**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff and resident interviews, pest control technician interviews, and Nurse Practitioner interviews, the facility failed to maintain an effective pest control program to protect vulnerable residents from ants. On 6/23/24 Resident #1 was observed in bed with small black ants all over the floor, bedside table, bed linens, her gown, inside her incontinence brief, and on her body. Resident #1 complained of itching everywhere and had numerous small, reddened areas spread across the back and sides of her body. On 6/26/24 Resident #2 was observed in bed with small black ants all over the floor, furniture, bed linens, and clothing of Resident #2. Fire ants inject venom when they bite that causes a burning sensation and can cause localized sterile blisters, whole body allergic reactions such as anaphylactic shock, and, occasionally, death. Individual ants can bite and sting several times and because large numbers of ants are often together, incidents usually involve multiple stings. High numbers of stings can lead to severe medical reactions even in people with normal immune systems. The elderly and immobile individuals are at a higher risk of multiple stinging incidents. A reasonable person would experience serious adverse psychosocial outcomes that would include feeling helpless, intense anxiety, humiliation, and panic during the incident and fear of recurrence after the incident from being covered with ants on their body and clothing while in bed and being unable to leave the bed without assistance. This deficient practice was for 2 of 3 residents reviewed for pest control (Resident #1 and Resident #2). Immediate jeopardy began on 6/23/24 when the facility failed to maintain an effective pest control program. The immediate jeopardy was removed on 7/10/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower level and severity of E (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put in place are effective. The findings included: Review of fire ant information titled Medical Problems and Treatment Considerations for the Red Imported Fire Ant, which was provided by the Entomological (scientific study of insects) Program Manager with the North Carolina Department of Agriculture and Consumer Services and the State Public Health Entomologist (a scientist who studies insects and related animals) with the North Carolina Division of Public Health, Communicable Disease Branch revealed the following: When a fire ant bites it injects venom that can cause localized sterile blisters, whole body allergic reactions such as anaphylactic shock, and, occasionally, death. The intense burning sensation that occurs from the injected venom accounts for the popular name of fire ant. Individual worker ants can bite and sting several times and the site of the sting hurts for a few minutes and then reddens. The bite will then swell into a bump or hive within 20 minutes and within several hours to a day after being stung, most people will develop a white fluid-filled sterile pustule (small, inflamed, pus-filled sores that look like blisters) which are a characteristic of the fire ant sting. Because large numbers of worker ants are often together stinging incidents usually involve multiple stings and the ants can crawl rapidly (1.6 centimeters per second) and within seconds, they begin stinging almost simultaneously. People vary greatly in their sensitivity to fire ant stings with some people being hypersensitive to it may have other medical conditions (such as a heart condition or diabetes) that can result in serious medical problems or even death from a single sting. High numbers of stings can lead to severe medical reactions even in people with normal immune systems. The elderly, infants, neurologically compromised people, and otherwise immobile or unaware individuals are at a higher risk of multiple stinging incidents and should be supervised carefully. The information further stated fire ant workers can easily enter structures through even tiny cracks and crevices. Occasionally, entire colonies will migrate into structures and nest in wall voids or other locations. This is particularly common when outdoor conditions become very hot and dry or when flooding occurs in the immediate landscape. Review of the facility's pest control logs revealed the facility had a contract which was dated 6/23/22 for monthly inspection of all exterior and interior areas of the facility for pest activity and emergency calls were available 24 hours a day 7 days a week. The pest control log with a service date of 6/17/24 revealed that all interior and exterior areas were inspected and serviced by Pest Control Technician #1 with no ant activity noted in the report. An observation of the 400 Hall was conducted on 7/09/24 at 10:05 am which revealed Resident #1's and Resident #2's rooms were located on the same side of the hall (400 Hall) and were the immediate next door to each other on the hall. a. Resident #1 was admitted to the facility on [DATE] and resided on the 400 Hall on the side of the hall located on the back exterior of the facility. The weekly skin assessment completed on 6/18/24 revealed Resident #1 had no skin issues noted. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #1 had moderate cognitive impairment, adequate vision without corrective lenses, and required staff assistance to get out of bed during the 7-day lookback period. The nursing progress note dated 6/23/24 at 6:25 am by Nurse #1 revealed there was an ant infestation in Resident #1's bed and room. Resident #1 was observed to have several small, reddened areas on the skin across the back and sides of the body and Resident #1 reported itching all over. Resident #1 was observed by Nurse #1 to be scratching the skin a lot. The nursing progress note further noted Resident #1 was moved to a new room and the provider was notified. A telephone interview was conducted on 7/09/24 at 11:32 am with Nurse #1 who revealed she had entered Resident #1's room during rounds and found Resident #1 to be covered in ants. Nurse #1 stated she was unable to say exactly how many ants were on Resident #1 but stated there were a lot of ants and that they were everywhere. Nurse #1 stated the ants were small, black ants and they were on the bed linens, the floor, tables, and on Resident #1's body including inside the incontinence brief. She stated Resident #1 was removed from the bed by staff because she was not able to get out of bed by herself. Nurse #1 stated Resident #1's gown was removed, her skin was wiped with the personal care wipes, and her body and scalp were checked to make sure there were no more ants. Nurse #1 stated they attempted to move Resident #1 to the empty room on the same side of the hall, which was along the back of the building, but she stated when they checked the room the small black ants were in that room as well, so they moved Resident #1 across the hall. Nurse #1 reported that she completed a thorough skin assessment of Resident #1 and noted there were so many tiny red marks on the back, sides, and buttock area of the body and Resident #1 reported she was so itchy and was scratching herself all over. Nurse #1 stated she had never seen ants like this in the resident rooms prior but had reported that at times would see one or two ants here or there. Nurse #1 stated she notified the Administrator, Director of Nursing (DON), the on-call medical provider, and the Maintenance Supervisor of the ants. A physician order dated 6/23/24 for diphenhydramine 25 milligram (mg) tablet every 6 hours as needed for itching for 3 days. A physician order dated 6/23/24 for calamine lotion to apply to red areas topically every 8 hours as needed for red areas for 7 days. Review of the Maintenance Log dated 6/23/24 Nurse #1 noted ant infestation in Resident #1's room. The Nurse Practitioner (NP) progress note dated 6/24/24 revealed Resident #1 recently complained of itching everywhere, was noted to have numerous small, reddened areas spread across the back and sides. The NP progress note further stated Resident #1's room was noted to have an ant infestation and was moved to another room. The NP noted that Resident #1 did not report pruritis (itching) during the visit. A telephone interview was conducted on 