**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and facility staff, Physician Assistant (PA) and Medical Director interviews, the facility failed to immediately notify the PA when Resident #1 had an acute change in condition after a fall. On 03/25/25 between 2:00 PM to 2:30 PM Resident #1 had an unwitnessed fall from the bed and was assessed to have no visible injuries and transferred back to bed. Resident #1 was prescribed an anticoagulant medication of apixaban 5 milligrams (mg) via gastrostomy tube twice a day for atrial fibrillation. Neurological checks were initiated. Resident #1 reported to staff that he did not hit his head. On 03/26/25 at approximately 8:30 AM Resident #1 was noted by staff to be hard to arouse, nonverbal, unresponsive, and lethargic. The PA was not notified until 4:50 PM on 03/26/25 of the acute change in condition. The PA ordered bloodwork, urinalysis with culture and sensitivity, and a chest x-ray for reports of lethargy. On 03/27/25 at 9:58 AM Resident #1's family came to the facility and found him unresponsive and called Emergency Medical Services (EMS) and Resident #1 was transported to the Emergency Department (ED) and diagnosed with a huge left subdural hematoma with a midline shift (shifting of brain past its center). Resident #1 was transitioned to Hospice services and passed away on 03/31/25. This affected 1 of 3 residents reviewed for notification. Immediate Jeopardy began on 03/26/25 when the medical provider was not immediately notified that Resident #1 had an acute significant change in condition. Immediate Jeopardy was removed on 04/05/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity 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 #1 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, history of pulmonary embolism, history of cerebral infarction with hemiplegia and traumatic brain injury. Review of a physician order dated 02/28/25 read; apixaban (anticoagulant) 5 milligrams (mg) via gastrostomy tube two times a day for atrial fibrillation. A review of Resident #1's Medication Administration Record (MAR) for 02/2025 and 03/2025 indicated the Resident had received an anticoagulant medication apixaban 5 mg via gastrostomy tube twice a day for atrial fibrillation. The MARs indicated Resident #1 received the anticoagulant as ordered since his admission date of 02/28/25. An incident report dated 03/25/25 at 2:00 PM and written by Nurse #1 revealed Resident #1 was in bed after lunch when Nurse #1 was called to the Resident's room and upon arrival Resident #1 was lying on the floor next to his bed. Resident #1 stated he rolled over and he did not know what he was trying to do. A head-to-toe assessment was done, and Resident #1 was moving all extremities without any problems. The Resident complained of back pain which he does most of the time and was given some pain medication for pain. No injuries were noted, and Resident #1 was assisted back to bed using the total lift. Neurologic checks were initiated, and all vital signs were within the normal limits. Staff were to do frequent rounding and ensure correct positioning while in bed. During an interview with Nurse #1 on 04/02/25 at 2:40 PM the Nurse confirmed that she worked the 7:00 AM shift on 03/27/25 after his fall on 03/25/25. Nurse #1 explained that when she returned to work on 03/27/25 for the 7:00 AM shift, Nurse #3 informed her that Resident #1 was lethargic, but she did not think to ask how long he had been lethargic. Nurse #1 explained that she went to assess Resident #1, and he was sleeping and when she tried to wake him up, the Resident would not wake up and he was lethargic. She stated she reviewed his progress notes which indicated he had labs drawn and a urine sample and a chest x-ray was due to be done. Nurse #1 reported that the Unit Manager (UM) asked her how Resident #1 was doing that day and Nurse #1 informed her that he was lethargic, and the UM stated that the Resident had labs drawn the day before. Nurse #1 reported that while she was passing her morning medications the radiology technician arrived to obtain a chest x-ray. Shortly after that, Resident #1's family came to visit and informed her that Resident #1 was not acting like himself and was aware that he had a fall on 03/25/25 and stated that Resident #1 had a history of two brain bleeds. The Nurse informed the family of the labs that were ordered, and the chest x-ray had been done but the family insisted that Resident #1 be transferred to the hospital, so Nurse #1 notified the PA and was given an order to transfer Resident #1 to the hospital. On 04/02/25 at 12:55 PM and 04/03/25 at 10:45 AM interviews were conducted with Nurse Aide (NA) #1 who confirmed she worked from 7:00 AM to 3:00 PM on 03/26/25 on a different assignment, but she went to check on Resident #1 because he had fallen on 03/25/25 and found him to be lethargic and basically not responding as his usual self. The NA stated that she helped NA #2 get Resident #1 out of the bed for therapy around mid-morning and the Resident was limp like a rag doll and lethargic and that was a change in the Resident since the day before. NA #1 reported that she went and got the Physical Therapy Assistant (PTA) and reported how the Resident was acting since the fall on 03/25/25 and they both put Resident #1 back in the bed. An interview was conducted with Nurse Aide #2 on 04/03/25 at 10:15 AM who confirmed she worked from 7:00 AM to 3:00 PM on 03/26/25. The NA explained that she had only worked with Resident #1 one time before 03/26/25, and he was alert and conversed with her about having a daughter with her name. NA #2 reported that when she went in to care for Resident #1 on that morning (03/26/25) around breakfast, she knew immediately that he was acting differently from their previous encounter because the Resident's response was slower, and he was not conversing with her like he normally did. NA #2 continued to explain that around 10:00 AM NA #1 helped her get Resident #1 out of bed for therapy and NA #1 went to inform therapy of how Resident #1 was acting and therapy and NA #1 put the Resident back to bed. NA #2 reported that she went to notify Nurse #2 of Resident #1's condition and Nurse #2 went to his room to assess him. NA #2 explained that Resident #1 acted the same throughout the rest of the shift when she went into care for him. During an interview with the Physical Therapy Assistant (PTA) on 04/02/25 at 11:45 AM the PTA explained that she had worked with Resident #1 since his admission, and he was able to participate in therapy. She reported that on the morning of 03/26/25 NA #1 came and got her to go to Resident #1's room because the Resident had a fall out of bed the day before (03/25/25) and they had gotten him out of bed for his therapy session, but he was not behaving like his normal behavior. The PTA stated she went into Resident #1's room and could see that he was lethargic and not responding to her as he normally did, and she and NA #1 put the Resident back to bed. The PTA explained that she reported her concern to Nurse #2 and the Nurse informed her that no one reported to her that Resident #1 had a fall. The PTA continued to explain that she periodically checked on Resident #1 throughout the rest of the shift and he barely made eye contact with the PTA. She indicated the Resident made groaning and moaning sounds while he was sleeping. Interviews were conducted with Nurse #3 on 04/02/25 at 9:20 PM and 04/04/25 6:55 AM. The Nurse confirmed that she worked with Resident #1 on 03/25/25 through 03/26/25 for the 7:00 PM to 7:00 AM shift and 7:00 PM to 7:00 AM for 03/26/25 through 03/27/25. Nurse #3 explained that she received in the report on 03/25/25 that Resident #1 sustained a fall from the bed and the neurologic checks were on going. Nurse #3 continued to explain that she reported off to Nurse #2 on the morning of 03/26/25 and informed the Nurse that Resident #1 had a fall and that his neurologic checks were on going and had been stable throughout the night and she documented it on the 24-hour report sheet. Nurse #3 stated when she came on duty at 7:00 PM on 03/26/25 she checked on the residents and found that Resident #1 was lethargic. Nurse #3 was then told by the UM that labs, urine and a chest x-ray had been ordered for Resident #1 and that she had to collect the urine and have it ready for the lab to pick up. The Nurse stated she obtained the urine, and the lab phlebotomist came in around 4:00 AM in the morning to obtain the Resident's labs so that just left the chest x-ray which she reported to Nurse #1 when she gave her report that morning. Nurse #3 continued to explain that Resident #1 slept all night, and she was able to perform the neurologic checks except the grips because he was sleeping. The Nurse indicated the Resident's vital signs were stable. Nurse #3 reported if it had been during the day she would have called the provider, but she knew the provider had already been informed of Resident #1's condition and his lab work was pending. Interviews were conducted with Nurse #2 on 04/02/25 at 11:30 AM and 04/03/25 at 11:35 AM. Nurse #2 confirmed that she worked with Resident #1 on 03/26/25 from 7:00 AM to 3:00 PM and it was the first time she had worked with the Resident. Nurse #2 stated between 8:00 AM and 8:30 AM a therapy staff (PTA) member informed her that Resident #1 had a fall the previous day (03/25/25) and was not acting like himself and she went to assess him. Nurse #2 stated Resident #1 would open his eyes when she called his name, but he would not respond to her. The Nurse indicated that she obtained the Resident's vital signs which were within normal limits and completed a change in condition assessment and reported the change in condition to the UM after the UM got out of a meeting which was around 10:30 AM and the UM informed Nurse #2 that she would call the PA. The Nurse explained that they received orders for some blood work, urine and a chest x-ray. When Nurse #2 was asked why she did not call the PA herself the Nurse indicated that she was not familiar with Resident and wanted to report the Resident's condition to her Unit Manager. A review of a Change in Condition Assessment completed by Nurse #2 on 03/26/25 at 2:35 PM revealed Resident #1 was drowsy, lethargic and very less responsive. Blood Pressure 115/62, Pulse 64, Respirations 18 and Temperature 97.7 via forehead and recent oxygenation 95%. Decreased level of consciousness (sleepy, lethargic). The assessment indicated the PA, and the responsible party were notified. A review of Resident #1's physician orders on 03/26/25 written around 5:40 PM indicated orders for a Complete Blood Count with Differential (CBC/Diff) in AM, Urine for Urinalysis and Culture and Sensitivity (UA/C&S) if indicated and a Chest X-Ray (CXR) for cough were obtained. The orders were written by the Unit Manager. Interviews were conducted with the Unit Manager on 04/02/25 at 5:00 PM and 04/03/25 at 10:45 AM. The UM explained that she was notified