**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident, staff, Nurse Practitioner, (NP) Psychiatric NP and Medical Director interviews, the facility failed to assess a resident for self-administration of her enteral feedings (a method of delivering nutrition directly into the gastrointestinal tract, typically through a feeding tube, for individuals who cannot consume food orally) and to put effective interventions in place after Resident #13 was repeatedly observed by staff putting unidentified liquids in her gastronomy tube (g-tube [provides nutrition via a liquid formula delivered through a flexible tube that is surgically placed through the abdomen into the stomach]); rummaging through the trash for food /liquids; chewing and spitting out food items into the trash can; obtaining food as a prize for bingo; and disconnecting herself from her g-tube pump and removing the tube feeding formula bag during continuous feedings. Resident #13 had a diagnosis of vascular dementia and had an order for NPO (nothing by mouth) status due to dysphagia (difficulty swallowing). She was determined to have impaired insight and judgement by the Psychiatric NP. On 9/15/25 Resident #13 was observed by the surveyor administering to herself via bolus (administration of a limited volume of formula through a feeding tube over brief periods of time) the contents of a bottle labeled Jevity (tube feeding formula) dated 9/12/25 that contained a light tan milk-like liquid. The Medical Director indicated Resident #13 self-administering her tube feedings put Resident #13 at risk of serious injury/harm from aspiration (accidental inhalation of foreign substances, such as food, liquid, or air, into the lung which can lead to aspiration pneumonia), overfeeding, and infection. The deficient practice occurred for 1 of 1 resident reviewed for tube feeding Resident #13).Immediate Jeopardy began on 9/15/25 when Resident #13 was observed self-administering via her g-tube the contents of a bottle labeled Jevity dated 9/12/25 that contained a light tan milk-like liquid. Immediate Jeopardy was removed on 9/20/25 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective.The findings included:A hospital Discharge summary dated [DATE] stated Resident #13 had a g-tube placement in 2015 secondary to a stroke. The discharge summary stated Resident #13 was admitted on [DATE] due to a swelling in her left hand and upper left extremity. She was diagnosed with left internal jugular vein thrombosis (a medical condition where a blood clot forms in a blood vessel and stops blood flow) and pneumonia. Her g-tube dislodged on 3/6/25 and she was treated for hypoglycemia (a condition where the blood sugar drops below normal) which was resolved after initiation of tube feeds. She was discharged to the facility on 3/8/25.Resident #13 was admitted to the facility on [DATE] with diagnoses that included dysphagia (difficulty swallowing) and gastrostomy (opening of the stomach) for enteral feedings, malnutrition and vascular dementia. Review of Resident #13's face sheet indicated Resident #13 was her own responsible party.A physician's order dated 3/8/25 read Jevity 1.5 Cal administer continuously via pump at 60 milliliters (ml) per hour 24 hours per day or until total nutrient delivered.The manufacturer's instructions for Jevity indicated careful handling was required to prevent potential for microbial contamination. Microbial contamination can lead to serious harm and/or death. All medical foods, regardless of type of administration system, require careful handling because they can support microbial growth.A physician's order dated 3/9/25 read NPO.Resident #13's care plan had a focus of tube feeding dated 3/12/25 which stated, Resident had an enteral feeding tube to meet nutritional needs r/t (related to) an inability to consume sufficient calories and/or nutrients by mouth safely due to NPO status, Gastrostomy, Vascular Dementia, CVA, Hemiplegia Affecting Left Nondominant Side, Dysphagia, Cachexia, Severe Protein-Calorie Malnutrition. Interventions included flush tube with 15 milliliters of water before and after each medication pass, flush tube with 15 milliliters of water with each medication, flush tube with 15 milliliters of water between each medication, check placement of tube daily and before administering feedings and medications, check for clogs in tube daily and before administering feedings and medications, check for gastric residual volume prior to feeding or medication administration, and monitor labs.A physician's order dated 3/14/25 specified to flush tube with 50 ml of water every 4 hours during continuous tube feeding.A Nurse Practitioner (NP) progress note dated 4/4/25 stated it had been reported by nursing that Resident #13 has been taking herself off tube feeding and had a blood sugar of 44 on 4/3/25 due to it not running. She was also observed by the NP taking gauze, tape and supplies off a nursing cart. When asked to return the supplies she did so. Resident was further noted to have a cup of water which she stated was to flush her feeding tube. She did not have a syringe. Resident received education that she cannot swallow properly and so she needs to be more careful and not to attempt to eat or drink.A NP progress note dated 4/7/25 stated Resident #13 had lost weight since admission since she had been disconnecting her tube feeding at times. The note further stated Resident #13's blood sugars were less than 100 when not running her tube feeding continuously. There was no mention of educating the resident within the note. A nursing progress note written by Nurse #9 dated 4/10/25 stated Resident #13 repeatedly stopping tube feeding, turning off pump, disconnecting tube, clamping off tube frequently throughout shift. She was trying to be off continuous feed more than she is allowing it to infuse throughout the course of the shift. Resident #13 was also getting up in wheelchair and going into other residents' rooms. She also was digging through the trash can in the day room more than once. She asked to keep partially used feeding bottles and flush bag when replaced daily. It was explained that once it had been accessed for 24 hours bacterial growth begins. It was further explained that only unpunctured bottles are shelf stable. Resident #13 continued to be found getting the bottles out of the trash and trying to store them in her closet.Nurse #9 was not interviewed.A physician's order dated 4/11/25 read Jevity 1.5 Cal. Administer continuous via pump 65 ml per hour 24 hours per day. A progress note written by Nurse #10 dated 4/14/25 revealed Resident #13 continued to pause her continuous feeding. The nurse spoke to Resident #13 about stopping her feeding without informing the nurse. The note also stated Resident #13 had to go to a local emergency department to have her g-tube replaced due to giving herself a bath. When her glucose was checked her range was 58/34. Resident #13 was given sugar water, med pass with sugar and a glucose injection in her right arm. Blood glucose was rechecked and her level increased to 101. The note additionally stated when resident is not on her feeding her glucose level decreases and education was provided.Nurse #10 was not interviewed.A speech therapist note dated 4/22/25 indicated speech therapy services were not indicated at this time. There were no other speech therapy assessments completed.A progress note dated 5/8/25 written by the NP revealed Resident #13 had been hoarding anything she could find in the facility and had developed a large pile of things by her bed. She stated they were her things and did not want them touched. The note further revealed the NP placed an order for a psychiatric consult due to paranoia, hoarding and anxiety. A nursing progress note written by Nurse #11 dated 5/21/25 read that Resident #13 had turned off her tube feeding and unhooked her g-tube to go out of her room for short periods of time. Resident #13 was educated that she is on continuous feedings at this time and is at risk for weight loss. An initial psychiatric evaluation by the Psychiatric NP dated 5/22/25 revealed Resident #13 was diagnosed with hoarding disorder and other specified anxiety disorders. She was referred due to paranoia and signs of hoarding and anxiety. During this evaluation, Resident #13 was noted to have multiple snacks in her wheelchair. She also was noted to have excessive oral secretions and had a cup in her wheelchair to spit in. Resident #13 was noted to exhibit extreme hoarding tendencies, often collecting medical items and belongings from others in her room. She had no explanation for doing this. Resident #13 was assessed as having limited insight and poor judgement. Her cognition was intact. Resident #13 was ordered fluoxetine (antidepressant that treats depression, anxiety and other disorders) 20 mg (milligrams) each morning for anxiety and hoarding. Follow-up included psychiatric follow-up for management of anxiety, hoarding and adjustment on a regular basis.A physician's order dated 5/23/25 read every day and night shift until 5/25/25 administer continuous Jevity 1.5 Cal via pump at 70 ml per hour. Increase by 20 ml per hour every four hours, until goal rate of 130 ml per hour. On at 8:00 PM and off at 8:00 AM. A physician's order dated 5/24/25 instructed staff to flush tube with 120 milliliters of water before each feeding and flush tube with 120 milliliters of water after each feeding.A medical provider order was written on 5/24/25 for fluoxetine 20 milligrams (mg) via g-tube once a day for anxiety and hoarding behaviors.A physician's order dated 5/25/25 specified Jevity 1.5 Cal administer every day and night shift via pump at 130 ml per hour 12 hours per day. On at 8:00 PM and off at 8:00 AM. Review of Resident #13's medical record revealed no assessments or physician orders for self-administration of her tube feedings. A follow-up psychiatric evaluation by the Psychiatric NP dated 6/5/25 revealed Resident #13 exhibited fair insight and judgement during this session.Resident #13's care plan dated 7/2/25 reflected behaviors such as retrieving items out of trash cans to include food items; self-administering water, soda, and enteral feeding in her g-tube; and putting food items in her mouth, chewing them up, and spitting them out. Interventions included: educate and remind resident that according to her physician's orders she is NPO status and cannot eat or drink by mouth and she can only receive 100% nutrition/medications/water via G-tube via nurses and notify physician/family as indicated. Another focus of the care plan dated 7/2/25 was physical behaviors related to poor impulse control as well as going into other patients' rooms and taking items. Interventions included: remind resident she cannot go in other rooms and take things, psych (psychiatric) consult as needed, seek staff support, and Social Service visits. An additional focus of the care plan dated 7/18/25 stated Resident #13 had a decline in cognitive function or impaired thought processes related to dementia. Interventions included: observe for changes in cognitive status, allow resident to make choices about care and explain all interventions. Resident #13's significant change Minimum Data Set (MDS) assessment dated [DATE] revealed she was assessed as having moderate cognitive impairment with no behaviors. Her assessment reflected the use of a feeding tube for 51% or more of her total calories. The assessment reflected Resident #13 needed extensive assistance from one person-assist for eating. Resident #13 utilized a wheelchair for mobility.A follow-up psychiatric evaluation by the Psychiatric NP dated 7/22/25 revealed reports that Resident #13 continued to take items that do not belong to her and store them in her room along with her own belongings that she has piled in her room. Resident #13 was assessed as having limited insight and poor judgement.A progress note dated 7/29/25 written by the NP revealed she was informed by nursing staff Resident #13 continued to roll around the unit taking things and placing them in her room. A physician's order dated 8/9/25 specified Jevity 1.5 Cal to be administered at 120 ml per hour, 12 hours per day. On at 8:00 PM and off at 8:00 AM.A follow-up psychiatric evaluation by the Psychiatric NP dated 8/19/25 revealed Resident #13 continued to take items that did not belong to her and couldn't explain why. Cognitive behavioral strategies were attempted but she was not cognitively able to participate. Evaluation further read, although she is fairly alert and oriented on basic cognition, screening, her insight and judgement are so impaired that I do not feel that psychotherapy is ‘sticking' from visit to visit.During an interview with the Psychiatric Nurse Practitioner on 9/17/25 at 10:07 AM she reported Resident #13 had no insight or judgement about her behaviors and how they may be harmful. She reported when Resident #13 was questioned about going through the trash she stated she was looking for something to use to make crafts for her grandchildren.A nursing progress note written by Unit Manager #1 dated 9/3/35 stated Resident #13 was found outside engaged in self-feeding with a syringe via g-tube utilizing several bottles of sports drink and juice to flush the tube. Resident #13 was educated about physician orders, the feeding process and safety measures. A review of Resident #13's September 2025 MAR recorded a Jevity 1.5 enteral feeding was started at 8:00 PM on 9/12/2025 by Nurse #6. There was no allotted time and/or space on the MAR to document when the second bottle of Jevity 1.5 enteral feeding bottle was started for Resident #13. Therefore, there was no documentation on the MAR when Nurse #6 started a second bottle of Jevity 1.5 enteral feeding for Resident #13 on 9/12/2025.A phone interview was conducted with Nurse #7 on 9/16/25 at 10:03 AM who stated Resident #13's tube feeding stayed on the pole of the tube feeding pump after it was