #1 into the van and quickly fastened her in. The Transportation Aide explained shortly after the transport began, she was approaching a stop light at an intersection, she heard Resident #1 say oh, oh and she looked back towards Resident #1 and discovered Resident #1 was no longer in her wheelchair and was laying on the floor of the van with her wheelchair no longer fastened to the floor of the van. The Transportation Aide expressed she immediately put the vehicle in park in the middle of the road, got out and slid along the side of the van to the door where she was able to access Resident #1 and tried to lift Resident #1 out of the floor but was unable to and acknowledged she needed assistance to lift Resident #1 back into her chair. The Transportation Aide stated she got back out of the van and ran into the middle of the street where she saw a fire truck passing by and flagged the fireman down for assistance. The Transportation Aide detailed she and the firefighter placed Resident #1 back in her wheelchair and she was brought back to the facility then left her in her room and did not report the fall to Resident #1's assigned nurse nor administration at that time. The Transportation Aide reported it was not until the following evening following a conversation with Resident #1, (2/5/23) she notified DON #1 via telephone to make her aware of the fall. The Transportation Aide said DON #1 told her to come to the facility and leave a statement for her and to ask the assigned nurse to complete an incident report. The Transportation Aide further reported when she arrived at the facility to write a statement, she approached Nurse # 1 about completing an incident report of which she refused stating she was not involved. The Transportation Aide explained it was not until the following day (2/6/23) she was asked further about the fall and was suspended. The Transportation Aide stated she had previously called the facility when incidents of a resident falling in the van had occurred and they sent a staff member to assist her to put the resident back in their chair, but since this occurred on the weekend, she was not sure what to do and therefore she flagged a member of the fire department instead. The Transportation Aide explained when she first became the van driver in the fall of 2022, she was provided minimal training and stated they just gave me the keys and turned me loose. She indicated she was never specifically provided training on what to do if a resident fell during transport. The Transportation Aide said she did not think Resident #1 was visibly injured and therefore did not call 911 or the facility on 2/4/23. The Transportation Aide stated she had asked Resident #1 if she was ok but she was not qualified to assess her for injuries and the fireman who assisted to place Resident #1 back in her chair only asked what happened to which Resident #1 replied she fell out of her wheelchair. A review of the nurse progress notes dated 2/4/23 and 2/5/23 revealed there was no documentation of Resident #1's fall from the wheelchair during transport in the facility van. An incident report initiated on 2/6/23 by the former Director of Nursing (DON #1) and dated 2/4/23 at 2:05 PM indicated Resident #1 was being transported to the facility from dialysis after the Transportation Aide secured Resident #1 in and ensured buckle was on, she stopped at a red light and Resident #1 fell out of her wheelchair. The report indicated the Transportation Aide attempted to pick Resident #1 up from the vehicle but was unsuccessful and flagged down a fire truck and firefighters were able to assist Resident #1 back into her wheelchair. A telephone interview with the former Director of Nursing (DON #1) on 2/20/23 at 12:50 PM revealed on 2/5/23 around 5 PM she received a phone call from the Transportation Aide who told her Resident #1 had fallen out of her wheelchair on the return trip from dialysis on the morning of 2/4/23. DON #1 instructed the Transportation Aide to go to the facility and tell Resident #1's nurse to complete an incident report. DON #1 stated she did not contact the facility on 2/5/23 and DON #1 was unable to provide any additional information regarding the incident on 02/4/23 because she was suspended from the facility. An interview with Nurse #1 on 2/21/23 at 11:00 AM revealed she was assigned to Resident #1 from 7AM to 7 PM on both 2/4/23 and 2/5/23. Nurse #1 indicated she did not learn about the fall involving Resident #1 until she was on a telephone call with Nurse #4 on 2/6/23 about something unrelated and overheard DON #2 (current DON) notify Nurse #4 about the incident. Nurse #1 stated she was asked if she knew about the incident because she had not been notified in the oncoming shift report and Nurse #1 told her she was not aware of the incident herself. Nurse #1 explained she was on duty around 6 PM on 2/5/23 when the Transportation Aide arrived to the facility and mentioned she needed to write a statement about some incident with buying cigarettes involving Resident #1 of which Nurse #1 admitted she did not feel the need to write an incident report and told the Transportation Aide she was not completing one but to leave the statements for DON #1 and/or the Administrator and it would be handled when they arrived the following morning and therefore did not ask any further questions. Nurse #1 acknowledged Resident #1 expressed mild asymptomatic pain at times over the weekend, but she thought the pain was the same pain she routinely described, and she was not anything acute therefore no assessment was completed at the time. An interview with Nurse #2 on 2/21/23 at 11:30 AM revealed she was assigned to Resident #1 from 7 PM to 7 AM on 2/4/23 and 2/5/23. Nurse #2 indicated she was not aware of the fall until 2/11/23 when she returned to work. Nurse #2 stated Resident #1 expressed some hip and lower extremity discomfort and received her scheduled PRN pain medication and Resident #1 was not evaluated further due to long term complaints of pain on the weekend of the fall. A progress noted written by the Nurse Practitioner (NP) dated 2/6/23 indicated Resident #1 was referred by nursing for right leg pain. The note detailed Resident #1 was involved in an incident on the transportation van over the weekend which resulted in her slipping out of her wheelchair onto the floor of the vehicle. It further indicated Resident #1 did not have her belts in place and had pain to her right leg since the time of the incident. An order for an x-ray of the right hip and pelvis was provided to rule out occult processes (not detectable by clinical methods alone). Attempts were made to contact the Nurse Practitioner without success. A review of the physician's orders revealed Resident #1 had an order for an x-ray of the right hip and pelvis dated 2/6/23. A radiological report dated 2/6/23 revealed an x-ray was obtained of the right hip and pelvis which indicated no fractures or dislocations were noted. A nurse progress noted written by Nurse #4 dated 2/6/23 at 4:04 PM revealed the x-ray results were communicated by staff to Resident #1 who requested further evaluation and was then transported to the ER via ambulance. An interview with Nurse #4 on 2/23/23 at 10:00 revealed she was the nurse assigned to Resident #1 on 2/6/23 when radiological studies were ordered and obtained due to complaints of pain in the right lower extremity and lower back region. Nurse #4 indicated she was not aware that Resident #1 fell in the van until DON #2 approached her on 2/6/23 asking about the fall. Nurse #4 indicated she was on the telephone with Nurse #1 about an unrelated topic and therefore asked Nurse #1 if she was aware of the fall. Nurse #4 stated both she and Nurse #1 were confused and both without knowledge that Resident #1 had a fall in the van on 2/4/23. Nurse #4 stated Resident #1 seemed normal but had continued to complain of pain after her PRN pain medications were provided and therefore, she had notified the nurse practitioner and obtained an order for x-rays. Nurse #4 explained when the x-ray results returned she was not the nurse who provided the results to Resident #1, but did prepare her for discharge per request to the ER for further evaluation on 2/6/23. Nurse #4 further stated she was not present when Resident #1 returned from the ER and was not aware of the CT results until she returned to work on her next scheduled shift. A review of the emergency room and ER radiological studies dated 2/6/23 