of Resident #1's fall by Nurse #1 on 03/25/25 shortly after the fall happened and was told that the Resident did not sustain any injuries from the fall. The UM continued to explain that the next day on 03/26/25 at approximately 4:30 PM after she got out of the Risk Management meeting, Nurse #2 informed her that Resident #1 had a change in condition and was lethargic and she was going to document a change in condition and call the responsible party. The UM stated that she stepped into Resident #1's room and laid eyes on him but the Resident did not appear to her to be lethargic. She indicated that she did not complete an assessment on Resident #1. The UM continued to explain that since she had to call the PA about other residents, she decided to call the PA at that time and reported that Resident #1 had a change in condition and was lethargic. The UM stated she received orders for lab work, urine for culture and sensitivity and a chest x-ray which she put in the computer. The UM reported that Nurse #3 was to collect the urine, and the phlebotomist was to obtain the blood when they made their next round to the facility. The UM indicated Resident #1's vital signs were stable, and they were trying to rule out infection. Review of a progress note made by Nurse #1 on 03/27/25 at 10:52 AM indicated Resident #1 continued to appear lethargic, family at the facility at the time, requested Resident #1 to be sent out to ED for more evaluation. The PA was notified, and an order was received. Resident #1 left with EMS at around 10:19 AM. Vital Signs: 133/94, T97.3, R18, P112, 02 saturation 97% on room air. A review of Resident #1's hospital records dated 03/27/25 revealed Resident #1 arrived at the ED with a history of intracranial hemorrhage, altered mental status and subdural hematoma. The Resident received apixaban 5 mg twice a day. Resident #1's vital signs rose to 212/108, 124, 40 but remained negative for fever. The Glasco Coma Scale (GCS) (a neurological assessment tool used to measure a person's level of conscientious especially in traumatic brain injury) was a 3 meaning the lowest possible level of consciousness and is usually associated with the deep coma or death meaning the person is wholly unresponsive. The computed tomography (CT) results of the brain revealed a huge left subdural hematoma measuring 15.1 centimeters (cm) in length, thickness of 3.4 cm and height of 9.7 cm. This results in severe compression of the left hemisphere with 1.5 cm midline shift. There is developing right side hydrocephalus (a buildup of fluid deep within the cavities of the brain). The report indicated the Resident's family was consulted on his condition and because of his condition the family opted to provide comfort measures only and to consult Hospice services. Interviews were conducted with the Physician Assistant on 04/02/25 at 2:15 PM and 04/03/25 at 12:45 PM. The PA explained that she was at the facility on 03/25/25 and was informed that the Resident sustained a fall and assessed Resident #1 late that same night. The PA reported that the UM called her the next day on 03/26/25 around 4:50 PM when the Resident had a change in condition. When the PA was asked if she was notified that Resident #1 was lethargic, the PA stated she could not remember the exact verbiage that the UM used in describing the Resident's change in condition, but she felt that she needed to obtain labs, urine and a chest x-ray to diagnose the issue. The PA reported that the next morning on 03/27/25 she was notified by Nurse #1 that Resident #1's family was at the facility and wanted him sent to the hospital and she gave the Nurse an order to send Resident #1 out to the hospital. During an interview was conducted with the Director of Nursing (DON) on 04/03/25 at 2:40 PM. The DON explained that she was aware that Resident #1 had a fall on 03/25/25 and that he had no injuries from the fall. The DON stated that she did not know that Resident #1 had a change in condition on the morning of 03/26/25 and indicated that when the change in condition occurred the PA should have been notified at that time. An interview was conducted with the Medical Director on 04/04/25 at 4:15 PM. The Medical Director stated that he was notified of Resident #1's situation by the PA and was aware of the events that led to the Resident being sent to the hospital. The Medical Director stated that given Resident #1's complex medical history, the facility should have notified the PA as soon as they noticed a change in the Resident's condition and sent Resident #1 to the hospital. He indicated that the outcome might not have changed but the facility should have sent him out. The Administrator was notified of Immediate Jeopardy on 04/03/25 at 4:40 PM. The facility implemented 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 immediately notify the Medical Provider when Resident #1 had a change in condition on 03/26/25 at approximately 8:30 AM. Resident #1 had a fall on 03/25/25 at approximately 2:00 PM and was assessed by the nursing staff to have no injuries and was transferred back to bed. On 03/26/25 at 8:30 AM Resident #1 had a change in condition as described by staff as having a decreased level of consciousness, unable to be awakened, lethargic slow to respond, much different than his baseline. The Medical Provider was not notified until 4:50 PM on 03/26/25 and gave orders for blood work, urinalysis, and chest x-ray. On 03/27/25 Resident #1's family came to visit and found him unresponsive and called Emergency Medical Services (EMS). Resident #1 was transferred to the emergency room and diagnosed with a large subdural hematoma with midline shift. Resident #1 was transferred to hospice and passed away on 03/31/25. On 4/3/25, the DON re-educated the nurse on the notification policy and process to include immediately notifying the Medical Provider when a resident has a change in condition. On 4/3/25, the DON and Nurse Consultant completed an audit of residents on anticoagulant therapy who have experienced a fall within the last 72 hours to ensure timely notification to the Medical Provider if a change in resident condition occurs. Two residents were identified and no concerns identified. On 4/4/2025, the facility reviewed all residents with changes in condition in 24 hours to ensure immediate notification to the Medical Provider occurred. Six residents were identified, and the Medical Provider was notified. Specify the action 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 complete. On 4/3/25, the Administrator, Director of Nursing (DON), [NAME] President of Risk and Quality Assurance (VPRQA), Nurse Consultant, Physician Assistant and Medical Director held an Ad Hoc QAPI meeting to discuss the incident to determine root cause analysis of the facility's failure to immediately notify the Medical Provider when Resident #1 had a change in condition. Root cause analysis determined that the facility failed to have effective systems in place and monitoring measures to ensure that a licensed nurse understood the seriousness of their responsibility to notify the Medical Provider when a resident experiences a change in condition post-fall, especially those on anticoagulants. On 4/3/2025, the Director of Risk of Quality Management, Nurse Consultant, Director of Nursing, Administrator, and Physician Assistant reviewed the notification and fall policy. No updates were made. Effective 4/3/25, the Director of Nursing, Nurse Consultant, and Nursing Administration initiated education with all facility and contracted licensed nurses and Certified Nursing Assistants on the facility Notification of Changes in Condition and Fall Prevention Policies. Education includes the licensed nurse's responsibility to immediately notify the Medical Provider of any resident's change in condition, especially post-fall, with a history of stoke and pulmonary embolism on an anticoagulant. Certified Nursing Assistants will immediately communicate to the licensed nurses any change in Residents condition. The Director of Nursing will ensure all newly hired licensed nurses and Certified Nursing Assistants will be educated during orientation and contracted staff educated prior to taking their assignment. Effective 4/3/25, the Administrator is ultimately responsible for the implementation and completion of this removal plan. Alleged Date of IJ Removal: 04/05/25 On 04/08/25 the credible allegation of Immediate Jeopardy removal with a removal date of 04/05/25 was validated by onsite verification through staff interviews, record reviews, and education reviews. The staff interviewed included members of administration, licensed nurses and nursing assistants. The staff interviews were related to the facility's policy and procedures for notification of changes in condition, specifically how to identify changes in conditions and notification the providers upon changes in conditions. The management team reported new procedures in monitoring for changes in conditions in order to notify the providers. The licensed nurses reported their responsibility to assess residents when changes in conditions occur so that timely notification can be made to the providers, and the nurse aides voiced their responsibility in notifying the nurses of changes in the residents' conditions as soon as possible. The education of Notification provided for the staff was evident through staff interviews and education attendance records. The Immediate Jeopardy removal date of 04/05/25 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, Emergency Medical Services (EMS) records, facility staff, Emergency Department (ED) Physician, Physician Assistant (PA) and Medical Director interviews, the facility failed to recognize the severity of an acute change in condition after a fall for Resident #1. Resident #1 had a past medical history that included atrial fibrillation with anticoagulation, recent pulmonary embolism, recent COVID-19, history of traumatic brain injury (TBI), history of hemiplegia (paralysis on one side of body) following a cerebral infarction, and history of previous subdural hematoma. Resident #1 was prescribed an anticoagulant medication of apixaban 5 milligrams (mg) via gastrostomy tube twice a day for atrial fibrillation. On 03/25/25 between 2:00 PM to 2:30 PM Resident #1 had an unwitnessed fall from the bed and was assessed to have no visible injuries and transferred back to bed. Neurological checks were initiated. Resident #1 reported to staff that he did not hit his head. On 03/26/25 at approximately 8:30 AM Resident #1 was noted by staff to be hard to arouse, nonverbal, unresponsive, and lethargic. At 4:50 PM on 03/26/25 the Unit Manager (UM) notified the PA that Resident #1 was lethargic and received orders for bloodwork, urinalysis, culture and sensitivity, and a chest x-ray. On 03/27/25 at 9:58 AM Resident #1's family came to the facility and found him unresponsive and called Emergency Medical Services (EMS) and Resident #1 was transported to the Emergency Department (ED) and