**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, Nurse Practitioner (NP), and Medical Director interviews, staff failed to consult with the on-call provider immediately to obtain treatment orders for hypoglycemia when Resident #1, who had diabetes, had a critically low blood glucose level of 31 (normal 80-100), was lethargic, mumbling, and unable to receive anything by mouth as assessed by Nurse #1. Staff failed to communicate other symptoms that indicated urgent medical attention including abnormal eye movements, and tightness in her hands as assessed by Nurse #2, and inability to receive sugar under her tongue due to a tight jaw, as assessed by Unit Manager #1. Resident #1 was transferred to the hospital on 7/17/25. An emergency medical services (EMS) report dated 7/17/25 indicated when EMS arrived on scene at the facility at 4:48 PM the patient was found lying in her bed, eyes open but only reactive to pain. The EMS report stated Resident #1 was noted to be comatose with seemingly left gaze with inability to follow any types of commands for more detailed assessment. The hospital Discharge summary dated [DATE] indicated Resident #1 did not have improvement in her mental status despite improvement in acute kidney injury and treatment for urinary tract infection. The hospital discharge summary stated, suspect she had prolonged low blood glucose and seizure which led to comatose state. Resident #1 was transitioned to inpatient hospice and passed away on 7/30/25. Immediate jeopardy began on 7/17/25 when staff failed to consult the physician about Resident #1's critically low blood glucose level of 31, abnormal eye movements and tightness in her hands and jaw. Immediate jeopardy was removed on 8/12/25 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level 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. Findings included:Resident #1 was admitted to the facility on [DATE]. Her diagnoses included type-2 diabetes mellitus. Resident #1's July 2025 medication administration record (MAR) revealed an order dated 12/4/23, for glucometer checks before breakfast and at bedtime. The blood sugar goal was a range of 100 - 250. Interventions included to notify the Nurse Practitioner (NP) if the results were greater than 250 consistently. For blood sugar less than 70, offer oral glucose and recheck blood sugar in 1 hour. Notify Medical Doctor (MD), if blood sugar is not improved or patient symptomatic.Review of the medical record revealed the facility did not have standing orders. Review of Resident #1's medical record revealed there were no nursing note entries from Nurse #1 on 07/17/25. The only entry made by Nurse #1 on 7/17/25 was a blood glucose result of 61 entered at 7:35 AM under vital signs. An interview was conducted on 8/7/25 at 9:09 AM with Nurse #1. She was the night shift (11PM-7AM) nurse for Resident #1 on the morning of 7/17/25. Nurse #1 recalled Resident #1 and her low blood sugars on the morning of 7/17/25. Nurse #1 recalled around 5:00 AM she checked Resident #1's blood glucose when she started her morning medication pass. She stated Resident #1's blood sugar was very low. Nurse #1 said Resident #1's blood sugar reading was 31. She remembered Resident #1 was lethargic and in and out of it, she stated Resident #1 would open her eyes and look at her and mumble inaudibly but would then close her eyes and go back to sleep. Nurse #1 said she would not have felt comfortable giving Resident #1 anything by mouth, that she was not alert enough. Nurse #1 explained she had intramuscular (IM) glucagon (emergency medicine used to treat low blood sugar) in the medication cart and administered the IM glucagon to Resident #1 right after she got the blood glucose reading of 31. Nurse #1 said she did not open Resident #1's medication administration record (MAR) or look at her orders for instructions on how to treat her hypoglycemia. She explained a few months ago Resident #1 had an episode of low blood sugar and IM glucagon had been used to treat the low blood sugar. Nurse #1 stated she assumed after that episode Resident #1 had an as needed standing order for IM glucagon. She reported she thought it was standard and that all residents with diabetes had an as needed order for IM glucagon. Nurse #1 stated after she administered the IM glucagon to Resident #1, she rechecked her blood glucose every 15 minutes. She recalled at first Resident #1's blood glucose went up steadily but then started to drop back down. Nurse #1 said the highest she could get Resident #1's blood glucose up to was 61. She reported by the time the day shift Unit Manager (UM #1) came in, around 6:45 AM, Resident #1's blood glucose was back down to 61. Nurse #1 said when UM #1 arrived at the facility she gave over care of Resident #1 to UM #1 because she had worked on Resident #1 for an hour and a half and 61 was the highest, she could get her blood sugar. Nurse #1 reported she asked UM #1 to call the on-call provider to let them know Resident #1 had an episode of hypoglycemia and what had been done to treat it and that what had been done was not effective. Nurse #1 explained she did not call the on-call provider during her shift when Resident #1's blood glucose was 31. Nurse #1 stated she was going to call the on-call provider after she treated Resident #1's hypoglycemia and let them know if it was effective or not. She explained she wrote down Resident #1's blood sugar results and gave them to UM #1. Nurse #1 stated she asked UM #1 if she would call the on-call provider and ask them what to do and to call Resident #1's family member to update them. Nurse #1 stated UM #1 said she would document the blood glucose results, call the on-call provider, and call Resident #1's family. Nurse #1 reported she did not notice any seizure like activity or vomiting for Resident #1. A progress note by the day shift Unit Manager (UM) #1 dated 7/17/25 at 7:13 AM read, night nurse reported resident was experiencing hypoglycemia, blood sugars as follows: 5:30 AM-31, 5:45 AM- 52, 6:00 AM- 56, 6:15 AM-61, 6:30 AM- 66, 6:45 AM- 61. On call notified and was advised to put sugar under her tongue and recheck blood sugar in 30 minutes.An interview was conducted with UM #1 on 8/6/25 at 3:05 PM. UM #1 reported she arrived to work on 7/17/25 between 6:30 AM and 7:00 AM. She did not recall the exact time. She said Nurse #1 reported to her when she arrived that Resident #1 had low blood sugar during the night. UM #1 said Nurse #1 reported she had given Resident #1 IM glucagon. She stated Nurse #1 did not ask her to document Resident #1's blood glucose checks from the night shift. UM #1 reported she did document the blood glucose results reported to her by Nurse #1 because she thought it was prudent to do so. UM #1 also reported Nurse #1 did not ask her to call the on-call provider or Resident #1's family. UM #1 did remember calling the on-call provider about Resident #1's low blood sugar and recalled the on-call provider gave her instructions to put sugar under Resident #1's tongue and recheck her blood sugar in 30 minutes. UM #1 stated when she went to put the sugar under Resident #1's tongue her mouth and jaw were tight, and she could not open her mouth. UM #1 said she did not want to pry open and force Resident #1's mouth open to put the sugar under her tongue. She reported she tried to put the sugar into her cheek as best as she could. UM #1 said she did not recall telling anyone about Resident #1's jaw being tight. She did not recall Resident #1 having tight arms or abnormal eye movement when she was in the room with her. A progress note by Nurse #2 dated 7/17/25 at 7:45 AM read, On coming to shift during report resident was reported to have struggled with low blood sugars throughout the night. Last blood sugar check was 61 at on coming of shift 7:00 AM. I was told to recheck blood sugar at 7:30 AM and call provider back. I rechecked blood sugar at 7:30 AM blood sugar dropped down to 59. I called provider to inform her of blood sugar level. Provider stated to just hold short acting and long-acting insulin for the morning and to recheck in an hour and give her a call back. Resident in bed. Eyes rolling side to side. Moaning. hands tight. Informed unit manager to recheck in an hour and call provider back.An interview was conducted with Nurse #2 on 8/6/25 at 2:53 PM. Nurse #2 was the day shift (7-3) and evening shift (3-11) nurse for Resident #1 on 7/17/25. Nurse #2 stated when she arrived on shift, the night shift (11PM-7AM) nurse (Nurse #1) reported to her Resident #1's blood sugars were extremely low in the 30's. Nurse #1 reported, she said 33 to be exact. Nurse #2 stated Nurse #1 reported to her the on-call provider was aware of Resident #1's low blood sugar and had said to recheck Resident #1's blood sugar around 7:30 AM and call the on-call provider back with what Resident #1's blood sugar was. Nurse #2 said she rechecked Resident #1's blood sugar at 7:30 AM and it was in the 50's, she did not recall the exact number. She reported she called the on-call provider back after checking Resident #1's blood sugar at 7:30 AM and was told by the on-call provider to hold Resident #1's insulin. She stated the provider instructed her to try to give her something to eat to increase her blood sugar and to recheck her blood sugar in an hour. Nurse #2 stated she told the provider she did not have time to do that or keep rechecking Resident #1's blood sugar because she had to pass medications and check blood sugars for her other residents with diabetes, so they sent a Registered Nurse (Nurse #3) to help with Resident #1. Nurse #2 said she did not remember Resident #1 having abnormal eye movements and tight hands during the morning or reporting it to anyone. Nurse #2 said she remembered that more from the evening right before Resident #1 went out. She stated Resident #1's eyes were moving left and right slowly like her head was turning side to side but her head was not moving, and her arms were tight and hard to move. Nurse #2 stated Resident #1 was transferred to the hospital between 4:30 PM and 5:00 PM on 7/17/25. An interview was conducted on 8/6/25 at 4:33 PM with Nurse #3. Nurse #3 said she communicated with the NP about Resident #1 and received orders from the NP throughout the day. Nurse #1 stated she had not noticed seizure symptoms, abnormal eye movements, tightness of hands, arms, or mouth, or foaming at the mouth when she was in Resident #1's room. She said staff had not mentioned those symptoms to her. Nurse #3 explained she left the facility in the afternoon after lunch before 3 PM- 11 PM shift change but was not sure of the exact time. Nurse #3 stated Resident #1's blood sugar had increased to 74 that afternoon before she left but Resident #1 had not had any improvement in her mental status. Review of an EMS report dated 7/17/25, revealed EMS received the emergency call from the facility at 4:33 PM and arrived on scene at the facility at 4:48 PM. The EMS report stated when they arrived the patient was found lying in her bed, eyes open but only reactive pain. Patient is noted to be comatose with seemingly left gaze with inability to follow any types of commands for more detained assessment. Her baseline is reported to be normal with some memory problems however, otherwise able to answer questions and hold conversation. The EMS report stated her blood sugar was 94 and then 84 with direct blood drawn from midline. She was given 125 milliliters (ml) of D10 (10% dextrose (glucose) in water) to see if it improved her mental status. The report stated no improvement in mental status was noted and D10 was stopped after 125 ml. The EMS report said they departed the scene at 5:09 PM. A hospital Discharge summary dated [DATE] indicated Resident #1 arrived to the hospital on 7/17/25 at 5:32 PM. The hospital course said Resident #1 presented to the hospital from the facility secondary to increasing lethargy, somnolence, with concern for acute metabolic encephalopathy. The discharge summary included the hospital workup was remarkable for acute kidney injury (AKI) and likely urinary tract infection (UTI). The hospital course stated Resident #1 did not have improvement in her mental status despite improvement in AKI and treatment for UTI. The discharge summary stated, suspect she had prolonged hypoglycemia and possible seizure which led to comatose state. The Discharge summary included that goals of care were discussed with family, and the decision was made to transitions to comfort care with inpatient hospice. A death certificate for Resident #1 documented she passed away on 7/30/25. Acute metabolic encephalopathy was listed as the cause of death.An interview was conducted on 8/7/25 at 12:15 PM with the NP. The NP reported Nurse #1 should have called the on-call provider when to report Resident #1's hypoglycemia and to get an order for how to treat the low blood glucose prior to giving Resident #1 glucagon. The NP said it had not been reported to her that Resident #1 had abnormal eye movements or tightness of her hands, arms, or mouth. She stated those were seizure symptoms and she was not made aware of that. NP #1 said she would have been worried about seizures if those symptoms had been reported to her and would have sent Resident #1 out that morning if she was concerned about seizures. An interview was conducted with the Medical Director on 8/7/25 at 11:15 AM. He stated the best thing in acute scenarios was to call the provider. He stated a medical provider should have been notified when Resident #1 had a critical blood sugar level of 31 at 5:30 AM on 7/17/25. He said the facility had a physician call service in place to manage hypoglycemia and that was better than paper standing orders. He explained the call service was 24 hours and if the on-call provider did not answer, the call would roll over to a backup on-call provider, and if the backup on-call provider did not answer, then the call would roll over to a second back up on call provider. He said he did not like standing orders because then you had someone with less knowledge making medical decisions. An interview was conducted with the interim Director of Nursing (DON) on 8/7/25 at 11:25 AM. The DON said Nurse #1 should have called the provider to report Resident #1's blood glucose level of 31 and to get an order for the IM glucagon. The DON stated the facility did not have standing orders and nurses needed to call the provider for everything. She reported Nurse #1 should have checked the MAR and called the provider before giving Resident #1 IM glucagon to get orders for how to treat her hypoglycemia. An interview was conducted with the Administrator on 8/7/25 at 3:50 PM. The Administrator said as a nurse she would have done what needed to be done to protect the resident at the time but would expect the nurse to call the provider timely to let them know what was going on. The facility's Administrator was informed of the immediate jeopardy on 8/7/25 at 4:03 PM. The facility submitted the following credible allegation of immediate jeopardy removal. 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On 7/17/25 at 5:30 AM Resident #1's blood glucose level was 31. Nurse #1 stated she administered intramuscular glucagon to Resident #1 to treat her low blood glucose. Nurse #1 said she did not call the physician or check Resident #1's medical record for hypoglycemia treatment orders before administering the glucagon. Nurse #1 reported when Unit Manager (UM #1) arrived to the facility around 6:45 AM she asked UM #1 to call the physician to notify them about Resident #1's low blood glucose and what had been done to treat her low blood glucose. UM #1 documented she contacted the Provider at 7:13 AM. Unit Manager #1 did recognize that she was unable to place sugar under resident #1's tongue due to her clinched jaw however she failed to notify the MD of resident #1's emergent situation. Nurse #2 failed to notify the MD of abnormal eye movement, and tight hands which were signs of an emergent situations. Failure to notify the physician about Resident #1's critically low blood glucose level could likely result in serious injury, harm, impairment, or death.All residents with diabetes or those taking antidiabetic medications are at risk. On August 8, 2025, the Director of Nursing and the Unit Manager reviewed medical records related to diabetes diagnoses and physician orders for diabetic medications and insulin. This was done to identify residents at risk of hypoglycemic episodes and to ensure that their physician orders were updated according to facility protocol.1. Notify the physician for blood glucose levels below 60 and above 500 or identified as Hi on the glucometer.For blood glucose levels 50 and below: (1) Verify blood glucose level using a finger on the opposite hand, if the blood glucose level remains the same or below 50, then (2) give 1milligram (mg) of Glucagon intramuscularly. (The Glucagon is located in the medication cart of each resident and in the pharmacy e-kit located in the medication room at the nursing units) and (3) notify the physician for additional orders and continue to monitor and evaluate the resident's status, (4) notify the physician of any changes. All licensed nurses, including agency nurses, were educated on 8/11/25 by the Director of Nursing or Unit Manager in person or via phone on notifying the physician of changes in the resident's condition or with an emergent life-threatening event and feel as if the on call/ extended practice provider does not respond to a call or does not address an identified emergent situation as emergent the facility is to contact the Medical Director/Designee. All residents who were transferred to the hospital within the past 30 days were reviewed for life threatening events which included initiation of symptoms, time reported to the physician and time transferred to the hospital by the Director of Nursing on 8/8/25 to ensure proper notification of the physician and management of symptom/changes. No further deficient practices were identified. 2. 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.All licensed nurses, including agency nurses, were educated on 8/7/25 by the Director of Nursing or Unit Manager in person or via phone on notifying the physician of changes in the resident's condition or with an emergent life-threatening event. This education included once you identify a change in a resident's baseline (usual) status, the physician must be notified for further direction; and the nurse must document in the resident's medical record the change in condition and physician notification. All staff education began on 8/7/2025 to notify the nurse if a resident emergent situation is identified or suspected and the importance of reporting resident emergent situations. Staff who have not received education by 8/8/2025 will not be allowed to work until education is completed. The Director of Nursing is responsible for ensuring all staff are educated prior to working. Nurse #1 has been suspended pending the completion of this investigation on 8/7/2025Nurse #1 was terminated on 8/8/2025 for deficient practice, failure to identify emergent resident situation, failure to notify MD of emergent situation in status, providing medications without MD order. On 8/8/2025, UM#1 and Nurse #2 received disciplinary action for not identifying an emergent resident situation and failing to notify the MD of emergent situation, by the Director of Nursing.Immediate Jeopardy Removal Date: 8/12/2025 On 8/14/25 the facility's credible allegation of immediate jeopardy removal was validated by the following: Review of facility audits revealed the facility completed an audit of all diabetic residents residing in the building. Review of physician orders for diabetic residents, including non-insulin dependent diabetic residents revealed as needed (PRN) glucagon orders had been added for all residents. Medication cart observations were completed. Each medication cart was overserved to have emergency glucagon kits for individual residents. Review of in-service education logs revealed licensed nurses including UM #1 and Nurse #2 were educated on the facility protocol for treatment of hypoglycemia, when to notify the physician, emergent vs. non-emergent situations, including when to call 911, notifying the physician for change in a residents condition, and when to contact the Medical Director and/or designee if a provider does not treat an identified emergent situation as emergent. Additional in-service logs were reviewed and revealed all staff (including UM #1 and Nurse #2) were educated on the signs/ symptoms of hypoglycemia, emergent situations, including when to call 911, and notifying the nurse of change in condition. Interviews were conducted with licensed nurses, including agency nurses. The nurses confirmed they had received education on the facility protocol for treatment of hypoglycemia, when to notify the physician, emergent vs. non-emergent situations, including when to call 911, notifying the physician when there is a change in resident condition, and when to contact the Medical Director and/or designee if a provider does not treat an identified emergent situation as emergent. The licensed nurses were able to accurately verbalize the education they received. Interviews were conducted with licensed nurses, nurse aides, dietary staff, housekeeping, maintenance, office, administration/management, therapy, and agency staff. Interviews were conducted with staff from different shifts. The staff interviews revealed they had received education on the symptoms of hypoglycemia/ hyperglycemia, emergent situations including when to call 911, and notifying the nurse for change of condition. Staff were able to accurately verbalize the education they had received. Review of provider in-service logs revealed on 8/8/25 providers were educated by the Medical Director on the importance of notifying the medical Director when a resident is identified as having a critically low blood sugar and is showing symptoms that require emergency care. Education included: identification of emergent situation versus nonemergent situation, what is within the capabilities of the facility to properly care for residents with critically low blood sugar, and when to get the resident emergency medical attention. Education included acknowledgement of the devastation this type of scenario could bring if not treated properly. It was verified Nurse #1 no longer worked at the facility. An interview with the Administrator confirmed the involved NP was removed from facility services beginning on 8/7/25. The Administrator stated the facility had contacted the board of nursing and reported the involved NP but had not heard back from the board of nursing. Immediate Jeopardy Removal Date of 8/12/25 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff, resident, family, Medical Director, and Nurse Practitioner (NP) interviews, the facility failed to protect a resident's (Resident #1) right to be free from neglect when the facility failed to ensure Resident #1 received emergent care extending beyond the capabilities of the facility when she had critically low blood sugar and was symptomatic. Symptoms included lack of responsiveness, eyes moving left to right, obtunded, jaw tightness, inability to swallow, tightness of hands, moaning, foaming at the mouth. Resident #1 was not transferred to the emergency room until her family arrived at the facility and requested, she be transferred. Resident #1 was transferred to the emergency room at 5:09 PM on 7/17/25. Resident #1 was admitted to the hospital on [DATE]. Her hospital diagnoses included acute metabolic encephalopathy (brains function is impaired due to metabolic distubance), prolonged hypoglycemia, acute kidney injury (AKI), and urinary tract infection (UTI). The hospital Discharge