indicated Resident #1 was assessed to have lumbar spinal tenderness upon examination by the ER provider and the CT scan resulted in moderate spinal canal stenosis at L3-L4 with possible right paracentral disc protrusion. (Ligaments from the spinal disc are intact but form a pouch that presses on the nerves). The document referenced needed treatment to include ongoing pain management and a referral to an orthopedic therapist for therapy. An interview with the Medical Director (MD) on 2/21/23 at 12:31 PM revealed he was made aware of the fall involving Resident #1 on 2/7/23 when he arrived at the facility for routine rounds. The MD stated he had been told that Resident #1 was not properly secured in the facility van during the transport on 2/4/23 and had been evaluated by ER staff to have a disc protrusion and was experiencing lower lumbar pain that radiated to her sides. The MD indicated he could not say for sure that the injury was a result of Resident #1 sustaining a fall during transport or not, but that it was a possibility. An interview with the Administrator on 2/23/23 at 10:15 AM revealed during her morning commute to the facility on 2/6/23, she learned of the fall experienced by Resident #1 on 2/4/23 while in transport from the dialysis. The Administrator indicated when she arrived, she placed all staff involved on suspension and began her investigation. She indicated that the Transportation Aide should have immediately pulled the van over, called emergency services to ensure Resident #1 was safe and without injury before moving her followed by contacting the facility Administrator and the Director of Nursing and/or the Manager on Duty. On 2/20/23 at 5:20 PM, the facility Administrator and Regional Corporate Consultant were notified of the Immediate Jeopardy. The facility provided the following corrective action plan with a compliance date of 02/10/23. 1. The facility failed to assess Resident #1 after she fell from her wheelchair while transported from dialysis in the facility van on 2/4/23. Resident #1 was lifted back into her wheelchair by the transporter and a member of a local fire department. Emergency Medical Services was not contacted, and the resident was transported back to the facility. Facility staff were not notified of the incident by the transporter until 2/5/23 at approximately 5:00 PM. Lack of a comprehensive assessment resulted in a delay of treatment for low back pain which required an orthopedic referral, pain management and therapy. On 2/6/23 Resident #1 reported pain to her low back and right leg, the Nurse Practitioner, available in the facility assessed resident #1 and ordered an x-ray which was negative for fracture. Resident #1 subsequently went to the emergency room for evaluation per resident's request on 2/6/23 where a CT scan reflected a bulging disc to L4-S1 and a referral to the orthopedic surgeon for ongoing care on 2/6/23. 2. On 2/6/23 the Assistant Director of Nursing initiated an incident report and an investigation into the event and included an interview with the resident, transporter, and Director of Nursing. An audit of current residents transported during the last 30 days was completed by the Assistant Director of Nursing and Regional Director of Clinical Services on 2/8/23 to identify any other residents possibly affected by the same practice. Any unreported events were documented on an incident report, investigated, assessment of the resident completed by the licensed nurse including safe repositioning following assessment for any injury, an SBAR documented in the resident medical record and the Physician and Responsible Party were notified by the Assistant Director of Nursing or Regional Director of Clinical Services by 2/9/23. By 2/9/23 the Assistant Director of Nursing, Nurse Manager, Social Worker and Regional Director of Clinical Services conducted interviews with current residents to identify any unreported incidents during the last 30 days. Any new incidents identified were reported to the Assistant Director of Nursing and Administrator, with resident assessment and notification of responsible party and physician. By 2/9/23 the Assistant Director of Nursing, Nurse Manager and Regional Director of Clinical Services completed a record review of all incidents and accidents to ensure completion of a nursing assessment and notification to the responsible party and physician. Root cause analysis for Resident #1 was conducted by the Assistant Director of Nursing, Medical Director, Administrator and Regional Director of Clinical Services on 2/9/23 and it was determined the transporter failed to follow emergency procedures, call 911 for help and report the incident timely which resulted in a delay in assessment and treatment. 3. By 2/9/23 all staff including agency staff were re-educated by the Assistant Director of Nursing and Administrator on the facility policy for Managing Incidents, to include reporting events immediately to the Administrator or Assistant Director of Nursing, always encouraging residents to report concerns and allegations, never persuading residents to avoid reporting concerns and allegations. Nurses were also educated on the facility policy for assessment with a change of condition to include a complete head to toe assessment with range of motion to identify injuries prior to repositioning post fall. After 2/9/23, the Assistant Director of Nursing and Nurse Managers will ensure no staff will be allowed to work, including any new hired staff and agency staff, without receiving this education. By 2/9/23 the Assistant Director of Nursing, Nurse Manager and Regional Director of Clinical Services re-educated all nursing staff, including agency staff regarding completion of an assessment, notification of the responsible party and the physician following a reported incident/accident. After 2/9/23, the Assistant Director of Nursing and Nurse Managers will ensure no nursing staff will be allowed to work, including any new hired staff and agency staff, without receiving this education. 4. The Assistant Director of Nursing, Nurse Managers and Regional Clinical Director will review all incidents daily during the morning clinical meeting to ensure completion of an assessment and documentation of the SBAR for 12 weeks. 5 residents and 5 staff will be interviewed weekly by the DON or Nurse Manager for 12 weeks regarding incidents to ensure the reporting of incidents. Any opportunities identified during these audits will be corrected by the Assistant Director of Nursing or Nurse Managers. 5. The results of these audits will be reported by the Assistant Director of Nursing at the monthly QAPI meeting. A QAPI meeting was held on 2/9/23 to review this plan. The QAPI Committee will make recommendations as needed. Completion date is 02/10/23 On 2/23/23 the facility's corrective action plan was validated for the compliance dated of 02/10/23 through staff interviews and review of in service training records (sign-in sheets), it was confirmed all current staff reeived education by 2/9/23. Interviews confirmed the facility was trained to perform assessments on residents when any change of condition occurred. Staff were able to verbalize the need to notify a nurse immediately in the event a change of condition is noticed. The nurses verbalized they were to assess a resident immediately and document the result in a progress note, complete an incident report, e-interact form, and notify both the medical provider and the family to the noted changes. All staff were able to verbalize that witness statements would be obtained and provided for the Director of Nursing and/or the Administrator on the date of the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of manufacturer's instructions, Nurse Practitioner, Medical Director, resident and staff interviews, the facility failed to ensure securement was according to manufacturer's recommendations to provide a safe van transport. Resident #1 fell out of her wheelchair onto her right side on the floor of the van with her wheelchair on top of her body after the transportation van made a left turn and stopped suddenly. The resident experienced pain in her back and right leg and was later sent to the emergency department and diagnosed with moderate spinal canal stenosis at L3-L4 with possible right paracentral disc protrusion (ligaments from the spinal disc are intact, but form a pouch that presses on the nerves) for 1 of 1 resident reviewed for accidents (Resident #1). The findings included: Review of the manufacturer's instructions for the van's locking system which is the system used on the facility's transport van to secure residents who are seated in wheelchairs during transport indicated: - secure each of the 4 retractors, 2 in front of the wheelchair and 2 in the rear metal locking link devices attached to the van floor - secure the patient with a seatbelt and shoulder harness device - pull each belt snug to ensure it is locked into place Resident #1 was re-admitted to the facility on [DATE] with diagnoses that included end stage renal disease (ESRD) and chronic pain syndrome. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 was cognitively intact, no behavioral concerns, required 1-person physical assistance with transfers, was able to self-propel her wheelchair with supervision assistance, and walked with 1-person physical assistance. The assessment further indicated that Resident #1 did not receive scheduled pain medications, but 7 days of opioid medications prescribed on an as needed frequency and 7 days of anticoagulant mediations. A review of the Medication Administration Record (MAR) dated February 2023 revealed Resident #1 was ordered to receive dialysis three times per week on Tuesday, Thursday, and Saturday. The MAR indicated Resident #1 received dialysis on Saturday, 2/4/23. An incident report initiated on 2/6/23 by the former Director of Nursing (DON #1) and dated 2/4/23 at 2:05 PM indicated Resident #1 was being transported to the facility from dialysis after the Transportation Aide secured Resident #1 in and ensured buckle was on, she stopped at a red light and Resident #1 fell out of her wheelchair. The report indicated the Transportation Aide attempted to pick Resident #1 up from the vehicle but was unsuccessful and flagged down a fire truck and firefighters were able to assist Resident #1 back into her wheelchair. A review of the nurse progress notes dated 2/4/23 and 2/5/23 revealed there was no documentation of Resident #1's fall from the wheelchair during transport in the facility van. A telephone interview with the former Director of Nursing (DON #1) on 2/20/23 at 12:50 PM revealed on 2/5/23 around 5 PM she received a phone call from the transportation aide who told her Resident #1 had fallen out of her wheelchair on the return trip from dialysis on the morning of 2/4/23. DON #1 instructed the Transportation Aide to go to the facility and tell Resident #1's nurse to complete an incident report. DON #1 stated she did not contact the facility on 2/5/23 and DON #1 was unable to provide any additional information regarding the incident on 02/04/23 because she was suspended from the facility. A progress noted written by the Nurse Practitioner (NP) dated 2/6/23 indicated Resident #1 was referred by nursing for right leg pain. The note detailed Resident #1 was involved in an incident on the transportation van over the weekend which resulted in her slipping out of her wheelchair onto the floor of the vehicle. It further indicated Resident #1 did not have her belts in place and had pain to her right leg since the time of the incident. An order for an x-ray of the right hip and pelvis was provided to rule out occult processes (a concealed or uneasily detected underlining disease). A review of the physician's orders revealed Resident #1 had an order for an x-ray of the right hip and pelvis dated 2/6/23. A radiological report dated 2/6/23 revealed an x-ray was obtained of the right hip and pelvis which indicated no fractures or dislocations were noted. A nurse progress noted written by Nurse #4 dated 2/6/23 at 4:04 PM revealed the x-ray results were communicated by staff to Resident #1 who requested further evaluation and was then transported to the ER via ambulance. A review of the emergency room and ER radiological studies dated 2/6/23 indicated Resident #1 was assessed to have lumbar spinal tenderness upon examination by the ER provider and the CT scan resulted in moderate spinal canal stenosis at L3-L4 with possible right paracentral disc protrusion. The document referenced needed treatment to include ongoing pain management and a referral to an orthopedic therapist for therapy. Resident #1 was discharged back to the facility the same day. A 5-day facility reported incident report completed by the current Director of Nursing (DON #2) dated 2/13/23 indicated on 2/4/23 Resident #1 sustained a fall during the transportation in the facility van following an appointment from dialysis. It further indicated the facility was notified of the accident on 2/5/23 at 9:00 AM by the Transportation Aide. The document indicated Resident #1 slid out of her wheelchair and no injuries were noted. It further detailed Resident #1 reported to the Administrator that the Transportation Aide had not secured the wheelchair to the van floor, nor did she tightly secured the seatbelt around her when she was loaded into the van on 2/4/23. When the van made a turn, the wheelchair began to roll, and Resident #1 slipped out of it and the wheelchair landed on top of Resident #1. Later in the evening on 2/4/23 and on 2/5/23, Resident #1 began complaining of pain to her lower extremities and was given a PRN (as needed) pain medication which was somewhat helpful. On Monday, 2/6/23, Resident #1 complained of her leg hurting and burning sensation and an x-ray was ordered and obtained which resulted in no acute fractures or dislocations. Resident #1 then requested further evaluation and was sent to the emergency room (ER) where a computer tomography (CT) was performed which indicated Resident #1 had a bulging disc at T4 (thoracic vertebrae #4). An interview with Resident #1 was conducted on 2/20/23 at 10:10 AM. Resident #1 was lying in her bed with the lights off and immediately voiced she was in pain in her lower back and right lower extremity. Resident #1 described the pain as a level 12 on a 1-10 scale (10 being the worst). Resident #1 stated she had some slipped discs in her lower back following a fall during transport in the facility van on 2/4/23 after an appointment with the local dialysis center. Resident #1 explained she was sitting in her wheelchair when the former Transportation Aide made a left turn and suddenly stopped which caused Resident #1 to be projected out of her wheelchair and into the aisle on the floor in the van. Resident #1 stated at the time of the fall, the wheelchair was not securely fastened to the van using the securing straps which caused the wheelchair to land on her when she fell out onto the van floor. Resident #1 explained when the Transportation Aide loaded her in the van, the straps which secure the wheelchair were not tightly strapped to the wheelchair and the shoulder harness/lap restraint portion was not in place. Resident #1 indicated she did not say anything to the Transportation Aide before she was in transport about the securement device not being intact. The Transportation Aide flagged down the firefighter for assistance to lift her back to her wheelchair. Resident #1 stated she initially had some pain; however, the intensity increased later that evening and over the next couple of days, but she was afraid to vocalized too much increase in severity to avoid getting questioned about not reporting the incident on the date of the occurrence. The Resident stated eventually her pain escalated to a level she felt needed to be treated more than with her routine PRN medication. Resident #1 explained on 2/6/23 she requested an emergency room evaluation and was sent to the ER and discovered she had suffered from a slipped disc and provided pain management and referred to the orthopedic outpatient center. An unsigned copy of a written statement by the former Transportation aide dated 2/5/23 read as follows: Yesterday I went to pick up Resident #1 from dialysis. I got her in the van, I secured her in the chair, and I put her seat belt on and left the dialysis place. At the light after making 3 left turns I stopped at the red light and she fell off her chair. Apparently, Resident #1 took off her seat belt and I was not aware of it so I put the van in park and I went to her. I couldn't pick her up and I saw a fire truck going by and I flagged them down. They came to help. They asked Resident #1 if she was hurting anywhere, she said no. They asked her if she wanted to go to the hospital, she said no. They asked her if she was OK, she said yes and asked to be put back in her wheelchair. She asked me not to say anything. Transportation