**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff, Law Enforcement Officer and Medical Director (MD) interviews, the facility failed to supervise a cognitively impaired resident from exiting the locked memory care unit of the facility unsupervised without staff knowledge for 1 of 2 residents reviewed for accidents (Resident #1). Resident #1 went through the adjoining bathroom to the neighboring room and removed a windowpane and exited through the window. Resident #1 walked approximately 2/10 mile after dark on a two-lane street with streetlights and no sidewalk. He was wearing pants, shirt, jacket, and shoes. Resident #1 was found across the three-lane road from the gas station/convenience store by a staff member. He was transported back to the facility by a law enforcement officer. There was the high likelihood of a serious adverse outcome for Resident #1 when he removed the heavy glass windowpane, exited through the window which was 79 inches from the ground, and walked unsupervised to the gas station/convenience store. Findings included: Resident #1, a [AGE] year-old male, was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, dementia, aphasia, anxiety, tobacco use and history of stroke. Resident #1's annual Minimum Data Set (MDS) dated [DATE] revealed he had moderately impaired cognition and his speech was unclear. Resident #1 was usually understood and usually understood by others. He exhibited no wandering behaviors during the lookback period (7 days prior to the MDS date). He was independent for walking at least 150 feet. Resident #1 did not utilize a mobility device and did not use a wander/elopement alarm. He was 74 inches tall and weighed 200 pounds. Resident #1 had verbal behavioral symptoms directed toward others 1-3 days during the lookback period (7 days prior to MDS date). Resident #1 had no range of motion impairment in his upper or lower extremities and was independent with transfers. Resident #1's elopement assessment dated [DATE] revealed he had no history of attempted elopement or actual elopement. Resident #1's care plan last revised on 8/02/24 had a focus which read in part the resident is at risk for elopement related to confusion. Interventions included to encourage resident's participation in activity preferences, divert resident by giving alternative objects or activities, and listen to resident and try to calm. Resident #1's care plan had another focus related to impaired communication with resident usually understood and usually understands and does have diagnosis of aphasia (Aphasia is a brain disorder where a person has trouble speaking or understanding other people speaking). Interventions included that resident does use gestures and nods yes or no, repeat answers to verify what you understood was correct, and allow sufficient time for resident to process and respond. The Weather Underground website revealed the outdoor air temperature where the facility was located on 9/18/24 at 11:54 PM was 69 degrees F with no precipitation. Nurse's progress note dated 9/19/24 at 1:00 AM written by Nurse #1 read in part that the resident had an event that warranted the MD notification. The Resident was ordered Ativan (an antianxiety medication) 1 milligram by mouth immediately. He was agitated, cursing, but calmed down and took the medication. Resident placed on 1:1 with a Nursing Assistant. An interview on 9/24/24 at 3:02 PM with Nurse #1 revealed she was the nurse assigned to Resident #1 on the night shift of 9/18/24. She stated she saw the resident between 10:00 PM and 10:17 PM when he was gesturing to go outside to smoke. Nurse #1 stated the resident was told they were in the middle of putting some other residents to bed and she was completing her medication pass and they were unable to take him outside at that time. Nurse #1 indicated Resident #1 went to his room and she and the other staff continued to provide care for other residents. Nurse #1 observed the resident wearing pajama pants, t-shirt, and was barefoot when she saw him on the unit between 10:00 PM and 10:17 PM. Then Nursing Assistant (NA) #1 informed her around 11:30 PM that Resident #1 was not in his room or his bathroom. Nurse #1 went to Resident #1's room (room [ROOM NUMBER]), and the resident was not in his room or bathroom. Nurse #1 indicated she went to the next room (room [ROOM NUMBER]) and saw a windowpane leaning up against the empty bed by the window. She directed staff to continue searching the facility and outside around the facility. Nurse #1 initiated the facility's missing resident/elopement procedure and called the police to notify them of the resident's elopement and then notified the facility Administrator and the on-call Department of Social Services employee. Resident #1 was located at a convenience store/gas station 2/10 mile from the facility by a staff member. The police went to the gas station and transported Resident #1 back to the facility around midnight. Nurse #1 explained Resident #1 was agitated when he returned, and she contacted the on-call physician for an order for medication to help with his agitation. Resident #1 was also placed on 1:1 observation. Resident #1 initially refused a skin check but later let her complete a skin check and vital signs where she noted no injuries or abnormalities. An interview on 9/24/24 at 4:05 PM with Nurse #2 revealed she was in the facility on night shift on 9/18/24 when Resident #1 eloped out the locked memory care unit window. Nurse #2 stated she was assigned to another unit at the facility, but when she became aware of the resident's elopement, she got into her personal vehicle and drove around the neighborhood to look for the resident. Nurse #2 further stated she went to the closest convenience gas station and asked the store clerk if they had seen anyone with Resident #1's description. The clerk indicated that someone matching Resident #1's description had been in the store twice, once to buy cigarettes and once to buy a drink. Nurse #2 stated she walked back out of the store and observed Resident #1 across the street. She called out to Resident #1, and he walked over to her. Resident #1 refused to get in her car, but the police were able to get him to ride in their car back to the facility. Nurse #2 stated Resident #1 was wearing pajama pants, white t-shirt, light jacket and shoes. An interview on 9/24/244 at 8:02 PM with Law Enforcement Officer #1 revealed he responded to Resident #1's elopement from the facility. He stated Resident #1 was located at a convenience store/gas station and was transported back to the facility. The interview further revealed Law Enforcement Officer #1 along with 2 other officers, put the windowpane back into the frame. An interview on 9/24/24 at 3:37 PM with Nursing Assistant (NA) #1 revealed he was working on the memory care unit the night shift of 9/18/24 when Resident #1 eloped. He stated that around 10:00 PM, Resident #1 wanted to go outside to smoke, but was told a staff member would take him out after they made rounds to provide care for some other residents. NA #1 went to check on Resident #1 around 11:30 PM and couldn't find him in his room or bathroom. NA #1 notified Nurse #1, and they started looking for the resident. NA #1 stated he did not remember what Resident #1 was wearing but noted he was wearing shoes when the officer brought him back to the unit. He stated after the resident was returned to the unit; he was assigned to provide 1:1 care for him the rest of his shift. Review of the [NAME] Police Department incident report dated 9/18/24 at 11:37 PM read in part that Law Enforcement Officer #1 was dispatched to the facility at approximately 11:40 PM and arrived at the facility at 11:41 PM. Resident #1 was found by Nurse #2 at approximately 11:57 PM and Law Enforcement Officer #1 went to the convenience store and transported the resident back to the facility. Several officers assisted with putting the window back in place and then left the scene. An interview on 9/24/24 at 1:20 PM with the Administrator revealed she was notified of Resident #1's elopement on 9/18/24 at 11:40 PM. She arrived at the facility around midnight and the police had already brought Resident #1 back. The Administrator stated they were already in the process of transferring the resident to another facility to be closer to his guardian and family and he was transferred to another facility on 9/20/24 which had an interior courtyard where the resident could smoke. Resident #1 was placed on 1:1 observation from the time he returned to the facility until he was transported to his new facility. The Administrator indicated all staff were in-serviced on the resident elopement policy and process. All residents were evaluated for their physical capabilities, behaviors, and wandering to assess whether they could remove a windowpane. The Administrator further stated all new admissions would be evaluated for their ability to remove the windowpanes. An interview on 9/25/24 at 8:40 AM with the Medical Director revealed he was notified of Resident #1's elopement 9/19/24. The Medical Director stated that he did not see how anyone could have anticipated that the resident would be able to remove a windowpane, and he had never heard of that happening before. The interview further revealed given Resident #1's diagnoses and the fact that he was in a locked memory care unit, it was not safe for him to be out of the facility unsupervised. An observation and interview on 9/24/24 at 11:43 AM with the Maintenance Director revealed that the window had 2 panes and measured 70 x 45 inches total. The right side of the window slid to the left side on a track. The left side of the track had a screw affixed to the bottom of the track to prevent the window from opening more than 6 and 5/8 inches. There was no screen in the window. The window in room [ROOM NUMBER] was 79 inches from the grass/ground outside. The Maintenance Director stated that he had been employed at the facility about 4 months and had completed a window audit in July to ensure that all the windows had a screw in the bottom track to prevent it from opening more than 7 inches. He also stated that the right windowpane was physically removed from the track by Resident #1. He did not know how Resident #1 was able to remove the windowpane. The Maintenance Director noted he had completed another window audit on 9/19/24 to ensure all the windows had a screw in the bottom track. An interview on 9/25/24 at 11:17 AM with the Director of Plant Operations revealed he had been the Maintenance Director at the facility for several years. The Director of Plant Operations stated he had looked at the window in room [ROOM NUMBER] where Resident #1 removed the windowpane on 9/19/24 and did not know how the resident got the windowpane out. An observation on 9/24/24 at 5:00 PM with the Administrator revealed from the facility to the convenience gas station was about 2/10 mile through the back parking lot, service area, and two neighborhood roads. There were streetlights observed on the two neighborhood roads. These roads were wide enough for 2 cars but had no painted lines or sidewalks. There were no posted speed limit signs. The convenience store/gas station was across the street at the end of the neighborhood road. The street the convenience gas station was located on was three lanes (middle turn lane) with painted lanes and streetlights. The posted speed limit sign was 20 miles per hour. An additional observation on 9/25/24 at 11:00 AM of the window in room [ROOM NUMBER] revealed there were four 2-inch scratch marks about ¼ inch deep on the window casement as well as a black scuff mark. The caulking was in place around the window frame. The Maintenance Director and the Administrator were present during the observation and reiterated they had no idea how Resident #1 was able to remove the windowpane to exit the facility. The Administrator was notified of the immediate jeopardy on 9/25/24 at 12:53 PM. The facility provided the following corrective action plan with a completion date of 9/20/24. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #1 is a [AGE] year-old male admitted to the facility on [DATE]. Resident #1 was admitted with a diagnosis of but not limited to unspecified injury of the head, aphasia, unspecified mood disorder and unspecified dementia. Resident does not have history of previous elopements Resident #1 is a smoker. Resident was admitted on the secured unit secondary to having diagnosis of unspecified dementia and ability to ambulate. On 9/18/24 approximately at 10:30 PM Resident #1 requested facility staff to have a smoke break. Facility staff addressed Resident #1 letting him know that it would be a little bit as he had just had a smoke, and staff were providing resident care. Resident #1 returned to his room and closed the door as he normally would. Resident #1 showed no signs of being upset or agitated and returned to his room as he normally would, closing the door behind him. This was normal behavior for Resident #1. While conducting rounds at approximately 11:40 PM staff identified that Resident #1 was not in his room. This alerted the staff to begin looking in other rooms and do a general sweep of the area. It was also identified that the windowpane in the adjoining room had been removed and placed on the floor. Facility staff immediately began systematic procedures for missing resident and notifying the Administrator, and Police Department. Nurse Aides and Nurse #1 began facility sweep while Nurse #2 went to her vehicle and began driving around surrounding areas in search of Resident #1. Nurse #2 drove to the only 24-hour business in the area which was a nearby gas station. Nurse #2 entered the gas station and provided the clerk with a description of Resident #1. The clerk stated that the resident had been in the gas station and purchased a soda and pack of cigarettes. Nurse #2 exited the gas station and began looking in the area when she saw Resident #1 on the sidewalk in front of the store and called his name. Resident #1 began walking towards Nurse #2. At this time the police arrived on the scene and Resident #1 agreed to return to the facility and chose to ride with the police officer. Upon arrival back at the facility a skin assessment was completed on Resident #1 and no issues were identified. Vital signs were also recorded for the resident by Nurse #1. Resident #1 was placed on 1:1 supervision. Three of the responding police officers were able to work together and put the windowpane back into place. The on-call provider and guardian were notified of the event. The center had previously been seeking alternative placement for the resident months prior to the event. Requirements for that location were that the new facility needed to be more proximal to the guardian's location and offer smoking. Arrangements were finalized earlier that evening prior to the event and communicated by the Administrator to the guardian. Arrangements were agreed upon and discharge was set for 9/20/2024. Post the event there was a discussion with the guardian and a new location was proposed. This facility differed from the original proposal because the structure of the center was a single level facility with an interior smoking area. Once discussed with the guardian, arrangements were made for the resident to be discharged there on 9/20/2024. Resident discharge as planned on 9/20/2024 with no adversity. The Director of Nursing, Administrator, and the attending nurse discussed the root cause and determined Resident #1's request to smoke was declined, and he went to his room while unsupervised. Resident #1 then went through an adjoining bathroom and removed a windowpane in the neighboring room and exited through the window. Address how the facility will identify other residents having the potential to be affected by the same deficient practice Residents currently residing in the facility have the potential to be affected. On 9/19/24 the Director of Nursing assessed current residents for ability to walk, cognitive impairment, ability to reasonably remove a windowpane and climb through the window opening. No residents were identified at risk during the assessment. During the investigation, a review of residents who pose as a potential elopement based on exit seeking behaviors and abilities to exit were assessed with no additional residents identified. All residents have open utilization data assessment (UDA) named elopement assessments scheduled for their Admission/ Quarterly, these assessments are completed by floor nursing. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur: The Maintenance Director conducted a house audit of windows to ensure that windows could not open greater than 7 inches on 9/19/24. Any window that indicated the ability to exceed the limit, or seemed defective was addressed and additional hardware such as additional screws were put into place. Center utilizes a keypad system on each of the exit doors. Each door has a different code and are frequently changes to prevent residents from exiting. On 9/19/24 the Maintenance Director reviewed the affected window and was unable to identify any deficits of the window, causing it to be easily removed. Screw was in place and there was no damage sustained to the glass or the tracks of the window. Maintenance Supervisor did replace a weather type seal of the window, but this was not part of the operations of the window. Window was found to not be defective. An interview with the Regional Maintenance Director took place on 9/19/24 at 10:31PM. Results from that indicated that the frames of the windows were not removeable and was part of the structure of the building, which is composited of brick and mortar. The windowpanes do have less than a ¼ inch space around them for expansion. The windows will continue to be assessed for any malfunction or age-related faults. The facility is equipped with door locks/alarms, keypad systems and wanderguards to help avoid elopements. These mechanisms were checked by the center's Maintenance Director on 9/19/24. The Wanderguard system and door monitoring system were also audited by the Maintenance Director on 9/19/24. Results from the audits indicated that all systems were operable. The education on the center's Elopement and Wandering Policy was initiated on 9/19/24 by the Administrator and carried on by the Unit Manager. All staff in Nursing, Agency, Therapy, Housekeeping, Administration, and Dietary have received education verbally or in-person prior to working. Education was provided face to face for individuals who were on shift, others not on-site were provided with education via phone. Those who received education via phone will be expected to sign the education prior to working next shift. The education included ensuring residents that exhibit exit seeking behaviors and/or at risk for elopement receive adequate supervision to prevent accidents in the facility's control. Staff were educated on how to identify exit seeking behaviors, monitor the affected resident, and interventions. Education highlighted that alarms doesn't replace the necessary supervision of a resident. Nor does it negate how vigilant that the staff should be in responding to alarms or actions of the resident that would indicate an elopement risk. Staff were instructed that if they were to witness a resident attempting to open a door or window, he / she should make efforts to remove the resident from the area through redirection and should never stop monitoring the resident. Once resident is safe the attending nurse should immediately notify the Nurse Leadership for interventions and make sure that a new elopement assessment is completed. Behaviors that indicate a risk for elopement of a resident should be communicated in report between staff and added to the elopement binder, which will be maintained by the Social Worker. The elopement binder was updated by the DON on 9/19/24. The elopement binder will be maintained moving forward by the Social Worker. The Social Worker was notified of this responsibility on 9/19/24. Staff were reminded that elopement binders are located at each Nurses Station and in the Social Worker's office. Education will be oversighted by DON, anyone not educated on 9/19/24 will need to be educated in- person prior to shift by the Unit Manger / DON. Both the Unit Manager and DON have been educated on their responsibilities effective 9/19/24 Newly hired staff members will receive education in orientation from the Director of Nursing and/or Maintenance Director on the day of orientation it is also during that time that staff will be educated on how to identify behaviors that will trigger a new elopement risk assessment to be completed. On 9/19/24 the Administrator implemented the Director of Nursing or Unit Manager would be responsible for conducting the elopement assessments on new admissions. Residents will be assessed for risk of elopement and unsafe wandering throughout their stay by the interdisciplinary care plan team. The Director of Nursing and Unit Manager have been educated by the Therapy Director on how to assess residents who are at risk exiting through a window and via the door. Assessments will take into consideration a resident; mobility, cognition, dexterity, and ability to balance bi-laterally. Both DON and Unit Manger have been made aware of the responsibility and comprehensively assess and complete the elopement risk UDA for each resident. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained: Audits were put into place on 9/19/24, the Maintenance Director will audit two times a week for 12 weeks to ensure that the residents' windows do not have any defective or bent areas that keeps them secured. Any defective item will be corrected immediately. While repair is being completed the window will have constant monitoring by a facility staff member. Audits will also consist of the responsiveness and demonstration from the staff to properly execute procedures outlined in the Elopement and Wandering Residents Policy. Random audits of the center's response to elopement drills will be completed 1 time a week for 12 weeks by the Maintenance Director or Administrator. Weekly assessment of the wanderguard system by the Maintenance Director will continue regularly thereafter. ADHOC QAPI was initiated by the IDT team about the event on 9/19/24. The Administrator directed the Director of Nursing and Maintenance Director on 9/19/24 that they are responsible for forwarding the results of their audits the QAPI Committee monthly for three months. The QAPI Committee will review the audit to determine trends and/or issues that may need further interventions put into place and to determine the need for further and/or frequency of monitoring. Completion date: 9/20/24 The corrective action plan of immediate jeopardy removal was validated on 9/25/24. Interviews were conducted with a sample of Nursing Assistants, Nurses, Director of Nursing, Unit Manager, and the Maintenance Director to verify education was conducted for elopement and wandering residents. Review of sign-in sheets confirmed all staff in departments received education regarding elopement and wandering residents. Review of audits revealed the twice weekly window audits were completed (9/19/24 and 9/24/24). Further review of audits revealed weekly wander guard assessments including doors, locks and alarm systems were completed on 9/19/24 and 9/23/24. An interview with the Unit Manager on 9/24/24 at 9:00 AM revealed she had received education about resident elopement and assessment of current and new residents for elopement risks. She will assess new admission for elopement risks. An interview with the Director of Nursing on 9/25/24 at 8:51 AM revealed she had assessed the current residents for elopement risks. She also will assess new admissions for elopement risks. An interview with the Maintenance Director on 9/24/24 at 11:43 AM revealed he had received education about resident elopement and wandering residents. He stated he will be conducting twice weekly window audits and weekly elopement drills. The facility's completion date for the corrective action plan of 9/20/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and staff, Nurse Practitioner, and Medical Doctor interviews the facility failed to notify the Nurse Practitioner or the Medical Doctor when a Urology Consult was not able to be scheduled per the Nurse Practitioner's order after a CT (computed tomography) scan noted decreased vascular flow to Resident #1's left testicle. Resident #1 experienced serious adverse outcome after an acute change in condition was noted on 03/11/24 and was transferred to the hospital emergency department (ED), diagnosed with severe sepsis and underwent a left orchiectomy (removal of the testicle) on 3/12/24. This practice affected 1 of 3 residents (Resident #1) reviewed for notification. Immediate Jeopardy began on 02/23/24 when the facility failed to notify a medical provider that they were not able to schedule a urology consultation per the Nurse Practitioner's order for as soon as possible. Immediate jeopardy was removed on 04/05/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of education and monitoring system are in place. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included anoxic brain injury, persistent vegetative state and neurogenic bladder. An interview was conducted with the Nurse Practitioner (NP) on 04/01/24 at 5:00 PM, 04/02/24 at 1:00 PM and 04/04/24 at 2:05 PM. The NP explained that she was notified of Resident #1's scrotal swelling on 02/14/24 and assessed his scrotum to be swollen to approximately the size of a softball with a little redness. The NP stated she offered to the family member to send the Resident to the local ED, but the family member did not want the Resident to go to the ED but wanted him treated at the facility. The NP stated she ordered an ultrasound to be performed on the scrotum immediately and antibiotics to be administered twice a day for 10 days. She reported the ultrasound was completed on 02/15/24 and she learned the results of the ultrasound on 02/19/24 when she went to the facility for rounds. The ultrasound showed decreased vascular flow to the left testicle, and she felt that Resident #1 needed a urology consult as soon as possible because anytime you have decreased vascular flow you need to get scooting, so she wrote the ordered for the urology consult as soon as possible that day on 02/19/24. She stated she assessed the Resident's scrotum on 02/19/24 and 02/28/24 and there was no change in the scrotum since the first time she assessed the scrotum on 02/14/24. She stated the facility needed to monitor the scrotum closely for changes and they could send him to the ED for any changes if need be. At the time of the interview the NP stated that she was not aware that the facility was having a difficult time getting a urology consult scheduled for Resident #1 and assumed the appointment had been made. She also stated she was not aware that Resident #1's urology consult was scheduled for 03/27/24 and explained that was too long away. She stated she could see maybe being scheduled for 2 weeks out from when it was ordered but 5 to 6 weeks away was too long. On 04/01/24 at 11:40 AM an interview was conducted with the Scheduler who explained that she was working on the hall as a nurse aide on 02/19/24 when she was given the order for Resident #1 to have a urology consult as soon as possible from the Staff Development Coordinator. She explained that as soon as possible meant it needed to schedule with high priority like then and there, but she was on the hall and knew she would have to follow up the next day. When she was able to follow up, she called a urology office that told her to fax over the information on Resident #1 and they would get back to her. She stated she waited several days, and they never followed up with her so when she was able to get back in touch with the urology office, they told her there was a mix-up in their records and they needed more information. The Scheduler stated that by that time it was about 03/03/24 or 03/04/24 so she decided to try to get Resident #1 a urology appointment at a local urology clinic and on 03/08/24 she was able to schedule a urology appointment for the Resident for 05/22/24. The Scheduler stated she kept that appointment and tried another clinic 03/08/24 and was able to schedule a urology appointment for the Resident for 03/27/24. The Scheduler stated she did not inform anyone that she was having difficulties with scheduling Resident #1 for a urology appointment because she thought she could manage it but now she knew different. During an interview with the Staff Development Coordinator (SDC) on 04/02/24 at 10:35 AM revealed that on 02/19/24 she put the order in Resident #1's electronic medical record for a urology consultation as soon as possible that was written by the NP on 02/19/24. She stated her routine was to make 2 copies of the orders and she kept one for herself and gave the other order to the Scheduler on 02/19/24 to make an appointment for the Resident. The SDC explained that she always highlighted the area of the order for the consultation and pointed it out to the Scheduler when she gave it to her on 02/19/24. If the Scheduler had any questions about the order, then she would get back to her, but the SDC stated she did not recall that the Scheduler had any questions about the order. The SDC stated that she did not know if the urology consultation was ever made because she did not follow up with the order. An interview was conducted with Nurse #1 on 04/01/24 at 3:00 PM who confirmed she was the Nurse on duty on 03/11/24 and sent Resident #1 to the emergency department. Nurse #1 continued to explain that Resident #1 seemed quieter than normal during her shift, and she did not have any trouble flushing his catheter and his feeding tube was patent and she took the Resident's blood pressure several times throughout the shift that fluctuated. She stated the third time she took his blood pressure it was 86/42 and that was lower than it had been all day and he seemed weaker, and she felt at that time that he was septic. The Nurse explained that she called the Nurse Practitioner and got an order to send Resident #1 to the emergency department. Review of Resident #1 progress notes from the local hospital ED dated 03/11/24 at 4:15 PM revealed the Resident presented with an oxygenation saturation of 89% and blood pressure of 73/46 with an additional reading of 70/39 during his limited stay at the local hospital. Abnormal labs included an elevated white blood cell (WBC) of 11.08 (normal range 4.80-10.80) and a blood urea nitrogen (BUN) of 107 (normal range 7-10) and Urine culture with greater than 100,000 CFU/ML (greater than 100,000 CFU/ML would indicate infection) gram negative bacilli (bacteria). Resident #1 was administered three liters of intravenous fluids and started on two different intravenous antibiotics. After consultation with internal and external providers it was decided Resident #1 would need to be transferred to a hospital with a higher level of care capabilities due to Resident #1's condition, the need for a bed in the intensive care unit and the specialty of an intensivist (physician who provides special care for critically ill patients) and infectious disease. The progress note described Resident #1's specific medical risks of worsening pneumonia, sepsis or death. Resident #1 had to be air lifted to the secondary hospital. There was no documentation in the ED progress notes about Resident #1's scrotum. discharge date and time was 03/11/23 at 11:14 PM with discharge diagnoses of dehydration, facility acquired pneumonia and kidney stone in the right ureter. Attempts to interview the local emergency department physician were unsuccessful. A review of Resident #1's progress notes dated 03/12/24 at 2:18 AM from the second hospital revealed he had a continuous medication infusing via intravenous access to improve his blood pressure which was effective. It was noted that he had received 3 liters of intravenous and the two antibiotics ordered at the previous hospital would be continued. The Resident was admitted with diagnosis of severe septic shock secondary to urinary tract infection, dehydration, aspiration pneumonia and right stone in ureter with hydronephrosis. A urology consultation was obtained on the morning 03/12/24 and orders were received for ultrasounds of the kidneys and testicles to be completed. The urology consultation revealed Resident #1 had a history of left testicular swelling and pain for one month with a previous ultrasound demonstration of decreased vascular flow to the left testicle. The ultrasound of the left testicle completed on 03/12/24 demonstrated no blood flow with surrounding necrotic changes consistent with the left testicle. On 03/12/24 an emergency stent was placed in the right ureter and a left orchiectomy (removal of the left testicle) was performed. An interview was conducted with the Medical Doctor (MD) on 04/01/24 at 4:30 PM. The MD explained he reviewed Resident #1's ultrasound done on 02/15/24 and noted that the Nurse Practitioner wrote an order to have a urology consultation as soon as possible, so it should have been done right away. He stated the facility should have let them know if they were having difficulty obtaining a urology consult because it was possible that he could have intervened and arranged for the Resident to be seen sooner to avoid the outcome of the orchiectomy. During an interview with the Director of Nursing (DON) on 04/02/24 at 9:00 AM the DON stated the Staff Development Coordinator at the time was the one who wrote the order for the urology consultation for Resident #1 so it would have been her responsibility to follow up with the Scheduler to make sure she made the appointment. She stated they normally discussed the new orders in the morning clinical meeting but the morning they would have discussed the order was when the state was in the building, and they did not have the morning meeting. The DON stated she did not know who the Scheduler's contact person was in house to go to if she was having scheduling problems but regardless the DON stated the Scheduler should have let someone in management know that she was having difficulty scheduling the urology appointment. An interview was conducted with the Administrator on 04/02/24 at 10:40 AM and 04/03/24 at 2:00 PM who explained that that the facility discussed physician orders in the clinical meeting which was held in the morning after a general meeting with all the managers. The Administrator stated she knew Resident #1 had an order for a urology consult but she did not know that he had a problem with his testicle. She reported the Scheduler received training from the previous Scheduler, but she could not say what the training entailed just that it was completed. She indicated, if need be, the Scheduler could have reached out to the previous Scheduler for instruction and at the least she could have notified the DON of difficulties in making the urology appointment for Resident #1. The Administrator indicated that the Physician should have been notified if they were having difficulty in scheduling a urology appointment. The Administrator was notified of Immediate Jeopardy on 04/03/24 at 3:55 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 the result of noncompliance. On 2/19/21 the Nurse Practitioner wrote an order for Resident #1 to have a urology appointment as soon as possible due to ultrasound of scrotum showing possible decreased vascular flow to left testicle. The facility transport scheduler scheduled the urology appointment for 3/27/24. The facility did not contact the nurse practitioner to notify her of the date of the appointment. On 3/11/24 Resident #1 experienced an acute change in condition with a blood pressure of 86/42 and weakness. Resident #1 was sent to the emergency department where he was diagnosed with severe septic shock, urinary tract infection and aspiration pneumonia. The left testicle was found to have no blood flow with necrotic changes to the left testicle and removal of the testicle had to be performed. On 4/3/24 and 4/4/24 the Nurse Managers reviewed residents who have change of condition during the last 30 days using 24-hour reports, x-rays, lab tests and vital signs. These items were reviewed for indicators of a change such as not at baseline, not normal for resident, lethargic, shortness of breath, new onset pain, out of range results, etc. Falls with major injuries for the last 30 days were reviewed. This audit included notification to the physician or nurse practitioner. Any opportunities identified during this audit will be corrected by the Nurse Managers by 4/4/24. On 4/3/24 the Administrator did an audit of all consult orders for all residents in the last 90 days. This information was pulled from the orders in the electronic health record. Any issues identified were addressed immediately by the Interdisciplinary Team. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: The Director of Nursing and The Regional Nurse Consultant educated all nurses, including agency, regarding the requirements for notification to the Physician or Nurse Practitioner following a change of condition. Verbal education was given on a change of condition is noted when a resident presents different than known baseline, lethargic, restless or short of breath. Furthermore, education was provided on how to use the on-call MD system after hours and on weekends. Hall nurses are responsible for retrieving faxed x-ray and lab results from the fax machine which is located at the nurse's station. Critical lab and x-ray results are called to the on-call provider at that time they are received. All other lab and x-ray results are to be placed in the communication book for physician/nurse practitioner follow up. The Director of Nursing will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift. This education was provided both in person and via telephone. Verbal understanding was demonstrated by conversation and return of information. Education will be completed by 4/4/24. On 4/3/24 the Director of Nursing was made aware that it was her responsibility to educate staff members prior to working their next scheduled shift and that she is to track this education. On 4/4/24 the Administrator educated the resident transport scheduler on notifying the Director of Nursing so that she can notify the physician and nurse practitioner when orders for consultation appointments cannot be scheduled per the physician or nurse practitioner orders. The Director of Nursing (DON) was notified of this responsibility on 4/4/24. In the event the DON is not in the building, the transport scheduler will notify the MDS Coordinator who will notify the physician or nurse practitioner. The MDS Coordinator was made aware of this responsibility 4/4/24. Newly hired transport schedulers will be educated in orientation. Effective 4/3/24 the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 4/5/24 An onsite validation of the immediate jeopardy removal plan was conducted on 04/8/24. Residents' information including vital signs, orders, assessments and incidences for the last 30 days were reviewed to identify if the providers had been notified of changes in condition. Specific orders for consultations were reviewed and all issues were corrected when identified. All nursing staff were educated on the new system of notification and ensured the nurses knew how to contact the on call provider when necessary. Return demonstration of understanding the system was ensured. All new nurses will be educated on the system upon hire. The Scheduler was educated to inform the DON when she was having trouble making appointments for consultations ordered by the providers. The immediate jeopardy removal date of 04/05/24 was validated.

Based on record reviews and staff, family member, Nurse Practitioner, Urology Surgeon, Wound Physician and Medical Doctor interviews the facility failed to protect a Resident's right to be free from neglect when the facility failed to identify the seriousness of a left swollen testicle, complete thorough and ongoing nursing assessments, schedule a urology appointment per the Nurse Practitioner's order which led to a delay in care and treatment for a serious medical emergency for 1 of 3 residents (Resident #1) reviewed for neglect. Resident #1 experienced a serious adverse outcome when an acute change in condition was noted on 03/11/24 with a blood pressure of 86/42 and weakness. The Resident was sent to the local emergency department where he was transferred to a hospital for a higher level of care and diagnosed with severe septic shock and urinary tract infection. An ultrasound showed no blood flow with necrotic changes to the left testicle and an orchiectomy (removal of the testicle) had to be performed. This practice affected 1 of 3 residents (Resident #1) reviewed for neglect. Immediate Jeopardy began on 02/23/24 when the facility failed to protect a Resident's right to be free from neglect when they failed to identify the seriousness of a left swollen testicle, complete thorough and ongoing assessments and schedule a urology appointment per the Nurse Practitioner's order which led to a delay in care and treatment for a serious medical emergency. Immediate jeopardy was removed on 04/05/24 when the facility provided and implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of education and monitoring system are in place. The findings included: This tag is crossed referenced to: F 684: Based on record reviews and staff, family member, Nurse Practitioner, Urologist and Wound Physician's interviews the facility failed to identify the seriousness of decreased vascular flow to Resident #1's left testicle and complete and document thorough and ongoing nursing assessments of left testicle after 03/23/24 to determine the need for further medical attention. In addition, a Urology Consultation for evaluation of the Resident's left testicle was scheduled for after 3/23/24 not as ordered by the NP which further delayed the determination of what medical interventions were necessary. The Resident experienced an acute change in condition on 03/11/24 with a blood pressure of 86/42 (normal blood pressure range 120/80) and weakness. The Resident was sent to the local hospital emergency department (ED) and was then life flighted to a second hospital due to the need for a higher level of care and capabilities. The Resident was diagnosed with severe septic shock and urinary tract infection. A renal ultrasound showed an obstructing stone in the right ureter with hydronephrosis (excessive fluid in the kidney due to a backup of urine) and a testicular ultrasound showed no blood flow with necrotic (death of cells or tissue due to disease or injury) changes to the left testicle. On 03/12/24 an emergency stent was placed in the right ureter and the left testicle was removed. This practice affected 1 of 3 residents reviewed for providing care according to professional standards of practice (Resident #1). F 580: Based on record reviews, and staff, Nurse Practitioner, and Medical Doctor's interviews the facility failed to notify the Nurse Practitioner or the Medical Doctor when a Urology Consult was not able to be scheduled per the Nurse Practitioner's order after a CT (computed tomography) scan noted decreased vascular flow to Resident #1's left testicle. Resident #1 experienced serious adverse outcome after an acute change in condition was noted on 03/11/24 and was transferred to the hospital emergency department (ED), diagnosed with severe sepsis and underwent a left orchiectomy (removal of the testicle) on 3/12/24. This practice affected 1 of 3 residents (Resident #1) reviewed for notification. The Administrator was notified of Immediate Jeopardy on 04/03/24 at 3:55 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. The facility failed to identify the seriousness of a swollen left testicle, complete thorough and ongoing assessments, schedule a urology appointment per the Nurse Practitioner's order which led to a delay in care and treatment for a serious medical emergency. On 12/21/23 Resident #1 was admitted to Lotus Village Center for Nursing and Rehabilitation with diagnosis of brain damage, dysphagia, hypertension and gastrostomy. On 2/19/24 the physician ordered Resident #1 to have urology appointment as soon as possible due to ultrasound showing possible decreased vascular flow to the left testicle. The facility scheduled the appointment for 3/27/24 and did not notify the ordering nurse practitioner of the delay between order and available appointment. Nursing staff did not complete ongoing and thorough assessments of the scrotal area to identify changes. On 3/11/24 Resident #1 had an acute change of condition noted with a blood pressure of 86/42 and weakness. Resident #1 was sent to the emergency room and was diagnosed with severe septic shock, urinary tract infection and aspiration pneumonia. Necrotic changes were found to the left testicle and removal of the testicle was performed. Current residents residing in the facility have the potential to be affected by the deficient practice. On 4/4/24 all alert and oriented residents with a BIMS of 12 or greater were interviewed by the Social Worker regarding care and questioned if they felt they were neglected of care and services. There were no issues reported. All residents with cognitive impairment, a BIMS of 11 or less had total body skin assessments completed by the MDS Coordinator. There were no signs of neglect identified. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: Beginning on 4/3/24 the Director of Nursing and Regional Nurse Consultant educated the staff in all departments including agency staff on the definition of neglect: the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Some examples of neglect include lack of sufficient staffing to be able to provide services, lack of knowledge of the needs of the resident, lack of supplies to provide care, or indifference or disregard for resident care and safety. The Director of Nursing and Administrator will ensure that staff members, to include agency staff, that have not received the education will not be able to work until they have received this education. The Director of Nursing and Administrator are responsible for tracking who has received the education and who still needs to receive it prior to working their next shift. Both the Director of Nursing and the Administrator were made aware of this responsibility on 4/3/24. The Director of Nursing will provide this education to newly hired staff, including agency, during orientation. Education was given verbally either in person or via phone and/or written format and the staff were asked to restate the information to confirm understanding of the education. Staff will not be able to work their next scheduled shift until education has been completed. Effective 4/3/2024, the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 4/5/23 On 04/08/24 an onsite validation of the immediate jeopardy removal plan was conducted. The facility assessed all residents either through interviews or skin assessments for signs and symptoms of neglect and there were no issues noted. The entire staff was educated on the definition of neglect and different examples of neglect and will ensure that no staff will be allowed to work without receiving the education. Newly hired staff as well as agency staff will be educated on neglect. Return understanding of neglect was demonstrated verbally after the education was completed. The immediate jeopardy removal date of 04/05/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff, family member, Nurse Practitioner (NP), Urology Surgeon and Wound Physician interviews the facility failed to identify the seriousness of decreased vascular flow to Resident #1's left testicle and complete and document thorough and ongoing nursing assessments of left testicle after [DATE] to determine the need for further medical attention. In addition, the Urology Consultation for evaluation of the Resident's left testicle was scheduled for [DATE] which further delayed the determination of what medical interventions were necessary. The Resident experienced an acute change in condition on [DATE] with a blood pressure of 86/42 (normal blood pressure range 120/80) and weakness. The Resident was sent to the local hospital emergency department (ED) and was then life flighted to a second hospital due to the need for a higher level of care and capabilities. The Resident was diagnosed with severe septic shock and urinary tract infection. A renal ultrasound showed an obstructing stone in the right ureter with hydronephrosis (excessive fluid in the kidney due to a backup of urine) and a testicular ultrasound showed no blood flow with necrotic (death of cells or tissue due to disease or injury) changes to the left testicle. On [DATE] an emergency stent was placed in the right ureter and the left testicle was removed. This practice affected 1 of 3 residents reviewed for providing care according to professional standards of practice (Resident #1). Immediate Jeopardy began on [DATE] when the facility failed to complete and document thorough and ongoing nursing assessments of Resident #1's left testicle. Immediate jeopardy was removed on [DATE] when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of education and monitoring system are in place. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included anoxic brain injury, persistent vegetative state and neurogenic bladder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had long and short-term memory problems, functional impairment of upper and lower extremities for range of motion, totally dependent on staff for all activities of daily living and had an indwelling urinary catheter. A review of Resident #1's medical record from [DATE] through discharge on [DATE] revealed there were no documented nursing assessments of the Resident's scrotum. An interview was conducted with the Nurse Practitioner (NP) on [DATE] at 5:00 PM, [DATE] at 1:00 PM and [DATE] at 2:05 PM. The NP explained that she was notified of Resident #1's scrotal swelling on [DATE] and assessed his scrotum to be swollen to approximately the size of a softball with a little redness. The NP stated she offered to the family member to send the Resident to the local ED, but the family member did not want the Resident to go to the ED but wanted him treated at the facility. The NP stated she ordered an ultrasound to be performed on the scrotum immediately and antibiotics to be administered twice a day for 10 days. She reported the ultrasound was completed on [DATE] and she learned the results of the ultrasound on [DATE] when she went to the facility for rounds. The ultrasound showed decreased vascular flow to the left testicle, and she felt that Resident #1 needed a urology consult as soon as possible because anytime you have decreased vascular flow you need to get scooting, so she wrote the ordered for the urology consult as soon as possible that day on [DATE]. She stated she assessed the Resident's scrotum on [DATE] and [DATE] and there was no change in the scrotum since the first time she assessed the scrotum on [DATE]. She stated the facility needed to monitor the scrotum closely for changes and they could send him to the ED for any changes if need be. At the time of the interview the NP stated that she was not aware that the facility was having a difficult time getting a urology consult scheduled for Resident #1 and assumed the appointment had been made. She also stated she was not aware that Resident #1's urology consult was scheduled for [DATE] and explained that was too long away. She stated she could see maybe being scheduled for 2 weeks out from when it was ordered but 5 to 6 weeks away was too long. During an interview with the Wound Physician (who was also a Surgeon) on [DATE] at 11:35 AM the Physician explained that he consulted weekly on Resident #1's pressure ulcers and when he made rounds on [DATE] it was brought to his attention by Resident #1's family member that his scrotum was swollen and appeared to be tender. He continued that he noticed that Resident #1's scrotum was swollen and tender and he would recommend a scrotal ultrasound to determine whether it was a cystocele (a bulge of the bladder) or a torsion. He indicated he spoke with the Nurse Practitioner about it on [DATE] who was already aware of the Resident's swollen scrotum and was going to order an ultrasound. The Wound Physician stated he made note of the assessment in his [DATE] notes but not after that because the NP was aware of the issue and that was not the area of his consultation. He continued to explain that when he made rounds on Resident #1 the following weeks, he noticed his scrotum was still swollen and he was told by the Resident's family member that he had a urology appointment scheduled. The Physician stated he informed the family member that Resident #1 would probably have to have the testicle removed. The Physician explained that the amount of time it took for the testicle to die depended on what the cause was, for example if the cause was torsion, then it would be faster. He stated the last two times ([DATE] and [DATE]) he looked at the Resident's scrotum it looked about the same as it did on [DATE] and he did not feel like it needed to be an emergency urology consultation, but it needed to be evaluated. He explained that according to the ultrasound where it showed decreased vascular blood flow Resident #1 may not have needed an orchiectomy but only more or a different antibiotic. He stated Resident #1 did not seem to have the pain the second and third time he saw him and the last time he rounded on Resident #1 ([DATE]) his scrotum did not seem painful or tender. The Physician stated it was possible the testicle could have twisted and untwisted and if so, the pain would have come and gone. On [DATE] at 11:40 AM an interview was conducted with the Scheduler who explained that she was working on the hall as a nurse aide on [DATE] when she was given the order for Resident #1 to have a urology consult as soon as possible from the Staff Development Coordinator. She explained that as soon as possible meant it needed to schedule with high priority like then and there, but she was on the hall and knew she would have to follow up the next day. When she was able to follow up, she called a urology office that told her to fax over the information on Resident #1 and they would get back to her. She stated she waited several days, and they never followed up with her so when she was able to get back in touch with the urology office, they told her there was a mix-up in their records and they needed more information. The Scheduler stated that by that time it was about [DATE] or [DATE] so she decided to try to get Resident #1 a urology appointment at a local urology clinic and on [DATE] she was able to schedule a urology appointment for the Resident for [DATE]. The Scheduler stated she kept that appointment and tried another clinic [DATE] and was able to schedule a urology appointment for the Resident for [DATE]. The Scheduler stated she did not inform anyone that she was having difficulties with scheduling Resident #1 for a urology appointment because she thought she could manage it but now she knew different. An interview was conducted with the Social Worker (SW) on [DATE] at 10:25 AM who explained that she had heard from the Scheduler (she could not remember when) that she was having trouble getting a urology appointment scheduled for Resident #1 and the family member did not agree with the first appointment that was made for him. The SW thought they worked it out because the final urology appointment was in the books for a urology clinic out of town but did not know when it was scheduled for. The SW stated she was made aware of the difficulty that the Scheduler was having making the urology appointment through the family member. During an interview with Nurse #7 on [DATE] at 2:00 PM the Nurse stated she had only worked with Resident #1 one time (Medication Administration Record indicated she worked with the Resident on [DATE] and [DATE]) and the Resident's family member brought the Resident's swollen scrotum to her attention. The Nurse explained that the scrotum appeared to be swollen and the scrotum was elevated using a pillow. There was no documentation in the Resident's medical record of the assessment. On [DATE] at 3:05 PM an interview was conducted with Nurse Aide (NA) #1 who stated that she mostly worked the hall where Resident #1 resided. The NA explained that she knew of the Resident's scrotum being swollen and hard and reported it to several nurses but could not remember which nurses she reported it to. She stated she did not know what was being done about the swelling other than keeping his scrotum elevated which they always did, and his family member did as well. The NA explained that Resident #1 flinched when you touched his scrotum but he flinched every time you touched him so she could not be sure it was painful. She stated the swelling eventually subsided. During an interview with Nurse Aide (NA) #2 on [DATE] at 3:06 PM the Nurse Aide explained that she worked on all the halls including the hall that Resident #1 resided. The NA continued to explain that she noticed Resident #1's scrotum to be slightly larger than the normal scrotum and it was fleshy looking. She stated the family member was very particular with his care and always kept his scrotum elevated on pillows. The NA stated she did not notice his scrotum being painful when touched because the Resident always yelled and screamed when he was touched even before his scrotum was swollen. She stated she would not have identified the scrotum to be swollen but maybe slightly enlarged therefore she did not report the swollen scrotum to the nurses. An interview was conducted with Nurse Aide #3 on [DATE] at 3:15 PM. The NA explained that she often worked the hall where Resident #1 resided and took him to the shower room for his showers. The NA continued to explain that she noticed that Resident #1's scrotum was swollen and red like it was irritated and she knew that nursing was aware of it but did not know what was being done. She stated the family member was particular about his care and kept his scrotum elevated all the time. The NA reported she did not notice his scrotum being painful because he hollered every time he was touched not just when you touched his scrotum. A review of Resident #1's progress notes dated [DATE] at 5:33 AM and written by the Director of Nursing (DON) revealed cleaned scant amount of blood from around catheter when providing resident care. Catheter patent and draining and not leaking at this time. Flushed catheter. Resident slept very soundly this shift. Tried not to disturb the resident too much because he does not sleep well usually. An interview was conducted with Nurse #3 on [DATE] at 12:00 PM and [DATE] at 8:50 AM who confirmed that she worked from 7:00 AM to 7:00 PM on [DATE] with Resident #1. Nurse #3 stated she never knew anything about Resident #1 having scrotal swelling and she even worked on [DATE] and flushed his catheter and did not notice any scrotal swelling. She stated she felt like if he had scrotal swelling, she would have seen it when she flushed his catheter on [DATE] and if so, she would have notified the Physician. On [DATE] at 11:45 AM an interview was conducted with Nurse #2 who confirmed she worked with Resident #1 on [DATE] from 7:00 PM to 7:00 AM on [DATE]. The Nurse reported she had never noticed any scrotal swelling on Resident #1 at that time nor had she ever noticed any scrotum swelling on the Resident nor was she aware that he had a scrotal ultrasound or what the results were. A review of Resident #1's progress note dated [DATE] at 4:05 PM and written by Nurse #1 revealed Resident was just not himself and appeared to be weaker than usual. Blood pressure 86/42 and heart rate was 80. His pupils were not as reactive as his baseline and the urinary catheter was draining adequate urine output. The feeding tube was intact. The Resident's family insisted that something was wrong and wanted the physician to send him to the hospital. Nurse Practitioner contacted and received an order to send him to the emergency department for further evaluation. An interview was conducted with Nurse #1 on [DATE] at 3:00 PM and [DATE] at 10:10 AM who stated she had recently worked with Resident #1 more often and confirmed she was the Nurse on duty on [DATE] from 7:00 AM to 7:00 PM and sent Resident #1 to the ED. Nurse #1 continued to explain that Resident #1 seemed quieter than normal during her shift. She did not have any trouble flushing his catheter and his feeding tube was patent and she took the Resident's blood pressure several times throughout the shift which fluctuated. She stated the third time she took his blood pressure it was 86/42 and that was lower than it had been all day and he seemed weaker, and she felt at that time that he was septic. The Nurse explained that she called the Nurse Practitioner and got an order to send Resident #1 to the ED. Nurse #1 reported that she did not know about Resident #1's scrotal swelling but she did know that he had an ultrasound ordered because she noted the order for the ultrasound of the scrotum on [DATE] the day it was written. She explained that she only occasionally worked with Resident #1, and she did not have to assess his scrotal swelling but that if he had scrotal swelling, she would have noticed it when she flushed his catheter. Nurse #1 stated that when she worked with Resident #1, she never noticed any swelling of his scrotum. When asked how she would know to assess for scrotal swelling the Nurse responded that would be considered an acute episode or a change in condition and when the issue was first identified the nurse who discovered the issue should set up a user defined assessment (UDA) that would automatically populate to be done once a shift for 72 hours or until it was resolved. Review of Resident #1 progress notes from the local hospital ED dated [DATE] at 4:15 PM revealed the Resident presented with an oxygenation saturation of 89% and blood pressure of 73/46 with an additional reading of 70/39 during his limited stay at the local hospital. Abnormal labs included an elevated white blood cell (WBC) of 11.08 (normal range 4.80-10.80) and a blood urea nitrogen (BUN) of 107 (normal range 7-10) and Urine culture with greater than 100,000 CFU/ML (greater than 100,000 CFU/ML would indicate infection) gram negative bacilli (bacteria). Resident #1 was administered three liters of intravenous fluids and started on two different intravenous antibiotics. After consultation with internal and external providers it was decided Resident #1 would need to be transferred to a hospital with a higher level of care capabilities due to Resident #1's condition, the need for a bed in the intensive care unit and the specialty of an intensivist (physician who provides special care for critically ill patients) and infectious disease. The progress note described Resident #1's specific medical risks of worsening pneumonia, sepsis or death. Resident #1 had to be air lifted to the secondary hospital. There was no documentation in the ED progress notes about Resident #1's scrotum. discharge date and time was [DATE] at 11:14 PM with discharge diagnoses of dehydration, facility acquired pneumonia and kidney stone in the right ureter. Attempts to interview the local emergency department physician were unsuccessful. A review of Resident #1's progress notes dated [DATE] at 2:18 AM from the second hospital revealed he had a continuous medication infusing via intravenous access to improve his blood pressure which was effective. It was noted that he had received 3 liters of intravenous and the two antibiotics ordered at the previous hospital would be continued. The Resident was admitted with diagnosis of severe septic shock secondary to urinary tract infection, dehydration, aspiration pneumonia and right stone in ureter with hydronephrosis. A urology consultation was obtained on the morning [DATE] and orders were received for ultrasounds of the kidneys and testicles to be completed. The urology consultation revealed Resident #1 had a history of left testicular swelling and pain for one month with a previous ultrasound demonstration of decreased vascular flow to the left testicle. The ultrasound of the left testicle completed on [DATE] demonstrated no blood flow with surrounding necrotic changes consistent with the left testicle. On [DATE] an emergency stent was placed in the right ureter and a left orchiectomy (removal of the left testicle) was performed. An interview was conducted with the Urology Surgeon on [DATE] at 4:35 PM. The Surgeon explained that he received a call from the hospital emergency department for a consultation for Resident #1 on the early morning of [DATE] and was informed that he was an air transfer from another hospital. The Physician Assistant (PA) reported that Resident #1 had tests from the previous hospital that showed an obstructing stone in the right ureter and was showing signs of sepsis, and the Surgeon's initial thought was that if it was a stone or stones then it was reason for urgent intervention and a stent needed to be placed to allow the infected urine to pass through which was a common procedure. The Surgeon continued to explain that the PA informed him that Resident #1's family member reported that the Resident had endured scrotal swelling and pain for about one month with a previous ultrasound that showed decreased vascular flow in the left testicle therefore, the Surgeon wanted a stat (immediate) ultrasound on the kidneys and testicles before the Surgeon arrived at the hospital so he would know what he was dealing with and what needed to be done. The Surgeon explained that when he read the results of the ultrasounds, he knew he needed to remove the stone in the right ureter and place a stent to relieve the hydronephroses in the right ureter and he needed to remove the left testicle because the repeat ultrasound showed no blood flow to the left testicle at all. He stated the ultrasound completed [DATE] showed missed to late torsion (twisting) and also showed the left testicle had been dead for a long time. He reported his belief was that the reason for the sepsis was the dead testicle. When asked if Resident #1's dead testicle was painful the Surgeon informed that during the process of dying (decreased blood flow) the testicle would be painful but after the testicle died there would be no pain and when the testicle died it was necessary to be removed. He stated there was no way to tell how long the testicle had been dead. The Surgeon indicated that he could tell that the testicle did not die from torsion that more than likely it died from orchitis (an inflammation of one or both testicles mainly caused by a bacterial or viral infection) that was not treated appropriately. The Surgeon was asked if the orchiectomy could have been prevented if Resident #1 had been sent for a urology consult when it was ordered on [DATE] the Surgeon stated that it was hard to say but that initially an antibiotic would be necessary to treat the infection (orchitis) but if after a few days of no improvement then he would have switched the antibiotic and obtained a repeat ultrasound. On [DATE] at 10:37 AM during an interview with Resident #1's family member she explained that the Resident had a history of recurrent urinary tract infections and had several trips to the emergency department for catheter changes due to blockages related to thick sediment in his urine that was treated with a medication used to flush the catheter. She informed Resident #1 had a 5 day stay at the hospital in [DATE] due to a severe urinary tract infection. The family member continued to explain that in mid-February she noticed his scrotum was swollen to the size of an orange and asked for him to be evaluated by the Nurse Practitioner (NP) which she did, and the NP ordered an ultrasound to be done. The ultrasound was done which showed a decreased vascular flow of his left testicle and on [DATE] the NP ordered an antibiotic and a urology consult as soon as possible due to decreased vascular flow to his left testicle. The family member stated she approached the Scheduler and Social Worker several times with her concerns about not getting a urology consult for the Resident and even helped with obtaining an appointment herself before one was eventually made on [DATE] for [DATE] at a urology clinic in a nearby town. The family member continued to inform that on the afternoon of [DATE] she went to the facility and found Resident #1 appearing white as a ghost, his gums were white, and he was clammy and barely breathing. She called for Nurse #1 to assess him, and the Nurse got a blood pressure of 68/33, then she told the Nurse to call 911. The family member reported that while at the local ED the doctor informed her that they were going to airlift him to another hospital when he was stable because he was severely dehydrated, malnourished and possible renal failure or septic shock. She stated they did a CT scan of his kidneys to verify the need to send him to the other hospital to see a kidney specialist. The family member stated Resident #1 was sent by helicopter to the other hospital late that same night on [DATE]. She informed that when she got to the hospital she informed the doctors of everything the Resident had been through and around 5:30 AM on [DATE] the Urology Surgeon told her that he was going to do emergency surgery because Resident #1 had a blockage related to a kidney stone in his right ureter and he had to place a stent (a tubular support placed temporarily inside a blood vessel, canal or duct to aid healing or relieve an obstruction). The Surgeon also informed that Resident #1's left testicle was dead, and he would have to remove it while he was placing the stent. The family member stated the surgery was successful and Resident #1 was due to be discharged on [DATE] to her home for her to provide his care. During an interview with the Director of Nursing (DON) on [DATE] at 9:00 AM and [DATE] at 5:30 PM the DON stated that she vaguely remembered Resident #1 having scrotal swelling, but she was not involved with it. She stated she saw his scrotum a couple of days after the reported swelling, but she did not think it looked swollen. The DON continued to explain that she assisted the nurse aide in turning and repositioning the Resident a couple nights before he was sent out and even changed and flushed his catheter and she did not see any signs of a swollen scrotum. The DON was asked how the facility managed the documentation on acute changes or changes in condition to ensure they were being monitored and documented correctly and she indicated the documentation was subject to the nurses' judgement as to whether the acute change warranted documentation. If so, the nurse would set up UDA documentation or at the very least she should document the assessment in the Resident's progress notes until the issue resolved. The DON was asked if Resident #1's scrotal swelling and decreased vascular blood flow to his left testicle should be considered an acute episode or a change in condition and the DON replied yes. When asked what the facility's policy stated about documentation on acute episodes or changes in conditions the DON informed, they did not have a policy on documentation of acute episodes or changes in the residents' conditions. The Administrator was notified of Immediate Jeopardy on [DATE] at 3:55 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. Resident #1 was admitted to the facility on [DATE] with diagnosis brain damage, dysphagia, hypertension, and gastrostomy. On [DATE] the physician ordered Resident #1 to have a urology appointment as soon as possible due to ultrasound of scrotum showing possible decreased vascular flow to the left testicle. A urology appointment was scheduled for [DATE]. Nursing staff failed to document on-going thorough assessments to include Resident #1's scrotum once the swelling was identified. On [DATE] Resident #1 had a change of condition noted with a blood pressure of 86/42 and weakness. Resident #1 was sent to the emergency room and was diagnosed with severe septic shock, urinary tract infection and aspiration pneumonia. Necrotic changes were found to the left testicle and removal of the testicle was performed. All residents residing in the facility have the potential to be affected by the deficient practice. On [DATE] the Director of Nursing and MDS Nurse Coordinator reviewed 30 days of vital signs and progress notes for all current residents to identify if there was a change in condition. If acute changes were identified, monitoring and assessments were reviewed for proper documentation. Physician and Nurse Practitioner orders including consultations, laboratory tests and x-rays were reviewed. Any issues were addressed upon identification by the Director of Nursing, MDS Nurse Coordinator and Regional Nurse Consultant. 