summary dated [DATE] said, Resident #1 did not have improvement in her mental status despite improvement in AKI and treatment for UTI. The discharge summary stated, suspect she had prolonged low blood glucose and seizure which led to comatose state. Resident #1 was transitioned to inpatient hospice and passed away on 7/30/25. This deficient practice occurred for 1 of 1 resident reviewed for neglect. Immediate jeopardy began on 7/17/25 when the facility failed to recognize Resident #1 who had critically low blood sugar and was symptomatic, needed emergency medical services extending beyond the capabilities of the facility. Immediate jeopardy was removed on 8/13/25 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level 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. Findings included: This tag is cross referred to:F 684- Based on observations, record review, staff, family, Nurse Practitioner (NP), Physician Assistant and Medical Director interviews the facility failed to recognize that a diabetic resident (Resident #1) with critically low blood sugar (normal 80-100) needed emergency medical care that required transfer to a higher level of care. On 7/17/25 at 5:30 AM Resident #1's blood sugar was 31(a serious life-threatening medical condition) and Resident #1 was lethargic (sluggish), in and out of it, mumbling, and not alert enough to eat or drink. After an intramuscular (IM) injection of glucagon (medication to treat low blood sugar) the resident remained symptomatic and was still lethargic, in and out of it, and not alert enough to eat or drink. Symptoms Resident #1 experienced from the initial low blood sugar of 31 at 5:30 AM on 07/17/25 until her discharge at 5:09 PM on 07/17/25 included lack of responsiveness, eyes moving left to right, obtunded (reduced level of alertness), jaw tightness, inability to swallow, tightness of hands, moaning, and foaming at the mouth. Resident #1's blood glucose level remained less than 70 until 1:08 PM when it was documented her blood glucose level was 77, however she remained obtunded with no verbal response. Resident #1's blood glucose decreased again to 59 at 2:30 PM. Resident #1 was not transferred to the emergency room until her family arrived at the facility and requested, she be transferred. Resident #1 was transferred to the emergency room at 5:09 PM on 7/17/25. Resident #1 was admitted to the hospital on [DATE]. Her hospital diagnoses included acute metabolic encephalopathy (brain dysfunction), prolonged hypoglycemia (low blood sugar), acute kidney injury (AKI), and urinary tract infection (UTI). The hospital Discharge summary dated [DATE] said, Resident #1 did not have improvement in her mental status despite improvement in AKI and treatment for UTI. The discharge summary stated, suspect she had prolonged low blood glucose and seizure which led to comatose state. Resident #1 was transitioned to inpatient hospice and passed away on 7/30/25. This deficient practice affected 1 of 3 residents reviewed for quality of care. F 580- Based on record review, staff, Nurse Practitioner (NP), and Medical Director interviews, staff failed to consult with the on-call provider immediately to obtain treatment orders for hypoglycemia when Resident #1, who had diabetes, had a critically low blood glucose level of 31, was lethargic, mumbling, and unable to receive anything by mouth as assessed by Nurse #1. Staff failed to communicate other symptoms that indicated urgent medical attention including abnormal eye movements, and tightness in her hands as assessed by Nurse #2, and inability to receive sugar under her tongue due to a tight jaw, as assessed by Unit Manager #1. Resident #1 was transferred to the hospital on 7/17/25. An emergency medical services (EMS) report dated 7/17/25 indicated when EMS arrived on scene at the facility at 4:48 PM the patient was found lying in her bed, eyes open but only reactive to pain. The EMS report stated Resident #1 was noted to be comatose with seemingly left gaze with inability to follow any types of commands for more detailed assessment. The hospital Discharge summary dated [DATE] indicated Resident #1 did not have improvement in her mental status despite improvement in acute kidney injury and treatment for urinary tract infection. The hospital discharge summary stated, suspect she had prolonged low blood glucose and seizure which led to comatose state. Resident #1 was transitioned to inpatient hospice and passed away on 7/30/25. The Administrator was notified of immediate jeopardy on 8/11/25 at 3:30 PM. The facility submitted the following credible allegation of immediate jeopardy removal 1. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance.The facility's failure to ensure Resident #1 received emergent care extending beyond the capabilities of the facility had the high likelihood of resulting in serious injury, serious harm, serious impairment or death. Failure to notify the physician about Resident #1's critically low blood glucose level could likely result in serious injury, harm, impairment, or death.On 7/17/25 at 5:30 AM Resident #1's blood glucose level was 31. Nurse #1 stated she administered intramuscular glucagon to Resident #1 to treat her low blood glucose. Nurse #1 said she did not call the physician or check Resident #1's medical record for hypoglycemia treatment orders before administering the glucagon. Nurse #1 reported when Unit Manager (UM #1) arrived to the facility around 6:45 AM she asked UM #1 to call the physician to notify them about Resident #1's low blood glucose and what had been done to treat her low blood glucose. UM #1 documented she contacted the Provider at 7:13 AM. Unit Manager #1 did recognize that she was unable to place sugar under resident #1's tongue due to her clinched jaw however she failed to notify the MD of resident #1's emergent situation. Nurse #2 failed to notify the MD of abnormal eye movement, and tight hands which were signs of an emergent situations. Resident #1 was not transferred to the emergency room until her family arrived at the facility and requested, she be transferred. Resident #1 was transferred to the emergency room at 5:06 PM on 7/17/25. Resident #1 was admitted to the hospital on [DATE]. The hospital course stated, suspect she had prolonged blood glucose and seizure which led to comatose state. Her hospital diagnoses included acute metabolic encephalopathy, prolonged hypoglycemia, acute kidney injury, and urinary tract infection. Resident #1 was transitioned to inpatient hospice and passed away on 7/30/25. All residents in the facility have the potential to be affected by this deficient practice. All residents with diabetes or those taking antidiabetic medications are at risk. On August 8, 2025, the Director of Nursing and the Unit Manager reviewed medical records related to diabetes diagnoses and physician orders for diabetic medications and insulin. This was done to identify residents at risk of hypoglycemic episodes and to ensure that their physician orders were updated according to facility protocol. Notify the physician for blood glucose levels below 60 and above 500 or identified as Hi on the glucometer.For blood glucose levels 50 and below: (1) Verify blood glucose level using a finger on the opposite hand, if the blood glucose level remains the same or below 50, then (2) give 1mg of Glucagon intramuscularly. (The Glucagon is located in the medication cart of each resident and in the pharmacy e-kit located in the medication room at the nursing units) and (3) notify the physician for additional orders and continue to monitor and evaluate the resident's status, (4) notify the physician of any changes. All licensed nurses, including agency nurses, were educated on 8/11/25 by the Director of Nursing or Unit Manager in person or via phone on notifying the physician of changes in the resident's condition or with an emergent life-threatening event and feel as if the on call/ extended practice provider does not respond to a call or does not address an identified emergent situation as emergent the facility is to contact the Medical Director/Designee. 2. 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 August 8, 2025, the Medical Director conducted a training session for all primary care physician extenders. The purpose was to emphasize the importance of notifying the Medical Director when a resident is identified as having critically low blood sugar and is showing symptoms that require emergency care. Education included identification of emergent situation versus nonemergent situation and within the capabilities of the facility to properly care for the resident with critically low blood sugar and when to get the resident emergency medical attention. Additionally, on August 8, 2025, the Director of Nursing, Minimum Data System (MDS) RN, and Weekend RN Unit Manager provided education for all staff. This education covered the signs and symptoms of hypoglycemia and provided guidance on when to notify the nurse, the medical doctor, and when to call 911 if a resident appears to be in an emergency situation. Education included if blood sugar levels fall outside the parameters specified in the physician's orders and the patient exhibits symptoms of hypoglycemia-such as shakiness, chills, nausea, a rapid heartbeat, or hunger-but remains responsive, this is considered a non-emergent situation. Education was provided regarding emergent events, such as non-responsiveness or seizure activity, which would require immediate notification of a physician and a call to 911. The training included the importance of treating hypoglycemia as it can lead to devastation including up to death if left untreated. A100% audit was conducted of all identified diabetic resident's medication orders was completed by the Director of Nursing, and/or Unit Manager on 8/8/25 to identify residents without parameters for when to contact the MD for abnormal glucose blood level. For those residents identified, orders were updated to include the parameters of when to notify the physician. New protocol established:1. Notify the physician for blood glucose levels below 60 and above 500 or identified as Hi on the glucometer.2. For blood glucose levels 50 and below: (1) Verify blood glucose level using a finger on the opposite hand, if the blood glucose level remains the same or below 50, then (2) give 1mg Glucagon intramuscularly. Glucagon is stored in the medication cart for all residents with a diabetic diagnosis, including those on diet control, insulin-dependent residents, and residents taking antidiabetic medications who are at risk for hypoglycemic episodes. Glucagon was added to each resident's medication drawer on 8/8/2025, who was identified as a diabetic. Additionally, it can be found in the pharmacy emergency kit located in the medication room at the nursing station. The following additional actions should be taken: (1) notify the physician for additional orders, (2) continue to monitor the resident, (3) evaluate their condition, and (4) inform the physician of any changes. All licensed nurses, including agency nurses, were educated on 8/7/25 by the Director of Nursing or Unit Manager in person or via phone on notifying the physician of changes in the resident's condition or with an emergent life-threatening event. This education included once you identify a change in a resident's baseline (usual) status, the physician must be notified for further direction; and the nurse must document in the resident's medical record the change in condition and physician notification. All staff education began on 8/7/2025 to notify the nurse if a resident emergent situation is identified or suspected and the importance of reporting resident emergent situations. Staff who have not received education by 8/8/2025 will not be allowed to work until education is completed. The Director of Nursing is responsible for ensuring all staff are educated prior to working. Nurse #1 has been suspended pending the completion of this investigation on 8/7/2025Nurse #1 was terminated on 8/8/2025 for deficient practice, failure to identify emergent resident situation, failure to notify MD of emergent situation in status, providing medications without MD order. On 8/8/2025, UM#1 and Nurse #2 received disciplinary action for not identifying an emergent resident situation and failing to notify the MD of emergent situation, by the Director of Nursing.Nurse Practitioner involved was removed from facility services effective 8/7/2025 by the Facility Director of Operations and the Extended Provider Practice. All staff education began on 8/11/2025 by the Director of Nursing and the Human Resource Director on Abuse, Neglect and Exploitation policy with the emphasis on neglect, such as failure to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Staff who have not received education by 8/11/2025 will not be allowed to work until education is completed. The Director of Nursing is responsible for ensuring all staff are educated prior to working. On 8/12/2025 The Facility Administrator filed a report to the North Carolina Board of Nursing regarding Nurse Practitioner involved. Immediate Jeopardy Removal Date: 8/13/2025On 8/14/25 the facility's credible allegation of immediate jeopardy removal was validated by the following: An onsite facility revisit was conducted on 8/14/25. Review of facility audits revealed the facility completed an audit of all diabetic residents residing in the building. Review of physician orders for diabetic residents, including non-insulin dependent diabetic residents revealed as needed (PRN) glucagon orders had been added for all residents. Medication cart observations were completed. Each medication cart was overserved to have emergency glucagon kits for individual residents. Review of in-service education logs revealed licensed nurses including UM #1 and Nurse #2 were educated on the facility protocol for treatment of hypoglycemia, when to notify the physician, emergent vs. non-emergent situations, including when to call 911, notifying the physician for change in a residents condition, and when to contact the Medical Director and/or designee if a provider does not treat an identified emergent situation as emergent. Additional in-service logs were reviewed and revealed all staff (including UM #1 and Nurse #2) were educated on abuse/ neglect including the facility abuse/ neglect policy, the signs/ symptoms of hypoglycemia, emergent situations, including when to call 911, and notifying the nurse of change in condition. Interviews were conducted with licensed nurses, including agency nurses. The nurses confirmed they had received education on the facility protocol for treatment of hypoglycemia, when to notify the physician, emergent vs. non-emergent situations, including when to call 911, notifying the physician when there is a change in resident condition, and when to contact the Medical Director and/or designee if a provider does not treat an identified emergent situation as emergent. The licensed nurses were able to accurately verbalize the education they received. Interviews were conducted with licensed nurses, nurse aides, dietary staff, housekeeping, maintenance, office, administration/management, therapy, and agency staff. Interviews were conducted with staff from different shifts. The staff interviews revealed they had received education abuse/ neglect, on the symptoms of hypoglycemia/ hyperglycemia, emergent situations including when to call 911, and notifying the nurse for change of condition. Staff were able to accurately verbalize the education they had received. Review of provider in-service logs revealed on 8/8/25 providers were educated by the Medical Director on the importance of notifying the medical Director when a resident is identified as having a critically low blood sugar and is showing symptoms that require emergency care. Education included: identification of emergent situation versus nonemergent situation, what is within the capabilities of the facility to properly care for residents with critically low blood sugar, and when to get the resident emergency medical attention. Education included acknowledgement of the devastation this type of scenario could bring if not treated properly. It was verified Nurse #1 no longer worked at the facility. An interview with the Administrator confirmed the involved NP was removed from facility services beginning on 8/7/25. The Administrator stated the facility had contacted the board of nursing and reported the involved NP but had not heard back from the board of nursing. Immediate Jeopardy Removal Date of 8/13/25 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff, family, Nurse Practitioner (NP), Physician Assistant and Medical Director interviews the facility failed to recognize that a diabetic resident (Resident #1) with critically low blood sugar (normal 80-100) needed emergency medical care that required transfer to a higher level of care. On 7/17/25 at 5:30 AM Resident #1's blood sugar was 31 (a serious life-threatening medical condition) and Resident #1 was lethargic (sluggish), in and out of it, mumbling, and not alert enough to eat or drink. After an intramuscular (IM) injection of glucagon (medication to treat low blood sugar) the resident remained symptomatic and was still lethargic, in and out of it, and not alert enough to eat or drink. Symptoms Resident #1 experienced from the initial low blood sugar of 31 at 5:30 AM on 07/17/25 until her discharge at 5:09 PM on 07/17/25 included lack of responsiveness, eyes moving left to right, obtunded (reduced level of alertness), jaw tightness, inability to swallow, tightness of hands, moaning, and foaming at the mouth. Resident #1's blood glucose level remained less than 70 until 1:08 PM when it was documented her blood glucose level was 77, however she remained obtunded with no verbal response. Resident #1's blood glucose decreased again to 59 at 2:30 PM. Resident #1 was not transferred to the emergency room until her family arrived at the facility and requested, she be transferred. Resident #1 was transferred to the emergency room at 5:09 PM on 7/17/25. Resident #1 was admitted to the hospital on [DATE]. Her hospital diagnoses included acute metabolic encephalopathy (brain dysfunction), prolonged hypoglycemia (low blood sugar), acute kidney injury (AKI), and urinary tract infection (UTI). The hospital Discharge summary dated [DATE] said, Resident #1 did not have improvement in her mental status despite improvement in AKI and treatment for UTI. The discharge summary stated, suspect she had prolonged low blood glucose and seizure which led to comatose state. Resident #1 was transitioned to inpatient hospice and passed away on 7/30/25. This deficient practice affected 1 of 3 residents reviewed for quality of care. Immediate jeopardy began on 7/17/25 when the facility failed to recognize that Resident #1 had a critically low blood sugar and was symptomatic and needed emergency care extending beyond the capabilities of the facility. Immediate jeopardy was removed on 8/9/25 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level 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 were effective. Findings included:Resident #1 was admitted to the facility on [DATE]. Her diagnoses included type-2 diabetes mellitus. She was discharged from the facility on 7/17/25 to an acute care hospital. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 had severe cognitive impairment. The MDS documented revealed that she received insulin injections and hypoglycemic medication.A care plan revised on 06/13/25 read, Resident #1 has diabetes mellitus and has fluctuations in blood sugars, sliding scale insulin and capillary blood glucose (CBG) per orders. Resident #1 often refuses meals at times. The care plan goal last revised on 6/13/25 was for Resident #1 to not have any complications related to diabetes through the review date. The care plan interventions included:-monitor/ document/ report as needed any signs or symptoms of hyperglycemia (high blood sugar) (increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, Kussmaul breathing (a deep and labored breathing pattern), acetone breath (smells fruity), stupor, coma. -Monitor/document/report as needed any signs or symptoms of hypoglycemia (low blood sugar) (sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait). -The care plan interventions additionally included, diabetes medications as ordered by the doctor, monitor/ document for side effects and effectiveness. Fasting serum blood sugar as ordered by the doctor. Review of Resident #1's July 2025 medication administration record (MAR) revealed the following orders:- An order dated 11/22/22 read, Jardiance (diabetic medication) tablet 25 milligrams (mg) give one tablet by mouth in the morning. The medication was documented by Nurse #2 as not administered on 7/17/25 at 8:00 AM due to drug refused. The MAR documented the medication was also not received on 7/11/25 due to drug refused. Resident #1 received all other doses as ordered for the month of July 2025. -An order dated 12/4/23 read, glucometer (blood sugar) checks before breakfast and at bedtime blood sugar goal-100-250 range. Notify Nurse Practitioner (NP) if greater than 250 consistently. For blood sugar less than 70 offer oral glucose and recheck blood sugar in 1 hour- notify Medical Doctor (MD) if blood sugar is not improved or patient symptomatic. Review of the medical record revealed Resident #1 had blood sugar results that ranged from 30-439 during the month of July 2025. -An ordered dated 2/27/25 read, Humalog (short acting insulin/diabetic medication) Kwik Pen subcutaneous solution pen injector 100 unit/ ml inject as per sliding scale:if 0 - 150 = 0151 - 200 = 2 units 201 - 250 = 4 units 251 - 300 = 6 units 301 - 350 = 8 units 351 - 400 = 10 units401 - 450 = 12 units451 - 999 = call Medical Doctor (MD)Subcutaneously before meals and at bedtime for diabetes. The order was discontinued on 7/17/25 at 1:39 PM. The MAR documented the medication was last administered on 7/15/25 at 8:00 PM. - An order dated 2/28/25 read, Tresiba (long-acting insulin/diabetic medication) FlexTouch subcutaneous solution pen injector 100 unit/ milliliter (ml) inject 45 units subcutaneously in the morning. The MAR documented the medication was last administered on 7/16/25 at 9:00 AM All of Resident #1's morning (8:00 AM and 9:00 AM) and evening (2:00 PM and 5:00 PM) scheduled medications on 7/17/25 were documented as not administered by Nurse #2 due to drug refused. Additional review of Resident #1's medical record revealed that there was no standing order for the administration of IM glucagon. Review of Resident #1's medical record revealed there were no nursing note entries from Nurse #1 on 07/17/25. An interview was conducted on 8/7/25 at 9:09 AM with Nurse #1. She was the night shift (11pm-7am) nurse for Resident #1 on the morning of 7/17/25. Nurse #1 recalled Resident #1 and her low blood sugars on the morning of 7/17/25. Nurse #1 recalled around 5:30AM she checked Resident #1's blood sugar when she started her morning medication pass. Nurse #1 said Resident #1's blood sugar reading was very low and was 31. She remembered Resident #1 was lethargic and in and out of it, she stated Resident #1 would open her eyes and look at her and mumble inaudibly but would then close her eyes and go back to sleep. Nurse #1 said she would not have felt comfortable giving Resident #1 anything by mouth, that she was not alert enough. Nurse #1 explained she had IM glucagon in the medication cart and administered the IM glucagon to Resident #1 right after she got the blood glucose reading of 31. Nurse #1 said she did not open Resident #1's MAR or look at her orders for instructions on how to treat her hypoglycemia. She explained a few months ago Resident #1 had an episode of low blood