**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, resident, and Physician's Assistant interviews the facility failed to immediately report an allegation of sexual abuse to the administrator for 1 of 3 residents reviewed for sexual abuse (Resident #38). A severely cognitively impaired female resident (Resident #38) was taken by a resident (Resident #241), a cognitively intact male resident, into the bathroom in his room. Resident #241's roommate, a cognitively intact male resident (Resident #47), used his call light to alert Nurse Aide (NA) #1 about Resident #241 and Resident #38. NA #1 did not report the allegation about Resident #241 and Resident #38 to a nurse. During this time when NA #1 did not report the allegation to a nurse, Resident #241 was in the bathroom with Resident #38. It was not until a nurse, who was coming to administer evening medications to Resident #241, discovered Resident #38 with her pants down, brief off, and shirt pulled up to below her breasts, as Resident #241 was standing in the bathroom with her. Findings included: A review of the facility's Abuse, Neglect and Exploitation Policy dated 10/20/2020 stated the facility's staff will report all alleged violations to the Administrator within specified timeframes: immediately if the events that caused the allegation involve abuse. Resident #241 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease and weakness. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #241 was cognitively intact, had not had behaviors, and required moderate assistance with walking and used a wheelchair and walker for ambulation. Resident #38 was admitted to the facility on [DATE]. Resident #38's cumulative diagnoses included: dementia, schizoaffective disorder, bipolar disorder, and posttraumatic stress disorder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #38 was severely cognitively impaired and she required moderate assistance for transfers and toileting, she did not have any behaviors, and she was occasionally incontinent of bowel and bladder. The MDS assessment further indicated Resident #38 could roll herself in her wheelchair for 150 feet without assistance. Resident #47 was admitted to the facility on [DATE] with diagnoses of stroke, mood disorder, and diabetes. A review of Resident #47's most recent quarterly Minimum Data Set (MDS) assessment indicated he was cognitively intact. On 2/13/2024, during the facility's investigation into the allegation of sexual abuse, the Director of Nursing interviewed Resident #241's roommate, Resident #47, and he stated Resident #241 pushed Resident #38 into his bathroom and shut the door. Resident #47 stated when Nurse Aide #1 entered the room to answer his call light he mouthed the words that Resident #241 and Resident #38 were in the bathroom, and he stated Nurse Aide #1 got Nurse #1. An interview was conducted on 3/21/2024 at 10:25 am with Resident #47, who was the roommate of Resident #241. Resident #47 stated Resident #241 pushed Resident #38 into their room on the evening of 2/13/2024 and they were watching television together. Resident #241 then wheeled Resident #38 into the bathroom and shut the door, and he knew that wasn't right. Resident #47 stated he put on his call light and Nurse Aide (NA) #1 answered. Resident #47 told Nurse Aide (NA) #1 that Resident #241 and Resident #38 were in the bathroom and Nurse Aide #1 went to get the Nurse. On 3/21/2024 at 5:03 pm Nurse Aide (NA) #1 was interviewed by phone and stated she answered Resident #47's (roommate for Resident #241) call light and he told her he thought his roommate, Resident #241, was trying to have sex with that lady (Resident #38) in the next room. Nurse Aide #1 stated she went to the next resident room and there was a resident in the room and then she checked the bathroom and there were no other residents in the bathroom, so she dismissed the allegation and did not look any further for the two residents. Nurse Aide #1 stated she might have told Nurse #2 about Resident #47's allegation but she was not sure if she told someone. A phone interview was conducted with Nurse #1 on 3/22/2024 at 9:10 am and she stated no one reported to her there was an allegation by Resident #241's roommate (Resident #47) that Resident #241 pushed Resident #38 into his bathroom, and he thought they were going to have sex. She stated she found Resident #38 in the bathroom with Resident #241 when she went to Resident #241's room to give him his evening medication. Nurse #1 stated Resident #38 was sitting in her wheelchair beside the commode with her brief on the floor beside her wheelchair and her pants pulled down to the floor, and her shirt pulled up to just below her breasts. She further stated Resident #241 was standing with his hands around his abdomen, he was fully clothed, and he stated Resident #38 was changing her brief and was doing a good job. Nurse #2 was interviewed by phone on 3/22/2024 at 9:15 am and she stated she was called to Resident #241's room by Nurse #1 and Nurse #1 told her she found Resident #241 and Resident #38 in Resident #241's bathroom and her pants were pulled down, her brief was on the floor, and her shirt was pulled up to just below her breasts. She stated when she arrived at Resident #241's room Resident #38 was sitting in her wheelchair in front of the commode with her pants below her knees, her brief on the floor, and her shirt pulled up to just below her breasts. Nurse #2 was interviewed by phone again on 3/22/2024 at 9:56 am and she stated Nurse Aide #1 did not notify her of Resident #47's allegation, she was notified of the incident by Nurse #1 after she found Resident #241 and Resident #38 in the bathroom together. Nurse #2 stated if Nurse Aide #1 told her about the allegation she would have investigated immediately. The written statements gathered by the Social Worker and the Director of Nursing on 2/13/2024 indicated Nurse Aide #1 stated between 9:00 pm and 9:15 pm the roommate, Resident #47, put his call light on and when she answered the call light, he stated Resident #241 was in bed with the lady in the next room and he was being fresh (inappropriate) with her. The written statement by Nurse #2 stated she was called by Nurse #1 for assistance and when she entered the room at 9:25 pm with Nurse #1 Resident #38 was sitting in her wheelchair with her pants down to her ankles, her shirt pulled up to just below her breasts, and her brief on the floor beside the wheelchair. On 3/21/2024 at 1:34 pm the Director of Nursing (DON) was interviewed, and she stated she received a phone call from Nurse #2 on 2/13/2024 at 9:30 pm. The DON stated during the phone call Nurse #1 told her Resident #38 was found in Resident #241's bathroom with Resident #241. The DON stated Nurse #2 reported Resident #38 was found undressed from the waist down, and Resident #241 was helping her to go to the bathroom. The DON stated she was not aware Nurse Aide #1 had not reported to Nurse #1 or Nurse #2 that Resident #47, Resident #241's roommate had reported an allegation of abuse and Nurse Aide #1 had not reported it to either Nurse #1 or Nurse #2. The DON stated Nurse Aide #1 should have reported the allegation to the Nurse #1 immediately. On 3/22/2024 at 12:32 pm the Administrator was interviewed, and she stated the facility had completed a plan of correction for the reporting of the allegation of sexual abuse that occurred on 2/13/2024 when Resident #38 was found sitting in her wheelchair with Resident #241, in his bathroom, with her shirt pulled up to below her breasts, her brief in the floor beside her wheelchair and her pants pulled down to her ankles. The Administrator stated Nurse Aide #1 should have immediately reported the allegation to a Nurse and the Nurse would report to the Director of Nursing or her. The Administrator was notified of Immediate Jeopardy on 3/22/2024 at 11:25 am. On 3/22/2024 at 11:25 am the Administrator stated the facility had completed a plan of correction regarding reporting of abuse on 2/13/2024: Corrective action for resident(s) affected by the allegation of deficient practice: On February 13, 2024, between 9:00 pm and 9:15 pm Resident #241's roommate, Resident #47, notified Nurse Aide #1 that Resident #241 was in the bed with the lady in the next room and he was being fresh (inappropriate) with her. Nurse Aide #1 stated she checked the next room and its adjoining bathroom and there was only one resident in the next room. On February 13, 2024, Nurse #1 entered Resident #241's room to give him his medications at 9:30 pm and Nurse #1 observed resident #38 in Resident #241's bathroom with her pants down to her ankles with her brief off sitting in her wheelchair with Resident #241standing beside Resident #38. Nurse #1 called Nurse #2 for assistance and Nurse #2 immediately removed Resident #241, who was cognitively intact, and stayed with him to ensure Resident #38's and other resident's safety. Nurse #2 stayed with Resident #38, a severely cognitively impaired resident, and assessed her for injuries, dressed her, and interviewed her. Nurse #2 notified the Director of Nursing of the incident, and the Director of Nursing notified the Administrator. The Administrator notified the Social Worker and the Treatment Nurse and requested their assistance with the incident. On 2/13/2024 the Administrator notified the police, notified Adult Protective Services, and submitted an initial allegation report to the State Survey Agency at 11:59 pm. The Administrator and DON notified Resident #38's responsible party and the on-call provider of the alleged abuse. The Administrator and the Police conducted an interview with Resident #38, Nurse #1, and Nurse #2 regarding the alleged abuse. The Social Worker and Administrator interviewed Resident #38 and Resident #47 for alleged abuse on 2/12/2024. Resident #38 was returned to her room; Resident #47 was moved to another room and Resident #241 was returned to his room and remained on 1:1 with nursing staff until he discharged on 2/14/2024. On 2/14/2024 the Administrator concluded the investigation of allegation of abuse and based on investigation finding the allegation was unsubstantiated for the allegation of abuse of Resident #38. On 2/14/2024 at 1:59 am the administrator submitted the investigation report to the State Survey Agency. Corrective action for residents with the potential to be affected by the deficient practice: On 2/13/2024 the Social Worker completed interviews with 100% alert and oriented residents for sexual abuse. On 2/13/2024 the Treatment Nurse completed skin assessments for 100% of residents with cognitive impairments for any signs of abuse. Findings included no other residents were affected by the alleged abuse. Measure/systemic changes to prevent reoccurrence of alleged deficient practice: On 2/13/2024 the Director of Nursing began in-service education of all full-time, part-time, and prn (as needed) staff, administration, housekeeping, dietary, nursing, therapy, and maintenance (including agency) on the abuse prohibition/reporting policy. The training will include all current staff including agency. This training included: abuse types, reporting abuse allegations immediately to the nurse/Director of Nursing/ Administrator, what to do if abuse is observed or suspected, assuring residents safety, zero tolerance of retaliation of reporting allegations of abuse, along with notification of local law enforcement, Adult Protective Services, and State Survey Agency. Staff were also asked if they were aware of any abuse occurring to any residents in the facility and what to do if observed or suspected. No staff were aware of any other alleged abuse occurring in the facility. The Director of Nursing will ensure that any of the above identified staff (all staff including agency) who does not complete the in-service training by 2/14/2024 will not be allowed to work until the training had been completed. This training will be included in new hire orientation for any newly hired staff. Monitoring procedure to ensure the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with regulatory requirements: Beginning the week of 2/14/2024, the Administrator or designee will monitor the abuse process to ensure residents are free from abuse and any abuse identified reported and addressed according to facility policy using the QA Tool for recognizing and reporting abuse. The Administrator or designee will interview 5 staff members to monitor if staff know the procedure for reporting alleged abuse and when and who to report to. The monitoring will be completed for 4 weeks and then monthly for 2 months or until resolved. Reports will be presented to the monthly Quality Assurance Committee by the Administrator or designee to ensure corrective action is initiated as appropriate. Compliance will