diagnosed with a huge left subdural hematoma with a midline shift (shifting of brain past its center). Resident #1 was transitioned to Hospice services and passed away on 03/31/25. This affected 1 of 3 residents reviewed for change in condition. Immediate Jeopardy began on 03/26/25 when Resident #1 was noted to have had an acute significant change in condition and was not evaluated or transferred to a higher level of care until 03/27/25. Immediate Jeopardy was removed on 04/05/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity 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 #1 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation, history of pulmonary embolism, history of cerebral infarction with hemiplegia and traumatic brain injury. Review of a physician order dated 02/28/25 read; Apixaban 5 milligrams (mg) via gastrostomy tube two times a day for atrial fibrillation. A review of Resident #1's care plan dated 02/28/25 indicated the Resident received an anticoagulant medication related to a diagnosis of atrial fibrillation. The goal that Resident #1 will be free from adverse side effects of the anticoagulation medication would be attained by utilizing interventions such as administering the anticoagulation medication as ordered and monitoring for side effects specifically for bleeding since Resident #1 has a history of gastrointestinal bleed. Further Review of Resident #1's care plan revealed no active care plan for falls prior to the fall on 03/25/25. A review of Resident #1's admission Minimum Data Set assessment dated [DATE] revealed he was cognitively intact. The Resident was coded as requiring substantial to maximal assistance with most activities of daily living except eating. It was documented that he had no falls since admission and received an anticoagulant. A review of Resident #1's Medication Administration Record (MAR) for 02/2025 and 03/2025 indicated the Resident had received an anticoagulant medication apixaban 5 mg via gastrostomy tube twice a day for atrial fibrillation. The MARs indicated Resident #1 received the anticoagulant as ordered since his admission date of 02/28/25. An incident report dated 03/25/25 at 2:00 PM and written by Nurse #1 revealed Resident #1 was in bed after lunch when Nurse #1 was called to the Resident's room and upon arrival Resident #1 was lying on the floor next to his bed. Resident #1 stated he rolled over and he did not know what he was trying to do. A head-to-toe assessment was done, and Resident #1 was moving all extremities without any problems. The Resident complained of back pain which he does most of the time and was given some pain medication for pain. No injuries were noted, and Resident #1 was assisted back to bed using the total lift. Neurologic checks were initiated, and all vital signs were within the normal limits. Staff were to do frequent rounding and ensure correct positioning while in bed. A nursing progress note written by Nurse #1 on 03/25/25 at 3:34 PM indicated Resident #1 was alert and able to make his needs known. The Resident was in bed after lunch when Nurse #1 was called to Resident #1's room (by Nurse Aide (NA) #1) and upon arrival the Resident was lying on the floor next to his bed. When Resident #1 was asked what he was trying to do, the Resident responded that he did not know what he was trying to do. A head-to-toe assessment was completed with Resident #1 being able to move all his extremities without any problems. No injuries noted. The Resident was transferred to bed via a total lift and 2 person assist (Nurse #1 and NA #1). Resident #1 complained of back pain and a pain medication was given and was effective. Neurologic checks were initiated, and the Resident's vital signs were within normal limits. A review of the neurologic checks with vital signs indicated the checks were initiated on 03/25/25 at 2:00 PM and continued through 03/27/25 at 9:00 AM. One neurologic check assessment dated [DATE] at 7:45 PM was not documented. The documented neurologic checks indicated the vital signs were within normal limits and the grips were present and the upper and lower motor function of the extremities were present. A review of the Physician Assistant progress note dated 03/25/25 revealed Resident #1 was assessed after sustaining a fall earlier in the day of 03/25/25. No injuries or cognition changes were reported. The neurologic exam was at baseline and no acute distress was appreciated. The Resident was status post recent complicated hospitalization with a history of atrial fibrillation, cerebral vascular accident with residual left hemiparesis, pulmonary embolism and recent gastrointestinal bleed. Medications include apixaban 5 mg two times a day. Vital signs 119/76, 73, 18, 97.6 and oxygen saturation of 96%. Assessment Plan: continue post fall measures and neuro checks per the facility policy and continue to monitor for bleeding. Nursing will continue to monitor changes and inform the provider as needed. During an interview with Nurse #1 on 04/02/25 at 2:40 PM the Nurse confirmed that she worked from 7:00 AM to 7:00 PM on 03/25/25. The Nurse explained that she was notified that Resident #1 was on the floor in his room by NA #1. Nurse #1 went to the Resident's room to find him lying on the floor and when the Nurse asked Resident #1 how he got on the floor, he stated that he guessed he turned over, but he could not remember. The Resident complained of back pain, and she gave him some pain medication that was effective. The Nurse continued to explain that they (Nurse #1 and NA #1) got Resident #1 back in the bed using the total lift. Nurse #1 stated she asked the Resident if he hit his head, and he made a remark of something funny which was his normal demeanor. She indicated she specifically looked for injuries on his head because it was an unwitnessed fall and there were no visible injuries. The Nurse reported she initiated neurologic checks, and they were within normal limits. Nurse #1 explained that she continued the neurologic checks throughout the rest of the shift and the neurologic checks remained within normal limits and Resident #1 was alert and talkative, which was his normal demeanor. The Nurse indicated that she reported off to Nurse #3 at the change of shift. Nurse #1 continued to explain that when she returned to work on 03/27/25 for the 7:00 AM shift, Nurse #3 informed her that Resident #1 was lethargic, but she did not think to ask how long he had been lethargic. Nurse #1 explained that she went to assess Resident #1, and he was sleeping and when she tried to wake him up, the Resident would not wake up and he was lethargic. She stated she reviewed his progress notes which indicated he had labs drawn and a urine sample and a chest x-ray was due to be done. Nurse #1 reported that the UM asked her how Resident #1 was doing that day and Nurse #1 informed her that he was lethargic, and the UM stated that the Resident had labs drawn the day before. Nurse #1 reported that while she was passing her morning medications the radiology technician arrived to obtain a chest x-ray. Shortly after that, Resident #1's family came to visit and informed her that Resident #1 was not acting like himself and was aware that he had a fall on 03/25/25 and stated that Resident #1 had a history of two brain bleeds. The Nurse informed the family of the labs that were ordered, and the chest x-ray had been done but the family insisted that Resident #1 be transferred to the hospital, so Nurse #1 notified the PA and was given an order to transfer Resident #1 to the hospital. On 04/02/25 at 12:55 PM and 04/03/25 at 10:45 AM interviews were conducted with Nurse Aide (NA) #1 who confirmed she worked from 7:00 AM to 3:00 PM on 03/25/25. The NA explained that after lunch she answered the call light for Resident #1's room and found Resident #1 lying on the floor on his left side between his bed and his roommate's bed. The roommate had pushed the call light for Resident #1. NA #1 continued to explain that she asked Resident #1 if he was hurt or if he hit his head during the fall and the Resident told her no and she saw no visible signs of injury or bleeding from Resident #1. NA #1 informed the Resident that she was going to get Nurse #1 which she did and after Nurse #1 assessed Resident #1 they used the total lift to put him back in bed. NA #1 reported that she checked on Resident #1 one more time before she went off shift and asked him what he was trying to do when he fell and the Resident responded, I don't know, dancing I guess. The NA explained that it was Resident #1's usual demeanor to joke with the staff. NA #1 continued to explain that she worked from 7:00 AM to 3:00 PM on 03/26/25 but she worked on a different assignment, but she went to check on Resident #1 and found him to be lethargic and basically not responding as his usual self. The NA stated that she helped NA #2 get Resident #1 out of the bed for therapy around mid-morning and the Resident was limp like a rag doll and lethargic and that was a change in the Resident since the day before. NA #1 reported that she went and got the Physical Therapy Assistant (PTA) and reported how the Resident was acting since the fall on 03/25/25 and they both put Resident #1 back in the bed. An interview was conducted with Nurse Aide #2 on 04/03/25 at 10:15 AM who confirmed she worked from 7:00 AM to 3:00 PM on 03/26/25. The NA explained that she had only worked with Resident #1 one time before 03/26/25, and he was alert and conversed with her about having a daughter with her name. NA #2 reported that when she went in to care for Resident #1 on that morning (03/26/25) around breakfast, she knew immediately that he was acting differently from their previous encounter because the Resident's response was slower, and he was not conversing with her like he normally did. NA #2 continued to explain that around 10:00 AM NA #1 helped her get Resident #1 out of bed for therapy and NA #1 went to inform therapy of how Resident #1 was acting and therapy and NA #1 put the Resident back to bed. NA #2 reported that she went to notify Nurse #2 of Resident #1's condition and Nurse #2 went to his room to assess him. NA #2 explained that Resident #1 acted the same throughout the rest of the shift when she went into care for him. During an interview with the Physical Therapy Assistant (PTA) on 04/02/25 at 11:45 AM the PTA explained that she had worked with Resident #1 since his admission, and he was able to participate in therapy. She reported that on the morning of 03/26/25 NA #1 came and got her to go to Resident #1's room because the Resident had a fall out of bed the day before and they had gotten him out of bed for his therapy session, but he was not behaving like his normal behavior. The PTA stated she went into Resident #1's room and could see that he was lethargic and not responding to her as he normally did, and she and NA #1 put the Resident back to bed. The PTA explained that she reported her concern to Nurse #2 and the Nurse informed her that no