**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews with staff, Nurse Practitioner, Medical Director, and urology office staff the facility failed to follow up with the Urologist for Resident #49 who was hospitalized for obstructing ureteral stones (kidney stones that get stuck in tubes composed of smooth muscle that transport the urine from the kidneys to the bladder) with hydronephrosis (swelling of one or both kidneys due to urine build up), urinary tract infection (UTI), pyelonephritis (an infection of the kidneys) and (a serious condition in which the body responds improperly to an infection). The Resident had a stent (a small tube placed in the ureter that allows the urine to drain) placed for renal stone obstruction on 4/23/24 and returned to the facility on 4/26/24 with a urinary catheter. The discharge summary specified further assessment by Urology next week and also included an order for antibiotics for a UTI. Resident #49 experienced and was treated for two UTIs, urinary pain and a yeast infection due to the antibiotics while waiting to see the urologist. The second UTI diagnosed on [DATE] showed the growth of two organisms which had a greater resistance to antibiotics. The presence of the urinary catheter and the stent both increased the risk of bacterial growth, UTIs and sepsis. In addition, the facility failed to obtain physician orders for use of an indwelling catheter and failed to use a securement device to anchor urinary catheter tubing (Resident #80) and ensure the urine collection bag remained below the level of the resident's bladder (Resident #11). These deficient practices affected 3 of 4 residents reviewed for urinary catheter or urinary tract infection (Resident #49, Resident #80 and Resident #11). Immediate jeopardy began on 5/3/24 when the facility failed to not follow up with urology for Resident #49. Immediate jeopardy was removed on 7/26/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. Example #2 and #3 were cited at a S/S of D. Findings included: 1. Review of nurses noted dated 4/22/24 revealed Resident #49's was complaining of stomach pain, nausea and chills. Resident #49 was noted to be shivering and had a temperature of 100.2 and oxygen saturation of 86%, resident placed on 2 liters via nasal canula. The doctor was notified and gave the order to send the resident to the emergency room (ER) for evaluation. Review of Resident #49's hospital Discharge summary dated [DATE] revealed she had been hospitalized from [DATE] to 4/26/24 for obstructing ureteral stones with hydronephrosis, UTI, pyelonephritis due in part to obstructing ureteral stones, and sepsis. Diagnostics showed she had a 5millimeter (mm) stone in the juncture where the kidney meets the ureter and a 4 mm stone in the juncture where the ureter meets the bladder as well as multiple other non-obstructing stones in both kidneys. Urology was consulted during her hospitalization to provide intervention for her urinary obstruction. She was taken to the operating room on 4/23/24 by the urologist and a stent was placed in her left ureter. Her blood culture and urine cultures grew out the organism Klebsiella. Her discharge summary read in part, per infectious disease recommendations will treat with Ciprofloxacin (antibiotic) 500 milligrams (mg) twice daily with end of treatment on 5/2/24, return to the facility today, follow-up with urology next week, urinary catheter to stay in place and be further assessed by urology next week. Resident #49 was readmitted to the facility on [DATE] with diagnoses including renal and ureteral calculous (kidney stones) obstruction with hydronephrosis, urinary tract infection (UTI), acute pyelonephritis (sudden and severe inflammation of the kidney due to a bacterial infection), sepsis, chronic kidney disease, and encounter for surgical aftercare following surgery on the genitourinary system. Review of Resident #49's Medication Administration Record (MAR) for April 2024 and May 2024 revealed an order dated 4/26/24 that read: Ciprofloxacin 500 milligrams (mg) one tablet by mouth every 12 hours for infection until 5/2/24. The MAR revealed all doses of Ciprofloxacin were documented as administered until 5/2/24. There was not a record of a urology appointment that had been scheduled for May 2024 in Resident #49's electronic medical record. Review of Resident #49's electronic medical record revealed there was an order dated 4/26/24 that read: follow up with urology next week. The order was discontinued by the Director of Nursing on 6/6/24. An interview was conducted on 7/12/24 at 11:27 AM with the Director of Nursing (DON). The DON said she had discontinued the order for Resident #49 from 4/26/24 that read follow up with urology next week. The DON said she had been removing old orders on all