be monitored, and on-going auditing program reviewed at month Quality Assurance Meeting. Immediate jeopardy removal date is 2/15/24. Date of Compliance is 2/15/24. Review of the Plan of Correction with compliance date of 2/15/2024: The facility provided documentation of interviews with staff who cared for Resident #38, Resident #241, and Resident #47 when Resident #47 reported an allegation of abuse to Nurse Aide #1 which she did not report. The Director of Nursing was notified, and the Director of Nursing notified the Administrator of the allegation of abuse and an investigation began on the evening of 2/13/2024. The Social Worker interviewed Resident #38 and all other residents that were cognitively intact regarding any abuse allegations on 2/13/2024 and there were no further allegations of abuse. The Wound Nurse completed skin assessments on all residents that were cognitively impaired, and no signs of abuse were identified on 2/13/2024. The Director of Nursing began in-service education on 2/13/2024 regarding the reporting of all types of abuse to the nurse/Director of Nursing/ Administrator; what to do if abuse is observed or suspected; assuring residents safety; zero tolerance of retaliation of reporting allegations of abuse, along with notification of local law enforcement, Adult Protective Services, and State Survey Agency. The facility also interviewed all staff to ensure they were not aware of any abuse that had occurred in the facility on 2/13/2024. The facility included the training in the orientation packet for all newly hired staff as of 2/13/2024. On 2/14/2024 the facility's Administrator began monitoring through interviews of 5 staff members a week for 4 weeks, then 5 staff members a month for 2 months to monitor through interviews if staff know the procedure for reporting alleged abuse and when and who to report to. The facility provided documentation of sign in sheets for education and staff were interviewed regarding their knowledge with no issues identified. The facility also provided documentation of the monitoring they had completed with no issues identified. The Plan of Correction compliance date of 2/15/24 was validated on 3/22/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, facility staff, and shelter staff interview the facility failed to develop and implement an effective discharge planning process to ensure discharge needs and goals were identified with the resident and the interdisciplinary team (IDT) as active participants in the discharge plan in order to prepare the resident for an effective transition to post-discharge care for a resident who was a planned discharge. On 2/14/24 Resident #241 was discharged without the facility verifying his discharge location and if his care needs were able to be met. In addition, the resident was discharged without adaptive equipment required for ambulation (rolling walker). Resident #241 indicated he was dropped off at a homeless shelter where he continued to reside and felt unsafe and was fearful. These failures created a high likelihood of harm for Resident #241. This deficient practice affected 1 of 4 residents reviewed for discharge. Immediate jeopardy began on 02/14/24 when the facility initiated a planned discharge of a resident without verifying the discharge location and ensuring the resident's needs were able to be met. The immediate jeopardy was removed on 03/24/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of a D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective. The findings included: Resident #241 was admitted to the facility on [DATE] following a hospital stay for a surgical hernia repair. He admitted with diagnoses that included hernia repair, Parkinson's disease, chronic obstructive pulmonary disease, hypertension, right lower quadrant pain, major depressive disorder, muscle weakness, lack of coordination. Resident #241's admission Minimum Data Set assessment dated [DATE] revealed he was cognitively intact. Resident #241 was coded as having the goal to discharge to the community. The assessment indicated no discharge planning was actively occurring. Resident #241 was coded as normally using a walker and wheelchair, required limited assistance with toileting hygiene, bathing, lower body dressing, personal hygiene, and picking up an object from the floor. He required supervision with rising from a seated position, moving from a chair to the bed and from the bed to a chair, toileting transfers, tub or shower transfer, walking 10 feet, walking 50 feet, and walking 150 feet. Resident #241 was coded as taking antidepressant medications. Review of Resident's #241's care plan initiated on 02/01/24 and last reviewed on 02/13/24, revealed a care plan for I wish to discharge to [assisted living facility] once able to do so. Interventions included evaluate and discuss with the resident/family/caregivers the prognosis for independent or assisted living. Identify, discuss, and address limitations, risks, benefits, and needs for maximum independence. Evaluate the resident's motivation to return to the community. Additional review of Resident #241's care plan revealed a care plan for Resident is (specify high, Moderate, Low) risk for falls related to gait or balance problems. Interventions included Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in wheelchair and for physical therapy to evaluate and treat as ordered or as needed. Review of resident's medications revealed he was taking the following medications: Carbidopa-Levodopa ER Oral Tablet Extended Release for the treatment of Parkinson's disease Spiriva Respimat Aerosol, solution for the treatment of chronic obstructive pulmonary disease (COPD) Albuterol Sulfate HFA Aerosol, solution for wheezing or shortness of breath Diclofenac Sodium External Gel for pain management Venlafaxine HCl ER Oral Capsule Extended Release 24 Hour for the treatment of depression Mirapex Tablet for the treatment of Parkinson's disease Trazodone HCl Oral Tablet for the treatment of insomnia Propranolol HCl Oral Tablet for the treatment of hypertension Trilogy Ellipta Inhalation Aerosol Powder Breath Activated for the treatment of COPD Carbidopa-Levodopa ER Oral Tablet Extended Release for the treatment of Parkinson's disease Atorvastatin Calcium Oral Tablet for the treatment of hyperlipidemia Baclofen Tablet for the treatment of muscle spasms Gabapentin Oral Capsule for the treatment of nerve pain On 02/13/24 Resident #241 was found in a bathroom with a female resident. The female resident was reportedly undressed from the waist down with her shirt pulled up to below her breasts. Review of Resident #241's progress notes revealed no notes or documentation related to discharge planning prior to 02/13/24 when the facility opened and began to complete a discharge summary. Review of Resident #241's discharge summary revealed it was created on 02/13/24 at 10:50 PM by the Social Worker. Resident #241's discharge summary indicated no transitional services or referrals were completed or recommended, and no durable medical equipment [wheelchair, walker, bedside commode, oxygen] was ordered. The discharge assessment indicated Resident #241 was independent with his activities of daily living and was cognitively intact. Physical therapy and occupational therapy referrals were completed but no home health services were recommended or ordered and there was no scheduled primary care physician appointment scheduled. The discharge summary did report a primary care physician of Doctor #1 with a provided phone number with instructions that read please follow-up with your primary care physician 1-2 weeks post discharge from facility. If you have any immediate medical needs, call 911. The discharge assessment indicated that Resident #241 discharged home, accompanied by agency and was ambulatory at the time of discharge and that no durable medical equipment (rolling walker) was ordered. The discharge assessment was completed on 02/14/24 and signed by the Social Worker, Nurse #8, Resident #241. Review of Resident #241's functional abilities and goals assessment completed on 02/14/24 revealed Resident #241 required the use of a walker prior to his admission, required supervision or touching assistance with toilet hygiene, bathing, was dependent on others for lower body dressing, and needed supervision with walking 50 and 150 feet. An interview with the Social Worker on 03/22/24 at 1:32 PM revealed Resident #241 had been admitted to the facility on [DATE] and subsequently discharged on 02/14/24. She stated on the morning of 02/14/24, Resident #241 approached her and told her he wanted to leave She reported she asked him if he would stay until she could make it safe, and he reported that he would not and that he was going to leave that day. The Social Worker reported Resident #241 had approached him with his belongings packed. She proceeded to try and put as much post-discharge assistance in place as she could, as fast as possible but by the time she had contacted the Medical Director to notify him of the pending discharge and returned from trying to reach out to the physician, Resident #241 had already left the facility. She reported from the time Resident #241 reported he wanted to leave until the time he left, it was approximately 30 minutes or less. The Social Worker stated it was her understanding that Resident #241 had arranged for a ride share driver to pick him up from the facility. She stated she had no knowledge where Resident #241 had departed to and that he had previously mentioned he would go to stay with his spouse in a neighboring county and had assumed that was where he had gone. She reported she attempted to reach Resident #241 via telephone post discharge at the number in his medical record, but was unsuccessful. She also stated she could not recall if she coded the discharge as planned on the discharge summary. She reported she had processed the discharge as a planned discharge because she had been receiving pressure to ensure that all discharges were safe. She indicated that due to the hasty nature of Resident #241's discharge, it probably should have been treated more as an unplanned discharge against medical advice, instead of a planned, safe discharge. She also indicated there had been no active discharge planning prior to 02/13/24. Review of a progress note completed by Nurse #8 dated 02/14/24 at 4:47 PM read Resident has been discharged from facility, ambulating. [The] writer reviewed discharge summary and medications. No questions asked. Medications on cart were released to the resident and explained/educated and written on medicine card in detail the times to self-administer. No further questions. Transportation driver transported resident to destination. An interview with Nurse #8 on 03/25/24 at 10:15 AM revealed she remembered the discharge for Resident #241 on 2/14/24 and reported it did not seem like it was rushed or hurried. Nurse #8 did not indicate who informed her the resident was going to discharge on that date (2/14/24). Nurse #8 stated that she was able to educate Resident #241 on his medications and when and how to take them. She reported he never mentioned to her that he was asked or being forced to leave and that she believed he mentioned that he was either going to go to a friend's house or to the shelter. She reported the process was not different from any other planned discharges she had been involved with in the past. Nurse #8 also stated that she coded that resident was transported to his destination on her discharge progress note by the transportation driver because Resident #241 had set up his own transportation at discharge and since it was not family, she coded it as a transportation driver. Nurse #8 reported she did not recognize the transportation driver. Resident #241's discharge Minimum Data Set assessment dated [DATE] revealed he had a planned discharge from the facility back to the community with a return to the facility being unanticipated. An interview was conducted with Resident #241 on 03/22/24 at 1:03 PM via telephone. Resident #241 reported he used to live at the facility and was currently living in a homeless shelter. He stated He reported he was accused of molesting female resident at the facility on 02/13/24 and the staff told him he had to leave after the incident. Resident #241 was unable to provide the staff member's name but was able to provide a physical description. The physical description did not pinpoint the staff member as it corresponded with multiple staff members. He described the staff member that told him he had to leave as a Caucasian female with dark hair, approximately 5'9 and weight approximately 180 pounds but he could not recall her name. Resident #241 reported he did not want to go to the shelter because he thought he would be