one reported to her that Resident #1 had a fall. The PTA continued to explain that she periodically checked on Resident #1 throughout the rest of the shift and he barely made eye contact with the PTA. She indicated the Resident made groaning and moaning sounds while he was sleeping. Interviews were conducted with Nurse #3 on 04/02/25 at 9:20 PM and 04/04/25 6:55 AM. The Nurse confirmed that she worked with Resident #1 on 03/25/25 through 03/26/25 for the 7:00 PM to 7:00 AM shift and 7:00 PM to 7:00 AM for 03/26/25 through 03/27/25. Nurse #3 explained that she received in the report on 03/25/25 that Resident #1 sustained a fall from the bed and the neurologic checks were on going. When the Nurse went into assess Resident #1, he was alert and talkative and informed her that he had a fall before she asked the Resident about the fall. The Nurse indicated that every time she went into assess Resident #1, he spoke with her and his neurologic checks and vital signs were within normal limits and remained within normal limits throughout the rest of the shift. Nurse #3 continued to explain that she reported off to Nurse #2 the morning of 03/26/25 and informed the Nurse that Resident #1 had a fall and that his neurologic checks were on going and she documented it on the 24-hour report sheet. Nurse #3 stated when she came on duty at 7:00 PM on 03/26/25 she checked on the residents and found that Resident #1 was lethargic. Nurse #3 was then told by the Unit Manager (UM) that labs, urine and a chest x-ray had been ordered for Resident #1 and that she had to collect the urine and have it ready for the lab to pick up. The Nurse stated she obtained the urine, and the lab phlebotomist came in around 4:00 AM in the morning to obtain the Resident's labs so that just left the chest x-ray which she reported to Nurse #1 when she gave her report that morning. Nurse #3 continued to explain that Resident #1 slept all night, and she was able to perform the neurologic checks except the grips because he was sleeping. The Nurse indicated the Resident's vital signs were stable. Nurse #3 reported that she was able to connect his external tube feeding, medicate him through his gastrostomy tube, clean the gastrostomy tube site and disconnect the external tube feeding without waking him but that was not unusual for the Resident because he could be a hard sleeper. Nurse #3 reported if it had been during the day she would have called the provider, but she knew the provider had already been informed of Resident #1's condition and his lab work was pending. Interviews were conducted with Nurse #2 on 04/02/25 at 11:30 AM and 04/03/25 at 11:35 AM. Nurse #2 confirmed that she worked with Resident #1 on 03/26/25 from 7:00 AM to 3:00 PM and it was the first time she had worked with the Resident. Nurse #2 explained that she did not receive in report from Nurse #3 that Resident #1 had fallen but she did receive other information about the Resident. Nurse #2 stated after that between 8:00 AM and 8:30 AM a therapy staff (PTA) member informed her that Resident #1 had a fall and was not acting like himself and she went to assess him. Nurse #2 stated Resident #1 would open his eyes when she called his name, but he would not respond to her. The Nurse indicated that she obtained the Resident's vital signs which were within normal limits and completed a change in condition assessment and reported the change in condition to the UM after the UM got out of a meeting which was around 10:30 AM and the UM informed Nurse #2 that she would call the PA. The Nurse explained that they received orders for some blood work, urine and a chest x-ray and Nurse #2 called the Resident's responsible party twice but had to leave a message on the cell phone and she did not know if the responsible party called back because she left off shift around 3:00 PM. When Nurse #2 was asked why she did not call the PA herself the Nurse indicated that she was not familiar with Resident and wanted to report the Resident's condition to her Unit Manager. A review of a Change in Condition Assessment completed by Nurse #2 on 03/26/25 at 2:35 PM revealed Resident #1 was drowsy, lethargic and very less responsive. Blood Pressure 115/62, Pulse 64, Respirations 18 and Temperature 97.7 via forehead and recent oxygenation 95%. Decreased level of consciousness (sleepy, lethargic). The assessment indicated the PA, and the responsible party were notified. A review of Resident #1's physician orders on 03/26/25 written around 5:40 PM indicated orders for a Complete Blood Count with Differential (CBC/Diff) in AM, Urine for Urinalysis and Culture and Sensitivity (UA/C&S) if indicated and a Chest X-Ray (CXR) for cough were obtained. The orders were written by the Unit Manager. Interviews were conducted with the Unit Manager on 04/02/25 at 5:00 PM and 04/03/25 at 10:45 AM. The UM explained that she was notified of Resident #1's fall by Nurse #1 on 03/25/25 shortly after the fall happened and was told that the Resident did not sustain any injuries from the fall. Nurse #1 initiated the neurologic checks which included vital signs as per protocol for post falls. The UM continued to explain that the next day on 03/26/25 at approximately 4:30 PM after she got out of the Risk Management meeting, Nurse #2 informed her that Resident #1 had a change in condition and was lethargic and she was going to document a change in condition and call the responsible party. The UM stated that she stepped into Resident #1's room and laid eyes on him but the Resident did not appear to her to be lethargic. She indicated that she did not complete an assessment on Resident #1. The UM continued to explain that since she had to call the PA about other residents, she decided to call the PA at that time and reported that Resident #1 had a change in condition and was lethargic. The UM stated she received orders for lab work, urine for culture and sensitivity and a chest x-ray which she put in the computer. The UM reported that Nurse #3 was to collect the urine, and the phlebotomist was to obtain the blood when they made their next round to the facility. The UM indicated Resident #1's vital signs were stable, and they were trying to rule out infection. During an interview with NA #3 on 04/04/25 at 11:40 AM the NA confirmed that she worked with Resident #1 on 3:00 PM to 11:00 PM on 03/26/25. The NA explained that she remembered Resident #1 being quiet and refusing his supper. She indicated that he would only answer her questions with one-word responses and slept most of the shift. NA #3 stated she had not worked with Resident #1 enough to determine if it was his normal demeanor, so she did not think it was abnormal to report his behavior. An interview was conducted with Nurse #4 on 04/03/25 at 8:15 AM who confirmed that she worked with Resident #1 on 03/26/25 from 3:00 PM to 7:00 PM. The Nurse explained that she only worked with the Resident that day and was unfamiliar with his usual demeanor. The Nurse stated she did not get in report that he had a fall, or she would have completed the neurologic checks. Nurse #4 reported that the Resident would answer her questions and allowed her to give him his enteral feeding. The Nurse stated if she had known or suspected that Resident #1 had a change in condition she would have notified the provider on call. An interview was conducted with Nurse Aide #5 on 04/03/25 at 10:30 AM. The NA confirmed that she worked with Resident #1 on 03/26/25 3:00 PM through 03/27/25 to 7:00 AM. The NA explained that she noticed that Resident #1 was not acting like his normal self on the evening of 03/26/25 and reported it to Nurse #3 who was working with her that night. The Nurse informed her that Resident #1 had a fall the day before and they had notified the PA and were given orders for lab work. NA #5 stated that she was able to check and reposition Resident #1 throughout the night and basically sleep through it all which was unusual because the Resident would normally grunt and moan when she turned him. Review of a progress note made by Nurse #1 on 03/27/25 at 10:52 AM indicated Resident #1 continued to appear lethargic, family at the facility at the time, requested Resident #1 to be sent out to ED for more evaluation. The PA was notified, and an order was received. Resident #1 left with EMS at around 10:19 AM. Vital Signs: 133/94, T97.3, R18, P112, 02 saturation 97% on room air. A review of the EMS records dated 03/27/25 revealed they were dispatched to the facility at 10:01 AM and arrived at the facility at 10:10 AM to find Resident #1 lying in the bed unresponsive, hot to touch and breathing approximately 40 times a minute. They were advised by facility staff that he had fallen 2 days prior but could not indicate how the Resident fell as it was noted that the Resident was paralyzed from previous cerebral vascular accidents. The family was also at bedside and advised that the Resident was normally alert and verbal and could carry a conversation, so they called EMS because the Resident was unresponsive. His temperature was obtained at 100.6 axillary, and intravenous access was established, and a fluid bolus was given. The Resident remained unresponsive throughout the transport. A review of Resident #1's hospital records dated 03/27/25 revealed Resident #1 arrived at the ED with a history of intracranial hemorrhage, altered mental status and subdural hematoma. The Resident received apixaban 5 mg twice a day. Resident #1's vital signs rose to 212/108, 124, 40 but remained negative for fever. The Glasco Coma Scale (GCS) (a neurological assessment tool used to measure a person's level of conscientious especially in traumatic brain injury) was a 3 meaning the lowest possible level of consciousness and is usually associated with the deep coma or death meaning the person is wholly unresponsive. The computed tomography (CT) results of the brain revealed a huge left subdural hematoma measuring 15.1 centimeters (cm) in length, thickness of 3.4 cm and height of 9.7 cm. This results in severe compression of the left hemisphere with 1.5 cm midline shift. There is developing right side hydrocephalus (a buildup of fluid deep within the cavities of the brain). The report indicated the Resident's family was consulted on his condition and because of his condition the family opted to provide comfort measures only and to consult Hospice services. An interview was conducted with the ED Physician on 04/04/25 at 10:20 PM. The ED Physician explained Resident #1 was brought to the ED by EMS who reported he had a fall one to one and a half days prior and had a decreased level of consciousness. He stated the Resident's vital signs were not terrible, but his blood pressure was 208/100 and his pulse was 124. The ED Physician continued to explain that the CT results showed a huge intracranial hemorrhage of a subdural hematoma that had a midline shift and after discussion with the family about the probable prognosis the family opted for Hospice services where he was sent that same day. The ED