sugar and IM glucagon had been used to treat the low blood sugar. Nurse #1 stated she assumed after that episode Resident #1 had an as needed standing order for IM glucagon. She reported she thought it was pretty standard and that all diabetic residents had an as needed order for IM glucagon. Nurse #1 stated after she administered the IM glucagon to Resident #1, she rechecked her blood sugar every 15 minutes. She recalled at first Resident #1's blood sugar went up steadily but then it started to drop back down. Nurse #1 said the highest she could get Resident #1's blood sugar up to was 66. She stated by the time the day shift Unit Manger (UM #1) came in around 6:45 AM her blood sugar was back down to 61. Nurse #1 said when UM #1 arrived at the facility she turned over care of Resident #1 to UM #1 because she had worked on Resident #1 for an hour and a half and 61 was the highest, she could get her blood sugar. Nurse #1 reported she asked UM #1 to call the on-call provider to let them know Resident #1 had an episode of hypoglycemia and what had been done to treat it and that what had been done was not being effective. Nurse #1 explained she did not call the on-call provider during her shift when Resident #1's blood glucose was 31. Nurse #1 stated she was going to call the on-call provider after she treated Resident #1's hypoglycemia and let them know if it was effective or not but she did not. She explained she did not document the every 15 minute blood sugar check results in Resident #1's medical record but she did write them down and gave them to UM #1. Nurse #1 stated she had asked UM #1 if she would call the on-call provider and ask them what to do and call Resident #1's family member to update them. Nurse #1 stated UM #1 said she would document the blood sugar results, call the on-call provider, and call Resident #1's family. Nurse #1 reported she did not notice any seizure like activity or vomiting for Resident #1. A progress note by UM#1 dated 7/17/25 at 7:13 AM read, night nurse reported resident was experiencing hypoglycemia, blood sugars as follows: 5:30 AM-31, 5:45 AM- 52, 6:00 AM- 56, 6:15 AM-61, 6:30 AM- 66, 6:45 AM- 61. On call notified and was advised to put sugar under her tongue and recheck blood sugar in 30 minutes. An additional progress note dated 7/17/25 at 8:33 AM by UM #1 read, blood sugar is 61 and resident is still not responding, called provider and left message for NP, as to resident's condition.An order dated 7/17/25 entered at 1:00 PM on the MAR read, please have midline catheter (IV access) placed one time only for 2 days. A progress note dated 7/17/25 at 2:11 PM by UM #1 read, [mobile X-ray vascular company] called to come and start PICC (peripherally inserted central catheter) line, informed they will be here around 3:15 PM. Rocephin (antibiotic) 1 gram, administered IM 1 gram in left hip and 1 gram in right hip, resident obtunded and made no response. [NP] notified. An interview was conducted with UM #1 on 8/6/25 at 3:05 PM. UM #1 reported she arrived at work on 7/17/25 between 6:30 AM and 7:00 AM, but she did not recall the exact time. She said Nurse #1 reported to her when she arrived that Resident #1 had low blood sugar during the night. UM #1 said Nurse #1 reported she had given Resident #1 IM glucagon. UM #1 reported she documented the blood glucose results reported to her by Nurse #1 because she thought it was prudent to do so. UM #1 stated Nurse #1 did not ask her to call the on-call provider or Resident #1's family. UM #1 remembered calling the on-call provider about Resident #1's low blood sugar at the start of her shift but did not recall the exact time. She recalled the on-call provider gave her instructions to put sugar under Resident #1's tongue and recheck her blood sugar in 30 minutes. UM #1 stated when she went to put the sugar under Resident #1's tongue her mouth and jaw were tight, and she could not open her mouth. UM #1 said she did not want to pry open and force Resident #1's mouth open to put the sugar under her tongue. She reported she tried to put the sugar into her cheek as best as she could. She did not recall Resident #1 having tight arms or abnormal eye movement when she was in the room with her and no one had reported that to her. UM #1 said she did not recall Resident #1 having any seizure like activity. UM #1 stated Resident #1 was given another dose of glucagon at some point, but she was not entirely sure when. UM #1 explained she thought there was no more glucagon in the building but that when she looked, she was able to find another dose of glucagon on the other side of the building. She was not sure if it was in the morning or the afternoon when she found the second dose. UM #1 stated she did not administer any glucagon to Resident #1 on 07/17/25. She reported when she found the glucagon she gave it to Nurse #2 to administer. She stated she was not sure if Resident #1 had an order for glucagon but thought it was a standing order for diabetic residents. UM #1 said Resident #1's blood sugar hoovered between 50 and 60 throughout the day, she stated Resident #1's blood sugar never came up above 61. She explained that a Registered Nurse (RN) who worked for the NP provider group (Nurse #3) was at the facility and was in and out of Resident #1's room all day. She said when Nurse #3 arrived at the facility she took over care of Resident #1 and communicated with the NP directly. UM #1 recalled that Nurse #3 attempted several times to start an intravenous (IV) access site on Resident #1 but was unsuccessful. She recalled 5% dextrose in water (D5W) was administered to Resident #1 by hypodermoclysis (clysis) (fluids administered subcutaneous) by Nurse #3. UM #1 recalled talking to the NP about vascular access for Resident #1 and setting that up with the mobile vascular company to come to the facility and place a midline (vascular access) for Resident #1. She stated she called the mobile vascular access company and set up for them to come to the facility to place the midline with an estimated time of arrival at 3:15 PM that day. UM #1 said she was in and out of Resident #1's room during the day and Resident #1 was not awake, not alert, and was not responsive at all the entire time. When asked if Resident #1 was able to eat or drink anything that day, UM #1 stated [NAME] no she was not eating she was somnolent [sleepy/drowsy]. UM #1 did not recall if she asked the NP about sending Resident #1 to emergency room (ER) when she spoke to her on the phone. UM #1 stated if it had been the facility's Medical Director provider group they would have sent Resident #1 out. UM #1 stated if she was the provider she would have sent Resident #1 out to the ER but that that was not a nurse's call to make. UM #1 stated she had no idea why the NP did not send Resident #1 out earlier. UM #1 reported Nurse #2 called Resident #1's family to update them on what was going on but was not sure what time she called. UM #1 explained Resident #1 was sent out the ER that afternoon after Nurse #2 called the family. UM #1 stated she did not see Resident #1 when she went out. A progress note dated 7/17/25 and timed 5:10 PM by Nurse #3 read, Seen today at the request of the nurse for low blood glucose levels. Nurse reports that member with noted blood glucose levels this morning 31-61. It was reported that she received 1 mg glucagon injection prior to my arrival. She is seen lying in bed, eyes open but she appears obtunded. [Capillary Blood Glucose] CBG at that time was 43. Glucagon 1 mg was repeated. NP aware with new order to obtain IV and administer D5 [5% dextrose (sugar) in water]. IV attempted x 3 unsuccessful. Clysis [fluids given subcutaneously] was initiated at that time at 60cc [cubic centimeters]/hr. Blood glucose levels checked periodically after initiation of clysis and slowly increased to 74, however she remained obtunded with no verbal responses. Underlying infection suspected- UA [urinalysis] C&S [culture & sensitivity] ordered, Rocephin [antibiotic] 2 gm IM x 1 dose. Tresiba decreased to 38 units daily- hold for CBG less than 150, SSI [sliding scale insulin] discontinued. Also order to have midline [vascular access] placed for continuous fluid with initial 500 cc bolus of NS [normal saline] and then resume D5 at 125cc/hr for remainder of current liter. She has had no po [by mouth] intake today and NA caring for member reports very little po intake for the previous day. UM updated on orders and reports that call has been placed for midline and approximate ETA [estimated time of arrival] is 3:15 pm. VS [vital signs] ordered every 4 hours x 3 days and CBG every 3 hours x 24 hours. NP left message for son to return call. Administrator also updated. Staff to notify provider group with any concerns or needs. An order dated 7/17/25 entered at 1:30 PM read, ceftriaxone (Rocephin) (antibiotic) injection solution, inject 2 grams (gm) intramuscularly one time only for urinary tract infection (UTI) for 1 day. An order dated 7/17/25 entered at 2:30 PM read, normal saline flush intravenous solution 0.9 %, use 500 ml intravenously one time only for dehydration for 1 day bolus 999 ml /hour (hr.) once midline placed. An order dated 7/17/25 entered at 1:45 PM read, dextrose (glucose) intravenous solution 5 %, use 1 liter intravenously one time only for Dehydration for 1 Day, 60 ml/hr. clysis. Call NP once midline placed. An interview was conducted on 8/6/25 at 4:33 PM with Nurse #3. Nurse #3 worked for the NP's provider group and with the NP which was a separate provider group from the Medical Director provider group. She explained she went to the facility several days a week to check on their patients. She reported she arrived at the facility around 9:00 AM on 7/17/25. She stated the NP called her that morning before she arrived at the facility and updated her that Resident #1 was having problems with low blood sugar. Nurse #3 reported when she arrived at the facility, she went to see Resident #1 first. Nurse #3 explained she checked Resident #1's blood sugar when she arrived and it was 43. Nurse #3 said it was reported to her Resident #1 had been given glucagon before she arrived, she was not sure what time it was given. She explained it was told to her there was no other glucagon available in the building at that time. Nurse #3 said when she arrived, Resident #1 was not her normal self and was not verbally responsive. She said Resident #1 was not able to take fluids, she explained she was not able to swallow the fluids and would just hold the fluids in her mouth. Nurse #3 explained she spoke with the NP and communicated with her throughout the day about Resident #1. She said the NP had wanted her to try to start an IV on Resident #1 to administer fluids. She further explained they had wanted to administer IV fluids because they were worried Resident #1 would aspirate because she was not swallowing and was holding fluids in her mouth. Nurse #3 stated she assumed Resident #1 usually did not have any trouble swallowing because she normally ate and drank. Nurse #3 said she tried three times to place an IV access site unsuccessfully. Nurse #3 reported then the facility found more glucagon and they gave it to Resident #1. She did not see them administer the glucagon and was not sure who administered it to Resident #1, but she thought it was UM #1. She thought it had been sometime between 9:00-10:00 AM but was not sure of the exact time. Nurse #3 was not sure what Resident #1's blood sugar came up to after the second dose of glucagon was administered. Nurse #3 said around 10:00 AM she started D5W administered by hypodermoclysis on Resident #1. She reported Resident #1's eyes were open, but she was not verbally responsive. Nurse #3 said she did not stay at Resident #1's bedside the entire time, she explained she had other patients to see at the facility. She reported she was in and out of Resident #1's room every 15-20 minutes to check on her and recheck her blood sugar. Nurse #3 said Resident #1's blood sugar was 55 at 12:06 PM. She explained she had checked Resident #1's blood sugar before that but did not remember what the blood sugar results were. She further explained she had rechecked her blood sugars to make sure they were going up and not falling, she recalled they had been going up but did not remember the results. Nurse #3 said after the hypodermoclysis was started she spoke to the NP again and the NP thought it would be best to get a mid-line (vascular access) placed for Resident #1. She did not remember what time she talked to the NP but said it was sometime between 10:00 AM- 12:00 PM. She said UM #1 called the mobile vascular access company and they were able to come to the facility at 3:15 PM that day to place the midline. Nurse #3 reported Resident #1 stayed in bed the entire day. She said she had arrived at the facility after breakfast, but the staff reported to her Resident #1 did not eat breakfast. Nurse #3 said Resident #1 did not eat lunch or anything because she was not alert enough to eat. She reported Resident #1's mentation was the same and unchanged the entire time she was there. Nurse #3 said she did not stay at the facility the entire day. She explained she left the facility sometime after lunch before the 3-11 shift change but was not sure of the exact time. She said Resident #1's last blood sugar before she left was 74 and she still had no improvement in her mental status. She explained she spoke with the NP, and they thought maybe there was another issue other than Resident #1's low blood sugar causing her decreased mental status. She explained that was why the NP ordered the intramuscular Rocephin (antibiotic) and a urinalysis (UA) for Resident #1. Nurse #3 said she was not in the room when the Rocephin was administered to Resident #1, but it was reported it had been given to her. Nurse #3 said she had not called the family but that the NP told her she had tried to call and update Resident #1's family. When Nurse #3 was asked if she and the NP discussed transferring Resident #1 to the ER, Nurse #3 said the NP had asked her what her thoughts were. Nurse #3 reported she told the NP she was at the facility and would hang around and see how Resident #1 did. Nurse #3 explained they were doing the fluids with hypodermoclysis and were going to be able to get the midline placed and would be able to get some hydration in her. She further explained the initial concern was her low blood sugar and treating her hypoglycemia. She reported that if Resident #1 had not stabilized after the midline was placed then she would have needed to go the ER. Nurse #3 stated she had not witnessed Resident #1 having any seizure activity. Nurse #3 stated she had not noticed any tightness in Resident #1's hands, arms, or jaw, abnormal eye movements, or foaming at the mouth. A progress note by Nurse #2 dated 7/17/25 at 7:45 AM read: On coming to shift during report resident was reported to have struggled with low blood sugars throughout the night. Last blood sugar check was 61 at on coming of shift 7:00 AM. I was told to recheck blood sugar at 7:30 AM and call provider back. I rechecked blood sugar at 7:30 AM blood sugar dropped down to 59. I called provider to inform her of blood sugar level. Provider stated to just hold short acting and long-acting insulin for the morning and to recheck in an hour and give her a call back. Resident in bed. Eyes rolling side to side. Moaning. hands tight. Informed unit manager to recheck in an hour and call provider back. A progress note dated 7/17/25 at 1:08 PM by Nurse #2 read, [Nurse #3] nurse reported resident's blood sugar increased to 77. Resident does have hypodermoclysis in right low abdominal. Resident is looking around. [Nurse #3] with resident. An interview was conducted with Nurse #2 on 8/6/25 at 2:53 PM. Nurse #2 was the day shift (7-3) and evening shift (3-11) nurse for Resident #1 on 7/17/25. Nurse #2 stated when she arrived on shift, the night shift nurse (Nurse #1) reported to her Resident #1's blood sugars were extremely low in the 30's. Nurse #2 reported, she said 33 to be exact. Nurse #2 stated Nurse #1 reported to her the on-call provider was aware of Resident #1's low blood sugar and had said to recheck Resident #1's blood sugar around 7:30 AM and call the on-call provider back with what Resident #1's blood sugar was. Nurse #2 said she rechecked Resident #1's blood sugar at 7:30 AM and it was in the 50's, she did not recall the exact number. She reported she called the on-call provider back after checking Resident #1's blood sugar at 7:30 AM and was told by the on-call provider to hold Resident #1's insulin. She stated the provider instructed her to try to give her something to eat to increase her blood sugar and to recheck her blood sugar in an hour. Nurse #2 stated she told the provider she did not have time to do that or keep rechecking Resident #1's blood sugar because she had to pass medications and check blood sugars for her other diabetic residents, so the NP's provider group sent a Nurse (Nurse #3) who worked for the NP provider group to help with Resident #1. She explained Nurse #3 was with Resident #1 during her day shift while she worked with the other residents, she was assigned to take care of. She reported UM #1 was also helping with Resident #1 throughout the day. Nurse #2 did not recall Resident #1 having abnormal eye movements and tight hands during the morning or reporting it to anyone. Nurse #2 said she remembered that more from the evening right before Resident #1 went out. She stated Resident #1's eyes were moving left and right slowly like her head was turning side to side but her head was not moving, and her arms were tight and hard to move. She said Resident #1 was not talking or responding. Nurse #2 said Nurse #3 checked Resident #1's blood sugars while she was at the facility and had communicated with the NP. She did not know what the blood sugar results were but reported Nurse #3 told her Resident #1's blood sugar would go up and then drop back down. Nurse #2 stated she did not administer any glucagon to Resident #1. She reported glucagon had not been mentioned to her to administer. Nurse #2 said it was the providers' call for how low someone's blood sugar needed to be before they sent them out to the hospital. Nurse #2 stated Nurse #3 left sometime around the 3-11 shift change. Nurse #2 said she needed someone there to help with Resident #1 because she had other residents to take care of. When she noticed no one was going to be there to watch Resident #1 she spoke to UM #1 and recalled UM #1 had to do something else. Nurse #2 reported she went and checked Resident #1's blood sugar herself and it was low, she said she could not remember the exact number but remembered it was in the 50's once again. Nurse #2 said she asked UM #1 if anyone had called Resident #1's family to let them know what was going on and UM #1 told her she had not. Nurse #2 said she looked in the nursing notes to see if anyone had reached out to the family and saw no one had called, so she called the family to let them know what was going on. She did not recall the exact time she called Resident #1's family. Nurse #2 stated Resident #1's family member arrived at the facility not long after she called them. She said when Resident #1's family member saw Resident #1 they were concerned about the way she looked and requested for her to be sent out to the hospital. Nurse #2 stated she called the provider and let them know Resident #1's family was requesting for her to go out to the hospital. She reported she called the on-call provider and the on-call provider initially said they were going to call the NP, Nurse #2 reported she told the provider her family wanted her to go to the hospital as soon as possible (ASAP) and the provider then said okay. Nurse #2 said she thought Resident #1 needed to go to the hospital that morning and that was why she had called the provider. She explained when someone's blood sugar was that low, she felt it was above the capabilities of the facility and that they could only do so much at the facility. She further explained they had been trying to increase her blood sugar, and it was going up and then dropping back down, she said there was only so much that could be done at the facility. Nurse #2 stated she called Resident #1's family herself because she knew Resident #1's family was usually there for her and had not been there that day, she thought Resident #1's family would want her to be sent out and what the family wanted went above the NP. She reported that Emergency Medical Services (EMS) arrived at the facility quickly after she called them. Nurse #2 stated she thought Resident #1 went out around 4:40 PM.An interview was conducted with Nurse Aide (NA) #1 on 8/6/25 at 5:00 PM. NA #1 recalled she had worked 1st shift (7am-3pm) and 2nd shift (3pm-11pm) on 7/17/25, she did not recall if Resident #1 was assigned to her that day but said she remembered going into her room to provide care to her on 7/17/25. She remembered 7/17/25 was the day she was transferred to the hospital. She recalled she was doing rounds when a nurse was trying to put an IV site in Resident #1, and she could not get to her for rounds. She recalled it had been between 10:00-11:00 AM and Resident #1 had been foaming at the mouth. She said in the afternoon right before Resident #1 went out to the hospital she was foaming at the mouth again, she said it had been around the 3-11 shift change. NA #1 recalled she had asked the nurse why Resident #1 was having foaming at the mouth. She reported the nurse told her they were handling it., She thought the nurse she spoke to was UM #1. An order dated 7/17/25 entered at 1:15 PM read, Glucagon Emergency Injection Kit 1mg, inject subcutaneously as needed for low capillary blood glucose (CBG), recheck CBG in 15 minutes. The glucagon was not documented as administered on the MAR. There were no other orders for glucagon present on the MAR. The order was entered by Nurse #4. An interview was conducted with Nurse #4 on 8/14/25 at 4:15 PM. Nurse #4 said she was not Resident #1's nurse on 7/17/25 but had worked day shift (7am-3pm) that day. She explained she had been an extra nurse and had been trying to help where needed that day. Nurse #4 reported she entered the order for IM glucagon into the electronic medical record for Resident #1 because UM #1 had asked her to. Nurse #4 said she did not know when the glucagon was administered or who had administered it. She remembered seeing Resident #1 during the morning on 7/17/25, she said Resident #1 was not well. Nurse #4 explained Resident #1 had a decreased level of consciousness and her eyes looked weird. She said Resident #1's eyes were set like they were stuck, and she showed no response when you spoke or talked to her. She stated Resident #1's eyes were open, but she was not alert or responsive. Nurse #4 recalled Resident #1's eyes would move but not like she was following or focusing on anything. She further recalled her eyes rocking back and forth moving left and right very slowly but she was not moving her head. Nurse #4 said her eyes were not always like that, that sometimes they would just stare straight off and then other times they would move slowly back and forth. Nurse #4 remembered being in Resident #1's room at mealtime, she did not say what meal but said the NA attempting to assist Resident #1 with her meal stated he could not feed Resident #1 because she would not open her mouth. Nurse #4 reported she told the NA Resident #1 did not look safe to eat. Nurse #4 said as far as she knew Resident #1 did not eat anything that day, she said she was not safe to eat because she was not alert enough. She did not remember the name of the NA. Nurse #4 reported she was in and out of Resident #1's room during her shift just checking on her because she was concerned and curious about what was going on. Nurse #4 stated she saw Resident #1 multiple times during her shift, she said she was trying to be helpful and available if she was needed. Nurse #4 stated she remembered Resident #1's blood sugar was in the 30's multiple times during the day. She was not sure about Resident #1's blood sugars from the night shift but remembered during the day shift her blood sugars were in the 30's and 50's multiple times. Nurse #4 stated she thought one time they were able to get Resident #1's blood sugar up to the 70's but then it dropped again. Nurse #4 said her shift ended at 3:00 PM and she left sometime between 3:00 PM and 4:00 PM that day. She recalled hearing Nurse #2 talking to Resident #1's family on the phone right before she left. Nurse #4 stated Resident #1 did not wake up and was non-responsive the entire time. Nurse #4 said Resident #1 was pretty much the same from the time she got there in the morning until she left at the end of her shift that day. She reported she did not remember seeing anything that lo

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #15 was initially admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses that included: displaced intertrochanteric fracture of the right femur, subsequent encounter for closed fracture with routine healing, muscle wasting/atrophy multiple sites, and primary osteoarthritis. Resident #15's care plan was last updated on 11/08/24 as being at risk for falls related to confusion, gait/balance problems, psychoactive drug use, unaware of safety needs, wandering and history of falls and used a reclining chair, with interventions that included fall mat at bedside, anticipate resident's needs, and bed in lowest position while resident is in bed. Resident #15 was also care planned for pain related to arthritis and hepatic (liver) mass with interventions that included administer analgesics as ordered, monitor/document for signs and symptoms of nonverbal pain, monitor/report/record resident complaints of pain to the nurse. Resident #15 had an active physician's order dated 11/11/2024 for oxycodone-acetaminophen (pain medication) oral tablet 7.5-325 milligrams (mg) give one tablet by mouth two times a day for pain management. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 was moderately cognitively impaired. Review of a discharge MDS assessment dated [DATE] indicated Resident #15 had a fall with major injury. Review of the progress note dated 12/28/2024 at 4:41pm, written by the Director of Nursing (DON) revealed the DON heard Resident #15 yelling and as the DON arrived at Resident #15's doorway the DON observed Resident #15 as she attempted to get out of bed. The DON was unable to reach Resident #15 before she fell onto her right side onto the fall mat. Resident #15 did not strike head but yelled out my hip is broken. The DON assessed Resident #15, leg length could not be assessed due to mild contraction. Resident #15 expressed pain when area to right hip was touched. Facility Physician Assistant (PA) was contacted and orders received to obtain right hip x-ray and to give a one-time dose of oxycodone 2.5 mg related to acute right hip pain. The progress note indicates Resident #15 was assisted back to bed by staff x 3 and x-ray was pending. Review of Resident #15's orders revealed on 12/28/2024 at 4:25 PM the PA ordered oxycodone HCL 5mg tab- give 0.5 (half) tablet by mouth one time only for right hip pain x 1day. Review of Resident #15's orders revealed on 12/28/2024 at 4:32 PM the PA ordered an x-ray of Resident #15's right hip one time only for pain x 1 day. Review of the x-ray completed on 12/29/2024 with results reported to the facility on [DATE] at 2:09 PM revealed Resident #15 sustained an acute right femoral intertrochanteric fracture. An interview with the DON on 6/20/2025 at 11:04 AM revealed she cared for Resident #15 on 12/28/2024 3:00 PM to 11:00 PM. The DON stated on 12/28/2024 she heard Resident #15 yelling for help and when she came to the door, Resident #15 was attempting to get out of bed and the DON was unable to reach Resident #15 in time, Resident #15 fell out of her bed, onto her right side. The DON stated Resident #15's bed was in the lowest position and Resident #15 had fallen onto her fall mat next to the bed. The DON stated Resident #15 yelled that her hip was broken. The DON stated she immediately assessed Resident #15. The DON stated due to Resident #15's legs being contracted it was difficult to assess the length of Resident #15's legs. The DON stated she called the facility PA to report the fall and received orders for a right hip x-ray and oxycodone 2.5 mg for pain. The DON stated after she received the orders from the PA, she and two staff members transferred Resident #15 back to her bed with a mechanical lift. The DON stated after being transferred back to bed and pain medication was administered, Resident #15 attempted to crawl out of the bed multiple times. The DON stated Resident #15 was then transferred using the mechanical lift into her reclining chair and placed next to the nurse's station. The DON verified when Resident #15 was placed in the reclining chair she was sitting up, unsure of the exact position, but stated it was probably 90 degrees because the reclining chair was not reclined. The DON stated that sitting at a 90 degree angle was not a good position to be in for a resident experiencing hip pain after a fall, but since Resident #15 was continuing to attempt to get up the DON felt it was the best option at that time. The DON verified she instructed the staff to get Resident #15 up into the reclining chair to prevent further falls. The DON stated Resident #15 had a history of yelling out and with her continued movement she did not think Resident #15 had sustained a fracture. The DON stated the PA had only given an order for the x-ray to be obtained, and did not specify it should be a stat (now) order. The DON stated that when Resident #15 was in her chair at the nurse ' s desk, Resident #15 responded she was not in pain when asked. The DON stated she called in the order for the right hip x-ray to the mobile x-ray service. The DON stated the x-ray was not called in stat. The DON stated a mobile x-ray order placed in the evening or on a weekend had the potential to not be completed until the next day. The DON stated she reported to the oncoming shift, Nurse #1, that an x-ray was ordered and was waiting to be completed for Resident #15. The DON stated that typically the mobile x-ray reports were automatically uploaded into the resident electronic medical record and any nurse with access to the medical record could review x-ray reports. If there was positive fracture results the mobile x-ray company would call and alert the facility. Once the facility was notified, she would expect the staff to immediately notify the provider for further orders. The DON added that she believed there was a delay in the facility receiving the x-ray report which also delayed Resident #15 in being transferred to emergency room (ER) for evaluation. During a telephone interview on 6/20/2025 at 12:12 PM Nurse #4, who was scheduled 11:00 PM to 7:00 AM on 12/28/2024 and 12/29/2025, stated he did not recall Resident #15 specifically or any information related to a fall. He stated he may have been scheduled to take care of Resident #15 but did not remember back that far. Review of Resident #15's Medication Administration Record (MAR) dated December 2024 revealed the following documentation: On 12/28/2024 at 6:55 PM oxycodone 2.5 mg was documented as administered by the DON for a pain level of 8 out of 10. On 12/28/2024 at 9:00 PM scheduled oxycodone-acetaminophen 7.5-325 mg was documented as administered by the DON. Pain assessments on 12/29/2024 revealed a documented pain level of 0 out of 10 on all 3 assessments. Pain assessment on 12/30/2024 revealed a documented pain level of 0 out of 10, for the shift 11:00 PM to 7:00 AM. Review of Resident #15's electronic medical record revealed no documentation regarding Resident # 15's right hip or x-ray in the progress notes that were dated 12/29/2024. Review of the 24-hour report sheets from 12/29/2024 indicated Resident #15 was status post fall day 1 and mobile x-ray company was coming 12/29/2024 in AM for right hip x-ray. Review of the x-ray results completed on 12/29/2024 at 1:19 PM revealed Resident #15 sustained an acute right femoral intertrochanteric fracture. Multiple attempts to reach Nurse #17, who worked with Resident #15 on 12/29/2024 from 7:00 AM to 3:00 PM were unsuccessful. Multiple attempts to reach Nurse #18 who worked with Resident #15 on 12/29/2024 from 3:00 PM to 11:00 PM were unsuccessful. During a telephone interview on 6/20/2025 at 4:35 PM Nurse #5 stated she was not at work when Resident #15 fell on [DATE] but worked on 12/30/24 and received the x-ray results. Nurse #5 stated she answered a call from the mobile x-ray company, who called to verify the facility had received the x-ray results for Resident #15. Nurse #5 stated after she received the call, she checked the electronic medical record for radiology results, saw that it indicated a fracture, printed the report and immediately brought it to the facility PA who reviewed the x-ray report and gave orders to send Resident #15 to the emergency room. Nurse #5 stated once she received the order from the PA she immediately called 911 for transport and started the process to send Resident #15 to the hospital. Review of Resident #15's electronic medical record revealed a Physician progress note dated 12/30/2024 at 1:16 PM written by a Nurse Practitioner (NP) that indicated Resident #15 had reported pain at a 10 out of 10 when she was assessed, but in no apparent distress, and no tenderness to palpation of bilateral upper and lower extremities, unable to test range of motion in the right lower extremity due to increased pain, and nursing reports she is being sent to the hospital for right hip fracture. During a telephone interview on 6/20/2025 at 12:56 PM the facility NP stated she had seen Resident #15 on the morning of 12/30/2024 as part of her rounds. Resident #15 complained repeatedly that her pain was 10 out of 10. The NP stated she was not aware of the hip fracture before she saw Resident #15 on 12/30/24. The NP stated after she saw Resident #15, she went to the nursing staff to report the resident's pain and was told Resident #15 was being sent to the hospital. The NP stated she would normally inform the facility PA but since she was informed the Resident was being sent out, she did not talk to the facility PA. Review of progress notes revealed a note dated 12/30/2024 at 9:29 AM written by Nurse #2 revealed x-ray results were received and reported to the facility PA and orders to send Resident #15 to the emergency room for further evaluation and treatment of right hip were received. Report was called to the hospital and Resident #15 was transferred to the hospital. Review of Resident #15's hospital records dated 12/30/24 revealed Resident #15 presented to the hospital on [DATE] with a right intertrochanteric femoral fracture and underwent closed reduction and cephalomedullary (hardware used to fix broken bones) nail fixation. Documentation from hospital physician revealed Resident #15 was confused, voiced right hip pain, no painful response noted when right hip was palpated, and resident had active range of motion in bilateral lower extremities while in bed. During an interview on 6/20/2025 at 8:52 AM the Physician Assistant (PA) stated he had received a call from the DON regarding Resident #15 and a fall on 12/28/24. The PA stated he did not recall the DON reporting that Resident #15 yelled my hip is broken, but that wound not have changed his mind regarding the order for the x-ray and not sending Resident #15 to the hospital on [DATE]. The PA stated Resident #15 was not a reliable historian. The PA stated he had received report Resident #15 did not have leg shortness. The PA stated normally an x-ray would take about 4 hours to be completed, but on evenings and weekends it sometimes took longer. The PA stated he was not aware that Resident #15 had been placed in the reclining chair prior to the x-ray being completed. The PA stated he would expect a resident to stay in bed until the x-ray had been done. The PA stated when he arrived at the facility on 12/30/2024 he was informed of Resident #15's x-ray results and immediately gave orders for Resident #15 to be sent to the hospital for an orthopedic evaluation. The PA stated they have on call providers on the weekend and ideally the x-ray results would have been received on 12/29/2024 and reported to him or the on-call provider and Resident #15 would have been sent to the hospital on [DATE]. During a telephone interview on 6/26/2025 at 11:23 AM the facility Physician stated x-ray reports were faxed to the facility and available in the resident ' s electronic medical record. The Physician stated all nurses would have access to review the x-ray results in the medical record and the fax would come in on the copy machine in the hallway. The Physician stated agency nurses may know to check the copy machine, but she would expect the nurses to answer the phone as soon as they were able and review the chart for results if an x-ray was pending. During a joint interview on 6/20/2025 at 4:35 PM with the Interim DON and Administrator, Interim DON stated she was not going to provide an answer to questions regarding the fall because she thought a loaded question had been asked and did not want to comment on an event she did not have all the details for. The Administrator stated she felt Resident #15 had received appropriate care after her fall on 12/28/2024. The Administrator stated after a fall she expected a nurse to assess the resident, notify the provider and report the findings from the assessment. The Administrator stated she felt the DON did what was appropriate to keep Resident #15 safe. The Administrator stated she would expect a resident with a fracture to be sent to the hospital once they were notified of the fracture. Based on record review, and resident, staff, Nurse Practitioner (NP), Physician Assistant (PA), Physician, and Contract Transport Company Owner interviews, the facility failed to complete a clinical assessment of injury after a fall. Resident #101 was being transported back from a medical appointment in a contract transport van in her specialized wheelchair. Resident #101 was not secured in wheelchair according to the manufacturer's instructions. Driver #1 hit a bump pulling into the facility entrance which caused Resident #101 to fall forward, landing partially out of her wheelchair with her legs under the chair. Driver #1 notified staff at the facility Resident #101 had fallen. Nursing Assistant (NA) #1 and NA #2 entered the van and lifted Resident #101 back into her chair without having the resident assessed for injuries by a nurse or medical provider. NA #2 returned Resident #101 to her room and notified Nurse #1 (agency nurse) who then completed an assessment of Resident #101. NA #1 and NA #2 were not qualified to provide a comprehensive physical assessment to determine if Resident #101 sustained any acute injury. In addition, the facility also failed review a resident's electronic medical record for x-ray results after Resident #15's fall on12/28/24 which resulted in a delay in medical treatment. The x-ray was completed on 12/29/24 and the report was sent to the facility that same day that indicated Resident #15 had an acute right femoral intertrochanteric fracture. The x-ray results were reported to the Nurse Practioner (NP) on 12/30/24 and when assessed by the NP Resident #15 reported a pain level of 10 (based on a scale of 1 to 10 with 10 being the worst pain). Resident #15 was sent to the emergency department on 12/30/24 and underwent a closed reduction and cephalomedullary (hardware used to fix broken bones) nail fixation and returned to the facility on [DATE]. This deficient practice affected 2 of 5 residents reviewed for quality of care (Resident #101 and Resident #15). Immediate Jeopardy began on 03/26/25 when Resident #101 was not assessed for injuries by a nurse or medical provider before being moved from the floor of the transportation van after a fall. The immediate jeopardy was removed on 06/20/25 when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of a D (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and monitoring systems put into place are effective. Example #2 was cited at a scope and severity of G. The findings included: 1. Resident #101 was initially admitted to the facility on [DATE] and was readmitted to facility on 05/13/25. Resident #101's diagnoses include end-stage kidney disease, cerebral infarction (stroke), muscle weakness, and limited mobility. A review of orders revealed an order dated 11/04/24 for apixaban (blood thinner) 5 milligrams by mouth twice daily. A review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #101 was severely cognitively impaired. Resident #101 utilized a wheelchair for mobility, a mechanical lift for all transfers, and had impairments to both upper and lower extremities with contractures. The MDS also noted Resident #101 received an anticoagulant. The care plan originally initiated 02/20/24 for Resident #101 revealed Resident #101 was at risk for falls due to deconditioning. The stated goal was Resident would be free from falls. Interventions included anticipating Resident's needs, staff would ensure call device was in place, and staff would provide reminders for Resident in fall prevention. The mobility care plan stated goal was Resident #101 would have activities of daily living (ADL) care needs met with assistance from staff. Interventions included assistance for all ADL, and Resident #101 was a 2-person transfer using the mechanical lift. A review of Nurse Aide (NA) #2's written statement dated 03/26/25 revealed front-desk staff had asked her to assist getting Resident #101 out of the transport van when Driver #1 notified staff Resident #101 fell on the transport van. NA #2 saw NA #1 and asked for her help and they both went to the transport van without notifying a nurse. NA #2 wrote she observed Resident #101 out of her chair, legs folded up under her, leaning to the right side. NA #2 reported she asked Resident #101 if she was ok or if anything hurt, and Resident #101 responded no. NA #2 further reported she and NA #1 arm and armed Resident #101 back to her wheelchair. NA #2 then brought Resident #101 back to her hall and notified the nurse. An interview with NA #2 (agency staff) on 06/19/25 at 3:35 PM revealed she had walked by the main entrance when Driver #1 told the front desk staff Resident #101 fell on the transport van and needed help. NA #2 stated she could not recall what staff reported fall to her. NA #2 observed Resident #101 on the van with the buckled seatbelt around her breast and had slid down under the seatbelt. NA #2 stated Resident #101 was seated on the wheelchair footrest with both legs positioned under the chair footrest. NA #2 stated she and NA #1 lifted Resident #101 back into the wheelchair by getting her upper and lower body. They removed Resident #101 from the van via the wheelchair lift and brought Resident inside the facility. NA #2 indicated when Resident #101 was returned to her room, she reported the fall to Nurse #1. NA #2 confirmed Resident #101 was not assessed by the nurse prior to being moved from the floor of the van. She stated Resident #101 was returned to her bed for an assessment by Nurse #1. A review of NA #1's undated written statement revealed at 4:45 PM, NA #2 asked for assistance getting Resident #101 out of the transport van after a fall. NA #1 revealed Driver #1 explained Resident #101 was adjusting herself during car ride and while pulling into the parking lot, she slid out into van floor. NA #1 observed Resident #101 lying on the floor of the van on right side with her legs bent against the back of the driver's seat and back was on the footrest of the wheelchair. It was noted the seatbelt was around wheelchair. NA #1 and NA #2 lifted Resident #101 back into her wheelchair. An interview with NA #1 (agency staff) on 06/19/25 at 3:23 PM revealed she recalled NA #2 requested her help on the transport van because Resident #101 had fallen. NA #1 stated, she observed Resident #101 on the floor of the van when she arrived to assist. NA #1 indicated Driver #1 stated Resident #101 had been fidgeting and he pulled into the facility driveway, hit a bump, and Resident #101 slid out of her chair. She reported Resident #101's back rested on the wheelchair footrest, which was extended out, and both of Resident #101's legs were on the floor under the footrest of her wheelchair. NA #1 reported the seat belt was fastened and was sitting on the back seat area of the wheelchair. NA #1 stated it appeared Resident #101 had slid under the seatbelt. NA #1 revealed she and NA #2 lifted Resident #101 back into the wheelchair. NA #1 reported she grabbed Resident #101's upper body and NA #2 grabbed Resident #101's lower body and they transferred Resident #101 from the floor to the wheelchair. She stated no nurse was notified of the fall or had been present for assessment prior to Resident #101 being lifted back into the wheelchair. NA #1 stated Resident #101 denied pain and asked to get up. Once Resident #101 was back in the wheelchair, NA #1 indicated she left and returned to her assigned hall. Review of facility incident report dated 03/26/25 completed by Nurse #1 stated the NA reported Resident #101 was on the floor of the transport van. Driver #1 reported Resident #101 slid from chair in a curve. No injuries were noted upon nurse assessment by Nurse #1. The physician and responsible party were notified. Resident #101 was transferred to the Emergency Department for evaluation after the incident. Review of nursing progress notes written by Nurse #1 dated 03/26/25 revealed a progress note which stated a NA reported to Nurse #1 Resident #101 was on the floor of the transport van. The note stated Resident #101 was placed back in the wheelchair using a sling. Resident #101 was then transferred to the Emergency Department for evaluation per responsible party's request. A second progress note also written by Nurse #1 dated 03/26/25 stated Resident #101's responsible party called facility and reported Resident #101 had been evaluated at the hospital, had no injury, and would return to the facility. A telephone interview with Nurse #1 (agency nurse) on 06/19/25 at 9:02 AM revealed Nurse #1 was assigned to Resident #101 on 03/26/25 during the shift when Resident #101 slid out of her wheelchair while on transport van. Nurse #1 stated she could not recall specifics but thought Resident #101 used a special chair that reclined and not a regular wheelchair. Nurse #1 stated she could not remember if she went to the van to assess Resident #101. Nurse #1 stated if so, she would have directed staff to get the Resident up with a blanket or sheet because Resident #101 used a total lift for transfers. Nurse #1 did not know where Resident #101 had fallen out of the chair during the drive, but believed it was not far from the facility. Nurse #1 stated Resident #101 was placed in Resident's room after the incident and Nurse #1 assessed her. The interview further revealed Nurse #1 was an agency nurse and had not worked at facility for months and could not recall the name of the staff member who reported to her that Resident #101 had fallen, but knew it was an NA. Review of the hospital Discharge summary dated [DATE] revealed Resident #101 was evaluated on 03/26/25 after fall at the Emergency Department. It was noted in the discharge summary that Resident #101 received an anticoagulant. The hospital record stated Resident #101 had no