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 [DATE] the Director of Nursing and Regional Nurse Consultant educated both in person and via phone the nursing staff to include nurses and nurse aides including agency staff. Verbal understanding was demonstrated by conversation and return of information. Education included when they recognize a resident with a change of condition nurse aides are to notify the nurse immediately. This is to include the definition of change in conditions. A change of condition was explained as changes from the resident's baseline, lethargy, confusion, increase/decrease vital signs, behaviors, skin issues, shortness of breath, swelling. Nurses were educated on completing and documenting their thorough assessment after a change has been noted. The MDS Coordinator will open a user defined assessment (UDA) which will flag in the resident's electronic medical record for the nurses to complete every shift on residents requiring on-going monitoring. The MDS Coordinator will be made aware of the need to open the UDA during daily stand-up and stand-down meetings. The Interdisciplinary Team will determine who needs the UDA opened based on the change of condition. The MDS Coordinator was made aware of this responsibility on [DATE]. This assessment will be left open until the IDT team resolves the issue. The need for monitoring will remain on the 24-hour report until resolved by the IDT team during the daily stand up and stand down meeting. Residents who are identified with changes in condition requiring on-going thorough assessments will be documented on every shift until resolved. The 24-hour summary will continue to be used for nurses to pass along information to the oncoming shift. Nurses were educated on changes in condition needing continuous monitoring to be reported to the oncoming nurse at shift change and placed on the 24-hour report. The 24-hour report communication will also be used for nurses to be aware of residents that require more than routine assessments. Nurses will notify their nurse aides at the beginning of the shift of the need to monitor said residents for changes and the frequency of the monitoring. Any change in condition needs to be documented in the medical record as well as physician notification and any new orders. On [DATE] the Director of Nursing was made aware that it was her responsibility to ensure staff members have the education prior to working their next scheduled shift and that she is to track this education. The Director of Nursing is responsible for ensuring any staff that have not been educated will be prior to their next shift. The Director of Nursing was notified of this responsibility on [DATE]. Effective immediately this education will be added to the new hire orientation and the Director of Nursing will educate newly hired staff. Education completed [DATE]. On [DATE] the Regional Nurse Consultant educated the Director of Nursing on completing a comprehensive clinical meeting. This meeting is attended by the Director of Nursing, Wound Nurse, Director of Therapy and Social Worker daily Monday through Friday immediately following 9 a.m. stand up meeting. This meeting will consist of reviewing physician orders, labs, x-rays and consultations to ensure that these items are followed up as needed. The DON is responsible for the gathering of this information. The Director of Nursing, Wound Nurse, Director of Therapy and Social Worker were made aware of these responsibilities on [DATE]. Effective [DATE] the Administrator will be ultimately responsible for ensuring implementation of this immediate jeopardy removal. Alleged Date of IJ Removal: [DATE] An onsite validation of the immediate jeopardy removal plan was conducted on [DATE]. Thirty days of residents' vital signs and progress notes were reviewed to identify if there were changes in conditions and if the changes were identified, monitoring and assessments were reviewed for proper documentation. Physician and Nurse Practitioner's orders such as lab tests and x-ray orders were reviewed as well, and any issues were addressed. All nursing staff including nurse aides were educated about reporting any changes in the residents' conditions related to anything from their baseline and informed to report changes. The Administrative staff will be responsible for setting up the assessments and responsible for monitoring the documentation until resolution. The changes will be discussed and monitored in the morning clinical meetings. The nursing staff will not be allowed to work until they have been educated on the new procedures and were expected to voice their understanding of the new procedures. The immediate jeopardy removal date of [DATE] was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff and Physician interviews the facility failed to notify the Medical Director when a resident (Resident #9) experienced an acute change in condition on [DATE] as described by Nurse Aide (NA) #3 as restless, pale in color, struggling to breathe, and a change in urinary continence and as described by NA #4 as restless and up and down all night for 1 of 1 resident reviewed for notification of change. A few hours later Resident #9 was found slumped over in his wheelchair in cardiac arrest. Resident #9 expired in the facility on [DATE]. Immediate jeopardy began on [DATE] when Resident #9 experienced an acute change in condition and Nurse #2 failed to notify the physician. Immediate jeopardy was removed on [DATE] when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity D (no actual harm with more than minimal harm that is not immediate jeopardy) to ensuring monitoring systems are in place and the completion of staff education. The finding included: Resident #9 was readmitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, atrial fibrillation and heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was cognitively intact. A review of Resident #9's medical record revealed the following medication and treatment orders: *[DATE] Ventolin HFA (Albuterol) Inhalation Aerosol Solution 108 micrograms (mcg) (90 Base) 2 puffs inhale orally four times a day for wheezing/dyspnea, give with spacer. A review of Resident #9's progress note dated [DATE] at 5:07 AM revealed, Resident #9 was up and down from his bed to his wheelchair and vice versa most of the night. He was constantly complaining of pain to bilateral lower extremities but would not take any physician ordered pain meds. His bilateral lower extremities were draining serous sanguineous, both blood and the liquid part of blood (serum), fluid in moderate amounts. Resident #9 had previously cut off his Unna boots (medicated dressings/wraps applied to his legs used to control swelling) and refused to allow staff to replace them. He was non-compliant with all meds and care. Would not allow staff to assist with any care at this time. Will continue to offer pain med and or treatment to bilateral lower extremities. The note was written by Nurse #2. A review of Resident #9's progress note dated [DATE] at 5:59 AM revealed, Ventolin HFA Inhalation Aerosol Solution 108 mcg (90 Base) 2 puffs inhale orally four times a day for Wheezing/Dyspnea give with spacer inhaler. Refused med. The note was written by Nurse #2. A review of Resident #9's Medication Administration Record for 06/2023 indicated Resident #9 refused his Ventolin Inhaler on [DATE] for 6:00 AM. A review of Resident #9's progress note dated [DATE] at 6:40 AM revealed, the nurse was called to room via staff, and upon arrival Resident #9 was noted to be slumped over in his wheelchair, non-responsive to verbal stimuli, blue in color with no respirations. Resident #9 was placed on floor and Cardiopulmonary Resuscitation (CPR)was initiated. 911 was called. CPR continued until 911 arrived. Pronounced deceased at 7:00 AM. MD was notified. The note was written by Nurse #2. On [DATE] at 9:10 PM during an interview with Nurse #2 the Nurse confirmed that she took care of Resident #9 about 3 nights a week and on the night of [DATE] until the morning of [DATE]. The Nurse reported the Resident was alert and oriented and was non-compliant with his medications mainly his heart medications and the medicated dressing to his legs. She explained that his legs were edematous and had draining sores and he would cut the medicated dressings off after the nurses applied them. The Nurse explained that Resident #9 acted no different that night of [DATE] to [DATE] as he did on any other night, she had taken care of him. She stated he was restless in that he was up and down from his bed to the chair and at one time they found him lying in the floor but that was not anything unusual about him either because he would often put himself on the floor. She stated the Resident complained of pain in his legs but refused to take pain medication for the pain. Nurse #2 continued to explain that around 4:00 AM she found the Resident using the telephone on the wall in the hall saying he wanted to call 911. She stated she took the phone from him and off the wall because he called 911 all the time and that was no change in his behavior. The Nurse reported if she thought he warranted being sent to the hospital she would have called 911 herself. Nurse explained that she last spoke with Resident #9 between 6:00 AM to 6:20 AM when he was sitting in his wheelchair in the hallway, and she gave him his Ventolin inhaler which was due at 6:00 AM. Nurse #2 continued to explain that during shift change she was giving report to the oncoming nurse when nurse aides yelled for the nurses to come down to Resident #9's room where they found him sitting in his wheelchair at the foot of his roommate's bed. He was slumped over and nonresponsive. The Nurse continued to explain that she and the Nurse Educator initiated CPR with the Nurse Educator starting the chest compressions first. Nurse #2 stated someone had called 911 and when the EMS arrived, the Nurse Educator had already stopped CPR due to Resident #9 not responding to the CPR. The Nurse again confirmed that she had not called the on-call provider services or the physician regarding a change in condition for Resident #9 because she did not think he had experienced any change in condition. The Nurse stated if she thought Resident #9 experienced a change in condition, she would have called EMS herself. Resident #9 expired in the facility on [DATE]. An interview was conducted with NA #4 on [DATE] at 4:25 PM. The NA stated he routinely worked with Resident #9 about 2-3 nights a week and had taken care of the Resident the Saturday and Sunday night prior to the morning of Monday [DATE]. The NA explained that Resident #9 was not his usual self throughout the shift in that he was restless, he was going from his chair then back to his bed like he was restless. He continued to explain that earlier in the night he found Resident #9 lying on the floor and went to get Nurse #2 and NA #3 to help him get the Resident out of the floor and back into his chair where he always stayed. He reported he had never known of the Resident to lie in the floor before. The NA explained that the Nurse asked the Resident if he was in pain and the Resident denied being in pain and wanted to stay in the floor where he said was more comfortable for him. After some encouragement the Resident agreed to get into his wheelchair. The NA stated he and NA #3 left the room to continue their rounds. Then later in the night Resident #9 turned his call light on and when the NA answered it the Resident wanted him to call an ambulance for him but did not say why he wanted the ambulance. The NA stated Resident #9 had never asked him to call an ambulance before that night and he went and got Nurse #2 for the Resident before the NA left the room to continue his rounds. The NA stated that he did not know what transpired between Resident #9 and Nurse #2 after he left the room, but the NA knew the Nurse did not call an ambulance for Resident #9 before he left off shift because the Resident was still at the facility. The NA continued to explain that after he got home that morning someone from the facility called and asked him if Resident #9 had asked him to call an ambulance and he told the person that he did, and the NA reported to Nurse #2 that the Resident wanted an ambulance called but did not say why. The NA stated he had never known of Resident #9 requesting an ambulance or calling for an ambulance himself nor did he observe the Resident trying to use the hall phone to call an ambulance himself. During an interview with NA #3 on [DATE] at 4:59 PM the NA reported that she was one of the two NAs that took care of Resident #9 on a routine basis but the night of [DATE] to [DATE] NA #4 was the Resident's aide and he helped with his care. NA #3 explained that earlier in the night NA #4 found him lying on the floor and came and got her and Nurse #2 to get Resident #9 up out of the floor. The Resident stated he wanted to stay in the floor, but they put him back into his chair and NA #3 left the room to continue her rounds. NA #3 continued to explain that around 4:30 AM she noticed Resident #9 trying to call 911 using the phone on the wall in the hallway. When the NA asked him what he was doing the Resident told her that he was having trouble breathing and wanted to go to the hospital. The NA stated Resident #9 seemed to be struggling to breathe and was pale, so she immediately went to Nurse #2 who was at the nurses' desk and told her that Resident #9 was trying to call 911 using the hall phone and he stated he was having trouble breathing and was pale. The NA stated the Nurse asked her why she didn't just take the phone from Resident #9 and the NA told the Nurse because he didn't look right and wanted to go to the hospital. The NA reported Nurse #2 went to Resident #9 who was still trying to call 911 from the hall phone and took the phone from the Resident and told him that he was asking to go to the hospital but he won't take his medications here so what was the hospital going to do for him then proceeded to remove the phone from the wall. Resident #9 sat back down in his wheelchair still looking pale and struggling to breath. NA #3 stated Nurse #2 walked back to the nurses' desk and did not come back to the hall until she started her med pass around 5:45 AM to 6:00 AM. The NA stated she knew Resident #9 was not his usual self that night because he would normally do what he wanted to like go smoke when he wanted then to go to his room, and he was normally continent but that night he was incontinent and had to be changed. The NA stated she was certain she reported his change in behavior to Nurse #2 because she and NA #4 discussed how Resident #9 was acting different that night. During an interview with the Director of Nursing (DON) on [DATE] at 1:15 PM the DON explained that after the morning meeting on [DATE] NA #5 informed her that third shift NA #3 reported that Resident #9 had fallen during the shift and had tried to call 911 himself by using the phone in the hall but Nurse #2 took the phone from him and did not assess him for a change in condition. She continued to explain that they found the Resident slumped over in his wheelchair and CPR was initiated but the Resident expired. The DON stated that based on the information she was given and the fact that there was no incident report about Resident #9's fall she reported the situation to the Administrator and an investigation was started because they felt Nurse #2 should have assessed the Resident's change in condition and notified the Medical Director for further orders. On [DATE] at 10:45 AM during an interview with the Administrator he reported that when he learned of the situation with Resident #9 on the morning of [DATE] he immediately started an investigation of the situation and found that the Resident was complaining of pain and had even requested to go to the emergency room and tried to call 911 himself until Nurse #2 took the phone from him and from the wall so that he couldn't call 911 himself. The Nurse should have assessed the Resident and called the Medical Director and the Nurse on Duty to report the Resident's change in condition, but she didn't and ultimately Resident #9 coded and expired. The Administrator stated he felt the Nurse was negligent in not assessing the Resident's change in condition and notifying the physician to obtain further guidance in the situation. An interview conducted with the resident's Physician on [DATE] at 2:20 PM revealed he was not surprised when he was notified that Resident #9 had expired because of his history of refusing his medications and treatments that were necessary to prevent swelling and fluid overload which were related to his significant heart failure. While reviewing Resident #9's death certificate the MD explained that the Resident went into biventricular dysrhythmia (arrhythmias that cause the heart to beat too fast, which prevents oxygen rich blood from circulating to the brain and body and may result in cardiac arrest) heart failure related to his coronary heart disease. He continued to explain that Resident #9's heart was beating so fast that even if he was in the emergency room there was a slight chance of survival but regardless, the MD indicated a medical provider should have been notified of Resident #9's change in condition status so that he could be evaluated and treated accordingly. On [DATE] at 2:30 PM the Administrator was notified of Immediate Jeopardy at F 580. The facility provided a Credible Allegation of Immediate Jeopardy Removal on [DATE]. On [DATE] at approximately 4:30 am Nurse Aide #3 identified Resident #9 as restless, pale in color, struggling to breathe, and a change in urinary continence. Nurse Aide #4 described Resident #9 as being restless and up and down all night long requesting to go to the hospital. There was no notification made to the MD regarding the change in condition for Resident #9. At approximately 6:40 am CNA #5 and CNA #6 started their round and discovered resident to be slumped over in wheelchair. At that time, they called for help. The Nurse Practice Educator responded. Upon assessment the Nurse Practice Educator determined resident was not breathing and did not have a pulse. Resident was placed on the floor by the Nurse Practice Educator, CNA #5, and CNA #6. Chest compressions were started by the Nurse Practice Educator after confirming resident was a full code. Resident #9 expired in the facility. On [DATE] the Nurse managers reviewed residents who have change of condition during the last 30 days using the 24-hour report. The 24-hour report was reviewed for indicators of a change such as not at baseline, not normal for resident, lethargic, shortness of breath, new onset pain, etc. Any opportunities identified during this audit will be corrected by the Nurse Managers by [DATE]. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: The Director of Nursing and Assistant Director of Nursing educated Licensed Nurses regarding the requirements for notification of the Physician following a change of condition. The Director of Nursing and Assistant Director of Nursing educated Nursing Assistants on identifying a change in resident condition and reporting to the Licensed Nurse immediately. Verbal education was given on a change of condition is noting when a resident presents different than known baseline, lethargic, restless or short of breath. Furthermore, education was provided on how to use the on-call MD system after hours and on weekends. The Director of Nursing will ensure no staff will work without receiving this education. Any new hires, including agency staff will receive education prior to the start of their shift. It will be the responsibility of the Director of Nursing to ensure this is completed. Education will be completed by [DATE]. Effective [DATE] the Administrator will be responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: [DATE] On [DATE] the facility's Credible Allegation for removal of Immediate Jeopardy on [DATE] was validated by verifying the nurse managers reviewed the 24-hour report sheets to identify residents that had any change in condition within the last 30 days and followed up on the changes by [DATE]. The nurse managers also educated the licensed nurses on the requirements for notifying the providers in the changes in conditions. Nurse aides were educated on identifying a resident's change in condition to be anything different from the resident's baseline and should be reported immediately to the licensed nurse. The Director of Nursing will be responsible to ensure no staff, facility or agency will work before being educated on the new procedure. The facility's removal date of [DATE] was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident, staff, and Psychiatric Nurse Practitioner interviews the facility failed to protect a resident's right to be free from abuse or mistreatment when Resident #11's arms were pinned between Nurse Aide (NA) #10 and the resident during incontinence care when Resident #11 became combative. On [DATE] during incontinence care Resident #11 became combative with staff and attempted to pinch, scratch, and bite the staff. When Resident #11 was turned on her side facing NA #10, NA #10 pinned Resident #11's arms and hands between the NA and Resident to prevent Resident #11 from pinching and scratching the staff and so they could finish the incontinence care. Resident #11 was noted to have bruises to bilateral hands and lower arms. This was for 1 of 1 resident reviewed for resident to staff abuse. The facility also failed to protect a female resident (Resident #1) from sexual abuse from a male resident (Resident #2) on [DATE] when Resident #2 entered Resident #1's room and touched her breast and vaginal area (outside of her clothes). NA #1 asked Resident #2 to stop touching Resident #1 and then left Resident #1 alone and unsupervised with Resident #2 while she went to report the sexual abuse to Nurse #1. Nurse #1 failed to notify the Administrator of the sexual abuse. Then on [DATE] Resident #2 again entered Resident #1's room and tried to touch and kiss her. Resident #1 did not want Resident #2 touching or kissing her. This affected 1 of 3 residents reviewed for resident-to-resident abuse. The facility further failed to prevent a resident (Resident #9) from being neglected on [DATE] when he experienced an acute change in condition. NA #3 described the change in condition as restless, pale in color, struggling to breathe, and a change in urinary continence. NA #4 described the change as restless and up and down all night. Resident #9 requested and attempted to call Emergency Medical Services (EMS) and Nurse #2 removed the phone from Resident #9 and took it off the wall. Nurse #2 neglected to call or seek medical assistance for 1 of 1 resident reviewed for neglect (Resident #9). Resident #9 was found slumped over in his wheelchair in cardiac arrest. Resident #9 expired in the facility on [DATE]. Immediate jeopardy began on [DATE] when Resident #11's arms were pinned down by NA #10 during incontinent care. Immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity E (no actual harm with more than minimal harm that is not immediate jeopardy to ensuring monitoring systems are in place and the completion of staff education. The findings included: 1. Resident #11 was admitted to the facility on [DATE] with diagnoses that included cerebral vascular accident, diabetes mellitus and dementia. A review of Resident #11's care plan initiated [DATE] revealed the Resident required assistance with her activities of daily living (ADL) related to left hemiparesis and mood symptoms. The goal indicated her needs would be anticipated and met through encouraging her to participate in the activity to her fullest capacity, provide the amount of assistance required to complete the task and promptly answering call light. Further review of the Resident's care plan dated [DATE] revealed Resident #11 exhibited verbal/manipulative behaviors by making false accusations about staff, continuously ringing call light for attention and conversation, periods of refusing care and being combative with staff, behaviors of pinching her arms causing abrasions and skin tears and will call staff names and hit staff while providing care. The goal that the Resident will seek care giver support when feeling frustrated would be attained by encouraging her to be changed and if refused report to nurse and return to provide care later, explain the procedure for care task before starting and allowing the Resident to express her feelings. A review of Resident #11's skin assessment dated [DATE] revealed there were no skin issues documented. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #11 was severely cognitively impaired and had no behaviors during the assessment reference period. Review of the Initial Allegation Report for resident abuse dated [DATE] revealed the Administrator was notified during the morning meeting that Resident #11 had new discolorations to her right and left arms. Nurse Aide (NA) #9 was listed as the accused individual. The report was signed by the Administrator. A review of the Investigation Report for resident abuse dated [DATE] revealed the accused individual was NA #9 with NA #10 and NA #11 witnessing the incident. The report summary read the Administrator interviewed staff and statements indicated that 3 staff members, NA #9, NA #10 and NA #11, were attending to Resident #11 while the Resident was attempting to hit, bite and scratch the staff while they were attempting to change her. NA #9 indicated that she did not hold the Resident's hands or arms during her interaction with the Resident. NA #10 indicated that she did hold the Resident's hands together so that the staff could finish changing the Resident without being injured. All the staff's statements were consistent indicating that Resident #11 was being combative with staff and swinging her bed remote. The incident resulted in physical injury of discolorations to the Resident's left and right forearms. The incident was substantiated. The summary of the investigation found that staff did hold down the Resident's arms to keep her from hitting and scratching them. During an observation and interview with Resident #11 on [DATE] at 10:10 AM the Resident was alert and talkative while lying in bed, well-groomed and without body odors. The Resident held the bed remote in her right hand which was resting next to her on the bed as was the call light and her cell phone. Resident #11 explained that she vaguely remembered the incident when two girls, she could not remember who they were, held her hands down and caused bruises on her hands but could not remember when it was or any details about it. She stated she thought it was just a big misunderstanding. There were no bruises or skin tears noted on the Resident's arms or hands. During an interview with NA #9 on [DATE] at 9:40 PM the NA explained that during that night in question she was asked to assist NA #11 with Resident #11 because the Resident can be combative so they must have 2 staff members to go into the Resident's room to render care. The NA stated Resident #11 was soiled from top to bottom and desperately needed to be changed and she agreed to let them change her. When NA #11 started to pull her covers down Resident #11 picked up her bed remote and hit NA #11 on her hand which made a loud thud. She stated they stopped and called Nurse #7 into the Resident's room and the Nurse tried to talk her into letting the NAs change her, but the Resident still refused care. They ended up not being able to provide care. The NA stated, later the Resident reported that staff hit her, even though the Resident #11 already had bruising on her left hand that was verified by Nurse #7. An interview was conducted with NA #10 on [DATE] at 7:52 PM revealed the NA assisted NA #11 who was assigned to Resident 11 during the night of [DATE] to [DATE], when the Resident refused to be changed for hours and was soaked and soiled with urine and stool. NA #10 stated that by the time Resident #11 allowed them to change her she required a full bed change along with her soiled brief and gown. The NA explained that when they were halfway finished with the task Resident #11 started pinching, scratching, and attempting to bite them. When they rolled Resident #11 onto her side facing NA #10, NA #10 indicated that she had to pin Resident #11's arms between their (Resident #11 and NA #10) bodies so they could finish care and prevent her from scratching. The NA was insistent that she did not touch the Resident's hands that if the Resident was bruised then the bruising was present before they went into her room to provide care. The NA stated that she positioned Resident #11 the way that she had been taught by the Nurse Educator when the staff had to care for combative residents. On [DATE] at 8:15 AM during an interview with NA #11 the NA explained that she was assigned to Resident #11 on [DATE] and that they attempted to change Resident #11 multiple times during the 12-hour shift, and multiple times she refused. She stated by the early morning you could literally smell the strong urine and bowel movement odor in the hallway and when she did allow them to change her the Resident required a brief change complete with her gown and bed sheets. NA #11 reported that Nurse #7 came into the Resident's room and asked the Resident not to pick at a sore on her hand because she had it bleeding but the Resident continued to pick at the sore. NA #11 explained NA #10 assisted her with the Resident's incontinence care and halfway through the process the Resident began to scratch, pinch and attempted to bite them while swinging the bed remote at them. She continued to explain when they turned the Resident towards NA #10 the NA had to lay the Resident's arms down and lean over her to prevent the Resident from scratching them and to finish changing her, but NA #10 never held the Resident's hands down. The NA stated she did not notice any bruising on Resident #11's hands or arms because if she had, she would have reported it. An interview was conducted with Nurse #7 on [DATE] at 8:40 PM who explained that she worked with Resident #11 often during the evening shifts and was on duty on [DATE] to the morning of [DATE]. The Nurse reported that Resident #11 already had bruises to her arms and hands before that evening shift because the Resident had pulled a band aid off her left arm earlier in the shift and was picking at the skin tear and had it bleeding with blood on her bed and I asked her several times that night not to pick at the skin tear that she was making it worse, but she continued to pick at the skin tear. She stated the Resident had bruise's on her arms as well, but she did not report the bruising, nor did she document the bruising because she always had bruising. That night Resident #11 had refused to be changed multiple times but at one point she agreed to be changed so all three NAs went in there to change her because they did not allow one aide to provide care for Resident #11 because of her behaviors. During an interview with Nurse #6 on [DATE] at 8:56 PM the Nurse confirmed she was on duty the night of [DATE] to [DATE] and assisted Nurse #7 in attending to Resident #11. Nurse #6 stated she did not remember or know about any bruising on Resident #11, but she knew that Nurse #7 had walked in on the Resident picking at a sore on her arm and had it bleeding. The Nurse reported that Resident #11 had refused care multiple times even after calling out for it several times that night. She stated she had instructed the NAs not to go into the Resident's room by themselves to provide care because of Resident #11's combative behaviors and false accusations toward the staff and she felt that was best for everyone's protection. Nurse #6 stated that she was not aware of any accusations made by Resident #11 against any of the NAs that worked that night until she came back on duty and learned that NA #10 was suspended because she crossed the Resident's arms in order to roll her over to provide care and NA #9 and Nurse #7 were in the room at the time. An interview was conducted with the Unit Manager (UM) on [DATE] at 1:50 PM who explained that she did not know any details about an incident with Resident #11 and NAs #9, #10 and #11 on the night of [DATE] to [DATE] except that she was asked by the Administrator on [DATE] to complete a skin assessment on Resident #11 that showed bruising on one of her hands, but she couldn't remember which hand. The UM stated Resident #11 told her that they held her hands down to change her but did not explain who they were. During an interview with NA #7 on [DATE] at 2:25 PM the NA explained that on the morning of [DATE] she overheard some aides talking about how Resident #11 had hit NA #9 with her bed remote and they took it from her. She stated when she went to see the Resident right after she overheard the conversation, the Resident had bruising on both hands, near her elbow and a skin tear which had steri strips on her hand that had dried blood on it that looked like it had already been tended to it. The NA stated the bruising was not there the Tuesday prior because she dried her hair, and it wasn't there. On [DATE] at 8:00PM during an interview with the Activity Assistant she explained that she visited Resident #11 on the morning of [DATE] and noticed the bruising and skin tears on the Resident's arms and hands. She stated the Resident told her that they held her hands down when they were changing her last night. The Activity Assistant continued to explain that she asked the NA (don't remember who it was) on the hall what happened, the NA told her that Resident #11 was trying to hit and bite the NAs on the night shift while they were changing her and they had to hold her hands down, with their hands flat on top of her hands to prevent the Resident from being combative while they changed her. An interview was conducted with the Nurse Educator on [DATE] at 9:00 PM who explained that she only educated the staff after the events that occurred, and she had educated the staff not to provide care for Resident #11 alone, always have at least 2 staff when providing her care because of the Resident's potential to be combative. During an interview with the former Director of Nursing (DON) on [DATE] at 2:55 PM the DON reported he was the acting DON from January through most of February 2023. The DON explained that he remembered Resident #11 in that she frequently accused the staff of being abusive to her and they were afraid to go into her room to provide care for her, so I had them go in with at least 2 people and to document the care provided. The Resident liked to use her call light and bed remote as a lasso and swing at them, threatening to hit them. An interview was conducted with the Administrator on [DATE] at 10:45 AM who explained that the staff (he could not remember who) informed him in the morning meeting on [DATE] that Resident #11 had bruise's on her arms and to his knowledge there had been no reports of bruising reported on the Resident before that day. The Administrator stated the Nurse Educator informed him that she had taught the staff to cross the residents' arms in front of them in order to make turning and repositioning easier for the residents but not intending to hurt them. The Administrator continued to explain that he interviewed Resident #11 on [DATE] and did not see any bruising nor did he document it in his statement that he did or did not observe any bruising. He stated the Resident reported to him that a large aide, NA #9 held her hands down during care which caused the bruising on her hands and NA #11 was present at the time. He reported that they collected written statements from the NAs involved which were NA #9 who denied holding the Resident's hands down, NA #10 who admitted to holding the Resident's hands down and NA #11 who denied holding the Resident's hands down. The Administrator was notified of the immediate jeopardy on [DATE] at 4:49 PM. The facility provide the following IJ removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. At approximately 9:00 am on [DATE] the Administrator was notified that Resident #11 had new discolorations to her right and left arms. The Administrator and Infection Preventionist entered the room to interview Resident #11 to gather information on the new discolorations to her arms. Resident #11 stated that a large black woman held her down last night causing the discolorations. The Administrator asked what led up to the event, Resident #11 stated she could not recall. The Administrator asked when the event occurred, Resident #11 stated last night. The Administrator asked Resident #11 to describe the event, Resident #11 stated it happened during the time the nursing aides attempted to change me and the nurse aide put her hands together. Resident #11 then stated it was a large nurse aide who held her down. Facility staff interviewed the staff working the hall from the previous night shift, interviews indicate that Resident #11 was combative with staff who attempted to change her clothing and bedding that were soiled. The Administrator collected written statements from the NAs that were involved in the allegation. NA #11 was present during the care and denied holding the residents' hands down. NA #9 denied holding the residents' hands down while providing care. NA #10 stated the resident was combative while providing care and she held the residents' hands together to avoid being injured. On [DATE] Nurse Aide #1 entered Resident #1 room and witnessed Resident #2 touching Resident #1 breast and vagina through her clothing. Nurse Aide #1 asked Resident #2 to stop touching Resident #1 and he did immediately. Nurse Aide #1 went and reported to Nurse #1. Resident #1 reported that Resident #2 entered Resident #1's room again on [DATE] and tried to touch and kiss her. Resident #1 was sent to the Emergency Department on [DATE] for evaluation and returned to the facility. Resident #1 was seen and will continue to be seen by psych services. Resident #2 no longer resides in the facility. All residents have the potential to be involved in resident-to-resident abuse but residents with cognitive impairment, dependent transfer statuses and such are more vulnerable to such situations. On [DATE] the Social Worker and Administrator conducted interviews with alert and oriented residents having a BIMs of 12 or greater to ensure there were no other reportable incidents. On [DATE] the Director of Nursing, Assistant Director of Nursing and Unit Manager completed skin assessments on residents that are not alert and oriented. There were no concerns identified. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: Initial education was completed on [DATE] with staff regarding identifying abuse. On [DATE] the Director of Nursing and Assistant Director of Nursing educated current staff in all departments on Abuse. Education included verbal abuse, sexual abuse, physical abuse, mental abuse, neglect, involuntary seclusion, exploitation, misappropriation of resident property, resident to resident abuse and mistreatment. Staff were educated on identifying any changes in behavior or patterns that may be indicative of resident-to-resident abuse. Staff in all departments were educated that if they identify changes in behavior, they should monitor the resident while reporting the concern to their supervisor and additional monitoring will be put into place. The staff and residents with Bims of 12 and greater were informed by the Director of Nursing, Assistant Director of Nursing or the Regional Nurse Consultant on [DATE] in one-to-one verbal communication that abuse of any type would not be tolerated in this facility. For the residents with a BIMs of 11 or less the RP was contacted with the same education. The Director of Nursing and Administrator will ensure that staff members, to include agency staff, that have not received the education will not be able to work until they have received this education. In the event abuse is witnessed the staff member should stay with the resident providing protection from the abuse. Furthermore, staff were educated to remain with the resident when they are alleging abuse on someone present. The Director of Nursing will provide education to newly hired staff, including agency during orientation. Education was given in a verbal and/or written format and the staff were asked to give feedback to confirm understanding of the education. Education was given in verbal format with written key points to include types of abuse provided. Effective [DATE], the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: [DATE] Validation of the immediate jeopardy removal plan was conducted in the facility on [DATE]. The interviews with alert and oriented residents were reviewed with no additional concerns noted. The skin assessment of non-alert and oriented residents were reviewed with no additional concerns noted. The initial education from [DATE] was reviewed along with the education completed on [DATE] along with staff signature sheets to verify completion and understanding of the education. The education included the different types of abuse, how to stop the abuse, how/when to report abuse or suspected abuse, and the importance of immediately notifying the Administrator of any suspected or witnessed abuse. The abuse education was verified to be included in the new hire orientation information for any newly hired staff. Interviews with staff across all departments in the facility revealed they were able to verbalize the abuse policy and procedure. They were able to verbalize the education points of stopping the abuse and immediately protecting the residents and reporting the suspected or witnessed abuse to the facility Administrator. The facility's IJ removal date of [DATE] was validated. 2. Resident #1 was admitted to the facility on [DATE]. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed that Resident #1 had clear speech and was able to make her needs known and was able to understand others. Resident #1 was moderately cognitively impaired and required limited to extensive assistance with activities of daily living. Resident #2 was admitted to the facility on [DATE] with diagnoses that included anxiety, major depressive disorder, vascular dementia, and others. Review of a care plan for Resident #2 initiated on [DATE] read Resident #2 tends to exhibit sexually inappropriate behavior towards staff members. The goal read, Resident #2 will verbalize an increased understanding and demonstration of control of sexually inappropriate behaviors. The interventions included: monitor medications for potential contribution to sexually inappropriate behaviors, monitor laboratory test results and report abnormal results to physician, evaluate need for behavioral health consult, when sexually inappropriate behaviors occur, approach Resident #2 in a calm, unhurried manner, reassure as necessary, if Resident #2 becomes combative or resistive postpone care/activity and allow time for him to regain composure, provide privacy as needed, allow time for expression of feelings, divert Resident #2 by giving alternate objects or activities, listen and try to calm resident, and remove Resident #2 from environment. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #2 was moderately cognitively impaired, had no delirium, no behaviors, rejection of care, or wandering during the assessment reference period. Resident #2 required limited to extensive assistance with activities of daily living and used a wheelchair for mobility. Review of a facility incident report dated [DATE] read, Resident #1 reported that Resident #2 came into her room and started holding her hand and kissing her hand, then proceeded to touch her breast on top of her clothing and under her clothing, then tried to touch her vaginal area. Resident #1 stated that she asked Resident #2 to stop, and he did. Resident #1 was not sure of the exact date and time the incident occurred. Resident #1 was assessed for injuries, and none were noted. An investigation was initiated. Resident #2 was placed on one-on-one supervision. Resident #1 was sent to the Emergency Department (ED) for evaluation. The report was completed by the Director of Nursing (DON). Resident #2 was discharged home from the facility on [DATE]. Review of the facility's schedule for [DATE] revealed that Nurse Aide (NA) #1 was caring for Resident #1 and Nurse #1 was on the unit where Resident #1 resided. An observation and interview were conducted with Resident #1 on [DATE] at 10:23 AM. Resident #1 was resting in bed and was well groomed. She stated that she recalled the incident with Resident #2. She stated she did not know the date or time but stated she was in her room but could not recall if she was in bed or in her wheelchair and Resident #2 came in her room and touched me on my breast and tried to touch my vagina but I pushed his hand away. She explained that he touched her on top of her clothes, but she did not like to talk about it and stated she tried to block it from her memory because she did not like to think about what had happened to her. Resident #1 explained her spouse had recently passed away and she did not want another man touching her. She added that Resident #2 had never made an inappropriate gesture or passes toward her before but again she did not wish to talk about the incident anymore. Nurse Aide (NA) #1 was interviewed via phone on [DATE] at 2:33 PM who confirmed that she was caring for Resident #1 on [DATE]. She stated that evening Resident #1 was in her wheelchair in her room and Resident #2 who had been outside smoking entered Resident #1's room in his wheelchair. NA #1 stated that when she entered Resident #1's room, they were both in their wheelchair's facing each other and Resident #1 stated to her, please tell him to remove his hand from my twat, NA #1 stated that Resident #2's hand was on top of Resident #1's clothes in her vaginal area. NA #1 stated she very sternly asked Resident #2 to stop touching Resident #1 and he did. NA #1 stated that she then left the room with Resident #1 and Resident #2 still in their wheelchairs alone facing each other to go and alert Nurse #1 of what had occurred. As NA #1 was returning to Resident #1's room she passed Resident #2 in the hallway in his wheelchair returning to his room on the same unit. NA #1 stated that both Resident #1 and Resident #2 were alert and oriented and aware of what was going on, and Resident #1 was very clear that she did not want Resident #2 touching her, she further explained Resident #1 was not sad or tearful but appeared like her usual self. NA #1 stated that at the end of her shift she had reported what had occurred to NA #7 and followed up with Nurse #1 about if she had documented what had occurred. NA #1 stated that Nurse #1 stated she had not documented anything regarding the incident because she felt it was consensual. NA #1 stated that she did not think anything about leaving Resident #1 and Resident #2 in the room together while she went to report to Nurse #1 because he instantly removed his hand from her when I asked him to. She added that she assumed Nurse #1 had taken care of what she needed to regarding the incident. Attempts to speak to Nurse #1 were made on [DATE] at 11:12 AM and were unsuccessful. A statement provided by Nurse #1 dated [DATE] at 5:00 AM read on Sunday night [DATE] during medication pass, staff reported to this writer of witnessing Resident #2 in Resident #1's room and had his hand in Resident #1's brief while both residents were sitting in wheelchairs in the room. This Nurse asked Resident #1 about the incident, and she replied, so this is my p***y, and I can do what I want. Resident #1 used other foul language and reported to this writer that the incident was consensual between the two parties involved. NA #7 was interviewed via phone on [DATE] at 3:20 PM who confirmed that she cared for Resident #1 on [DATE] during the day shift. She stated that during report that morning NA #1 had told her about the incident that had occurred between Resident #1 and Resident #2 during the night. She reported that Resident #2 touched Resident #1 on the outside of her pants in her vaginal area and touched her breast and that she had reported the incident to Nurse #1. NA #7 stated that Resident #1 did not mention anything to her about the incident with Resident #2 during that shift and was her usual self. NA #7 stated that Resident #2 never had sexual behaviors toward other residents that she was aware of, but he did at times grab staff inappropriately. NA #5 was interviewed on [DATE] at 2:07 PM and confirmed that she was caring for Resident #1 on [DATE]. She stated that Resident #1 had turned her call light on and requested to get out of bed, she stated that she and NA #6 were going to assist Resident #1 with getting up. During the transfer NA #5 stated that Resident #1 had tears in her eyes and told her that Resident #2 had his hands down Resident #1's pants and had touched her breasts. NA #5 stated she left the room while NA #6 stayed with Resident #1 and went and told Nurse #4 what Resident #1 had reported. NA #5 was certain that Resident #1 was sad and had tears in her eyes when she told her what had happened, and it was very clear that Resident #1 did not want Resident #2 touching her. NA #5 stated that after they reported to Nurse #4, she, reported to the DON and Administrator, and they immediately began an investigation. She added that she had not seen Resident #2 touch another resident inappropriately, but he did have a foul mouth and would grab staff inappropriately from time to time. NA #5 stated that Resident #2 stayed in the building for a bit after this incident, but he was on one-to-one supervision until he discharged home. NA #6 was interviewed on [DATE] at 1:04 PM who confirmed that she was caring for Resident #1 on [DATE] during the day shift. She stated that Resident #1 had requested to get out of bed and she and NA #5 were assisting with the transfer. During the transfer Resident #1 stated that Resident #2 had touched her in places that he should not be touching her and Resident #1 was very clear she did not want Resident #2 touching her at all. NA #6 stated that Resident #1 stated that Resident #2 had touched her inside her pants and her breast area, and that NA #1 had gotten Resident #1 to stop and reported it to Nurse #1. NA #6 stated that when Resident #1 told her and NA #5 what had happened, they immediately reported it to Nurse #4 who told the DON and Administrator and they began an investigation. NA #6 stated she did not recall Resident #1 being tearful or sad, but she was very clear she did not want Resident #2 touching her. NA #6 stated that Resident #2 stayed in the building for a few weeks and was on one-to-one supervision until he discharged home. Nurse #4 was interviewed via phone on [DATE] at 11:52 AM who confirmed that she was caring for Resident #1 on [DATE]. She stated she had gotten report that morning from a nurse she could not recall but stated that there was nothing in report about the incident with Resident #1 and Resident #2. She stated that Resident #1 had requested to get out of bed by NA #5 and NA #6 and during the transfer Resident #1 was not acting like her usual self, she was very upset and not joking with them like she normally did. Resident #1 reported that Resident #2 had stuck his hands down her pants and touched her breast and NA #5 and #6 immediately came and reported to Nurse #4. Nurse #4 confirmed that she went and reported to the DON who asked that Resident #1 be sent to the ED for evaluation which she was and returned with no new orders. Nurse #4 explained that she had worked at the facility since [DATE] but was not familiar with Resident #2 or his history but the time she had worked with Resident #2 this type of inappropriate behavior was not his normal. Review of an ED note dated [DATE] [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, staff and resident interviews the facility failed to identify abuse, protect all residents from abuse, and report abuse to the state agency and local law enforcement and complete a thorough investigation that included staff interviews of bruising that was reported to have occurred during incontinence care for 1 of 3 residents (Resident #11) reviewed for abuse. On 02/16/23 Nurse Aide (NA) #10 pinned Resident #11's arms between their bodies when Resident #11 became combative during incontinent care. After the care Resident #11 was noted to have bruising to her bilateral lower arms. At the conclusion of the investigation the facility substantiated abuse but allowed NA #10 to return to work to care for other residents in the facility. The facility further failed to protect Resident #1 on 03/19/23 when Resident #2 entered Resident #1's room and touched her on her breast and vaginal area, the incident was witnessed by NA #1 who asked Resident #2 to stop touching Resident #1 then left Resident #1 and Resident #2 alone and unsupervised in the room while she went to report the sexual abuse to Nurse #1. Nurse #1 failed to report the sexual abuse to the Administrator on 03/19/23 which allowed a second incident of sexual abuse on 3/20/23 to occur. On 03/21/23 Resident #1 reported the sexual abuse that occurred on 03/19/23 to NA #5 and NA #6 who then reported the sexual abuse to the Director of Nursing (DON) and Administrator. The facility failed to thoroughly investigate the allegation of abuse to ensure all residents were assessed for sexual abuse. This affected 1 of 3 residents reviewed for resident-to-resident abuse (Resident #1). Immediate jeopardy began on 02/16/23 when the facility failed to identify, thoroughly investigate, report, and protect all residents from abuse after an allegation of staff to resident abuse. Immediate jeopardy was removed on 06/23/23 when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity E (no actual harm with potential for harm) to ensure monitoring systems are in place and the completion of staff education. The finding included: A review of the facility's policy titled Abuse Prohibition revised 10/24/22 revealed: Centers prohibit abuse, mistreatment, misappropriation of property, exploitation and neglect. The Center will implement an abuse prohibition program through the following: investigation of incidences and allegations. 7. Immediately upon receiving information concerning a report of suspected or alleged abuse the administrator will perform the following: 7.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses on: 7.7.1 whether abuse occurred and to what extent; 7.7.2 clinical examination of injuries; 7.7.3 causative factors. 7.8 The investigation will be thoroughly documented in Risk Management Portal. Ensure that documentation of witnessed interviews is included. Further review of the facility's policy read: a. A review of the facility's policy titled Abuse Prohibition revised 10/24/22 revealed: Centers prohibit abuse, mistreatment, misappropriation of property, exploitation, and neglect. 7. Immediately upon receiving information concerning a report of suspected or alleged abuse the administrator will perform the following: 7.2 report allegations to state and local authorities involving abuse (verbal, mental, physical, and sexual) no later than 2 hours after the allegation is made. 1. Resident #11 was admitted to the facility on [DATE] with diagnoses that included cerebral vascular accident, diabetes mellitus and dementia. A review of the Initial Allegation Report dated 02/16/23 indicated the facility became aware of the abuse incident of new discolorations on Resident #11's right and left arms at 9:00 AM on 02/16/23. The Report indicated local law enforcement was notified on 02/16/23 at 3:00 PM. A review of the facility Investigation Report dated 02/20/23 for Resident #11 abuse that occurred on 2/16/23 revealed the accused individual was Nurse Aide (NA) #9 with NA #10 and NA #11 witnessing the incident. The report summary read the Administrator interviewed staff and statements indicated that 3 staff members, NA #9, NA #10, and NA #11, were attending to Resident #11 and the Resident was attempting to hit, bite and scratch the staff while they were attempting to change her. NA #9 indicated that she did not hold the Resident's hands or arms during her interaction with Resident #11. NA #10 indicated that she did hold Resident #11's hands together so that the staff could finish changing the Resident without being injured. All the staff's statements were consistent indicating that Resident #11 was being combative with staff and swinging her bed remote. The incident resulted in physical injury of discolorations to the Resident 11's left and right forearms. The summary of the investigation found that NA #10 did hold down Resident 11's arms to keep her from hitting and scratching the staff and the incident was substantiated but NA #10 continued to work and provide care to the other residents. During an observation and interview with Resident #11 on 06/20/23 at 10:10 AM the Resident was alert and talkative while lying in bed. Resident #11 explained that she vaguely remembered the incident when two girls, she could not remember who they were, held her hands down and caused bruises on her hands but could not remember when it was or any details about it. She stated she thought it was just a big misunderstanding. During an interview with NA #9 on 06/20/23 at 9:40 PM the NA explained that she was still worked at the facility and worked a few nights a week. She continued to explain that on 2/16/23 she was asked to assist NA #11 with Resident #11 because the Resident could be combative so they must have 2 staff members to go into the Resident's room to provide care. NA #9 stated Resident #11 was soiled from top to bottom and needed to be changed and she agreed to let them change her. When NA #11 started to pull the Resident's sheet down Resident #11 picked up her bed remote and hit NA #11 on her hand which made a loud thud. She stated they stopped and called Nurse #7 into the Resident's room and the Nurse tried to talk the Resident into letting the NAs change her, but the Resident still refused care. They ended up not being able to provide care. The NA stated, later Resident #11 told other staff members (she could not recall who) that they hit her, but the Resident already had a bruise on her left hand. When NA #9 was asked if she was interviewed by anyone about the situation the NA stated that she had not been interviewed about the incident, but Nurse #6 asked her to write a statement about the events of 2/15/23 before she left the faciity on [DATE]. An interview conducted with NA #10 on 06/20/23 at 7:52 PM revealed she assisted NA #11 who was assigned to Resident #11 during the night of 02/15/23 to 02/16/23. NA #10 stated that by the time Resident #11 agreed to allow them to change her she required a full bed change along with her soiled brief and gown. NA #10 explained when they were halfway finished with providing care, Resident #11 started pinching and scratching them so when they rolled the Resident over to facing her, she crossed the Resident arms and extended them downward between her body and the Resident's body to prevent the Resident from scratching and biting. NA #10 was insistent that she did not touch Resident 11's hands and if the Resident was bruised then the bruising was present before they went into her room to provide care. NA #10 was asked if she was interviewed by anyone from the facility about the incident and she indicated, no one had spoken with her about the events of the night of 2/16/23 with Resident #11 or she would have demonstrated to them how she crossed the Resident's arms. She stated she was only asked by Nurse #6 to write a statement about the night of 2/16/23 before she left that morning. NA #10 reported she was suspended pending investigation then was allowed to go back to work but has not been assigned to Resident #11. The NA stated the last night she worked at the facility was Friday 06/16/23. On 06/22/23 at 8:15 AM during an interview with NA #11 she explained she still worked at the facility and the last night she worked was 06/21/23. The NA stated she was assigned to Resident #11 on 02/16/23 and that they attempted to change Resident #11 multiple times during the 12-hour shift, and multiple times she refused. She stated by the early morning you could literally smell the strong urine and fecal odor in the hallway and when the Resident did allow them to change her, Resident #11 required a brief change including her gown and bed sheets. NA #11 explained NA #10 assisted her with Resident 11's incontinence care and halfway during the process the Resident began to scratch, pinch and attempted to bite them while swinging the bed remote at them. She continued to explain when they turned Resident #11 toward NA #10 the NA had to lay the Resident's arms down and lean over her to prevent the Resident from scratching them and to finish changing her, but NA #10 never held the Resident's hands down. NA #11 stated she did not notice any bruising on Resident #11's hands or arms because if she had, she would have reported it. The NA stated no one from administration had interviewed her about the situation but she did write a statement as requested by Nurse #6 for her protection because it was common for Resident #11 to accuse the staff of doing things that they did not do. An interview was conducted with Nurse #7 on 06/20/23 at 8:40 PM who explained that she worked with Resident #11 often during the evening shifts and was on duty the night of 02/15/23 to the morning of 02/16/23. The Nurse reported that Resident #11 already had bruising to her arms and hands before that evening shift because the Resident had pulled a band aid off her left arm earlier in the shift and was picking at the skin tear and had it bleeding with blood on her bed and I asked her several times that night not to pick at the skin tear that she was making it worse, but she continued to pick at the skin tear. She stated the Resident had bruising on her arms as well, but she did not report the bruising because she always had bruising. The Nurse explained that night Resident #11 had refused to be changed multiple times but at one point she agreed to be changed so all three NAs went in there to change her mainly because they did not allow one aide to provide care for Resident #11 because of her behaviors. The Nurse stated she did not know anything about Resident #11's accusations toward the nurse aides during that shift until she came back to work her next scheduled shift and learned that NA #10 had been let off for several days. The Nurse stated no one from administration interviewed her about the nights events or she would have told them how Resident #11 acted and that the bruising on the Resident's arms and the skin tear was there when she started her shift the evening of 02/15/23. During an interview with Nurse #6 on 06/20/23 at 8:56 PM the Nurse confirmed she was on duty the night of 02/15/23 to 02/16/23 and assisted Nurse #7 in attending to Resident #11. Nurse #6 stated she did not remember or know about any bruising on Resident #11, but she knew that Nurse #7 had walked in on the Resident picking at a sore on her arm and had it bleeding. The Nurse reported that Resident #11 had refused care multiple times even after calling out to be changed several times that night. Nurse #6 stated she had instructed the NAs not to go into the Resident's room by themselves to provide care because of Resident #11's combative behaviors and false accusations toward the staff and she felt that was best for everyone's protection. Nurse #6 stated that she was not aware of any accusations made by Resident #11 against any of the NAs that worked that night until she came back on duty and learned that NA #10 was suspended because she crossed the Resident's arms in order to roll her over to provide care and NA #9 and Nurse #7 were in the room at the time. The Nurse stated she had the staff write statements about the night's events and gave them to the Nurse Educator but was never interviewed by administration about the events or she would have explained what happened during the shift. An interview was conducted with the Unit Manager (UM) on 06/20/23 at 1:50 PM who explained that she did not know any details about an incident with Resident #11 and NAs #9, #10 and #11 on the night of 02/15/23 to 02/16/23 except that she was asked by the Administrator on 02/16/23 to complete a skin assessment on Resident #11 that showed bruising on one of her hands, but she couldn't remember which hand. The UM stated Resident #11 told her that they held her hands down to change her but did not explain who they were. The UM explained that she did not report what Resident #11 told her about how the bruising occurred because the Administrator was already aware of the bruising and had interviewed the Resident during her presence. The UM stated she was not asked to investigate the incident, nor did she interview any staff about the incident because that was not her job to do so. An interview was conducted with the Nurse Educator on 06/20/23 at 9:00 PM who explained that she was no longer employed at the facility but stated she only educated the staff after the incidents of abuse had occurred. The Nurse continued to explain that she educated the staff on abuse from 02/17/23 to 02/20/23 which included identifying and reporting abuse as well as dealing with the abusive resident which included not providing care for Resident #11 alone and to always have a least two staff when providing care for her. The Nurse insisted that she did not investigate the accusation of bruising on Resident #11 that happened back in February because that was not her job to do that. She indicated the investigation would have been done by the Director of Nursing at the time of the incident. During an interview with the former Director of Nursing (DON) on 06/22/23 at 2:55 PM the DON reported he was the acting DON from January through most of February 2023. The DON explained that he remembered Resident #11 in that she frequently accused the staff of being abusive to her and they were afraid to go into her room to provide care for her, so he had them go in with at least 2 people and to document the care provided. He stated Resident #11 liked to use her call light and bed remote as a [NAME] and swing at them, threatening to hit them. The DON stated he investigated several incidences involving Resident #11 that happened with the daytime staff but not the nighttime staff and he did not remember investigating anything pertaining to bruising on Resident #11 before he left. The DON stated if he had there would have been documentation of his investigation and he would have assessed the Resident and documented it in Resident 11's chart. An interview was conducted with the Administrator on 06/21/23 at 10:45 AM who explained that the staff (he could not remember who) informed him in the morning meeting on 02/16/23 that Resident #11 had bruising on her arms and to his knowledge there had been no reports of bruising reported on the Resident before that day. The Administrator stated the Nurse Educator informed him that she had taught the staff to cross the residents' arms in front of them in order to make turning and repositioning easier for the residents but not intending to hurt them. The Administrator continued to explain that he interviewed Resident #11 on 02/16/23 and did not see any bruising nor did he document it in his statement that he wrote. He stated Resident #11 reported to him that a large aide, NA #9 held her hands down during care and that caused the bruising and NA #11 was present at the time. He reported they collected written statements from NAs #9, #10, and #11, who were involved, and NA #9 denied holding the