residents from the electronic computer system and had discontinued the order because it had been old. The DON said she did not check to see if Resident #49 had been to the urologist for follow up prior to discontinuing the order. The DON indicated she thought it had been an old order and had already been taken care of. A History and Physical (H&P) was completed on 5/2/24 by the Medical Director (MD). Under history of present illness, the note read in part: [AGE] year-old female seen at bedside for readmission H&P. Patient recently admitted to the hospital for sepsis and UTI secondary to obstructive stone in the left ureter. The patient underwent several days of IV antibiotics. After appropriate treatment, the patient was sent back to facility for continued rehabilitation. Under the section past surgical history, it read: recent left ureter stent placement. Under the note section labeled physical exam there was not a genitourinary assessment/exam included. The note did not mention Resident #49 needing to follow up with the urologist or her indwelling urinary catheter. The significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was cognitively intact. She was coded for an indwelling catheter. The MDS revealed she was also coded for receiving antibiotics and septicemia (disease caused by the spread of bacteria and their toxins in the blood stream). Review of Resident #49's care plan revised on 5/9/24 revealed she had a care plan in place for an indwelling catheter due to ureter obstruction, pyelonephritis, hydronephrosis, and UTI. The care plan goal was to not have any complications from the indwelling catheter, will not develop a UTI. The care plan interventions included: to follow up urology as recommended, monitor for signs/ symptoms of infection, and catheter care every shift. Further Review of Resident #49's electronic medical record revealed: A medical provider progress note dated 5/29/24 that read in part: Nurse reports that patient has bladder pain on and off. Urinalysis (UA) (a lab used test for an infection in the urine) with Culture and Sensitivity (C&S) (a report used to determine which antibiotic to use to treat an infection) ordered. Lab results showed Resident #49 had a UA completed on 5/30/24. The urine C&S report dated 6/1/24 showed the growth of the organism morganella morganii (bacteria) with a colony count of greater than 100,000 (cultures with greater than 100,000 colony count usually indicate infection). The organism was resistant to multiple antibiotics listed on the urine culture sensitivity report. An order entered by the Medical Director (MD) dated 5/30/24 read: Cephalexin (antibiotic) 500 mg tablet give one tablet by mouth three times a day for infection for 7 days. The order was discontinued on 6/3/24. Review of Resident #49's MAR for May 2024 and June 2024 revealed Cephalexin was given as ordered. A medical provider telehealth visit note dated 6/3/24 read in part: I gave an order to administer Ceftriaxone (antibiotic) 1 gram (gm) intramuscular once daily for 7 days. Patient was ordered Cephalexin prior, started 5/30/2024 until 6/6/2024. I discontinued cephalexin at this time. The note did not indicate why Cephalexin had been discontinued and a new antibiotic had been ordered. An order dated 6/3/24 for Ceftriaxone (antibiotic) 1 gm intramuscularly every 24 hours for infection for 7 days. Review of Resident #49's June 2024 MAR revealed Ceftriaxone was given as ordered. A medical provider progress note dated 6/4/24 read: nurse reports patient complaining of pain 10/10 even after pain medication given. Patient states pain is in groin related to UTI. Order given for Pyridium (a medication used to treat urinary pain) 200 milligram (mg) three times daily as needed for two days. A review of Resident #49's active physician orders revealed an order dated 6/4/24 given by the Medical Director (MD) that had been entered by the Minimum Data Assessment (MDS) Nurse that read: Urology consult/ follow up diagnosis pyelonephritis status post stent placement. A progress note from NP #1 dated 6/27/24 read in part: Being seen today for follow up regarding urinary pain and not feeling well. Nurses report patient states she is not feeling well and having discomfort with urination. Patient reporting discomfort with urination, even though she has an indwelling urinary catheter. Under the section labeled assessment and plans it read: Dysuria: UA and C&S. A progress note from NP #1 dated 6/29/24 read in part: Patient seen today for discomfort with urination and low-grade temp. Will start on antibiotics while awaiting lab results. Urinary tract infection: Previous 5/30/24 sensitivity noted to Ceftriaxone (Rocephin-antibiotic). Orders to give Ceftriaxone 1 gram (gm) give every 24 hours for 7 days intramuscular. Awaiting