7/09/24 at 3:45 pm with the NP who revealed she saw Resident #1 on 6/24/24 as a follow-up to the on-call provider notification of the ant infestation and reported itching. The NP reported that Resident #1 was unable to get out of bed without staff assistance based on her observations and knowledge of the resident. The NP stated Resident #1 was alert and oriented and had never reported itching prior to the ant infestation. She reported that based on the time frame of the ant infestation, Resident #1's noted reddened marks, and reported itching, the reddened marks and itching were due to the ant bites. An interview was conducted on 7/09/24 at 10:02 am with Resident #1 who was identified as alert and oriented by the Administrator, revealed that about two weeks ago, unable to recall exact date, she thought she saw ants on the floor and on the furniture in her room and told someone who came in and killed the ants. Resident #1 stated sometime later that night the nurse woke her and told her she had ants all over her and she needed to get out of the bed quickly. Resident #1 stated the staff got her out of bed and into her wheelchair then moved her to another room. Resident #1 stated she did see a lot of ants on her bed, the floor, and on the furniture when she got out of the bed. Resident #1 stated she could not tell that she was bitten but she stated the nurse told her she had bites from the ants. Resident #1 reported her body and arms were itchy for a few days from the bites. Resident #1 stated she had difficulty repositioning in the bed to get comfortable that night, but she was unable to get out of bed without help and she didn't realize the ants were in the bed or she would have called staff for help. Resident #1 stated she had not seen ants in her room prior to that night. A telephone interview was conducted on 7/09/24 at 2:37 pm with Nurse Aide (NA) #1 who revealed she was assigned to Resident #1 on 6/22/23 from 3:00 pm until 6/23/24 at 7:00 am. NA #1 stated Resident #1 had told her about the ants in her room during the 3:00 pm shift and she killed and cleaned up the ants. NA #1 stated she saw a few ants on the floor around some crumbs and did not see any more ants at that time, so she did not report the ants to anyone. NA #1 stated she provided incontinence care to Resident #1 throughout both of her shifts and did not observe ants in her room until she was called to the room by Nurse #1 in the morning. NA #1 reported when she entered Resident #1's room there were a lot of ants, not sure how many, just a lot of ants and they were all around the room. She stated they were small black ants and they were on Resident #1's body, bed, floor, and tables in Resident #1's room. NA #1 stated when they tried to find another room for Resident #1 to go to since her room had so many ants she stated the empty rooms on the same side of the hall, along the back of the building, also had ants in them so they moved Resident #1 across the hall. NA #1 stated Resident #1 required assistance to get out of bed. She indicated Resident #1 was able to turn a little bit in bed but needed help to fully turn in bed. NA #1 stated she had not seen that many ants before, but she stated she had seen small amounts of ants in the facility around food crumbs on the floor. A telephone interview was conducted on 7/10/24 at 9:44 am with Nurse #3 who revealed she was new to the facility and was on orientation with Nurse #1 on the morning of 6/23/24 when Resident #1's room was infested with ants. Nurse #3 stated she and Nurse #1 entered Resident #1's room in the morning for rounds and first noticed ants on top of the blanket but when the blanket was lifted, oh my goodness they were all over. Nurse #3 reported small black ants were all over the room, floor, tables, bed, and Resident #1. Nurse #3 stated they got Resident #1 out of the bed and cleaned her up to make sure no more ants were on her. She stated she did not do the actual skin assessment, so she was unable to state if any bites were present. Nurse #3 stated Resident #1 was alert and oriented and reported that her whole body itched, and she was scratching herself. Nurse #3 reported when they tried to move Resident #1 to another room on the same side of the hall, she saw ants in two empty rooms, so they had to move her across the hall. Nurse #3 stated there were just so many ants, that she felt itchy herself just seeing how many ants were on Resident #1. During an interview with the Maintenance Supervisor on 7/9/24 at 3:30 pm he revealed he was called by a Nurse from the facility about the ants in Resident #1's room on 6/23/24 and he came in the same day and sprayed the ant spray he had used at the facility in Resident #1's room and thoroughly cleaned and sanitized the room. The Maintenance Supervisor stated he did not see any other areas on the hall that Resident #1 was located on when he came in on 6/23/24, but he sprayed the entire hall as a precaution with the same spray. The Maintenance Supervisor stated he did not call for the Pest Control Company to come because he treated the room and did not observe any further ant activity in any other rooms on Hall 400. The Maintenance Supervisor stated the ants that were in Resident #1's room were small black ants. During an interview on 7/09/24 at 3:19 pm the Administrator revealed she did not recall being notified by Nurse #1, but she recalled the progress note about the ants and discussed it with the Maintenance Supervisor on 6/24/24. The Administrator stated Resident #1 was moved to a new room and the room was cleaned and sprayed. The Administrator stated she believed the Maintenance Supervisor called for the Pest Control Company to treat the facility, but she would have to speak to the Maintenance Supervisor to confirm. b. Resident #2 was admitted to the facility on [DATE] and resided on the 400 Hall on the side of the hall located on the back exterior of the facility. The care plan initiated on 6/07/24 revealed Resident #2 required extensive staff assistance to turn and reposition in bed and for transfers from bed to chair. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #2 was cognitively intact, had adequate vision without corrective lenses, and required staff assistance to get out of bed. The nursing progress note dated 6/26/24 at 6:01 am by Nurse #2 revealed Resident #2 was moved from her room due to an ant infestation. Nurse #2 noted that multiple ants were swept from Resident #2's room at the beginning of the shift but Resident #2 refused to change rooms. Nurse #2 further noted that by the end of the shift there were even more ants in the room and Resident #2 was moved to another room. Nurse #2 noted that Resident #2 did not have any areas of concern noted on the skin at this time. A telephone interview was conducted on 7/09/24 at 11:29 am with Nurse #2 who revealed she was notified by Nurse Aide (NA) #2 around 6:00 am on the morning of 6/26/24 that ants were all over Resident #2's room. She stated when she entered Resident #2's room she observed small black ants everywhere. She explained they were on the bed, floor, tables, sheets, bed pad, clothes, and few on the outside of the incontinence brief. She stated she brushed the ants from Resident #2's body with her hands. Nurse #2 stated the ants were all over everything and it was unsafe for Resident #2 to remain in the room. She stated Resident #2 did not want to change rooms, but she did agree at that time to move to another room since there were so many ants. Nurse #2 clarified that Nurse #5 had observed the ants, cleaned up the ants, and attempted to have Resident #2 change rooms prior to her shift and that was reported to her at shift change. Nurse #2 stated she had not observed ants in Resident #2's room during her shift until notified by NA #2 at approximately 6:00 am. She reported she completed a skin check of Resident #2 and did not observe any bites and Resident #2 did not report any complaints of itching. Nurse #2 stated she had seen a few ants in the facility in the past but never had seen that many ants before. An attempt to conduct a telephone interview with Nurse #5 on 7/10/24 at 11:28 am and 1:05 pm was unsuccessful. An attempt to conduct a telephone interview with NA #2 on 7/10/24 at 9:30 am was unsuccessful. An interview was