turned off in the morning on 9/13/2025. She stated either Resident #13 unhooked herself or the night shift nurse did this. Nurse #7 stated on 9/13/25 at 7:00 AM when she assumed care Resident #13 was unhooked from the feeding pump and dressed. She reported she had caught Resident #13 with water in a sports drink bottle approximately one month ago. She stated Resident #13 used the water to flush her tube. Nurse #7 stated she stopped Resident #13 from flushing her tube and disposed of the sports drink bottle. She indicated this occurred only once and she provided education to the resident. During an observation on 9/14/25 at 9:30 AM as the survey team was entering the facility, Resident #13 was observed in a wheelchair to the left of the facility's front entrance on the concrete sidewalk. She was observed holding her gastrostomy tube (g-tube) with her left hand and holding a milk-like substance in a clear bottle in her right hand. Resident #13 was observed on 9/15/25 at 7:10 AM self-propelling herself via wheelchair into the room leading outside into the smoking area. A black bag was observed on the back of the wheelchair with two bottles of clear liquid and a bottle with a milk-like substance with no labels on the bottles observed.A continuous observation occurred on 9/15/25 from 7:20 AM until 7:30 AM of Resident #13 in a wheelchair in the living room that had the door that led out to the smoking area. She was positioned between a drink machine and a table with three clear plastic bottles on the table. Two of the bottles were small, unlabeled and filled with a clear liquid and one labeled (could not read the label) medium sized bottle that contained a light tan milk-like liquid. Resident #13 was observed connecting a syringe (60 milliliters) to the g-tube opening and turning the lock on the g-tube. She held her g-tube in her left hand and reached for one of the bottles with clear liquid with her right hand and filled the syringe with the clear liquid substance. Resident #13 then filled the syringe full of the light tan milk-like liquid while holding the g-tube upright and allowed the liquid to infuse by gravity. She followed with another syringe full of light tan milk-like liquid and used the piston of the syringe to push the remainder of the liquid into the g-tube. Resident #13 then filled the syringe with the clear liquid from one of the clear unlabeled plastic bottles to infuse via gravity. She continued and filled the syringe with the light tan colored milk-like liquid to infuse via gravity into the g-tube followed by a second syringe full of light tan milk-like liquid. She was observed using the piston to push the last syringe of the milky liquid into the g-tube. Resident #13 then filled the syringe full of clear liquid to flow via gravity into the g-tube. She then pushed the lock of the g-tube and placed the bottles that had the clear liquid into the black bag on the back of her wheelchair. She returned the syringe and piston into a plastic bag. The syringe and piston was observed in a plastic bag that was not labeled with the date and placed it in the black bag on the back of her wheelchair. The medium sized bottle was observed on the table and was labeled Jevity 1.5 with a label dated 9/12/25 0500 (5:00 AM) 130 ml/hr and there was approximately 100 milliliters left in the bottle. There was no expiration date observed on the bottle of Jevity 1.5. Resident #13 stated it was her bottle, and it came from her house. While the surveyor was addressing Resident #13 about the bottle of milky liquid Unit Manager #3 walked in and asked if there was a problem. Unit Manager #3 was shown the label of the bottle and informed the surveyor was attempting to identify the liquid Resident #13 was observed inserting in her g-tube and the surveyor returned the bottle to the table.In an interview with Unit Manager #3 on 9/15/2025 at 8:07 pm, she stated she had started at the facility a couple weeks ago and Resident #13 was a resident that did her own thing at the facility self-propelling through the hallways. She stated she had never seen Resident #13 self-administer an enteral feeding through the g-tube and on the morning of 9/15/25 she only recalled seeing Resident #13 with the Jevity bottle and the milk-like liquid in the Jevity bottle on the table in the living room.An interview was conducted with Resident #13 on 9/16/25 at 11:00 AM. She reported she did not get her tube feeding on 9/14/25 because it was never hooked up. She reported she was hungry and that was the reason she was observed giving herself a tube feeding the previous morning (9/15/25). Resident #13 stated she gave herself 3 tube feedings daily and sometimes she received tube feeding continuously at night. She further stated she disconnected her tube feeding to go to smoke and to use the bathroom at night. She reported the tube feeding solution she was using on 9/15/25 came from her home. Resident #13 indicated she would dig in the trash cans in order to use the items she found to make crafts for her grandchildren. She was not aware of the amount of formula she was ordered and could not articulate dangers of administering more tube feeding than ordered. A telephone interview was conducted with Nurse #6 on 9/15/25 at 6:55 PM who reported she was familiar with Resident #13. She stated Resident #13 had turned her tube feeding off when not asleep. Nurse #6 stated Resident #13 often does what she wants to do. She reported that she hung a bottle of tube feeding solution at 5:00 AM on 9/12/25. Nurse #6 stated Resident #13 must have taken the bottle down from the pole for the bottle dated 9/12/25 to be in Resident #13's possession. She further stated staff had discussed among themselves to not leave trash in Resident #13's room. Nurse #6 stated some nights Resident #13 had been caught self-administering her tube feeding and she would redirect her. She further stated Resident #13 would steal tube feeding solution from the top of the medication carts. Nurse #6 stated she had witnessed Resident #13 taking another resident's tube feeding off the medication cart and retrieved it from Resident #13. She stated she had not witnessed Resident #13 going through trash cans. Nurse #6 indicated Resident #13 kept empty bottles in her room and filled the empty bottles with water from the bathroom sink. She stated she had never seen Resident #1 get bottles out of the trash, but suspected Resident #13 was going through the trash to obtain them. Nurse #6 reported she would stop Resident #13 from filling the empty bottles with water. On 9/15/25 at 8:45 am a 1000 milliliter bottle of Jevity 1.5 with 1000 milliliters observed hanging on the pump for continuous feedings in Resident #13's room. A syringe packet was observed which was dated 9/15/25, the Jevity 1.5 bottle was labeled 9/14/25 2000 (8:00 PM) and a water bag was dated 9/13/25 0500 (5:00 AM). The tip of the tubing connected to the tube feeding formula and water was observed hanging downward from the pump with no end cover. When the tube feeding pump was turned on the settings were observed cleared. There was no flush or tube feeding infusion rate set on the pump. Resident #13 was not present in the room at the time of the observation.Review of Resident #13's September 2025 Medication Administration Record (MAR) revealed the 9/14/25 feeding was signed off at 8:00 PM by Nurse #1. The order specified for Jevity 1.5 Cal to be administered every day and night shift continuous via pump at 130 milliliters per hour. 12 hours per day (On at 8:00 PM and off at 8:00 AM). A telephone interview was conducted with Nurse #1 on 9/15/25 at 6:36 PM who stated 9/14/25 was her first time working with Resident #13. She reported that she worked from 7:00 PM to 7:00 AM on 9/14/25. She stated she was told in report by Nurse #7 that Resident #13 administered her own tube feeding. When Nurse #1 was asked if Resident #13 self-administered enteral feedings through the g-tube, Nurse #1 stated she was unaware if Resident #13 had an order for self-administration for tube feeding. Nurse #1 stated she was told Resident #13 gets up out of bed and disconnects the tube feeding. She stated she was also told that Resident #13 turned the pump on and off when she got up and at night. Nurse #1 stated Resident #13 was already hooked up to her tube feeding when she entered the room on 9/14/25 at 8:00 PM. Nurse #1 could not explain why there was still 1000 ml in the tube feeding formula bottle on 9/15/25 at 8:45 am. An interview was conducted with Unit Manager #1 on 9/15/25 at 3:03 PM who stated she had removed the Jevity and water bottle from Resident #13's room that morning. She reported the Jevity bottle was dated 9/14/25 at 8:00 PM and the water flush was labeled 9/13/25. Unit Manager #1 stated she removed the items because she observed there was no cover on the tip of the tubing that was inserted into the g-tube. Unit Manager #1 stated she could not recall how much tube feeding formula was in the Jevity bottle when she removed the bottle from the pole on 9/15/2025. An interview and observation were conducted with Resident #13 on 9/15/25 at 8:53 AM who stated sometimes she administered her tube feeding and sometimes the facility did it. She further stated she administered her tube feedings when she lived at home. Resident #13 indicated it was not a continuous feeding. Resident #13 stated she was not able to swallow and spit her saliva into a cup. She was observed with a cup to spit her saliva in during the interview and observation.During an observation on 9/15/25 at 4:30 PM Resident #13 was observed leaning into the trash can at the front entrance of the facility. Unit Manager #2 was observed outside at this time. Resident #13 was not observed taking anything out of the trash can. An interview was conducted with Unit Manager #2 on 9/16/25 at 12:00 PM who stated she was outside on 9/15/25 but did not see Resident #13 take anything out of the trash can. She reported she did not see Resident #13 at the trash can. During an observation of Nurse #4 hanging Resident #13's the tube feeding on 9/15/25 at 8:20 PM, an empty Jevity 1.5 bottle enteral feeding bottle labeled 9/15/2025 2000 (8:00pm) at 50 ml/hr was observed in the trash can, a 12-ounce unopened soda can was observed on the floor and a small 8-ounce apple juice bottle that was 1/2 full of a cloudy yellow substance was observed on the bedside table. Resident #13 stated the drinks were not hers. Nurse #4 started the tube feeding after the tube feeding solution was hung. At the end of the observation Nurse #4 left the room without emptying the trash which contained an empty Jevity 1.5 bottle or remove the bottle of apple juice and the can of soda.During an interview with Nurse #4 at 9/15/25 at 8:45 pm, she stated she was unaware of Resident #13's behavior of rummaging through the trash; however, she stated she was aware of Resident #13's behaviors concerning turning her enteral feeding pump on and off throughout the night. Nurse #4 reported she turns the pump back on when she hears the pump beeping which means it is not running. During an interview with the Activities Director on 9/15/25 at 8:15 PM she reported she was advised by the Speech Therapist last week that Resident #13 could not swallow. She stated the Speech Therapist asked her to consider other prizes other than food for bingo. The Activities Director stated she was not aware that Resident #13 could not have any nutrition or fluids by mouth. She reported this information was never reported to her. The Activities Director stated Resident #13 had received food prizes for winning bingo beginning 7/15/25. She stated the prizes consisted of oatmeal cakes, toaster pastries, and peanut-butter and cheese crackers. The Activities Director stated she had never seen the resident consume any food or fluids. A telephone interview was conducted with Speech Therapist on 9/17/25 at 11:20 AM. She reported Resident #13 was unable to swallow. Speech Therapist #1 stated she spoke with the Activities Director the previous week about considering other prizes other than food for bingo. Resident #13 liked to go to bingo and should not be given food prizes. The Speech Therapist stated there is a risk of choking if Resident #13 attempted to eat food and there was a risk of aspiration as she was not able to swallow. The Speech Therapist stated she was not working with Resident #13 and Resident #13 had never been on her caseload because the resident was not able to swallow. She reported Resident #13 had come to her on several occasions and asked to be evaluated to eat again. She reported that she had told Resident #13 when she was able to swallow her saliva they could work on an evaluation to eat again. The Speech Therapist further stated she had given Resident #13 ice chips when Resident #13 would come to her and discuss receiving nutrition by mouth and Resident #13 would have to spit them out because she could not swallow. She stated she had been made aware by staff that Resident #13 had food in her room but didn't take any action. She reported she felt the food couldn't be removed because it was the resident's property. The Speech Therapist stated she did not document when she gave Resident #13 ice chips.A telephone interview was conducted with Registered Dietician (RD) #1 on 9/17/25 at 11:44 PM who stated speech therapy was working with Resident #13 on her ability to eat so she had not addressed changing her feedings. She stated she reviews resident charts from home and does not work within the facility. The ST stated the resident had never been on caseload. She reported she was unaware of any concerns related to Resident #13 eating, self-administration of tube feeding or going through trash cans. She stated she could not address concerns related to swallowing but there was potential for infection due to cross contamination from self-administration of tube feeding and using items from the trash in her tube feeding. A phone interview