**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff, Nurse Practitioner (NP), and Responsible Party (RP) interviews, the facility failed to protect a cognitively impaired resident, Resident #6, when he was allowed to exit the facility through the locked main entrance door. Nurse Aide (NA) #1 unlocked and opened the door for Resident #6 and allowed him to leave the facility, in the dark, on the evening of 1/26/25. Resident #6 was found in the parking lot of a restaurant near a gas station 1.4 miles from the facility. There were multiple roads between the facility and where the resident was found including a divided 4 lane road, a 4-lane highway, sidewalks, posted speed limits of up to 45 miles per hour, in 38-degree Fahrenheit weather while wearing shoes, pajamas, a coat, and a hat. Upon being unable to locate Resident #6 Nurse #1 failed to immediately implement and activate the elopement process, which included notifying the police, when she became aware Resident #6 had left the building. After the facility initiated the elopement process, the resident was discovered by police who returned the resident to the facility. Due to the facility's noncompliance through allowing the resident to exit the facility followed by the failure to immediately contact the police, the resident's cognitive impairment, exposure to cold weather, time of day when the resident exited the facility, distance traveled by the resident, and having to traverse on sidewalks, possibly the road, and cross multiple roads there was the high likelihood of serious harm. The deficient practice was found for 1 of 2 residents reviewed for supervision to prevent accidents (Resident #6). Findings included: Resident #6 was admitted to the facility on [DATE] with diagnoses including dementia and congestive heart failure. The resident was discharged on 2/10/25. The admission wandering assessment dated [DATE] showed Resident #6 scored a two on the wandering risk assessment, which is low risk for elopement. The care plan dated 1/22/25 revealed Resident #6 was a wanderer and at risk for elopement due to wandering behavior and being disoriented due to new placement at the facility with a goal to minimize risks for elopement through current interventions over the next 90 days. Interventions included redirection away from exits as needed, provide diversional activities, and notifying the Director of Nursing (DON) of any exit seeking behaviors. During an interview with Nurse #2, Nursing Supervisor, on 2/25/25 at 3:07 pm, she indicated she completed Resident #6's care plan and that all residents who have at risk for elopement added to their care plans scored something other than zero on their assessment. She reported that Resident #6 had been admitted less than a week and had exhibited no exit-seeking behaviors. Nurse #2 stated, Resident #6 would be seen walking up and down the halls at times or sitting in the common area watching television. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had moderate cognitive impairment and wandering behaviors were indicated for 1 to 3 days. The MDS also indicated Resident #6 ambulated independently. A handwritten, undated, statement by NA #1 documented, around 11:00 pm, Resident #6 walked up and asked NA #1 to let him out of the building which NA #1 did because NA #1 thought Resident #6 was visiting. NA #1 wrote Resident #6 told NA #1 he had fallen asleep and that he needed to get home to [NAME]-Salem. NA #1 also wrote that they both walked together to the main entrance and the NA opened the door. Resident #6 then walked out of the building. During a phone interview with NA #1 on 2/25/25 at 2:25 pm, NA #1 reported not letting any residents out of the building. NA #1 reported seeing Resident #6 leaving the building around 11:00 pm but did not let Resident #6 out and was unaware who may have unlocked the door. NA #1 explained not recognizing Resident #6 as living at the facility because the NA had never worked with him, so the NA did not stop Resident #6 from leaving. NA #1 also indicated it wasn't unusual to see visitors coming and going at all times during the night, so the NA didn't question seeing someone leaving at that time. NA #1 indicated noticing Resident #6 was wearing dark shoes, a coat, and a hat the night of 1/26/25. NA #1 added not noticing Resident #6 was wearing flannel pajamas the night of 1/26/25. NA #1 explained the contradiction between the written statement provided regarding Resident #6 leaving the building compared to information shared during the interview was because the facility had NA #1 write what was in the written statement. A handwritten statement, undated, by Nurse #1 read, she saw Resident #6 walking down the hall toward the lobby. Nurse #1 indicated she redirected Resident #6 by having him follow her back toward his room. Nurse #1 wrote she went into the room next door to assist that resident and when she came out of that room several minutes later, she didn't see Resident #6 in the hallway anymore. Nurse #1 reported after looking for him around other units, she was advised by NA #1 that the NA saw the resident and that the NA let Resident #6 out of the building assuming he was a visitor. Nurse #1 documented all of the staff began searching for the resident and the Nursing Supervisor (Nurse #2) called the police and the DON (Director of Nursing). During an interview with Nurse #1 on 2/25/25 at 3:10 pm, she stated she was assigned to Resident #6 for the 7pm-7am shift on 1/26/25. Nurse #1 indicated Resident #6 liked to walk a lot but she had not seen him show any exit-seeking behaviors such as attempting to open outside doors. Nurse #1 reported she saw Resident #6 walking toward the lobby area from the 300 hall around 11:00 pm wearing his flannel pajamas and shoes. She indicated he wasn't wearing a hat or coat when she saw him walking in the hallway. Nurse #1 stated she had Resident #6 follow her back down the 300 hall toward his room where Nurse #1 left him as she went into Resident #6's neighbor's room to assist. Nurse #1 indicated that Resident #6 didn't seem distraught or express to her anything was wrong. Nurse #1 reported several minutes later, she came out of the room and noticed Resident #6 was not in the hallway anymore, so she looked in Resident #6's room, assuming he may have gone to bed, and then proceeded to look in all the rooms on the 300 hall without finding Resident #6. Nurse #1 then stated she expanded her search to other units before meeting NA #1 on the 100 hall who told her the NA let someone who matched the description of Resident #6 out of the building earlier. Nurse #1 explained the NA was unable to provide her with the exact time of when the resident had left the facility. Nurse #1 then reported she went out the front door and proceeded to look for Resident #6 throughout the facility parking lot, both the whole front and then the back lot where employees park, and to the street in front of the building before returning to the facility. Upon returning inside the facility Nurse #1 explained she went to find Nurse #2, Nursing Supervisor, to let her know Resident #6 was missing. Nurse #1 stated she searched for Resident #6 outside for only 5-10 minutes before coming back in. She stated she didn't think about finding the Nursing Supervisor first to let her know before searching outside herself because she was anxious to find Resident #6. Nurse #1 stated she hoped the resident would be right outside on the sidewalk, which led to looking in the parking lot, and then she went to the street. An incident note, which was documented in the nurses' notes, dated 1/27/25 at 6:44 am made by Nurse #2 stated on the evening of 1/26/25 around 11:30 pm, Resident #6 was let outside of the building by a Nurse Aide (NA) #1. Nurse #1 had stated she went outside looking for the resident for about 30 minutes prior to telling the supervisor that a resident was out the facility. She stated she then came back into the building, went to the nurses' station on 100 hall and informed the Nursing Supervisor that a resident had left the building, and she could not find him. Nurse #2 wrote she called the (Director of Nursing) DON, and 911 who was informed of the resident missing from the facility with a detailed description of him and what he was wearing when he was last seen. The staff was alerted that a resident was missing from the facility. The DON called Nurse #2 while she was in her car and said the police had found the resident and he was safely brought back to the facility. During an interview with Nurse #2 on 2/25/25 at 3:07 pm, she stated she was the Nursing Supervisor, and she was made aware of Resident #6 exiting the building by Nurse #1 right before midnight on 1/26/25. Nurse #2 stated Nurse #1 told her she had been searching for Resident #6 for 30 minutes outside and had not been able to locate him. Nurse #2 reported, following the elopement policy, she immediately notified all staff to begin looking for Resident #6 and also notified the DON who advised her to call 911 immediately, which she did. Nurse #2 stated she got in her own car and began driving around the area near the facility looking for Resident #6. Nurse # 2 explained looking for a resident in her own car was not part of the policy, but she was hoping it would result in finding the resident quicker. Nurse #2 reported the DON called her on her cell phone while she was driving, advised her the police had located the resident, and had just returned him to the facility. Nurse #2 stated she returned to the facility and completed an assessment of Resident #6. A police report dated 1/27/25 read police were dispatched at 12:04 am after a staff member called stating an aide let a resident out of the building. Staff made the dispatcher aware Resident #6 had cognitive impairments. Resident #6 was located on NC Hwy 66 near the gas station and was transported back to the facility. The report further stated, NA #1 told the police the NA did not know Resident #6 was a resident at the facility and thought he was letting out a family member after visiting. NA #1 informed the police the doors to the facility were locked and only staff members open the doors. The report also documented the facility searched for Resident #6 for approximately 30 minutes after being made aware the resident had left the building. The resident was unharmed and required no medical attention. The time Resident #6 was returned to the building was not documented. During an interview with the responding Police Officer on 3/3/25 at 4:35 pm, he indicated he was dispatched at approximately midnight on 1/26/25 and advised there was a resident missing from the facility. He stated Resident #6 was found around a fast food restaurant and gas station approximately 1 ½ miles away from the facility and was wearing a hat, shoes, long pajamas and a dark overcoat. He stated Resident #6 appeared unharmed and told him he needed to get home to [NAME]-Salem. The officer reported he spoke with NA #1 after returning Resident #6 to the facility who told the officer he let Resident #6 out by accident thinking he was a family member there visiting. The officer added that he was told by an unnamed staff member that the facility had been searching for Resident #6 for about 30 minutes before dialing 911. Observation of the facility layout from Resident #6's room to the door where the resident was allowed egress revealed the following: a right turn has to be made when coming out of Resident #6's room, followed by a short walk in the 300 hall until a mid-point in the hall, and then a right turn must be made to the middle hall. From the middle hallway the front common areas can be accessed, to the left of the common areas, there was a double door entrance which had locks controlled by a magnetic lock system, and there was a visible keypad which allowed the magnetic lock to be disengaged by entering a code which would allow the two automatic doors to be opened. Observation of Google map on 2/25/25 at 4:25 pm revealed the following information about the roads located between the facility and where the resident was discovered by the police. Upon exiting the facility and going through the parking lot there was a two-lane road with a sidewalk on each side of the road, a left turn on the two-lane road would take an individual to an intersection of a 4-lane divided road, where there was also a sidewalk on each side of the road. A right turn would be needed at the 4-lane intersection to travel in the direction of where the resident was found. The 4-lane road had a posted speed limit of 40 miles per hour, had streetlights, and traveled through a mostly wooded area with one commercial building. There was an intersection with a 4-lane highway where a left turn would need to be made to get onto the 4-lane highway with a posted speed limit of 45 miles per hour. There were sidewalks on each side of the 4-lane highway. According to the police report and police interview, Resident #6 was discovered at a closed fast food restaurant parking lot near a gas station on the other side of the 4-lane highway. According to the map, the distance between the facility and the restaurant and gas station where Resident #6 was found was 1.4 miles. A review of the data from the National Weather Service (NWS) web site the hourly temperatures beginning at 10:54 pm on 1/26/25 were as follows: 10:54 pm-38 degrees, 11:54 pm-40 degrees, 12:54 am-40 degrees, and 1:54 am-38 degrees. There was no precipitation documented. A progress note by the facility's Nurse Practitioner dated 1/27/25 read that Resident #6 had a normal exam and he had no signs of any injury related to the elopement. During an interview with the Nurse Practitioner (NP) on 2/25/25 at 4:20 pm, he stated he saw and examined Resident #6 on the morning of 1/27/25. He reported an exam with no injuries as a result of the elopement. When asked if he thought there was a higher likelihood of harm to Resident #6 based on his current physical condition and cognition he stated, although Resident #6 could ambulate independently, he had only seen the resident once before and didn't feel like he had enough information yet to make that determination. During an interview with both the Director of Nursing (DON) with the Regional Nurse Consultant (RNC) present on 2/25/25 at 4:45 pm the DON stated she reported to the facility as soon as Nurse #2 alerted her Resident #6 had exited the building. The DON stated NA #1 should have never unlocked the door to let anyone out who was unfamiliar without verifying the person was not a resident. The DON also stated Nurse #1 should have immediately implemented the elopement process which stated the secondary search procedure is to be initiated by the Nursing Supervisor in charge which would have been Nurse #2. The Nursing Supervisor, in turn, would notify all staff of a missing resident, contact the DON, and then the police. Nurse #1 did not follow procedure when she failed to alert her supervisor immediately after she was unable to locate Resident #6 on her unit and learned he had left the building. The RNC also stated the facility immediately began a plan of correction for all staff members regarding the elopement process. The facility's Administrator was notified of immediate jeopardy on 2/25/25 at 6:04 pm. The facility implemented the following corrective action plan: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #6 is an [AGE] year-old male who was admitted on [DATE] with falls, balance issues, and vascular dementia. Resident #6's Brief Interview for Mental Status (BIMS) was 8 which suggests moderate cognitive impairment. On admission Resident #6 scored a two on the wandering risk assessment, which is low risk for wandering. A low risk indicates the resident has not exhibited wandering behaviors and has no history of wandering. Resident #6's care plan indicated he was at risk for falls, risk for elopement, and was displaying inappropriate behaviors. During Resident #6's stay at the facility, he showed no signs of wandering or exit seeking behaviors according to nurse notes and staff interviews, he was ambulatory in his room only. He did have behaviors such as urinating in the trash can, on his bed, and on his floor, in his room. On 1/26/25 around 11:30pm, Resident #6 walked up to Nurse Aide (NA) #1 and asked to let him out of the building. NA #1 thought Resident #6 was a family member visiting a resident. Resident #6 stated to NA #1 he fell asleep at facility, he lived in [NAME]-Salem and needed to go home. Nurse Aid #1 walked Resident #6 to the main entrance, manually unlocked the front door by turning the knob, opened the door, and Resident #6 walked