conducted on 7/09/24 at 9:44 am with Resident #2 who revealed about one week ago her room was infested with small black ants, and she needed to change her room. Resident #2 stated she saw the black ants on her hands, gown, floor, and bed linens. Resident #2 stated she saw ants in her room earlier that day, but she didn't want to move to another room and the nurse had cleaned the ants up. Resident #2 stated she didn't think the ants would have been on the bed later, so once that happened she was okay being moved. Resident #2 stated the staff helped her get out of bed and they moved her to another room. Resident #2 stated she did not have any bites or itchiness from the ants being on her and she stated she had not seen ants in her room since that day. An interview was conducted on 7/09/24 at 1:56 with the Maintenance Supervisor who revealed he was notified of the ants in Resident #2's room on the morning of 6/26/24 and notified the Pest Control Company that an emergency visit was needed. He stated he sprayed Resident #2's room prior to the Pest Control Company's arrival and observed quite a few small black ants in the room around the baseboards and air conditioning unit. The Maintenance Supervisor reported the ants entered the facility from the outside normally around the air conditioning units, and he stated the ants were worse at this time of the year. The Maintenance Supervisor stated when the Pest Control Company arrived on 6/26/24 he was told that the small black ants in Resident #2's room were sweet ants the kind that were normally in homes and were attracted by food. Review of the pest control visit log dated 6/26/24 revealed a visit was conducted for ants. Pest Control Technician #2 observed dead ants in the resident care area reported for ants. Pest Control Technician #2 also reported live fire ant mounds on the exterior building perimeter were identified, and they were treated at that time. A telephone interview was conducted on 7/09/24 at 3:00 pm with Pest Control Technician #2 who reported he was notified on 6/26/24 that two resident rooms were reported to have ants prior to his arrival. He stated he did not see any live ants in the two resident rooms, but it was reported that the Maintenance Supervisor had sprayed the ants prior to his arrival. Pest Control Technician #2 stated that he believed the dead ants he saw in Resident #2's room were odorous house ants (also known as sweet or sugar ants) which were small ants that were black in color. He stated the odorous house ants were very small and were not normally known to bite or be aggressive. Pest Control Technician #2 stated he walked the perimeter of the building and observed several active live fire ant mounds around the back of the building on the side of the hall where the two resident rooms were located. He stated he treated all the live fire ant mounds he observed at that time. Pest Control Technician #2 stated fire ants were aggressive in nature and did bite. He stated fire ants were able to access a building through gaps in doors, around windows, or air conditioner units. An interview was conducted on 7/09/24 at 1:27 pm with the Rehabilitation Director who revealed that she observed approximately 10-12 small black ants on the floor in the rehabilitation office on either 6/29/24 or 6/30/24. She stated she first saw one on the desk which was why she looked on the floor and observed the other ants. She stated she killed the ants and then swept to make sure no more ants were present. The Rehabilitation Director stated she had not seen ants in the rehabilitation office prior and had not observed any ants in the rehabilitation gym. Review of the pest control visit log dated 7/01/24 revealed Pest Control Technician #1 completed a routine visit and inspected the Physical Therapy room for ants and live ants were observed and treated. A telephone interview was conducted on 7/09/24 at 2:33 pm with Pest Control Technician #1 who revealed he received the call from the facility on 6/26/24 for a visit due to ants but he was unavailable that day, so Pest Control Technician #2 went to the facility. He stated he received the report from Pest Control Technician #2 that fire ant mounds were identified and treated on the exterior back of the facility. He stated he returned to the facility on 7/01/24 for the routine visit and he observed one active fire ant mound located at the exterior rear of the facility near the rehabilitation office and the previously reported resident hall, which he treated. He stated he also observed dead ants in the rehabilitation office on this visit, which he identified as fire ants. Pest Control Technician #1 stated fire ants were small (not tiny) dark reddish to black in color, they were aggressive in nature, and more prone to biting and stinging than odorous house ants. A walking tour and interview was conducted on 7/10/24 at 10:50 am with Pest Control Technician #1 and the Maintenance Supervisor of the perimeter of the facility. Pest Control Technician #1 identified the previous fire ant mounds that were treated on 6/26/24 to this surveyor. The area was observed as a hard, dry area of dirt with multiple ant holes along the side/rear exterior wall which was identified by the Maintenance Supervisor as the rehabilitation gym. No live fire ants were noted at this location. The tour continued around the rehabilitation gym where Pest Control Technician #1 identified the fire ant mound that was treated on 7/01/24 which was located approximately four feet from the back exterior wall of the resident hall where Resident #1 and Resident #2 were located. The area was observed as a hard, dry area of dirt with no live fire ants observed. An additional active fire ant mound was identified by the Pest Control Technician #1 at this time which was approximately eight feet from the back exterior of the resident hall. He agitated the fire ant mound with his foot, and live fire ants were observed to be small, dark reddish brown to black in color. Pest Control Technician #1 treated the active fire ant mound. Pest Control Technician #1 stated fire ants were known to move long distances for food sources and were capable of entering the facility from the locations of the mounds that were treated. An interview was conducted with the Administrator on 7/10/24 at 2:46 pm who revealed resident room rounds were completed daily by the Administrative team and the ant infestation was not identified during the rounds prior to the incident. The Administrator was notified of immediate jeopardy on 7/09/24 at 4:33 pm. The facility provided the following credible allegation of immediate jeopardy removal: 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On 6/23/24 Resident #1 was observed in bed by Nurse #1 with small black ants all over the floor, bedside table, bed linens, gown, inside the incontinent brief, and on her body. Resident #1 was unable to get out of bed without staff assistance. On 6/23/24 Resident #1's skin assessment by Nurse #1 revealed several small, reddened areas across her back and sides, resident complained of itching and was observed scratching. Nurse #1 removed the ants from the resident and the resident was moved to another room. On 6/23/24 Nurse #1 called the Medical provider; orders were given for Benadryl 25 mg 1 tab by mouth every six hours PRN x three days and Calamine lotion to red areas three times a day as needed for 7 days. Resident #1 is her own responsible party. On 6/24/24 the resident was seen by the Nurse Practitioner and resident had no reports of pruritis during her visit and resident currently is not experiencing any skin irritation, itching or discomfort per nursing assessment on 7/9/24. On 6/23/24 the Maintenance Supervisor cleaned and sanitized the room. He checked the adjoining rooms with no observed pests on 6/23/24. On 6/24/24 the Maintenance Supervisor initiated daily inspection of 100% of all rooms on 400 hall for any signs of pests. On 6/26/24 the Maintenance Supervisor called Pest control to come to the facility as his daily inspection did identify ants observed in a vacant room which he cleaned and sanitized. On 6/26/24 Resident #2 was observed in bed by Nurse #2. Nurse #2 observed small black ants all over the floor, furniture, bed linens, and clothing of Resident #2. Resident #2 was unable to get out of bed without staff assistance. Nurse #2 did not observe any signs of physical injury from the ants on Resident #2 and resident was immediately moved into another room. Pest control came to the facility on 6/26/24 and sprayed rooms 405,407,409. There were some dead ants but there were no live pests noted by pest control. Pest control proactively treated 100% of the exterior perimeter of 400 hall. Pest Control identified and treated fire ant mounds on the exterior of the facility on 6/26/24. The Maintenance Supervisor has completed ongoing pest control monitoring of 100% of 400 hall 5x weekly since 6/26/24 without additional identification of pests. All residents are at risk of harm due to this deficient practice. On 7/9/24 licensed nurses did skin checks on 100% of the residents and there were no identified skin concerns associated with pest/insect bites. On 7/9/24 the Admissions Coordinator, Therapy Director, Nurse Secretary, Human Resources, Maintenance Supervisor, Activity Coordinator, and the Business Office Manager did 100% room checks and did not identify any pests in the facility. On 7/9/24 the Maintenance Supervisor was educated to notify pest control immediately upon identifying any pests by the Administrator. On 7/9/24 the Maintenance Supervisor called pest control to come to the facility on 7/10/24 and do a thorough inspection and provide treatments as needed. 2. Specify the actions the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring and when the action will be completed. On 7/9/24 the Administrator began in servicing all staff (full time, part time, and prn including agency) on the need to provide effective Pest management to ensure residents are safe from ants and pests. This education will be provided to new hires during the orientation process by Human Resources. No staff shall work without this education effective 7/10/24. The Administrator, Director of Nursing, and Human Resources will monitor to ensure no staff works without completing the education. This education included: The facility maintains high standards of cleanliness and sanitation throughout the facility to eliminate food and water sources that attract pests. The facility will ensure proper storage and disposal of waste to prevent attracting pests. Educate staff to ensure food is stored properly, waste is disposed of properly, and we maintain cleanliness to reduce the risk of pest infestations. The Maintenance Supervisor weekly inspects and repairs (as needed) any structural issues, such as cracks, holes, or gaps that could allow pests to enter the building. The Maintenance Supervisor and the Department Heads conduct regular inspections of all areas of the facility, including resident rooms, common areas, kitchens, and storage areas to identify any signs of pest activity. The Maintenance Supervisor will maintain detailed records of all pest control activities, including inspection reports, treatment records, and any actions taken to address identified issues. Staff will need to recognize signs of pest activity, they were educated on what pests are, and understand the importance of maintaining a pest free-free environment. Staff should know how to report any pest sightings or concerns immediately. Any pest sightings should be reported immediately to the Maintenance Supervisor or the on-call Administration. Always address any concerns or complaints from residents or their families regarding pest control promptly and effectively. The alleged date of immediate jeopardy removal is 7/10/24. The credible allegation of immediate jeopardy removal was validated by onsite verification on 7/10/24 as evidence by staff interviews, alert and oriented resident interviews, record review, and observations. Interviews were conducted with those residents identified as alert and oriented by the facility with no additional concerns regarding ants. The Maintenance Supervisor's education dated 7/09/24 presented by the Administrator and signed by the Maintenance Supervisor was reviewed. Interviews were conducted with staff which included nursing, housekeeping, laundry, dietary, and administration to confirm education had been completed regarding identification and notification when ants or other pests were identified, ensuring the area was clean, proper waste disposal, and food storage. Staff education logs dated 7/09/24 and 7/10/24 were reviewed for all departments including dietary, rehabilitation, housekeeping, administrative, and nursing. Those staff that have not received education in person or via telephone on 7/09/24 will be educated prior to the beginning of their next scheduled shift by the Administrator, Director of Nursing, or Human Services. Administrative room round logs dated 7/09/24 were reviewed with no newly identified concerns. Skin assessment sheets dated 7/09/24 were reviewed with no newly identified concerns. Observations were conducted on 7/09/24 and 7/10/24 with no identified active ants or pests in the resident rooms, common areas, or bathrooms. The facility's Immediate Jeopardy removal date of 7/10/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, Emergency Medical Services (EMS) personnel, and Medical Director interviews, the facility failed to identify the urgent need for medical attention for a resident with new onset seizure activity on 8/12/23 at approximately 10:30 am which is a medical emergency. They did not immediately initiate EMS (Emergency Medical Services) to transfer the resident to an acute care hospital for medical evaluation and interventions for 1 of 2 residents reviewed with a medical emergency. EMS was contacted at 10:58 am and upon their arrival Resident #1 continued with seizure activity and required 3 doses of Versed (a medication used to stop a seizure) for seizure activity to cease. Upon arrival at the hospital Resident #1 was unresponsive and in status epilepticus (a seizure lasting for more than 5 minutes), a medical emergency that may lead to brain damage or death. A CT (computerized tomography) scan revealed a subarachnoid hemorrhage (bleeding in the space that surrounds the brain), Resident #1 required intubation (a tube inserted into the airway) and was admitted to the ICU (intensive care unit). Immediate Jeopardy began on Saturday, 8/12/23, when the facility failed to initiate EMS immediately when Resident #1 was observed with onset of seizure activity. The immediate jeopardy was removed on 8/31/23 when the facility provided an acceptable credible allegation for immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of a D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and that monitoring systems put into place are effective. The findings included: Resident #1 was admitted to the facility on [DATE]. Resident #1's diagnoses did not indicate any history of seizures. Review of the quarterly Minimum Data Set (MDS) completed on 7/1/23 identified Resident #1 as severely cognitively impaired. The MDS did not reveal a diagnosis of seizures. Resident #1's physician's order summary for August 2023 revealed Resident #1 had no orders for seizure medication. On 8/23/23 at 9:47 AM Nurse Aide (NA) #2 (agency staff) was interviewed and stated on Saturday 8/12/23 she took Resident #1's breakfast meal tray away around 9:30 AM and did not remember anything unusual with Resident #1. On 8/29/23 at 9:24 AM NA #1 was interviewed and stated she was coming up the hall on 8/12/23 at 10:30 AM and saw Resident #1 had movement of her head, like a seizure. The NA stated she had never worked with the resident before but knew she did not look right and went to tell Nurse #2 right away. A phone interview was conducted with Nurse #1 (agency staff) on 8/23/23 at 3:48 PM. She indicated on 8/12/23 she saw Resident #1 with a mild twitch of her lips and continued to observe her for about one minute. When the twitch did not stop she stepped to the doorway and saw Nurse #2 (who was the weekend Supervisor) on the hall and reported the resident's head was moving like a little twitch. Nurse #1 revealed she could not remember what time she observed the resident and notified Nurse #2. Nurse #1 indicated that Nurse #2 took over and contacted the On Call Physician. Nurse #1 indicated Resident #1's breathing was normal/regular and she denied observing any other