was conducted with Registered Dietician #2 on 9/17/25 at 12:03 PM. She stated she was not aware that Resident #13 had disconnected her tube feedings and a concern with Resident #13 disconnecting her tube feedings was not knowing how much tube feeding solution she was receiving. Registered Dietician #2 further stated it would be important to monitor Resident #13's blood sugar to ensure it does not drop. Registered Dietician #2 stated another concern would be fluid overload. She stated she was unsure if she had ever met Resident #13 because she is only in the facility one or two days a week. She reported Register Dietician #1 was responsible for reviewing charts and she (RD #2) attends care plan meetings and meets with new admissions.During an interview with the DON on 9/15/25 at 8:37 PM, she was informed Nurse #4 was observed exiting Resident #13's room and leaving an empty tube feeding bottle in the trash can, a half of a bottle of cloudy apple juice and a canned drink in Resident #13's room. The DON stated Resident #13 was care planned for retrieving items from the trash and reported Nurse #4 was an agency nurse and was not aware to remove the bottles and trash from Resident #13's room. DON stated she would educate Nurse #4 on Resident #13's care plan for behaviors. The DON stated staff, including agency staff, were educated on Resident #13's behaviors including rummaging through trash but could not provide specifics and did not provide documentation. During an interview with the Director of Nursing (DON) on 9/15/25 at 4:48 PM she reported Resident #13 could not swallow liquids or food. She reported she was aware that the resident would go through the trash, ask other residents for drinks and would disconnect her tube feeding at times. The DON was also aware Resident #13 would chew food items and spit them out. She reported the resident had been educated about the dangers of these behaviors by the staff members when they made the observation. The DON indicated that the resident had not been assessed for self-administration of her tube feeding. The DON stated she was not aware the Activities Director was giving food for bingo prizes to Resident #13. The DON acknowledged the dangers of all these behaviors and stated staff members would redirect Resident #13 when they observed the behaviors. An interview was conducted with the facility Nurse Practitioner (NP) on 9/17/25 at 12:25 PM. She reported it was dangerous for Resident #13 to self-administer her tube feedings. She stated Resident #13 had low blood sugars in the past from not receiving her tube feedings because she disconnected herself from the pump. NP further stated she was aware of Resident #13 self-administering her tube feeding and putting sports drink in her g-tube. She further stated she had seen Resident #13 in the trash and had witnessed her steal items such as gauze, gloves and briefs from the nurse's cart and she convinced Resident #13 to return the items. The NP stated the Registered Dietician needs to be aware of a deviation in the amount of tube feeding solution Resident #13 received in order to adjust tube feeding to ensure Resident #13 receives an adequate number of calories. She stated she was not aware the Registered Dietitian had not been informed about Resident #13 disconnecting her tube feedings and she had not discussed this with the physician. The NP stated that Resident #13 was going to do what she was going to do and that she did not have time to call the physician every time Resident #13 had behaviors. She stated she had talked with Resident #13 about the dangers of not getting her full amount of tube feeding but Resident #13 voiced compliance but then would continue the behaviors.During an interview with the Medical Director on 9/18/25 at 11:10 AM he stated Resident #13 self-administering her tube feedings put Resident #13 at risk of serious injury/harm from aspiration, overfeeding, and infection. He stated he was not made aware of this behavior or the behaviors such as digging in the trash and chewing/spitting out food. and had he been made aware he would have recommended 100% supervision during Resident #13's tube feedings.The Administrator was notified of Immediate[TRUNCATE

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews with staff, medical physician, responsible party, nurse practitioner and paramedic, the facility failed to ensure staff notified the physician when a resident (Resident # 13) was observed by nurse aides to be zonked, talking out of his head, not eating any of his supper meal and complaining of being tired in conjunction with a new rash observed on multiple areas of his body by multiple staff members. Additionally, one staff member referenced the rash as a death rash and thought the physician had already been notified. The resident was transferred to the hospital by emergency services when staff called 911 the following day. The resident was identified to be in septic shock and expired while hospitalized . (Sepsis occurs when an individual's immune system has a wide spread reaction to an infection which can lead to multi system organ failure and is considered life threatening. Septic shock is the last stage of sepsis and results in a low blood pressure). Additionally, the facility failed to notify the responsible party when Resident # 6 had a change in her narcotics. This was for two of five residents who were reviewed for change in condition and or treatment orders (Resident #13 and Resident #6). The findings included: Immediate jeopardy began on [DATE] when Resident # 13 was observed to have a rash, which was described by one staff member as a death rash, on multiple areas of his body in conjunction with a change in his mental status and eating habits without the physician being notified. Immediate jeopardy was removed on [DATE] 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 level of D to ensure education is completed and monitoring systems put in place are effective. The facility is being cited at a scope and severity level of D for example # 2 regarding Resident # 6. 1. Resident # 13 was admitted to the facility on [DATE]. Review of Resident # 13's [DATE] hospital discharge summary. The [DATE] hospital discharge summary listed the following diagnoses at the time of hospital discharge: proctocolitis (inflammation of the colon and rectum), failure to thrive, hyponatremia, emphysema, lung lesion, abdominal aortic aneurysm, aneurysm of the iliac artery, trochanteric avulsion fracture of the femur, external iliac artery occlusion, compression fracture of thoracic vertebra, compression fracture of lumbar vertebra with delayed healing, and urinary retention. He was discharged to the facility for rehabilitation on [DATE]. Review of physician orders revealed the resident was a full code. This order remained as an active order until the resident was discharged . Nurse # 5 had cared for Resident # 13 on [DATE] from 7:00 AM to 7:00 PM. Nurse # 5 was interviewed on [DATE] at 1:40 PM and again on [DATE] at 12:15 PM. Nurse # 5 reported the following information. The resident had been voiding and going to the bathroom on [DATE]. He did not recall any problems with the resident on his shift. Supper trays did not arrive till the end of the shift or after his shift, and he did not recall anyone mentioning to him that Resident #13 was having problems. He knew the resident was planning to go home. NA # 10 had cared for Resident # 13 on the 7:00 AM to 3:00 PM shift on [DATE]. NA # 10 was interviewed on [DATE] at 1:14 PM and reported the resident was fine on her [DATE] shift and he was excited because he was planning to go home. There were no nursing progress narrative notes for the date of [DATE] or any documentation the physician was consulted about changes in the resident's status. The next nursing narrative in the record was documented on [DATE] at 8:47 AM by Nurse # 5 who documented, Resident sent out to hospital via EMS on a stretcher. Resident presented with altered mental status only responding to name being called with eyes opening. Vitals: 74/41, 42, 97.7, 30 breaths/min (minutes), O2 (oxygen) saturation was undetectable with absent bilateral radial pulses. Rapid, shallow breathing with use of accessory muscles. Resident is full code, notified (provider) at approximately 0805 (8:05 AM) about residents condition and plan to send out to {name of hospital} O2 administered at 3 Liters and monitored with AED (automated external defibrillator) at bedside until EMS arrived at approximately 0815 (8:15 AM). ). ( A systolic blood pressure reading of less than 90 or a diastolic blood pressure reading of less than 60 is considered hypotension (low). A normal pulse is 60 to 100. Normal respirations are 12-20.) Nurse Aide (NA) # 8 cared for Resident # 13 from 3:00 PM to 11:00 PM on [DATE]. NA # 8 was interviewed on [DATE] at 12:44 PM and reported the following information. The resident had a rash on his body during her shift. It was on his arms, his back, his stomach, and top of his legs. She had never seen the rash on Resident # 13 before when she took care of him, and it was a new problem. He was also zonked like, not himself and did not want to eat. She was able to get him to drink some for supper but he ate nothing at all for his supper meal which was not like him. He usually would eat. The RN Supervisor (Nurse # 9) and Medication Aide (MA) # 1 came into the room to look at the rash that evening before Nurse #8 came on duty. One of them called his name trying to get him to respond. He did look up at that point and they asked him if he itched or was in pain. The resident was able to say no. She thought that someone put him on the physician's board to be seen. Near the end of the shift he livened up some. Medication Aide # 1 was interviewed on [DATE] at 1:44 PM and reported the following. She had been called by a Nurse Aide to look at Resident # 13 on the evening shift of [DATE]. He had a rash all over his body in various places. When she looked at the rash a thought process went through her head that it looked like what she had seen before as ringworm, but it was not raised. It was beyond her scope of practice to know what to do and therefore the Nursing Supervisor (Nurse # 9) was called. The resident wanted to be left alone. Nurse #9 was interviewed initially on [DATE] at 2:42 PM and reported she worked all over the facility as the evening shift (3:00 to 11:00 PM supervisor) and did not recall the resident well. She planned to review the record. Nurse #9 did report at that time that if there was something that needed to be communicated to a physician they could call and face time after business hours with a provider. If it was not deemed important, then it could be placed on a physician's communication board for a resident to be seen when they arrived at the facility the next time. Nurse # 9 was interviewed again on [DATE] at 12:41 PM and reported after looking at the resident's record she recalled the following information. On the evening of [DATE] the resident had a rash that appeared as red circles and white in the middle. To her it did not look like mottling ((discolored patches of skin which can result from a lack of blood flow to the skin). It was on his legs, arms and chest. The resident was sleepy. He did not carry on a conversation but he was able to answer questions. She did not know his baseline well. She did recall someone saying the rash was a death rash but she did not recall who said it or when it was said. She felt NA # 8 was a good Nurse Aide. She (Nurse #9) did not recall NA #8 mentioning that the resident did not eat or was zonked on the evening shift. According to Nurse #9 that did not mean that NA # 8 did not tell her. She (Nurse #9) could have been told and was not remembering. When she (Nurse #9) looked at Resident # 9's rash she did not take the resident's vital signs. She did not know if others had done so. She did not call the physician on her shift. On [DATE] at 2:39 AM Nurse # 8 documented a skilled evaluation which noted the following information. The resident's skin was warm and pink with brisk capillary refill. He was alert and oriented. His pulse registered 70 at 10:52 PM on [DATE], respirations16 at 10:52 PM on [DATE], oxygen level 100 % at 10:52 PM on [DATE]. The resident was documented to have brusing on his left forearm and brusing on his left wrist. There was no information in the nursing entry regarding any type of rash on the resident's body. Nurse # 8 had cared for Resident # 13 from 7 PM on [DATE] until 7:00 AM on [DATE]. Nurse # 8 was interviewed on [DATE] at 9:44 AM and reported the following information about caring for Resident # 13 on her shift. The resident had a rash on her shift which Nurse # 8 referred to as a death rash while being interviewed by the surveyor. When she arrived for work at 7 PM she thought the rash had already been reported to the physician and that the resident had already been checked by the physician. The rash was circular and showed up as redness on his skin. It appeared on his legs and his stomach. When interviewed by the surveyor what the plan was for the death rash, Nurse # 8 was not sure about that. She did not call the physician about further treatment orders concerning the death rash. She reported that the resident was stable and she checked his oxygen saturations which were okay. The Nurse Aide (Nurse Aide # 9) who had worked with him during the night shift had also said he was okay. Then at change of shift at 7:00 AM on [DATE] when she and another nurse (Nurse # 5), who had come into work at 7:00 AM, were counting controlled substances, a nurse aide approached them. She did not recall which nurse aide. The nurse aide let them know Resident # 13 was awake but would not say anything. She and Nurse # 5 went to the room. She grabbed a crash cart. The resident was still pink when they went into the room and they sent him out to the hospital. NA # 9 had cared for Resident # 13 from 11:00 PM on [DATE] until 7:00 AM on [DATE]. NA # 9 was interviewed on [DATE] at 10:00 AM. NA # 9 reported the following information. The resident was not doing too well. On rounds through the night, he would say he was okay but would complain of being tired and needing sleep. She checked on him each round and would encourage him to get some sleep. He also had a rash. She had never seen anything like it before and remembered asking herself, What kind of rash is this? It appeared as big splotches of red. The rash also appeared as squiggly, squiggly lines and it was on the resident's stomach, his buttocks and his scrotum. During her last rounds on night shift she asked him if he wanted water and he said nuh uh and nothing further. NA # 10 had cared for Resident # 13 on the 7:00 AM to 3:00 PM shift on [DATE]. NA # 10 was interviewed on [DATE] at 1:14 PM and reported the following information. She did rounds with the night shift NA (NA # 9) when she got to work. They looked in on Resident # 13 during that time. He was not talking at that point. NA #9 said he had not been like that during the night. According to NA # 10 at times the resident did not wake up and talk always and she continued the rounding with NA # 9. Around 8:00 AM she took Resident # 13 his breakfast tray and he would not wake up at that point and eat. She immediately went and got Nurse # 5. Nurse # 10 was assigned to care for Resident # 13 on the 7 AM to 7 PM shift of [DATE]. Nurse # 10 was interviewed on [DATE] at 11:03 AM and reported [DATE] was her second day working at the facility as an agency nurse. Nurse # 10 reported the following information. During report at 7:00 AM, Nurse # 8 had reported that Resident # 13 had a rash since the day before. That was all that was said about the rash. There was nothing said that would signify the resident's physician needed to be contacted right away. There was no mention that the rash was a death rash. After report, a Nurse Aide went to Nurse # 5. (Nurse # 5 was working on the hall, was a routine nurse at the facility, and knew the resident). The Nurse Aide let Nurse # 5 know that something was not right with Resident # 13. She and Nurse # 5 both went in the room. She (Nurse # 10) saw that the resident's breathing was wacky and his respirations were in the 40s. Nurse # 5, who routinely worked at the facility knew what to do and called 911. They (she and Nurse # 5) stayed with the resident until EMS arrived. The resident also had mottling on his legs, arms, and chest. Nurse # 8 had not left the facility while she and Nurse # 5 were waiting with the resident and she came into the room. Nurse # 10 reported that it was verified that what Resident # 8 had reported as a rash and had been seeing on the previous shift appeared as mottling to her. Nurse # 10 reported it was very evident the resident was mottled. During the interviews with Nurse # 5 on [DATE] at 1:40 M and again on [DATE] at 12:15 PM, Nurse # 5 reported the following information. He had already started his medication pass when a Nurse Aide came to get him. He did not recall which Nurse Aide. When he went to check the resident, the resident had mottling on all his extremities. The mottling was very noticeable. His breathing was rapid. The resident was not responding to a sternal rub. His vital signs were very low. He checked his code status and called 911. Review of EMS records revealed the following information. They were called at 8:05 AM on [DATE]. They were at the facility at 8:14 AM and at the resident's side at 8:17 AM. At 8:17 AM the paramedic documented the resident was nonresponsive. His blood pressure was 89/59, heart rate 121 and respirations 28. They were unable to get a good oxygen reading on him due to his fingers being cold. The paramedic documented in part, The nurse in the room stated that normally the patient is talkative is cussing them out however in the last hour he has become non-responsive and starting to breath fast. The patient does not normally wear O2. When I called the resident's name he would flutter his eyes but no other responses. He was very skinny and all of his ribs were showing. He was barrel chested. His skin was pink and looked like it began to model (mottle) on his legs, arms and the lower half of his stomach. The paramedic, who responded on [DATE], was interviewed on [DATE] at 4:04 PM and reported the following. Upon her assessment she found Resident # 13 to have mottling on his legs, arms, hands and feet. She described the mottling as blotchy skin, circular, reddish blue. There was no other rash that she saw on the resident's body. The only response he was making was that he would blink his eyes a little to his name. Otherwise he was nonresponsive. He was very thin and looked very sick to her. The hospital ER records, dated [DATE], noted the following information. The resident's skin was mottled upon arrival and he was nonresponsive. His systolic blood pressure was in the 70s and they were unable to obtain an oxygen level on him. Fluids, which had been started by EMS, were continued and lab work was done. The resident was intubated (a tube was placed down the resident's airway to facilitate breathing) soon after arrival (9:30 AM on [DATE]). Labs and diagnostic tests were performed. A central line (a long catheter for intravenous fluids which goes to a vein near an individual's heart) was placed at 11:40 AM. The resident was admitted to the Intensive Care Unit (ICU)for care. The resident's admitting ICU note indicated the resident's principle problem was septic shock which was secondary to pneumonia. The resident's chest x-ray showed multilobar bilateral pulmonary nodular opacity superimposed on emphysema, likely multilobar pneumonia although a component of neoplasm is not excluded. A review of the resident's hospital discharge summary included the following information. The resident expired at the hospital on [DATE]. While hospitalized his blood cultures had grown MRSA (Methicillin Resistant Staphylococcus Aureus). Sputum cultures had grown staph and pseudomonas. His urine specimen had grown staph and strep. By [DATE] he had minimal urine output and remained on full mechanical ventilation. Family was consulted by the hospital staff and the decision was made to make the resident comfort measure only. He was withdrawn from mechanical ventilation and his time of death was listed as 10:05 PM on [DATE]. The Director of Nursing was interviewed on [DATE] at 4:20 PM, [DATE] at 10:17 AM, and [DATE] at 1:25 PM and reported the following. It had not been called to her attention that the resident had a death rash on [DATE] or any problems related to his care before he was transferred out to the hospital. After hours the facility had a telehealth provider who could be called if needed for acute changes in condition. She had looked into the situation after the surveyor brought to her attention that the nurse was reporting the resident had a death rash on the evening prior to him being transferred to the hospital. She had found that no one had contacted the provider on [DATE] or on the morning of [DATE] before the resident was in an emergency situation. Resident # 13's medical physician, who served as the facility's medical director, was interviewed on [DATE] at 2:12 PM and again on [DATE] at 2:11 PM and reported the following. During the interview, the surveyor shared with the physician the interviews provided by the nursing staff as it related to how the resident's rash had been described in conjunction with what NA # 8 had observed on [DATE]. The medical director, reported the following. A rash by itself does not warrant immediate urgency or notification to the physician. A rash in conjunction with a change in mental status, change in vitals, any decline can be a red flag and can escalate the need to act. A death rash or mottling would indicate someone was in critical condition. If he had been called and told the resident had a rash on the evening of [DATE] as described by Nurse # 9, Nurse # 8, NA # 8, and NA # 9 along with information that the resident had been noted by NA #8 not to eat anything for supper, was talking out of his head, and zonked then he would have expected them to do a critical assessment of the resident to determine if fluids needed to be started and he would have had the resident sent out to the hospital. He had reviewed the record also and the vital signs noted in the facility record on [DATE] when EMS was summoned would have indicated the resident was in shock at the time EMS was called. Shock can happen quickly as sepsis occurs. The resident was very thin and his baseline indicated he was possibly immunocompromised and did not have the reserves a robust person to fight the infection and sepsis. Therefore, he did not feel the outcome would have been different for the resident if they had called the evening prior to [DATE]. The facility was notified of immediate jeopardy on [DATE] at 5:02 PM. The facility submitted the following immediate jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance F-580- Notification of Change in Condition: The facility failed to notify the Physician of a change of condition for Resident #13 in a timely manner and failed to have effective systems in place for Nursing staff to know what changes need to be reported and what needs to be reported immediately. The Director of Nurses and/or designee conducted a 30 day look back to review other residents identified with a change in condition to verify Physician and/or Provider was notified in a timely manner. This review was completed by the Assistant Director of Nursing (ADON) on [DATE] and consisted of a thorough review of change of condition assessments. A change of condition is identified as a significant change in the patient's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) Change of Condition assessments are located in our electronic medical record under the user defined assessments in Point Click Care. No additional concerns were identified. 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 Nurse Practice Educator (NPE) and/or designee re-educated Licensed Nurses on facility policy Change of Condition: Notification of and Physician/Advanced Practice provider (APP) Notification with emphasis on changes that require immediate physician notification and documentation by [DATE]. Changes requiring prompt notification include a significant change in resident physical, mental, or psychosocial status, an accident involving the resident that results in injury or the potential for requiring physician intervention, a need to alter treatment significantly, and a decision to transfer or discharge the resident. Additionally, re-education was completed with Certified Nursing Assistants on early identification of changes in condition and prompt notification of changes to the Licensed Nurse by [DATE]. The E-Interact Stop and Watch tool/alert was introduced as an early warning tool to be utilized by direct care givers as another mechanism to communicate changes in condition to the Licensed Nurse. The Director of Nursing and/or Nurse Practice Educator will track and verify that employees with scheduled time off, on leave of absence (FMLA), vacation, agency staff or PRN staff will be re-educated prior to returning to duty. New hires will be educated by the Nurse Practice Educator during the orientation process. Effective [DATE], the Director of Nursing and/or designee will review changes in condition by reviewing the change in condition assessments, and stop and watch alerts in the morning Clinical Meeting to verify prompt and/or immediate notification is communicated to the Physician and/or Provider. Removal of Immediate Jeopardy is [DATE]. Onsite validation of the immediate jeopardy removal plan was completed on [DATE]. Interviews confirmed that all staff were educated on significant changes in resident physical, mental, or psychosocial status, an accident involving the resident that results in injury or the potential for requiring physician intervention, a need to alter treatment significantly, and a decision to transfer or discharge the resident. Nurse aides indicated they would notify the nurse about any changes in condition of a resident. Additionally, re-education was completed with Certified Nursing Assistants on early identification of changes in condition and prompt notification of changes to the Licensed Nurse. Training was completed on the E-Interact Stop and Watch tool/alert and passed post testing required. The Stop and Watch tool/alert was successfully used for one resident who experienced shortness of breath. Verification was completed for all staff scheduled to work on [DATE] were re-educated prior to returning to duty. Review of documentation revealed 1 resident had a change in condition on [DATE] related to a fall; all facility policy and procedures were followed, MD/NP notified, no injury sustained requiring hospitalization. The immediate jeopardy removal date of [DATE] was validated. 