going to an assisted living facility, but stated he was not given a choice. Resident #241 reported he could not go live with his spouse because they were estranged and he did not want her to have to see him deteriorate as his Parkinson's disease progressed. He indicated he had not set up his own transportation as he did not want to leave the facility. Resident #241 stated he had been at the homeless shelter since he was dropped off and that he had not seen his physician since he left the facility. He explicitly stated that he did not feel safe and explained that a week prior to this interview a fight occurred at the shelter where knives were being thrown and he was pushed hard into a wall. He reported he was fearful he would be injured or hurt. When Resident #241 was asked if he was in pain, he stated I hurt from my ankles to the tips of ears. He indicated he was still at the shelter because he had nowhere else to go. During a follow-up interview with Resident #241 on 03/22/24 at 5:21 PM, he reported prior to his admission to the hospital for hernia repair, he was living in a different shelter. He stated he was admitted to a local hospital for hernia repair, and then was moved to the facility for aftercare and therapy. He stated he believed the plan was for him to go to an assisted living facility down the street from the facility he was in when he finished his therapy, but they kicked him out before that could happen. Resident #241 reported on 2/14/24 he was transported in an old ambulance type vehicle driven by and African American man. Resident #241 also indicated that he was not included in his discharge planning and that it surprised him. An interview with the Transportation Driver #1, who was the only transportation driver employed by the facility that matched the description provided by Resident #241 on 03/25/24 at 10:55 AM, revealed he had been at the facility since August 2022 and provided transportation in the facility's van for residents. He stated he remembered Resident #241 and stated he believed he had transported him to and from a couple appointments during his admission. Transportation Driver #1 reported he did not provide transportation services to Resident #241 at the time of his discharge (2/14/24). An interview with the Case Manager, who worked at the homeless shelter where Resident #241 was currently residing at, was conducted on 03/22/24 at 2:00 PM. She reported Resident #241 had been at the shelter approximately 2 months. She stated he arrived there straight from the facility. The Case Manager reported when Resident #241 arrived, he (Resident #241) indicated he was unsure why the facility had dropped him off at the shelter. She continued, stating that another staff member (Shelter Staff #1) from the shelter observed a facility labeled transportation van drop Resident #241 off at the shelter with his belongings and a whole bunch of medicine. She stated the shelter staff were helping Resident #241 with his medication management but stated they needed to find him a rolling walker as when he arrived, he did not have one and was having difficulty ambulating without a rolling walker. She also stated Resident #241 was able to continue to stay at the shelter for 120 days and then the shelter staff would have to reassess Resident #241 to determine if he would be allowed to stay longer. The Case Manger stated that Resident #241 was able to stay at the shelter through the day as he was paying a small amount of money while he was there. The Case Manager also reported Resident #241 was receiving some assistance with his activities of daily living from other residents such as tying his shoes and bathing as the shelter staff were unable to assist him. The Case Manager reported another resident at the shelter was able to provide Resident #241 with an extra rolling walker they had, and he was currently using it all the time when ambulating. An interview with Shelter Staff #1 on 03/27/24 at 3:48 PM revealed he worked on the evening of 02/14/24 from 5:00 PM until 10:00 PM. He stated he did not see the vehicle that Resident #241 arrived in but that when Resident #241 arrived he had only a bag of medicine and the clothes on his back. Shelter Staff #1 stated that Resident #241 had no wheelchair or walker and that the shelter staff had to scramble to find him a walker because Resident #241 walked with a shuffled gait and the shelter staff were concerned he would fall and seriously injure himself. Shelter Staff #1 stated Resident #241 currently used the walker the shelter provided at all times when he was ambulating. An interview with Shelter Coordinator on 03/26/24 at 8:23 AM revealed she had worked at the shelter for approximately 1 year. She reported she was familiar with Resident #241 and had processed his intake when he arrived (2/14/24). She reported when Resident #241 arrived, he had a box and a suitcase with only medications and clothing. She also stated he was confused when he arrived, stating he thought the plan was for him to go to an assisted living facility, but the facility had dumped him here. The Shelter Coordinator continued, stating the shelter cannot provide the care that Resident #241 needed and indicated if he was not such a nice guy, we would have had to discharge him due to not being able to take care of him. She did not provide information on the Resident #241's care needs. She stated that other residents at the shelter helped him when possible. She also provided information that Resident #241 was running out of medication and the Case Manager and Resident #241 had reached out to the facility (no specific facility staff member was identified) the previous week and requested assistance and were denied. The facility reported that since he no longer was a resident, they could not do anything to assist him. The Shelter Coordinator stated Resident #241 will most likely have to be sent to the hospital soon to get treatment and medication refills. She stated one medication he received was for tremors and when he runs out, it will become more difficult for him to care for himself. An interview with the Director of Therapy on 03/22/24 at 2:23 PM revealed Resident #241 was mostly independent with his activities of daily living at the time of his discharge. She reported he was walking more than 300 feet with the use of a rolling walker. She indicated that Resident #241 would require the use of a rolling walker to ambulate long distances. She indicated Resident #241 needed the rolling walker in order to ambulate long distances safely. The Therapy Director reported therapy last provided services to him on 02/13/24, the day before he discharged . She stated she was not included in the discharge planning process. She reported she did not know whether Resident #241 wanted to leave or if he was told to leave. The Director of Therapy reported she had no knowledge of where Resident #241 discharged to and indicated she had no knowledge if he had a rolling walker when he discharged but stated that was the recommendation at the time of discharge from therapy. An interview with Unit Manager #1 on 03/22/24 at 2:32 PM revealed she was assigned to be one on one with Resident #241 following an incident between him and another resident at the facility on 02-13-24. She reported the morning of 02/14/24, Resident #241 was quiet and reserved and stayed to himself. She reported prior to that day, Resident #241 was outgoing and friendly and spent most of his day out in the facility visiting with other residents. Unit Manager #1 reported he placed a few phone calls while she was providing 1:1 supervision, but she did not overhear what they were about. She also reported Resident #241 had mentioned to her once on 02/14/24 that he wanted to go home. She stated she could not recall if she observed Resident #241 packing his belongings. Unit Manager #1 reported around 3:00 PM or 4:00 PM, Resident #241 exited the facility via the front door and got into a vehicle and left. She reported she could not recall the type, color, make, or model of vehicle Resident #241 left in. Unit Manager #1 stated she did not know where Resident #241 discharged to. An interview with the Former Medical Director on 03/24/24 at 3:12 PM revealed he only saw Resident #241 one time during his admission. He stated when he saw Resident #241, he was using a wheelchair as a walker, had a shuffling gait, was being treated for Parkinson's disease and surgical aftercare. He reported he was not involved in the discharge of Resident #241 and that he did not know what the discharge goal for Resident #241 was after he completed his therapy. The Former Medical Director stated that Resident #241 had a shuffling gait and that he would have needed a rolling walker to ambulate. He also reported there would be some concern with Resident #241's involuntary movements from his Parkinson's disease worsening should he not take his medications or if they were unable to be filled. An interview with the Director of Nursing on 03/23/24 at 2:34 PM revealed she had returned to the facility on the evening of 02/13/24 after being informed of an incident between Resident #241 and another resident. She reported at that time, Resident #241 informed her he wanted to discharge immediately and requested some of his belongings that the facility had been storing for him in the medication room. The Director of Nursing reported she spoke with Resident #241 and encouraged him to stay since it was so late, and the weather was cold. She stated Resident #241 agreed to stay through the night but that he was adamant the following morning that he was going to discharge. The Director of Nursing reported Resident #241 discharged on his own accord on 02/14/24 and she had no knowledge of where he discharged to, if he had everything he needed, and whether where he was going was safe and could meet his needs. The Director of Nursing indicated she could not recall if she had contacted adult protective services and stated she did not call the Medical Director but thought the Administrator had notified him. An initial interview with the Administrator on 03/22/24 at 4:17 PM revealed she did not have a lot of information regarding Resident #241's discharge from the facility and that she felt they did what they could to make it as safe as possible. She reported her interdisciplinary team typically set up discharges and discharge planning began when residents stated they wanted to discharge. She reported she was not involved in the discharge process for Resident #241 and did not know where he went. She was unable to indicate what staff were involved with Resident #241's discharge process. The Administrator reported she was informed that Resident #241 voiced he wanted to discharge home and had planned to return to his spouse. She was unable to state who informed her or when she was informed. She stated it was her knowledge that he called a ride share company for transportation and left on his own accord. She was unable to explain where she received this knowledge from. The Administrator stated she did not believe the facility had transported Resident #241 to the homeless shelter as they did not provide discharge transportation services. She also reported that the facility's transportation van did not have any markings on it until 03/14/24 when they paid to have it wrapped in their facility's name. The Administrator reported there had been an incident between Resident #241 and another resident in the facility on the evening of 02/13/24 and that the police department had questioned him and notified him (Resident #241) that the other resident's family wanted to press charges and she wondered if that conversation may have scared him and made him want to leave to avoid the situation. Regarding Resident #241 being discharged without a rolling walker, she indicated that the facility routinely and provided equipment to discharging residents if there was an issue with backorders of equipment, or if needed equipment was not going to arrive before the scheduled discharge date . The Administrator reported she would have approved for Resident #241 to take a rolling walker with him had she been aware he needed one. She also reported that Resident #241 did not have a primary care physician and that he received a small income each month and stated he could utilize an urgent care physician if he needed and that he could also afford to pay for his own transportation. During a follow-up interview with the Administrator on 03/23/24 at 2:04 PM, she reported during Resident #241's 48-hour baseline care plan meeting, he voiced his desire to eventually discharge to an assisted living facility when he was able to. The Administrator continued, stating that Resident #241 had participated with therapy. She reported after the incident between him