signs of acute injury upon assessment and had no complaints of pain during visit. A computed tomography (CT) of Resident #101's head, thoracic (middle) spine, and lumbar (lower) spine were completed and results indicated no acute injury was noted on the CT. A review of the Transport Company and facility contract dated 08/24/12 revealed the Transport Company would provide safe transit which was defined as transporting patients to required destinations without scare or endangerment. A review of Driver #1's undated statement revealed Driver #1 picked up Resident #101 after her dialysis treatment and secured Resident #101 into the wheelchair inside the transport van using the 4-point anchor system. Driver #1 stated he also secured Resident #101's seatbelt under her arms and snug around her midsection. Driver #1's statement further revealed when he pulled into the facility entrance, Resident #101 had slid out from under her seatbelt and was sliding out of her chair. Driver #1 contacted the facility staff for assistance and observed both NAs lift Resident #101 back into her wheelchair. Driver #1 reported one of the NAs stated Resident #101 needed a belt to better keep her in her chair as Resident #101 cannot sit up properly. Driver #1 left after Resident #101 was taken back into the facility. A phone interview was attempted with Driver #1 but was unable to be reached. Telephone interviews with the Transport Company Owner on 06/19/25 at 12:53 PM and 2:44 PM revealed he did recall the incident on 03/26/25 but could not recall who the driver was but would check his records. Transport Company Owner stated he had no written records of the incident but remembered what the driver told him. The Transport Company owner stated Driver #1 told him Resident #101 had not fallen out of the chair, but her buttocks had come out a little forward in her wheelchair when Driver #1 hit a bump pulling into the facility driveway. He reported the Driver #1 parked the transport van, and Resident #101 was on the edge of her wheelchair seat and her seatbelt still held her in the wheelchair. Driver #1 unfastened the seatbelt and lowered Resident #101 to the floor of the van. Driver #1 then entered the facility and notified the staff who helped get Resident #101 up. The Transport Company Owner stated the Driver #1 resigned from the company 6 weeks ago. The Transport Company Owner explained all drivers were trained to stop the van during any adverse event when safe to do so and tend to the residents' needs which Driver #1 did immediately after Resident #101 fell when he pulled into the facility entrance. An interview with the facility PA on 06/20/25 at 10:08 AM revealed Resident #101 was totally dependent on staff for all activities of daily living. The PA stated Resident #101 was severely cognitively impaired, and Resident had very limited mobility due to upper and lower body contractures. He reported Resident #101 was unable to do anything to brace herself or prevent a fall. The PA stated Resident #101 received an anticoagulant (blood thinner) and thus would be at risk for bleeding with any fall or accident. Due to the use of an anticoagulant, bleeding could occur anywhere in the body. With an anticoagulant, the PA indicated he would be most concerned about the possibility of a head injury with bleeding on or around the brain which would be life threatening. The interview further revealed anytime a Resident fell, they would need to be assessed by a nurse before being moved, who would then notify the provider of the fall or any injury. An interview with the Director of Nursing (DON) on 06/19/25 at 1:11 PM stated NA #1 and NA #2 were agency staff but had fall protocol training prior to starting at facility. The DON stated the NAs should have notified a nurse for a comprehensive assessment prior to Resident #101 being moved. The interview with the Administrator on 06/19/25 at 4:15 PM revealed after the incident, she had interviewed Driver #1 who stated when he had hit a bump pulling into the facility driveway Resident #101 had slid out of the wheelchair. NA #1 and NA #2 stated the driver reported Resident #101 slid out of chair. The two NAs went out to the van, but did not notify a nurse prior to moving Resident #101 for assessment. The Administrator was aware the nurse had not completed an assessment before staff moved Resident #101. From the Administrator's recollection, Resident #101 had been evaluated at the Emergency Department, and had no injury from the fall. The Administrator indicated she would have expected NAs to notify a nurse to assess Resident #101 for injury prior to moving the resident. The facility was notified of immediate jeopardy on 06/19/25 at 7:35 PM. The facility provided the following plan for IJ removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On 03/26/25, Resident #101 was picked up by a contract transportation company to transport the resident round trip to a dialysis appointment. While on the return route back to the facility the contract driver hit a bump when turning into the facility parking lot, causing Resident #101 to slide forward from the chair. The contract driver notified an employee of the facility Resident #101 had fallen out of chair. Two nursing assistants responded to the contract driver's request for assistance. The nursing assistants went to the transportation vehicle, lifted Resident #101 from the floor of the transportation vehicle, placed Resident #101 back into the wheelchair, then brought the resident into the facility. The nursing assistants notified Nurse #1 of the fall in the transportation vehicle. Resident #101 was assessed by Nurse #1, once the resident arrived at the facility and found no injuries. The physician was notified of the incident with Resident #101 by Nurse #1. The physician gave a verbal order to Nurse #1 to send the resident to the hospital for further evaluation as a precautionary measure. All residents in the facility, who are transported for appointments via contracted transportation company and by the facility transport vehicle have the potential to be at risk of being moved by nurse aides after a fall without having an assessment by qualified personnel. 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. As of 06/19/25, the facility will provide transportation services with our facility van unless the residents require stretcher service, then they are transported by EMS (ambulance service). The facility will continue with its current process of determining the appropriateness of wheelchair or stretcher transportation for residents. All residents who lack upper body strength and are unable to sit up in a wheelchair will be transported to appointment via stretcher. All appointments are discussed in the morning meeting daily for the next week with the Director of Nursing, Director of Rehabilitation and Administrator. Any resident identified at time requiring special accommodation for transport will have the change made for transportation. The care plan will be updated when the resident is identified as requiring stretcher transportation, for future reference. The facility van drivers, which included 2 alternate drivers (Maintenance Director and admission Coordinator), were educated by the Director of Facility Services on 06/20/25, to notify a nurse or medical provider if a resident falls while being transported or calling 911 immediately via their personal cell phones. A reminder notice was placed in the transportation vehicle stating to call 911 in case of an emergency. The education also included a nurse or medical provider must conduct a head-to-toe assessment of the resident prior to being moved. On 06/19/25, the Administrator in-serviced all department heads (Director of Rehabilitation, Food Service Manager, Environment Service Manager, Activities Director, Human Resources Director, Social Services, Director of Nursing, Business Office Manager, Staff Development Coordinator, MDS Coordinator and admission Director) on notifying a nurse or medical provider immediately, if notified by the driver of a fall on the van. On 06/19/25 the Staff Development Coordinator, Director of Nursing, Activities Director and Human Resources Director conducted an in-service for all employees in person and via phone including agency personnel, on what to do if they witness a resident fall. Employees, including agency personnel, will not be allowed to complete a shift before completion of this training by the Director of Nursing, Staff Development Coordinator or designee. The Staff Development Coordinator, Director of Nursing and Administrator are responsible for ensuring all employees including agency personnel have completed the training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, resident, observation, staff, Physician Assistant (PA), Transport Company's Owner, and Driver #1 (Transport Company's Driver) interviews, the facility failed to ensure a resident was safely secured in the transport company's van during the return trip from an appointment back to the facility. On 3/26/25 Driver #1 failed to secure Resident #101 in a specialized wheelchair in the Transport Company's van per manufacturer's instructions and according to Driver #1 when the van hit a bump pulling into facility entrance, Resident #101 fell forward, landing partially out of her wheelchair with her legs under the chair. Resident #101 was assisted back into the wheelchair by facility staff at the facility and was wheeled inside the facility. After being assessed by the nurse, Resident #101 was transported to the Emergency Department (ED) on 03/26/25, evaluated for injury, and then returned to the facility on [DATE] with no injury noted upon assessment at the ED. There was a high likelihood of serious injury, or death, to Resident #101 due to the resident being an unsecured passenger in a specialized wheelchair which was not designed for transportation as she was transported back to the facility from an appointment. The facility also failed to provide effective supervision to prevent a resident-to-resident altercation when Resident #76 hit Resident #58 in the lip when Resident #76 attempted to grab the television remote from Resident #58. When Resident #58 grabbed the remote back, Resident #76 hit Resident #58 on the lip. Resident #58 had a small bruise on top of his left hand, but no visible injury to lip or face. This deficient practice affected 2 of 7 residents reviewed for abuse (Resident #101 and Resident #58). Example #2 was cited at a scope and severity of D. Immediate Jeopardy began on 03/26/25 when Resident #101 was improperly secured in the wheelchair van and slid out of her wheelchair on the transportation company's van while being transported back to the facility from a scheduled appointment. The immediate jeopardy was removed on 06/20/25 when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of a D (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure completion of education and monitoring systems put into place are effective. The findings included: 1. A review of the Transport Company's van vehicle anchorage and accessory manufacturer instructions indicated wheelchairs would be anchored to the van using a retractable 4-point anchor tie-down system. Two anchors would be applied to the front base of the wheelchair and two would be attached to the back base of the wheelchair. A detachable lap belt would fasten to the floor anchor system, and chest belt would then be anchored to the side and behind the resident and applied for all wheelchair-bound residents during transport. A review of the Transport Company and facility contract dated 08/24/12 revealed the Transport Company would provide safe transit which was defined as transporting patients to required destinations without scare or endangerment. Resident #101 was initially admitted to the facility on [DATE] and was readmitted to facility on 05/13/25. Resident #101's diagnoses include end-stage kidney disease, encephalopathy (brain disease which caused confusion), cerebral infarction (stroke), muscle weakness, and limited mobility. A review of Resident #101's physician orders revealed an order dated 11/04/24 for apixaban (blood thinner) 5 milligrams by mouth twice daily; and an order dated 12/11/24 for hemodialysis every Monday, Wednesday, and Friday at 11:30 AM at the local dialysis center. A review of the annual Minimum Data Set (MDS) dated [DATE] revealed Resident #101 was severely cognitively impaired. Resident #101 utilized a specialized wheelchair for mobility, a mechanical lift for all transfers, and had impairments to both upper and lower extremities with contractures. The MDS also noted Resident #101 received an anticoagulant (blood thinner) and dialysis. The care plan originally initiated 02/20/24 included the problem for Resident #101 of the resident being at risk for falls due to deconditioning. The stated goal was the resident would be free from falls. The listed interventions included anticipating the resident's needs, staff would ensure the call device was in place, and staff would provide reminders for the resident in fall prevention. A review of Driver #1's undated statement revealed he picked up Resident #101 after her dialysis treatment and secured Resident #101 into her specialized wheelchair inside the transport van using the 4-point anchor system. Driver #1 indicated he also secured Resident #101's seatbelt Under her arms and snug around her midsection. Driver #1's statement further revealed when he pulled into the facility entrance, he noticed Resident #101 had slid out from under her seatbelt and was sliding out of her chair. Driver #1 entered the facility and requested staff assistance. The statement revealed Driver #1 observed [name redacted (NA#1)] and [name redacted (NA #2)] lift Resident #101 back into her wheelchair. Driver #1 reported one of the NA's stated Resident #101 needed a belt to better keep her in her chair as Resident #101 cannot sit up. Driver #1 left after Resident #101 was taken back into the facility. A phone interview was attempted with Driver #1, but he was unable to be reached. A review of nursing progress note dated 03/26/25 written by Nurse #1 revealed the NA reported to Nurse #1 Resident #101 was on the floor of the transport van. Review of a facility incident report dated 03/26/25 completed by Nurse #1 documented the Nursing Assistant (NA) reported Resident #101 was on the floor of the transport van. Driver #1 reported Resident #101 slid from chair in a curve. No injuries were noted upon nurse assessment by Nurse #1. The physician and responsible party were notified. Resident #101 was transferred to the ED for evaluation after the incident on 03/26/25. A review of NA #1's undated written statement revealed at 4:45 PM, NA #2 asked NA #1 to assist Resident #101 in the transport van after a fall. The statement revealed Driver #1 explained to them (NA #1 and NA #2) Resident #101 was adjusting herself during car ride and while pulling into the parking lot, she slid out into van floor. The statement revealed NA #1 observed Resident #101 lying on the floor of the van on her right side with her legs bent against the back of driver's seat and her back was on the footrest of the wheelchair. It was noted the seatbelt was around Resident #101's wheelchair. An interview with NA #1 on 06/19/25 at 3:23 PM revealed she recalled NA #2 had requested her help on the transport van because Resident #101 had fallen. NA#1 stated, she observed Resident #101 on the floor of the van when she arrived to assist. NA #1 indicated Driver #1 told them Resident #101 had been fidgeting and when he pulled into the facility driveway, he hit a bump and Resident #101 slid out of her chair. NA #1 reported Resident #101's back rested on the wheelchair footrest, which was extended out, and both of Resident #101's legs were on the floor under the footrest of her wheelchair. NA #1 reported the seat belt was fastened and rested on the back seat area of the wheelchair. NA #1 stated it appeared Resident #101 had slid under the seatbelt. NA #1 also stated Resident #101 had asked to get up off the van floor and denied any pain. NA #1 revealed once Resident #101 was back into her wheelchair, NA #1 left and returned to her assigned hall. A review of NA #2's written statement dated 03/26/25 revealed staff had asked her to assist getting Resident #101 off of the transport van when Driver #1 notified staff Resident #101 fell. NA #2 saw NA #1 and asked for her help and they both went to the transport van. NA #2 wrote she observed Resident #101 out of her chair, legs folded up under her, leaning to the right side. She reported she asked Resident #101 if she was ok or if anything hurt, and Resident #101 responded no. An interview with NA #2 on 06/19/25 at 3:35 PM revealed NA #2 had walked by the main entrance when Driver #1 told the front desk staff Resident #101 fell on the transport van and needed help. NA #2 observed Resident #101 on the van with the buckled seatbelt around her breasts and she had slid down under the seatbelt. NA #2 stated Resident #101 was seated on the wheelchair footrest with both of her legs positioned under the chair footrest. Review of the hospital Discharge summary dated [DATE] revealed Resident #101 was transferred via Emergency Medical Services (EMS) to be evaluated after fall. It was noted in the hospital discharge summary Resident #101 received an anticoagulant. The hospital record stated Resident #101 had no signs of acute injury upon assessment and had no complaints of pain during examination. A computed tomography (CT) of Resident #101's head, thoracic (middle) spine, and lumbar (lower) spine were completed and results indicated no acute injury was noted on the CT. No acute injuries were reported. No new orders were received and Resident #101 returned to facility on 03/26/25 via EMS. A review of the facility transport van vehicle anchorage and accessory manufacturer instructions, which were a different system than what was used in the transport company van, indicated wheelchairs would be anchored to the van using retractable 4-point anchor tie-down system. Two anchors would be applied to the front base of the wheelchair and two would be attached to the back base of the wheelchair. A detachable lap belt would fasten to the floor anchor system, and chest belt would then be anchored to the side and behind the resident and applied for all wheelchair-bound residents during transport. An interview with Driver #2, who was employed by the facility, on 06/19/25 at 10:50 AM revealed Resident #101 was transferred to her dialysis appointments on Monday, Wednesday, and Friday. Driver #2 reported Resident #101 used a specialized reclining wheelchair during transport. Driver #2 indicated Resident #101 was placed in a high-reclined position, while still upright during transport for resident comfort. The facility transport van had 4 detachable floor anchors that hooked to the wheelchair base which secured the wheelchair to the van. Driver #2 reported the seatbelt was placed over Resident #101's wheelchair armrest because there were no open areas on the armrest of the wheelchair to loop the lap belt through. Driver #2 indicated there was a shoulder strap attached to the lap belt, but since Resident #101 was in the reclined wheelchair, it was often not tight. Driver #2 reported Resident #101 preferred the seat belt loose around her abdomen for comfort. An observation was conducted on 06/19/25 at 1:18 PM of Driver #2 loading Resident #101 into facility transport van, not the transport company van, for a medical appointment. The observation revealed a detachable 4-point wheelchair securement system on transport van in place. Resident #101's specialized wheelchair wheels were locked, and the wheelchair was anchored using a 4-point wheelchair securement system and appeared secure. Observation of application of the lap belt revealed a removable pelvic belt which attached to the floor anchor. The pelvic belt was applied over Resident #101's lap on top of the arm rest of her wheelchair. Resident #101 was reclined slightly in the wheelchair. The detachable shoulder strap was then applied but did not contact Resident #101's body and did not cross her shoulder and chest. During observation, Driver #2 stated Resident #101's wheelchair only allowed the lap belt to go over the wheelchair armrests due to no opening on the side of the armrests. She stated the detachable shoulder strap was positioned loosely due to the type of wheelchair Resident #101 had, but Driver #2 stated she felt Resident was secured. She asked Resident #101 if the belt bothered her to which Resident #101 responded no. An observation and interview with Resident #101 on 06/16/25 revealed she was alert sitting in her specialized wheelchair after her dialysis appointment but was not able to be interviewed due to cognitive loss. An observation of the driveway was performed on 06/19/25 which revealed two entrances to the facility's main entry from the road the facility was on. The first entrance had an inclined curve that led into the parking lot. The second entrance had a short, steeper hill which turned sharply to the left into the parking lot. No discernable speed humps, holes, or bumpy areas were noted. It could not be determined which entrance Driver #1 entered the facility through on 03/26/25. Telephone interviews with the Transport Company Owner on 06/19/25 at 12:53 PM and 2:44 PM revealed he did recall the incident on 03/26/25 but could not recall who the driver was during the first interview but would check his records. He stated he had no written records of the incident but remembered what the driver told him. He stated Driver #1 told him Resident #101 had not fallen out of her chair, but her buttocks had come out a little forward in her wheelchair when Driver #1 hit a bump pulling into the facility driveway. The Transport Company owner reported Driver #1 parked the transport van, and Resident #101 was on the edge of her wheelchair seat and her seatbelt still held her in place in the wheelchair. Driver #1 reported to Transport Company Owner Driver #1 unlatched Resident #101's seatbelt and lowered the resident to the floor. Driver #1 entered the facility and told the staff who helped get Resident #101 up. During the second interview, the Transport Company Owner stated Driver #1 resigned from the company 6 weeks ago and no longer worked for them. The Transport Company Owner stated he voiced concerns to the facility about the chair for Resident #101 and felt it was unsafe. The Owner stated he had not documented this on an incident report, but he spoke with Driver #2 about his concerns. He stated he had recommended a stretcher chair which he had available for use, but the facility would not use it. He reported there were several incidents where Resident #101 would slide down in her wheelchair, and he notified the facility when that occurred, but he stated there was no record of that. He reported after that episode on 03/26/25, he refused to transport Resident #101 due to his safety concerns. He indicated he believed there was no way to place the belt on her wheelchair according to the manufacturer's instructions, thus his company could not transport her safely. An interview with the facility PA on 06/20/25 at 10:08 AM revealed Resident #101 was totally dependent on staff for all activities of daily living. The PA stated Resident #101 was severely cognitively impaired. PA indicated Resident #101 had very limited mobility due to upper and lower body contractures. PA reported Resident #101 was unable to do anything to brace herself or prevent a fall. Resident #101 received an anticoagulant (blood thinner) and thus would be at risk of bleeding with any fall or accident. Due to the use of an anticoagulant, bleeding could occur anywhere in the body. Regarding a fall when Resident #101 was on an anticoagulant, the PA would be most concerned about the possibility of a head injury with bleeding on or around the brain which would be life threatening. The interview with the Administrator on 06/19/25 at 4:15 PM revealed after the incident, she had interviewed Driver #1 who stated he had hit a bump pulling into the facility driveway and Resident #101 had slid out of her wheelchair. The Administrator indicated the transport company owner would not cooperate with the investigation and would not initially provide a statement or records of training the company provided Driver #1, but did eventually provide a written statement to the facility from Driver #1. The Administrator indicated the transport company owner never spoke to her prior to this incident about any concerns related to the safety of Resident #101's wheelchair. After the incident, the transport company owner sent an email dated 04/03/25 to the Administrator that the company had a stretcher chair available for use beginning 04/01/25. Information on the stretcher chair was included in the email. The Administrator reported the stretcher chair the transport company owner recommended had built in restraints that they were not allowed to use. The Administrator recalled at that time; the decision was made to transport Resident #101 by facility van only and no longer use the Transportation Company for Resident #101. The Administrator indicated Resident #101 had never been evaluated by therapy for transport chair needs, but a non-skid mat was added to wheelchair after the incident. The Administrator further stated Resident #101 continued to be transported by the same specialized wheelchair that was used during the 03/26/25 fall. The facility was notified of immediate jeopardy on 06/19/25 at 7:35 PM. The facility provided the following plan for IJ removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance On 03/26/25, Resident #101 was picked up by contract transportation Contracted Driver from a scheduled dialysis appointment for transport back to the facility. Prior to leaving the appointment, Driver #1 secured Resident #101's specialized wheelchair to the vehicle but failed to secure Resident #101 to the vehicle. The construction of the specialized chair prevented a snug restraint around Resident #101 and did not stop Resident #101 from falling forward in the chair. Resident #101 had a high likelihood of suffering an adverse outcome related to not being secured to the vehicle to prevent them from falling out of the chair onto the footrest and using a chair not designed for transport in a vehicle. All residents in any type of wheelchair are at risk of an adverse outcome while being transported if the wheelchair used is not secured to the vehicle in compliance with the restraint manufacturer and if they are not in a wheelchair designed for transport. 