2. Resident #6 had diagnoses of history of dementia, left femur fracture, chronic pain syndrome, and neuropathy. Documentation on the most recent quarterly Minimum Data Set assessment dated [DATE] revealed Resident #6 was coded as having severe cognitive impairment with scheduled pain medication and receiving opioid pain medication for frequent moderate pain. Documentation in the physician orders for Resident #6 revealed an order dated as initiated on [DATE] and discontinued on [DATE] for 10 milligrams (mg) of Oxycodone Hydrochloride (HCL) extended release (ER) to be administered as 1 tablet by mouth every 12 hours for pain. Documentation in the physician order for Resident #6 revealed an order dated as initiated on [DATE] for 15 milligrams of Morphine Sulfate ER to be administered as 1 tablet by mouth every 12 hours for pain. This order was renewed and continued [DATE] through [DATE] for Resident #6. Documentation in a Nurse Practitioner (NP) #1 progress note dated as initiated on [DATE] and signed [DATE] revealed Resident #6 had an order placed on [DATE] to discontinue the Oxycodone ER and change to Morphine ER for the treatment of chronic pain. An interview was conducted with NP #1 on [DATE] at 9:21 AM. NP #1 revealed the Responsible Party (RP) for Resident #6 was very involved her care and emailed and communicated with the facility on a regular basis her concerns and questions. NP #1 indicated a month prior to the change of Oxycodone ER to Morphine ER for Resident #6, the pharmacy let her know that the medication Oxycodone was requiring prior authorization, and the medication Oxycodone would no longer be covered under her insurance. NP #1 stated she ordered the equivalent of pain medication strength in Morphine for Resident #6 so that she could be kept comfortable. NP #1 stated she puts the orders into the electronic medical record, but it was the responsibility of the nursing staff to notify the RP for Resident #6 of the change in medication. NP #1 did not feel like the medication change had altered Resident #6 in any way other than perhaps making her feel more comfortable allowing her to get more rest. The RP for Resident #6 was interviewed on [DATE] at 1:11 PM. The RP for Resident #6 provided the following information. Resident #6 had a slow healing femur fracture and had been taking 10 mg of Oxycodone ER twice a day since November of 2023 with no problems. The RP noted a change in Resident #6 in [DATE] in that she was sleepier and not as alert. The RP was notified by the Director of Nursing (DON) on [DATE] via an email Resident #6 had a change in medication from 10 mg Oxycodone ER twice a day to 15 mg Morphine ER twice a day on [DATE]. The RP for Resident #6 was not notified of this change in medication until the DON sent her the email after the RP raised concerns. Nurse #2, the Unit Manager for 100 and 200 halls, was interviewed on [DATE] at 3:05 PM. Nurse #2 stated it was her responsibility to confirm orders written by NP #1 and to notify the RP of any changes in the medication to include discontinuation of a medication and new medication orders. Nurse #2 stated she may have overlooked informing the RP of Resident #6 of a medication order change. The DON was interviewed on [DATE] at 1:36 PM. The DON stated she received an email on [DATE] from the RP of Resident #6 inquiring about what medications she was on because Resident #6 seemed drowsier. The DON stated she at that point discovered the RP had not been notified of the medication change from Oxycodone to Morphine for Resident #6. The DON revealed this was an oversight on the part of Nurse #2 and one on one education was provided to Nurse #2. The DON confirmed the facility received notice from the pharmacy the medication Oxycodone was no longer covered by insurance, and they recommended the equivalent of the medication in Morphine ER twice a day for Resident #6. The DON confirmed the RP should be notified of all changes in medication to include dosage, form, and frequency when the change occurs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews with staff, physician, and paramedic, the facility failed to ensure staff recognized the need for communication amongst themselves and with the physician to ensure a resident received medical services to address an emergency situation (Resident # 13). Resident # 13 reportedly had a death rash in conjunction with nurse aides' observations of him being zonked, talking out of his head, not eating any of his supper meal and complaining of being tired. The morning following these observations, which were noted by staff members on the previous evening and night shift, the resident was found by the morning shift staff nurses to be without a detectable radial pulse, without a detectable oxygen level, mottled skin (discolored patches of skin which can result from a lack of blood flow to the skin), and not responding to a sternal rub. The resident required emergency transfer to the hospital where he was identified to be in septic shock. (Sepsis occurs when an individual's immune system has a wide spread reaction to an infection which can lead to multi system organ failure and is considered life threatening. Septic shock is the last stage of sepsis and results in a low blood pressure). The resident's blood, sputum, and urine cultures were positive for bacterial growth, and he expired on 9/9/24. The facility also failed to ensure that a resident (Resident # 2) who had sustained a head injury following a fall was assessed by a licensed nurse prior to the resident being moved. This was for two of five sampled residents reviewed for professional standards of practice (Resident #13 and Resident #2). The findings included: Immediate jeopardy began on 9/3/24 when Resident # 13 was observed to have a rash, which was described by one staff member as a death rash on multiple areas of his body in conjunction with a change in his mental status and eating habits observed by a nurse aide without staff taking action to ensure the resident received medical care. Immediate jeopardy was removed on 10/2/24 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity D to ensure education is completed and monitoring systems put in place are effective. Example # 2, which relates to Resident # 2, is cited at a scope and severity level of D. 1. Resident # 13 was admitted to the facility on [DATE]. Review of Resident # 13's 8/5/24 hospital discharge summary revealed prior to being admitted to the facility, the resident had been hospitalized from [DATE] to 8/5/24 after being found at home in poor living conditions by social services. The hospital discharge summary also contained the following information. Upon hospital admission on [DATE] the resident was found to be alert and oriented times three and reported to hospital staff he had not seen a primary physician in 20 years. The resident further reported he had been losing weight for the past year, had not been having a good appetite, and was falling more. He also reported he had been having some fecal incontinence over the past two to three days prior to going to the hospital on 8/1/24. The hospital summary also noted the resident was severely malnourished, weighed 88 pounds, was 5'10 in height, and had chronic alcoholism. A CT (computerized tomography) scan conducted while the resident was hospitalized showed he had left upper cavitary interstitial scaring and a soft tissue density and nodularity in the right posterior upper lobe. There was no discrete solid pulmonary nodules bilaterally and it was recommended that he have a repeat CT scan in three months to evaluate the scaring in his lungs. Also, according to the hospital discharge summary, the vertebrae compression fractures were mostly chronic, and the left trochanteric fracture was considered acute but of unknown origin date. The resident was deemed to need protected weight bearing for his leg and a walker upon discharge. The 8/5/24 hospital discharge summary listed the following diagnoses at the time of hospital discharge: proctocolitis (inflammation of the colon and rectum), failure to thrive, hyponatremia, emphysema, lung lesion, abdominal aortic aneurysm, aneurysm of the iliac artery, trochanteric avulsion fracture of the femur, external iliac artery occlusion, compression fracture of thoracic vertebra, compression fracture of lumbar vertebra with delayed healing, and urinary retention. He was discharged to the facility for rehabilitation on 8/5/24 with an indwelling catheter for his urinary retention. On 8/7/24 Resident # 13 was seen by Nurse Practitioner (NP) who noted the following information. The resident appeared cachetic (appearance of weight loss and muscle mass loss) and denied any pain or discomfort. He knew he was at the facility for rehabilitation and told the NP he was looking forward to getting stronger. He was aware he had declined before his recent hospitalization of 8/1/24 and reported there had been someone getting groceries for him while he had been at home, but the person did not stay with him all the time. He drank alcohol on a regular basis and did not eat much because he was not hungry. Resident # 13's admission MDS (Minimum Data Set Assessment, dated 8/12/24, coded the resident as cognitively intact and able to independently roll in bed. He was able to walk 10 feet with supervision and or touching. He was independently able to go from a lying in bed to a sitting position. He required partial to moderate assistance with his bathing and hygiene needs. Review of physician orders revealed the resident was a full code. This order remained in effect through the resident's discharge. On 8/14/24 Resident # 13 was seen again by the NP who noted the following information. He reported feeling well and was attending therapy which he knew would help him get stronger. He reported he had been eating and drinking better since admission. He was afebrile and his heart rate and blood pressure were stable. The Nurse Practitioner was interviewed on 10/2/24 at 3:52 PM and reported the following. She had never seen a resident with such a low BMI (body mass index) reading and felt that signified he was not a well person. The last time she assessed Resident # 13 was on 8/14/24 and he indicated he was trying to eat better and get stronger. It was only about two weeks into his stay and it was too soon to determine how he would progress. Weight records for Resident # 13 included in part the following information showing the resident gained weight since admission up until 8/28/24. 8/5/24-88 pounds 8/21/24-94 pounds 8/22/24-94.1 pounds 8/23/23-94 pounds 8/28/24-97.2 pounds On 8/30/24 at 5:44 PM Nurse # 4 documented Resident # 13 was complaining of his catheter feeling weird during the shift of 7AM to 7PM. He had been found to have some swelling in his groin which he reported had happened before. The catheter was deflated and removed, and the resident refused to have the catheter reinserted. He was voiding in a urinal. The physician had been contacted and reported to monitor the resident and send him out if he had pain or problems voiding. Following Nurse # 4's note, there was no order entered into the electronic record to discontinue the catheter. There were no nursing progress notes documenting voiding patterns or problems with the resident's groin. On 9/3/24 at 4:24 PM the social worker entered a progress note documenting that she made a phone call to the resident's first family contact to set up discharge for the resident and left a voice mail. The facility social worker was interviewed on 10/2/24 at 3:49 PM and reported the following information. The resident's insurance had changed and he was wanting to go home on 9/5/24. He had not completed his therapy goals yet and the facility felt it would be against medical advice. They wanted him to be completely independent before going home. He was walking with a walker but was unsteady. Prior to his hospitalization he had some home health services a few times per week. She had placed a phone call to the resident's family member on 9/3/24 to talk about the resident's choice to discharge on [DATE]. He had informed the facility staff that he was able to go home alone and no longer wanted to stay. There were no nursing progress narrative notes for the date of 9/3/24. Nurse # 5 had cared for Resident # 13 on 9/3/24 from 7:00 AM to 7:00 PM. Nurse # 5 was interviewed on 9/26/24 at 1:40 PM and again on 9/30/24 at 12:15 PM. Nurse # 5 reported the following information. The resident had been voiding and going to the bathroom on 9/3/24. He did not recall any problems with the resident on his shift. Supper trays did not arrive until the end of the shift or after his shift, and he did not recall anyone mentioning to him that Resident #13 was having problems. He knew the resident was planning to go home. NA # 10 had cared for Resident # 13 on the 7:00 AM to 3:00 PM shift on 9/3/24. NA # 10 was interviewed on 9/30/24 at 1:14 PM and reported the resident was fine on her 9/3/24 shift and he was excited because he was planning to go home. Physical Therapist # 1 was interviewed on 9/27/24 at 1:56 PM and reported the following information. The resident participated in therapy on 9/3/24 by doing leg kicks while sitting on the side of the bed. He had a chronic cough. She did not do any exercises that would aggravate his cough. He would do chin to chest posturing to compensate for any breathing problems and therefore he tolerated his rehab session okay. He was able to converse during his therapy session on 9/3/24. The resident was wearing a hospital gown and she could see his legs. There was no rash on his legs or discoloration during the therapy session. Nurse Aide (NA) # 8 cared for Resident # 13 from 3:00 PM to 11:00 PM on 9/3/24. NA # 8 was interviewed on 9/27/24 at 12:44 PM and reported the following information. The resident had a rash on his body during her shift. It was on his arms, his back, his stomach, and top of his legs. She had never seen the rash on Resident # 13 before when she took care of him, and it was a new problem. He was also zonked like, not himself and did not want to eat supper. She was able to get him to drink some for supper but he ate nothing at all for his supper meal which was not like him. He usually would eat. The RN Supervisor (Nurse # 9) and Medication Aide (MA) # 1 came into the room to look at the rash that evening before Nurse #8 came on duty. One of them called his name trying to get him to respond. He did look up at that point and they asked him if he itched or was in pain. The resident was able to say no. She thought that someone put him on the physician's board to be seen. Medication Aide # 1 was interviewed on 9/27/24 at 1:44 PM and reported the following. She had been called by a Nurse Aide on the evening of 9/3/24 to look at Resident # 13 on the evening shift of 9/3/24. He had a rash all over his body in various places. When she looked at the rash a thought process went through her head that it looked like