and another resident (2/13/24), he was informed that he would have to remain on one-to-one supervision but insisted that at no time during Resident #241's admission was he told he had to leave. The Administrator stated the discharge summary was opened on 02/13/24 because Resident #241 indicated that he wanted to leave that night, so the Social Worker began to prepare him for discharge from the facility. She continued, stating the Social Worker was eventually able to convince Resident #241 to stay until they could set up a safe and orderly discharge and the facility staff were under the impression on 02/13/24 that Resident #241 had agreed to stay until a safe and orderly discharge could occur. The Administrator reported the facility should have processed the discharge as leaving against medical advice instead of a safe discharge. She reported she had educated the Social Worker on how to better code discharges on the discharge assessment in the future. The Administrator reported a safe discharge would include a resident being prepared to go home or to another facility, with education received on care needs and medications. A safe discharge would include her interdisciplinary team and would now include knowing exactly where a resident will be discharging to. The Administrator and DON were notified of the Immediate Jeopardy on 03/22/24 at 5:22 PM. The facility provided the following IJ removal plan: F660 Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The facility failed to develop a discharge plan and implement a discharge plan to ensure resident #241's needs would be met. The facility did not ascertain how resident's needs would be met post discharge. The facility failed to ensure recommended adaptive equipment was available upon discharge. The facility did not follow up after discharge to see if resident #241's needs were being met. The facility failed to involve the IDT team in the discharge process. The Administrator made multiple attempts to contact resident #241 by phone with phone number provided by surveyor on 03/23/2024. The voicemail box was full and a message could not be left. The administrator sent a text message notifying of attempt to reach and voicemail being full, inquiring if resident was ok and if he had any current care need that I could help with and requested a return call. As of 3/24/2024 at 1:50 pm the Administrator has not received any follow up text or phone call from resident #241. In the event that resident #241 contacts administrator the administrator will inquire as to care needs of resident and attempt to provide assistance with current care needs. Residents discharging from the facility have potential to be affected by the same deficient practice. On 3/22/24 the Director of Nursing reviewed the last 30 days of planned discharges to community for development of a discharge plan that included: adaptive equipment, ensuring basic needs (food, shelter, water) were met, location was identified, physician appointments and discharge was safe and orderly. There were no issues identified during this review, regulatory criteria were met for safe discharge of all 13 residents reviewed. There were no issues identified during this review, regulatory criteria were met for safe discharge of all 13 residents reviewed. On 3/22/24 the Director of Nursing reviewed the last 30 days of un-planned discharges to community for documentation to support the voluntary revocation of all services without clearance or proper notice to implement a safe and orderly discharge. There were no issues identified during this review, regulatory criteria were met for unplanned discharge of all 2 residents reviewed. On 3/22/2024 the Administrator notified the interdisciplinary team of reviewing upcoming planned discharges daily in morning meetings to ensure the discharge planning process has been followed and resident care/ discharge needs are addressed prior to final discharge and to provide the medical director with information regarding upcoming discharges to ensure proper orders and discharge paperwork are implemented. The administrator also notified the interdisciplinary team they will meet weekly to review residents with goals to discharge from the facility to identify and address resident goals for care, treatment, preferences, barriers to discharge such as: care giver support, education, resident interests in any referrals made to local contact agency, post discharge needs such as nursing and therapy services, medical equipment or modification to the home or activities of daily living assistance. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: On 3/22/2024 the Administrator completed education with the interdisciplinary team. Education included: the discharge planning processes for facility initiated and resident initiated discharges; determining when safe discharge planning is attainable and/or unsafe discharge/against medical advice. Education also included understanding the regulatory requirements for the discharge planning processes, in the State Operations Manual for F 660, to ensure the interdisciplinary team understands the intent of the regulation as follows and has discharge planning processes in place for residents prior to planned discharges. The discharge planning process will address each resident's discharge goals and needs including caregiver support and referrals to local contact agencies, as appropriate, and involves the resident and if applicable, the resident representative and the interdisciplinary team in developing the discharge plan to ensure a safe discharge for those residents discharging from the facility. This will also include having knowledge of the discharge location, adaptive equipment as needed, ensuring basic needs (food, shelter, water) were met, location was identified, physician appointments, medications as needed, and discharge was safe and orderly. The Administrator will educate newly hired social workers and other newly hired IDT members in orientation. Education completed 3/22/24. Effective 3/22/24 the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for the alleged non-compliance. Alleged Date of IJ Removal: 3/24/2024 On 03/25/24, the credible allegation of Immediate Jeopardy removal was validated onsite by verification through facility staff interviews and record review. The interviewed staff across disciplines included nursing, administration, and therapy. The interviewed staff indicated they had received in-service training on discharge planning and processes and what constituted a safe and orderly discharge. The facility also reviewed previous discharges for the past 30 days to see if other residents had possibly been affected. The facility's alleged Immediate Jeopardy removal date of 03/24/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #241 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease and weakness. An admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #241 was cognitively intact and required moderate assistance with walking and used a wheelchair and walker for ambulation. There were no behaviors documented on the MDS. Resident #241's Care Plan dated 2/9/2024 indicated he was independent but could require set-up assistance with transferring to his wheelchair. The Care Plan did not indicate he had behaviors. Resident #38 was admitted to the facility on [DATE]. Resident #38 cumulative diagnoses included: dementia, schizoaffective disorder, bipolar disorder, and posttraumatic stress disorder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #38 was severely cognitively impaired, she did not ambulate, and she required extensive assistance for transfers and toileting, she did not have any behaviors, and she was occasionally incontinent of bowel and bladder. Resident #38's Care Plan was reviewed and stated she had impaired cognitive function due to impaired thought process related to dementia, psychoactive medication use, and a history of head injury; she required care with all activities of daily living due to dementia, decreased balance, and limited mobility; and she had behaviors of wandering and decreased safety awareness. The Care Plan included interventions of monitoring and reporting any changes in cognitive function, providing a home like environment, and assisting with decision making for impaired cognitive function; assisting with activities of daily living such as showering, bathing and personal care as needed; providing medications as ordered, and anticipate the residents needs for behaviors. Resident #47 was admitted to the facility on [DATE] with diagnoses of stroke, mood disorder, and diabetes. A review of Resident #47's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated he was cognitively intact. Resident #47's Care Plan dated 2/10/2024 indicated he did not have cognitive issues or behaviors. An interview was conducted on 3/21/2024 at 10:25 am with Resident #47, who was the roommate of Resident #241. Resident #47 stated Resident #241 pushed Resident #38 into their room on the evening of 2/13/2024 and they were watching television together. Resident #241 then wheeled Resident #38 into the bathroom and shut the door, and he knew that wasn't right. Resident #47 stated he put on his call light and Nurse Aide (NA) #1 answered. He stated he told Nurse Aide #1 that Resident #241 and Resident #38 were in the bathroom and Nurse Aide #1 went to get the Nurse. On 3/21/2024 at 5:03 pm Nurse Aide (NA) #1 was interviewed by phone and stated she answered Resident #47's (roommate for Resident #241) call light and he told her he thought his roommate, Resident #241, was trying to have sex with that lady (Resident #38) in the next room. Nurse Aide #1 stated she went to the next resident room and there was a resident in the room and then she checked the bathroom and there were no other residents in the bathroom, so she dismissed the allegation and did not look any further for the two residents. Nurse Aide #1 stated she might have told Nurse #2 about Resident #47's allegation but she was not sure if she told someone. During an interview with Resident #38 on 3/21/2024 at 6:28 pm she stated she could not remember what happened when she was found in the bathroom with Resident #241 on 2/13/2024. She stated she thought it was something unpleasant and she felt violated but was unable to verbalize any details of the incident and she did not remember if the incident happened in the facility or somewhere else. On 2/13/2024, during the facility's investigation into the allegation of sexual abuse, the Director of Nursing interviewed Resident #241's roommate, Resident #47, and he stated Resident #241 pushed Resident #38 into his bathroom and shut the door. Resident #47 stated when Nurse Aide #1 entered the room to answer his call light he mouthed the words that Resident #241 and Resident #38 were in the bathroom. The facility provided a copy of the statement Resident #241 gave on 2/13/2024 and he stated Resident #38 was complaining about her brief rubbing against her because it was too tight, and she could not break the tape on the brief, so he tore the tape and pushed the brief down for her. Resident #241 also stated during the statement that he did not touch her he just pushed the brief down. A phone interview was conducted 3/22/2024 at 1:03 pm with Resident #241 and he stated the facility had accused him of doing something to Resident #38. He stated they were friends and they held hands, and he bought her candy. He stated he went into the bathroom with Resident #38 because she needed to use the toilet and she could not remove her brief without assistance. Nurse #1 was interviewed by phone on 3/22/2024 at 9:33 am, she stated she worked for an agency staffing company, and she was Resident #241's nurse on 2/13/2024 on the 7:00 pm to 7:00 am shift. Nurse #1 stated she went into Resident #241's room at approximately 9:30 pm to give him his evening medications. She stated when she did not see Resident #241 in his room she went to the bathroom door, which was closed, and when she opened it, Resident #38 was sitting in her wheelchair, her brief was on the floor beside her wheelchair, her pants were pulled down to the floor, and her shirt was pulled up to just below her breasts. Nurse #1 stated Resident #241 was standing with his hands in front of his abdomen, he was fully clothed, and he told Nurse #1, Resident #38 was changing her brief and she was doing a good job. Nurse #1 stated she called for Nurse #2 to help her separate the residents. Nurse # 2 was interviewed by phone on 3/22/2024 at 9:15 am and she stated Nurse #1 called her to Nurse #2's unit and stated Resident #241 was with Resident #38 in his bathroom and she needed her assistance. She stated Resident #241 was standing at the door to the bathroom when she arrived at the room and did not want to