changes with the resident. Nurse #2 was interviewed on 8/23/23 at 11:13 AM. She indicated on 8/12/23 around 10:30 AM, NA #1 came and reported to her Resident #1 was twitching. Nurse #2 stated she went to Resident #1's room and when she saw the resident her head was twitching left to right. Nurse #2 revealed Nurse #1 joined her in the resident's room and she (Nurse #2) indicated it appeared the resident was having a seizure. Nurse #2 stated the resident did not have a diagnosis of seizures. She reported she told Nurse #1 to stay with resident until she returned with her electronic tablet to contact the On Call Physician. Nurse #2's triage note documentation for 8/12/23 revealed the following information related to Resident #1: - At 10:38 AM Nurse #2 contacted the on-call physician group via electronic tablet communication. The On Call Physician requested information on any history of seizures and if the resident was on seizure medication. Nurse #2 indicated no to both questions and was instructed to get vital signs (VS) to include blood pressure (BP). - At 10:46 AM Nurse #2 responded back to the On Call Physician with VS as heart rate 118 and temperature of 96.9. The nurse indicated she was not able to get a BP due to Resident #1's arm movement. The On Call Physician ordered Ativan intramuscular (IM) (used as a rescue medication to stop a seizure). Ativan IM was not available in the facility and the order was given to send Resident #1 to the emergency room (ER). The EMS report dated 8/12/23 indicated a call was received from the facility at 10:58 AM and they were dispatched to the facility at 10:59 AM. A Health Status note completed by Nurse #2 dated 8/12/23 at 11:03 AM revealed the writer observed Resident #1 having constant seizure like activity. Nurse #2 contacted the On Call Physician through tablet communication and an order to send to the ER was obtained. In a follow up phone interview on 8/24/23 at 1:21 PM Nurse #2 indicated on 8/12/23 she followed the facility's normal protocol for physician communication and used her tablet to email the On Call Physician. She indicated the resident was laying on her back with her head turned to the right and her head was twitching back and forth. Nurse #2 indicated the resident was not having convulsions, her body was shaking more like a tick, and had no thrashing. She reported this information to the On Call Physician. Nurse #2 indicated the On Call Physician asked for VS and BP, she indicated she was able to get VS but not able to obtain BP as Resident #1 had to be completely still for an accurate BP. After providing information on the VS and inability to obtain a BP, the On Call Physician wanted to know if the resident was on any seizure medications. She revealed at first she answered yes to the On Call Physician and then checked the medical record and realized Resident #1 was not ordered any seizure medication and informed the On Call Physican of the correct information (no ordered seizure medication). Nurse #2 indicated the On call Physician ordered Ativan IM, but the facility did not have any in stock and she received the order to send Resident #1 to the ER prior to calling EMS. A phone interview was conducted on 8/28/23 at 11:02 AM with the On Call Physician who took the call from the facility related to Resident #1 on 8/12/23. The On Call Physician revealed the facility called to report Resident #1 was having seizure activity. The On Call Physician indicated staff were asked to get VS, BP and if the resident was receiving any seizure medications. Staff reported VS and there was initially some confusion with staff as to whether the resident did or did not receive seizure medication. She indicated when staff clarified the resident did not have orders for seizure medication an order was given for Ativan IM. Staff reported back that there was no Ativan IM in the facility. The On Call Physician stated if the resident had received Ativan IM, it could have resolved her seizures. The On Call Physician indicated that most facilities had liquid Ativan available for emergency situations. The EMS Report dated 8/12/23 indicated they arrived at the facility at 11:07 AM. The report revealed on arrival at the facility, Nurse stated that [Resident #1] had been seizing for approximately an hour and they had no standing orders or medication. [Resident #1] was found sitting [on] her bed obvious seizure, right side, facial droop, irregular, respirations. Staff advised that Resident #1 was seen at approximately 9:30 AM this morning for medication administration. A 2.5 mg dose of Versed was first administered in a previously established IV (intravenous) at 11:13 AM and the Resident 's response was documented as unchanged. A second 2.5 mg dose was administered at 11:22 AM and the Resident's response was documented as unchanged. Oxygen was applied via a non-rebreather mask (a face mask that gives you oxygen). Resident #1 left the facility with EMS at 11:20 AM. The resident was noted to continue to seize and a third 2.5 mg dose of Versed was administered at 11:30 AM (while enroute to the hospital) and the Resident's response was documented as improved. During transport Resident #1 continued to have irregular breathing and a nasopharyngeal airway (NPA) was inserted (a thin, clear, flexible tube that is inserted into a patient's nostril to bypass upper airway obstruction) and breathing became more regular. EMS arrived at the hospital at 12:01 PM. In a phone interview on 8/28/23 at 2:57 PM EMS personnel revealed on arrival at the facility on 8/12/23, she observed Resident #1 with seizure activity. EMS reported that Nurse #2 indicated the resident had been having seizures for about an hour. EMS stated the resident had an established IV line and had facial droop on her right side. She indicated she gave the Resident a dose of medication (Versed) to help with seizures and moved the resident onto their ambulance. EMS stated before they left the facility she administered a second dose of seizure medication, and while on route to the hospital, she gave a third dose. She indicated after the third dose Resident #1's condition improved. The hospital record revealed Resident #1 presented on 8/12/23 for status epilepticus. She was noted with tonic-clonic seizure activity (involves a loss of consciousness with stiffening of muscles and twitching/jerking muscle contractions) with duration of one hour and right-sided gaze deviation (abnormal movement of the eyes). On arrival she had a Glasgow Coma Scale (scale used to describe the extent of impaired consciousness) score of 3 (the lowest possible score indicating the resident was completely unresponsive). Resident #1 was intubated for airway protection. A CT scan showed an acute subarachnoid hemorrhage. The hospital course indicated on 8/13/23 Resident #1's gaze deviation that was previously to the right was now on the left. An MRI (magnetic resonance imaging) of Resident #1's brain was conducted on 8/14/23 and showed no acute signs of stroke. Resident #1 was hospitalized until 8/23/23 at which time she was transferred to an inpatient hospice. On 8/28/23 at 12:12 PM during a phone interview the Medical Director indicated that the conversation on 8/12/23 with the On Call Physician group was through electronic messaging/tablet (emailing back and forth) and not on the phone. The Medical Director further stated that this was a new onset of seizures for Resident #1, and the delay was in trying to see if there was anything staff could do to stop or treat the seizures in the facility. The Medical Director said they did treat the situation as a medical emergency and the nurse called the On Call Physician group and followed their directions/orders to send Resident #1 out. The On Call Physician was trying to do the right thing for a resident with first time seizures which included getting the resident's history and trying to see if they could treat/resolve in house before sending out. She indicated she believed their response was appropriate. An interview on 8/24/23 at 1:11 PM the Nurse Support Staff stated if a resident were having seizures, staff should call the physician and send the resident out immediately. The Administrator was notified of immediate jeopardy on 8/30/23 at 11:00 AM. The facility provided the following