Aide told Resident #1 she had to report the incident. Resident #1 said no don't, you're going to get in trouble, don't say anything, so I agreed to take her to the facility she was fine and moving around. An interview with the former Transportation Aide on 2/20/23 at 12:05 PM revealed she was suspended from the facility on 2/6/23 and terminated on 2/9/23 following a fall in the van involving Resident #1. The Transportation Aide stated she was scheduled to pick up Resident #1 from dialysis on 2/4/23. Upon arrival to the dialysis center around 10:30 AM, she loaded Resident #1 into the van and quickly fastened her in. The Transportation Aide explained shortly after the transport began, she was approaching a stop light at an intersection, she heard Resident #1 say oh, oh and she looked back towards Resident #1 and discovered Resident #1 was no longer in her wheelchair and was laying on the floor of the van with her wheelchair no longer fastened to the floor of the van. The Transportation Aide expressed she immediately put the vehicle in park in the middle of the road, got out and slid along the side of the van to the door where she was able to access Resident #1 and tried to lift Resident #1 out of the floor but was unable to and acknowledged she needed assistance to lift Resident #1 back into her chair. The Transportation Aide stated she got back out of the van and ran into the middle of the street where she saw a fire truck passing by and flagged the fireman down for assistance. The Transportation Aide detailed she and the firefighter placed Resident #1 back in her wheelchair and she was brought back to the facility then left her in her room and did not report the fall to Resident #1's assigned nurse nor administration at that time. The Transportation Aide reported it was not until the following evening following a conversation with Resident #1, (2/5/23) she notified DON #1 via telephone to make her aware of the fall. The Transportation Aide said DON #1 told her to come to the facility and leave a statement for her and to ask the assigned nurse to complete an incident report. The Transportation Aide further reported when she arrived at the facility to write a statement, she approached Nurse # 1 about completing an incident report of which she refused stating she was not involved. The Transportation Aide explained it was not until the following day (2/6/23) she was asked further about the fall and was suspended. An interview with Nurse #1 on 2/21/23 at 11:00 AM revealed she was assigned to Resident #1 from 7AM to 7 PM on both 2/4/23 and 2/5/23. Nurse #1 indicated she did not learn about the fall involving Resident #1 until she was on a telephone call with Nurse #4 on 2/6/23 about something unrelated and overheard DON #2 notify Nurse #4 about the incident. Nurse #1 stated she was asked if she knew about the incident because she had not been notified in the oncoming shift report and Nurse #1 told her she was not aware of the incident herself. Nurse #1 explained she was on duty around 6 PM on 2/5/23 when the Transportation Aide arrived to the facility and mentioned she needed to write a statement about some incident with buying cigarettes involving Resident #1 of which Nurse #1 admitted she did not feel the need to write an incident report and told the Transportation Aide she was not completing one but to leave the statements for DON #1 and/or the Administrator and it would be handled when they arrived the following morning and therefore did not ask any further questions. Nurse #1 acknowledged Resident #1 expressed mild asymptomatic pain at times over the weekend, but she thought the pain was the same pain she routinely described, and she was not anything acute therefore no assessment was completed at the time. An interview with Nurse #2 on 2/21/23 at 11:30 AM revealed she was assigned to Resident #1 from 7 PM to 7 AM on 2/4/23 and 2/5/23. Nurse #2 indicated she was not aware of the fall until 2/11/23 when she returned to work. Nurse #2 stated Resident #1 expressed some hip and lower extremity discomfort and received her scheduled PRN pain medication and Resident #1 was not evaluated further due to long term complaints of pain on the weekend of the fall An interview with the Medical Director (MD) on 2/21/23 at 12:31 PM revealed he was made aware of the fall involving Resident #1 on 2/7/23 when he arrived at the facility for routine rounds. The MD stated he had been told that Resident #1 was not properly secured in the facility van during the transport on 2/4/23 and had been evaluated by ER staff to have a disc protrusion and was experiencing lower lumbar pain that radiated to her sides. The MD indicated he could not say for sure that the injury was a result of Resident #1 sustaining a fall during transport or not, but that it was a possibility. A handwritten statement written by the Administrator dated 2/6/23 indicated Resident #1 came into the Administrator's office on 2/6/23 at 10:59 AM and stated she had fallen in the transportation van on 2/4/23 with Transportation Aide who did not put her seat belt on. Resident #1 stated that Transportation Aide was fabricating stories and telling people that Resident #1 had unstrapped her seat belt but that was not true. Resident #1 also stated that the Transportation Aide told her not to tell anyone and she had text messages regarding the conversation. The Administrator asked how Resident #1felt and she said she was okay, just a little pain. An interview with the Administrator on 2/23/23 at 10:15 AM revealed during her morning commute to the facility on 2/6/23, she learned of the fall experienced by Resident #1 on 2/4/23 while in transport from the dialysis. The Administrator indicated when she arrived, she placed all staff involved on suspension and began her investigation. She indicated that the Transportation Aide should have immediately pulled the van over, called emergency services to ensure Resident #1 was safe and without injury before moving her followed by contacting the facility Administrator and the Director of Nursing and/or the Manager on Duty (MOD). On 2/20/23 at 5:20 PM, the facility Administrator and Regional Corporate Consultant were notified of the Immediate Jeopardy. The facility provided the following corrective action plan with a compliance date of 02/10/23. 1. The facility failed to secure Resident #1 in her wheelchair while being transported from dialysis in the facility van on 2/4/23 at approximately 10:30 AM which resulted in a fall to the van floor when the van made a stop and her wheelchair landed on top of her. Resident #1 was lifted back into the wheelchair by the transporter Nurse Aide and a member of the local fire department. Resident #1 had pain which continued to her low back and right leg and was subsequently sent to the emergency room for evaluation per resident's request on 2/6/23 where a CT scan reflected a bulging disc to L4-S1 and a referral to the orthopedic surgeon for ongoing care. 2. On 2/6/23 the facility immediately suspended the transporter and the Director of Nursing and initiated an investigation of this event. On 2/6/23 the Administrator suspended all transports using the facility van. A 24-hour report was submitted and a call to Adult Protective Services completed. On 2/6/23 an incident report was initiated and an investigation into the event began and included an interview with the resident, transporter, and Director of Nursing. An audit of current residents transported during the last 30 days was completed by the Assistant Director of Nursing and Nurse Managers on 2/8/23 to identify any other residents possibly affected by the same practice. Any unreported events were documented on an incident report, investigated, an assessment of the resident completed, documented in the medical record and Physician and Responsible Party were notified by the Assistant Director of Nursing and Nurse Managers by 2/9/23. By 2/9/23 the Assistant Director of Nursing, Nurse Manager, Social Worker and Regional Director of Clinical Services conducted interviews with current residents to identify any unreported incidents during the last 30 days. Any new incidents identified were reported to the Assistant Director of Nursing and Administrator for further investigation, resident assessment and notification of responsible party and physician. By 2/9/23 the Assistant Director of Nursing, Nurse Manager and Regional Director of Clinical Services completed a record review of all incidents and accidents to ensure completion of a nursing assessment and notification to the responsible party and physician. Root cause analysis for Resident #1 was conducted by the Assistant Director of Nursing, Medical Director, Administrator and Regional Director of Clinical Services on 2/9/23 and it was determined the transporter failed to follow manufacturer guidelines for securing a wheelchair in the van prior to transport. 