out of the facility. According to Nurse Aid #1 Resident #6 was wearing a white short- sleeve tee shirt, a plaid button-down long sleeve shirt, a black coat, long pajama pants, and hard bottom black shoes. During the time Resident #6 was let out of the facility by NA #1 he was not identified as a wandering risk during this time as an elopement risk, therefore he was not in the elopement book. According to Nurse #1 Resident #6 was wearing long pants, a coat, a shirt, and shoes during her shift that evening which began at 7:00pm. Interview with Nurse #1, I do not know what time it was when I realized Resident #6 was missing but it was some time after 10:30pm. Nurse #1 immediately went to Resident #6's room and he was not there. Nurse #1 then walked down the hallway to the living room near the main entrance and did not see Resident #6. She then walked to 200 hall and he was not there. Nurse #1 then saw NA #1 and asked if Resident #6 had been seen in the facility. NA #1 then told Nurse #1 Resident #6 was mistaken for a visitor and let out the main entrance per the resident's, who thought was a visitor, request. Nurse # 1 immediately unlocked the front door and exited the main entrance to find Resident #6. Nurse #1 left the property on foot and searched to the main road but did not visualize Resident #6. Nurse #1 came back to the facility and reported to the Night Shift Supervisor immediately the missing resident. The Night Shift Supervisor then activated code pink (the facility's code for a missing resident), this was around 11:55pm. The Night Shift Supervisor called the Director of Nursing and local police department. Nurse # 1 contacted the Responsible Party and made her aware. Resident #6 was returned to the facility at 12:30am on 1/27/25 by the local police department. According to local police, Resident #6 was found 1.4 miles away from the facility at a gas station trying to make a phone call. The resident was placed on 1:1, an intervention where 1 staff member is assigned to 1 Resident. Resident #6 was not able to verbalize where he had been or what he had done when he returned to the facility. A head-to-toe assessment was completed by Nurse #1 on duty at 12:40am. Resident #6's skin was intact and all vital signs were stable. The resident's Provider was notified. New orders received to place resident on 1:1 and place an elopement transmitter to the left lower extremity, the careplan, and [NAME] were updated to reflect the elopement risk and the elopement transmitter. Resident #6's Responsible party was made aware. The three elopement books were also updated to reflect Resident #6 was an elopement risk. Resident #6 discharged on 2/10/25 to home with his family. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On 1/27/25 the Director of Nursing (DON) identified current residents who were potentially impacted by this practice by completing a 100% audit on all current residents to ensure they were all present and accounted for. The audit was completed on 1/27/25. The results concluded: 107 of 107 residents were present and accounted for in the facility. On 1/27/25 the DON identified current residents who were potentially impacted by the deficient practice by completing a 100% audit on all current residents to ensure wandering assessments were accurate and residents identified as at risk or high risk to wander had appropriate interventions including: elopement transmitters, updated information in the elopement books, and or 1:1. This was completed on 1/27/25. The results concluded: 107 of 107 residents had correct wandering assessments completed. There were elopement books located at each nurse's station and front desk with pictures of residents and physical description. On 1/27/25 3 of 3 elopement books were checked by the Activities Director to ensure they were up to date for all current residents that had been identified as potential to elope and they were accurate and up to date. 107 of 107 current residents had elopement risk audits completed on 1/27/25 by the Director of Nursing to ensure they were completed accurately. The results revealed no negative findings. All risk assessments had been completed accurately. All new admission risk assessments will be reviewed daily Monday through Friday in the clinical meeting to ensure risk assessments are completed accurately. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 1/27/25, the Staff Development Clinician (SDC) initiated an in-service for all staff (including agency) on the Elopement Prevention policy. This training will include all current staff including agency. This training included: -When a resident is assessed as being high risk for elopement a transmitter bracelet is placed on the resident. Staff should check the placement of the transmitter bracelet and battery. The task of batteries being checked by using the transmitter checking device is assigned to the floor nurses on the unit then documented in the Medication Administration Record (MAR) every shift. -New admissions with high risk or at risk to wander will be monitored or placed with a sitter until they can be re-evaluated by the Interdisciplinary Team and an appropriate intervention is implemented which can include: continued sitter, application of elopement transmitter device, careplan and [NAME] will be updated to reflect and information added to elopement books. -Risk assessments will be completed on admission, quarterly and/or as needed on all residents. -Any resident identified to be at High Risk for elopement or wandering will be discussed with the interdisciplinary team, documentation of interventions noted, and the careplan updated to reflect interventions, and the elopement books will be updated to reflect resident is and elopement risk. -Location of the three elopement books and when and how to reference them. -Never let a person out of the facility unless you reference the elopement book and ask nurse if the person can exit the facility. Initial Search Procedure -As soon as a resident is noted to be missing ALL staff will search their assigned areas and report to the nursing station. All other areas will then be checked including but not limited to linen rooms, storage rooms, general baths, bathrooms and closets. -If the resident is not located during the initial search then initiate a secondary search. -Secondary Search Procedure: -The charge nurse will assign staff members to search the outdoor facility grounds and report back to charge person. -If the resident has not been found on the secondary search in the facility and facility Grounds, the person in charge will notify the local police or sheriff department. Inform them a search is in progress and request search assistance. This will be done immediately after confirming the secondary search is unsuccessful. - This search should be completed timely and involve all members of the team so that more ground can be covered in a shorter time period. The search for a resident should not be for more than 30 minutes without activating police involvement -The Charge Nurse will assemble all staff at the Nurses' station by announcing over the paging system Missing Resident. This should be completed timely. The Director of Nursing will ensure that any of the above identified staff who do not complete the in-service training by 1/28/25 will not be allowed to work until the training is completed. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The Director of Nursing and Unit Manager will audit all admission and readmission risk assessments beginning 1/29/25 weekly for 2 weeks and then monthly for 3 months using the Quality Assurance Elopement Tool. This tool will consist of accurate completion of risk assessment on admission, identification of high or at risk to wander residents, and as changes occur, elopement transmitter is in place, care plan and [NAME] revised, and if the elopement book has been updated to reflect elopement risk. Staff knowledge checks will also be completed beginning 1/29/25 using the Mock Elopement Drill Knowledge Checks Audit Tool weekly x2 weeks and monthly x3 months. 5 Random employees from all different departments will be asked when and how to implement code pink for missing residents. These knowledge checks will include: Have you been educated on code pink initial search to start immediately with all staff searching assigned areas and reporting to charge nurse; Have you been educated on code pink secondary search which is when a resident is not found inside the facility timely; When should you call code pink; Who should be involved in code pink; Should you let a person out the door if you don't know if he or she is a resident or visitor, What do you do? Reports of the results will be presented to the weekly QA committee by the Administrator or Director of Nursing to ensure corrective action is implemented and effective. Compliance will be monitored through an ongoing auditing program reviewed at the weekly QA Meeting. The weekly QA Meeting is attended by the Administrator, DON, Minimum Data Set (MDS) Coordinator, Therapy, Health Information Manager, and the Dietary Manager. The alleged IJ removal date is 1/29/25. The alleged date of compliance will be 2/4/25. On 2/25/25, the facility's corrective action plan was validated on-site by record review, observations, and interviews. Individual interviews of current staff members working all reported to have completed the elopement process training dated 1/27/25. Record review of the in-service documents dated 1/27/25 and 1/28/25 noted the DON and the Staff Development Coordinator completed the in-person training. Signed staff rosters were reviewed with no issues or concerns. Interviews conducted with multiple staff members revealed they had received training about the elopement process and were able to identify what processes to put into place in the event a resident cannot be located. All new staff members will also complete the training before their first shift at the facility. Observation of the three elopement books showed they were current and now also included photographs of residents. Review of audits showed the facility completed new wandering assessments on all residents. The facility's immediate jeopardy removal date of 1/29/25 was validated. The date of compliance was validated as 2/4/25.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with staff, Nurse Practitioner, and the resident, the facility failed to provide care in a safe manner when a dependent resident rolled off her bed onto the floor during incontinence care. The resident was not injured. The deficient practice affected 1 of 7 residents reviewed for accidents (Resident #18). Findings included: Resident #18 was admitted to the facility on [DATE] with the diagnosis of osteoarthritis. Resident #18 had a significant change Minimum Data Set, dated [DATE] for mobility decline, pressure ulcer, and a fall. The resident required extensive assistance with bed mobility and was always incontinent of bowel and bladder. The care plan for Resident #18 dated 11/26/24 documented the resident had an increased risk for falls and required assistance with her activities of daily living for bed mobility, transfers, bathing, and personal hygiene. Resident #18's nurses' note dated 11/29/2024 at 7:36 am documented by Nurse #4 documented the resident fell from her bed to the floor. Nursing Assistant (NA) #3 informed Nurse #4 she was attempting to provide care to the resident, turned her, and the resident fell off the bed onto the floor. The resident was assessed and she complained of pain in her head and her right hip. The on-call physician was notified, an order was given to send the resident to the Emergency Department (ED) for assessment. Resident #18's change in status note dated 11/29/2024 at 6:05 am written by Nurse #4 documented the resident had fallen. At the time of evaluation, the resident's vital signs were: Blood Pressure (BP): 109/67, Pulse (P): 60, Respiratory Rate: 18, Temperature: T 98.1, oxygen saturation- 98.0 % on room air and Mental Status Evaluation: No changes observed A fall incident report for Resident #18 dated 11/29/24 was documented by Nurse #4. Resident #18 fell out of bed during care provided by NA #3. The staff was educated on resident bed mobility during care. The resident was sent to the ED. On 1/8/25 at 11:46 am Nurse #4 was interviewed. Nurse #4 stated she remembered Resident #18 and the fall incident on 11/29/24. Nurse #4 stated NA #3 was assigned and reported to her that when care was provided to Resident #18 the NA turned the resident and the resident rolled out of bed. Nurse #4 was not aware whether there were any side rails. The resident required maximal assistance in bed for turning and the NA should have 2 staff to prevent rolling out of bed when turning a dependent resident. Resident #18 was assessed and had no apparent injury and had no complaints. The resident was sent to the hospital for evaluation. Nurse #4 stated she asked NA #3 what happened, and the NA stated she provided care by herself and when she turned the resident for care she rolled out of bed onto the floor. Nurse #4 stated she provided the NA education to use 2 staff for a dependent resident. The Director of Nursing (DON) was informed. The physician was notified, and the resident was sent to the Emergency Department (ED) for an evaluation. The resident returned from the ED the same day and had no injury. Attempts were made to interview NA #3 by phone on 1/09/25 and 1/10/25. A voice mail was left but NA #3 did not return the calls. On 1/9/25 at 2:42 pm an interview was conducted with Resident #18. Resident #18 stated she remembered when she fell out of bed. Resident #18 stated when the NA was providing care she placed her on the side of the bed (the resident pointed to the right side of her bed) and I fell off. She further stated I was not hurt. The resident did not remember if the bed was raised for care. Resident #18's ED after visit summary dated 11/29/24 documented the resident was evaluated after a fall. A CAT (radiograph of the brain) scan of head showed no injury. The resident had pain in both knees and an x-ray was completed. The results were negative for injury. The resident had a history of osteoarthritis to both knees. The resident was sent back to the facility. A nurses' note dated 11/29/24 documented Resident #18 complained of right hip pain and had an x-ray completed at the facility after return from the ED. The x-ray result showed no fracture. There was moderate osteoarthritis of the hip joint. On 1/9/25 at 1:04 pm an interview was conducted with the DON. The DON was aware that Resident #18 had rolled out of bed during care by NA #3. The DON stated NA #3 was provided education. On 1/9/25 at 12:10 pm an interview was conducted with the Nurse Practitioner (NP). The NP stated he was not aware Resident #18 had rolled out of the bed. The NP stated the resident complained of left hip pain and an x-ray was done 11/30/24. The x-ray result was osteoarthritis, no injury. He further stated that the resident long standing pain from osteoarthritis in both hips and knees.