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. All staff and agency staff were in-serviced on 06/20/2025 by the Director of Nursing, Staff Development Coordinator and Human Resources on identifying safe wheelchairs to be used during transportation. This education included that any patient in a specialized wheelchair will be transported by non-emergent ambulance services or in a facility designated transport wheelchair that is designed for vehicle transportation. This education also included the removal of additional objects from the wheelchair that might be placed inappropriately and interfere with the ability to apply the restraint as designed. The contract was cancelled on 06/19/2025 for the outside transportation company used during the adverse incident. We will only use our in-house transportation vehicle except for stretcher services. All residents requiring a specialized chair for transport will be transported by EMS stretcher service until a chair designed for vehicle transportation has been obtained. The in-house transportation driver and all designated back up drivers were in-serviced on 06/20/2025 by the Regional Maintenance Director. This in-service included how to secure residents according to manufacturer's instructions during wheelchair transportation. The manufacturer's manual and restraint system manual were referenced for this training. A return demonstration by all individuals trained was performed as well. Alleged Date of IJ Removal: 06/21/25. The facility's IJ removal plan was validated on 06/21/25 by the following: Interviews with the facility transporters revealed they had received education on restraint system in van and how to secure a resident in the van per manufacturer's instructions, as well as the transport securement form that was to be completed prior to leaving facility with residents. The facility transporters also stated they had to verbalize their understanding of the education they had received and complete a demonstration showing they were capable of securing residents per manufacturer's instructions inside the van for transport. The facility transporters revealed they would only transport residents in standard wheelchairs inside the facility vans at this time and any resident that required a different type of chair for transport would have to be transported by non-emergent EMS transport. The facility cancelled their contract with the Transport Company on 06/19/25. Review of facility orientation education for new hire transport drivers verified the education included the transport securement form and educational material on van restraint system and securing residents per manufacturer's instructions into van prior to transport. Review of the audit tools and the transport securement form was completed with no issues noted. An observation was made on 06/20/25 of the facility transport driver securing a resident into their wheelchair inside the van in accordance with the manufacturer's instructions prior to being transported. Interviews were also conducted with alert and oriented residents who had been transported since 06/20/25 with no concerns and no additional transportation incidents were identified. Interviews with all staff revealed they had been educated on the correct chair to use for resident transport and if a resident required a specialized chair they could only be transported by non-emergent transport via Emergency Medical Services (EMS), making sure all residents are restrained per manufacturer's instructions in their transport chairs, remove any items from transport chairs that might interfere with the residents ability to be restrained per manufacturer's instructions, and notify administration immediately if there are any issues or concerns with a resident's transport chair. An interview with the Administrator revealed she had educated the facility transport drivers on securing residents per manufacturer's instructions into the vans, completing the transport securement form, hands-on observations of drivers securing residents into vans prior to transport, and completed audits with no issues. The Administrator also stated the facility had ordered an approved transport wheelchair but until that chair was delivered, they would only transport residents with standard wheelchairs in their facility vans and residents who required a transport wheelchair would be transported by non-emergent EMS transport. The facility's immediate jeopardy removal date was validated as 06/21/25 and the IJ removal plan completion date was validated as 06/21/25. 2. Resident #76 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia, cerebrovascular disease, and chronic obstructive pulmonary disease (COPD). The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #76 was severely cognitively impaired, had no impairment of range of motion to upper or lower extremities, and used a wheelchair for mobility. Resident #76 required moderate assistance with transfers and could propel himself in a wheelchair. A review of Resident #76's care plan noted a plan in place for behavior problems due to resistance to care, yelled at staff, verbally aggressed to roommates, and refused medications at times. The stated goal for the care plan was Resident #76 would have fewer episodes of behavior. Interventions included administering medications, explaining procedures to Resident #76 prior to care, discussing appropriateness of behaviors, and intervening to prevent injury to others. A second care plan in place noted Resident #76 had a mood problem. The stated goal was Resident #76 would demonstrate improved mood state. Interventions included administering medications as ordered. A third care plan is in place for impaired cognition related to dementia. The stated goal for the care plan is Resident #76 would be able to communicate his needs. Interventions include staff to have appropriate communication with Resident #76. Resident #58 was admitted to the facility on [DATE] with diagnoses that included cognitive communication deficit, generalized anxiety disorder, unspecified osteoarthritis, and major depressive disorder. The annual MDS dated [DATE] revealed Resident #58 was cognitively intact. No behaviors were noted on lookback period. Resident #58 used a wheelchair for mobility and both legs were amputated above the knee. MDS noted Resident #58 had no impairment of range of motion to his upper extremities. The care plan for Resident #58 dated 02/22/25 included a care plan for assistance with activities of daily living (ADL) due to amputation of both legs above the knee, and weakness. The stated goal was Resident #58 would be free from a decline in ADL. Interventions included assist Resident #58 with ADL as needed, allow rest, break up tasks into smaller steps, encourage self-care, and observe for changes in ADL and notify the nurse. A review of the initial allegation report completed by the Director of Nursing (DON) for an incident which occurred on 05/27/25 at 1:30 PM. Resident #58 was hit in the face near the lip area by Resident #76. Resident #58 was noted to have a small bruise on the top of his left hand, but no visible injury to lip or face. Resident #76 was noted to have a skin tear to the inside of his left forearm. Resident #76 and Resident #58 were separated by staff immediately and assessed for injuries. Resident #76 agreed to a room change, and his room was changed that day. The DON notified local law enforcement and the Department of Adult Protective Services. The report was signed by the DON on 05/27/25. The completed initial allegation report was faxed to the Division of Health Service Regulation on 05/27/25 at 3:11 PM. A review of the investigation report completed by the DON about the incident which occurred on 05/27/25 at 1:30 PM. Resident #58 was hit in the face near the lip area by Resident #76. Resident #58 was noted to have a small bruise on the top of his left hand, but no visible injury to lip or face. Resident #76 was noted to have a skin tear to the inside of his left forearm. Resident #76 and Resident #58 were separated by staff immediately and assessed for injuries. Resident #76 agreed to a room change, and he was moved that day. The DON notified local law enforcement and the Department of Adult Protective Services on 05/27/25. Corrective actions included Resident #76 room change and corporate maintenance were contacted to provide 2 televisions per room to prevent future altercations. The investigation end date was signed by the DON as 06/02/25. The completed investigation report was faxed to the Division of Health Service Regulation on 06/02/25 at 7:51 PM. An interview with Therapy Staff #1 on 06/19/25 at 1:38 PM revealed she had walked down the hallway towards another resident's room when she heard Resident #58 and Resident #76 yelling at each other from their shared room. She entered the room and observed Resident #76 sitting in his wheelchair beside his bed and Resident #58 was also seated in his wheelchair facing Resident #76 who held the remote. Resident #58 reported to Therapy Staff #1 he had been watching television when Resident #76 grabbed the remote from him and changed the channel. Therapy Staff #1 reported she immediately separated the Residents. Therapy Staff #1 indicated after Residents were separated, she notified the nurse on the hall but could not recall the name of the nurse who was notified. Therapy Staff #1 indicated she did not observe any obvious injury on either Resident. An interview with the Infection Preventionist on 06/19/25 at 1:47 PM revealed she was notified of altercation between Resident #58 and Resident #76 by Therapy Staff #1. Therapy Staff #1 reported to Infection Preventionist Resident #58 and Resident #76 were heard fighting in their shared room. Therapy Staff #1 indicated to the Infection Preventionist that she had immediately separated the Residents. The Infection Preventionist stated she went to Resident #58 and Resident #76's room to assess both residents. Resident #58 stated to Infection Preventionist that Resident #76 took the television remote and changed the channel while Resident #58 was watching the television. Resident #58 further explained when he tried to grab the remote back from Resident #76, Resident #76 hit him (Resident #58) in the face. Upon assessment, Resident #58 had no injury noted to his lip or face, but a small bruise was noted on his left hand. The Infection Preventionist indicated Resident #76 could be confused and had changed rooms prior to this incident for not getting along with his roommates. The Infection Preventionist stated she was not aware of any other incidents of Resident #76 assaulting others. A progress note for Resident #58 dated 05/27/25 at 2:50 PM completed by Infection Preventionist stated Therapy Staff #1 observed Resident #58 and Resident #76 fighting over the television remote. Therapy Staff #1 was able to separate them, and Resident #58 explained he was watching television when Resident #76 came in and took the remote and changed the channel. Resident #58 reported to staff Resident #76 hit him in the face. No injury for Resident #58 noted upon physical assessment. The facility provider was notified of the incident. An additional progress note for Resident #76 dated 05/27/25 at 3:07 PM also completed by the Infection Preventionist stated Resident #58 and Resident #76 were fighting over the television remote. The residents were able to be separated by Therapy Staff #1. The note indicated Resident #58 accused Resident #76 of stealing the remote and changing the channel. Resident #58 also reported to staff Resident #76 hit him in the face. Resident #58 denied hitting Resident #76 back. Resident #58 and Resident #76 were separated. An observation and interview with Resident #58 on 06/16/25 at 11:38 AM revealed him to be alert, sitting upright in his wheelchair in his room watching television. He verbalized he recalled the altercation which occurred on 05/27/25 and reported Resident #76 grabbed the television remote when he was watching something and changed the channel. When Resident #58 attempted to grab the remote back from Resident #76, Resident #76 struck him on the lip. Resident #58 stated he had no injury from the altercation and denied physical pain. He reported he felt safe after Resident #76 was moved to another room, but he tried to avoid him when out of room. An observation and interview with Resident #76 on 06/17/25 at 11:15 AM noted he was alert, sitting upright in his wheelchair in his room. Resident #76 stated he recalled the altercation which occurred with Resident #58 on 05/27/25. He reported Resident #58 would not let him watch what he wanted so he grabbed the remote and hit Resident #58. Resident #76 further stated he did not get hurt and he agreed to move the same day. Resident #76 indicated he had no problems with his current roommate or sharing the television. An interview with the Director of Nursing (DON) on 06/19/25 at 1:55 PM, who reported the Infection Preventionist notified her Resident #58 and Resident #76 were fighting over the television remote. The DON reported she completed an assessment of both Residents on 05/27/25 after the altercation. She indicated Resident #76 had reopened a skin tear on his left forearm which required no treatment; and Resident #58 did not sustain any visible injury to his lip or face but had a small bruise on his left hand. The DON stated Resident #76 agreed to a room change the same day. An interview with the Administrator and Corporate Nurse on 06/20/[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff, Physician Assistant, and Medical Director interviews, the facility failed to supervise a severely cognitively impaired resident with wandering behaviors from exiting the facility unsupervised, without staff knowledge, for 1 of 1 resident reviewed for accidents related to unsafe wandering/elopement (Resident #1). The facility also failed to immediately notify administration of the missing resident. The resident exited the facility which was in a rural residential area and walked 1/3 mile on a two-lane road with no streetlights and no sidewalk without shoes, wearing socks. She was found lying in a ditch beside the road by a neighbor walking his dog. On evaluation by Emergency Medical Service personnel, Resident #1's blood sugar was 500 milligrams per deciliter. She was transported to the hospital for evaluation and treatment where she was given intravenous Insulin and fluids. She was later discharged from the hospital to another long-term care facility's locked memory care unit. Findings included: Resident #1 was admitted to the facility on [DATE] with a diagnosis of dementia and Diabetes Mellitus. Review of Resident #1's physician's orders dated 3/09/24 and 3/12/24 revealed orders for antidiabetic medications (non insulin). She was not on scheduled blood sugar checks. Antidiabetic medications ordered: - 3/09/24 8:00 PM - Metformin 500 mg by mouth two times a day for Diabetes - 3/12/24 00:00 - Dulaglutide 0.75 milligrams (mg) subcutaneous every Tuesday for Diabetes Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] revealed she was severely cognitively impaired. She exhibited wandering behaviors 1-3 days during the lookback period. The lookback period was 7 days prior to the MDS date. She was independent for walking at least 150 feet. She did not use a wander/elopement alarm. Review of Resident #1's wandering/elopement assessment dated [DATE] revealed she had no history of wandering and wandered within the home without leaving the grounds. The progress note section read in part that resident ambulates within facility, does not exit seek. Resident #1's care plan dated 7/19/24 had a focus which read in part that the resident is an elopement risk/wanderer related to disoriented to place, exit seeks. The intervention included to distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and book. Another care area focus included the resident had a behavior problem related to dementia. The resident sundowns with increased confusion, wanders, and yells out. The interventions included to divert attention and remove from situation and take to alternate location as needed. Also to monitor behavior episodes and attempt to determine underlying cause. Another care area focus included the resident had Diabetes Mellitus and the interventions included to give Diabetes medication as ordered and monitor for any signs or symptoms of high or low blood sugars. The Weather Underground website revealed the outdoor air temperature where the facility was located on 8/09/24 at 4:54 AM was 71 degrees F with no precipitation. An interview on 8/13/24 at 11:03 AM with Nurse #1 revealed she was the nurse assigned to Resident #1 the night shift of 8/09/24. She stated she had completed a skin assessment on Resident #1 around 3:00 AM and had gone to the nurses' station to document. She heard Nursing Assistant (NA) #2 talking to Resident #1 who had walked out into the hall. Resident #1 did not want to go back to bed and became agitated. Nurse #1 stated she told NA #2 to just let the resident walk in the hall for a little bit. Nurse #1 then left the nurses' station to go to another resident's room and returned to the nurses' station about 20-30 minutes later. Nurse #1 stated that NA #2 was at the nurses' station, and she asked about Resident #1. They looked and Resident #1 was not in her room and they started searching for the resident. Nurse #1 stated that Resident #1 had a history of getting in other resident's beds or going in their rooms. Nurse #1 stated they walked around the outside of the building and were unable to locate the resident. She then informed the Nurse #2 that administration needed to be notified. Nurse #1 stated that they contacted the Director of Nursing (DON) who assisted them in looking at the facility security camera to determine which direction the resident had walked. By looking at the camera, they were able to determine that Resident #1 had walked down the hall toward the front door and had not come back. She stated that the front door was not clearly visualized by the security camera. Nurse #1 was unsure exactly what time the DON had been contacted. She stated she had been educated to notify administration in the event a resident could not be located but was unable to specify a time frame. Nurse #1 stated she did not know how Resident #1 got out the front door. She stated the door was kept locked at all times and required a code to be entered for the door to open. She stated that she had not tested the door during her shift and was unable to state if the door was functioning correctly. An interview on 8/13/24 at 11:35 AM with Nursing Assistant (NA) #1 revealed she was working the night shift and assigned to Resident #1 on the early morning of 8/09/24. She stated around 3:00 AM she and NA #2 were making resident rounds when Resident #1 walked out into the hall. She stated that NA #2 attempted to redirect Resident #1 back to bed, but when the resident got agitated, Nurse #1 just told them to let her walk around the facility. NA #1 stated they continued resident rounds and later Nurse #1 asked them if they had seen Resident #1 and they started searching the facility for her. NA #1 stated she thought this was around 3:50 AM and they looked in and outside the facility for approximately 1 hour prior to calling the DON. NA #1 stated that she had tried all the exit doors when searching for the resident and they were all locked. She stated that she did not know how Resident #1 got out the front door. She also stated that she had seen Resident #1 exit seeking in the past. An interview on 8/13/24 at 11:51 AM with NA #2 revealed that she was working the night shift on the early morning of 8/09/24. She stated that she and NA #1 were making resident rounds when she saw Resident #1 out in the hall. She stated that the resident did not want to go back to bed and Nurse #1 just told them to let the resident walk around. She stated she and NA #1 resumed resident rounds and when they came back to the nurses' station, they noticed Resident #1 was not in her bed. A room-by-room search was initiated for the resident. She stated that she did not know how the resident got outside. An interview on 8/13/24 at 12:15 PM with Nurse #2 revealed that she was in the facility as the Unit Manager on 8/09/24 when Resident #1 eloped. She stated it was around 4:40 AM with the DON was contacted. She stated the DON talked her through accessing the security camera to determine which direction Resident #1 had gone. She stated that she could see the resident go down the hall toward the front door and then didn't see her again. Nurse #2 stated she had no idea how Resident #1 got out the front door and did not believe the resident could have entered the door code. She stated she had observed Resident #1 to exit seek and open doors in the past. Nurse #2 stated she had received education on resident elopement which included notification of