3. Beginning 2/6/23 outside transportation services will be used for all required transports permanently, facility van keys secured with the Administrator until the facility van is relocated from the facility parking lot. Current and ongoing appointments were scheduled with the outside transportation service by the Assistant Business Office Manager on 2/6/23. The Assistant Business Office Manager was trained on this change of system by the Regional Director of Clinical Services on 2/6/23. 4. The Nurse Manager trained the Assistant Business Office Manager to randomly observe resident being secured in the outside transport van prior to leaving the facility, training included instruction to stop the transport in the event the wheelchair is not secured or the seatbelt is not in place and report to the Administrator or Assistant Director of Nursing immediately. The outside transportation service provided the Regional Director of Operations with proof of training on securing a resident in the outside transport van prior to moving the van. The results of these audits will be reported by the Assistant Director of Nursing at the monthly QAPI meeting. A QAPI meeting was held on 2/9/23 to review this plan. The QAPI Committee will make recommendations as needed. Compliance date is 2/10/23 On 02/23/23 the corrective action plan was validated for a compliance date of 02/10/23 through observations, staff interviews and review of in-service training records. Observations confirmed the facility no longer uses their own transportation van. Staff were able to verbalize the process of the facility for notifying the nurse and administrative staff of any incident and validate their observations and knowledge immediately and document all necessary details. Review of audit reports verified the system for monitoring to ensure residents were secured for transportation. The Buisness Office Manager (BOM) verified that she is responsible to visualize random residents transported via a contrated transport company.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of facility smoking policy dated 10/22/20 revealed residents who smoke would be assessed using the resident safe smoking assessment during the admission process and during each quarterly or comprehensive Minimum Data Set (MDS) assessment process. Resident #16 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of resident safe smoking assessment dated [DATE] completed by Nurse #4 revealed Resident #16 met the criteria for a safe smoker but was checked as requiring supervision while smoking. Nurse #4 was not available for interview. The revised care plan dated 08/28/22 revealed Resident #16 was a smoker, and the goal was smoking without supervision or assistance out of the facility door and while smoking through next review date. Resident #16's interventions included, in part, required supervision while smoking, and required assistance entering and exiting smoking area door. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #16 was cognitively intact. There were no further smoking assessments completed for Resident #16 from 5/6/22 through 12/14/22. Observation and interview with Resident #16 on 12/13/22 at 10:30 AM revealed her outside smoking in the designated smoking area while being supervised by nursing staff. Resident #16 was able to smoke and extinguish her cigarettes with no issues or concerns observed. She stated she was only allowed to smoke during scheduled smoking times while staff were present, and they provided her with her cigarettes and lighter. She revealed she was not allowed to smoke outside by herself because she has trouble getting in and out of the door to the smoking area, so staff had to be with her to help her. An interview conducted with Nurse #2 on 12/13/22 at 12:33 PM revealed she was familiar with Resident #16 and her being a supervised smoker. She stated Resident #16 required supervision while smoking due to her requiring assistance with entering and exiting the doors to the smoking area. She revealed she does not recall how she was made aware of Resident #16 requiring supervision while smoking but believed she has been a supervised smoker since her admission. An interview conducted with Regional Director of Clinical Services (RDCS) and Director of Nursing (DON) on 12/15/22 at 6:08 PM revealed they were familiar with Resident #16 and her being a supervised smoker due to requiring assistance with entering and exiting the smoking area door. The RDCS and DON stated resident smoking assessments should be completed upon admission, quarterly, annually, and when any significant changes occur, and they were not aware Resident #16's smoking assessment had not been completed since May 2022. The RDCS and DON revealed the MDS nurse was responsible for notifying the DON when resident smoking assessments were due, and the DON would assign nursing staff to complete them and had no knowledge why a smoking assessment had not been completed for Resident #16 since May 2022. The RDCS and DON also revealed they were not aware there was no documentation made on Resident #16's smoking assessment (dated 05/05/22) explaining that she was deemed a supervised smoker due to requiring assistance with entering and exiting the door to the smoking area. They indicated this should be documented on the smoking assessment for nursing staff to be able to review. The RDCS and DON stated going forward all nursing staff and the MDS Nurse would be educated on completing smoking assessments for all residents accurately and timely. An interview conducted with the MDS Nurse on 12/15/22 at 02:54 PM revealed she had only been working at the facility since September 2022 and was in the process of making sure all resident assessments were up to date. She stated resident smoking assessment reminders would be sent out to the DON prior to quarterly and annual MDS being due so they could be completed timely, and it would be the responsibility of the DON and nursing staff to notify of any changes with smoking status. An interview was conducted with Administrator on 12/15/22 at 7:13 PM and revealed all resident smoking assessments should be completed accurately and timely. 4. Review of revised facility smoking policy dated 10/22/20 revealed if a resident who smoked experienced any decline in condition or cognition, he or she would be reassessed for ability to smoke independently and evaluate whether any additional safety measures were indicated. Resident #36 was admitted to the facility on [DATE] and readmitted on [DATE]. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #36 was cognitively intact and was coded for tobacco use. Review of a physician order dated 12/02/22 revealed Resident #36 to receive continuous supplemental oxygen at 4 liters via nasal cannulas every shift. Review of a re-entry resident safe smoking assessment completed by Nurse #3 dated 12/02/22 revealed Resident #36 was deemed safe (unsupervised) smoker. Question C5 pertaining to resident use of supplemental oxygen was answered no although Resident #36 was readmitted to facility with an order for supplemental oxygen dated 12/02/22. Directions for completion of section C located on the resident safe smoking assessment revealed if question C5 was answered yes for use of supplemental oxygen then the resident must be at minimum a supervised smoker. Observation of Resident #36 on 12/12/22 at 10:35 AM revealed her outside smoking unsupervised without her oxygen in the designated smoking area. There were no staff present while Resident #36 was smoking, and she was able to smoke with no issues or concerns observed. The revised care plan dated 12/13/22 revealed Resident #36 was a smoker, and the goal was practicing safe smoking through the review date. Interventions included, in part, educate Resident #36 on risk and benefit of smoking while on oxygen, smoking cessation and use of nicotine patch. Ensure Resident #36 does not wear oxygen outside to smoke and instruct about facility policy on smoking locations, times, and safety concerns. Resident #36 was reassessed as an