Resident's hands down, NA #10 admitted to holding Resident 11's hands down and NA #11 denied holding the Resident's hands down. The Administrator stated they suspended NA #10 pending the outcome of the investigation because she admitted to holding the Resident 11's hands down during care even though Resident #11 stated it was NA #9. The Administrator stated he did not personally interview the named staff about the incident or get a verbal explanation of their written statements because the verbal investigation was done by the Unit Manager and the Nurse Educator. The Administrator stated he only reviewed the NAs written statements, which were all consistent in that Resident #11 was combative during care which made himself and the upper management question whether it was abuse. He stated they did not feel it was abuse and therefore, they did not terminate the employee and explained he must have marked the investigation report as substantiated by mistake. The Administrator stated NA #10 returned to work after the investigation and continued to work at the facility as were NA #9 and #11. During the interview the Administrator was asked how the facility protected the other residents who were under the care of accused NA #10 and the Administrator was unable to explain nor was he able to provide demonstration of the other residents' protection from NA #10 since she continued to work in the facility since the incident on 2/26/23. The Administrator indicated he should have been more thorough with investigating the incident and remarked that he was unfamiliar how things were done in this state coming from another state, but he had learned that he needed to be more detailed and thorough when he investigated abuse and report abuse to local law enforcement and state agencies within the 2-hour timeframe. The Administrator added he did not report the incident to the local law enforcement or the state agency in the two-hour time frame because he was waiting for direction from upper management to do so but he never received permission. The Administrator was notified of the immediate jeopardy on 07/12/23 at 4:49 PM. The facility provided the following IJ removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. At approximately 9:00 AM on 2/16/2023 the Administrator was notified that Resident #11 had new discolorations to her right and left arms. The Administrator and Infection Preventionist entered the room to interview Resident #11 to gather information on the new discolorations to her arms. Resident #11 stated that a large black woman held her down last night causing the discolorations. The Administrator asked what led up to the event, Resident #11 stated she could not recall. The Administrator asked when the event occurred, Resident #11 stated last night. The Administrator asked Resident #11 to describe the event, Resident #11 stated it happened during the time the nursing aides attempted to change me and the nursing aide put her hands together. Resident #11 then stated it was a nurse aide who held her down. Facility staff interviewed the staff working the hall from the previous night shift, interviews indicate that Resident #11 was combative with staff who attempted to change her clothing and bedding that were soiled. The incident happened approximately 1:30 AM 2/16/2023. The employees did not inform the supervisor nor the Administrator at the time the incident happened. The Administrator was notified approximately at 9:00AM on 2/16/2023 and the incident was reported on 2/16/2023 at 5:24PM. NA #9, NA #10, and NA #11 were suspended pending an investigation. The Administrator failed to report and failed to investigate the allegation per the facility policy which led to further abuse allegations. On 3/19/23 Nurse Aide #1 entered Resident #1 room and witnessed Resident #2 touching Resident #1 breast and vagina through her clothing. Nurse Aide #1 asked Resident #2 to stop touching Resident #1 and he did immediately. Nurse Aide #1 left the room with the perpetrator present and reported to Nurse #1. Nurse #1 failed to immediately report the incident to her supervisor as directed by the facility's policy. The failure of Nurse #1 to report to the Administrator led to not reporting to law enforcement, Adult Protective Services, not starting an investigation, lack of protection, and then the perpetrator approached the resident again on 3/20/23 attempting to touch her. All facility staff have the potential to repeat the same deficient practice. On 6/21/23 the Administrator reviewed 24 hour/5 days for the last 30 days to identify if reporting was completed per policy. There was one issue identified and corrected. 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: Initial education was completed on 3/22/23 with current staff including agency regarding identifying and reporting abuse. On 6/21/23 the Director of Nursing and Assistant Director of Nursing educated current staff on Abuse. Education included verbal abuse, sexual abuse, physical abuse, mental abuse, neglect, involuntary seclusion, exploitation, misappropriation of resident property and mistreatment. The staff members, to include agency staff, that have not received the education will not be able to work until they have received this education. The Director of Nursing is responsible for ensuring this is enforced. In the event abuse is witnessed the staff member should stay with the resident providing protection from the abuse. Immediately after removing the abuse the abuse must be reported to the Administrator. The Administrator was educated by the Chief Nursing Officer on 6/21/23 on how he should confirm the abuse and potential has been removed, the perpetrator is monitored, submit an initial investigation to the State, contact the police department and Adult Protective Services and complete a thorough investigation prior to submitting the five-day report to the State. Staff were asked to return information verbally to confirm understanding of education. The Director of Nursing will educate in orientation for newly hired staff, to include agency staff. Education completed 6/21/23. In the event of resident-to-resident abuse the perpetrator will be placed on a 1:1 monitoring until a medical/psychiatric evaluation can be completed to protect the victim and all other residents. The charge nurse on duty is responsible for assigning the 1:1 monitor. Charge nurses were notified of this responsibility on 6/22/23 by the Director of Nursing. Effective 6/21/2023/2022 the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. On 06/28/23 a credible allegation of Immediate Jeopardy removal was conducted in the facility. The facility's current Abuse policy and procedure was reviewed, along with facility reported incidents in the last thirty days to ensure timely reporting. No additional concerns were noted. The education used to re-educate the facility staff on abuse was reviewed along with staff sign in sheets to confirm receipt of the education. Interviews with staff across the disciplines were conducted and staff were able to verbalize the steps they should take if they witness or suspect any type of abuse. The staff were able to verbalize that they must stop the abuse and stay with the resident providing protection from the abuse and then immediately report the abuse to the Administrator. The perpetrator is to be placed on one-on-one supervision immediately for the protection of other residents. The education was verified to be a part of the orientation program for all newly hired staff. The Administrator was able to verbalize his reporting requirements and time frames after becoming aware of any witness or suspected abuse in the facility. The facility's removal date of 06/23/23 was validated. 2. Review of the facility's abuse policy dated 07/01/13 and revised on 10/24/22 read in part, if the suspected abuse is patient to patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation and an investigation will be completed. The Center will protect the patient from further harm during an investigation. Anyone who witnesses an incident of suspected abuse, neglect, or involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately, regardless of shift worked. The notified supervisor will report the suspected abuse immediately to the Administrator or designee and other officials in accordance with state law. Resident #1 was admitted to the facility on [DATE]. Review of the significant change Minimum Data Set (MDS) dated [DATE] revealed that Resident #1 had clear speech and was able make her needs known and was able to understand others. Resident #1 was moderately cognitively impaired and required limited to extensive assistance with activities of daily living. Resident #2 was admitted to the facility on [DATE] with diagnoses that included anxiety, major depressive disorder, vascular dementia, and others. Review of the quarterly MDS dated [DATE] revealed that Resident #2 was moderately cognitively impaired, had no delirium, no behaviors, rejection of care, or wandering during the assessment reference period. Resident #2 required limited to extensive assistance with activities of daily living and used a wheelchair for mobility. Review of a facility incident report dated 03/21/23 read, Resident #1 reported that Resident #2 came into her room and started holding her hand and kissing her hand, then proceeded to touch her breast on top of clothing and under clothing then tried to touch her vaginal area. Resident #1 stated that she asked Resident #2 to stop, and he did. Resident #1 was not sure of the exact date and time the incident occurred. Resident #1 was assessed for injuries, and none were noted. Investigation initiated. Resident #2 placed on one-on-one supervision. Resident #1 was sent to the Emergency Department (ED) for evaluation. The report was completed by the Director of Nursing (DON). Resident #2 was discharged home from the facility on 03/29/23. Review of the facility's schedule for 03/19/23 revealed that Nurse Aide (NA) #1 was caring for Resident #1 and Nurse #1 was on the unit where Resident #1 resided. Nurse Aide (NA) #1 was interviewed via phone on 06/20/23 at 2:33 PM who confirmed that she was caring for Resident #1 on 03/19/23. She stated that evening Resident #1 was in her wheelchair in her room and Resident #2 who had been outside smoking entered Resident #1's room in his wheelchair. NA #1 stated that when she entered Resident #1's room, they were both in their wheelchair's facing each other and Resident #1 stated to her, please tell him to remove his hand from my twat, NA #1 stated that Resident #2's hand was on top of Resident #1's clothes in her vaginal area. NA #1 stated she very sternly asked Resident #2 to stop touching Resident #1 and he did. NA #1 stated that she then left the room with Resident #1 and Resident #2 still in their wheelchairs alone facing each other to go and alert Nurse #1 of what had occurred. As NA #1 was returning to Resident #1's room she passed Resident #2 in the hallway in his wheelchair returning to his room on the same unit. NA #1 stated that at the end of her shift she had followed up with Nurse #1 about if she had documented what had occurred. NA #1 stated that Nurse #1 stated she had not documented anything regarding the incident because she felt it was consensual. NA #1 stated that she did not think anything about leaving Resident #1 and Resident #2 in the room together while she went to report to Nurse #1 because he instantly removed his hand from her when I asked him to. She added that she assumed Nurse #1 had taken care of what she needed to regarding the incident. Attempted phone interview to Nurse #1 were made on 06/20/23 at 11:12 AM and were unsuccessful. A statement provided by Nurse #1 dated 03/22/23 at 5:00 AM read on Sunday night 03/19/23 during med pass, staff reported to this writer of witnessing Resident #2 in Resident #1's room and had his hand in Resident #1's brief while both residents were sitting in wheelchairs in the room. This Nurse asked Resident #1 about the incident, and she replied, so this is my p***y, and I can do what I want. Resident #1 used other foul language and reported to this writer that the incident was consensual between the two parties involved. An observation and interview were conducted with Resident #1 on 06/20/23 at 10:23 AM. Resident #1 was resting in bed and was well groomed. She stated that she recalled the incident with Resident #2. She stated she did not know the date or time but stated she was in her room but could not recall if she was in bed or in her wheelchair and Resident #2 came in her room and touched me on my breast and tried to touch my vagina but I pushed his hand away. She explained that he touched her on top of her clothes, but she did not like to talk about it and stated she tried to block it from her memory because she did not like to think about what had happened to her. Resident #1 explained her spouse had recently passed away and she did not want another man touching her. She added that Resident #2 had never made an inappropriate gesture or passes toward her before but again she did not wish to talk about the incident anymore. NA #5 was interviewed on 06/20/23 at 2:07 PM who confirmed that she was caring for Resident #1 on 03/21/23. During care and transfer of Resident #1, NA #5 stated that Resident #1 had tears in her eyes and told her that Resident #2 had his hands down Resident #1's pants and had touched her breasts. NA #5 stated she left the room while NA #6 stayed with Resident #1 and went and told Nurse #4 what Resident #1 had reported. NA #5 was certain that Resident #1 was sad and had tears in her eyes when she told her what had happened, and Resident #1 made it very clear she did not want Resident #2 touching her. NA #5 stated that after they reported to Nurse #4, she reported to the DON and Administrator, and they immediately began an investigation. NA #6 was interviewed on 06/20/23 at 1:04 PM who confirmed that she was caring for Resident #1 on 03/21/23 during the day shift. She stated while transferring Resident #1 out of bed she stated that Resident #2 had touched her in places that he should not be touching her, and Resident #1 was very clear she did not want Resident #2 touching her at all. NA #6 stated that Resident #1 stated that Resident #2 had touched her inside her pants and her breast area, and that NA #1 had gotten Resident #1 to stop and reported it to Nurse #1. NA #6 stated that when Resident #1 told her and NA #5 what had happened, they immediately reported it to Nurse #4 who told the DON and Administrator and they began an investigation. Nurse #4 was interviewed via phone on 06/20/23 at 11:52 AM who confirmed that she was caring for Resident #1 on 03/21/23. She stated that Resident #1 had requested to get out of bed by NA #5 and NA #6 and during the transfer Resident #1 was not acting like her usual self, she was very upset and not joking with them like she normally did. Resident #1 reported that Resident #2 had stuck his hands down her pants and touched her breast and NA #5 and #6 immediately came and reported to Nurse #4 who confirmed that she went and reported to the DON who asked that Resident #1 be sent to the ED for evaluation which she was and returned with no new orders. Review of a statement recorded by the SW dated 03/21/23 read, the questions were asked by the Administrator to Resident #1: Resident #1 reported that Resident #2 came into her room and tried to play with my titties and Resident #1 reported, I do not like that. He also tried to play with my twat. He tried to k[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility policy and procedure for scabies with an effective date of 9/1/2004 and review on 11/15/2021 revealed: Definition: Crusted (Norwegian) Scabies- single or multiple cases: an infestation characterized by thick crusts of skin that contain large numbers of scabies mites and eggs. It is a severe form of scabies. 1.Identify signs and symptoms of scabies: 1.1: intense itching, especially at night, 1.2: maculopapular rash, 1.3: tiny, irregular reddish lines (burrows), 2.1 Document daily patient skin checks for 8 weeks, 2.2 Maintain a high index of suspicion that scabies may be the cause of undiagnosed skin rash; suspected cases should be evaluated and confirmed by obtaining skin scrapings. 2.5 Maintain accurate line listings with patient name, age, sex, room number, roommate name, skin scraping status and result and name of all staff who provided hands on care to the patient before implementation of infection control measures. 2.10 Follow contact precautions until 24 hours after treatment. 2.13 Ensure bedding and clothing used by a person with scabies is collected and transported in a plastic bag and emptied directly into washer to avoid contaminating other surfaces and items. Machine wash and dry all items using the hot water and high heat cycles (temperature in excess of 50 degrees Celsius or 122 degrees Fahrenheit for 10 minutes will kill mites and eggs). Ensure laundry personnel use protective garments and gloves when handling contaminated items. 2.15 Store items that cannot be washed (shoes, slippers, pillows, stuffed animals, etc.,) in a sealed plastic bag for at least 72 hours. a. Resident #21 was admitted to the facility on [DATE]. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #21 was cognitively intact and required extensive to total assistance with activities of daily living (ADLs). Review of Resident #21's care plan initiated on 7/8/2022 revealed a care plan in place for rash on admission to upper, inner and posterior thighs, bilateral buttocks, abdominal folds and bilateral groin with interventions of redirect from scratching, administer as needed anti-itch medication initiated 8/18/2022 and was treated for scabies initiated 7/26/2022. Review of physician's orders for July 2022 revealed an order on 7/20/2022 of apply Permethrin Cream 5% (medication used to treat scabies, a condition caused by tiny insects called mites that infest and irritate the skin) apply cream to entire body topically one time for scabies to include scalp and skin scrapping and send samples to lab one time only for screening for scabies. Both orders documented as completed by Nurse Supervisor on the Medication Administration Record. Review of Resident #21's skin checks revealed: 1. No skin check documented for admission of 7/8/2022. 2. 7/17/2022 documented rash on bilateral arms 3. 7/24/2022 documented rash bilateral arms and legs. 4. 7/31/2022 documented rash continues 5. 8/16/2022 documented rash continues 6. 8/24/2022 documented rash continues 7. 9/9/2022 documented rash continues An interview was conducted with Resident #21 on 9/11/2022 at 3:47 PM. Resident #21 stated she was admitted to the facility on [DATE] with skin sores on her bilateral arms, legs, chest, bilateral legs, back and buttocks. She revealed she had scabies before, did not remember the date. Resident #21 stated she just thought she might have come in contact with something she was allergic to at the hospital, since her Cardiologist told her it was not scabies, but an allergic reaction to something. She indicated it was very itchy and she kept scratching the sores. An observation and interview of Resident #21 was made on 09/13/22 at 5:27 PM. Resident #21 was up in chair at the nursing station. She stated that this was her first time up and out of her room since admission. She was dressed in long pants and short sleeve shirt. Resident #21's bilateral arms were covered with small irregular scabs that were approximately the size of pencil eraser. They were well defined, and each area was scabbed over. There was no redness or erythema or drainage and were not crusted. Resident #21 indicated that her arms looked better than they have in a long time. An interview was conducted with Nurse Aide (NA) #5 on 9/13/2022 at 4:21 pm. NA #5 stated she was normally assigned to 100 hall and took care of Resident #21 on 07/23/22, 07/24/22, and 07/25/22. She revealed Resident #21 was admitted to the facility with a rash all over her. She stated the Nurse Practitioner was here when Resident #21 was admitted and came to assess Resident #21's rash. NA #5 revealed Resident #21 was contact precautions because we were told she had a bad bug in her urine, so we were only wearing personal protective equipment (PPE) to empty her urinary catheter. The Nurse applied cream to Resident #21's entire body on Saturday, 7/23/2022, and the Nurse told me that it would need to be washed off after 24 hours. NA #5 stated she gave Resident #21 a bath on Sunday, 7/24/2022, and wore a gown, gloves and mask during the bath. She stated she worked on 7/25/2022 and she scratched all day and did not work again until 08/02/22. When she got home on the 25th, and removed her uniform, she noticed she had a rash between her breasts and under one arm. NA #5 stated she took a picture of the rash and sent it to the DON on 7/26/2022 and did not receive a reply from the DON until 7/27/2022, that stated she should go and be treated for scabies. On 7/28/2022, NA #5 went to the emergency room and was prescribed permethrin cream and triamcinolone cream (for itching). She stated returned to work on 8/2/2022 and noticed a couple of new spots. She went back to the emergency room on 8/3/2022 and was treated with Ivermectin. When she returned to the facility, all of 100 hall was on isolation for scabies. The Nurse Practitioner was interviewed on 06/14/22 at 6:29 PM. The NP confirmed that she had seen and evaluated Resident #21 upon her admission to the facility on [DATE] and suspected scabies by the crusted lesion she had on her arms and legs. The Nurse Practitioner stated that she had ordered Triamcinolone cream for the itching and Permethrin cream for the scabies but later learned that she did not enter a date and time on the order, so the order never got carried out and the medication never got applied until it was again ordered on 07/20/22. The Nurse Practitioner also stated she had conferred with the Medical Director about obtaining a scraping of the lesions and he indicated it was really not necessary and that if was suspected by observation to go ahead and treat it. b. Resident #17 was re-admitted to the facility on [DATE]. Resident resided on 300 hall. Review of the quarterly MDS, dated [DATE] revealed Resident #17 was not cognitively intact and was independent to total assistance of 1-2 staff for ADLs, and was totally dependent for bathing. Review of the care plan initiated on 7/29/2022 revealed a care plan in place for scabies with interventions of contact isolation, notify medical doctor/nurse practitioner of any changes and treatments as ordered. Review of physician orders for 7/27/2022 revealed two orders: 1. Apply permethrin cream 5% to entire body 2. Obtain a skin scraping for scabies and send sample to lab one time only for screening Review of the Treatment Administration Record for July 2022 revealed on 7/27/2022 documented as administered permethrin cream 5% and skin scraping obtained. c. Resident #61 was readmitted to the facility on [DATE] and resided on 100 hall. A physician order dated 08/03/22 read; Permethrin Cream 5% apply to entire body topically one time only for exposure to scabies for 2 days. Leave on for 8-14 hours then rinse. An interview was conducted with Nurse Aide (NA) #5 on 9/13/2022 at 4:21 pm. NA #5 stated she was normally assigned to 100 hall and took care of Resident #61 on 07/23/22 and 07/24/22 and during that time Resident #61 was not under any precautions for scabies so she did not wear any