administration, and she thought the timeframe for notification was 30 minutes. An interview on 8/13/24 at 1:37 PM with the DON revealed Resident #1 had some wandering behaviors, got confused, and would go in and out of other resident's rooms. She stated that she had no idea how Resident #1 got out the door. She stated that Nurse #2 contacted her at 4:56 AM on 8/09/24 and she drove to the facility. She stated local law enforcement had been notified at 5:19 AM. The DON stated that Resident #1 had never exited the facility in the past. She stated that the staff had looked for the resident for approximately 1 hour prior to notifying her. She stated that the staff had received training on a missing resident which included notifying administration but did not specify a timeframe. Review of Emergency Management Services report dated 8/09/24 revealed they were called to the facility at 6:48 AM and arrived at 7:00 AM. The report narrative read in part that the resident was located sitting in a wheelchair in the front office. She had no obvious injuries and was noted that her blood sugar level was 500 milligrams per deciliter (mg/dL). A normal blood sugar range is 72 to 108 mg/dL. The resident was conscious and alert, however, has severe dementia and is unable to recall any of the events. The resident was transported to the hospital at 7:13 AM. An interview on 8/13/24 at 12:38 PM with the facility Physician Assistant (PA) revealed he had been notified of Resident #1 elopement on 8/09/24 around 7:00 AM and given the order for her to be transported to the hospital for evaluation after she was located. He stated he did not think the resident could have entered the door code. He also stated that he expected the facility to keep the resident safe. Review of the hospital emergency room report dated 8/09/24 at 7:37 AM read in part that this wanderer does not have any apparent injury. The resident was given intravenous Insulin and fluids to bring the blood sugar down to the 200s. The diagnosis read in part that the hyperglycemia was suspected to be stress response. The resident was discharged to a dementia unit in another facility. An interview on 8/13/24 at 10:33 AM with the Maintenance Director revealed when he checked the door on 8/09/24 after Resident #1's elopement, it was working correctly. He stated he tested it with and without the facility electrical power, using the generator, and he was unable to get it to malfunction. He stated the door stayed locked 24/7. An interview on 8/13/24 at 5:17 PM with the Medical Director revealed he had been notified of the situation and it was 'less than ideal'. An interview on 8/13/24 at 5:31 PM with the Administrator revealed that had she had been notified of the elopement after the resident had been located and taken to the hospital. She stated that she and the DON had reviewed the footage and put together a timeline of events. She also stated that staff education and resident elopement assessments had been completed. The Administrator stated that the PA, Medical Director, and resident representatives had all been notified. She stated that the front door had been extensively checked and they were unable to determine how Resident #1 was able to exit the facility. The Administrator stated that Resident #1 was transported from the hospital to another facility with a locked memory care unit which had been approved by the resident representative. An additional interview and observation were completed on 8/13/24 from 2:45 PM until 3:15 PM with the Maintenance Director. The observation was a recreation of the possible path Resident #1 took after exiting the facility front door. As stated by the Maintenance Director, Resident #1 was located by a neighbor walking his dog lying in a ditch calling for help. Maintenance Director stated he had arrived at the facility around 5:00 AM and immediately started looking for the resident. He looked in the wooded area beside the facility and then started looking down the road. The road was a 2-lane paved road with a double yellow line in the center. The posted speed limit was 40 miles per hour. Maintenance Director stated he and the Maintenance Assistant had taken a truck down the road using flashlights to look for the resident. Approximately 3/10th's of a mile down the road they observed the neighbor with the resident. The neighbor had already gotten the resident out of the ditch. The Maintenance Director stated the resident was wearing pants, a sweatshirt, and socks. He stated her clothing was dry and he had not observed any obvious injuries. The Maintenance Director and the Maintenance Assistant had assisted the resident into the truck and brought her back to the facility. The Maintenance Director stated the grass was wet with dew and the roads were dry. He stated that Resident #1 kept saying she was sorry for the trouble and asking for water. Observation of the front door on 8/13/24 at 3:20 PM revealed a single door with a push bar to exit. There was a door code box located on the right side of the door. The exit code was 4 digits with a hashtag to unlock the door. The door automatically closed and locked when released. The door had no audible alarms when opened or when held open. There was no automatic release if the push bar was held down. There was no method to bypass the door code to exit the door. The Administrator was notified of Immediate Jeopardy on 8/13/24 at 5:50 PM. The facility provided a corrective action plan with alleged date of compliance of 8/10/24. The corrective action plan indicated. Problem Identified: Resident #1 was admitted to the facility on [DATE] with the following diagnosis: left femur fracture, diabetes, dementia, cardiovascular disease, hypertension, hyperlipidemia and depression. Resident #1 has a BIMS of 3 as of 5/12/24. On August 9, 2024 at approx. 3:30am Resident #1 had an unsupervised exit via the front door of the facility. Order of events: Approximately 4:15am the facility staff noticed during routine rounds that Resident #1 was not in her bed and began searching for her. The Director of Nursing was notified at 4:56am that Resident #1 was missing and could not be found. The Director of Nursing gave the facility instructions to call the administrator, the police and to continue searching every room, as well as outside. The Director of Nursing arrived at the facility at 5:30am, reviewed the security cameras and noted Resident #1 leaving the facility via the front door at 3:20am. At 5:39am the Director of Nursing notified all management staff that Resident #1 was missing, and all available staff were to report to the facility and search on their way to the building. The sheriff department and Emergency Medical Services first responders arrived at approximately 6:00am and received a description of Resident #1. The Deputy reviewed the security camera footage and issued a silver alert. At approximately 6:30am the Maintenance Director and his assistant located Resident #1 and brought her back to the facility. The Emergency Medical Services with the Director of Nursing present assessed her for injuries and no injuries were identified. Resident #1 was identified as having a blood glucose level in the 500s by Emergency Medical Services. The Nurse Practitioner was notified at 6:45am and based on the resident's glucose levels Resident #1 was sent to the emergency room for further evaluation. Address how corrective action will be accomplished for resident (s) found to have been affected. On 8/9/24 at approximately 6:30am the Maintenance Director and his assistant located Resident #1 and brought her back to the facility. The Emergency Medical Services with the Director of Nursing present assessed her for injuries and no injuries were noted. A full set of vital signs and blood glucose monitoring was also conducted. Resident #1 was identified as having a blood glucose level in the 500's by Emergency Medical Services. The Nurse Practitioner and Medical Director were notified at 6:45am and based on the resident's current condition, orders were given to send the resident to the emergency room for further evaluation. Resident #1 was sent to Mission Hospital at approx. 7:08am. While Resident #1 was in the emergency room arrangements were made with her RP's approval for her to be transferred to a sister facility with a secure unit. Once Resident #1 was cleared to be discharged from the emergency room the facility transported Resident #1 from the emergency room to our sister facility around 12:00pm. Address how corrective action will be accomplished for resident(s) having potential to be affected by the same issue needing to be addressed: A 100% review of residents was conducted for the entire facility on 8/9/2024 to identify residents at risk for elopement to ensure they have an elopement risk assessment and care plan to address their behaviors. This review was completed by the Director of Nursing. Those residents identified were added to the Elopement Risk binder. Elopement binders were reviewed, updated accordingly and placed at each nurses' station by the Unit Manager on 8/9/24. These books contain the list of residents with exit-seeking behaviors, their pictures and resident's description. The admission Coordinator will continue to be responsible for maintaining the elopement binders based on information provided by the Director of Nursing or Administrator. The admission Director was reeducated on this task by the Administrator on 8/12/24 (upon her return from vacation). Also, those residents identified care plans and care guides were updated by the DON and MDS Coordinator on 8/9/24. Door checks were completed on 8/9/2024 by the Regional Director of Facility Maintenance to ensure all doors are locking properly. All doors were locking properly. Address what measures will be put in place and systemic changes made to ensure that the identified issue does not occur in the future. All staff working on 8/9/2024 were educated by the administrative nurses (Director of Nursing and Unit Managers) and Maintenance Director currently in the facility and completed phone education for those not present in the facility regarding the facility elopement policy, the location of the elopement binder to identify residents who are at risk for elopement, ensuring residents who are assessed at risk for elopement are supervised by facility staff, where to locate care plan intervention regarding residents at risk for elopement, immediate notification of the Administrator and Director of Nursing when it is identified a resident maybe missing. Any staff members who have not received the education after 8/9/2024, will not be allowed to work until they have completed the education. This education will be included in the new hire orientation for employees including agency personnel, which is conducted by the Staff Development Coordinator. The Staff Development Coordinator was educated by the Administrator regarding this matter on 8/12/24 (upon her return from vacation). On 8/9/24, the Interdisciplinary Team (IDT) to include but not limited to the Director of Nursing, Unit Manager, Activities Director, Social Worker, MDS Coordinator, Maintenance Director and Dietary Manager were re-educated by the Administrator on the Elopement Policy to include ensuring residents who are assessed at risk for elopement are supervised by facility staff and signs of elopement risk are recognized. Additionally, they were educated on their role in developing plans/interventions in response to any elopement risk. This includes a written care plan with elopement risk interventions formulated. On 8/9/24 all licensed nurses including licensed agency personnel were educated on completion of the Elopement assessments by the Director of Nursing and Unit Managers. They are completed on admission, then quarterly and/or as needed by the Licensed Nurse. Any newly identified residents noted at risk will be communicated by the licensed nurse during shift huddle at the change of each shift. On 8/9/24 the Maintenance Director was educated by the Regional Director of Facility Maintenance on conducting monthly elopement drills and weekly door checks (with all exit doors). Indicate how the facility plan to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. The plan must be implemented and the corrective action evaluated for its effectiveness. Effective 8/9/24, the Director of Nursing (DON) will review the residents at risk for wandering or exit-seeking behaviors, which will include the residents currently in the elopement binder and any newly identified residents based on their elopement assessment and/or behaviors weekly for 12 weeks to ensure interventions/behaviors are being managed. Residents exhibiting new behaviors of wandering or exit seeking will be reviewed to ensure the wandering/elopement assessment is accurate, care plan updated, and interventions are in place. The Director of Nursing (DON) will report findings monthly to the Quality Assurance Performance Improvement Team (QAPI) for 3 months. The Maintenance Director will conduct monthly elopement drill and weekly door checks (with all exit doors). The findings and validation of this audit/task will be reported to the Quality Assurance Performance Improvement Team (QAPI) Committee monthly for 3 months. Immediate Jeopardy Removal Date: 8/10/24 The credible allegation of immediate jeopardy removal was verified on 8/13/24. Interviews were conducted with a sample of Nursing Assistants, Nurses, and the Maintenance Director to verify education was conducted for elopement. Documentation of in-service records was reviewed. Documentation of an elopement drill was reviewed. An interview with the Maintenance Director on 8/13/24 at 3:15 PM, he stated that he had received education resident elopement. He stated he will be conducting monthly elopement drills and weekly door checks with all exit doors for 3 months. The facility's alleged date of compliance was validated to be effective 8/10/24.

Based on observations and record review the facility failed to remove an accident hazard (grill with 2 propane tanks) from the resident smoking area. In addition, the facility did not have a policy for safe operation of a gas grill in a common area used by residents. The resident smoking area contained 21 of 22 residents who smoked at the facility when the grill and 2 propane tanks were present. Findings included: The facilities smoking policy titled Resident Smoking Deer Park Health and Rehab was last revised on 4/16/24. A review of the policy found it did not include the storage and use of propane tanks in the resident smoking area. An observation of the resident smoking area occurred on 7/2/24 at 1:47 PM. A gas grill with 2 connected propane tanks was found sitting approximately 6 feet from the resident smoking area. The resident smoking area contained 21 residents actively smoking and using vapes, with 4 residents sitting at a table approximately 6 feet from the grill. On 7/2/24 at 1:52 PM the Activity Director stated he was unaware if the gas grill with propane tanks could be near the smoking area. He stated he would ask the Maintenance Director to come to the smoking area. On 7/2/24 at 1:54 PM the Maintenance Director stated he had placed the gas grill in the smoking area on Monday (7/1/24), and he did not know if the grill and propane tanks could be in the smoking area or if the grill and propane tanks needed to be a specific distance away from the smoking area. He said the facility was using the grill for a cookout on 7/4/24. The Maintenance Director removed the grill and propane tanks from the smoking area at that time. The Administrator stated on 7/2/24 at 2:20 PM the gas grill was brought to the smoking area the previous day. She stated she was not aware of any regulation for the distance requirements that the propane and grill should be from the smoking area while residents were smoking. A follow-up interview was conducted with the Administrator on 7/2/24 at 4:10 PM. She stated the facilities smoking policy did not include information about gas grills in the smoking area. The Administrator said the gas grill should be moved away from the smoking area for resident safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and resident, resident representatives, staff, psychotherapist, Psychiatric Nurse Practitioner (NP), Physician Assistant and Medical Director interviews, the facility failed to protect a resident's right (Resident #3) to be free of sexual abuse from another resident (Resident #52). Resident #3 had severely impaired cognition and Resident #52 had moderately impaired cognition and a history of sexual behaviors. On 3/25/23 Resident #52 was observed by staff inviting Resident #3 into his room and was told by staff to leave the door open. Shortly after, Resident #52 was observed inappropriately touching Resident #3's leg. On 7/25/23 Resident #52 was found in Resident #3's room looking at her while she slept. On 1/30/24 Nurse Aide (NA) #1 heard yelling coming from Resident #3's room. NA #1 and Nurse #1 found Resident #52 in Resident #3's room with his hand inside of her incontinent brief with skin to skin contact. Resident #3 stated stop you're hurting me. Resident #3 was incapable of consenting to the sexual act. Resident #3's Responsible Party (RP) indicated she would have been very upset by the incident. A reasonable person expects to be protected from abuse in their home environment and sexual abuse would cause trauma. In addition, the facility failed to prevent resident to resident abuse when a resident (Resident #264) used his fist to punch Resident #30 on the right side of the face. This deficient practice affected 4 of 12 residents reviewed for abuse. Immediate jeopardy began on 1/30/24 when Resident #3 was not protected from sexual abuse. Immediate jeopardy was removed on 4/22/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at the lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. Example #2 was cited at a scope and severity of D. The findings included: 1. Resident #52 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke), and dementia. Resident #52's care plan dated 10/18/22 indicated he had a behavior problem and had been sexually promiscuous with other residents. Resident #52 would deny and was easily redirected. Interventions included to administer medications as ordered, monitor/document for side effects and effectiveness, anticipate and meet the resident's needs, intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention, and remove from situation and take to alternate location as needed. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #52 had moderately impaired cognition and had no behaviors. He was independent with all his mobility and used a manual wheelchair. Resident #3 was admitted to the facility on [DATE] with the following diagnoses: cerebral infarction (stroke), dementia with agitation, Alzheimer's disease and Parkinson's disease. Resident #3's care plan dated 12/2/22 indicated at times, Resident #3 had been verbally and sexually inappropriate while in a heavy traffic area of the facility. Her word for sex is [NAME]. Interventions included to assess resident's understanding of the situation, allow time for the resident to express self and feelings towards the situation, and psychiatric/psychogeriatric consult as indicated. The quarterly MDS dated [DATE] indicated Resident #3 had severely impaired cognition and no behaviors. Resident #3 was a partial/moderate assist for her mobility and used a manual wheelchair. A review of Resident #52's medical record indicated a progress note dated 3/26/23 at 11:15 AM documented by Nurse #2. The progress note indicated it was a late entry note for 3/25/23 at 10:00 AM. Nurse #2 documented that Resident #52 was heard by several staff members inviting a female resident down to his room. Staff told him he needed to leave his door open. A few minutes later, as a staff member went by the room, the two were seen touching each other inappropriately and were parted from each other by two staff members. Resident #52 immediately denied inviting her to his room and said he did not want her to come back. A phone interview with Nurse #2 on 4/21/24 at 9:22 AM revealed the female resident who was observed in Resident #52's room on 3/25/23 was Resident #3. Nurse #2 stated she could barely remember all the details but Resident #52 was seen inviting Resident #3 into his room earlier that day. Nurse #2 stated she thought it was fine because they were just talking, and she told Resident #52 to keep his door open. Nurse #2 further stated that a few minutes later, it might have been a housekeeper (she was not certain) who witnessed Resident #52 and Resident #3 touching inappropriately. Nurse #2 stated she did not witness it and both residents denied having done anything. From what she could remember, the staff member reported that Resident #52 was seen touching Resident #3's knee. Nurse #2 removed Resident #3 from Resident #52's room. Nurse #2 stated she reported the incident to an on-call provider, but she could not remember whether she reported it to the Director of Nursing or the Administrator. There were no revisions made to Resident #52's care plan related to sexually promiscuous behaviors after the 3/25/23 incident. Further review of Resident #52's medical record indicated he was seen by the psychotherapist on 3/30/23. Resident #52 reported sadness and depression and missing his family. He also reported increased tiredness and sleeping throughout the day. The therapist provided review of alternative symptoms often experienced with depression: irritability, forgetfulness, and lack of interest to engage in activities. The therapist recommended for Resident #52 to increase time he listened to music. A Psychiatry Follow-up Note dated 4/25/23 by the Psychiatric NP in Resident #52's medical record indicated he was made aware of the incident on 3/25/23 between Resident #52 and Resident #3. He documented that Resident #52 could be sexually inappropriate with staff at times. He was prescribed Paroxetine (a medication used to treat depression) 30 milligrams (mg) daily and Estradiol (hormone essential for modulating libido, erectile function, and spermatogenesis or the process of sperm cell development) 1 mg daily for history of sexual inappropriate behavior. Paroxetine had been increased to 40 mg daily on 3/29/23. He was treated with Paroxetine, Trazodone (antidepressant and sedative), Clonazepam (sedative), and Estradiol. He was agreeable to a visit next month. The Psychiatric NP indicated in his note to monitor him closely. A progress note dated 7/24/23 at 5:21 AM documented by Nurse #3 in Resident #52's medical record indicated Resident #52 had insomnia tonight. He had been wandering in the hallways and going into other residents' rooms but was quickly redirected back to his room. A phone interview with Nurse #3 on 4/22/24 at 1:24 PM revealed that on 7/24/23, Resident #52 kept rolling around near the day room and kept heading towards Resident #3's room. Nurse #3 stated that Resident #52 told her that he was just rolling around. She indicated at approximately 1:30 AM she saw Resident #52 enter Resident #3's room, she went down to the room and saw Resident #52 by Resident #3's bedside and he was just looking at her. Resident #3 was sleeping at the time. Nurse #3 stated that she did not see Resident #52 touch Resident #3, and that she moved him out of the room and back to his room. Nurse #3 indicated she was not aware of the 3/25/23 incident between Resident #52 and Resident #3. She reported she was aware of Resident #52's care plan having a care area identified for inappropriate sexual behaviors, but she did not know the history or why he had this care planned. There were no revisions made to Resident #52's care plan related to behaviors after the 7/24/23 incident. The annual MDS