independent smoker. A telephone interview was conducted with Nurse #3 on 12/14/22 at 8:27 AM and revealed she was familiar with Resident #36 and her being assessed an independent safe smoker. She stated she did recall completing the resident safe smoking assessment when Resident #36 was readmitted from the hospital to the facility on [DATE] and assessed her as being a safe smoker. She revealed Resident #36 had been assessed a safe smoker at the facility prior to her hospital stay and to her knowledge there had been no changes to her ability to smoke safely. Nurse #3 stated she did not recall if she had been made aware Resident #36 was readmitted with an order for continuous oxygen before she completed the resident safe smoking assessment. She revealed she was not aware residents receiving supplemental oxygen were to be at a minimal a supervised smoker according to the resident safe smoking assessment and if she had known she would have assessed Resident #36 correctly. An interview was conducted with Nurse Practitioner (NP) #1 on 12/14/22 at 4:02 PM revealed she was familiar with Resident #36. She stated Resident #36 had health issues where her oxygen levels would drop and required her to be on continuous oxygen. She revealed Resident #36 had also been deemed an independent smoker and was allowed to smoke anytime of the day or night. NP #1 stated Resident #36 would refuse to wear her oxygen so she could stay outside and smoke which caused her oxygen levels to drop and her having to be sent out to the hospital for treatment. She stated she had safety concerns with Resident #36 being deemed an independent smoker due to her oxygen levels dropping. NP #1 reviewed the resident safe smoking assessment and stated she was not aware Resident #36 should have been a supervised smoker if receiving supplemental oxygen. She revealed Resident #36 would have benefiting from being a supervised smoker and having scheduled smoking times, it would have helped with her oxygen levels in general. A follow up interview conducted with Nurse Practitioner (NP) #2 on 12/15/22 at 12:48 PM revealed Resident #36 would benefit from being a supervised smoker and having supervised smoking times would help with her being more compliant with her oxygen and her care. She stated she was not aware residents receiving supplemental oxygen should be deemed supervised smokers on the resident safe smoking assessment and all resident assessments should be completed correctly. An interview was conducted with Director of Nursing (DON) and Regional Director of Clinical Services (RDCS) on 12/15/22 at 6:18 PM revealed they were familiar with Resident #36 and her being assessed as an independent safe smoker. The DON and RDCS stated Resident #36 was ordered supplemental oxygen, but because she refused to wear her oxygen, they did not believe the question on the resident safe assessment pertaining to supplemental oxygen applied to her. The DON and RDCS revealed resident smoking assessments should be completed accurately and timely and according to Resident #36's continuous supplemental oxygen order, she should have been assessed as a supervised smoker. An interview was conducted with the Administrator on 12/15/22 at 7:10 PM revealed all resident smoking assessments should be completed accurately and reflect all current physician orders. 2. Resident #25 was admitted to the facility on [DATE] with diagnoses that included hepatic failure, right foot drop, osteoarthritis, contracture of the left hand and right hand, and muscle weakness. The significant change in status Minimum Data Set assessment dated [DATE] indicated Resident #25 was moderately cognitively impaired and required extensive assistance of 2 staff to accomplish activities of daily living (ADL) including bed mobility and toileting. Resident #25 had impairment to both sides of her upper extremities, weighed 258 pounds and received hospice care at the time of this assessment. The Care Area Assessment summary indicated Resident #25 was at risk for falls due to muscle weakness, medication use, impaired mobility, and incontinence. Resident #25's care plan revised on 11/5/22 indicated Resident #25 had ADL self-care performance deficit related to activity intolerance, fatigue, impaired balance, limited mobility, and right foot drop. Interventions included Resident #25 required extensive assistance by 2 staff to turn and reposition in bed on care rounds and as necessary. Resident #25's care guide revised on 11/5/22 indicated she required extensive assistance by 2 staff to turn and reposition in bed on care rounds. An incident report dated 11/26/22 at 1:09 AM indicated Nurse #1 was called to Resident #25's room by Nurse Aide (NA) #1. Upon arrival, Resident #25 was witnessed kneeling on the fall mat with her upper body resting on the bed. Resident #25 was alert and complained of pain to bilateral knees. NA #1 was present during incident that occurred while providing care to Resident #25. NA #1 stated that Resident #25 was lying on left side in bed when the right leg slid, and Resident #25 landed on her knees on the fall mat. Full body assessment done. Vital signs as follows: blood pressure of 105/65, pulse of 82, respiratory rate of 20, temperature of 97.9, oxygen saturation of 96% on oxygen at 2 liters/minute via nasal cannula. Redness noted on the left thigh with no active bleeding. Pain medication administered. Resident #25 was sent out to the ER (emergency room) for further evaluation. Nurse Aide (NA) #1's statement dated 12/1/22 indicated that on Friday, 11/25/22, NA #1 assisted Resident #25 with changing her brief. NA #1 cleaned her up, turned her on her side and made sure she was holding on to the bed rails. After that she placed a brief under her and at the same time Resident #25 rolled onto the floor on the fall mat on her knees while still holding onto the bed rails. NA #1 immediately stepped out of the room, motioned for Nurse #1 to let her know that Resident #25 was on the floor. Nurse #1 came in, saw Resident #25 on her knees on the fall mat and went to get NA #2. NA #2 came in and they laid Resident #25 flat on the fall mat. NA #1 went and got the total mechanical lift so they could get Resident #25 in her bed. After that NA #2 and NA #1 put Resident #25's brief on while Nurse #1 asked her if she was in pain. Resident #25 said yes, and Nurse #1 went to get her some pain medication. About 30 minutes later, Resident #25 said she was still hurting, and Nurse #1 said she gave Resident #25 all the pain medicine she could give her. Nurse #1 asked Resident #25 if she wanted to be sent out, if she wanted to call a doctor or call her family but Resident #25 said no, she was okay but was still in pain. A phone interview with Nurse Aide (NA) #1 on 12/14/22 at 10:57 AM revealed the fall incident that involved Resident #25 happened on 11/25/22 around 9:30 PM when she went in by herself to Resident #25's room to change her brief and provide incontinence care to her. NA #1 stated when she walked into the room, Resident #25's bed was already at her waist level, so she didn't need to raise it up. Resident #25 had an air mattress on her bed. NA #1 stated she cleaned Resident #25's front perineal area and then turned her to her left side, facing the door. NA #1 stated she made sure Resident #25 was holding on to the bed rail after she turned her. NA #1 cleaned Resident #25's back side and got a brief ready to place on her. When NA #1 placed the brief underneath Resident #25's buttocks, Resident #25 rolled onto the fall mat with her knees first. While Resident #25 was on her knees on the fall mat but still holding on to the side rail with her hands, NA #1 stepped over to the door and motioned for Nurse #1 who was standing in the hallway by her medication cart to come into the room. When Nurse #1 walked into the room, Resident #25 was still holding on to the side rail with her hands, but she was on her knees on the fall mat. Nurse #1 went to get NA #2 while NA #1 continued to stay with Resident #25. They laid her flat on the fall mat on the floor. Resident #25 complained of pain to her knees and legs. Nurse #1 continued her assessment and gave Resident #25 her pain medication. NA #1 then obtained the total mechanical lift, and they transferred Resident #25 back to her bed. NA #1 further stated that after 15-20 minutes she checked on Resident #25 again and she was still in pain but at that time she refused to be sent out to the hospital. NA #1 stated that this was her first