Physician reported that he saw no signs of injuries to account for the subdural hematoma, but it would not be uncommon for there not to be visible signs. He stated his opinion was that the hematoma was acute, but he could not be sure when it started because everyone was different and it could have even been before the fall. He indicated it could have been a slow bleed and when it crossed the midline shift was when Resident #1 started having a decreased level of consciousness. The ED Physician was asked if he thought Resident #1's recent diagnosis of COVID-19 affected his outcome and the ED Physician stated probably not. Interviews were conducted with the Physician Assistant on 04/02/25 at 2:15 PM and 04/03/25 at 12:45 PM. The PA explained that she was at the facility on 03/25/25 and was informed that the Resident sustained a fall and assessed Resident #1 late that same night. She reported that Resident #1 had an extensive complicated history with multiple comorbidities and recently contracted COVID-19 which made his condition worse since he had a neurological condition. The PA continued to explain that when she assessed the Resident, she did not order anything but to continue the facility's protocol for post fall neurologic checks. The PA reported that the UM called her the next day on 03/26/25 around 4:50 PM when the Resident had a change in condition. When the PA was asked if she was notified that Resident #1 was lethargic, the PA stated she could not remember the exact verbiage that the UM used in describing the Resident's change in condition, but she felt that she needed to obtain labs, urine and a chest x-ray to diagnose the issue. The PA reported that the next morning on 03/27/25 she was notified by Nurse #1 that Resident #1's family was at the facility and wanted him sent to the hospital and she gave the Nurse an order to send Resident #1 out to the hospital. The PA stated she now knew that Resident #1 had a subdural hematoma which could show up in 72 hours after a fall with head injury and as soon as the facility noticed a change in condition, they called the PA for guidance. The PA stated it was possible that Resident #1 could have had a slow hemorrhage from a previous bleed. During an interview was conducted with the Director of Nursing (DON) on 04/03/25 at 2:40 PM. The DON explained that she was notified of Resident #1's fall shortly after it happened but could not remember who notified her, but they told her that there were no injuries, and he did not hit his head. The DON reported that they talked about Resident #1 in the Risk Management meeting, and she specifically looked at his neurologic checks that were being done and there were no problems that she could determine. The DON stated that she always tried to follow up with the residents after falls and on Wednesday 03/26/25 she went into see Resident #1 who was in bed and asked him how he fell, and the Resident told her that he did not know how he fell and that he was not having any pain that he did not usually have. The DON reported that the next thing she knew was that Resident #1 was being sent to the emergency department on 03/27/25 at the family's request. The DON stated she did not know that Resident #1 had a change in condition on 03/26/25. On 04/03/25 at 3:10 PM an interview was conducted with the Administrator. The Administrator explained that the facility followed the fall protocol and conducted neurologic checks with vital signs and the neurologic checks were stable until Resident #1 had a change in condition on 03/26/25. At that time the Physician Assistant was notified, and orders were received for labs, urine and a chest x-ray which were pending when the family insisted that Resident #1 be sent to the hospital. She indicated that when families insist on the residents to be sent to the hospital the facility accommodated the request. The Administrator acknowledged Resident #1's hospital admission diagnosis of a huge left subdural hematoma with a midline shift and indicated it could have been growing since the Resident's last traumatic brain injury. An interview was conducted with the Medical Director on 04/04/25 at 4:15 PM. The Medical Director stated that he was notified of Resident #1's situation by the PA and was aware of the events that led to the Resident being sent to the hospital. The Medical Director stated that given Resident #1's complex medical history, the facility should have sent Resident #1 to the hospital when they noticed a change in his condition. He indicated that the outcome might not have changed but the facility should have sent him out. The Administrator was notified of Immediate Jeopardy on 04/03/25 at 4:40 PM. The facility implemented 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 recognize the severity of a change in condition for Resident #1 who sustained a fall from bed on 03/25/25 at approximately 2:00 PM. Resident #1 had a past medical history significant for history of stroke, recent pulmonary embolism, recent COVID-19, atrial fibrillation, and traumatic brain injury, who was prescribed Apixaban (anticoagulant) 5 milligram (mg) via gastrostomy tube twice a day for atrial fibrillation. In the morning hours of 03/26/25 at approximately 8:30 AM, Resident #1 was noted by staff with a change in condition as described by staff as having a decreased level of consciousness, not easily aroused, lethargic slow to respond, much different than his baseline. On 3/26/25 at approximately 4:50 PM the Unit Manager notified the Physician Assistant (PA), and orders obtained for blood work, urinalysis, and Chest Xray. Vital signs and neurological checks remained stable throughout the night. On 03/27/25 at approximately 9:58 AM Resident #1 became non-responsive and Emergency Medical Services (EMS) was called by the licensed nurse and family as ordered by the Physician Assistant. Resident #1 was diagnosed with sepsis and a left subdural hematoma and transferred and placed on Hospice services where he passed away on 03/31/25. On 4/3/25, the DON and Nurse Consultant completed an audit of residents on anticoagulant therapy who have experienced a fall within the last 72 hours to ensure timely recognition and response occurred if the resident experienced a change in condition. Two residents were identified and no concerns identified. On 4/4/2025, the DON and Unit Managers reviewed all residents with changes in condition in 24 hours to ensure immediate notification to the Medical Provider occurred. Six residents were identified and assessed, and the Medical Provider was notified. Specify the action 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 complete. On 4/3/25, the Administrator, Director of Nursing (DON), [NAME] President of Risk and Quality Assurance (VPRQA), Nurse Consultant, PA and Medical Director held an Ad Hoc QAPI meeting to discuss the incident to determine root cause analysis of the facility's failure to recognize the severity of a change in condition for Resident #1. Root cause analysis determined that the facility failed to have effective systems in place and monitoring measures to ensure timely response and notification is made to a medical provider for proper intervention up to and including transfer to a higher level of care. On 4/3/2025, the Director of Risk and Quality Assurance, Nurse Consultant, Director of Nursing, Administrator, and Physician Assistant reviewed the change in condition and fall policy. No changes were made. Effective 4/3/25, the Director of Nursing, Nurse Consultant, and Nursing Administration initiated education with all facility and contracted licensed nurses and Certified Nursing Assistants on the facility Notification of Changes in Condition and Fall Prevention policies. Education includes recognizing the severity of a change in condition status post fall to include post fall assessment changes for 72 hours, changes in level of consciousness, and altered mental status away from baseline. Upon licensed nurse's assessment recognizing the severity of the residents change in condition away from baseline post fall, the Medical Provider will be immediately n[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, news article review, North Carolina Board of Nursing Investigator, staff, power of attorney, and detective interviews the facility failed to assure that a resident's (Resident #156) property was safeguarded, and that staff did not misappropriate the resident's property. Nurse #1 was found to have in her possession Resident #156's driver's license, social security card, and debit card without his permission or knowledge and was alleged to have made unauthorized charges on the debit card which included reoccurring charges to a taxi services, online shopping services, and a gas station in a nearby county (Gastonia). The unauthorized charges started in February 2023 and recurred until the card was cancelled in [DATE] for an undisclosed amount of money. The reasonable person concept was applied for this deficient practice in that a reasonable person would have the high likelihood of being upset about the loss of financial resources, the invasion into one's personal financial status, and increased anxiety over the risk of identity theft. The deficient practice was discovered for 1 of 3 residents reviewed for abuse, neglect, and misappropriation of resident property. Immediate Jeopardy began on [DATE] when Nurse #1 first worked in the facility and likely misappropriated Resident #156's documents, including his driver's license, social security card, and bank debit card. Immediate jeopardy was removed on [DATE] when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at lower scope and severity of D (no actual harm with more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place and the completion of staff education. The findings included: Resident #156 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (chronic degenerative disorder), heart disease, and congestive heart failure. Resident #156 expired on [DATE]. Review of Resident #156's medical record revealed no record of inventory of his personal belongings that he had in his possession upon admission to the facility, or during any part of his stay. Further review of Resident #156's history of stay revealed that he had been hospitalized on [DATE] and readmitted to the facility on [DATE] and remained in the facility until [DATE]. He was again hospitalized on [DATE] and readmitted on [DATE] and remained in the facility until his passing on [DATE]. A quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #156 was cognitively intact and had no behaviors. A facility document titled Timecard Detail Report for [DATE]-[DATE] indicated that Nurse #1 an agency nurse clocked into the facility on [DATE] at 7:30 PM and clocked out at 7:07 AM and on [DATE] she had clocked in at 11:07 PM and clocked out at 7:07 AM. Review of the Iredell Free News website article titled [County Sherriff's Office] ICSO Felony Arrests [NAME] 12-18 [2023] revealed Nurse #1, on [DATE], was charged