results from UA C&S. Follow up as soon as possible (ASAP) with urologist regarding indwelling placement status post left ureter stent placement. An order to follow up with the urologist as soon as possible was not located in Resident #49's physician orders. An order dated 6/29/24 that read: Ceftriaxone sodium solution reconstituted 1 gm inject 1 gm intramuscularly every 24 hours for infection related to urinary tract infection for 7 days. The order was discontinued on 7/5/24 the reason for discontinuation read due to sensitivity report shows resistance; antibiotic changed. Review of Resident #49's June 2024 and July 2024 MAR revealed Ceftriaxone had been given as ordered. Lab results showed Resident #49 had a UA that was completed on 7/1/24. The urine C&S report dated 7/4/24 showed the growth of two different organisms, Provedencia Stuartii (bacteria) and Acinetobacter baumannii complex (bacteria) The two organisms were not sensitive to the same antibiotic. Both organisms were resistant to multiple antibiotics listed on the urine culture and sensitivity report. An order dated 7/4/24 that read: Ciprofloxacin 250 mg tablet give one tablet by mouth twice daily related to UTI for 7 days. An order dated 7/5/24 that read: Bactrim (an antibiotic) oral tablet 400-80 mg tablet give one tablet by mouth twice daily for 3 days related to UTI, do not give at the same time as Cipro. A progress note from NP #1 dated 7/8/24 read in part: Urine culture is not sensitive to Rocephin this has been discontinued. There are two bacteria isolation in urine culture: one is sensitive to Cipro (antibiotic); and the other sensitive to Bactrim (antibiotic); patient can take both safely. A medical provider progress note dated 7/11/24 read: Nursing reports resident with severe, yeast infection. Previously on antibiotic for UTI, Diflucan (a medication used to treat fungal infections) 150 mg one dose ordered. An interview was conducted on 7/10/24 at 8:04 AM with the Transportation Aide. The Transportation Aide explained he primarily scheduled the facility resident appointments but that the receptionist helped schedule appointments if he was out on transport. The Transportation Aide said he had scheduled Resident #49's 5/17/24 urology appointment. He said 5/17/24 had been the date the urologist office had been able to get Resident #49 in to be seen. The Transportation Aide said he thought that Resident #49 had refused to go to the urology appointment that had been scheduled for her in May but was not sure. He stated Resident #49's urology appointment in June had been cancelled because another resident had an urgent appointment they needed to go to. The Transportation Aide stated he had been out on transport and that the Receptionist moved and rescheduled Resident #49's 6/14/24 appointment. He said Resident #49 had an upcoming urology appointment scheduled at the end of July on 7/31/24. He explained he looked at appointments when they needed to be moved and decided if appointments were okay to be moved. The Transportation Aide indicated the facility had a new DON and that now he discussed medical appointments that needed to be changed or moved with the DON to make sure it was clinically okay. He was unsure if the receptionist had spoken to anyone to make sure it was okay to move her appointment. He said the receptionist was currently out on medical leave. The Receptionist was unavailable to be interviewed. A telephone interview was conducted on 7/9/24 at 9:05 AM with the Urology Office Appointment Scheduler. The Scheduler stated that Resident #49's original urology appointment had been scheduled for 5/17/24. She said the office had received a call from the facility to cancel /reschedule the appointment, and that the appointment had been rescheduled to 6/14/24. She stated there was not a note as to why the appointment on 5/17/24 had been cancelled and moved. The Scheduler further stated the facility called again on 6/13/24 and had cancelled the appointment for 6/14/24 and rescheduled it for 7/31/24. She said there was a note attached to the appointment re-scheduled for 7/31/24 that said it was the only time and date they had available for a driver to take her. The Scheduler explained the turnaround time for appointments depended on the reason why someone needed to be seen. She said if the needed appointment was related to kidney stones or post-op the office would usually get them in within 2 weeks or sooner. If an initial hospital follow-up appointment had been cancelled the office would not re-schedule the appointment for a month out, she said the office would be able to get them in to be seen sooner. A telephone interview was conducted on 7/9/24 at 10:51 AM with the Urology Office Clinical Coordinator Nurse. She reviewed Resident #49's notes and confirmed