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, Nurse Practitioner (NP) and hospital radiologist interviews, and record reviews, the facility failed to transfer a resident safely from her recliner to the bathroom toilet with the assist of one while using a sit-to-stand lift for 1 of 2 residents reviewed for accidents (Resident #4). Resident #4 experienced a fall when the nurse aide did not fasten the sling's chest support strap securely in accordance with the manufacturer's instructions and did not use the leg straps attached to the lift resulting in the resident falling from the lift to the floor. Resident #4 was sent out to the hospital for evaluation / treatment and was found to have a right acetabular roof/iliac bone fracture (the main weight-bearing area of the hip joint) and 3 lumbar vertebral fractures (two fractures on the 3rd lumbar vertebra or L3; and one fracture on the 4th lumbar vertebra or L4). The lumbar vertebrae are 5 bones located at the bottom section of the spine (lower back) and are identified as L1 to L5. Resident #4 reported her pain level after the fall as an 8 to more than 10 (with 0 indicative of no pain and 10 representative of the worst pain possible). Immediate Jeopardy began on 1/2/23 when Resident #4 was transferred by a nurse aide with a sit-to-stand lift without either the chest support strap or leg straps being securely fastened, resulting in her falling to the floor and sustaining multiple fractures. Immediate Jeopardy was removed as of 1/19/23 when the facility implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) for the facility to continue staff education and ensure monitoring systems put into place are effective. The findings included: A review of the manufacturer's Instructions for Use for the facility's sit-to-stand lift (dated October 2019) included directions for the safe use of the lift. The instructions read in part, To fasten the [chest] support strap securely, press the buckles (if available) or hook and loop strap (if available) together. The strap shall be tight, but comfortable for the resident Remember to tighten the strap once the resident becomes raised from the chair .The sling support strap will help to support the resident in the sling during the raising procedure. The strap also retains the sling in the correct position around the resident. Additionally, the manufacturer's instructions included a boxed warning in bold print which read, Warning: The sling chest support strap must always be applied and fastened when using the sling. The role of the lower leg straps attached to the lift were also described in the instructions as follows: [The lower leg straps are an] Accessory used to ensure that the lower parts of the resident's legs stay close to the knee support. They pass around the knee supports, then around the resident's lower calves. To fasten, click the strap into it's socket as with a seatbelt. Ensure that the straps are firm but comfortable for the resident. Resident #4 was admitted to the facility on [DATE]. Her cumulative diagnoses included a history of acute respiratory failure with hypoxia (low oxygen level in the blood). A review of Resident #4's Care Plan included the following area of focus, in part: -- I have an Activities of Daily Living (ADL) self-care performance deficit related to impaired balance (Date Initiated: 2/2/18; Revision on: 10/26/22). The 10/26/22 revision indicated a sit-to-stand lift with a large sling was required for transfers. Resident #4's Occupational Therapy Treatment Encounter Notes included a notation authored by the facility's Occupational Therapist (OT) on 11/2/22 at 1:50 PM. The note read in part: .Pt [Patient] educated regarding need to use knee strap during use of stand up (sit-to-stand) lift for toileting tasks, as pt has refused to allow staff to use same in past due to c/o [complaints of] pain. OT educated pt regarding allowing OT to pad strap to increase comfort and allow proper support. Pt agreeable to same. Pt educated regarding staff inability to use stand up machine (sit-to-stand lift) without proper strapping due to heightened fall risk. Resident #4's level of pain was documented in her electronic medical record (EMR) 0 to 4 times a day during the two week period prior to her fall using the numeric pain scale rating ranging from 0 to 10. From 12/18/22 to 1/1/23, there were the 34 documented reports of the resident's pain level which included: --On 12/19/22 at 9:23 PM, the resident's level of pain was documented as 3; --On 12/26/22 at 8:23 PM, the resident's level of pain was documented as 2; --On 12/27/22 at 10:27 PM, the resident's level of pain was documented as 3; --On 12/28/22 at 8:10 PM, the resident's level of pain was documented as 3. Thirty (30) of the 34 reports of the resident's level of pain were documented as 0 from 12/18/22 and 1/1/23. The resident's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS reported Resident #4 had intact cognition. She was totally dependent on staff for transfers and required two plus (2+) persons physical assist. Resident #4's EMR included a Change in Condition report dated 1/1/23 at 8:16 PM which indicated the resident was sent out to the hospital Emergency Department (ED) for evaluation and treatment due to chest pain and shortness of breath. A Nursing Note dated 1/2/23 at 3:32 AM reported the resident returned to the facility on 1/2/23 at 3:00 AM with a diagnosis of a urinary tract infection (UTI) and fungal infection. The note reported an antibiotic and antifungal medication were prescribed. The resident was reported as still complaining of difficulty breathing. Her oxygen saturation level (O2 sat) was 93% on 3 liters / minute of supplemental oxygen. A Fall Report dated 1/2/23 at 5:37 PM and authored by the facility's Director of Nursing included a description of an incident involving Resident #4 which read, The resident was being transferred to the bathroom by two CNAs [Certified Nurse Aides] on the stand up [sit-to-stand] lift. The resident was holding on to the lift properly but suddenly she was observed falling, so the CNAs lowered her to the floor. The resident had a syncope episode [temporary loss of consciousness]. Resident stated that she had fainted. The Fall Report indicated the Immediate Action Taken as: The nurse was noted by CNAs that the resident had been lowered to the floor after fainting. The nurse assessed the resident and she was lifted off the floor by [brand name of a total mechanical lift]. No injury noted but received orders to send to hospital for evaluation. The Fall Report indicated no injuries were observed at time of incident. The resident's level of pain was reported to be 0. An interview was conducted with Resident #4 on 1/17/23 at 12:00 PM as she recalled the incident of 1/2/23 when she had a fall in the bathroom. The resident reported the Nurse Aide (NA) who assisted her to the bathroom was new and this was her first day working at the facility. When asked to detail what occurred on the day she fell, the resident again reported she had a new NA working with her on that day. She did not recall the NA's name. The resident stated she was being transferred from the recliner to the toilet in her bathroom. The resident then stated, The girl didn't fasten the center strap (referring to the chest support straps on the sling). She reported I told her she didn't hook the cross-straps on me. Resident #4 reported only the two long straps that connected each side of the sling to the lift were used for the transfer. However, the cross straps which secured the sling to her (the resident's) chest were not used. Resident #4 stated during the transfer, she slipped a little and felt weak, then fell to the ground. Resident #4 reported her back hurt and stated, They had to call the fire truck to get me off of the floor. Upon further inquiry, the resident reported the sit-to-stand lift (not a total mechanical lift) was always used to transfer her but she reiterated the NA who transferred her did not use the straps like they were typically used. When specifically asked, the resident reported she did not actually faint or lose consciousness during the transfer on 1/2/23. Resident #4 reiterated she just felt weak when she fell in the bathroom. A telephone interview was conducted on 1/17/23 at 4:02 PM with NA #1. NA #1 was identified as the agency (temporary staff) nurse aide who was assigned to care for Resident #4 on first shift of 1/2/23 from 7:00 AM to 7:00 PM. During the interview, the NA reported 1/2/23 was the first and only shift she worked at the facility. NA #1 reported, No one gave me rounds I did not know anything about the resident. The NA stated she did not have access to the residents' electronic Kardex (an electronic record which provided details of the type of care a resident required) or any other information typically available via the electronic Kiosk (a computer terminal) until the end of her shift. NA #1 reported she had to ask residents and other staff for information about resident care. NA #1 stated right before dinner, Resident #4 needed to use the bathroom. The NA reported she understood the resident usually kept a sit-to-stand lift inside her bathroom but it was not there so she had to go to another hall to get a lift for the transfer. NA #1 recalled the leg straps on the lift were attached to the lift but they were in knots and tied up to the machine. The NA stated she was able to use the strap of the sling under the arms only but did not provide additional details about whether or not the chest support strap was secured. The NA then reported she began to transfer Resident #4 from her recliner to the bathroom. NA #1 stated, She was hanging on fine. Then the NA noticed the resident appeared to be getting weak so she grabbed her from behind and slid her down to the floor. She stated the resident did not faint or lose consciousness. NA #1 reported another NA (NA #2) had been in and out of the resident's room during the transfer and reported that NA was in the room just as the resident fell to the floor. NA #1 then stated, When this lady fell, I caught her and put her on the floor. The NA recalled Resident #4 complained of pain so she put a pillow behind her legs and back and had the resident lean on her leg for support. When EMS arrived, the Emergency Medical Technicians (EMTs) transferred the resident off of the floor and onto the stretcher. A telephone interview was conducted on 1/18/23 at 9:27 AM with NA #2. NA #2 was identified as an agency (temporary staff) nurse aide who worked on the first shift of 1/2/23 from 7:00 AM to 7:00 PM. During the interview, the NA reported 1/2/23 was the first and only time she worked at the facility. NA #2 reported her assignment was to provide showers for the residents. When asked about the incident involving Resident #4, the NA reported a nurse had told her the resident needed to use the bathroom and asked her to go in and check on her. NA #2 stated she went into the room and the resident confirmed she wanted to use the bathroom so the NA went and told NA #1 the resident needed assistance. NA #2 also went into the room to help with the transfer but recalled before lifting the resident up, she noticed the resident was on supplemental oxygen. However, the oxygen tubing was not long enough to reach the bathroom. She told NA #1 to wait while she found a longer oxygen tube. When NA #2 returned to the resident's room, she observed that NA #1 had already hooked the resident up to the sit-to-stand lift and began the transfer to the bathroom. NA #2 reported she observed NA #1 trying to lower Resident #4 to the toilet but she was not close enough (the legs on the base of the sit-to-stand lift were not open) and she was not able to transfer her successfully. NA #2 also observed the resident did not have the harness (sling) fastened and her legs had not been secured with the leg straps on the lift. NA #2 stated she tried to help slide the resident down while attempting to hold on to the harness. The NA explained the resident was losing the harness (sling) because it had not been fastened. The resident was still holding on to the lift's metal bars as she fell. She did not observe Resident #4 to lose consciousness. After the resident reached the floor, the harness (sling) was disconnected from the lift. NA #2 stated while NA #1 tried to stabilize the resident with her leg, she saw the NA's knee was into the resident's back. After the fall, NA #1 went out of the room to get help while NA #2 hooked up the resident's supplemental oxygen. NA #2 reported Resident #4 complained of pain in her back, legs, and feet. The resident rated her pain as more than 10. When EMS arrived, NA #2 resumed her other duties. An interview was conducted on 1/17/23 at 3:30 PM with Nurse #1. Nurse #1 was identified as having worked on 1st shift (7:00 AM to 7:00 PM) on 1/2/23 at the time of Resident #4's fall. When asked to recall the details of his involvement with Resident #4 on 1/2/23 (the date of her fall from the lift), Nurse #1 reported he was not in the room at the time of the fall and was actually in the process of sending another resident out to hospital. After Resident #4's fall, he reported both he and the Unit Manager went into Resident #4's room. He observed the resident sitting on the bathroom floor with an NA still holding on to her and the resident was still holding onto the sit-to-stand bars. He could not recall noticing which lift or sling straps were fastened at that time because his focus was on the resident. Nurse #1 recalled the resident was complaining of back pain and he reported the Unit Manager told him to go ahead and get her ready to be sent out to the hospital. He called EMS and accompanied them down to Resident #4's room when they arrived. The EMS team transferred the resident off of the floor and onto the stretcher for transport to the hospital. An Interdisciplinary Team (IDT) progress note authored by Nurse Practitioner (NP) #1 and dated 1/2/23 at 8:33 PM reported the resident was sent to the hospital ED for pulsating sensation in abdomen as reported by nursing. The note reported this feeling was not new however prior workup had been unremarkable. The NP also wrote, Of note, staff report that patient had a witnessed fall during transfer with lift, no notable injuries, no acute reports of pain . however reports that it felt like 'she swallowed her heart.' Sent to ER [Emergency Room] at request of patient. This writer spoke with MD [Doctor] at [name of hospital] who states that patient is still being worked up. Resident #4's hospital records included the following: - An ED Provider Note dated 1/2/23 at 7:23 PM. The note indicated Resident #4 presented to the ED for evaluation of injuries sustained in a fall. The note reported, She had a witnessed ground-level fall in the restroom at her skilled nursing facility earlier today. The patient states that she felt generally weak and then fell to the ground. There was not a loss of consciousness. She states that she hit her head and back against the ground and is complaining of diffuse pain, but mostly headache and back pain. EMS [Emergency Medical Services] was called, patient was subsequently transported to our emergency department for further evaluation. - On 1/2/23 at 8:30 PM, computerized tomography (CT) of the resident's thoracic (12 vertebrae located in the upper and middle part of the back) and lumbar spine was performed with a comparison to a CT of the resident's abdomen and pelvis conducted on 11/22/21. The findings were reported by Radiologist #1. The radiology report noted the presence of a fracture cleft (a possible indication of a compression fracture) through the superior (upper) aspect of the 3rd lumbar (L3) vertebral body, a left L3 transverse process (a wing-shaped protrusion on the vertebra) fracture, and a minor superior endplate (a transitional area where the vertebral body and disc between the vertebrae come together) compression fracture deformity of the L4. A chronic healed L2 compression fracture deformity was also included in the findings. On 1/2/23 at 8:27 PM, a CT of Resident #4's chest, abdomen and pelvis was completed. The radiology findings reported the resident had an acute nondisplaced fracture through the right acetabular roof / iliac bone. Additional radiology tests conducted of the resident's lower extremities noted the resident had osteopenia. - Resident #4's hospital Discharge summary dated [DATE] at 12:11 PM reported the resident was admitted to the Trauma Service for further management and monitoring. The hospital records reported Orthopedic Trauma was consulted for her right acetabular roof and iliac bone fracture with the fracture managed non-operatively. Neurosurgery was consulted for the lumbar spine fractures, which were also managed without surgical intervention. Resident #4 was fitted in a Thoracic-Lumbar-Sacral Orthosis (TLSO) brace used to limit motion of the thoracic, lumbar and sacral regions of the spine and upright imaging was obtained. The resident's spine was cleared for mobility while wearing the TLSO brace. The resident's hospital Discharge Summary also reported the resident was discharged back to the facility on 1/4/23 after receiving treatment for her injuries present on admission. These injuries were noted on the Discharge Summary to include an acute nondisplaced fracture of the right acetabular roof / iliac bone fracture and fractures of the L3 vertebral body, left L3 transverse process and L4 superior endplate. The resident's discharge medications included 325 milligrams (mg) acetaminophen to be given as two tablets by mouth every 8 hours as needed (PRN) for pain, headache, or fever; and 50 mg tramadol (an opioid pain medication) to be given as one tablet by mouth twice daily as needed. Resident #4 was readmitted to the facility on [DATE]. A review of the resident's medications orders dated 1/4/23 included 325 mg acetaminophen to be given as two tablets by mouth every 8 hours as needed for pain, headache, or fever; and 50 mg tramadol to be given as one tablet by mouth twice daily as needed. A review of Resident #4's January 2023 Medication Administration Record (MAR) revealed the resident received one dose of acetaminophen on 