credible allegation of immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident #1 was discharged to the care of Emergency Medical Service on 08/12/2023 and is no longer a resident of the facility. No further corrective action could be completed specific to Resident #1. All residents are at risk of requiring emergency medical services. On 08/30/2023, the Nurse Consultant, Interim Director of Nursing (DON), and Licensed Practical Support Nurse (LPN) completed an audit of 100% of hospital transfers for current and discharged residents for the last 3 months from 05/30/2023 - 08/30/2023. This audit consisted of review of each hospital transfer to identify any residents with any acute change in condition to include: Any symptom, sign or apparent discomfort that is: acute or sudden in onset, and is a marked change (i.e., more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed and where immediate emergency medical services was required and not initiated when physician response time was delayed, or if emergent care needs couldn't be met at the facility. This audit was completed on 08/30/2023. The audit identified that 1 of 30 hospital transfers had an acute change in condition to include: Any symptom, sign or apparent discomfort that is: acute or sudden in onset, and is a marked change (i.e., more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed and where immediate emergency medical services was required and not initiated when physician response time was delayed, or if emergent care needs couldn't be met at the facility. Resident #1 was the resident identified as a result of the audit. No corrective actions were required for Resident #1 as the resident remains out at the hospital. On 08/30/2023, the Interim DON met with all floor nurses and initiated assessment of all current residents to identify any residents with any acute change in condition to include: Any symptom, sign or apparent discomfort that is: acute or sudden in onset, and is a marked change (i.e., more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed and where immediate emergency medical services was required and not initiated when physician response time was delayed, or if emergent care needs couldn't be met at the facility. No current residents were identified as having any acute change in condition. No other residents were impacted. Specify the actions the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring and when the action will be completed. On 08/30/2023 the DON began in servicing all licensed nurses, Registered Nurses (RN) and Licensed Practical Nurses (LPN) and certified nursing assistants (full time, part time, and prn including agency) on any change in condition to include: Any symptom, sign or apparent discomfort that is: acute or sudden in onset, and is a marked change (i.e., more severe) in relation to usual symptoms and signs, or unrelieved by measures already prescribed. Additionally, education included activation of emergency services when physician response time was delayed, or if emergent care needs couldn't be met at the facility. Additional education included that if conditions worsened and nurse's assessment warrants, activate emergency medical services, call the attending physician and resident's family or responsible party, as appropriate to ensure resident receives emergent care needs to address the change in condition. The DON will ensure that all licensed nurses, RN's, LPN's, and CNA's (full time, part time, and prn including agency) who do not complete the in-service training by 08/30/2023 will not be allowed to work until the training is completed. This in-service was incorporated into the new employee facility and agency orientation for all licensed nurses and certified nursing assistants (full time, part time, and prn including agency.) Alleged date of immediate jeopardy removal: 08/31/2023 Onsite validation was completed on 9/1/23 through interviews and record review. Inservice sign in sheets and staff interviews verifed in-services were completed on any change in condition and activation of emergency services when physician response time was delayed, or if emergent care needs couldn't be met at the facility. Education was confirmed for agency nursing staff, facility nursing staff through interviews and any staff who did not complete the in-service training by 8/30/23 will not be allowed to work until the training is completed. Evidence of audits were reviewed for hospital transfers for current and discharged residents. Resident interviews were conducted with no issues identified. The facility's immediate jeopardy removal date was validated as 8/31/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with Orthopedic Surgeon, Nurse Practitioner (NP), Medical Director, and staff, the facility failed to safely transfer a dependent resident for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). On 12/23/22 Resident #1, a resident totally dependent for 2 staff's assistance and a mechanical lift for transfers, fell while being transferred by Nursing Assistant #1 and Nursing Assistant #2 without a mechanical lift. Resident #1 experienced pain rated a 10 out of 10 (with 10 representing the worst pain imaginable), she suffered femur (thigh bone) fractures to both legs, and she underwent two orthopedic surgeries to address the fractures. Findings included: Resident #1 was most recently readmitted to the facility on [DATE] with diagnoses that included dementia, end stage renal disease with dialysis, difficulty in walking, and muscle weakness. Resident #1's annual Minimum Data Set (MDS) assessment dated [DATE] coded Resident #1 as being moderately cognitively impaired and totally dependent on two persons for transfers. She was not steady and only able to stabilize with staff assistance when moved from seated to standing position and with surface-to-surface transfers. Resident #1 was not coded for any falls since the prior assessment. Review of Resident #1's care plan active care plan on 12/23/22 revealed the following: - A focus area dated 4/8/21 revealed she was at increased risk for falls and had a fall in the past related to confusion, deconditioning, gait/balance problems, and poor communication/comprehension. Interventions included a stand-up lift with 2-person assistance for all transfers. - A focus area was added on 11/23/20 for activities of daily living (ADL) self-care performance deficit related to confusion, dementia, weakness, deconditioning, and impaired balance. Interventions included total assistance of 2 staff members using a mechanical lift for all transfers. Review of the Nursing Assistant task list history active on 12/23/22 for Resident #1 concerning transfers (last updated on 8/13/22) revealed the following: - Sit to stand lift required for transfers on non-dialysis days - Total mechanical lift required for transfers on dialysis days with dialysis pad - Use 2 staff members for designated lift transfer. A health status note written by Nurse #1 dated 12/23/22 at 6:01 AM read in part; she heard Resident #1 yelling and when she went to the room, she observed her in front of the wheelchair with Nursing Assistant (NA) #1 and NA #2 on either side of her. Resident #1 told her she was trying to slide back in the wheelchair, but her leg gave out on her. NA #1 and NA #2 stated they had assisted the resident to the floor. A pain assessment was performed with a 4/10 and Tylenol 650 milligrams (mg) was administered. Resident #1 stated she was hurt, but not that bad. There were no open areas or bleeding observed. After she was wheeled up to the front door for dialysis transportation, Resident #1 stated her knee was hurting worse. When Nurse #1 picked up her pant leg to assess, Resident #1 yelled out in pain. She requested to go to the hospital. An order was obtained, and Emergency Medical Services (EMS) was called. An Emergency Department (ED) report dated 12/23/22 revealed a computerized tomography (CT) scan (x-ray images from different angles) of Resident #1's right leg showed a distal (away from the center) femur acute extra-articular (outside of the joint) fracture with mild posterior medial (back midline) displacement. There was not any documentation regarding a scan performed to the left leg and no irregularities were documented of the left leg