let her in, and he stated he was helping Resident #38 change her brief. Nurse #2 stated Nurse #1 took Resident #241 out of the room and she assisted Resident #38 with dressing, and she spoke with Resident #38 after assisting Resident #241 out of the bathroom and Resident #38 told her Resident #241 stimulated her and touched her boobs. Nurse #2 further stated Resident #38 said Resident #241 did not hurt her, but it was not pleasurable, or painful. Nurse #2 stated Resident #38 did not act like she was upset and did not appear to be trying to get away from Resident #241 when she entered the bathroom. Review of Resident #38's Nurse's Progress notes revealed a note by the Director of Nursing (DON) on 2/13/2024 at 11:19 pm which stated she was notified by Nurse #2 of Resident #38 being discovered in Resident #241's bathroom and Resident #38 stated Resident #241 had touched her breasts and stimulated her. The DON's Progress Note further revealed the residents were separated; Resident #38's Responsible Party was notified of the situation; and an investigation was initiated. The DON's Progress Note also stated Resident #38 denied pain, stated she felt safe; and exhibited no distress. During a review of the facility's investigation after the incident the Director of Nursing and Social Worker interviewed Resident #38 and a written statement indicated Resident #38 stated she remembered she was not hurt or scared; it felt good; and she felt like he (Resident #241) was playing a game, and she was being taken advantage of. On 3/21/2024 at 1:34 pm the Director of Nursing (DON) was interviewed, and she stated she received a phone call from the Nurse #2 on 2/13/2024 at 9:30 pm. She stated during the phone call Nurse #1 told her Resident #38 was found in Resident #241's bathroom with Resident #241. When Resident #38 was found with Resident #241 she was undressed from the waist down, and Resident #241 stated he was helping her go to the bathroom. She stated she and the Social Worker began an investigation immediately and Resident #38 was calm and did not appear to be in distress. The DON stated they interviewed Nurse #1, Nurse #2, Nurse Aide #1, and Resident #47 after they interviewed Resident #38 and Resident #241. She stated Nurse #1 put Resident #241 on 1:1 observation and separated him from Resident #38. The DON stated Resident #47 requested a room change and he was moved to another room that evening. A Progress Note written by the Physician's Assistant (PA) on 2/14/2024 stated Resident #38 was seen due to an allegation of sexual assault by a male resident. The Progress Note stated staff reported Resident #38 was found with her pants and brief pulled down and a male resident grabbed her breast. The Progress Note further stated Resident #38 was severely cognitively impaired, had a history of bipolar disorder and suffered from post-traumatic stress disorder and her recall of events is limited. The PA's Progress Note stated a physical assessment was performed and no bruising, bleeding or other abnormal findings were found from the physical exam; no pain was reported; and the resident did not appear to be in acute distress. The Physician's Assistant (PA) was interviewed on 3/21/2024 at 11:59 am and she stated she was on call when Resident #38 was found in the bathroom with Resident #241 when her brief was off, and her pants were pulled down. The PA stated she saw Resident #38 the next day and she could recall some things but could not specify what had happened. The PA stated Resident #38 could remember a man in the bathroom. She stated she denied pain and her physical exam was normal. On 3/19/2024 at 4:30 pm a phone interview was conducted with the Family Member of Resident #38, and he stated the Administrator called him on the evening of 2/13/2024 and reported she was found Resident #38 in male resident's bathroom partially unclothed. He stated the facility had separated Resident #241 from Resident #38 and protected her from any further incidents. He stated Resident #38 was severely cognitively impaired and did not talk about the incident after it happened. On 3/22/2024 at 12:32 pm the Administrator was interviewed, and she stated the facility had completed a plan of correction for the allegation of sexual abuse on 2/13/2024 when Resident #38 was found sitting in her wheelchair with Resident #241, in his bathroom, with her shirt pulled up to below her breasts, her brief on the floor beside her wheelchair, and her pants pulled down to her ankles. She stated the Director of Nursing (DON) and Social Worker (SW) began interviewing the staff and residents involved. She stated Nurse #1 and Nurse #2 put Resident #241 on 1:1 observation and at Resident #47's request, they transferred him to another room. The Administrator further stated she and the DON began education about the facility's Abuse Prohibition and Reporting Policy on 2/13/2024 with all staff including the nursing department, dietary department, maintenance department, housekeeping department, therapy department and administration staff. She stated they educated all staff on the kinds of abuse, signs of abuse, and what to do if the staff suspect or have abuse reported to them. The Administrator stated they had continued to educate all new staff and they had taken the results of their monitoring to their monthly Quality Assurance Meetings. The Administrator was notified of the immediate jeopardy on 03/22/2024 at 7:55 pm. The facility provided the following credible allegation of immediate jeopardy removal for Resident #38: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On February 13, 2024, nurse #1 entered resident #241's room. Nurse #1 observed resident #38 in resident #241's bathroom with her pants down to her ankles with her brief off sitting in her wheelchair with resident #38 standing beside resident #241. Nurse #1 called for nurse #2. Nurse #1 immediately removed resident #241, who is cognitively intact, from resident #241's bathroom and stayed with him in the dayroom [ROOM NUMBER]:1 while nurse # 2 remained with resident #38. Nurse #2 assessed, dressed, and interviewed resident #38, who is severely cognitively impaired with a diagnosis of Dementia/Alzheimer's. Nurse #2 then removed resident #38 and returned her to her room. Nurse #2 notified the Director of Nursing (DON) of incident with resident #38 and resident #241. DON notified Administrator of incident with resident #38 and resident #241. The administrator notified social worker and treatment nurse and requested their assistance with incident in the building. On 2/13/2024, upon notification by phone of incident, the Director of Nursing (DON) and treatment nurse drove to the facility to meet with Resident #38, who was severely cognitively impaired, with a diagnosis of Dementia/Alzheimer and was assessed by the DON and treatment nurse for any injury on the residents' body as a result of the alleged abuse and incontinent care was provided for resident #38. The assessment revealed that resident #38 had no obvious bruising or redness on her body or genitals. 0n 2/14/2024 the psych provider was notified of incident with resident #38. On 2/20/2024 the psych provider visited with resident #38. On 2/13/2024, upon notification by phone of incident, the Administrator drove to the facility, it was determined that there was suspected abuse, notified police and adult protective services and submitted initial allegation report to State Survey Agency at 10:59 pm. The Administrator and DON notified Resident #38's responsible party and the on-call provider of the alleged abuse. The Administrator and police conducted an interview of resident #241, nurse #1, and nurse #2 regarding alleged abuse. Upon notification by phone the social worker drove to the facility to meet Resident #38 and conduct interview for alleged abuse. On 02/13/2024, the Social Worker and Director of Nursing interviewed resident #38 regarding alleged abuse. On 2/13/2024 at 10:00 pm resident #241's roommate was moved from room [ROOM NUMBER]B to 108B. Resident #241 was then taken back to his room by nurse remaining 1:1 until he discharged on 2/14/24. On 02/14/2024, the Administrator concluded alleged abuse investigation and based on investigation findings, unsubstantiated the alleged abuse of resident #38. On 02/14/2024 at 1:59 am, the Administrator submitted an investigation report to the State Survey Agency. Resident # 241 was discharged from the facility on 02/14/2024. On 2/13/2024, social worker completed 100% interviews of alert and oriented residents for sexual abuse. On 02/13/2024 the treatment nurse completed 100% skin checks of cognitively impaired residents for signs of abuse. Findings included: No other residents affected by alleged abuse. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 02/13/2024 the Director of Nursing began in-service of all full-time, part-time, and PRN (as needed) staff, administration, housekeeping, dietary, nursing, therapy and maintenance (including agency) on the abuse prohibition/reporting policy. This training will include all current staff including agency. This training included: Residents' right to be free from abuse, Abuse Types, screening of residents for red flags indicative of potential perpetrator behavior, identifying what constitutes abuse, recognizing signs of abuse, understanding behavioral symptoms of residents that may increase their risk of abuse and/or of being victimized, what to do if abuse is observed or suspected, and assuring resident safety. Staff were also educated to have heightened awareness, understanding and identifying resident #38 behaviors that placed her at an increased risk of abuse and monitoring, prohibiting and preventing abuse for resident #38. Staff were also asked if they were aware of any abuse occurring to any resident in the facility. No staff were aware of any other alleged abuse occurring in the facility. The Director of Nursing will ensure that any of the above-identified staff (all staff including agency) who do not complete the in-service training by 02/13/2024 will not be allowed to work until the training is completed. The Director of Nursing will ensure this training will be included in new hire orientation for any newly hired staff. Alleged date of IJ removal was 02/15/24. The facility provided evidence of correction of action accomplished for Resident #38 on 03/22/24. The facility provided documentation of Resident #241 being put on 1:1 observation immediately after the incident was discovered and continued until he was discharged from the facility on 2/14/24. The facility began an investigation by interviewing all staff involved on 2/13/2024. The facility also provided documentation of assessment of Resident #38 by Nurse #2 on 3/13/2024 and by the Nurse Practitioner on 3/14/2024. The facility provided evidence of actions accomplished for all other residents by providing skin assessments of all residents that were cognitively impaired and could not answer a questionnaire. They also provided documentation of questionnaires completed with any residents that were able to answer questions regarding any allegations of abuse and no issues were reported. The facility provided in-service education for all staff, for all departments, including agency and contracted staff regarding their abuse and neglect policy. The facility provided documentation of their monitoring, review of the monitoring, and their monthly Quality Assurance Committee meeting which included the review monitoring and in-servicing of all employees. The IJ removal date of 02/15/24 was validated. Based on record review, staff, resident, Emergency Service Services (EMS) Personnel, Infectious Disease Nurse Practitioner, facility Nurse Practitioner, Medical Director, family, and Physician Assistant interviews the facility neglected to provide intravenous (IV) antibiotic medication as ordered for 14 days to a resident when his IV access became dislodged and neglected to direct him to a higher level of care, to replace the IV access line for 1 of 3 residents reviewed (Resident #244) for abuse/neglect. There was the the high likelihood of physical harm by not administering the IV antibiotic as ordered by the infectious disease clinic. The untreated bacterial infection had the high likelihood of causing loss of function to his extremities or possible amputation of his extremities. The facility also failed to protect a resident's right to be free of sexual abuse for 1 of 3 residents reviewed for abuse/neglect (Resident #38). A cognitively intact male resident (Resident #241) was discovered in the bathroom of his room with a female resident (Resident #38), a severely cognitively impaired resident, with her pants off, brief off, and shirt pulled up near her breasts. During the facility's investigation in an interview, Resident #38 stated Resident #241 had stimulated and rubbed her breast(s) and stated she felt like she was being taken advantage of by Resident #241. Immediate jeopardy began on 07/14/23 when Resident #244's IV access become dislodged, and the facility neglected to re-establish his IV access or direct him to a higher level of care to ensure his IV access was restored and he could receive the IV medication he was prescribed. Immediate jeopardy was removed on 03/28/24 for Resident # 244 when the facility implemented a credible allegation of immediate jeopardy removal. Immediate jeopardy began on 2/13/24 for Resident # 241 and was removed on 2/15/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of education and monitoring system are in place. The findings included: 1. This tag is crossed referred: F684: Based on record review, staff, family, Emergency Medical Services (EMS) personnel, Infectious Disease Nurse Practitioner, facility Nurse Practitioner #2, and Medical Director interviews the facility failed to send Resident #244 to the emergency room (ER) as directed by the Infectious Disease office on 07/14/23 to have his intravenous (IV) access restored and to resume his previously prescribed IV antibiotics. Resident #244's peripherally inserted central catheter (PICC) line became dislodged on 07/11/23 and on 07/14/23 Nurse #10 was notified by the Infectious Disease office to send Resident #244 to the ER to have his PICC line reinserted so that he could resume his antibiotics as ordered and Nurse #10 failed to send him to the ER. Resident #244 was discharged from the facility on 07/24/23 and followed up at the Infectious Disease office on 07/26/23, had his IV access restored and his IV antibiotics resumed at an outpatient infusion center. This deficient practice affected 1 of 2 residents reviewed for significant medication errors. F760: Based on record review, staff, family, Infectious Disease Nurse Practitioner, facility Nurse Practitioner #2, and Medical Director interviews the facility failed to prevent a significant medication error when staff failed to administer 14 ordered doses of intravenous (IV) antibiotic from 07/11/23 to 07/24/23 after the residents peripherally inserted central catheter (PICC line) was dislodged for 1 of 2 residents reviewed for significant medication error (Resident #244). Resident #244's infection if left untreated could lead to loss of limb function. During an interview with the Director of Nursing (DON) on 03/21/24 at 4:14 PM, she stated if the infectious disease office called on 07/14/23 and gave an order to send Resident #244 to the ER then they should have sent him to the ER. She explained that there was no documentation of Resident #244's refusal to go to the ER and she stressed the importance of documentation to the nursing staff all the time. The DON stated that it was not acceptable to not administer Resident #244's IV antibiotics as prescribed and they should have sent him to the ER so his IV access could be restored, and his IV antibiotics resumed. The Administrator was interviewed on 03/21/24 at 4:53 PM, she stated that Resident #244 was very difficult and extremely non complaint with staff, she further stated, What he did not want he did not want. She explained he pulled his PICC line out and the staff attempted to get vascular access and it was unsuccessful. The nursing staff spoke to Infectious Disease on 07/17/23 and made them aware that he was still receiving antibiotic by mouth and not receiving the IV antibiotic. The Administrator stated, I feel like we did everything we could have done, we notified the provider and did our due diligence. He refused everything. The Administrator was notified of the immediate jeopardy on 03/27/24. The facility provided the following credible allegation of immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The facility neglected to provide intravenous antibiotics for 14 days to a resident when his intravenous access became dislodged. Administering the antibiotics was necessary to avoid physical harm. There was a high likelihood of serious hard or impairment when Resident #244's thoracis osteomyelitis (infection of the bone) and staphylococcus bacteremia (infection of the bloodstream left untreated for 14 days and the facility neglected to direct him to a higher level of care that could provide the ordered services. On 03/27/2024 the Director of Nursing reviewed all current residents receiving IV antibiotics for IV access placement/ patency/ function, orders for administration of IV antibiotic therapy course to ensure residents are receiving their antibiotics as ordered by the physician and do not require a higher level of care to meet resident current needs. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: On 03/27/2024 the Director of Nursing educated all licensed nurses on directing residents to a higher level of care if the needs of the resident cannot be met in the facility to avoid serious harm or impairment/ neglect of services needed. On 03/27/2024, the Director of Nursing educated all licenses nurses on following physician orders, notification of physician and documenting any barriers to IV antibiotic administration. On 03/27/2024 the Director of Nursing educated all certified nursing assistants on reporting changes in resident baseline, and any new acute observations to include observed IV issues. On 03/27/2024 the Director of Nursing educated all staff on heightened awareness of the definition of neglect, what constitutes neglect, and how to provide necessary care and services to the residents to ensure resident receive appropriate goods and services. On 03/27/2024, the Director of Nursing reviewed all current residents receiving IV antibiotics for IV access placement/ patency/ function, orders for administration of IV antibiotic therapy course to ensure residents are receiving their antibiotics as ordered by the physician and do not require a higher level of care to meet resident current needs. The Director of Nursing will educate newly hired licensed nurses. Education completed 3/27/24. Effective 3/28/24 the Director will be responsible for ensuring implementation of this immediate jeopardy removal for the alleged non-compliance. Alleged Date of IJ Removal: 3/28/24 On 03/28/24 an onsite credible allegation validation was conducted. The audit of all in house residents on IV antibiotics was reviewed and revealed two residents. Those two residents' orders, administration record, dressings, and duration of medication were all verified, and no issues were identified. Interviews with all staff revealed that they had been educated on neglect, what it was, how to identify it, and who and when to report it to. Interviews with all nursing staff revealed that they had been educated on identifying and reporting any changes in resident status or barriers to medication administration to the medical provider and carrying out any orders received and the ensuring that it was documented in the medical record. If the new orders entailed transferring the resident to a higher level of care the staff were able to verbalize the process for transferring a resident to the ER for treatment. The IJ removal date of 03/28/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, family, Emergency Medical Services (EMS) personnel, Infectious Disease Nurse Practitioner, facility Nurse Practitioner #2, and Medical Director interviews the facility failed to send Resident #244 to the emergency room (ER) as directed by the Infectious Disease office on 07/14/23 to have his intravenous (IV) access restored and to resume his previously prescribed IV antibiotics. Resident #244's peripherally inserted central catheter (PICC) line became dislodged on 07/11/23 and on 07/14/23 Nurse #10 was notified by the Infectious Disease office to send Resident #244 to the ER to have his PICC line reinserted so that he could resume his antibiotics as ordered and Nurse #10 failed to send him to the ER. Resident #244 was discharged from the facility on 07/24/23 and followed up at the Infectious Disease office on 07/26/23, had his IV access restored and his IV antibiotics resumed at an outpatient infusion center. This deficient practice affected 1 of 2 residents reviewed for significant medication errors. Immediate jeopardy began on 07/14/23 when the Infectious Disease office instructed the facility staff to send Resident #244 to the ER to have his PICC line replaced so that he could resume his IV antibiotics and the facility failed to do so. Immediate jeopardy was removed on 03/28/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of education and monitoring system are in place. The finding included: Review of Resident #244's discharge summary from the local hospital dated 06/29/23 read in part, chronic left humeral fracture from a motor vehicle accident in 2018 with fixation with hardware and recurrent infection/osteomyelitis due to methicillin sensitive staphylococcus aureus (MSSA) status post recent left arm amputation 2 weeks ago. The discharge summary further indicated severe thoracic spinal stenosis with cord flattening, posterior disc bulging, vertebral abnormal marrow signal intensity possible osteomyelitis. Infectious disease on board and antibiotics were switched to daptomycin and ciprofloxacin to complete 8 weeks of antibiotic regimen. Resident #244's discharge medications included: Daptomycin (antibiotic) 500 milligrams (mg) intravenously (IV) daily and Ciprofloxacin (antibiotic) 750 mg by mouth twice daily. Both were to be given for a total of 8 weeks and were to be discontinued on 08/19/23. Resident #244 was admitted to the facility on [DATE] and was discharged on 07/24/23. Resident #244's diagnoses included thoracic osteomyelitis with spinal stenosis and left upper extremity amputation. Review of physician orders dated 06/30/23 read, Ciprofloxacin 750 mg by mouth twice a day until 08/19/23. Daptomycin 500 mg IV every day until 08/19/23. Review of the Medication Administration Record (MAR) dated July 2023 revealed that Resident #244's Ciprofloxacin was administered as prescribed during his time in the facility. The MAR further revealed that the Daptomycin was not given from 07/11/23 through 07/24/23. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #244 was cognitively intact with no rejection of care. The MDS further indicated he received IV medications and 7 days of antibiotic during the assessment reference period. A nurses note dated 07/11/23 at 7:24 PM read in part, nurse entered room to check on resident and his PICC line. Resident was digging in closet and nurse asked what was wrong and he stated his PICC line came out and PICC line noted on bedside table. This nurse requested resident to allow nurse to place pressure dressing on site and resident refused and stated it was fine. Nurse attempted to educate resident on need for pressure dressing and resident started cussing and threatening nurse. Resident told this nurse not to return to his room for any reason. No obvious signs of bleeding noted at the PICC line site with tip intact. The note was written by Nurse #3. Review of a physician order dated 07/12/23 read pulled IV out, unable to place new line. PICC line to be put in place by third party. Medication to be held until PICC line inserted. The order was entered by Nurse #4. The order was a verbal order from the Medical Director (MD). Review of a care plan initiated on 06/30/23 read, I have osteomyelitis/discitis of the vertebra and am receiving IV antibiotic therapy, unless otherwise specified this event will be resolved as of 08/22/23. The goal read, The resident will be free from complications related to infection through the review date. The interventions included, administer antibiotics as per MD order, follow facility policy and procedures for line listing summarizing and reporting infections, maintain universal precautions when providing care, monitor temperature/pulse as ordered, monitor and report signs of delirium. Review of a document from a third-party company dated 07/13/23 at 1:00 PM read in part, large red area to the inner side of right arm, patient pulled out at least 2 lines already maybe more. Right cephalic vein (superficial vein in arm) with good blood return but the guide wire (used to insert catheter) only went up 8 centimeters. Right brachial vein (another superficial vein in arm) good blood return by would not thread guidewire. Not a candidate for future PICC or midline access. The form was signed by the technician that attempted to reinsert the PICC line. Review of intraoffice communication from the Infectious Disease office dated 07/14/23 at 2:01 PM read, had a call today from {Unit Manager} stated that Resident #244's picc line was out that had someone to come there and try to put it in and they could not get it in. I