1/5/22 at 4:34 AM for a documented level of pain rated as 6 on a scale of 0 to 10 (with 0 indicative of no pain and 10 representative of the worst pain possible). Resident #4 also received PRN tramadol in accordance with the physician's orders on 1/5/23 at 10:03 AM for a pain level of 7. The medication was reported to have been effective. The resident's EMR included a Comprehensive Encounter notation dated 1/5/23 and authored by NP #2. The NP reported Resident #4 was seen on this date for a post hospitalization visit due to a witnessed fall. The notation read, in part: .Patient seen today for post hospitalization for a witnessed fall resulting in closed nondisplaced dome fracture of right acetabulum and iliac bone fracture with recommendations of non-surgical conservative treatment, WBAT [weight bearing as tolerated] to BLE [bilateral lower extremities], and lumbar spine fractures. Patient fitted for a TLSO for L3 vertebral body fx [fracture], L3 transverse process fracture, and L4 superior end plate fx . Further review of Resident #4's January 2023 MAR revealed the resident received PRN medication on each of the following dates / times: --1/8/23 at 9:20 AM for a pain level of 8. The medication was reported to have been effective. --1/9/23 at 9:24 AM for a pain level of 4 and at 9:12 PM for a pain level of 10. The medication was reported to have been effective on both occasions. --1/10/23 at 10:21 AM for a pain level of 9. The medication was reported to have been effective. --1/11/23 at 5:28 PM for a pain level of 9. The medication was reported to have been effective. A notation made in Resident #4's EMR indicated the resident was seen by NP #1 on 1/12/23 at 11:49 AM. The note read, in part: Patient returned from [hospital] stay on 1/4/23 following a fall and found to have lower back compression fx and fx to sacral [the portion of the spine between the lower back and tailbone]. Has prn order for tramadol q12h [every 12 hours as needed], using occasionally. Pain to lower back controlled, patient is not routinely using recommended back brace bc [because] she is spending majority of time in bed .patient states that she is doing fair without acute concerns . A follow-up interview was conducted with Resident #4 on 1/18/23 at 10:57 AM. When asked how she was doing, the resident responded by stating she was not doing good. The resident reported she was receiving therapy and with their help, she sat of on the side of the bed. Upon further inquiry, the resident stated she was glad to sit up for a short time but reported it was painful. During the interview, the resident was asked to rate her level of pain. She reported having pain all the time and rated the level of pain as an 8 to more than 10. The resident reported the pain medications prescribed for her were helpful in reducing the pain. When asked, the resident confirmed during the 1/2/23 transfer (when she fell from the lift) her sling was loose, the cross straps were not secured, and no leg straps were fastened on her legs. Resident #4 added, I told the lady it usually takes two [staff] but she didn't say nothing. An interview was conducted on 1/18/23 at 2:50 PM with the facility's Maintenance Director. During the interview, the Maintenance Director reported safety checks were done on all lifts once weekly on Fridays. He stated he inspected all mechanical lifts on 1/3/23 (after Resident #4's fall). When asked, the Director reported on 1/3/23 he noticed the leg straps on one of the sit-to-stand lifts were tied up in knots so he replaced those straps. An interview was conducted on 1/18/23 at 10:10 AM with NP #1. During the interview, the NP recalled she had given the order to send Resident #4 to the hospital on 1/2/23. She reported that initially when she gave the okay to send her out, she understood it was due to breathing issues. NP #1 stated the resident did have chronic pain. The NP also acknowledged she conducted a visit with the resident on 1/12/23. The hospital radiology reports were discussed during the interview and included the finding of osteopenia. When asked, the NP reported both osteopenia (reduced bone mass, but less severe than osteoporosis) and osteoporosis place a resident at an increased risk of sustaining any type of fracture as compared to someone else with normal bone density. A telephone interview was conducted on 1/18/23 at 12:49 PM with NP #2. During the interview, the NP reported she saw Resident #4 on 1/5/23 after the resident returned to the facility. The NP stated during her visit, the resident did not have a lot of pain while lying in bed. The NP thought unless the resident was moving, her pain should be controlled. Upon inquiry, NP #2 reported Resident #4's fractures could possibly take 8-10 weeks to mend. In the meantime, unless therapy was working with the resident it was best for her to lay in bed. When asked, the NP reported even a hard sit could potentially cause fractures for someone with osteopenia or osteoporosis. An interview was conducted on 1/19/23 at 7:45 AM with the facility's Director of Nursing (DON). When asked, the DON reported as long as she had been working at the facility, the facility's policy was for two staff members to be present for all transfers using a sit-to-stand or total mechanical lift. On 1/19/23 at 9:45 AM, the Administrator requested an observation be conducted as she and two facility staff members attempted to re-enact Resident #4's 1/2/23 fall from the sit-to-stand lift. The Administrator stated the re-enactment was based on information provided by Resident #4. She reported Resident #4 stated the cross-straps (chest support straps) of the sling itself were not fastened during the transfer, the leg straps were not used, and only the two straps (one on each side) of the sling were fastened to the lift . Based on the re-enactment conducted and observed on 1/19/23 at 9:45 AM, the Administrator questioned whether the resident would have been able to fall from the sit-to-stand lift. However, when asked, the Administrator confirmed neither of the NAs who worked with the resident on 1/2/23 (the time of the fall) had participated in a re-enactment of the transfer. She reported one NA said she would come in and do the re-enactment but she did not. The other NA declined to participate. When the Administrator was asked if there was question about the resident having experienced a fall from the lift and sustaining fractures, the Administrator responded by saying she was not certain the resident actually sustained her fractures from the 1/2/23 incident. An interview was conducted on 1/19/23 at 11:07 AM with the facility's Occupational Therapist (OT). This OT was identified as having worked with Resident #4 in November and December 2022 to determine the safety of lifts used to transfer the resident. During the interview, the OT was asked about her work with Resident #4. The OT reported the resident basically got agitated when staff used the knee (leg) strap for her when using the sit-to-stand lift. The OT reported she educated the resident that the leg straps were used for her safety. She stated Therapy provided the resident with sheepskin to use on the back of the lift's leg straps so they would be more comfortable. During the interview with the OT, inquiry was made as to why it was important for the sit-to-stand leg straps to be utilized during a transfer. The OT responded by saying that if the resident was not able to maintain her grasp for any reason (such as a weak spell), she could slide down and out of the machine without the leg straps. She stated the leg straps would be an extra measure for her safety. When asked what the OT's thoughts were with regards to a resident being transferred with a sit-to-stand lift without using leg straps and with the chest support strap either loose or not being used at all, the OT responded, Oh no, it's not safe. The hospital radiologist was interviewed by telephone on 1/20/23 at 2:59 PM. During the interview, the radiologist confirmed he reviewed Resident #4's thoracic / lumbar films. The radiologist reported the resident's L3 and L4 lumbar vertebral fractures were unhealed and likely acute fractures. He stated, a fracture of this nature was likely something recent. At that time, Resident #4's fall on 1/2/23 was described to the radiologist. When asked if the resident's lumbar fractures could be the result of her fall on 1/2/23, the radiologist stated, they certainly could be. Upon request, the facility provided documentation of a Review to Ensure Quality (initiated on 1/4/23) for review on 1/17/23 at 2:00 PM. This review indicated the facility began an investigation of Resident #4's fall on 1/4/23. The initial report indicated an investigation was needed because Resident complained of feeling weak and her legs gave way during transfer in sit to stand lift. Immediate education that was being initiated included Mechanical lift education; Agency orientation checklist; and Nursing admin (administrative) staff on agency orientation checklist being completed before agency staff can work in facility. The Root Cause Analysis statement read: The resident was being transferred when she had an emergent situation where she went unconscious causing her to have decreased alertness and compromising her mobility. The plan for correcting the specific area of concern identified and process that led to the concern included a 4-point plan that addressed: 1) Corrective action for resident involved; 2) Corrective action for potentially impacted residents; 3) Systemic changes; and 4) Quality Assurance. The date of completion for the systemic changes involving the in-service training of nursing staff was 1/18/23. The Administrator was notified of immediate jeopardy on 1/18/23 at 1:40 PM. The facility provided an acceptable credible allegation on 1/18/23. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On 01/02/2023 Resident #4 received injury during a lift transfer resulting in injury. On 01/04/2023, the Administrator, Director of Nurses, Staff Development, Rehab Manager, MDS, Unit Manager and the Clinical Nurse Consultant began identification of residents that were potentially impacted by this practice. This audit was completed by reviewing current residents who were identified as requiring transfer utilizing of the sit to stand and hoyer lift on 100/200 halls and if the transfer device was appropriate. This audit was completed on 01/05/2023. The Director of Nurses and the Clinical Nurse Consultant began updating the care plan to ensure it included the required number of individuals to complete a safe transfer and the proper device that needed to be used. This care plan update was completed on 01/05/2023. Since 1/05/2023, the Director of Nurses, Rehab team and the nurse management team have reviewed residents at the time of admission, quarterly and with significant changes to ensure that lift status and number of staff needed for transfer was documented on the care plan for the resident. Specify the actions the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring and when the action will be completed. On 01/04/2023, the Director of Nurses and Staff development coordinator began in-servicing all licensed nurses and certified nursing assistants (full time, part time, prn and agency employees) on Mechanical Lift Safety Education which included education on how to use the lift, how many caregivers are required to use the lift, and what to do if there is a problem with the lift. This was completed on 01/18/2023. After 01/18/2023, this in-servicing was incorporated into all new hire orientation for nurses, certified nursing assistants and agency staff that are allowed to use the lift. The training included both sit to stand and mechanical lift manufactured. Additionally, on 01/04/2022, the Director of Nurses began validation of competency of certified nursing assistants and nurses (agency and non-agency) on use of the lift. This was completed on 01/18/2023. Competency was continued during the orientation process for new hires and as a part of the agency training. Agency staff are not allowed to use lifts until they have received training. They received education on this restriction at the beginning of their first shift in the facility. Once they are properly trained on lift use they are allowed to use lifts according to facility policy. Supervisory staff are notified when an agency staff member has been trained. On 01/16/2023, the Director of Nurses or a designee began weekly monitoring (which included facility staff and agency staff) to identify if training had been completed, on how to use the lift and if the correct number of caregivers were used to complete the transfer. These audits included actual observation of staff (including agency) carrying out transfers. There were no concerns identified from any of the audits that were completed. The Director of Nurses has ensured that all licensed nurses and certified nursing a[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews and record review, the facility failed to provide agency Nurse Aides (NA #1 and NA #2) with orientation and training to meet individual residents' care needs, including education and verification of the NA's competency on the safe use of the facility's mechanical sit-to-stand lift. One (1) of 2 residents reviewed for accidents (Resident #4) experienced a fall when the nurse aide did not fasten the sling's chest support strap in accordance with the manufacturer's instructions and did not use the leg straps attached to the lift. The resident fell from the lift to the floor. The resident was sent out to the hospital for evaluation / treatment and was found to have a right acetabular roof/iliac bone fracture (the main weight-bearing area of the hip joint) and 3 lumbar vertebral fractures (vertebrae located in the lower back). Immediate Jeopardy began on 1/2/23 when two new agency NAs (NA #1 and NA #2) began working at the facility without receiving orientation, training, and verification of their competency to transfer a resident safely with a sit-to-stand lift, resulting in her falling to the floor and sustaining multiple fractures. Immediate Jeopardy was removed as of 1/19/23 when the facility implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) for the facility to continue staff education and ensure monitoring systems put into place are effective. The findings included: A review of the manufacturer's Instructions for Use for the facility's sit-to-stand lift included directions for the safe use of the lift. The instructions read in part, To fasten the [chest] support strap securely, press the buckles (if available) or hook and loop strap (if available) together. The strap shall be tight, but comfortable for the resident Remember to tighten the strap once the resident becomes raised from the chair .The sling support strap will help to support the resident in the sling during the raising procedure. The strap also retains the sling in the correct position around the resident. Additionally, the manufacturer's instructions included a boxed warning in bold print which read, Warning: The sling chest support strap must always be applied and fastened when using the sling. The role of the lower leg straps attached to the lift were also described in the instructions as follows: [The lower leg straps are an] Accessory used to ensure that the lower parts of the resident's legs stay close to the knee support. They pass around the knee supports, then around the resident's lower calves. To fasten, click the strap into it's socket as with a seatbelt. Ensure that the straps are firm but comfortable for the resident. Resident #4 was admitted to the facility on [DATE]. Her cumulative diagnoses included a history of acute respiratory failure with hypoxia (low oxygen level in the blood). A review of the resident's Care Plan included the following area of focus, in part: -- I have an Activities of Daily Living (ADL) self-care performance deficit related to impaired balance (Date Initiated: 2/2/18; Revision on: 10/26/22). The 10/26/22 revision indicated a sit-to-stand lift with a large sling was required for transfers. The resident's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS reported Resident #4 had intact cognition. She was totally dependent on staff for transfers and required two plus (2+) persons physical assist. A Fall Report dated 1/2/23 at 5:37 PM and authored by the facility's Director of Nursing included a description of an incident involving Resident #4 which read, The resident was being transferred to the bathroom by two CNAs [Certified Nurse Aides] on the stand up [sit-to-stand] lift. The resident was holding on to the lift