time working with Resident #25 and she did not know that she was supposed to have two staff member assistance. NA #1 also stated that NA #2 gave her report when she started her shift, but he did not mention about Resident #25 needing the assistance of two staff members for incontinence care. A phone interview with Nurse #1 on 12/13/22 at 12:10 PM revealed she was doing her medication pass around 9:30 PM on 11/25/22 when NA #1 came to the door and motioned to her to come to Resident #25. When Nurse #1 entered Resident #25's room, she observed Resident #25 kneeling in front of her bed with her upper body still on the bed and her knees on the fall mat beside her bed. NA #1 told her that she was providing incontinence care to Resident #25 and had her turned towards her left side with her right leg crossed over her left leg as she was cleaning her. And then Resident #25 started sliding off the bed with her knees first. Resident #25 told Nurse #1, I can't be in this position. My knees are killing me, with her knees bent on the fall mat. Nurse #1 exited Resident #25's room to get NA #2. After assessing Resident #25, they transferred her back to bed using a total mechanical lift. Nurse #1 stated she observed some redness on Resident #25's left thigh but she did not notice any bruising or swelling. Resident #25 complained of pain to both knees, and she gave her prn (as needed) pain medication. Nurse #1 also obtained an order for x-ray after she notified the provider on-call about Resident #25's fall and pain to both knees. Resident #25 kept on calling staff to her room over and over because of pain to her knees so Nurse #1 offered to send her to the hospital if the pain was unbearable. At first, Resident #25 refused to go to the hospital and stated to her that she felt some relief but after a few minutes, Nurse #1 learned that Resident #25 had called EMS (emergency medical services) herself and that she had changed her mind and wanted to go to the hospital instead. Resident #25 told Nurse #1 that the pain was unbearable and that she had decided to go to the hospital. Nurse #1 stated that Resident #25 required 2 staff assist with ADL in bed and that NA #1 should have called another staff member to help her while providing care to Resident #25. Nurse #1 stated that Resident #25 was able to move her arms some but couldn't move her legs. Resident #25 had been bed bound and had never been on her knees before. Attempts were made to contact NA #2 on 12/14/22 at 10:04 AM, 12/15/22 at 9:51 AM and 12/15/22 at 4:31 PM but they were unsuccessful. An interview with the Therapy Manager on 12/13/22 at 3:10 PM revealed she was familiar with Resident #25, and they had provided occupational therapy treatment to her due to her hand contractures. Resident #25 was barely able to bend both legs with the right leg worse than the left leg. She couldn't bear any weight on her legs and required a total mechanical lift for transfers. Resident #25 was dependent on staff assistance with mobility which meant she couldn't do anything by herself. She stated they had recommended for nursing to have at least 2 staff members present during care in the bed mainly because of her weight and her impaired mobility. A review of the hospital discharge summary revealed Resident #25 was admitted to the hospital on [DATE] and discharged to another facility on 12/6/22. Her admitting diagnoses included a closed fracture of the left tibial plateau (top surface of the tibia or shin bone), a closed fracture of the right femur (thigh bone), and a closed traumatic fracture of the left tibial plafond (end of the shin bone and involves the ankle joint). Orthopedics was consulted and they opted for non-surgical management. Resident #25 complained of severe pain to both knees which was worsened by movement and alleviated by nothing. Resident #25 was discharged from the hospital on [DATE] to another skilled nursing facility with hospice (which she had prior to hospital admission). An interview with Nurse Practitioner #2 on 12/15/22 at 12:48 PM revealed she was familiar with Resident #25 and knew she needed total assistance with bed mobility. Resident #25 was not able to move herself in bed and required two staff members with incontinence care and with any care in the bed. An interview with the Medical Director on 12/15/22 at 2:32 PM revealed Resident #25 required assistance from 2 staff members with incontinence and ADL care. He stated he found out that Resident #25 fell after the incident had occurred, but he wasn't aware that her fall was caused by one staff member taking care of her. He further stated there should have been two staff members providing care to her while she was in bed due to her impaired mobility. An interview with the Director of Nursing (DON) on 12/14/22 at 10:41 AM revealed she became aware of Resident #25's fall on 11/28/22 when Resident #25's family member called her. The DON stated she talked to Nurse #1, NA #1 and NA #2 and she found out that NA #1 had gone in to provide incontinence care to Resident #25 by herself. The DON stated there should have been 2 staff members to provide care to Resident #25. They had enough staff that day for them to pair up and provide care to the residents for each hall. She further stated NA #1 was an agency nurse aide, but NA #2 had oriented her about her assigned residents at the start of her shift. NA #2 was supposed to have shared with NA #1 information about the residents such as how they ate, if they required assistance with eating, what size of brief they wore, how they transferred and whether they required one or two persons for turning and repositioning in bed. The DON stated the facility used care guides and NA #1 should have looked at it prior to providing care to Resident #25. The Administrator was notified of immediate jeopardy on 12/14/22 at 2:50 PM. The facility provided an acceptable removal action plan on 12/21/22 that read: *Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident #114 with history of left below the knee amputation was having ADL (Activity of Daily Living) care provided related to an incontinent episode on 11/17/22. When the resident was rolled over to the left, her legs continued to roll off over the side of the bed. Nurse Aide #3 yelled for help and Nurse #3 came to assist him. The Nurse was able to hold the resident's leg and assist her back onto the bed. As a result of this event, Resident #114 received a non-displaced, comminuted, proximal tibia-fibula fracture of the right leg. Resident #25 had a fall from the bed on 11/25/22. Resident #25 was receiving ADL care while in bed. While being turned and repositioned, her legs rolled off the bed and landed on the floor mat at the bedside. She was assessed for injury then assisted back to bed. At that time, she was given as needed medication and stated that she had some relief. Shortly thereafter, she called 911 and stated that she now wanted to go to the hospital but had refused to go when asked by the nurse earlier. On 11/21/22 the DON (Director of Nursing) and ADON (Assistant Director of Nursing) initiated education to current nursing staff regarding safe turning and repositioning. Education was not completed by all nursing staff prior to the next event occurring on 11/25/22. Root cause analysis for Resident #25 was conducted by the DON, NHA (Nursing Home Administrator) and RDCS (Regional Director of Clinical Services) on 11/29/22 and it was determined the Nurse Aide failed to have 2 staff members present while providing care for a dependent resident resulting in a fall out of bed. Root cause analysis for Resident #114 was conducted by the DON, Medical Director, NHA and RDCS on 12/20/22 and it was determined the Nurse Aide failed to have another staff member present while providing care for a dependent resident resulting in an awkward sliding of the lower extremities off the side of the mattress. *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. On 11/29/22 a review of the Resident #25's current mobility assessment was completed and verified that she required two persons to assist with bed mobility and ADL care. The DON created a new assignment sheet to include the amount of assistance each resident requires for bed mobility and ADLs. This assignment sheet will be accessible to Nurses and Nurse Aides, in a notebook labeled Assignment Sheets, at the Nurses station. This assignment sheet will be updated daily to include new admissions and readmissions by the DON and ADON during the