what she had seen before as ringworm, but it was not raised. It was beyond her scope of practice to know what to do and therefore the Nursing Supervisor (Nurse # 9) was called. The resident wanted to be left alone. Nurse #9 was interviewed initially on 9/27/24 at 2:42 PM and reported she worked all over the facility as the evening shift (3:00 to 11:00 PM supervisor) and did not recall the resident well. She planned to review the record. Nurse #9 did report at that time that if there was something that needed to be communicated to a physician they could call and face time after business hours with a provider. If it was not deemed important, then it could be placed on a physician's communication board for a resident to be seen when they arrived at the facility the next time. Nurse # 9 was interviewed again on 9/30/24 at 12:41 PM and reported after looking at the resident's record she recalled the following information. On the evening of 9/3/24 the resident had a rash that appeared as red circles and white in the middle. To her it did not look like mottling. It was on his legs, arms and chest. The resident was sleepy. He did not carry on a conversation but he was able to answer questions. She did not know his baseline well. She did recall someone saying the rash was a death rash but she did not recall who said it or when it was said. She felt NA # 8 was a good Nurse Aide. She (Nurse #9) did not recall NA #8 mentioning that the resident did not eat or was zonked on the evening shift. According to Nurse #9 that did not mean that NA # 8 did not tell her. She (Nurse #9) could have been told and was not remembering. When she (Nurse #9) looked at Resident # 9's rash she did not take the resident's vital signs. She did not know if others had done so. She did not call the physician on her shift. On 9/4/24 at 2:39 AM Nurse # 8 documented a skilled evaluation which noted the following information. The resident's skin was warm and pink with brisk capillary refill. He was alert and oriented. His pulse registered 70 at 10:52 PM on 9/3/24, respiratons16 at 10:52 PM on 9/3/24, oxygen level 100 % at 10:52 PM on 9/3/24. The resident was documented to have brusing on his left forearm and brusing on his left wrist. The nurse also entered the resident's catheter was intact (which was incorrect given that the resident's catheter had been removed and never replaced). There was no information in the nursing entry regarding any type of rash on the resident's body. There was no blood pressure reading documented within this entry. Nurse # 8 had cared for Resident # 13 from 7 PM on 9/3/24 until 7:00 AM on 9/4/24. Nurse # 8 was interviewed on 9/27/24 at 9:44 AM and reported the following information about caring for Resident # 13 on her shift. The resident had a rash on her shift which Nurse # 8 referred to as a death rash while being interviewed by the surveyor. When she arrived for work at 7 PM she thought the rash had already been reported to the physician and that the resident had already been checked by the physician. The rash was circular and showed up as redness on his skin. It appeared on his legs and his stomach. When interviewed by the surveyor what the plan was for the death rash, Nurse # 8 was not sure about that. She knew he was very malnourished and they were supposed to try to get him to eat. He typically would eat things like oatmeal cakes and kool-aid rather than nutritious food. Through the night he was stable and she checked his oxygen saturations which were okay. The Nurse Aide who had worked with him during the night shift had also said he was okay. NA # 9 had cared for Resident # 13 from 11:00 PM on 9/3/24 until 7:00 AM on 9/4/24. NA # 9 was interviewed on 9/27/24 at 10:00 AM. NA # 9 reported the following information. The resident was not doing too well. On rounds through the night, he would say he was okay but would complain of being tired and needing sleep. She checked on him each round and would encourage him to get some sleep. He also had a rash. She had never seen anything like it before and remembered asking herself, What kind of rash is this? It appeared as big splotches of red. The rash also appeared as squiggly, squiggly lines and it was on the resident's stomach, his buttocks and his scrotum. During her last rounds on night shift she asked him if he wanted water and he said nuh uh and nothing further. NA # 10 had cared for Resident # 13 on the 7:00 AM to 3:00 PM shift on 9/4/24. NA # 10 was interviewed on 9/30/24 at 1:14 PM and reported the following information. She did rounds with the night shift NA (NA # 9) when she got to work. They looked in on Resident # 13 during that time. He was not talking at that point. NA #9 told NA #10 he had not been like that during the night. According to NA # 10 at times the resident did not wake up and talk always and she continued the rounding with NA # 9. Around 8:00 AM she took Resident # 13 his breakfast tray and he would not wake up at that point and eat. She immediately went and got Nurse # 5. Nurse # 10 was assigned to care for Resident # 13 on the 7 AM to 7 PM shift of 9/4/24. Nurse # 10 was interviewed on 9/30/24 at 11:03 AM and reported 9/4/24 was her second day working at the facility as an agency nurse. Nurse # 10 reported the following information. During report at 7:00 AM, Nurse # 8 had reported that Resident # 13 had a rash since the day before. That was all that was said about the rash. There was nothing said that would signify the resident was in need of urgent medical attention. There was no mention that the rash was a death rash. After report, a Nurse Aide went to Nurse # 5. (Nurse # 5 was working on the hall, was a routine nurse at the facility, and knew the resident). The Nurse Aide let Nurse # 5 know that something was not right with Resident # 13. She and Nurse # 5 both went in the room. She (Nurse # 10) saw that the resident's breathing was wacky and his respirations were in the 40s. She could not recall how responsive he was. Nurse # 5, who routinely worked at the facility knew what to do and called 911. They (she and Nurse # 5) stayed with the resident until EMS arrived. The resident also had mottling on his legs, arms, and chest. Nurse # 8 was still at the facility and had not gone home yet when Nurse # 5 and Nurse # 10 assessed Resident # 13. Nurse # 8 came into the room after Nurse # 10 and Nurse # 5 were in the room. Nurse # 10 reported what Nurse # 8 had reported as a rash on the previous shift appeared as mottling to her. Nurse # 10 reported it was very evident the resident was mottled. The next nursing narrative in the record was documented on 9/4/24 at 8:47 AM by Nurse # 5 who documented, Resident sent out to hospital via EMS on a stretcher. Resident presented with altered mental status only responding to name being called with eyes opening. Vitals: 74/41, 42, 97.7, 30 breaths/min (minutes), O2 (oxygen) saturation was undetectable with absent bilateral radial pulses. Rapid, shallow breathing with use of accessory muscles. Resident is full code, notified (provider) at approximately 0805 (8:05 AM) about residents condition and plan to send out to {name of hospital} O2 administered at 3 Liters and monitored with AED (automated external defibrillator) at bedside until EMS arrived at approximately 0815 (8:15 AM). ( A systolic blood pressure reading of less than 90 or a diastolic blood pressure reading of less than 60 is considered hypotension (low). A normal pulse is 60 to 100. Normal respirations are 12-20.) During the interview with Nurse # 8 on 9/27/24 at 9:44 AM the nurse reported the following information about the end of her shift which ended on 9/4/24 at 7:00 AM. At change of shift at 7:00 AM on 9/4/24 when she and another nurse (Nurse # 5), who had come into work at 7:00 AM, were counting controlled substances, a Nurse Aide approached them. She did not recall which Nurse Aide approached them. The Nurse Aide let them know Resident # 13 was awake but would not say anything. She and Nurse # 5 went to the room. She grabbed a crash cart. The resident was still pink when they went into the room and they sent him out to the hospital. During the interviews with Nurse # 5 on 9/26/24 at 1:40 PM and again on 9/30/24 at 12:15 PM, Nurse # 5 reported the following information. He was working the dayshift on 9/4/24. He had already started his medication pass when a Nurse Aide came to get him. He did not recall which Nurse Aide. When he went to check the resident, the resident had mottling on all his extremities. The mottling was very noticeable. His breathing was rapid. From the extent of the mottling, he (Nurse # 5) was not sure how it had gone undetected during the night shift. The night shift had reported that there was nothing wrong with the resident. The resident was not responding to a sternal rub. His vital signs were very low. He checked his code status and called 911. Nurse # 8 had her bag and was headed out the door. She did get the crash cart for him and Nurse # 10 before she left. He and Nurse # 10 stayed with the resident until EMS arrived. Night shift had reported to dayshift that the resident had been okay during the night. Review of EMS records revealed the following information. They were called at 8:05 AM on 9/4/24 (which was an hour and five minutes after the change of shift from night shift to day shift). They were at the facility at 8:14 AM and at the resident's side at 8:17 AM. At 8:17 AM the paramedic documented the resident was nonresponsive. His blood pressure was 89/59, heart rate 121 and respirations 28. They were unable to get a good oxygen reading on him due to his fingers being cold. The paramedic documented in part, The nurse in the room stated that normally the patient is talkative is cussing them out however in the last hour he has become non-responsive and starting to breath fast. The patient does not normally wear O2. When I called the resident's name he would flutter his eyes but no other responses. He was very skinny and all of his ribs were showing. He was barrel chested. His skin was pink and looked like it began to model (mottle) on his legs, arms and the lower half of his stomach. Patient was placed on 15L O2 NRB (oxygen by nonrebreather). The patients' vitals were obtained along with a BGL (blood glucose level). BGL was normal limits but the patient was hypotensive. I asked the patient staff at [name of facility} have they noticed anything new about the patient's daily life with them and they stated that he has not been wanting to eat or drink hardly and yesterday when they needed to place a {indwelling} catheter in him because he was not producing urine he refused. 12 lead (heart monitoring leads) placed on the patient and it read Afib. (a type of heart arrhythmia) 20 gauge IV (intravenous) obtained in the patient's right AC (anticubital). Patient was then moved with a drawsheet to the stretcher and secured. His respirations slowed down and he started to belly breath. Patient then taken to the ambulance where he was loaded and secured. Lactated Ringers (a type of intravenous fluid) started on the patient, wide open. The patient began snoring respirations again. Vitals obtained and his blood pressure went lower . According to the paramedic's report they transferred care to the hospital staff at 9:03 AM on 9/4/24. The paramedic, who responded on 9/4/24, was interviewed on 10/1/24 at 4:04 PM and reported the following. Upon her assessment she found Resident # 13 to have mottling on his legs, arms, hands and feet. She described the mottling as blotchy skin, circular, reddish blue. There was no other rash that she saw on the resident's body. The only response he was making was that he would blink his eyes a little to his name. Otherwise he was nonresponsive. He was very thin and looked very sick to her. The hospital ER records, dated 9/4/24, further noted the following information. The resident's skin was mottled upon arrival and he was nonresponsive. His systolic blood pressure was in the 70s and they were unable to obtain an oxygen level on him. Fluids, which had been started by EMS, were continued and lab work was done. The resident was intubated (a tube is placed down their airway to facilitate breathing) soon after arrival (9:30 AM on 9/4/24). Labs and diagnostic tests were performed. A central line (a long catheter for intravenous fluids which goes to a vein near an individual's heart) was placed at 11:40 AM. The resident was admitted to the Intensive Care Unit (ICU) for care. The resident's admitting ICU note indicated the resident's principle problem was septic shock which was secondary to pneumonia. The resident's chest x-ray showed multilobar bilateral pulmonary nodular opacity superimposed on emphysema, likely multilobar pneumonia although a component of neoplasm is not excluded. A review of the resident's hospital discharge summary included the following information. The resident expired at the hospital on 9/9/24. While hospitalized his blood cultures had grown MRSA (Methicillin Resistant Staphylococcus Aureus). Sputum cultures had grown staph and pseudomonas. His urine specimen had grown staph and strep. By 9/8/24 he had minimal urine output and remained on full mechanical ventilation. Family was consulted by the hospital staff and the decision was made to make the resident comfort measure only. He was withdrawn from mechanical ventilation and his time of death was listed as 10:05 PM on 9/9/24. The Director of Nursing was interviewed on 9/27/24 at 4:20 PM, 9/30/24 at 10:17 AM, and 9/30/24 at 1:25 PM and reported the following. It had not been called to her attention that the resident had a death rash on 9/3/24 or any problems related to his care before he was transferred out to the hospital. After hours the facility had a telehealth provider who could be called if needed for acute changes in condition. She had looked into the situation after the surveyor brought to her attention that the nurse was reporting the resident had a death rash on the evening