properly but suddenly she was observed falling, so the CNAs lowered her to the floor. The resident had a syncope episode [temporary loss of consciousness]. Resident stated that she had fainted. The Fall Report indicated the Immediate Action Taken as: The nurse was noted by CNAs that the resident had been lowered to the floor after fainting. The nurse assessed the resident and she was lifted off the floor by [brand name of a total mechanical lift]. No injury noted but received orders to send to hospital for evaluation. The Fall Report indicated no injuries were observed at time of incident. The resident's level of pain was reported to be 0. Resident #4's hospital Discharge summary dated [DATE] at 12:11 PM reported the resident was discharged back to the facility on 1/4/23 after receiving treatment for her injuries present on admission. These injuries were noted on the Discharge Summary to include an acute nondisplaced fracture of the right acetabular roof / iliac bone fracture and fractures of the L3 vertebral body, left L3 transverse process and L4 superior endplate. Resident #4 was readmitted to the facility on [DATE]. An interview was conducted with Resident #4 on 1/17/23 at 12:00 PM as she recalled the incident of 1/2/23 when she had a fall in the bathroom. When asked to detail what occurred on the day she fell, the resident reported she had a new NA working with her on that day. She did not recall the NA's name. The resident stated she was being transferred from the recliner to the toilet in her bathroom. The resident then stated, The girl didn't fasten the center strap (referring to the chest support straps on the sling). She reported I told her she didn't hook the cross-straps on me. Resident #4 reported only the two long straps that connected each side of the sling to the lift were used for the transfer. However, the cross straps which secured the sling to the resident's chest were not used. Resident #4 stated during the transfer, she slipped a little and felt weak, then fell to the ground. When specifically asked, the resident reported she did not actually faint or lose consciousness during the transfer on 1/2/23. Resident #4 reiterated she just felt weak when she fell in the bathroom. A follow-up interview was conducted with Resident #4 on 1/18/23 at 10:57 AM. When asked, the resident confirmed during the 1/2/23 transfer (when she fell from the lift) her sling was loose, the cross straps were not secured, and no leg straps were fastened on her legs. Resident #4 added, I told the lady it usually takes two [staff] but she didn't say nothing. A telephone interview was conducted on 1/17/23 at 4:02 PM with NA #1. NA #1 was identified as the agency (temporary staff) nurse aide who was assigned to care for Resident #4 on first shift of 1/2/23 from 7:00 AM to 7:00 PM. During the interview, the NA reported 1/2/23 was the first and only shift she worked at the facility. NA #1 reported, No one gave me rounds I did not know anything about the resident. The NA stated she did not have access to the residents' electronic [NAME] (an electronic record which provided details of the type of care a resident required) or any other information typically available via the electronic Kiosk (a computer terminal) until the end of her shift. NA #1 reported she had to ask residents and other staff for information about resident care. Attempts made to conduct a follow-up telephone interview with NA #1 were unsuccessful. A telephone interview was conducted on 1/18/23 at 9:27 AM with NA #2. NA #2 was identified as an agency (temporary staff) nurse aide who worked on the first shift of 1/2/23 from 7:00 AM to 7:00 PM. During the interview, the NA reported 1/2/23 was the first and only time she worked at the facility. When asked, NA #2 reported the orientation she received at the facility consisted of a walk-through of the facility conducted at the start of her shift. She stated other new NAs were included in this walk-through to let them know where everything was. The NA reported she did not receive an orientation packet. NA #2 also stated that although she had asked for access to the residents' [NAME] and other information available from the Kiosk so she could do her charting, she did not receive access to these records until late in the shift. An interview was conducted on 1/18/23 at 11:09 AM with the facility's Staff Development Coordinator (SDC). The SDC reported she was new to the facility with a start date of 12/29/22. Upon inquiry, the SDC reported the facility had a structured orientation process for new employees and agency staff conducted by the Human Resources (HR) staff member. This orientation process was already in place when the SDC started in her position. An interview was conducted on 1/18/23 at 1:00 PM with the HR staff member who was identified as being responsible for the facility's orientation of new staff (both employees and agency). During the interview, the HR staff member reported the orientation process for new NAs was a two-day orientation. Day 1 of the education included general information about the company and facility. Day 2 of the education was provided for nurses and NAs covering more clinical information. Upon inquiry, the HR staff member reiterated both new facility staff employees and new agency staff attended this orientation prior to working their first shift. She also reported there was a Skills Checklist that was typically signed off on by either the facility's Director of Nursing (DON) or SDC. A review of Day 2's printed orientation packet included information on the use of lifts. This information included the following statement in bold print which read, Before you lift: Must have a spotter before lifting a resident with either lift. Total or stand aide [sit to stand lift]. Additional written information provided indicated a skills check off and return demonstration on the use of lifts. A notation on the skills checklist indicated this form was required to be completed within 10 days of hire. An interview was conducted on 1/18/23 at 5:00 PM with the facility's DON. During the interview, the DON was asked about the orientation provided to agency NAs. The DON clarified that only agency staff coming from one specific agency (not the agency employing NA #1 or NA #2) went through the 2-day orientation previously discussed with the HR staff member. She reported the Unit Manager typically stayed in the facility and provided a more condensed orientation and information on The [Company] Way for new agency staff coming from the other agencies (such as NA #1 and NA #2). She reported, Agency staff can't start working at the facility without the orientation. Upon request, the orientation and training material for NA #1 and NA #2 was provided for review on 1/18/23 at 4:07 PM by the facility's Unit Manager. The packet of information was entitled, Agency Nurse Aide Orientation. This packet included the following, in part: --An outline of the topics covered in the information packet included Falls and the Content read: In each resident's [NAME] under Safety, will be listed fall prevention information. You are responsible for knowing what these are. Residents should be rounded on frequently. --Another topic in the outline was entitled, Lists and how residents transfer and noted the following: We have lifts stored in clean utility. Lift pads are kept in the storage closet on the floor. Residents who require a lift for transfers will be noted in the resident's [NAME]. It also read in bold print: Agency aides must not operate a mechanical lift. If you are assigned to a resident that needs a lift, the facility aide will operate the lift and the agency aide will assist as a spotter. Remember: It is your responsibility to know what lift is required to transfer a resident. You will know this by checking the [NAME] as seen below [referring to a sample diagram]. You can access a residents [NAME] on the [computer terminal] by logging into the resident's chart . --A skills checklist for a sit-to-stand lift was also included in the orientation packet. Nothing was checked as completed. The checklist was signed only by the Unit Manager and dated 1/2/23. --A Mechanical Lift Transfer Safety and Change in Condition Education Packet for nurses and NAs noted in bold print, **Prior to performing a transfer, it is important that you always completed the following: One bullet point listed read, When using any lift, 2 caregivers [in bold print] must be present during the lift. One operating the lift and the other acting as a spotter. This is important to protect the resident from potential injury such as hitting their leg on the lift mast, etc. All of the training material in both NA #1 and NA #2's training / orientation packet was signed by the Unit Manager and dated 1/2/23. However, neither NA #1 or NA #2 signed any of the orientation training information or checklists included in her orientation / training packet. An interview was conducted on 1/18/23 at 5:10 PM with the facility's Unit Manager. The Unit Manager reported, That day [1/2/23] was hectic with several people being oriented. The Unit Manager recalled she did provide an orientation to the building and walked around with the new agency staff on 1/2/23. The Unit Manager also stated she asked the orientees to sign the forms in their orientation packet. NA #1 and NA #2 did not sign any documents in their orientation packets before they left their shift on that date. It was noted NA #1 and NA #2's lift checklists were not completed. The Unit Manager reported she would normally try to orient the new agency staff before the start of their shift but 1/2/23 was a very busy day with a lot going on so she had to get the NAs on the floor as soon as possible. A follow-up interview was conducted on 1/19/23 at 12:50 PM with the Unit Manager. The Unit Manager reported each of the NAs were supposed to come to her to complete the orientation packets at some point during their shift, but NA #1 and NA #2 did not come back to do so on 1/2/23. During a second follow-up interview conducted on 1/19/23 at 2:33 PM with the Unit Manager, she reported, We verbalized the orientation materials but did not do the lift checklist as a return demonstration. An interview was conducted on 1/19/23 at 7:45 AM with the facility's Director of Nursing (DON). During the interview, the orientation and training of agency NAs were discussed. The concern identified with the facility's failure to provide and/or document orientation, training and competencies provided for the two agency NAs (NA #1 and NA #2) working when Resident #4 fell to the floor was discussed. The DON stated she understood the concern. The DON reported she should have followed-up with the new SDC at the facility to ensure a process for the orientation of the new agency NAs was in place. Upon request, the facility provided documentation of a Review to Ensure Quality (initiated on 1/4/23) for review on 1/17/23 at 2:00 PM. This review indicated the facility began an investigation of Resident #4's fall on 1/4/23. Immediate education that was being initiated included Mechanical lift education; Agency orientation checklist; and Nursing admin [administrative] staff on agency orientation checklist being completed before agency staff can work in facility. The plan for correcting the specific area of concern identified and process that led to the concern included a 4-point plan that addressed: 1) Corrective action for resident involved; 2) Corrective action for potentially impacted residents; 3) Systemic changes; and 4) Quality Assurance. The date of completion for the systemic changes involving the in-service training of nursing staff was 1/18/23. The Administrator was notified by telephone of immediate jeopardy on 1/26/23 at 5:35 PM. The facility provided an acceptable credible allegation on 1/27/23. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On 01/02/2023 Resident #4 received injury during a lift transfer resulting in injury. On 01/04/2023, the Director of Nurses, Rehab Manager, and the Clinical Nurse Consultant began identification of residents that were potentially impacted by the alleged deficient practice. The alleged deficient practice includes: agency nurse aides who did not have proper orientation and training to meet the care needs of residents and verification of competency which would include safe use of the facility's mechanical lift. This audit was completed by reviewing current residents on 100/200 hall who were identified as requiring transfers utilizing a lift. This audit was completed on 01/05/2023. The Director of Nurses and the Clinical Nurse Consultant began updating the care plan to ensure it included the required number of individuals to complete a safe transfer and the proper device to be used. This care plan update was completed on 01/05/2023. Since 1/05/2023, the Director of Nursing and assessment nurses and therapy have reviewed residents on admission, quarterly and with significant changes to ensure that care plans include the use of lift and number of nursing assistants that should assist with transfers. This information is also included on all care guides Specify the actions the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring and when the action will be completed. On 01/04/2023, the Director of Nurses and Staff development coordinator began in-servicing all licensed nurses and certified nursing assistants (full time, part time, prn and agency employees) on Mechanical Lift Safety Education which included education on how to use the lift, how many caregivers are required to use the lift, and what to do if there is a problem with the lift. This was completed on 01/18/2023. After 01/18/2023, this in-servicing was incorporated into all new hire orientation for nurses, certified nursing assistants and agency staff that are allowed to use the lift. The training included both sit to stand and total mechanical lifts. All facility lifts are by the same manufacturer Additionally, on 01/04/2023, the Director of Nurses began validation of competency of certified nursing assistants and nurses (agency and non-agency) on use of the lift. This was completed on 01/18/2023. Competency was continued during the orientation process for new hires and as a part of the agency training. Facility and Agency staff are not allowed to use lifts until they have received training and have validated competency. Competency is validated by noting the NA identifying the proper transfer technique and the proper device needed for the resident, the use of the transfer device and ensuring that all safety mechanisms related to the device are used properly, as well as return demonstration. Transfer status is located on the [NAME] for each resident and is found in PCC. Every employee including agency receives a login with PCC access at the start of their shift. They receive education on this restriction at the beginning of their first shift in the facility. Once the staff member is properly trained on lift use, they are allowed to use lifts according to facility policy. Supervisory staff are notified when an agency staff member has been trained. The facility Scheduler and Educator keeps a record of all trained staff and ensures the staff member on the schedule has been trained. If a schedule modification is made, the Educator and Supervisor on Duty are notified by the scheduler and the Educator or designee completes the staff member's training and competency before the start of their shift. The current education is that an agency NA can use the lift with any other NA if both are properly trained. A list of all trained staff, including agency, is kept by the scheduler and the Educator and is updated as new staff are educated. On 01/16/2023, the Director of Nurses or a designee began weekly monitoring (which included facility staff and agency staff) to identify if training had been completed on how to use the lift, and if the correct number of caregivers were used to complete the transfer. These audits included actual observation of staff (including agency) carrying out transfers, as well as Sit to Stand Staff Knowledge checks. The facility will perform 2 transfer observations per week for three weeks and then monthly times 2 months. There were no concerns identified from any of the audits that were completed. The Director of Nurses has ensured that all licensed nurses and certified nursing assistants (full-time, part time, as needed and agency) employees who do not complete the in-service training will not be allowed to work until the training is completed. The Director of Nursing, nurse managers, Educator and Scheduler accomplished this by: making sure that the