for Resident #3 dated 12/9/23 indicated she was severely cognitively impaired, and had no behavioral symptoms. Resident #3 required substantial/maximal assistance with most activities of daily. Resident #3 used a manual wheelchair and was able to self-propel herself. A review of Resident #52's quarterly MDS dated [DATE] revealed that he was moderately cognitively impaired. He did not display any physical or verbal behavioral symptoms towards others but rejection of care occurred 1 to 3 days during the assessment period. He only required supervision from staff with most activities of daily living including bed mobility and transfers. Resident #52 used a manual wheelchair and was able to self-propel himself. On 1/29/24 the Psychiatric NP saw Resident #52. The note indicated one of the chief complaints was staff reporting resident had become more sexually inappropriate. The NP did an examination and found Resident #52 oriented to person, place and situation and found him to be moderately impaired. His findings were Resident #52 had dementia with behavioral disturbances, depression, anxiety, insomnia and sexually inappropriate behavior. The NP's recommendations were no new psychiatric medications at this time. To continue ongoing supportive/behavioral strategies as currently implemented by staff. To encourage participation in recreational activities. He recommended Buspirone 5 mg three times a day for sexual inappropriate behavior. The NP will assess at the next visit. An incident report dated 1/30/24 completed by Nurse #1 indicated that on 1/30/24 at 1:35 AM during rounds Nurse Aide (NA) #1 and Nurse #1 observed Resident #52 at the bedside of Resident #3 with his hands inside the top of her brief. Resident #3 and #52 were separated immediately. Resident #3 was assessed for injury, and none was identified. Resident #3 was moved to his room and Resident #52 was placed on 15 minute checks. No physical or mental injury/harm was identified. On 1/30/24 at 8:30 AM, the local police department was notified of the incident. An observation was made on 4/14/24 at 9:51 AM of the room locations for Resident #3 and Resident #52 prior to the 1/30/24 incident. The residents resided on the same hall with 1 room in between their rooms. An interview with the assigned police officer was attempted by phone on 4/22/24 at 3:00 PM and was unsuccessful. A written statement dated 1/30/24 by Nurse Aide (NA) #1 indicated during his round, he went to check on Resident #3 and found Resident #52 with his hands down Resident #3's pants. Both residents were separated while the nurse was notified. The incident occurred at 1:35 AM on 1/30/24 in Resident #3's room. On 4/19/24 at 10:48 AM, a telephone interview was conducted with NA #1. He stated on the night shift on 1/30/24 around 1:30 AM, he was doing rounds on the floor and he heard yelling coming from Resident #3's room. When he went to check on Resident #3, he found Resident #52 with his hands under Resident #3's brief. There was skin to skin contact. NA #1 was unable to recall if Resident #3 said anything when he entered the room. NA #1 got Nurse #1 to come down and then they separated Resident #52 and Resident #3. He put Resident #52 back in his room. NA #1 stated he could not remember the details of how he notified the nurse but did say he did not leave the two residents. NA #1 stated he had not ever seen Resident #52 in this resident or any other resident's room before. NA #1 was not aware of any previous incidents of sexual behavior. NA #1 also stated that he could barely remember the details regarding this incident between Resident #3 and Resident #52 and he would go by whatever was indicated in his written statement. A progress note dated 1/30/24 at 2:49 AM in Resident #3's medical record documented by Nurse #1 indicated she was alerted by NA #1 to come to Resident #3's room around 1:35 AM. Upon entering the room, Nurse #1 noted Resident #52 at Resident #3's bedside. Upon further assessment, Resident #52 was noted to have his right hand in Resident #3's brief. Resident #3 was stating, stop you're hurting me. Both residents were immediately separated. A skin assessment was completed on Resident #3 and no injuries were noted. Resident #3 was alert per baseline with confusion. No signs and symptoms of pain, discomfort, or acute distress were noted or reported. Resident #3 was relocated to a different room. On 4/19/24 at 8:20 AM, a telephone interview was conducted with Nurse #1. Nurse #1 stated that she was alerted by NA #1 to come to Resident #3's room and saw Resident #52 sitting at her bedside. Resident #52's hand was in Resident #3's brief and there was skin to skin contact. Nurse #1 stated she didn't remember seeing his hand moving but it looked like he was fondling her under her brief because his hand was right over her pelvic area. Nurse #1 stated as she entered Resident #3's room, she heard Resident #3 stating, stop, you're hurting me. After Nurse #1 told Resident #52 to remove his hand from under Resident #3's brief, she asked him what he was doing and Resident #52 stated to her, She asked for it. The two residents were immediately separated, and Resident #3 was moved to another room and eventually off the hall to the other side of the building in an empty room. Nurse #1 notified the administration and the Physician Assistant who saw the residents on the next shift. Nurse #1 stated that she had never seen Resident #52 go into another female's room prior to this incident. Nurse #1 was not aware of the 3/25/23 or 7/24/23 incidents between Resident #52 and Residents #3. Nurse #1 further stated that she assessed Resident #3 and did not find any physical injury. Prior to this incident, Nurse #1 stated that she saw Resident #52 in his room, but she couldn't remember what time. When Resident #52 went back in his room after the two residents were separated, he kept coming down to the nurses' station, and trying to explain about what happened. Resident #52 stated that Resident #3 invited him to her room. Nurse #1 stated she could not remember anything else that Resident #52 said about the incident. Resident #52 was placed on 15 minute checks starting on 1/30/24 till 2/9/24. Nurse #1 stated that in her opinion, what happened between Resident #52 and Resident #3 was sexual abuse because Resident #52 was alert during the incident and he knew what he was doing, while Resident #3 was not able to give consent. On 4/16/24 at 9:30 AM, Resident #52 was interviewed. Resident #52 stated that Resident #3 used to come to his room, and she would flirt with him. When asked if he remembered the incident on 1/30/24 in Resident #3's room, Resident #52 stated that he did not remember the incident. Resident #52 stated that he was a married Christian man. He denied ever going into Resident #3's room. Resident #52 stated he didn't want to talk about it anymore and refused to answer any more questions. On 4/16/24 at 1:20 PM, a telephone interview with Resident #3's responsible party (RP) was conducted. Resident #3's RP said that he was made aware of the 1/30/24 incident and they ended up moving Resident #3 to another room. He stated that Resident #3 was still very confused by the move. The RP stated that Resident #3 was raped 3 times by the age of 9. The RP also stated that Resident #3 did have a history of touching men at a different facility. He was not aware of any other issues with her and other men at this facility other than on 1/30/24. A follow-up phone interview with Resident #3's RP on 4/24/24 at 3:30 PM revealed Resident #3 was not able to give sexual consent. Resident #3's RP stated that she would be offended by a stranger touching her and she would be very upset. The RP indicated he had not spoken with the police. A progress note dated 2/13/24 by Nurse #3 revealed that she overheard a conversation with Resident #52 and another resident at the nurses desk. Nurse #3 stated that Resident #52 noticed that Resident #3 was no longer in the room on the south hall and Resident #52 stated there's a man in Resident #3's room. She's gone. On 4/19/24 at 2:50 PM, a phone interview was conducted with the Psychotherapist. She stated that she saw Resident #52 once a month. She stated that he had not been very engaging the last few months and was more isolated. She said that she had noticed that his cognition was declining since the start of this year. He had been more confused as time went on. She stated that she had not seen any hypersexuality with him prior to the 1/30/24 incident. She was not aware of any other incidents between Resident #52 and a female resident since the incident on 1/30/24. She stated that she thought he would have had an understanding of what he was doing during the 1/30/24 incident. The Psychotherapist also saw Resident #3 every two weeks. She stated that Resident #3 had declined as well in her cognition. The Psychotherapist stated that she did not observe any changes with Resident #3 after the incident on 1/30/24. She stated that Resident #3 told her that she did not remember the incident. On 4/19/24 at 3:18 PM, a phone interview was conducted with the Psychiatric NP. He stated that he met Resident #52 for the first time on 12/4/23. Resident #52 was seen by a different provider prior to this. The Psychiatric NP stated that he usually saw Resident #52 every 4 to 6 weeks unless there was something acute and he would see him sooner. He stated that he was aware that Resident #52 was sexually inappropriate with another resident (Resident #3) on 1/30/24. He stated that Resident #52 had dementia and his ability to make decisions was not good. He shared that when he spoke with Resident #52, he had no recall of the event. The Psychiatric NP stated that he had seen a cognitive decline with Resident #52 since he started seeing him on 12/4/23. He went on to say that Resident #52's confusion fluctuated, and he had times of clarity and times of confusion. On 1/29/24 when he saw Resident #52, he was alert and oriented to person, place and situation. He stated that when he saw Resident #52 on 1/29/24 one of the chief complaints was that staff were reporting that Resident #52 was becoming more sexually inappropriate. The Psychiatric NP made the recommendation of Buspirone 5 mg three times a day for sexually inappropriate behaviors. The Psychiatric NP stated that he couldn't say how Resident #52's cognition was during the incident without being there himself. The Psychiatric NP further stated that he last saw Resident #3 on 2/26/24. Resident #3 had many diagnoses including Parkinson's disease and dementia. The Psychiatric NP stated that Resident #3's mental cognitive ability also fluctuated. When he saw her on 2/26/24, Resident #3 had no recollection of the incident and could not remember any stressful events happening to her. The Psychiatric NP stated that he was not able to say if Resident #3 could give consent sexually, and that it depended on her cognition at that day and time. On 4/19/24 at 4:00 PM, an interview with the Physician Assistant (PA) revealed that he saw Resident #3 on 1/30/24 after the incident had happened but she (Resident #3) did not remember anything. The PA stated that Resident #3 was very confused. The PA also stated that he saw Resident #52 on 1/30/24 and he denied anything had happened. The PA stated that Resident #52 could also be confused but he also had periods when he was not confused. The PA could not say if the incident was sexual abuse since both residents could have times of confusion. He stated that he didn't think there was any intent from Resident #52 to hurt Resident #3. He added that he had never seen Resident #52 in other resident rooms. On 4/22/24 at 1:24 PM, an interview with the Medical Director (MD) revealed he was unsure where the history of sexually inappropriate behavior came from regarding Resident #52. He stated that when the facility received history and physical from the hospital or wherever the resident was coming from, it generally didn't give much detail. The MD stated that the notes from the psychotherapist would indicate more information about Resident #52's sexually inappropriate behavior. The MD refused to answer any questions regarding the incident on 1/30/24 between Resident #52 and Resident #3. The MD asked for guidance on what the facility could have done to prevent the incident that happened between Resident #52 and Resident #3. On 4/18/24 at 2:57 PM, an interview with the Director of Nursing (DON) revealed that she was an MDS Nurse in the facility at the time of the 1/30/24 incident but she remembered Resident #52 being placed on frequent observations. She indicated she had no idea Resident #52 had a history of sexually inappropriate behaviors prior to the 1/30/24 incident. The DON stated that for the past few months Resident #52 mostly stayed in his room while Resident #3 was out and about all the time. The DON shared that Resident #3 usually didn't go into other residents' rooms and that she just stayed in the hallways. She stated that Resident #3 would make sexual remarks to staff at times. She said that after the 1/30/24 incident the staff kept Resident #3 and Resident #52 separated and they did frequent observations. On 4/19/24 at 12:49 PM, a telephone interview was conducted with the former DON. She stated that she remembered the incident that happened on 1/30/24. The former DON stated that she was not working that day (1/30/24), but she remembered calling the local police department about the incident. The former DON further stated that she did not know the details of the incident in March 2023 involving Resident #52 and Resident #3, but she knew that an incident had happened. The previous DON felt that the facility did not do enough to prevent Resident #52 from getting access to Resident #3. On 4/19/24 at 9:00 AM, the Administrator was interviewed. She stated that she was in training when the incident happened on 1/30/24 between Resident #52 and Resident #3. The Administrator stated she remembered the local police department and the on call psychiatric provider were notified. She stated that she knew Resident #3 would make sexual suggestions but Resident #3 was unable to recall the events on that day. The Administrator stated she did not know of any other incidents that involved Resident #52, but the facility gave Resident #52 a 30-day discharge notice after the incident on 1/30/24 but they had been unsuccessful in finding another facility that would take him. The Administrator stated that they ended up substantiating the allegation of abuse because there were witnesses. The Administrator was notified of immediate jeopardy on 4/19/24 at 6:49 PM. The facility provided the following immediate jeopardy removal plan. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On 1/30/24, at approximately 1:30 AM, Resident #52 was sitting in Resident #3's room with his hand inside Resident #3's brief as Nurse Aide (NA) #1 staff entered the room. Resident #3 was severely cognitively impaired and was not capable of consenting to sexual activity. NA #1 alerted Nurse #1 to come to the room. Resident #3 was heard stating stop you're hurting me when Nurse #1 walked into the room. Resident #52 and Resident #3 were separated by NA #1 and Nurse #1 immediately on 1/30/24. Resident #3 was examined by Nurse #1 for any injuries including a skin check and no injuries were noted. Resident #3 was moved to 117 on 1/30/24 at 2:00 AM and then after consideration by the Director of Nursing (DON) and Administrator she was moved to room [ROOM NUMBER] on the other side of the facility at 8:30 AM. Resident #52 was taken to his room and was placed on every 15- minute checks from 1/30/24 to 2/9/24. No sexually inappropriate behavior was observed during the observation period and the Interdisciplinary Team (IDT) discontinued every 15-minute checks on 2/9/24. A review of nursing notes dated 1/30/24 and 1/31/24 revealed Resident #3 did not demonstrate or verbalize anxiety and no emotional or physical distress was observed. The facility's Physician Assistant was informed of the incident on 1/30/24. Resident #3 was examined on 1/30/24 by the Physician Assistant. Full assessment completed by Physician Assistant with no bruising noted and the resident denied the event. Resident #3 was seen by Psychiatric services on 2/8/24. It was determined that Resident #3 was at baseline. Observation by Psychiatric services included resident report of decreased memory recall during the examination. The Psychiatry provider for Resident #52 was notified on 1/30/24 of his inappropriate sexual behaviors and emailed an order on 1/30/24 to change Resident #52's Buspirone to 5 mg po three times for inappropriate sexual behaviors and anxiety. This order was initiated on 1/31/24. Resident #52 was seen by Psychiatric services on 3/11/24. The Physician Assistant examined Resident #52 on 1/30/24. On 4/19/24, Resident #52 was placed on 1:1 observation indefinitely. The Administrator reviewed the schedule to ensure that the facility has an individual assigned by the Staffing Coordinator as 1:1 supervision with Resident #52. Resident #52 is not in hallways or other resident areas unsupervised. Any behaviors identified during the 1:1 supervisor will be documented and reported to the facility Administrator and Director of Nursing. Head to toe skin assessments for residents with Brief Interview for Mental Status (BIMs) lower than 11 were completed by the Administrative Nurses (including the Director of Nursing) on 4/19/24. No concerns were identified. On 04/19/24, the Social Worker interviewed all residents with a BIMs score of 12 or above. The questions included with Social Worker interviews with residents were the following: 1. Have you had ever been inappropriately touched/abused/neglected or experienced misappropriation of resident property by another resident or staff here at the facility? 2. Do you feel safe here at the facility? Based on resident interviews there were no other reported incidents of abuse from any residents. Other residents at risk for abuse and other residents with inappropriate sexual behaviors were discussed and identified with the IDT during the Ad Hoc Quality Assurance and Performance Improvement (QAPI) held on 4/19/24. Staff interviews for those currently in the facility were conducted by the Social Worker and Administrator on 4/19/24 in person which included: 1. Have you witnessed or been made aware of inappropriate touching or any other form of abuse by staff or a resident? Staff not interviewed on 4/19/24 will be interviewed by the Staff Development Coordinator (SDC), Staffing Coordinator, and Nursing Supervisors prior to working their next shift. Interviews will be conducted in person, and via phone. The SDC, Staffing Coordinator, and Nursing Supervisors were notified and educated by the Administrator of this responsibility on 4/19/24. Staff will not be allowed to work before they have been interviewed by either the Staff Development Coordinator, Staffing Coordinator or the Nursing Supervisors. The active employee list will be tracked by the SDC and given to the Staffing Coordinator and Nursing Supervisors to ensure all staff have been interviewed prior to their next working shift via phone or in person. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring. The Director of Nursing (DON) educated 100% of facility staff, including agency staff, on abuse/neglect/misappropriation policy as well as identification of sexual abuse in the elderly, and reporting of abuse/neglect/misappropriation per facility policy with a review of the F600 regulation including inappropriate sexual behaviors. Abuse education specifics include definition of abuse, forms of abuse, how to recognize abuse, and what to do if abuse is suspected. In addition, education was completed on signs of Sexual Abuse against the Elderly and verbal descriptions of the typical signs. Staff were educated either in person or by phone on 4/19/24. The Staff Development Coordinator (SDC) will continue education for any staff member including Agency staff not available for education on 4/19/24. Any staff member including Agency staff who was not available to receive the education on 4/19/24 will not be permitted to work until education is completed. The SDC will be responsible for tracking staff, including Agency staff not educated on 4/19/24 by comparing the staffing schedule and active employee roster daily to verify education. The Director of Nursing will verify completion of education. The Director of Nursing and the Staff Development Coordinator were notified of the plan on 4/19/24. Nursing supervisors were provided the abuse education and informed on 4/19/24 by the Director of Nursing and the Staff Development Coordinator of the need to provide the abuse education after hours and on weekends. Nursing Supervisors will be notified by the Staff Development Coordinator of the employees that need the education prior to their next working shift. The abuse education will be included for new hires during orientation by the Staff Development Coordinator. Director of Nursing, Administrative Nurses and Social Worker reviewed the electronic medical records and care plans to identify current residents with behaviors of inappropriate sexual behaviors or potential for behaviors of inappropriate touching on 4/21/24. Care plans were reviewed to ensure interventions were in place and any new interventions were added to the resident's Kardex (care plan interventions) documentation for staff to reference key resident information. Staff will be made aware of residents with behaviors of inappropriate sexual behaviors, or potential for behaviors of inappropriate touching by resident specific Kardex interventions. Nurses, Nurse Aides and Department Heads were educated on how to review resident Kardex's by the Staffing Coordinator in person and via phone on 4/21/24. After 4/21/24 Nurses, Nurse Aides, and Department Heads will not be allowed to work their next shift until they have received the education from the Staffing Coordinator or Nursing Supervisors. The Staffing Coordinator and the Nursing Supervisors will compare the staffing schedule and active employee roster daily to verify education. The Staffing Coordinator and the Nursing Supervisors were notified of the plan by the Administrator on 4/21/24. This education will be included for new hires during orientation by the Staff Development Coordinator. On 4/19/24, the facility completed an Ad Hoc QAPI to review the Immediate Jeopardy for sexual abuse, the immediate jeopardy removal plan, education, and discuss and plan for audits and monitoring. Other residents at risk for abuse and other residents with inappropriate sexual behaviors were discussed and identified with the IDT during the Ad Hoc QAPI held on 4/19/24. The Ad Hoc QAPI meeting was attended by the Administrator, Director of Nursing, Unit Managers, Social Worker, Activities Director, Dietary Manager, Housekeeping Manager, Staffing Coordinator, Business Office Manager, Admissions Director, Maintenance Director, and Regional MDS Consultant. The Medical Director was in attendance via phone. The facility Administrator and Director of Nursing are responsible for continued compliance. The alleged date of immediate jeopardy removal is 4/22/24. On 4/25/24, the facility's credible allegation of immediate jeopardy removal was validated. Resident #52 was observed to have a 1 on 1 staff with him. Documentation regarding staff training on abuse/neglect/misappropriation policy as well as identification of sexual abuse in the elderly and reporting of abuse/neglect/misappropriation per facility policy with a review of the F600 regulation including inappropriate sexual behaviors. Staff interviews revealed receipt of training related to the definition of abuse, forms of abuse, how to recognize abuse, and what to do if abuse was[TRUNCATED]