prior to him being transferred to the hospital. She had found that no one had contacted the provider on 9/3/24. The information that he had a rash had been put in the binder where information is left for the provider to request a resident be seen when they next come. She had talked to Nurse # 8 who reported that she did not see anything life threatening on the night shift of 7 PM to 7 AM beginning on 9/3/24. The DON had questioned Nurse # 8 about why she had used the term death rash to describe the rash she saw to the surveyor. After thinking more Nurse #8 thought maybe she had later heard after the resident was transferred to the hospital that what he had been experiencing was a death rash. Resident # 13's medical physician, who served as the facility's medical director, was interviewed on 9/30/24 at 2:12 PM and again on 10/1/24 at 2:11 PM and reported the following. During the interview, the surveyor shared with the physician the interviews provided by the nursing staff as it related to how the resident's rash had been described in conjunction with what NA # 8 had observed on 9/3/24. The medical physician reported the following. A rash by itself does not warrant immediate urgency or notification to the physician. A rash in conjunction with a change in mental status, change in vitals, any decline can be a red flag and can escalate the need to act. A death rash or mottling would indicate someone was in critical condition. The medical director was interviewed about actions that would have been taken if he had been called and told the resident had a rash on the evening of 9/3/24 as described by Nurse # 9, Nurse # 8, NA # 8, and NA # 9 along with information that the resident had been noted by NA #8 not to eat anything for supper, was talking out of his head, and zonked. The medical director reported he would have expected them to do a critical assessment of the resident to determine if fluids needed to be started and he would have had the resident sent out to the hospital. The medical director further reported the following information. He had reviewed the record also and the vital signs noted in the facility record on 9/4/24 when EMS was summoned would have indicated the resident was in shock at the time EMS was called. Shock can happen quickly as sepsis occurs. The resident was very thin and his baseline indicated he was possibly immunocompromised and did not have the reserves a robust person to fight the infection and sepsis. Therefore, he did not feel the outcome would have been different for the resident if they had called the evening prior to 9/4/24. The facility was notified of immediate jeopardy on 9/30/24 at 5:02 PM. The facility submitted the following immediate jeopardy removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance F-684- Quality of Care: Nursing staff failed to recognize when a resident experienced a change in condition warranting immediate action. The Licensed Nurses and/or designee completed a head to toe assessment to include vital signs on all residents by October 1, 2024. No additional residents were identified with an emergent change of condition that would require immediate medical attention. 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 Nurse Practice Educator and/or designee will provide education to Licensed Nurses on how to complete a focused physical assessment to include a thorough skin assessment with vital signs, to include any changes that would require immediate medical attention to include but not limited to; deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications by October 1, 2024. A post-test has been created and is in progress to validate knowledge and/or comprehension of education. The Director of Nursing, Assistant Director of Nursing and/or Nurse Practice Educator will ensure that the post-test have been completed. The Director of Nursing/Assistant Director of Nursing and/or Nurse Practice Educator will track and verify no Licensed Nurse (s) will be allowed to return to work with scheduled time off, on leave of absence (FMLA), vacation, agency nurses or PRN until they have successful completed the education/training and post-test. Starting 10/2/2024, no licensed nurse will be permitted to work until required education is completed prior to the start of their shift. New hires will be educated by the Nurse Practice Educator during the orientation process. The Nurse Practice Educator and/or designee will educate Licensed Nurses on the importance of conducting a thorough skin assessment, documenting the assessment, and on specific measures to take if a new skin condition is identified; notifying the Physician/Provider by October 1, 2024. The Director of Nursing and/or Nurse Practice Educator will track and verify Licensed Nurses with scheduled time off, on leave of absence (FMLA), vacation, agency nurses, or PRN staff will be re-educated prior to returning to duty. Starting 10/2/2024, no licensed nurse will be permitted to work until required education is completed prior to the start of their shift. New hires will be educated by the Nurse Practice Educator during the orientation process. The Nurse Practice Educator and/or designee re-educated Certified Nursing Assistants on early identification of changes in condition and prompt notification of changes to the Licensed Nurse by October 1, 2024. The E-Interact Stop and Watch tool/alert was introduced as an early warning tool to be utilized by direct care givers as another mechanism to communicate changes in condition to the Licensed Nurse. The Director of Nursing and/or Nurse Practice Educator will track and verify that employees with scheduled time off, on leave of absence (FMLA), vacation, agency staff, or PRN staff will be re-educated prior to returning to duty. Starting 10/2/2024, no certified nurse aide will be permitted to work until required education is completed prior to the start of their shift. New hires will be educated by the Nurse Practice Educator during the orientation process. Effective October 1, 2024, the Director of Nurses and/or designee will review changes in condition by reviewing the change in condition assessments, in the morning Clinical Meeting to verify a thorough assessment has been completed.  [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility's smoking policy reviewed 11/4/19 indicated that the admitting nurse would conduct a Smoking Evaluation on all persons wishing to smoke, the person would only be able to smoke with direct supervision until evaluated by the interdisciplinary team, smoking status would be documented in the Care Plan, and if deemed independent, the resident would not be able to maintain own cigarettes and lighters unless the facility chose to provide a lock box. Resident #108 was admitted to the facility on [DATE] with diagnoses that included cancer and lung disease. Resident #108's admission Minimum Data Set (MDS) indicated she was cognitively intact and independent for transfers, locomotion on and off unit, and other activities of daily living. Her MDS did not indicate tobacco use. A Nursing admission assessment dated [DATE] revealed Resident #108 used tobacco products daily or almost daily for the past year. A Quarterly Recreation Progress Note dated 3/1/22 indicated that Resident #108 enjoyed smoking. Record review for Resident #108 did not reveal a Smoking Evaluation. Record review of Resident #108's Care Plan did not indicate she used tobacco. During an observation on 3/16/22 at 10:25 AM, Resident #108 were observed smoking in the designated smoking area of the courtyard. During an interview on 3/16/22 at 10:30 AM, Resident #108 revealed she was able to smoke independently, and she kept her cigarettes and lighter in her room in her drawer or her jacket pocket. She indicated she received instruction from the other residents not to share cigarettes with other residents. She had not received instructions from staff or been asked about her smoking. During an interview on 3/16/22 at 11:10 AM, the Director of Nursing (DON) indicated that independent smokers were encouraged to provider lighters to staff to put into a lock box. She revealed residents are asked at admission if they smoked and the admitting nurse would complete a Smoking Evaluation. During an interview on 3/18/22 at 9:20 AM, Nurse #1 revealed when she had filled out the admission Nursing Assessment, Resident #108 said she was going to quit smoking since she had been in the hospital for so long. Nurse #1 indicated she did not fill out the Smoking Evaluation because Resident #108 said she was not going to smoke. She further revealed she did not know when Resident #108 started smoking again because she no longer worked on that floor. During an interview on 3/18/22 at 9:25 AM, Resident #108 revealed she had been smoking in the facility since the day after she arrived. She indicated she had not had an intention to quit smoking. During an interview on 3/18/22 at 9:50 AM, the Administrator indicated most residents did not have the lock boxes in their room and were able to keep the cigarettes in their room but were encouraged to give lighters to staff. She further revealed the smoking policy likely needed to be revised to better fit the facility. The administrator revealed that Resident #108 had only recent started smoking again and that was why she did not have Smoking Evaluation completed. 2. Resident #112 was admitted to the facility on [DATE] with diagnoses which included chronic kidney disease, cerebral vascular infarction with hemiplegia (CVA), diabetes mellitus and hypertension. Resident #112 had a history of falls. The Annual Minimum Data Set (MDS) dated [DATE] revealed Resident #112 was cognitively intact and demonstrated no moods or behaviors. He required extensive assistance with 1 staff physical assistance with bed mobility related to one-side impairment for upper and lower body, transfer, dressing and toileting. A review of the care plan dated 03/02/2022 revealed Resident #112 was at risk for falls related to CVA with hemiplegia, lack of safety awareness, a history of falls, and required 1 staff assist with transfers. Interventions included a floor mat to the left side of his bed. A review of the facility falls incident report dated 03/06/2022 revealed Resident #112 attempted to transfer from his bed to electric wheelchair and the wheelchair was not locked. The wheelchair rolled backward, and Resident #112 fell on the floor. Education was provided to Resident #112 to make sure his wheelchair is turned off and locked before transferring to and from the wheelchair. The report also revealed there was not a fall mat beside his bed at the time of the fall. An interview with Resident #112 on 03/15/2022 at 11:55 am revealed he remembered his fall on 03/06/2022 when he tried to get in his electric wheelchair from his bed. He stated he thought he could do it himself, but he didn't make it. An interview with Nurse #3 on 03/15/2022 at 12:06 pm revealed Resident #112 had a recent fall on 03/06/2022 after he attempted to transfer to his electric wheelchair from his bed, the wheelchair rolled out from under him, and he fell. Nurse #3 stated there was not a fall mat beside Resident #112's bed at the time of the fall. Interview with Nurse #6 on 03/17/2022 at 9:09 am revealed Resident #112 had moved rooms on 03/11/2022 and his fall mat didn't make it to his new room and was aware he was care planned to have a fall mat beside his bed. Interview with the Director of Nursing (DON) on 03/17/2022 at 9:17am revealed Resident #112 should have had a fall mat beside his bed as outlined in his care plan. The DON stated nursing is responsible for making sure the care plans are followed. Based on observation, record review, police interview, and staff interviews the facility failed to prevent a resident with cognitive impairment and exit seeking behaviors from exiting the facility unsupervised on two occasions. On 1/30/21 Resident #125 exited the building from a first floor window and was found in a bush. This second incident on 5/21/21 resulted in Resident #125 being brought back to the facility by law enforcement after being found approximately a quarter of a mile from the facility. The facility also failed to implement the fall risk intervention of a fall mat at bedside (Resident #112), and to assess a resident (Resident #108) for safe smoking prior to allowing independent smoking and keeping smoking materials in her room. This was for 3 of 4 residents reviewed for accidents. Immediate Jeopardy began on 1/30/21 when Resident #125 exited the facility unsupervised through a first floor window. Immediate Jeopardy was removed on 9/1/21 when the facility implemented a credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure interventions implemented are effective. Examples #2 and #3 were cited at scope and severity of D. Findings included: 1. Resident #125 was admitted to the facility on [DATE] with diagnoses that included dementia. Resident #125 ' s admission Minimum Data Set assessment dated [DATE] revealed she was moderately cognitively impaired with no behaviors. She was independent for bed mobility, transfers, walking, and locomotion on and off the unit. She was not coded for wandering. A nurse ' s progress note completed by Nurse #5 dated 1/24/21 revealed wandering occurred daily or almost daily. A wanderguard (an electronic alert system that alarms and locks the facility exit doors when cognitively impaired residents with wandering behaviors attempt to exit the building) was ordered on 1/24/21. There was no plan developed for Resident #125 for wandering when the wanderguard was initiated on 1/24/21. There were no elopement risk assessments completed for Resident #125 on admission or after the wanderguard was implemented on 1/24/21. 