written agency orientation packet is provided to the agency staff prior to their first shift in the facility. The facility leaves orientation packets near the time clocks for the Supervisor and will follow up by phone, as needed, to notify the Supervisor that a new agency employee requires education that needs to be completed before they can begin the shift. The Supervisor will ensure that the packet is reviewed. This process of notifying the on shift Supervisor is performed by the Scheduler, Educator and Director of Nursing or designee prior to the start of the employees (agency employee) first shift. All employees must complete general orientation prior to working with residents. Transfer status is located on the [NAME] for each resident and is found in PCC. Every employee including agency receives a login for PCC access at the start of their shift. This training is included in the orientation process. Completed 01/18/2023. This in-service was incorporated into the new employee facility orientation for all licensed nurses and certified nursing assistants (full time, part time, prn and agency employees). This began on 1/16/2023 and will continue. Completed 01/18/2023 Date of IJ removal-01/19/2023 The facility's credible allegation of immediate jeopardy removal was validated on 2/2/23. The validation was evidenced by review of facility and agency licensed nursing staff and nurse aides' (NAs) training and education files regarding both initial education and re-education of proper use of all mechanical lifts in the facility, demonstration of mechanical lifts used, re-demonstration of mechanical lift use and a written quiz related to use of mechanical lifts. Both facility and agency licensed nursing staff and NAs on all units were interviewed and were able to verbalize the mechanical lift education they received prior to returning to work or prior to beginning to work at the facility. Immediate Jeopardy was removed on 1/19/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, Nurse Practitioner, and Medical Director interviews, the facility failed to notify the physician of critical laboratory results. Resident #46's blood sugar was critically low at 37 milligrams/deciliter (mg/dl) on [DATE] and critically low at 25 mg/dl on [DATE] through laboratory work. These results were not acted on by the facility, daily insulin continued, and no further blood sugars were done. This deficient practice occurred for 1 of 2 residents reviewed for notification of changes (Resident #46). Immediate jeopardy began on [DATE] when nursing staff failed to identify critical laboratory results resulting in the lack of physician notification and was removed on [DATE] when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity D (not actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring and all staff have been in-serviced. The findings included: Resident #46 was readmitted to the facility on [DATE] with diagnoses including Covid, left hip fracture and insulin-dependent diabetes mellitus. He was prescribed insulin with regular blood sugar checks during previous admission. A hospital Discharge summary dated [DATE] included an order for long-acting basal insulin 20 units daily (long-acting means insulin enters bloodstream in 2-4 hours from administration time and can last up to 24 hours in the body) and blood sugar test strips to check blood sugars four times daily as directed. The hospital Discharge summary dated [DATE] also included an order to draw a complete blood count (CBC), basic metabolic panel (BMP), and thyroid stimulating hormone (TSH) on [DATE]. Resident #46's bloodwork dated [DATE] showed a critical low blood sugar value of 37 milligrams/deciliter (mg/dl) (normal level 70-99 mg/dl). Per laboratory report, multiple, unsuccessful attempts were made to contact the facility staff about this critical value. This result was released to the electronic medical record and faxed to the facility on [DATE] at 3:28pm. Review of the medical record for Resident #46 revealed there was no documentation the physician was notified of the critically low blood sugar on [DATE]. Review of Resident #46's MAR showed that blood work was drawn again on [DATE] and there was no documentation that it was done on [DATE]. Resident #46's laboratory results for the BMP dated [DATE] showed a critical low blood sugar of 25 mg/dl. Per report, this critical result was called Nurse #9 on [DATE] at 5:02pm by lab technician #1. This result was released to the electronic medical record and faxed to the facility on [DATE] at 5:02 pm. Review of the medical record for Resident #46 revealed there was no documentation the physician was notified of the critically low blood sugar on [DATE]. During an interview with lab technician #1 on [DATE] at 2:47 pm, he stated that he was never able to reach a staff member on [DATE] to relay critical sugar results but did reach Nurse #9 on [DATE] and informed him of the current critical level of 25 (mg/dl), as well as the previous result of 37 (mg/dl) at that time. He also stated that, if he was unable to reach a staff member by phone, per the laboratory policy, he would release the results to the facility's system to be flagged and would continue to try to reach the facility by phone. During an interview with Nurse #9 on [DATE] at 9:45 am, he stated that he had no recollection of ever receiving a phone call from the lab regarding critical lab results for Resident #46. When asked about critical lab results, he stated he would contact the on-call provider, get any orders that may be needed, and then place a printed copy of the results in the doctor's folder for him/her to sign off on when they come into the facility next. He again stated that he did not recall receiving any phone calls about any critical results on [DATE]. During an interview with the Nurse Practitioner on [DATE] at 3:35 pm, the state surveyor notified her of critical lab results from [DATE] and [DATE]. She stated that she was not aware of any critical blood levels for Resident #46. She stated the phone number to contact the on call doctor was available 24 hours a day. She also stated, along with immediate verbal notification, there was a folder where the staff will put any critical lab value reports for her to review upon next visit to the facility. She also stated that she was in the facility on [DATE] and there were no critical levels in her folder for her to review. During an interview with the Medical Director on [DATE] at 5:02 pm, the state surveyor notified him of critical lab results from [DATE] and [DATE]. He stated the phone number to contact him or whomever was on call for him is available 24 hours a day. He also stated, along with immediate verbal notification, there was a folder where the staff will put any critical lab value reports for him or his staff to review upon next visit to the facility. The Administrator was notified of immediate jeopardy on [DATE] at 11:16am. The facility provided a credible allegation of immediate jeopardy removal dated [DATE]. 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. Resident # 46 was deceased on [DATE] and is no longer a resident of the facility. On [DATE], the Nurse Consultant completed an audit of 100% of all current resident's lab values to identify if there were any alert lab values that were not communicated to the Nurse Practitioner or Medical Provider for the last 60 days. The audit revealed eleven alert lab values were reviewed. Six alert lab values had provider notification upon receipt. The Director of Nurses and the Assistant Director of Nurses immediately notified the Medical Director and Individual providers on [DATE] of the five required alert lab values that were not previously communicated at the time of the lab results. Specify the actions the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring and when the action will be completed. On [DATE] the Director of Nurses and Assistant Director of Nurses began in servicing of all licensed nurses (full time, part time, and prn including agency nurses) on Critical Labs. Staff were educated on how critical labs are received, to promptly notify the physician and/or on call of all critical labs, document notification in the electronic record, and to notify the resident and RP of the critical labs. The DON will ensure that any licensed staff who has not completed the in-service training on [DATE], will not be allowed to work until the critical lab training is completed. The critical lab in-service will be incorporated into the new employee facility orientation program for both facility and agency licensed staff. On [DATE], the DON was notified of the responsibility to ensure the critical lab in-service will be incorporated into the new employee facility orientation program for both facility and agency licensed staff by the Clinical Nurse Consultant. Date of IJ removal [DATE] The credible allegation of immediate jeopardy removal was verified on [DATE] as evidenced by onsite validation through record review, and staff interviews. A review of facility in-service materials titled Critical Lab Education, Changes in Condition, and Preventing Errors on Admission were reviewed for content. Staff were interviewed to validate in-service completion on signs and symptoms of hypoglycemia and physician notification regarding critical lab results. The DON, assistant DON, the floating DON, and the corporate nurse met with all floor nurses and assessed all current residents to identify any signs and symptoms of hypoglycemia. Per their assessment, no current residents were identified having any signs and symptoms of hypoglycemia. The immediate jeopardy was removed on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, Nurse Practitioner, and Medical Director interviews, the facility failed to monitor blood sugar levels for a resident with insulin-dependent diabetes (Resident #46). The facility administered long acting insulin without monitoring the resident's blood sugar. On [DATE], Resident #46's blood sugar was critically low at 37 milligrams/deciliter (mg/dl) and, on [DATE], it was critically low at 25 (mg/dl) through laboratory work. These results were not acted on by the facility, daily insulin continued, and no further blood sugars were done. This deficient practice occurred for 2 of 3 sampled residents. Also, the facility failed to assess, notify the physician, and obtain orders to treat an open area on the right lower leg and left lower leg for 1 of 4 residents reviewed for pressure ulcers (Resident #15). Immediate jeopardy began on [DATE] when staff gave Resident #46 his first insulin dose without knowing his current blood sugar level and was removed on [DATE] when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity D (not actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring and all staff have been in-serviced. The facility was also cited at a scope and severity of D for example #2 (Resident #15). The findings included: Resident #46 was readmitted to the facility on [DATE] with diagnoses including left hip fracture, Covid-19, and insulin-dependent diabetes mellitus. He was on insulin with regular blood sugar checks during previous admission. A hospital Discharge summary dated [DATE] included an order for long-acting basal insulin 20 units daily (long-acting means insulin enters bloodstream in 2-4 hours from administration time and can last up to 24 hours in the body) and blood sugar test strips to check blood sugars four times daily as directed. The hospital Discharge summary dated [DATE] also included an order to draw a complete blood count, basic metabolic panel, and thyroid stimulating hormone on [DATE]. The physician's order dated [DATE] was insulin deglu[DATE] unit/milliliter-inject 20 units subcutaneously one time a day for diabetes mellitus. There were no orders for monitoring blood sugar levels. During an interview with Nurse #8 on [DATE] at 10:05 am, she stated she completed Resident #46's admission upon arrival. She stated she faxed the hospital discharge medication orders to the pharmacy and then hand-entered the same orders into the computer system which the on-call doctor approved remotely and then the pharmacy filled the order. She stated she was aware a resident on insulin needed regular finger stick blood sugar checks but did not remember whether or not she entered that into the system as he came with a lot of orders that day. She stated she would have entered blood sugar test strips and treatment orders separate from the pharmacy order. Resident #46's medication administration record (MAR) for [DATE] - 17, 2022 showed no current order for fingerstick blood checks. His MAR included documentation that insulin was administered on dates with staff initials. Resident #46's bloodwork dated [DATE] showed a critical low blood sugar value of 37 milligrams/deciliter (mg/dl) (normal level 70-99 mg/dl). Per laboratory report, multiple, unsuccessful attempts were made to contact the facility staff about this critical value. Blood work was drawn again on [DATE] because no one documented that it was done on [DATE]. Resident #46's bloodwork dated [DATE] showed a critical low blood sugar of 25 mg/dl. Per report, this critical result was called Nurse #9 on [DATE] at 5:02pm by the technician who completed the test. During an interview with the lab technician on [DATE] at 2:47 pm, he stated that he was never able to reach a staff member on [DATE] to relay critical sugar results but did reach Nurse #9 on [DATE] and informed him of the current critical level of 25 (mg/dl), as well as the previous result of 37 (mg/dl) at that time. He also stated that, if he was unable to reach a staff member by phone, per the laboratory policy, he would release the results to the system to be flagged and would continue to try to reach the facility by phone. During an interview with Nurse #9 on [DATE] at 9:45 am, he stated that he had no recollection of ever receiving a phone call from the lab regarding critical lab results for Resident #46. He stated that he was aware Resident #46 was on insulin. He stated that if blood sugars are done then they are put on the resident's medication administration record. He did not recall doing any fingerstick blood sugar tests on Resident #46 since he was admitted on [DATE]. He also stated Resident #46 ate pretty good while he was there. He added that he was not working on that hall when Resident #46 was admitted and wasn't responsible for entering his initial orders into the system. He was unsure who was assigned to him. Record review showed a Nurse Aide #4 documented that Resident #46 was seen awake and sipping on water and stated he was fine on [DATE] at 3:30 am when she made rounds. Multiple attempts to reach Nurse Aide #4 were unsuccessful. On [DATE] at 10:15 am, a review Resident #46's meal intake report for [DATE]-[DATE] showed he consumed 76-100% of his meal one time and 51-75% one time. All other meals were either < 25% or meal was refused. During an interview with the floating Director of Nursing on [DATE] at 3:10pm she stated you should never give insulin without knowing what the current blood sugar level is. She added that how orders are entered into the system and the lack of monitoring blood sugars was something the facility will be working on and will be included in their interdisciplinary meetings. During an interview with the Nurse Practitioner on [DATE] at 3:35 pm, the state surveyor notified her that there were no blood sugar checks. She stated the importance of finger stick sugar checks in the presence of insulin and added that you should never administer insulin if you don't know what the current sugar level is. She stated that she was not aware of any critical blood levels for Resident #46. She stated he was newly admitted and she had not had a chance to evaluate him yet. She also stated that she was in the facility the previous day and there were no critical levels in her folder for her to review. She also stated that she expected all staff, including agency staff, to take care of the residents, for nurses to know current sugar levels prior to administering insulin, and to be able to recognize hypoglycemia signs. During an interview with the Medical Director on [DATE] at 5:02 pm, the state surveyor notified her that there were no blood sugar checks. He stated there should be regular finger sticks with all residents who have insulin-dependent diabetes. He stated he was not aware of any critical blood sugar levels. He stated that it was vital to be aware of a resident's blood sugar levels when administering insulin. The Administrator was notified of immediate jeopardy on [DATE] at 11:16am. The facility provided a credible allegation of immediate jeopardy removal dated [DATE] at 7:52pm. 