called back and down there and talked to the nurse with him today {Nurse #10} and she said she was not given any orders for IV antibiotics. She was giving him the cipro. I told her she needed to take him to the ER and get the PICC line put back in. I told her if PICC line had been out it was 2 days he has gone without his medication. The Unit Manager was interviewed on 03/20/24 at 3:45 PM, she stated that she had worked at the facility for 9 months. She stated she did not recall calling Infectious Disease regarding Resident #244 and did not recall having any involvement with the Resident #244 or the situation. Review of intraoffice communication from the Infectious Disease office dated 07/17/23 read, I called the nursing home and spoke with {Nurse #11} to see if they took him to the hospital to have PICC line put in. she said no they had someone to come out there. They could not get it in. Said his arm was too sore. Nurse #11 was interviewed via phone on 03/20/24 at 3:05 PM. Nurse #1stated that she had received in report that Resident #244's PICC line was out, and he missed doses of his antibiotic. She stated that she had called the Infectious Disease office and made them aware that Resident #244's PICC line came out and that they tried to re-insert it and it was unsuccessful. She could not recall who gave her report that day or who she spoke to at the Infectious Disease office, but they did not give me any orders, or I would have put them in my notes. Nurse #11 stated she did recall speaking the facility NP or MD regarding Resident #244's PICC line or medication. Resident #244's family was interviewed via phone on 03/20/24 at 4:41 PM. The family member stated that after Resident #244 was discharged from the facility he had followed up at the Infectious Disease office and continued his antibiotic treatment. Nurse #10 was interviewed via phone on 03/21/23 at 9:01 AM. She stated that it had been a while since she had worked at the facility. She stated that she really did not recall Resident #244, she remember that she came to work one day, and someone did not have an IV line so she could not administer the IV antibiotic. It rings a bell that maybe I called to have the line replaced but it is odd that I did not make a note about it. Typically, I would have called the provider and told them that he did not have IV access and then carry out whatever orders they gave. If they would have told me to send Resident #244 to the hospital I would have done so because it is unacceptable to skip an antibiotic. A follow up interview was conducted with Nurse #10 on 03/21/24 at 3:38 PM. Nurse #10 confirmed that she did not receive a call with instructions to send Resident #244 to the ER. If she would have, she would put the order into the system, called Emergency Medical Services (EMS) and notified the management team. Finally, I would have documented in the medical record the situation. Nurse #6 was interviewed via phone on 03/22/24 at 10:43 AM, she stated that she had not worked at the facility for 6 months. She stated that she did not recall getting any orders from Infectious Disease or from the providers regarding Resident #244. She added that she was not able to give him his IV antibiotic because he did not have a PICC line in place. She stated she believed the staff tried to send him to the ER and when EMS came, they told them that the ER would not place a PICC line. She stated that EMS had called the ER, and the ER staff told them no they could not replace a PICC line. Nurse #6 stated that most of the time the pharmacy would come and replace the PICC line, and she believed they were contacted to come and replace the line. An interview was conducted with EMS personnel on 03/26/24 at 3:15 PM and they had no record of any run reports for Resident #244 at the facility from 07/11/23 through 07/24/23. The DON was interviewed on 03/20/24 at 5:07 PM who stated she recalled Resident #244 as he only had one arm and he pulled his PICC line out. She stated that he refused to have it reinserted as he wanted to go home. The DON stated that the Infection Disease office was notified on 07/17/24 that his line was out, and he had missed doses of the IV Daptomycin. When asked why she did not send Resident #244 to the emergency room (ER) for assistance in getting a PICC line or other line inserted for the antibiotic she replied, if we cannot get a line the ER cannot get a line. The ER cannot put a PICC line in because they do not have access people over there to do it. The ATB was placed on hold pending an appointment with Infection Disease. The DON stated, I do not when the appointment was it has been over a year ago. He only had one arm and if we could not get a line the ER could not get a line. She added that she had no contact with Infectious Disease office during this time. The DON stated that with no IV access the IV antibiotic could not be administered. The Infectious Disease Nurse Practitioner (NP) was interviewed via phone on 03/20/24 at 12;15 PM who stated that if Resident #244's PICC line was dislodged, or he did not have access and access was unable to be obtained then he should have been immediately sent to the ER so we could have restored his access. She explained that there were numerous other types of line access that they could have done for Resident #244 including a central line or tunneled PICC line in the groin. The NP stated, it is not reasonable to not receive antibiotics for a portion of time due to access issues. It is prudent of any skilled nursing facility if the PICC line is out and attempts to reinsert failed, then he should have been directed to higher level of care, not say oh well and not give for 2 weeks. The NP added, if the facility could not figure out how to work through the access issues we could have helped them. She added that Resident #244 had thoracic spinal osteomyelitis with spinal stenosis and staphylococcus bacteremia and untreated could lead to loss of limb function and he was already a left upper extremity amputee. The NP stated that Resident #244 was seen in the office 2 days after discharging from the facility on 07/26/23 and his access was restored, and we resumed his IV antibiotic at an outpatient infusion center and extended the duration to make up for the missed doses at the facility. The MD was interviewed via phone on 03/20/24 at 1:26 PM. He stated that he did not recall being made aware that his PICC line was out and that he had missed 14 doses of the IV antibiotic. The MD stated had he been aware that an attempt to reinsert the PICC line was unsuccessful, he would have directed the staff to send Resident #244 to the ER to have access regained. The MD stated, it was very concerning that he missed 14 doses of antibiotic. The facility NP #2 was interviewed via phone on 03/20/24 at 4:47 PM, she stated she recalled Resident #244 but stated she did not recall any issues with his PICC line or missing doses of his scheduled antibiotic. She explained that she was out of state on personal business during this time but had someone contacted her, she would have directed the staff to send Resident #244 to the ER. The Administrator was notified of immediate jeopardy on 03/27/24. The facility provided the following immediate jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The facility failed to send resident #244 to the hospital to have his intravenous access (IV) replaced, when his peripherally inserted central catheter became dislodged, as directed by the Infectious Disease provider on 07/14/2023. Resident #244 missed 14 doses of the IV antibiotics before being discharged from the facility, and then resuming his IV antibiotic course at a outpatient infusion center. There was a high likelihood of serious harm of impairment when resident #244 was not directed to a high level of care, and when attempts to restore his IV access were unsuccessful at the facility. On 03/27/2024, the Director of Nursing assessed all current residents receiving IV antibiotics for: IV access placement/ patency/ function, and orders for administration of IV antibiotic therapy course, to ensure residents are receiving their antibiotics as ordered by the physician, and do not require a higher level of care to meet resident current needs. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: On 03/27/2024, the Director of Nursing educated licensed nurses on directing residents to a higher level of care, if the needs of the resident cannot be met in the facility to avoid serious harm or impairment. 03/27/2024, the Director of Nursing educated licenses nurses (to include agency) on following facility provider orders (to include consulting physicians and notification of facility provider/consulting physicians within the realm of practice) and documenting any barriers to IV antibiotic administration. On 03/27/2024, the Director of Nursing educated all certified nursing assistants on reporting changes in resident baseline, new acute observations; to include observed IV issues. On 03/27/2024, the Director of Nursing reviewed all current residents receiving IV antibiotics for: IV access placement/ patency/ function, and orders for administration of IV antibiotic therapy course; to ensure residents are receiving their antibiotics as ordered by the physician, and do not require a higher level of care to meet resident current needs. The Director of Nursing will educate newly hired licensed nurses and agency nurses. Education completed 3/27/24. Effective 3/28/24 the Director will be responsible for ensuring implementation of this immediate jeopardy removal for the alleged non-compliance. Alleged Date of IJ Removal: 3/28/24 On 03/28/24 an onsite credible allegation validation was conducted. The audit of all in house residents on IV antibiotics was reviewed and revealed two residents. Those two residents' orders, administration record, dressings, and duration of medication were all verified, and no issues were identified. Interviews with all nursing staff revealed that they had been educated on identifying and reporting any changes in resident status or barriers to medication administration to the medical provider and carrying out any orders received and the ensuring that it was documented in the medical record. If the new orders entailed transferring the resident to a higher level of care the staff were able to verbalize the process for transferring a resident to the ER for treatment. The IJ removal date of 03/28/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, family, Infectious Disease Nurse Practitioner, facility Nurse Practitioner #2, and Medical Director interviews the facility failed to prevent a significant medication error when staff failed to administer 14 ordered doses of intravenous (IV) antibiotic from 07/11/23 to 07/24/23 after the residents peripherally inserted central catheter (PICC line) was dislodged for 1 of 2 residents reviewed for significant medication error (Resident #244). Resident #244's infection if left untreated could lead to loss of limb function. Immediate jeopardy began on 07/14/23 when Resident #244's PICC line become dislodged, and the facility failed to direct him to higher level of care to ensure he received the IV antibiotic he required. Immediate jeopardy was removed on 03/28/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of education and monitoring system are in place. The findings included: Review of Resident #244's discharge summary from the local hospital dated 06/29/23 read in part, chronic left humeral fracture from a motor vehicle accident in 2018 with fixation with hardware and recurrent infection/osteomyelitis due to methicillin sensitive staphylococcus aureus (MSSA) status post recent left arm amputation 2 weeks ago. The discharge summary further indicated severe thoracic spinal stenosis with cord flattening, posterior disc bulging, vertebral abnormal marrow signal intensity possible osteomyelitis. Infectious disease on board and antibiotics were switched to daptomycin and ciprofloxacin to complete 8 weeks of antibiotic regimen. Resident #244's discharge medications included: Daptomycin (antibiotic) 500 milligrams (mg) intravenously (IV) daily and Ciprofloxacin (antibiotic) 750 mg by mouth twice daily. Both were to be given for a total of 8 weeks and were to be discontinued on 08/19/23. Resident #244 was admitted to the facility on [DATE] and was discharged on 07/24/23. Resident #244's diagnoses included thoracic osteomyelitis with spinal stenosis and left upper extremity amputation. Review of physician orders dated 06/30/23 read, Ciprofloxacin 750 mg by mouth twice a day until 08/19/23. Daptomycin 500 mg IV every day until 08/19/23. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #244 was cognitively intact with no rejection of care. The MDS further indicated he received IV medications and 7 days of antibiotic during the assessment reference period. Review of the Medication Administration Record dated July 2023 revealed that Resident #244 did not receive Daptomycin 500 mg IV from 07/11/23 through his discharge on [DATE]. A nurses note dated 07/11/23 at 7:24 PM read in part, nurse entered room to check on resident and his PICC line. Resident was digging in closet and nurse asked what was wrong and he stated his PICC line came out and PICC line noted on bedside table. This nurse requested resident to allow nurse to place pressure dressing on site and resident refused and stated it was fine. Nurse attempted to educate resident on need for pressure dressing and resident started cussing and threatening nurse. Resident told this nurse not to return to his room for any reason. No obvious signs of bleeding noted at the PICC line site with tip intact. The note was written by Nurse #3. Review of a physician order dated 07/12/23 read pulled IV out, unable to place new line. PICC line to be put in place by third party. Medication to be held until PICC line inserted. The order was entered by Nurse #4. The order was a verbal order from the Medical Director (MD). Review of a Medication Administration Note dated 07/11/23 at 8:26 PM by Nurse #3, Daptomycin 500 mg every 24 hours until 08/19/23 hold pending PICC replacement. Review of a Medication Administration Note dated 07/12/23 at 9:48 PM read in part, placement of PICC line unsuccessful. The note was written by Nurse #5. Review of a document from a third-party company dated 07/13/23 at 1:00 PM read in part, large red area to the inner side of right arm, patient pulled out at least 2 lines already maybe more. Right cephalic vein (superficial vein in arm) with good blood return but the guide wire (used to insert the catheter) only went up 8 centimeters. Right brachial vein (another superficial vein) good blood return by would not thread guidewire. Not a candidate for future PICC or midline access. The form was signed by the technician that attempted to reinsert the PICC line. Review of a Medication Administration Note dated 07/13/23 at 7:58 PM read, attempts to replace PICC line this shift were unsuccessful. The note was written by Nurse #5. Review of intraoffice communication from the Infectious Disease office dated 07/14/23 at 2:01 PM read, had a call today from {Unit Manager} stated that Resident #244's picc line was out that had someone to come there and try to put it in and they could not get it in. I called back and down there and talked to the nurse with him today {Nurse #10} and she said she was not given any orders for IV antibiotics. She was giving him the cipro. I told her she needed to take him to the ER and get the PICC line put back in. I told her if PICC line had been out it was 2 days he has gone without his medication. Review of a Medication Administration Note dated 07/14/23 at 7:50 PM read, PICC line to be replaced. The note was written by Nurse #2. Review of a Medication Administration Note dated 07/15/23 at 9:52 PM read in part, Daptomycin 500 mg every 24 hours until 08/19/23, no access. The note was signed by Nurse #6. Review of a Medication Administration Note dated 07/16/23 at 8:08 PM read in part, Daptomycin 500 mg every 24 hours until 08/19/23, held until PICC line placed. The note was signed by Nurse #7. Review of intraoffice communication from the Infectious Disease office dated 07/17/23 read, I called the nursing home and spoke with {Nurse #11} to see if they took him to the hospital to have PICC line put in. she said no they had someone to come out there. They could not get it in. Said his arm was too sore. Review of a Medication Administration Note dated 07/17/23 at 8:36 PM read in part, Daptomycin 500 mg every 24 hours until 08/19/23, hold pending infectious disease appointment and PICC placement. The note was signed by Nurse #3. Review of a nurses note dated 07/18/23 at 9:37 AM read in part, resident continues on therapy, IV antibiotic on hold due to unable to obtain line due to multiple attempts with resident pulling PICC lines out. On oral antibiotic to discharge home when complete. The note was signed by the Director of Nursing (DON). Nurse #3 was interviewed on 03/20/24 at 3:21 PM who stated that she recalled Resident #244 had rolled over in bed and pulled his PICC line out. She stated she found it on his bedside table. Nurse #3 stated that Resident #244 would not allow the area to be dressed and began cursing at Nurse #3. She stated she had called and got an order for reinsertion and to hold the IV antibiotic pending reinsertion. Resident #244's family was interviewed via phone on 03/20/24 at 4:41 PM. The family member stated that after Resident #244 was discharged from the facility he had followed up at the Infectious Disease office and continued his antibiotic treatment. The DON was interviewed on 03/20/24 at 5:07 PM who stated she recalled Resident #244 as he only had one arm and he pulled his PICC line out. She stated that he refused to have it reinserted as he wanted to go home. The DON stated that the Infection Disease office was notified on 07/17/24 that his line was out, and he had missed doses of the IV Daptomycin. When asked why she did not send Resident #244 to the emergency room (ER) for assistance in getting a PICC line or other line inserted for the antibiotic she replied, if we cannot get a line the ER cannot get a line. The ER cannot put a PICC line in because they do not have access people over there to do it. The ATB was placed on hold pending an appointment with Infection Disease. The DON stated, I do not know when the appointment was it has been over a year ago. He only had one arm and if we could not get a line the ER could not get a line. She added that she had no contact with Infectious Disease office during this time. The DON stated that with no IV access the IV antibiotic could not be administered. Nurse #2 was interviewed via phone on 03/22/24 at 9:58 AM. Nurse #2 stated she worked all the units and did not recall Resident #244's name or situation, she stated I see some of everyone. Nurse #6 was interviewed via phone on 03/22/24 at 10:43 AM, she stated she no longer worked at the facility for the last 6 months. She stated she was not able to administer Resident #244's IV Daptomycin because he did not have a PICC line. She stated she thought they had called the pharmacy to request a new PICC line be placed but after that she did not recall working with Resident #244 again. Nurse #7 was interviewed via phone on 03/22/24 at 11:00 AM. Nurse #7 stated that he did not work at the facility anymore and had been gone for approximately 2 months. He stated that he recalled Resident #244 was very particular about his PICC line dressing but did not recall much else about Resident #244 or the situation. He stated if his PICC line was out we should have held the medication and notified the Medical Director (MD) for orders to have the line replaced. Nurse #4 was interviewed via phone on 03/24/24 at 12:50 PM who stated she had not worked at the facility for almost a year and did recall Resident #244 or anything about the situation. An attempt to speak to Nurse #5 via phone was made on 03/24/24 at 3:38 PM and was unsuccessful. The Infectious Disease Nurse Practitioner (NP) was interviewed via phone on 03/20/24 at 12;15 PM who stated that if Resident #244's PICC line was dislodged, or he did not have access and access was unable to be obtained then he should have been immediately sent to the ER so we could have restored his access. She explained that there were numerous other types of line access that they could have done for Resident #244 including a central line or tunneled PICC line in the groin. The NP stated, it is not reasonable to not receive antibiotics for a portion of time due to access issues. It is prudent of any skilled nursing facility if the PICC line is out and attempts to reinsert failed, then he should have been directed to higher level of care, not say Oh well and not give for 2 weeks. The NP added, if the facility could not figure out how to work through the access issues we could have helped them. She added that Resident #244 had thoracic spinal osteomyelitis with spinal stenosis and staph bacteremia and untreated could lead to loss of limb function and he was already a left upper extremity amputee. The NP stated that Resident #244 was seen in the office 2 days after discharging from the facility on 07/26/23 and his access was restored, and we resumed his IV antibiotic at an outpatient infusion center and extended the duration to make up for the missed doses at the facility. The MD was interviewed via phone on 03/20/24 at 1:26 PM. He stated that he did not recall being made aware that his PICC line was out and that he had missed 14 doses of the IV antibiotic. The MD stated had he been aware that an attempt to reinsert the PICC line was unsuccessful, he would have directed the staff to send Resident #244 to the ER to have access regained. The MD stated, it was very concerning that he missed 14 doses of antibiotic. The facility NP #2 was interviewed via phone on 03/20/24 at 4:47 PM, she stated she recalled Resident #244 but stated she did not recall any issues with his PICC line or missing doses of his scheduled antibiotic. She explained that she was out of state on personal business during this time but had someone contacted her, she would have directed the staff to send Resident #244 to the ER. The Administrator was notified of the Immediate Jeopardy on 03/27/24 at 10:10 AM. The facility provide the following credible allegation of immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The facility failed to administer an intravenous (IV) antibiotic for 14 days after the residents peripherally inserted central catheter was dislodged in 07/11/2023 (Resident #244). Resident #244 was discharged on 07/24/2023 and was seen at the Infectious Disease office on 07/26/2023, access was restored, and his IV antibiotic was resumed. There was a high likelihood that Resident #244 would lose the function of his one remaining upper extremity without having the IV antibiotics as ordered. On 03/27/2024 the Director of Nursing assessed all current residents receiving IV antibiotics for IV access placement/ patency/ function, orders for administration of IV antibiotic therapy course to ensure residents are receiving their antibiotics as ordered by the physician and do not require a higher level of care to meet resident current needs. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: On 03/27/2024 the Director of Nursing educated licensed nurses on directing residents to a higher level of care if the needs of the resident cannot be met in the facility to avoid serious harm or impairment. On 03/27/2024 the Director of Nursing educated medication aides on reporting to licensed nurses any observations of adversities to resident care that may indicate assessment by a licensed nurse to avoid serious harm or impairment. 03/27/2024 the Director of Nursing educated licenses nurses on following physician orders and notification of physician and documenting any barriers to medication administration. 03/27/2024 the Director of Nursing educated medication aides on following physician orders and notification to a licensed nurse any barriers to medication administration. On 03/27/2024 the Director of Nursing reviewed all current residents receiving IV antibiotics for IV access placement/ patency/ function, orders for administration of IV antibiotic therapy course to ensure residents are receiving their antibiotics as ordered by the physician and do not require a higher level of care to meet resident current needs. The Director of Nursing will educate newly hired licensed nurses and medication aides. Education completed 3/27/24. Effective 3/28/24 the Director will be responsible for ensuring implementation of this immediate jeopardy removal for the alleged non-compliance. Alleged Date of IJ Removal: 3/28/24 On 03/28/24 an onsite credible allegation validation was conducted. The audit of all in house residents on IV antibiotics was reviewed and revealed two residents. Those two residents' orders, administration record, dressings, and duration of medication were all verified, and no issues were identified. Interviews with all nursing staff revealed that they had been educated on identifying and reporting any changes in resident status or barriers to medication administration to the medical provider and carrying out any orders received and the ensuring that it was documented in the medical record. If the new orders entailed transferring the resident to a higher level of care the staff were able to verbalize the process for transferring a resident to the ER for treatment. The IJ removal date of 03/28/24 was validated.