with seven counts of taking a financial transaction card, possession of methamphetamine, maintaining a dwelling or vehicle for sale or use of controlled substances and a misdemeanor drug offense. An email dated [DATE] from Detective #1 to the Administrator read, as discussed, the detective was emailing about the incident with Resident #156 and the theft of his North Carolina Driver's License, his social security card, and his bank debit card. The detective spoke with Resident #156 via phone, and the resident advised he did not report the documents stolen because with his declining health and issue with memory he thought maybe he just lost it or hid it and could not remember where he put it. Resident #156 further stated he closed the debit card once he realized it was gone and did not worry about the license or social security card because he was in the nursing home, and he did not need it at the time. The detective explained when Nurse #1 was stopped by a police officer, she was found to have both the driver's license and social security card for Resident #156 in her possession along with multiple other bank cards for other elderly people. Nurse #1 was charged for other cards which were in her possession. During the investigation it was discovered all of the alleged victims had been in and out of hospitals, have had to have home health care, and the detective had been attempting to identify how all of the patients (alleged victims) may have been linked (to Nurse #1) and that was how she found Resident #156 and the facility. Resident #156's license and card were in the evidence locker at the county sheriff's office and would be held until after Nurse #1's trial. The items could be picked up when the trial was complete. (This could be several years.) Detective #1 was interviewed via phone on [DATE] at 8:41 AM and explained Nurse #1 was stopped by a patrol officer in the county. The detective said the officer was able to charge Nurse #1 on the spot because she had charges of intercepting a mail truck and was alleged to have stole something from an elderly person that lived nearby that she claimed to be their caretaker. Detective #1 stated after the patrol officer charged Nurse #1, she had received the case because Nurse #1 had so many stolen cards in her possession. She explained she was able to locate the victims and had forwarded cases to surrounding counties where Nurse #1 had stolen cards from so the individual counties could press charges against Nurse #1. Detective #1 added in addition to intercepting the mail truck, Nurse #1 was also the subject of a medication theft of another nursing home in another county. Nurse #1 was working through an agency and was accepting jobs in numerous other counties and had last resided in [NAME]. Detective #1 stated she located a phone number for Resident #156 and talked to him via phone and as far as he knew no money had been taken and that was why the resident had not reported it to the staff. She explained to Resident #156 his cards were in the safe at the county courthouse. Detective #1 stated she had worked diligently to report Nurse #1 to the board of nursing because I did not want her near old people. Detective #1 also confirmed that Nurse #1 was not in the Iredell County jail at the time of interview. Resident #156's power of attorney (POA) was interviewed via phone on [DATE] at 2:46 PM who stated Resident #156 had told him his driver's license, social security card, and debit card were missing, and he needed to go the bank to get it replaced either in late [DATE] or early [DATE]. He further explained Resident #156 did not drive at the time, and he transported Resident #156 wherever he needed to go. When they got to the bank, they went over the charges on his account that Resident #156 was not aware of and did not authorize which were reoccurring charges to a taxi services, online shopping services, and a gas station in nearby county (Gastonia) and the charges started in February 2023 and reoccurred until the card was cancelled in April2023. Resident #156 explained to the bank he just wanted a replacement card and not to close the account because his mind was failing, and he did not want to learn new account numbers. The POA stated the bank replaced Resident #156's debit card and he gave it to the POA to keep in his possession so this would not happen again. The POA stated the bank did an investigation and did replace some of the money that had been taken. He added no one from the facility had contacted him regarding the incident and stated Resident #156 was very sick and it was easy for someone to come along and take something. The POA stated they had not reported the missing documents, or the alleged fraudulent charges, to the facility because they did not know if the fraudulent charges were made by a facility employee. An attempt to speak to the agency that Nurse #1 worked for was attempted on [DATE] at 10:30 AM. An attempt to speak to Nurse #1 was made on [DATE] via phone at 8:34 AM and again on [DATE] via phone at 5:31 PM and was unsuccessful. The North Carolina Board of Nursing Investigator was interviewed via phone on [DATE] at 8:22 AM. She stated that they had received a public complaint regarding Nurse #1 on [DATE] alleging the theft of credit cards then on [DATE] Detective #1 called and informed them that Nurse #1 had been arrested for being in possession of illegal drugs and stolen credit cards from various other towns. The investigator stated that she called the facility and spoke to Former DON #1 who reported that Nurse #1 had only worked 2 shifts at the facility. The investigator further explained that Nurse #1 had gone to trial and was convicted of 2 felonies. She also explained that the Board of Nursing recommendation was to suspend Nurse #1's nursing license. However, they could not do that without her acknowledgment and thus far she has made no acknowledgement of their attempts to notify Nurse #1 of the action. The Investigator added that they would take it to a hearing and after the hearing they could formally suspend Nurse #1's nursing licenses. There was no date scheduled for the hearing, but the Investigator stated she hoped by the spring of 2024 they would have date. An attempt to interview Former DON #1 was made on [DATE] at 9:25 AM and again at 5:29 PM without success. The Administrator was interviewed on [DATE] at 11:59 AM. She stated she had received a call from a local detective letting her know Nurse #1 had been pulled over and had in her possession credit cards, driver's license, and social security cards from several elderly folks including one of our residents (Resident #156) on [DATE]. She explained they ran an employee report from the previous 60 days in the facility and Nurse #1 had not worked in the facility, and it was reported it to the State Survey agency and to the North Carolina Board of Nursing. The Administrator confirmed they had not spoken to any of the other residents but did some education on misappropriation and stated, there is no way to safeguard his own personal belongings he was alert and oriented. The Administrator was notified of Immediate Jeopardy on [DATE] at 1:15 PM. The facility provided the following credible allegation of immediate jeopardy removal: o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to assure that a resident's property was safeguarded, and that staff did not misappropriate the resident's property (driver's license, social security card, and debit card) without the resident's permission or knowledge. On [DATE], the facility Administrator was notified by a Detective from the Iredell County Sheriff's office of an ongoing investigation concerning Nurse #1 who was stopped on a traffic violation and was found to have in her possession several people's bank cards to include Resident #156's driver's license, social security card, and bank card. Resident #156 was interviewed by the Detective and again by the Director of Nursing (DON) on [DATE] which revealed that the resident was aware that the identified items were missing but he just thought that he lost or misplaced the items. Resident #156 reported to the Detective and the DON that he had cancelled the bank card and was not worried about the license or the social security card. Resident #156 also reported to DON that he had not reported the missing items to the staff. Review of the resident's medical record revealed that Resident #156 was his own responsible party and had a BIMs of 15 (Highest). Review of the admission agreement, section 9 regarding Personal Possessions, indicated that Resident #156 was aware that he could secure his personal property with the facility but preferred to secure his own personal property. In addition, the Detective revealed that all of the identified people who had missing possessions recently had home health care, or a hospital stay. Review of the medical records revealed that Resident #156 was recently in the hospital on [DATE] - [DATE]. Resident #156 was unsure if he might have lost his wallet during his recent hospitalization The Administrator reviewed the resident grievances and there were no additional concerns noted of the current and/or discharged residents related to missing possessions including social security cards, driver's licenses and debit cards. No other resident property was identified by the Detective that belonged to current and/or former facility residents. Review of the findings revealed, however, that the facility failed to provide ongoing education/reminders to all facility staff, interviewable residents and non interviewable resident responsible parties of the facility options to secure resident property. These include lock boxes, the facility safe and utilizing the resident trust system (banking). On [DATE], education was initiated related to Abuse and Neglect to include misappropriation of resident property and Preventing Elder Abuse by the Director of Nursing and the Unit Managers that included all facility staff (licensed nurses, certified nursing assistants, administrative staff, social service, business office, housekeeping/laundry, dietary, therapy, agency staff, weekend staff and prn staff). All current residents who prefer not to lock/secure their valuable personal possessions are at risk as a result of this deficient practice. On [DATE] an audit was initiated by the Unit Managers to identify current residents who prefer not to lock/secure their valuable personal items. The identified residents that preferred not to lock/secure their belongings were made aware that lock boxes and/or resident trust fund accounts were available. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete The administrator and the Director of Nursing were educated on [DATE] by the Chief Nursing Officer on misappropriation of resident possessions to include the facility options to secure resident possessions such as lock boxes and resident trust accounts. Starting [DATE], the education will be initiated by the Staff Development Coordinator and the Unit Managers to all staff, interviewable residents, and non interviewable resident families. The Administrator will be starting to distribute and mail the letters by [DATE] to the residents and/or resident's responsible parties that include education related to resident lock boxes and resident trust accounts to aid in safeguarding resident possessions. Starting [DATE], the Staff Development Coordinator (SDC) will complete education on misappropriation of resident property which includes facility options to secure resident possessions such as lock boxes and resident trust accounts to the facility staff which includes licensed nurses, certified nursing assistants (CNA), certified medication aides (CMA), dietary, housekeeping/laundry, therapy staff, maintenance, administrative staff, business office, social services, weekend staff, agency and prn staff. Starting [DATE], the Staff Development Coordinator (SDC) and the Director of Nursing will be responsible for ensuring all staff to include licensed nurses, housekeeping/ laundry, dietary, administrative, therapy, social services, business office, weekend staff, CNA, and CMA receive the Abuse and Neglect education to include misappropriation of resident funds that include facility options to secure resident possessions. Staff including new hires and prn staff will not be allowed to work without completing this education. The education will be ongoing to include new hires and prn staff. The SDC will be responsible for ensuring the ongoing education is completed. Effective [DATE], the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. A credible allegation of immediate jeopardy removal was conducted on [DATE]. Review of all alert and oriented resident interviews regarding any misappropriation of property were reviewed and education provided to resident, staff, and family was reviewed explaining what misappropriation was, who to report it to, and ways the facility had to safeguard the resident's belongings and personal effects. Interviews with staff across all departments revealed that they had received the education on misappropriation and were able to verbalize what misappropriation was, who to report to, and way that the facility had in place to store resident's belongings. The immediate jeopardy removal date of [DATE] was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of an Initial Allegation Report from the facility to the Department of Health and Human Services (DHHS) for an allegation of resident abuse dated 10/12/22 revealed the facility was made aware of an allegation of resident-to-resident abuse on 10/11/22 when Resident #28 reported Resident #46 touched her without her permission. Review of the facility's 5 working day read in part, the investigation reveal[ed] that Resident #[28] reported that Resident #[46] touched her inappropriately on her breast. Resident #[46] was interviewed and admitted to touching Resident #[28] and reported to social services that he would no do this again. Resident #[28] was placed on 1 to 1 monitoring by staff with a new room change. Resident #[28] continues to be observed for changes in mood and behavior with none observed. Both residents' care plans were reviewed and revised as needed. Resident #28 was admitted to the facility on [DATE] with diagnoses that included vascular dementia, dementia without behaviors, anxiety disorder, and major depressive disorder. Review of Resident #28's quarterly Minimum Data Set, dated [DATE] which was prior to the alleged incident revealed her to be cognitively impaired with no psychosis, behaviors, rejection of care, or instances of wandering. Resident #46 was admitted to the facility on [DATE] with diagnoses that included vascular dementia with mood disturbances, anxiety disorder, and history of stroke. Review of Resident #46's quarterly Minimum Data Set assessment dated [DATE] which was prior to the alleged incident revealed him to be cognitively impaired with no psychosis, behaviors, rejection of care, or instances of wandering. Review of the facility's collective investigations of facility reportable incidents revealed this allegation to not have any additional investigation provided other than the 24 hour and 5 working days reports. There were no written statements from staff, or the residents involved. There were also no skin checks or other information regarding the complete and thorough investigation of the allegation. Review of Resident #46's progress notes revealed a note dated 10/11/22 at 1:05 PM, written by Social Worker #1 that read, Social Services was made aware of resident inappropriate touching behavior towards a resident. Spoke with resident, nurse, and family. Resident recognized and admit[ted] to inappropriate behavior and informed social services that this behavior will not happen again. [Medical Director] mad aware. An interview with Social Worker #1 on 01/25/24 at 2:34 PM revealed she had no recollection of the event. After reviewing her note dated 10/11/22, she reported Resident #46 had inappropriately touched another resident. She spoke with Resident #46 about the incident and stated Resident #46 reported he recognized it was inappropriate and would not do it again. Social Worker #1 stated she did not know what the inappropriate touching behavior was and stated she could not define what type of behavior would cause her document inappropriate touching behavior. Social Worker #1 reported having no further information than what was in her progress note. An interview with Resident #28 on 01/25/24 at 9:16 AM revealed she had no recollection of the event and stated she felt safe. An interview with Resident #46 on 01/24/24 at 2:37 PM revealed he had no recollection of the event. He stated he did not know Resident #28 and stated he had never touched anyone inappropriately. An interview with DON #3, who was the Director of Nursing at the time the incident occurred, was attempted by phone on 01/25/24 at 4:47 PM, but unsuccessful. An interview with Administrator #3 who was the Administrator at the time of the incident, was completed on 01/25/24 at 5:01 PM. It was revealed that he had no other information to provide to the investigation other than what was in the file at the facility. He stated if there were any written statements or skin checks, they would have been in the folder with the report given to the Division of Health Service Regulation. Administrator #3 also reported he would have sent his complete investigation, which included written statements with his 5 working day report. An interview Administrator #1 on 01/26/24 at 4:14 PM, she reported all facility reportable incidents should have a thorough and complete investigation. She stated the incident between Resident #28 and Resident #46 happened before she arrived and she could not speak to why the investigation was not thorough and complete. Based on record review, staff, news article review, North Carolina Board of Nursing Investigator, power of attorney, and detective interviews the facility failed to follow their Abuse, Neglect, and Exploitation policy by failing to immediately initiate protective measures to safeguard residents from misappropriation of property and complete a thorough investigation when they received a report from local law enforcement of misappropriation of resident property. On 05/18/23 the facility received a call from Detective #1 informing them that Nurse #1 had been involved in a traffic stop and was in possession of Resident #156's driver's license, social security card, and debit card. There was a high likelihood that Nurse #1 misappropriated the property of other residents leading to the loss of financial resources for residents who resided at the facility at the time of Nurse #1's employment. The facility also failed to thoroughly investigate an allegation of abuse (Resident #28). This deficient practice was for 2 of 3 residents reviewed for allegations of abuse, neglect, and misappropriation of property. Immediate jeopardy began on 05/18/23 when the facility was made aware by law enforcement that Nurse #1 was found to be in possession of Resident #156's driver's license, social security card, and debit card and failed to immediately implement measures to protect other residents from misappropriation of property. Immediate jeopardy was removed on 01/30/24 when the facility provided and 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 more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place and the completion of staff education. Example #2 is being cited at a lower scope and severity of D (no actual harm with more than minimal harm that is not immediate jeopardy). The finding included: Review of a facility policy titled, Abuse, Neglect, and Exploitation revised on 10/22/23 read in part: Investigation of Alleged Abuse, Neglect, and Exploitation- an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. Written procedures for investigations included: identify staff responsible for the investigation, exercising caution in handling evidence that could be used in criminal investigation, investigating different types of alleged violations, identifying, and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Focusing the investigation on determining if abuse, neglect, exploitation, and/or misappropriation has occurred, the extent, and cause. Providing complete and thorough documentation of the investigation. Further review of the policy titled, Abuse, Neglect, and Exploitation revised on 10/22/23 read, Protection of Resident: the facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. 