during the physical examination. A health status note written by a Nurse #5 on 12/23/22 at 2:31 PM indicated, in part, the nurse spoke with the hospital regarding Resident #1 and was told the resident had a femur fracture. Surgery was planned for the next day. A phone interview was conducted with Nurse #1 on 1/12/23 at 10:32 AM. She revealed she was getting ready to start passing medication on the morning of 12/23/22, and she heard Resident #1 scream. Nurse #1 stated she went to her room and saw Resident #1 on her knees on the floor. NA #1 and NA #2 were in the room with the resident. After she performed an assessment of Resident #1, NA #1 and NA #2 told her they were trying to transfer her from the bed to the wheelchair. Resident #1 started to slide, so they assisted her to the floor. At the time (12/23/22), Nurse #1 revealed she did not know what assistance and equipment was required for transferring Resident #1. Right after the fall, Nurse #1 indicated Resident #1 was able to perform range of motion but did complain of pain (4/10) to her right knee. All 3 staff members assisted her up into the wheelchair, and Nurse #1 went back to passing medications. Resident #1 ate a snack and watched TV until NA #1 went into her room and wheeled her up to the front for transport to dialysis. When Nurse #1 was wheeling her medication cart to the front area, she stated she had heard Resident #1 moan and said her knee pain had increased to 10/10. Nurse #1 indicated that she had tried to perform another assessment to the right knee, but when she pulled the pant leg up Resident #1 grimaced/yelled with pain. Nurse #1 stated she contacted the physician on call because Resident #1 requested to go to the hospital. When Nurse #1 received the order for transfer, she called 911 and Resident #1 was picked up by EMS. During a follow-up interview with Nurse #1 on 1/12/23 at 12:44 PM, she revealed she may have seen a mechanical lift outside the door to Resident #1's room but not inside the room when she entered after the incident on 12/23/22. During a phone interview with NA #1 on 1/12/23 at 10:57 AM, she revealed she gave Resident #1 a bath the morning of 12/23/22. She then dressed her and asked for help from NA #2 to transfer Resident #1 to the wheelchair. NA #1 indicated that she and NA #2 were getting ready to put Resident #1 in the wheelchair, and she started to yell/resist, so they guided her to the floor. Nurse #1 then came into the room and helped put Resident #1 in the wheelchair. After she was in her chair, Resident #1 seemed fine. Nurse #1 and NA #2 left the room, and she placed Resident #1 in front of the TV. After about 10 minutes, NA #1 stated she brought the resident in the wheelchair to the front door for dialysis transport. At that time, Resident #1 did not complain of any pain/discomfort, and that was the last time she saw the resident. NA #1 stated prior to transferring the resident on 12/23/22 she found care details for Resident #1 in the electronic care plan where it instructed for the mechanical lift to be used for all transfers. Before she asked for help from NA #2, she retrieved the mechanical lift and placed it in Resident #1's room. However, NA #2 told her that they did not use the lift for Resident #1, and he did not tell her why. NA #1 stated this was her first-time asking NA #2 for assistance and guidance. NA #2 was interviewed on 1/12/23 at 2:23 PM. He revealed on Resident #1's scheduled dialysis days, he assisted the NA assigned to Resident #1 with transfers. On 12/23/22, NA #2 stated Resident #1 was on the edge of her bed, and he performed a 2-person assist with NA #1 to the wheelchair like he had always done for the past 3 years. When they got her up to turn from the bed, her leg gave out and he and NA #1 assisted her to the floor. He stated he then went to get Nurse #1, who assessed Resident #1, and all 3 staff members helped her get back into the wheelchair. NA #2 indicated he then left the room and went back to his assignment. He stated there was a mechanical lift in the room, but he never had to use a lift when transferring Resident #1 in the last 3 years he had worked with her. NA #2 indicated he told this to NA #1 on 12/23/22 before transferring Resident #1. NA #2 stated he had heard of the care plan but never looked at Resident #1's care plan before, and no one had ever instructed him to use a mechanical lift with Resident #1. Hospital #1's record dated 12/24/22 indicated Resident #1 was sent to a secondary hospital (Hospital #2) for surgery on 12/24/22. Hospital #2's record from 12/24/22 through 12/29/22 revealed that on 12/24/22 the initial physical exam performed on Resident #1 noted no lower extremity edema, swelling of the right knee, and sensation/motion intact distally (away from where the bone or muscle is attached). An x-ray of Resident #1's right knee and right femur (leg) was performed on 12/24/22 and showed an impacted fracture of the distal femoral diaphysis (central part of the bone). Surgery was performed on 12/27/22 of the closed bicondylar (2 plateaus of the bone) fracture of the right distal femur. After the initial physical therapy evaluation on 12/28/22, x-rays of the left lower extremity revealed a closed left distal femur fracture. It was initially discovered during the tertiary trauma survey (a prospective study of missed injury) on 12/28/22. Orthopedic surgery was performed on 12/29/22. A Review to Ensure Quality (the facility's investigation for review of risk management) initiated on 12/23/22 and signed/completed by the Director of Nursing on 12/29/22 was reviewed. It revealed Resident #1 sustained a fall with a femur fracture. Nurse #1, NA #1, and NA #2 were interviewed and suspended pending the investigation. The RP and physician were notified on 12/23/22 at the time of the incident. Nurse #1 completed and documented her assessment of the resident after the incident. Resident #1 received medication for pain of 4/10 and sent to the ED for complaint of right knee pain. The following timeline of the fall incident on 12/23/22 was included: - 4:30 AM: NA #1 had resident dressed and ready for transfer to wheelchair - 4:40 AM: While transferring, Resident #1 began resisting and/or went limp. She was assisted to the floor. - 4:50 AM: Resident #1 was assisted back to the wheelchair. - 5:00 AM: Resident #1 was left in her room to watch television. - 5:20 AM: Resident #1 complained of knee pain 4/10. She was given Tylenol by Nurse #1 without Medication Administration Record (MAR) documentation. Corrective action included an in-service that began on 12/26/22 by the Director of Nursing to all nursing staff regarding safe transfers, utilizing the care plan/[NAME] (a task list for NAs), falls, and handling residents with challenging behaviors. All staff who had not participated in the training as of 12/30/22 were not allowed to return to work until completed. A telephone interview was conducted with the NP on 1/12/23 at 10:42 AM. She revealed Resident #1 did not typically stand and bear weight, and she was not sure if that was because she did not want to or was not capable. The NP stated she had called over to the ED on 12/23/22 and was informed Resident #1 had a right leg fracture but was then sent out to another hospital. At that time, medical staff had not found the left leg fracture yet. After the right leg surgery, Resident #1 began physical therapy at the second hospital, the NP indicated she complained of pain and an x-ray was performed where a fracture in the left leg was found as well. During a telephone interview with the Medical Director on 1/12/23 at 11:49 AM, she revealed she could not confirm the left leg fracture was a result of the fall, since it was not discovered initially. An interview was conducted on 1/18/23 at 2:24 PM with the Orthopedic Surgeon, who operated on Resident #1 in the secondary hospital (Hospital #2) on 12/27/22. He stated he believed with great certainty the left femur fracture was related to the fall on 12/23/22, and the second injury was missed by both hospitals. Physician #1 stated he had fixed the right femur and noticed Resident #1 was having pain on the other side. During follow-up exams, Resident #1 was having pain on the left side as a result, which was an identical injury to the right leg fracture. Physician #1 stated a fracture would begin to heal within 2-4 weeks (subacute), which could be identified with imaging. From Resident #1's operation and imaging results, both leg fractures appeared fresh (acute) with similar timelines. Resident #1 did not want anyone touching her anywhere, and all the medical attention was placed on her right leg. Usually, Physician #1 indicated that localized pain to a leg held the focus of the treatment. An interview was attempted with the Radiologist who performed an x-ray on 12/24/22 of Resident #1's right leg at Hospital #2, but she was unable to be reached during the investigation. The Director of Nursing (DON) was interviewed via telephone on 1/13/23 at 4:28 PM, and she revealed her expectation was that all nursing assistants be skilled on how to use the mechanical lift and to utilize the care plan/task list before assisting with any ADL care. During a telephone interview with the Administrator on 1/13/23 at 4:19 PM, she revealed her expectation was for all nursing staff to follow the care plan in each resident's medical record and to follow the tasks as listed. The Administrator stated Resident #1's care plan listed mechanical lift with transfers, but she was not sure if the care plan was updated properly. She reported that the lift was added for Resident #1 after she underwent a mastectomy surgery in April of 2021. She explained that the mastectomy surgery caused Resident #1 to have more difficulty with using a bar to stand up. The Administrator revealed the NA care tasks did specify a 2-person assist and the use of the mechanical lift on dialysis days and that nursing staff assigned to Resident #1 were to use the mechanical lift only on dialysis days. She reported that the dialysis center where Resident #1 was treated required a lift pad underneath all patients prior to entry. She acknowledged that on that 12/23/22, the day of the fall, NA #1 and NA #2 were preparing the resident for dialysis when they transferred her from the bed to her wheelchair without the mechanical lift. The Administrator was notified of Immediate Jeopardy on 1/18/23 at 4:56 PM. The facility provided the following Plan of Correction (POC) with a completion date of 12/31/22: Resident #1 was discharged from the facility; therefore, no further corrective action could be obtained for Resident #1. On 12/28/2022 and 12/29/2022, a meeting to discuss Root Cause Analysis was held with the Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Support Nurse, Administrator, Nurse Consultant, and Regional Director of Operations. Results of the investigation were discussed during the root cause meeting and shared with Quality Assurance Committee (QA) members and with the facility Medical Director (MD). On 12/29/2022 a final root cause was identified as: employee knowledge of residents transfer status, efficiency while providing resident care, and residents medical complexities and diagnosis related to weak and brittle bones. On 12/29/2022 a final root cause was identified. On 12/28/2022, the DON, ADON, and the Unit Support Nurse reviewed 100% of the current resident's most recently completed nursing assessments and observations to identify the correct transfer status, whether a lift was required, what type of lift was required, and the number of individuals required to complete a transfer. This audit was completed on 12/28/2022. On 12/28/2022, the DON reviewed the care plans for 100% of current residents. This audit consisted of a review to ensure the identified transfer status was accurately reflected on the resident's plan of care including the correct transfer status, whether a lift was required, what type of lift was required, and the number of individuals required to complete a transfer. This audit was completed on 12/29/2022. The results included: 5 out of 68 care plans required updating. On 12/29/2022, the DON implemented corrective action for those residents which included: Updating the 5 resident care plans that required updating to include the correct transfer status, whether a lift was required, what type of lift was required, and the number of individuals required to complete a transfer. This care plan update was completed on 12/29/2022 by the DON. On 12/28/2022, the Nurse Consultant audited the falls for the last 30 days. This audit consisted of review of falls to identify if there were any other residents who had a fall where the plan of care wasn't followed for transfers. This audit was completed on 12/28/2022. The results included: There were no other residents who had a fall where the plan of care wasn't followed. No corrective action was required. On 12/26/2022, the Director of Nursing in serviced all Licensed Nurses, Registered Nurses (RN's) and Licensed Practical Nurses (LPN's) and Certified Nursing Assistants (Full time, Part time, and PRN staff) on Safe Transfers, falls process which included falls prevention, falls risk, and what to do if a fall occurs. This training included all current staff including agency. This training included education on: Safe Transfers, Utilizing the [NAME], when to utilize the [NAME], and the falls process. Additionally, on 12/26/2022, the DON began validation of competency of certified nursing assistants and nurses on how to access the [NAME] and care plan. This competency included staff demonstration of how to view the plan of care/[NAME] and verbalization of the need to review the plan of care prior to providing care. This was completed on 12/30/2022 by the DON. Since 12/28/2022, the DON, ADON, Unit Support Nurse, and the Minimum Data Set nurse (MDS) and the nurse management team have reviewed residents at the time of admission, quarterly, and with significant changes to ensure that the transfer status was accurately reflected on the resident's plan of care including the correct transfer status, whether a lift was required, what type of lift was required, and the number of individuals required to complete a transfer. The Director of Nurses has ensured that all licensed nurses, RN's and LPN's and CNA's (full time, part time, and as needed) who do not complete the in-service training will not be allowed to work until the training is completed. This information has been integrated into the standard orientation training. As of 12/30/2022, any staff required to receive scheduled in-service training will not be allowed to work until training has been completed. On 01/02/2023, the Director of Nurses or a designee began monitoring for compliance to identify if staff could verbalize or demonstrate how to access the plan of care, direct observation of the care provided, and if the correct number of caregivers was used to provide the care. The monitoring is being completed using the Transfers QA Tool weekly for 4 weeks and monthly for 2 months monitoring 5 random staff completing transfers/care on various shifts and days to ensure care is being complete according to the plan of care. There have been no concerns identified from any of the monitors that were completed. The monitoring will be presented to the weekly QA committee by the Administrator or Director of Nursing to ensure corrective action initiated as appropriate. Compliance will be monitored, and ongoing auditing program reviewed at the weekly QA Meeting. The weekly QA Meeting is attended by the Administrator, DON, MDS Coordinator, Therapy, HIM, and the Dietary Manager. Additionally, reports will be presented at the quarterly QA Meeting. The Quarterly QA Meeting is attended by the Administrator, DON, MDS Coordinator, Therapy, Health information Manager (HIM), Medical Director, Infection Preventionist, and the Dietary Manager. Onsite validation was completed on 1/23/23 through staff interviews, observation, and record review. Staff were interviewed to validate in-services completed on safe transfers, fall prevention, falls risk, and fall intervention/reporting/notification/action. Observation of a transfer with mechanical lift for Resident #4 revealed no issues, and a review of audits for transfers/lifts/staff required for transfers with lifts/care plans and [NAME] were implemented. Review of residents audited for falls/transfers and resident interviews verified no additional issues were identified. The facility's action plan was validated to be completed as of 12/31/22.