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. Resident # 46 was deceased on [DATE] and is no longer a resident of the facility. On [DATE], the Nurse Consultant completed an audit of 100% of all current insulin dependent diabetic residents to identify if they have orders for accuchecks and if they had any critical sugar labs. This audit was completed on [DATE]. The audit identified that 19 of 19 current insulin dependent diabetic residents had orders for accuchecks. No corrective actions were required. Additionally, 0 of 0 current insulin dependent diabetic residents had a critical sugar lab in the last 60 days. No corrective actions were required. All current insulin dependent diabetic residents blood sugars are being monitored as ordered. On [DATE], the Director of Nurses and the nurse management team began an audit of residents who were potentially affected by the noncompliance by completing an audit of all new admissions/readmissions for the month of [DATE], to identify any new admissions/readmissions who are insulin dependent diabetic residents to ensure no orders for accuchecks on the discharge summary were not entered at the time of the admission. The audit was completed on [DATE]. The audit identified 18 total admissions. 2 of 18 admissions were insulin dependent diabetics with orders for accuchecks. The 2 admissions identified as insulin dependent diabetics at admission did have orders for accuchecks with blood sugars that are being monitored as ordered. No corrective actions were required. On [DATE], the Director of Nursing and Assistant Director of Nurses met with all floor nurses and assessed all current residents to identify any signs and symptoms of hypoglycemia. No current residents were identified having any signs and symptoms of hypoglycemia. No other residents were impacted. Specify the actions the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring and when the action will be completed. On [DATE] the Director of Nurses and Assistant Director of Nurses began in servicing all licensed nurses and certified nursing assistants (full time, part time, and prn including agency nurses) on changes in condition which includes hypoglycemia and decreased meal intake. The education also included identifying signs and symptoms of hypoglycemia, assessment monitoring including blood sugar levels, following the diabetic protocol for hypoglycemia, notification of physician of signs and symptoms and documentation of assessment and actions taken in the medical record. On [DATE] the Director of Nurses and Assistant Director of Nurses began in servicing of all licensed nurses (full time, part time, and prn including agency nurses) on Critical Labs. Staff were educated on how critical labs are received, to promptly notify the physician and/or on call of all critical labs, document notification in the electronic record, and to notify the resident and RP of the critical labs. All critical lab results are currently phoned to the nurse from a lab representative. If the lab is unable to reach the nurse at the facility, the lab representative will contact the on-call nurse to report the critical lab result. The lab manager has been provided the phone number for the nurse on-call phone number by the DON [DATE]. The lab representative facility contacts will be updated to include the nurse on-call phone number by the DON on [DATE]. The on-call nurse will then be responsible for following up to ensure the following occurs: Physician and/or on call is notified of the critical lab results, documentation of the result in the electronic record, and to notify the resident and RP of the critical labs. On [DATE], the Director of Nursing and Assistant Director of Nurses also began in servicing of all licensed nurses (full time, part time, and prn including agency nurses) on the admissions process and review to ensure one nurse enters the orders into the EMR and a second nurse verifies the orders for accuracy. The nurses were also educated on the need to obtain blood sugar monitoring orders for all insulin dependent diabetics and those on diabetic medications. This will be reviewed for all new admissions/readmissions and those with new diagnosis or medication orders for diabetes. The DON will ensure that all licensed nurses (full time, part time, and prn including agency nurses) who does not complete the in-service training will not be allowed to work until the training is completed. This in-service was incorporated into the new employee facility and agency orientation for all licensed nurses (full time, part time, and prn including agency certified nursing assistants and nurses). Date of IJ removal [DATE] 2. Resident #15 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, edema and atrial fibrillation. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had moderately impaired cognition and required extensive assistance to total dependence with 1-2 people for his activities of daily living. He had no skin impairment. A review of the care plan included a focus on incontinence with risk for skin breakdown initiated on [DATE] and anticoagulant therapy with an intervention to inspect skin and report abnormalities to nurse. A Weekly Skin assessment dated [DATE] revealed no new areas. On [DATE] at 11:43 AM, an observation was made of Resident #15 sitting in his wheelchair. A bordered gauze dressing with visible dark drainage was observed to the left lower leg. A hydrocolloid dressing was observed to the right lower leg with a date of [DATE]. Resident #15 did not know why the bandages were on his legs. A record review revealed no documentation or orders for the areas to Resident #15 ' s right and leg lower legs. On [DATE] at 11:49 AM, a second observation was made of Resident #15 ' s lower legs. The resident still had the bordered gauze dressing to the left lower leg and the hydrocolloid dressing dated [DATE] was still in place to the right lower leg. On [DATE] at 8:25 AM, Nurse #7 stated she didn ' t know anything about the areas or dressings to Resident #15 ' s lower legs. Nurse #7 removed the dressing to the left lower leg and a small open area was observed with a small amount of drainage noted. The right lower leg also had a small open area present. A nurses noted dated [DATE] at 8:25 AM by Nurse #7 read, this nurse noted open area to BLE (bilateral lower extremities). Area cleansed with normal saline and dry dressing applied. Physician notified and wound care requested to assess. Orders received. A review of the physician ' s orders revealed an order dated [DATE] to clean right and left shin with normal saline, pat dry with gauze, apply triple antibiotic ointment, cover with dry dressing, and secure with tape twice a day until healed. On [DATE] at 10:54 AM, an interview was conducted with the Director of Nursing who stated when a resident develops a new area on their skin, the staff member that identifies the area should document it in the medical record with the description, notify the physician and family and put a treatment order in place if needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #22 was admitted to the facility on [DATE] with diagnoses that included a cerebral infarction, Parkinson's disease, depression, dementia, and anxiety. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #22 had severe cognitive impairment with inattention, disorganized thinking and verbal behaviors directed towards others. The assessment documented she received an antipsychotic 6 days and an antidepressant 7 days of the 7-day lookback period. The antipsychotics were on a routine basis only. A review of the electronic medical record for Resident #22 revealed an initial admission AIMS was completed on the date of [DATE]. A review of the Pharmacy medication regimen review for [DATE] written by the Pharmacy Consultant #1 for Resident #22 requested an AIMS due to the Resident receiving Olanzapine, an antipsychotic medication. A review of the Pharmacy medication regimen review for [DATE] written by the Pharmacy Consultant #1 for Resident #22 repeated the request for an AIMS for the Resident. A review of the Pharmacy medication regimen review for [DATE] written by the Pharmacy Consultant #1 for Resident #22 repeated the request for an AIMS for the Resident. A review of the electronic medical record for Resident #22 revealed a second AIMS assessment was completed on [DATE]. A review of the Pharmacy medication regimen review for [DATE] written by the Pharmacy Consultant #1 for Resident #22 requested an AIMS due to the Resident continuing to receive an antipsychotic medication. A review of the Pharmacy medication regimen review for [DATE] written by the Pharmacy Consultant #1 for Resident #22 repeated the request for an AIMS for the Resident due to her continuing to receive an antipsychotic medication. On [DATE] at 2:04 p.m. an interview was conducted with the Unit Manager, and she revealed she received emails from the pharmacy consultant with the nursing monthly medication regimen review recommendation and request that also stated when to conduct an AIMS assessment. She revealed she was not sure if the AIMS assessment were due every three months or six months and would need to ask her Director of Nursing because she completed the AIMS assessments when she received instructions to do so in the emails from the Pharmacy consultant and Minimum Data Set (MDS) consultant. She reviewed the chart for Resident #22 and revealed she was able to see where the Pharmacy consultant documented the request for an AIMS on [DATE], [DATE], and [DATE] and then again on [DATE] and [DATE]. She stated she had been out of work due to an illness in June, 2022 and was not sure who the request had been emailed to but the AIMS was not completed in [DATE] as requested. She revealed in [DATE] and [DATE] a different Director of Nursing (DON) had been employed and the emails were going directly to the DON. The nursing recommendations requested from the Pharmacy Consultant had begun to be sent to the Unit managers in addition to the DON to improve on the follow up. She added the second AIMS was not completed until March of 2022. An interview was conducted with the interim DON on [DATE] and he revealed the facility protocol for an AIMS assessment was to be conducted upon admission and every 6 months. He stated the facility protocol to follow up on Pharmacy consultant recommendations was for the request to be expedited as quickly as possible based on the situation and medication. He added a request for an assessment like an AIMS, the goal was for a turn around as quickly as possible, and this should be conducted before the pharmacist returns the following month. Based on record review, consultant pharmacists, Nurse Practitioner and Medical Director interviews, the facility failed to complete an evaluation of Resident #46's medication regimen that identified the need to monitor insulin administration. Resident #46's initial medication regimen review did not identify the inadequate monitoring of insulin administration. Resident #46 received daily insulin without blood sugar testing and experienced critically low blood sugars identified through bloodwork. This was for 1 of 3 residents reviewed for pharmacy services. Also, the facility failed to retain the consultant pharmacist's findings, recommendations, and provider response in the resident's medical record or within the facility so the records were readily available for 6 of 13 residents whose medications were reviewed (Resident #24, #15, #4, #65, #168, and #218). And the facility failed to act on the Pharmacy Consultant recommendations to complete an abnormal involuntary movement (AIMS) assessment for 1 of 5 residents (Resident #22) reviewed for unnecessary medications. Immediate jeopardy began on [DATE] when consultant pharmacist #1 reviewed Resident #46's medications and failed to recognize there were no physician orders for blood sugar testing with the administration of insulin and was removed on [DATE] when the facility provided an acceptable credible allegation of compliance. The facility will remain out of compliance at a scope and severity E (not actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring and all staff have been in-serviced. The facility was also cited at a scope and severity of E for example #2 (Resident #24, #15, #4, #65, #168, and #218) and for example #3 (Resident #22). The findings included: Resident #46 was readmitted to the facility on [DATE] with diagnoses including Covid, left hip fracture and insulin-dependent diabetes mellitus. He was on insulin with regular blood sugar checks during previous admission. Resident #46 died in the facility on [DATE]. A hospital Discharge summary dated [DATE] included an order for long-acting basal insulin 20 units daily (long-acting means insulin enters bloodstream in 2-4 hours from administration time and can last up to 24 hours in the body) and blood sugar test strips to check blood sugars four times daily as directed. The hospital Discharge summary dated [DATE] also included an order to draw a complete blood count, basic metabolic panel, and thyroid stimulating hormone on [DATE]. A physician's order dated [DATE] was insulin degludec (long-acting insulin) 100 unit/milliliter-inject 20 units subcutaneously one time a day for diabetes mellitus. There were no orders for monitoring blood sugar levels. The initial pharmacy review dated [DATE], completed by consultant pharmacist #1 showed no medication issues with Resident #46's current insulin orders. The review did not acknowledge the insulin. Consultant pharmacist #1 was unable to be interviewed. During an interview on [DATE] at 3:20 pm, consultant pharmacist #2 stated that consultant pharmacist #1 completed the initial medication reviews for the new admissions to the facility. She stated that they do not receive fingerstick blood sugar orders. They only receive medication orders and that is what they review and base their recommendations on. She stated that the facility was responsible for ordering and keeping up with fingerstick orders. When asked if blood sugars were something they would monitor during their pharmacy reviews, she stated no, she probably would not look at those. She stated the review was based on medication orders only. During an interview with the Nurse Practitioner on [DATE] at 3:35 pm, she stated that she was not aware that Resident #46 was not receiving any fingerstick blood checks. She stated he was newly admitted and she had not had a chance to evaluate him yet. She also relayed the importance of finger stick sugar checks in the presence of insulin and she would expect finger stick blood sugar results to be on the resident's medication administration record for review. She added that you should not administer insulin if you don't know what the current sugar level is and that insulin is adjusted based on the daily blood sugar results. The Administrator was notified of immediate jeopardy on [DATE] at 12:37pm. The facility provided a credible allegation of immediate jeopardy removal dated [DATE]. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident # 46 was deceased on [DATE] and is no longer a resident of the facility. On [DATE], the Pharmacy Director completed an audit of 18 residents who were potentially affected by the noncompliance by completing a comprehensive review of all new admissions/readmissions for the month of [DATE]. The audit consisted of a review of insulin dependent diabetics to ensure orders for diabetic monitoring are in place. The pharmacy consultant also reviewed current lab results. Recommendations based on this review were sent to the physician by the nurse supervisor on [DATE]. These recommendations may include: additional labs, order changes, or additional diabetic monitoring. There were no other residents impacted. Specify the actions the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring and when the action will be completed. As of [DATE], the nurse consultant educated the pharmacy director on the need for all pharmacist consultants to review new admissions and readmissions to conduct comprehensive review that includes reviewing discharge summaries and comparing pre-hospital admission diabetic monitoring with readmission orders for monitoring and blood work orders and ensuring that the facility is providing comprehensive services for those residents with diabetic needs. In cases of irregularities identified, the consultant pharmacist will notify facility clinical leadership for immediate follow-up to the medical provider. Pharmacy consultants will review all discharge summaries for new admissions and readmissions. In the event the pharmacy review identifies any insulin dependent diabetics, the consultant must review all orders to ensure orders for diabetic monitoring are in place. Additionally, the pharmacist consultant will review current labs and make recommendations to the physician if order changes, additional labs or additional diabetic monitoring is required. This will be completed at the time of the initial review to ensure residents with diabetes are receiving a comprehensive review with the necessary care and services, monitoring for their diabetes. On [DATE], The Regional Director of Operations had a conversation with the pharmacy director detailing the process for ongoing monitoring for those residents with diabetic needs, specifically closer monitoring of chart information for new admissions and readmissions, to include reviewing the facilities practices for providing care and services. Previous pharmacy audits did not include review of blood work or orders for insulin dependent diabetics. The Pharmacy Director will in-service all consultant staff that are assigned reviews for the facility on [DATE]. The Pharmacy Director will provide the completed in service packet the facility leadership to ensure the training has been completed and for review. The pharmacy director will ensure that any consultant pharmacists who does not complete the in-service training will not be allowed to review charts for the facility until the training is completed. This in-service was incorporated into the new pharmacy employee orientation for the above identified staff including the agency staff orientation. IJ Removal [DATE] The credible allegation of immediate jeopardy removal was verified on [DATE] as evidenced by onsite validation through record review, and staff interviews. The facility nurse consultant met with the consulting pharmacist on [DATE] to complete an audit of current diabetic residents. They also met to discuss the need for reviewing discharge summaries for any monitoring orders for new and readmissions. The pharmacist will also review lab work and make recommendations depending on results. The facility immediate jeopardy removal was validated to be completed as of [DATE]. 2-a) Resident #168 was admitted to the facility on [DATE] with re-entry on [DATE]. His cumulative diagnoses included diabetes, hypertension, chronic obstructive pulmonary disease, Alzheimer ' s disease, dementia with behavioral disturbance, major depressive disorder and anxiety disorder. The resident ' s electronic medical record (EMR) included monthly MRRs completed by the consultant pharmacist. The MRRs included the following, in part: --On [DATE], an MRR conducted by the pharmacist included recommendations which read: repeat. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: AIMS (Abnormal Involuntary Movement Scale), GDR (gradual dose reduction). --On [DATE], an MRR conducted by the pharmacist included recommendations which read: f/u (follow-up), AIMS. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: AIMS, documentation. No additional information was provided related to the consultant pharmacist ' s recommendations. Resident #168 ' s ' s EMR revealed a consultant pharmacist conducted an initial MRR on [DATE]. The pharmacist ' s note from the MRR read: Initial pharmacist medication regimen review completed. Recommendations made, see report. No additional information was provided related to the consultant pharmacist ' s recommendations. The resident ' s EMR included monthly MRRs completed by the consultant pharmacist. The MRRs included the following, in part: --On [DATE], an MRR conducted by the pharmacist included recommendations which read: AIMS, documentation. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: Repeat, AIMS. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: documentation. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: clinical doc (documentation). --On [DATE], an MRR conducted by the pharmacist included recommendations which read: repeat. No additional information was provided related to the consultant pharmacist ' s recommendations. An initial MRR was completed by a consultant pharmacist for Resident #168 on [DATE]. The pharmacist note read, Initial pharmacist medication regimen review completed. Recommendations made, see report. No additional information was provided related to the consultant pharmacist ' s recommendations. On [DATE], a monthly MRR was conducted by the consultant pharmacist. The pharmacist recommendations read: documentation. No additional information was provided related to the consultant pharmacist ' s recommendations. Further review of Resident #168 ' s EMR revealed there were no Pharmacy Consultation Reports included in the resident ' s medical record to provide details from the MRR recommendations dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], or [DATE]. Additionally, there was no documentation in Resident #168 ' s medical record to indicate the consultant pharmacist ' s findings / recommendations were reviewed or a response was received from the provider. 2-b) Resident #218 was admitted to the facility on [DATE]. Her cumulative diagnoses included Alzheimer ' s disease, osteoporosis, and depression. The resident ' s electronic medical record (EMR) included monthly MRRs completed by the consultant pharmacist. The MRRs included the following, in part: --On [DATE], an MRR conducted by the pharmacist included recommendations which read: GDR (gradual dose reduction. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: f/u (follow-up). --On [DATE], an MRR conducted by the pharmacist included recommendations which read: APAP (acetaminophen. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: GDR. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: clinical doc (documentation). --On [DATE], an MRR conducted by the pharmacist included recommendations which read: prn (as needed). No additional information was provided related to the consultant pharmacist ' s recommendations. Resident #218 ' s most recent Minimum Data Set (MDS) was a significant change assessment dated [DATE]. The MDS assessment revealed she had severely impaired cognitive skills for daily decision making. The MDS reported the resident ' s medications included an antidepressant on 1 out of 7 days, an antibiotic on 7 out of 7 days and an opioid medication on 7 out of 7 days during the 7-day look back period. Further review of Resident #218 ' s EMR revealed there were no Pharmacy Consultation Reports included in the resident ' s medical record to provide details from the MRR recommendations dated [DATE], [DATE], [DATE], [DATE], [DATE], or [DATE]. Additionally, there was no documentation in Resident #218 ' s medical record to indicate the consultant pharmacist ' s findings / recommendations were reviewed or a response was received from the provider. 2-c) Resident #4 was admitted to the facility on [DATE]. Her cumulative diagnoses included diabetes, renal insufficiency, and an adjustment disorder with mixed anxiety and depressed mood. The resident ' s electronic medical record (EMR) included monthly MRRs completed by the consultant pharmacist. The MRRs included the following, in part: --On [DATE], an MRR conducted by the pharmacist included recommendations which read: repeat, documentation. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: documentation. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: lab. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: lab. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: GDR, repeat. No additional information was provided related to the consultant pharmacist ' s recommendations. Resident #4 ' s most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS assessment revealed she had cognitively intact skills for daily decision making. The MDS reported the resident ' s medications included insulin injection and antidepressant medication on 7 out of 7 days during the look back period. On [DATE], a monthly MRR conducted by the pharmacist included recommendations which read: labs. No additional information was provided related to the consultant pharmacist ' s recommendations. Further review of Resident #4 ' s EMR revealed there were no Pharmacy Consultation Reports included in the resident ' s medical record to provide details from the MRR recommendations dated [DATE], [DATE], [DATE], [DATE], [DATE] or [DATE]. Additionally, there was no documentation in Resident #4 ' s medical record to indicate the consultant pharmacist ' s findings / recommendations were reviewed or a response was received from the provider. 2-d) Resident #65 was admitted to the facility on [DATE]. Her cumulative diagnoses included anemia, hypertension, renal insufficiency, chronic obstructive pulmonary disease (COPD), anxiety disorder and depression. The resident ' s electronic medical record (EMR) included monthly MRRs completed by the consultant pharmacist. The MRRs included the following, in part: --On [DATE], an MRR conducted by the pharmacist included recommendations which read: prn (as needed), lab. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: f/u (follow-up). --On [DATE], an MRR conducted by the pharmacist included recommendations which read: repeat. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: lab, documentation. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: repeat. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: repeat. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: documentation. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: clinical doc (documentation). No additional information was provided related to the consultant pharmacist ' s recommendations. Resident #65 ' s most recent Minimum Data Set (MDS) was an annual assessment dated [DATE]. The MDS assessment revealed she had moderately impaired cognitive skills for daily decision making. The MDS reported the resident ' s medications included an antidepressant, antibiotic, and opioid medication on 7 out of 7 days and a diuretic on 1 out of 7 days during the 7-day look back period. On [DATE], a monthly MRR conducted by the consultant pharmacist included recommendations which read: Probiotic, inhalers, documentation. No additional information was provided related to the consultant pharmacist ' s recommendations. Further review of Resident #65 ' s EMR revealed there were no Pharmacy Consultation Reports included in the resident ' s medical record to provide details from the MRR recommendations dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], or [DATE]. Additionally, there was no documentation in Resident #65 ' s medical record to indicate the consultant pharmacist ' s findings / recommendations were reviewed or a response was received from the provider. 2-e) Resident #15 was admitted to the facility on [DATE]. His cumulative diagnoses included a seizure disorder, hypertension, heart failure, and respiratory failure. Resident #15 ' s most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS assessment revealed he had moderately impaired cognitive skills for daily decision making. The MDS reported the resident ' s medications included an antidepressant, anticoagulant, and diuretic medication on 7 out of 7 days during the look back period. The resident ' s electronic medical record (EMR) included monthly MRRs completed by the consultant pharmacist. The MRRs included the following, in part: --On [DATE], an MRR conducted by the pharmacist included recommendations which read: documentation. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: lab, repeat. --On [DATE], an MRR conducted by the pharmacist included recommendations which read: repeat. No additional information was provided related to the consultant pharmacist ' s recommendations. Further review of Resident #15 ' s EMR revealed there were no Pharmacy Consultation Reports included in the resident ' s medical record to provide details from the MRR recommendations dated [DATE], [DATE] or [DATE]. Additionally, there was no documentation in Resident #15 ' s medical record to indicate the consultant pharmacist ' s findings / recommendations were reviewed or a response was received from the provider. 2-f) Resident #24 was admitted to the facility on [DATE]. His cumulative diagnoses included a history of multiple fractures, hypertension and unspecified dementia with behavioral disturbance. The resident ' s electronic medical record (EMR) revealed a consultant pharmacist conducted an initial pharmacist medication regimen review (MRR) on [DATE]. The pharmacist ' s note from the MRR included documentation which read: Initial pharmacist medication regimen review completed. Recommendations made, see report. Resident #24 ' s admission Minimum Data Set (MDS) dated [DATE] revealed he had moderately impaired cognitive skills for daily decision making. The resident ' s MDS assessment indicated his medications included an antipsychotic medication on 4 out of 7 days and a diuretic on 5 out of 7 days during the look back period. The resident ' s EMR included the following monthly MRRs completed by the consultant pharmacist: --On [DATE], an MRR conducted by the pharmacist included recommendations which read: documentation, AIMS (Abnormal Involuntary Movement Scale). --On [DATE], an MRR conducted by the pharmacist included recommendations which read: repeat, AIMS. Further review of Resident #24 ' s EMR revealed there were no Pharmacy Consultation Reports included in the resident ' s medical record to provide details from the MRR recommendations dated [DATE], [DATE], or [DATE]. Additionally, there was no documentation in Resident #24 ' s medical record to indicate the consultant pharmacist ' s findings / recommendations were reviewed or a response was received from the provider. An interview was conducted on [DATE] at 10:27 AM with the corporate floating Director of Nursing (DON) who served as the facility ' s Interim DON from [DATE] - [DATE]. During the interview, the float DON was asked if the consultant pharmacist recommendations, consultation reports and provider response for Resident #168, Resident #218, Resident #4, Resident #65, Resident #15, and Resident #24 were available for review. During a follow-up interview conducted with the floating DON, she reported only one Note to Attending Physician/Prescriber originating from a pharmacist MRR could be located. She stated no additional pharmacy recommendations were found in the residents ' medical records or elsewhere in the facility. An interview was conducted on [DATE] at 9:56 AM with the facility ' s consultant pharmacist. During the interview, the pharmacist was asked to describe the process used at the facility for sharing the MRR monthly recommendations with the residents' provider. The pharmacist reported she would write a progress note in each resident ' s EMR to indicate whether or not she had pharmacy recommendations. She reported some recommendations were intended for nursing staff and these would go into a Nursing Note. Other pharmacy recommendations were intended for the provider. The pharmacist reported she would typically send all of her notes and recommendations via email to the DON and Regional Nurse Consultant and would flag important or urgent issues. The pharmacist stated it was up to the DON to print and distribute/delegate the Nursing Notes. The pharmacist reported she has asked the facility to upload the pharmacy recommendations with responses from the provider into each resident ' s EMR. When asked, the consultant pharmacist reiterated she would expect the pharmacy recommendations with the provider ' s response to be scanned into each resident ' s electronic medical record. A telephone interview was conducted on [DATE] at 2:00 PM with the facility ' s Nurse Practitioner (NP). During the interview, the NP described the process employed for receiving the pharmacist's recommendations, reviewing, and responding to them. She reported she received the pharmacist ' s recommendations when the DON put them in her book. The NP stated she typically reviewed the recommendations, noted what she wanted to be done, and gave them back to the DON. The NP reported the DON would enter any order changes into the resident ' s EMR. After that, it was the NP ' s understanding that the DON would give these reports to medical records to be scanned in to the resident's EMR. An interview was conducted on [DATE] at 3:55 PM with the facility ' s Interim DON. During the interview, the DON reported he was aware of the concern regarding the pharmacist ' s recommendations and provider responses not being available for review. The DON indicated he would expect the regulations to be followed.