1a. A progress note written by Nurse #5 on 1/30/21 at 10:40 AM stated Resident #125 was seen at breakfast at approximately 8:30 AM on 1/30/21. When Nurse #5 went to administer medications at approximately 9:10 AM to Resident #125 she was not in her room. Nurse #5 did a sweep of the building twice and couldn ' t locate Resident #125. At that time Nurse #5 alerted her supervisor and an elopement alert (an elopement alert was when a building-wide alarm was activated notifying staff that a resident was unable to be located. All staff were to assist in searching the facility and grounds to locate the resident) was activated. Resident #125 was found outside of the window in the back of the building by Nurse #4. An event summary report completed by Nurse #4 for an incident on 1/30/21 read in part, Resident states she was going to her car to go home. Staff assisted her back inside facility, full body assessment completed. Resident placed on 1:1 observation due to elopement and resident had cut off wander guard prior to exiting facility. Compassionate care visit to be completed by family to assist in increased anxiety due to isolation from family [related to] COVID protocols. The report indicated during a full body assessment, scratches to lower extremities and hands were discovered. The event summary report also indicated Resident #125 was discovered missing at 9:10 AM on 1/30/21 and was found at 9:40 AM. Observation on 3/15/22 at 11:30 AM of the area behind the building where Resident #125 exited out of on 1/30/21 revealed an approximate two-foot drop from the window to the ground. The bushes outside the window were below the windowsill. The reported temperature on 1/30/21 was 35 degrees Fahrenheit at 9:00 AM (www.wunderground.com). The medical records department was approximately 25 feet from Resident #125 ' s room at the time. An interview was conducted with Nurse #4 on 3/15/22 at 11:20 AM who stated Resident #125 was found under a window in the back of the building. She reported the window was open. Nurse #4 stated Resident #125 was wearing a blouse and pants. Resident #125 had socks and shoes on. She reported Resident #125 ' s pants were pushed up to her knees as is the resident ' s usual preference. A phone interview was conducted with Nurse #5 on 3/15/22 at 1:52 PM who stated Resident #125 had attempted to exit the building since she was admitted to the facility on [DATE]. Nurse #5 stated she could not recall any details regarding Resident #125 being found in the bushes outside the back of the building. During an interview with the Corporate Maintenance Director (CMD) on 3/15/22 at 11:30 AM he stated a contractor was replacing some of the windows in the building on 1/30/21. He stated the windows in the Medical Records office had been replaced that day. The CMD reported when the contractor left, he zipped up the zip wall that had been placed at the door of Medical Records. Based on the investigation conducted by the facility it was determined Resident #125 entered the zip wall, opened the window, and pushed the window screen out to exit the building. She was found in the bushes under the window and the screen was ajar with the window raised. He reported locks were placed on the windows in the facility to ensure they are not able to be raised higher than six inches. The care plan for Resident #125 had a focus area initiated 1/30/21 for wandering and at risk for elopement related to expressions of a desire to leave the facility and resident has made one or more attempts to leave the facility. Interventions included monitor resident ' s location with visual checks encourage participation in activity preferences, utilize and monitor security bracelet, and utilize diversional techniques to redirect resident when she verbalizes or exhibits the desire to leave the facility. During an interview with the Receptionist #1 on 3/16/22 at 10:01 AM she stated Resident #125 tried to exit the building daily since her admission. An interview was conducted with Receptionist #2 on 3/16/22 at 4:06 PM who stated she was familiar with Resident #125 and she did wander frequently. 1b. An event summary report prepared by Nurse #5 for an incident that occurred on 5/21/21 read in part, Dinner trays were served, and resident [Resident #125] was not able to be located for dinner. Resident had been refusing to be in her room for most of the day. Resident wanting to hang out in front lobby throughout the day. Resident last seen sitting in lobby on the couch. Staff completed a search throughout the building and notified proper authorities. Resident was located by local authorities and brought back to the facility. There were no injuries. A phone interview was conducted with Nurse #5 on 3/15/22 at 1:52 PM. She stated she recalled the resident had eloped and was brought back to the facility by the police on one occasion. Nurse #5 stated she could not recall any additional details about e the 5/21/21 incident. An interview was conducted with the facility Social Worker on 3/16/22 at 9:35 AM. She reported she observed Resident #125 on the afternoon of 5/21/21. She stated Resident #125 attempted to exit the building via the front door but was unable to do so due to her wander alarm at approximately 5:30 PM. She revealed she had not informed any other staff members that Resident #125 attempted to exit through the front door. The social worker indicated the receptionist was present and the wander alarm prevented her from opening the door so was not concerned at that time. The Social Worker stated she was in her office at approximately 5:55 PM and received a phone call from the kitchen staff regarding the alarm going off on one of the dining room doors. She stated she went to the dining room and found the door ajar and turned the alarm off. She stated she looked out the door but did not see anyone so returned to her office. The Social Worker stated she immediately recalled Resident #125 had been at the front door. The Social Worker stated she did not see Resident #125 so she asked the charge nurse to help locate her at 5:56 PM. Resident was unable to be found in the facility or on the grounds so local law enforcement was contacted. Resident #125 was returned to the facility at 6:33 PM by local law enforcement. The Social Worker stated she was advised by local law enforcement Resident #125 was located at the intersection of a nearby street. The resident was confirmed to be absent from the facility grounds for 38 minutes. She revealed the law enforcement indicated the location Resident #125 was found was across the highway. When measured by the corporate Maintenance Director the likely path taken by Resident #125 measured 1,407 feet (0.26 miles). Observation on 3/16/22 at 9:30 AM of the facility revealed the facility front door faced a two-lane highway with a speed limit of 35 miles per hour. The recorded temperature on 5/21/21 at 6:00 PM was 81 degrees Fahrenheit (www.wunderground.com). During an interview with a former kitchen staff member on 3/16/22 at 7:00 PM she stated she recalled Resident #125 leaving the building on 5/21/21. She reported Resident #125 tried to enter the kitchen several times on that day. The kitchen staff member stated they locked the door to prevent Resident #125 ' s entry. She reported she was unaware of Resident #125 ' s exit from the building until the social worker contacted her after Resident #125 was discovered absent from the facility. She further stated the alarm on the dining room door was not her responsibility and was unaware Resident #125 exited from that door. The former kitchen staff member stated she did not advise anyone of Resident #125 ' s had attempts to enter the kitchen on 5/21/21. An interview with the local law enforcement agency on 3/15/22 at 4:05 PM revealed no report was filed by the agency and no one recalled the incident. The Administrator was notified of Immediate Jeopardy on 3/16/22 at 3:48 PM. On 3/18/22 the facility provided an acceptable credible allegation of Immediate Jeopardy removal that included: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Facility failed to prevent Resident # 125 from exiting the facility unsupervised on 1/30/21 and 5/21/21. A. On 1/30/21, Resident #125 exited the facility through an open window in an unlocked office on Wing 3 that had been under construction. The window had been removed during construction and the construction crew working on this room had left the office door unsecured. Resident # 125 had last been seen at breakfast approximately 8:30 a.m. Nurse went to give a.m. medications and noted resident was not in room. Search initiated, unable to locate resident in the facility, search expanded to exterior and Elopement Code (overhead announcement of an elopement for all staff to respond according to policy to search for missing resident). called at 9:10 a.m. Staff members looked for resident and supervisor found resident outside in a bush behind the building outside of window, all belongings including clothes, walker and cane were outside as well. Resident assessed outside to determine if any major injuries incurred, resident able to move all extremities with no issue no gross injuries noted, resident escorted back inside, resident had total body check performed to further determine no injuries incurred, resident noted to have 2 scratches to right hand, 2 scratches to left hand and smaller scratches noted to bilateral lower extremities. ADON (Assistant Director of Nursing), DON (Director of Nursing) and administrator notified, family notified. Immediate Action for the 1/30/21 unsupervised exit included: An Immediate plan of correction was initiated on 1/30/21 which included placing resident # 125 on 1:1 supervision, followed by implementation of 15 minute checks. Resident #125 had an updated Elopement Assessment completed on 1/30/21 and Wander Guard alert bracelet was placed on resident. Facility leadership completed a head count on 1/30/21 of all current residents and all residents were accounted for. The office door was locked to prevent further egress. Maintenance completed an egress audit on 1/30/21 to ensure all doors and windows were secure. Windows were secured with metal locking tabs. B. On 5/21/21 Resident # 125 resident exited the center through the dining room door. The dining room door alarmed at approximately 5:55 pm and the Director of Social Services responded, turned off the alarm, she then asked a nurse for assistance. At 5:58 Elopement Code was called and search initiated. Resident was unable to be located at the facility and the local Police Department as notified at 6:10 p.m. of a missing resident. Resident was found by the police and returned to the facility at approximately 6:33 p.m. Immediate Action for the 5/21/21 unsupervised exit included: On 5/21/21 Immediate plan of correction started and education initiated. On the evening of 5/21/21 the Maintenance Director came into the facility to inspect the dining room door and found the door plunger was malfunctioning and provided an immediate repair to the door. While in the facility on the evening of 5/21/21 the Maintenance Director completed an audit of all doors to ensure secure/function. On 5/21/21 Facility leadership completed a head count of all current residents and all residents were accounted for. Resident # 125 remains in the center and has had no Elopements since 5/21/21. Resident # 125 remains an Elopement Risk and has a Wander Guard alert bracelet. All residents who wander and those identified at risk for Elopement have potential to be effected. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. On 1/30/21 Maintenance Director added Window checks to the TELs system to ensure that windows are checked monthly. TELs system is an electronic system that maintenance work orders are entered into and routine maintenance assigned tasks are entered into and documented for compliance by the facility Maintenance Director. On 02/01/21 Education was completed on Elopement, by the Assistant Director of Nursing. This education included a review of the Elopement Policy and Procedure which includes: ensuring a heightened awareness with all staff of the residents at risk for elopement and the systemic measures to prevent unsupervised exits. Policy/ Procedure also includes monitoring and supervising residents who wander. Wander Guard Audit completed on 1/30/21 and 5/21/21 by nursing leadership on residents identified at risk to ensure that the Wander Guard was on per order and that it was properly functioning, no concerns noted. On 5/21/21 Education was completed with dietary staff on responding immediately to alarms sounding, by the Assistant Director of Nursing. On 5/21/21 Re-Education was initiated on Elopement Policy, by the Assistant Director of Nursing for all staff to include full time, part time, as needed (PRN), and contracted staff. This education was a review of the Elopement Policy and Procedure which includes ensuring a heightened awareness with all staff of the residents at risk for elopement and the systemic measures to prevent unsupervised exits. Policy/ Procedure also includes monitoring and supervising residents who wander. Education completed on 5/28/21. Alleged Date of immediate jeopardy removal: 5/29/21 The credible allegation of immediate jeopardy removal was verified on 3/18/22 by onsite validation. During the verification process it was revealed training was not fully completed until 8/31/21. Staff were interviewed and confirmed they received training from the Assistant Director of Nursing and Corporate Maintenance Director pertaining to elopements. An observation on 3/18/22 at 9:00 AM revealed Resident #125 interacted with staff in the hallway. An interview was conducted with the Administrator on 3/17/22 at 5:15 PM who stated the last of the employees were educated on 8/31/21 by the Corporate Maintenance Director when an elopement drill was conducted. An interview was conducted with Maintenance Worker #1 on 3/18/22 at 9:23 AM. He confirmed he received education regarding elopements on 8/31/21 from the Corporate Maintenance Director. The facility ' s immediate jeopardy removal date was determined to be 9/1/21 based on the validation.