personal protective equipment while caring for him that weekend. NA #5 confirmed that she also cared for Resident #21 that weekend that was suspected to have scabies and she had worn personal protective equipment while caring for that resident but stated it clearly did not prevent the spread. An interview was conducted with the Director of Nursing on 9/11/2022 at 12:54 PM. The DON stated she had been the acting Infection Preventionist (IP) since the Agency Nurse IP left 2 weeks ago. She revealed the facility did have an outbreak of scabies a few months ago, it started when a resident who was admitted with scabies. The DON stated scabies did spread from one hall to the other, and she was not sure how the spread happened, since staff wore PPE and residents were placed on contact precautions. An interview was conducted with the former Nurse Practice Educator on 9/13/2022 at 2:52 PM, by telephone. She stated she worked at the facility as an Agency Nurse. She stated the scabies outbreak started with Resident #21 who was admitted with scabies and affected 4 resident on 2 different units along with 2 staff members. The Nurse Practitioner diagnosed Resident #21 by observation and ordered skin scrapings, she stated the DON told her she had obtained the scrapings and dropped them off at the local hospital and Nurse Practice Educator called every hospital in the surrounding area, within 50 miles, and no one had the scrapings. She revealed that one of the NA's got scabies, and was treated, but still worked for several days before she was sent home by the DON. She stated she educated staff on the proper PPE, how to put it on and take it off, and how to dispose of it. She stated she had taken the DON down to Resident #21's room for her to observe staff had hung used PPE gowns on the outside of the room and were re-wearing them. She provided on the spot verbal education to staff on how to dispose of and the proper use of PPE. An interview was conducted with the Housekeeping Supervisor on 9/13/2022 at 4:52 PM. She stated housekeeping had bagged up all personal belongings and took them to the laundry, where it was washed and dried on high heat. If the resident had scabies, the room was deep cleaned, bagged up the belongings and if unable to launder then the belongings were double bagged for 1 week. She stated laundry personnel wore PPE when they did the laundry. Items from scabies positive rooms were washed separately from other laundry and housekeeping staff had education that any laundry that had anything to do with scabies was placed in a barrel. An interview was conducted with the former Administrator, by telephone, on 9/13/2022 at 5:14 PM. He stated his last day at the facility was 8/26/2022. He revealed the facility had some residents with rashes, and skin samples were sent to the lab, We treated residents who had rashes and their roommate prophylactically. He revealed he thought the Nurse Practice Educator, or the DON had collected the skin samples, the results were not available to him by the time he left the facility. He stated scabies had not been confirmed by the time he left the facility. Former Administrator stated he made rounds and did a lot of teaching on the spot, for example: put on your goggles, and read the signage on the door before entering the room. He revealed the interdisciplinary team (IDT) made rounds to make sure PPE was stocked, signage on the doors for isolation and that staff was compliant with PPE. He stated the Health Department came for a visit approximately one to two months ago and conducted rounds for scabies outbreak he did not recall any recommendations from that visit. An interview was conducted with Housekeeper #1 on 9/14/2022 at 9:58 AM. She stated she had been at the facility for 26 years. She revealed the scabies laundry was put outside in a grey cart, and she would have to go outside and get it, that laundry was not mixed with other laundry. She stated she wore a plastic gown, mask an goggles and washed the laundry separately on hot water and dried on high, hot heat. Housekeeper #1 stated there was very little personal laundry, but a lot of linens and towel. She stated after she used her gown, she sprayed it with a substance then washed it after 3 uses, she stated she had 2 gowns to alternate with. The Nurse Supervisor was interviewed on 9/14/2022 at 10:16 AM. She stated Resident #21 was admitted with scabies, but she was unsure if the diagnosis came from symptoms or if confirmed by skin scraping. She revealed an Agency Nurse obtained a skin scraping from another resident (Resident #7) and took it to the local hospital, but the DON informed her that the hospital was unable to perform skin scrapings. Nurse Supervisor stated the Health Department did come out to the facility, but she is unaware of the outcome of the visit. She revealed that Resident #21 was on 100 hall and was on transmission-based precautions, so she questioned the DON about how scabies had traveled from 100 hall to 300 hall and was told that one of the NAs had floated to 300 hall but could not recall which NA that was. She indicated she had seen staff not be compliant with PPE use all of the time and that if staff had been compliant scabies would not have spread from one hall to the other. She stated the lack of compliance contributed to the scabies outbreak. Nurse Supervisor stated she was unsure when everyone was treated, but the residents and roommates had treatment. She revealed she had asked the Nurse Practitioner if all staff should be treated and was told yes, but that never happened, she does not know why. She stated the former Nurse Practice Educator was doing surveillance rounds, but she did not personally see her do them. She stated the Former Nurse Practice Educator reported to the Administrator and the DON. A second interview was conducted with the Director of Nursing (DON) on 9/14/2022 at 2:24 PM. DON stated she was on vacation when Resident #21 was admitted to the facility, from 7/8/2022 through 7/16/2022, so she was unaware that Resident #21's admission assessments, to include a skin assessment, had not been completed. DON revealed she was supposed to have daily clinical meetings to talk about resident findings and concerns, this team is supposed to made up of the DON, Social Worker, Minimum Data Set Nurse (MDS), Nurse Supervisor, Assistant Director of Nursing and Therapy, but right now the clinical team consisted of the DON and Nurse Supervisor. DON stated Resident #21 told her that she was itching in the hospital and thought it was because of detergent the hospital used. She stated Resident #21 had been treated multiple times for scabies since her admission to the facility. DON revealed she had reached out to the Corporate Infection Control Prevention Nurse and was advised that according to research, scabies required prolonged touch to be spread and that should not have happened. She stated to her knowledge the spread of scabies was from staff and that she was in the facility for 14 hours a day and monitored staff usage of PPE and they wore it correctly while she was in the building. DON revealed she had no documentation on the scabies outbreak because the former Nurse Practice Educator was responsible for education and line listing of positive residents, staff and their contacts, and left before giving her the information. The DON stated she was ultimately responsible for the facility infection control program and should have been aware of everything that was done to prevent spread of infection in the building. She stated her expectation was for staff to follow policy and procedures regarding PPE and general infection control to reduce the risk of and spread of infectious disease. A telephone interview was conducted with the Medical Director on 9/14/2022 at 4:10 PM. He stated he took over as Medical Director in May or June 2022. He stated he was aware of the scabies outbreak in July 2022. He stated he assessed the first resident (Resident #21) with scabies, he identified a lesion on her arm that looked suspicious for scabies. He stated scabies was usually treated symptomatically and was only truly identified by biopsy or a skin scraping. Medical Director stated he was unsure if a skin scraping had been obtained with Resident #21. He stated he remembered Resident #21 had some issues with being compliant with her laundry being washed by her family, the facility had asked that the family not do the laundry and allow staff to do the laundry. He stated scabies was transmitted from person to person or linen to person or other objects shared by residents, such as the drapes, and bedspreads, scabies will infest those items, scabies does not require prolonged exposure or contact, and the mite gets on the person and penetrates the skin. He stated he expected staff to follow infection control policies and procedures and to wear PPE when required. Based on observations, record review, staff, Nurse Practitioner, and Medical Director interviews the facility failed to follow the Center for Disease Control and Prevention (CDC) guidelines and facility policy when they did not identify Covid 19 positive residents and failed to place them on transmission-based precautions, therefore the staff (Nurse Aide (NA) #3, NA #4, and Housekeeper #1) failed to don/doff personal protective equipment (PPE) when entering and exiting a Covid 19 positive room and before interacting with other residents (Resident#35, Resident #41, and Resident #44) this affected 3 of 24 residents on 1 of 4 units (memory care unit.) The facility failed to have personal protective equipment available for the staff to use when caring for Covid 19 positive residents that resided on the memory care unit. The facility was in outbreak status that started on 08/26/22 and affected 10 of 24 residents on the memory care unit. There were 5 residents that had not had Covid 19 in the last 90 days and of those 5 residents 1 was unvaccinated against Covid 19. The facility further failed to identify and prevent the spread of scabies (a very contagious skin condition caused by a tiny burrowing mite). This affected 3 of 4 residents (Resident #21, Resident #17, and Resident #61 that resided on 2 of 4 units in the facility (100 and 300 units). Immediate jeopardy began on 09/11/22 when the facility direct care staff and housekeeping staff were unable to identify the Covid 19 positive residents or rooms on the memory care unit. The staff were observed caring for Covid 19 positive residents without personal protective equipment and then caring for and/or interacting with Covid 19 negative residents. The immediate jeopardy was removed on 09/13/22 when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity Level G (actual harm that is not immediate jeopardy) to implement a plan of correction for the second example. The findings included: Review of a facility document titled, Hand Hygiene dated 12/01/06 read in part, wash hand with soap and water in the following situations: when visibly soiled or contaminated, before any direct contact with residents, before putting on gloves, after contact with residents ' intact skin, after contact with inanimate objects in the immediate vicinity of the resident and after removing gloves. Review of a facility document titled, Suspected Covid 19 Facility Checklist revised on 07/30/21 read; for all suspected or confirmed patients: close door to affected patients' room and wear appropriate PPE when entering the room(s) of affected patients (gown, gloves, full face shield, N95 respirator). Review of the Center for Disease Control and Prevention (CDC) guidelines dated 02/02/22 read in part, Manage Residents with Suspected or confirmed SARS-CoV-2 (Covid 19) infection: Healthcare personnel caring for residents with suspected or confirmed SARS-CoV-2 infection should use full personal protective equipment (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator). 1a. Upon entrance to the facility on [DATE] at 10:32 AM the Nurse Supervisor stated that the facility had 5 of 24 residents that were Covid positive, and all resided on the 400 hall that was the facility's memory care unit. An observation of the door to the memory care unit was made on 09/11/22 at 10:44 AM, the door contained a sign that read: Patient Specific: Contact Plus Airborne Precautions: STOP: Perform hand hygiene before and after patient contact with environment and after removal of PPE, Wear a N95 respirator, Gown, Face shield and gloves upon entering the room. Change gown after each patient contact, keep room door closed. There was no PPE available at the entrance to the unit. Nurse #6 was interviewed on 09/11/22 at 11:15 AM and confirmed that he was working on the memory care unit of the facility, and he was unable to confirm who the Covid 19 positive residents were but stated he had a list at the station. After Nurse #6 retrieved his list, he was able to report that the follow rooms were Covid positive rooms: room [ROOM NUMBER] A and B, room [ROOM NUMBER] B, room [ROOM NUMBER] A, room [ROOM NUMBER] A, room [ROOM NUMBER] B, and room [ROOM NUMBER] B. Observation of the memory care unit was made on 09/11/22 at 11:45 AM and revealed that room [ROOM NUMBER] room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] contained no sign on the door indicating that either resident in the room were Covid positive. The observation further revealed that there were 2 PPE containers sitting on the hallway of the unit. One at the far end of the hallway and one near the upper end of the hallway. Neither PPE cart contained any gowns for the staff to wear. Each PPE cart contained a box of gloves and a few N95 mask but no other PPE. The residents in room [ROOM NUMBER], 405, 406, 408, and 409 were all in their rooms in their bed. The resident in room [ROOM NUMBER] which had a transmission-based precaution sign on their door was ambulating and wandering in/out of other resident rooms on the unit. A follow up interview was conducted with Nurse #6 on 09/11/22 at 3:03 PM who confirmed he only worked the memory care unit when he worked at the facility through an agency and had worked on 09/10/22 and 09/11/22 twelve-hour shifts. Nurse #6 stated that they kept a list of the Covid positive residents and room numbers at the nurse's station and he would always verify the information with the off going nurse in report. He stated that the Nurse Aides (NAs) would get report from the off going NAs about which residents who were Covid positive and if they did not get that information, they could always ask the nurse on the unit. Nurse #6 stated I treat the whole hall as a Covid unit. He stated we are supposed to have gowns, gloves masks and goggles on the unit but he could not say why they did not have personal protective equipment on both 09/10/22 and 09/11/22. Nurse #6 stated they were not supposed to leave the hall to get supplies and was not aware if the facility had supplies in other areas of the facility or not. He indicated that he wore his N95 mask for the duration of his 12-hour shift and was not aware of what the protocol was for changing his N95 mask. Nurse #6 confirmed that during the weekend of 09/10/22 and 09/11/22 he had not called the other side of the facility or the Director of Nursing (DON) to obtain the personal protective equipment and stated, in the past they have brought it to us. He further added that when a resident tested positive for Covid the PPE container did not always get put out for use by the staff on the unit. 1b. Resident #13 admitted to the facility on [DATE] and resided in room [ROOM NUMBER] B and tested positive for Covid 19 on 09/05/22. Resident #24 was readmitted to the facility on [DATE] and resided in room [ROOM NUMBER] A and tested positive for Covid 19 on 09/08/22. NA #3 and NA #4 were observed to enter room [ROOM NUMBER] (both Covid positive) on 09/11/22 at 11:45 AM wearing a N95 mask and eye protection. They were observed to interact with both residents and their environment. They adjusted covers on bed, moved bedside tables and touched Resident #13's hand. NA #3 and NA #4 exited the room and neither changed their N95 mask or cleaned or disinfected their eye protection and did not perform hand hygiene. They exited into the hallway and entered the common area on the unit where other residents were located. NA #3 and NA #4 were interviewed on 09/11/22 at 11:48 AM. Neither NA #3 nor NA #4 could verbalize who the Covid positive residents were on the unit. They both confirmed that this was their weekend to work and during report no one gave them the names or room numbers of the Covid positive residents. Both NAs stated that sometimes they had a Covid positive and Covid negative in the same room and it was so confusing on what they should do with their PPE. NA #3 stated that if she was aware that a resident was Covid positive then she would put on a gown before entering the room but stated we don't have any right now and we did not have any yesterday either and of course we already have on goggles and N95 mask. NA #3 stated that when they came out of a Covid positive room they would remove their gown and gloves but did not change their N95 mask or clean/disinfect their goggles. NA #4 confirmed that they wore their N95 mask for the duration of their 12-hour shift on the memory care unit. Both NAs stated that none of the residents had any symptoms of Covid 19 and added we treat everyone like their positive. NA #3 stated that they had not received any education since their Nurse Educator that was here temporarily left a few weeks ago but added that they used to get education on Covid and PPE pretty often. A subsequent observation of NA #3 was made on 09/11/22 at 3:14 PM. There was a sign on the door of room [ROOM NUMBER] that read; Contact Plus Airborne Precautions: STOP Perform hand hygiene before and after patient contact with environment and after removal of PPE, Wear a N95 respirator, Gown, Face shield and gloves upon entering the room. Change gown after each patient contact, keep room door closed. NA #3 entered room [ROOM NUMBER] (both resident Covid positive) wearing a N95 mask and goggles. She reapplied Resident #24 ' s oxygen cannula in his nose and moved his bedside table back within his reach. She exited the room without performing hand hygiene or changing her N95 mask and she did not clean/disinfect her eye protection. Once in the hallway NA #3 was observed to approach two wandering residents (Resident #35 (who was currently Covid negative but had Covid 07/19/22) and Resident #41 (who was currently Covid negative but had Covid 08/03/22) and grab their hand and walk them down the hallway to the common area again without performing hand hygiene. NA #3 was interviewed on 09/11/22 at 3:16 PM. NA #3 stated that if she was aware that a resident was Covid positive then she would put on a gown before entering the room but stated we don't have any right now and we did not have any yesterday either and of course I already have on goggles and N95 mask. NA #3 stated that when she came out of a Covid positive room she would remove her gown and gloves but did not change her N95 mask or clean/disinfect her goggles. She stated she had not noticed the sign on the door when she entered room [ROOM NUMBER] but also there was no gowns for her to apply anyway when she entered the room. NA #3 also stated that she forgot about using hand sanitizer because when she walked out of room [ROOM NUMBER] there were 2 residents in the hallway that she needed to redirect. 1c. Resident #36 was admitted to the facility on [DATE] and resided in room [ROOM NUMBER] B and tested positive for Covid 19 on 09/06/22. An observation of Resident #36 was made on 09/11/22 at 11:59 AM. Resident #36 was observed wandering on the memory care unit. She was observed to enter room [ROOM NUMBER] (Resident#44 who resided in 408 B was Covid Negative) and shut the door behind her. Nurse Aide (NA) #3 was notified that Resident #36 had gone into room [ROOM NUMBER] and shut the door on 09/11/22 at 12:03 PM. NA #3 replied she is hiding in that room she will be ok and continued up with the hallway without redirecting Resident #36 out of the room. An observation of Housekeeper #1 was made on 09/11/22 at 3:17 PM. Housekeeper #1 was observed in the hallway wearing a N95 mask and a face shield he was observed to enter Resident #36's room that had a sign on the door that read: Contact Plus Airborne Precautions: STOP Perform hand hygiene before and after patient contact with environment and after removal of PPE, Wear a N95 respirator, Gown, Face shield and gloves upon entering the room. Change gown after each patient contact, keep room door closed. Housekeeper #1 was observed to enter the room and place a trash bag in the trash can and then enter the bathroom and exit out of the adjoining room which was room [ROOM NUMBER] (Covid negative) room. He returned to the housekeeping cart in the hallway and proceed to empty the trash and clean the trash can. Housekeeper #1 did not change his N95 mask, clean/disinfect his eye protection or perform hand hygiene in between a Covid positive room and a Covid negative room. Housekeeper #1 was interviewed on 09/11/22 at 4:36 PM. He stated that he did not see the sign on the door of room [ROOM NUMBER], so he did not apply his gown or gloves and did not change his N95 mask when he exited the room. Housekeeper #1 stated that generally if he was entering a Covid positive room he would follow the instructions on the door as to what personal protective equipment he needed to apply but because he had not seen the sign posted on the door, he had not done that earlier in the day. An observation of NA #4 was made on 09/12/22 at 8:32 PM. NA #4 was observed to enter Resident #36's room wearing gown, gloves, N95 mask and eye protection and provided morning care to Resident #36 and assisted her with meal set up. Prior to exiting Resident #36's room NA #4 removed her gown and gloves and bagged them in a trash bag and exited the room she did not clean/disinfect her eye protection and did not change her N95 mask. NA #4 was interviewed on 09/12/22 at 8:33 AM and confirmed that she had removed her gown and gloves but had not changed her N95 mask or clean/disinfected her goggles and she should have. NA #4 could not provide a reason why she did not change her N95 mask or clean/disinfect her goggles. The former Nurse Practice Educator was interviewed via phone on 09/13/22 at 2:52 PM via phone. The former Nurse Practice Educator stated that she had worked at the facility through an agency and a couple of weeks into her contract the Director of Nursing (DON) informed her that she would also be responsible for maintaining the infection control program at the facility. She stated she was responsible for ensuring appropriate signage was on the door if we had Covid 19 positive resident in the facility, ensuring PPE was available, ensure staff were wearing the PPE correctly, provide education on donning/doffing PPE, hand washing, Covid testing, keeping line listing of infections and tracking resident quarantine days. The Nurse Practice Educator stated the biggest issue she had was the staff was not compliant at all no one wanted to apply the PPE correctly. The Nurse Practice Educator explained that she was on vacation when the memory care unit had its first initial outbreak on 08/05/22, she stated when she returned to work on Monday 08/08/22 and found out that they had 7 residents that tested positive on 08/05/22 and nothing had been done. She stated that on 08/08/22 in the afternoon the former Administrator had asked her to round