1. Review of an Initial Allegation Report from the facility to the Department of Health and Human Services (DHHS) for an allegation of misappropriation of property dated 05/18/23 read in part, Administrator received a call from Detective #1 indicating Nurse #1 had been stopped by police and Nurse #1 was in possession of Resident #156's social security card and driver's license. The report was signed by the Administrator. An email dated 05/18/23 from Detective #1 to the Administrator indicated when Nurse #1 was stopped by law enforcement she was found to have the driver's license and social security card for Resident #156 in her possession along with multiple other bank cards for other elderly people. She has been charged for other cards which were in her possession. Detective #1 was interviewed via phone on 01/25/24 at 8:41 AM and explained that Nurse #1 was stopped by a patrol officer in the county and the officer was able to charge Nurse #1 on the spot because she had charges of intercepting a mail truck and stole something from an elderly person that lived nearby that she claimed to be their caretaker. Detective #1 stated that after the patrol officer charged Nurse #1, she had received the case because she had so many stolen cards in her possession including those of Resident #156. She explained that she was able to locate the victims and had forwarded cases to surrounding counties that she had stolen cards from so the individual counties could press charges against Nurse #1. Detective #1 stated she had worked diligently to report Nurse #1 to the board of nursing because I did not want her near old people. An online news article from the county where the facility was located was posted on 5/21/23 and indicated on 5/16/23 Nurse #1 was charged with multiple offenses to include seven counts of taking a financial transaction card. Review of Investigation Report from the facility to DHHS dated 05/25/23 read in part, facility interviews with staff to include agency staff and resident interviews did not reveal any additional concerns. Nurse #1 was no longer being utilized in the facility. The police were still investigating and the agency that Nurse #1 was with was notified as well. Education to the staff on abuse, but not limited to misappropriation of property was conducted with the facility to include agency staff. The board of nursing will also be made aware of the incident. The report was signed by Former Director of Nursing (DON) #1. An attempt to interview Former DON #1 was made by phone on 01/26/24 at 9:25 AM and again at 5:29 PM without success. The investigation folder provided by the facility regarding the incident initially contained the Initial Report and the Investigation report. The facility later provided signature sheets of education completed on 05/18/23 and 05/19/23 regarding abuse, neglect, misappropriation of funds and a submission of complaint to the North Carolina Board of Nursing on 05/26/23 about Nurse #1. No other investigation items were provided from the facility including statements from other residents and/or staff. The North Carolina Board of Nursing Investigator was interviewed by phone on 01/30/24 at 8:22 AM. She stated that they had received a public complaint regarding Nurse #1 on 05/19/223 alleging the theft of credit cards then on 05/25/23 Detective #1 called and informed them that Nurse #1 had been arrested for being in possession of illegal drugs and stolen credit cards from various other towns. The investigator stated that she called the facility and spoke to Former DON #1 who reported that Nurse #1 had only worked 2 shifts at the facility. The investigator further explained that Nurse #1 had gone to trial and was convicted of 2 felonies. Resident #156's Power of Attorney (POA) was interviewed via phone on 01/25/24 at 2:46 PM who stated that Resident #156 had told him that his driver's license, social security care, and debit card were missing, and he needed to go the bank to get it replaced. The POA stated that he could not recall exactly when they went to the bank, but he guessed it was late March 2023 or early April 2023. When they got to the bank, they went over the charges on his account that Resident #156 was not aware of and did not authorize which were reoccurring charges to a taxi services, online shopping services, and a gas station in nearby county. He revealed the charges started in February 2023 and recurred until the card was cancelled in April. He added that no one from the facility had contacted him regarding the incident. An initial interview with the Administrator on 01/24/24 at 12:30 PM revealed that she had not done anything regarding the incident, and no investigation was completed on the incident with Nurse #1 because she had been told by her staff that she had never been their employee. A facility document titled Timecard Detail Report for 02/19/23 through 03/04/23 indicated that Nurse #1, an agency nurse, clocked into the facility on [DATE] at 7:30 PM and clocked out at 7:07 AM and on 02/24/23 she had clocked in at 11:07 PM and clocked out at 7:07 AM. A follow-up interview was conducted with the Administrator on 01/25/24 at 11:59 AM. She stated that she had received a call from a local detective (5/18/23) letting her know that Nurse #1 had been pulled over and had in her possession credit cards, driver's license, and social security from several elderly folks including one of the facility's residents (Resident #156). She explained that they ran an employee report from the previous 60 days in the facility and Nurse #1 had not worked in the facility, so they reported it to the State Survey agency and to the North Carolina Board of Nursing and that was it. The Administrator confirmed that they had not spoken to any of the other residents but did some education on misappropriation. When asked to explain why further investigation was not conducted the Administrator reported the facility believed Nurse #1 obtained Resident #156's driver's license, social security card, and debit card during a hospitalization he had in April of 2023. The Administrator was notified of Immediate Jeopardy on 01/25/24 at 1:15 PM. The facility provided the following credible allegation of immediate jeopardy removal: o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance The facility failed to fully implement their abuse policy when the facility failed to interview all staff, other residents, or family members when the facility received a credible allegation of misappropriation by Nurse #1 of Resident #156's driver's license, social security card, and debit card on 5/18/23. On 5/18/23, the facility Administrator was notified by a Detective from the Iredell County sheriff's office related to an ongoing investigation concerning Nurse #1 who was stopped on a traffic violation and was found to have in her possession several people's bank cards to include Resident #156's driver's license, social security card, and bank card. Resident #156 was interviewed by the Detective and again by the Director of Nursing (DON) on 5/18/23 which revealed that the resident was aware that the identified items were missing but he just thought that he lost or misplaced the items. Resident #156 reported to the Detective and the DON that he had cancelled the bank card and was not worried about the driver's license or the social security card. Resident #156 also reported to the DON on 5/18/23 that he had not reported the missing items to the staff. Review of the resident's medical record revealed that Resident #156 was his own responsible party and had a BIMS (Brief Interview Mental Status) of 15 (Highest). In addition, the Detective revealed that all of the identified people who had missing possessions recently had home health care or a hospital stay. Review of the medical records revealed that Resident #156 was recently in the hospital on 4/12/23 - 4/17/23. Resident #156 was unsure if he might have lost his wallet during his recent hospitalization. The Administrator reviewed the facility's grievance book on 5/18/23 which revealed no entries related to missing possessions to include social security cards, driver's licenses and debit cards for resident #156 or any current or former resident/responsible party. No other resident items were identified by the Detective that belonged to current and/or former facility residents. The Administrator was unable to identify any other staff except for Nurse #1. This incident appears to be an isolated incident. After review of the findings, it was determined that the facility failed to interview all the facility staff, the interviewable current residents and the non interviewable resident's responsible parties in the facility to ensure that no other residents may have been affected. On 5/18/23, education was initiated related to Abuse and Neglect to include misappropriation of resident funds and Preventing Elder Abuse by the Director of Nursing and the Unit Managers that included all facility staff which includes licensed nurses, certified nursing assistants, administrative staff, social service, business office, housekeeping/laundry, dietary, therapy, agency staff, weekend staff and prn staff. All current residents who prefer not to lock/secure their valuable personal items are at risk as a result of this deficient practice. On 1/26/24 an audit was initiated by the Unit Managers to identify current residents who prefer not to lock/secure their valuable personal items. o 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 Administrator and the Director of Nursing were educated on 1/26/24 by the Chief Nursing Officer related to ensuring that Abuse investigations include interviews of all staff, interviewable residents, and non-interviewable resident responsible parties when allegations of misappropriation of resident property occur and per facility policy provide complete and thorough records of documentation of the investigation. Starting 1/26/24, the Staff Development Coordinator (SDC) will complete interviews of the interviewable current residents to ensure resident concerns related to misappropriation of resident funds/ property to include driver's license, social security card, and debit cards have been identified and addressed. Starting 1/26/24, the Staff Development Coordinator, Unit Managers, and Nursing supervisors will complete interviews of the facility staff to include licensed nurses, certified nursing assistants (CNA), certified medication aides (CMA), dietary, housekeeping/laundry, therapy staff, maintenance, administrative staff, business office, social services, weekend staff, agency and prn staff to ensure all reports of resident Abuse/Neglect to include misappropriation of resident's property have been reported and follow up completed if needed. Starting 1/26/24, the Staff Development Coordinator (SDC) and the Director of Nursing will be responsible for ensuring all staff to include licensed nurses, housekeeping/ laundry, dietary, administrative, therapy, social services, business office, weekend staff, CNA, and CMA receive the Abuse and Neglect education to include misappropriation of a resident's property. The SDC and/or DON will complete this education for new hires and prn staff to ensure that they receive the training before they return to work. Effective 1/30/24, the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. A credible allegation of immediate jeopardy removal was conducted on 02/01/24. Education that was completed at the time the facility was made aware of the incident was reviewed along with the education that was currently used to educate all staff on abuse, neglect, and misappropriation. Interviews with residents and staff that were conducted were reviewed and no other significant findings were noted. The letter that was sent to families about misappropriation and the availability of lock boxes was also reviewed. Administrative interviews with the Administrator and Director of Nursing revealed that they had been educated by the Chief Nursing Officer on completing a thorough investigation and retaining proper documentation of the investigation per facility policy. Interviews across all departments revealed that they had been educated on abuse, neglect, and misappropriation of resident property. The staff were able to verbalize what misappropriation was, who to report to, and options the residents had to safeguard their belongings. The immediate jeopardy removal date of 01/30/24 was validated.