morning clinical meeting. The DON and ADON were educated by the RDCS on this new process on 11/29/22. DON and ADON completed an audit on 11/29/22 of all current residents to identify required staff assistance for bed mobility and ADLs. On 11/29/22 care plans were revised by the DON, ADON and MDS (Minimum Data Set) Nurse to include 1- or 2-person assistance when providing care for dependent residents. Residents #25 and #114 were no longer in the facility. The DON, ADON and RDCS re-educated all current nursing staff (Nurses and CNAs) including agency staff on safe technique for assisting with bed mobility, turning, and repositioning with incontinent care and ADLs, utilizing the resident assignment sheet to determine assistance required prior to providing care and the location of the assignment sheets at the nurse's station, by 12/20/22. After 12/20/22, the DON and Nurse Managers will ensure no nursing staff will be allowed to work, including any new hired staff and agency staff, without receiving this education. A QAPI (Quality Assurance and Performance Improvement) meeting was held on 12/20/22 to review this plan. The QAPI Committee will make recommendations as needed. Date of IJ Removal: 12/21/22 On 12/30/22, the facility's credible allegation for immediate jeopardy removal effective 12/21/22 was validated by the following: Staff interviews revealed they had received education on safe technique for assisting with bed mobility, turning, and repositioning with incontinent care and activities of daily living (ADL). Audits were completed of all current residents to identify required staff assistance for bed mobility and ADLs. A new assignment sheet was created and included the amount of assistance each resident requires for bed mobility and ADLs. Based on record reviews, and interviews with resident, family member, staff, Nurse Practitioner and Medical Director, the facility failed to provide care in a safe manner for 2 of 6 residents reviewed for supervision to prevent accidents (Resident #114 and Resident #25). On 11/17/22, Resident #114's lower half of her body went off the other side of the bed during incontinence care resulting in a non-displaced, comminuted (bone that is broken in at least two places) proximal tibia-fibula (explain) fracture of the right leg. The facility failed to investigate the injury and complete a root cause analysis and as a result no plan was in place to prevent further injury to residents. On 11/25/22, Resident #25 who required two staff member assistance with bed mobility, fell out of a raised bed onto the floor during incontinence care which resulted in a closed fracture of the left tibial plateau, a closed fracture of the right femur, and a closed traumatic fracture of the left tibial plafond (end of the shin bone and involves the ankle joint). She complained of severe pain to both knees which was worsened by movement and alleviated by nothing. In addition, the facility failed to complete accurate smoking assessments to provide a safe smoking environment for 2 of 2 residents reviewed for smoking (Resident #16 and Resident #36). Immediate jeopardy began on 11/17/22 when Resident #114 suffered an injury during incontinence care by one staff member that resulted in a non-displaced, comminuted proximal tibia-fibula fracture of the right leg and continued when Resident #25 fell out of a raised bed onto the floor during incontinence care by one staff member. Immediate jeopardy was removed on 12/21/22 when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) to ensure education and monitoring systems put into place are effective. Examples #3 (Resident #16) and #4 (Resident #36) were cited at a scope and severity level of D where a plan of correction is required. 1. Resident #114 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Her admission diagnoses included diabetes, osteopenia, and osteoporosis. Resident #114's admission Minimum Data Set (MDS) dated [DATE] revealed she was moderately cognitively impaired and was able to make all needs known. The MDS also revealed the resident required extensive assistance of 1 staff member for bed mobility and toileting (incontinence care) and extensive assistance of 2 staff members for personal hygiene. Review of Resident #114's baseline care plan dated 11/10/22 revealed a focus area for being at risk of falls. The interventions included anticipate and meet the resident's needs, be sure the resident's call light is within reach and encourage her to use it for assistance as needed, and resident needs prompt response to all requests for assistance. Review of Resident #114's chart revealed no progress notes regarding an injury to the resident or an assessment of the resident on 11/17/22. Review of a fall report completed by the Director of Nursing (DON) on 11/17/22 at 8:51 PM revealed the resident was being changed by 1 staff member and the lower half of her body went off the other side of the bed. An initial assessment was completed by Nurse #3 with no apparent injury. Phone interview on 12/13/22 at 4:48 PM with NA #3 who had been assigned to care for Resident #114 on 11/16/22 at 11:00 PM through 11/17/22 at 7:00 AM revealed the resident had not fallen out of the bed but had slid to the edge of the bed and her feet were dangling off the bed. NA #3 stated he was able to grab her at her midsection so she would not fall off the bed and flagged her nurse (Nurse #3) for assistance in getting her legs back on the bed. NA #3 further stated he had no idea how the resident could have broken her bones and was not sure if her leg had hit the wall or anything else while dangling off the bed. He indicated he yelled for help from the nurse while holding the resident's upper body to prevent her from falling from the bed. Phone interview on 12/13/22 at 3:03 PM with Nurse #3 who was assigned to Resident #114 on 11/16/22 at 7:00 PM through 11/17/22 at 7:00 AM revealed Nurse #3 had not witnessed what had happened on 11/17/22 around 5:30 AM but when she walked into her room the resident's upper body was on the bed and her legs were dangling off the bed. Nurse #3 further stated she went into the room and scooped the resident's legs and threw them back on the bed. She indicated NA #3 who was assigned to the resident was at the doorway to her room waving his arms and asking for assistance, so she had gone into the room to assist with her care. Nurse #3 further indicated she stayed in the room at her bedside until Resident #114's care was completed. She explained she could not remember if she assessed the resident because she had not actually fallen but her legs had slid off the bed. Nurse #3 further explained she had not notified the family because she had been told by NA #3 the resident had not fallen out of bed and said the resident was not complaining of pain at the time of the incident. Interview on 12/13/22 at 11:30 AM with Resident #114's family member revealed she met the resident at her appointment with the orthopedic surgeon on 11/17/22. The family member stated Resident #114 told her she had fallen out of bed around 5:30 AM and her right leg was hurting her when she moved it. The family member further stated she had to hold her mother's right leg up using a towel when she pushed her in the wheelchair because there was no footrest on her wheelchair. She indicated Resident #114 told the orthopedic surgeon that she had fallen out of bed around 5:30 AM on 11/17/22 and her leg was hurting so the orthopedic surgeon sent her back to the facility with an order for mobile x-ray to the right leg and hip. Review of a mobile x-ray report completed on 11/17/22 revealed the resident had an acute transverse fracture of the proximal tibia and fibula. Review of Resident #114's progress notes dated 11/18/22 revealed she was transferred to the local hospital for evaluation and treatment of her fractured tibia and fibula on the right leg. Review of the hospital Emergency Department (ED) notes dated 11/18/22 revealed the ED physician noted the resident's chief complaint was fall and leg injury (fell out of bed, placed back in bed), complained of leg pain at a level of 7 out of 10. The notes further revealed the resident was sent for a CT scan which showed the following: There is mild medial compartment knee osteoarthritis with posttraumatic soft tissue edema seen about the knee. The visualized osseous structures are diffusely decreased in mineralization consistent with osteopenia/osteoporosis. Impression: 1. Acute nond[TRUNCATED]