she was supposed to follow up with the urology office a week after her hospital discharge on [DATE]. The Urology Office Clinical Coordinator Nurse indicated she thought the reason Resident #49 had not been seen was due to transportation issues with the facility. The Clinical Coordinator stated that if the physician had wanted to Resident #49 her for a follow-up in a week, then ideally Resident #49 should had been seen. She said typically at the one week follow up appointment the office would check to ensure the UTI causing her sepsis had resolved and schedule for surgery to bust the renal stone up. The Clinical Coordinator stated if the stent was in place, it would allow the urine to drain and keep the ureter from becoming blocked again. She said Resident #49 could become septic again if her ureter became blocked again. The Clinical Coordinator was unable to speak to if Resident #49 would have been able to pass the renal stones on her own without having the surgical procedure to break up the stones. She said if the plan was for Resident #49 to come back in a week for follow up, then at the follow up appointment they would have made sure her infection was resolving and set up for surgery to deal with the stones that had caused the urinary blockage and sepsis. She said that Resident #49 had a urology appointment scheduled for 7/31/24 and there was a note on the appointment that stated it was the only date and time the facility had a driver. The Clinical Coordinator explained that some patients kept urinary stents in place for months and some patients had to have them replaced quarterly if the stent was due to a chronic issue. She said a stent did not usually stay in place for a renal stone obstruction. The office was not aware Resident #49 had been treated with antibiotics for two additional UTIs since her hospitalization. She explained a urinary stent could cause urinary irritation and bacteria would accumulate around the device. The Clinical Coordinator stated the stent could cause the urine to have traces of blood in it and would cause the patient to feel uncomfortable because a urinary stent was not comfortable. She said the ureter was opened with the stent and the next step would be to bust up the stones. The Clinical Coordinator further explained after the stones were busted up, the old stent would be removed, and a new stent placed while in the operating room. The Clinical Coordinator stated that the new stent would remain in place for a certain amount of time, then it would be removed, and the ureter assessed for stricture. She could not say if or how long Resident #49's catheter would need to be in place or if the catheter would have been removed at the follow up appointment. She said kidney stones tended to hide infection and that with Resident #49 already having had urosepsis and having a catheter she was at a huge risk of further infection. An interview was conducted on 7/10/24 at 8:15 AM with Resident #49. Resident #49 did not remember anyone coming to talk to her about a urology appointment in May and that she did not remember refusing to go a urology appointment in May. Resident #49 stated she did not remember being told by anyone in June that they needed to change/ reschedule her urology appointment. Resident #49 said she knew she had was supposed to go see the urologist after being in the hospital but was not sure why she had not been. Resident #49 thought she had been doing okay, until she had gotten another infection in her urine. Resident #49 stated she had pain in her bladder and stomach when she had the infections in her urine but said she did not currently have any discomfort. Resident #49 stated she did not have a urinary catheter before she had gone to the hospital and that she would rather have it out than in and if the catheter was able to be removed, she wanted it to be removed An interview was conducted on 7/10/24 at 3:59 PM with the MDS Nurse. The MDS Nurse stated that Resident #49's indwelling catheter had been brought up during a clinical meeting. The MDS said she was unsure which meeting it had come up in, but that it was around the same date (6/4/24) that she had entered the order from the MD for Resident #49 to follow up with the urologist. The MDS Nurse said that she had heard Resident #49 had asked about her indwelling catheter and wanted to know when or if it would be able to come out. The MDS Nurse was unsure who had told her Resident #49 had asked about her indwelling catheter. The MDS nurse stated she had asked the Medical Director (MD) about Resident #49's indwelling catheter regarding if the plan was to keep the catheter in place long term, the diagnosis, and if it was necessary. She said the MD gave her the order to have Resident #49 follow up with urology for her indwelling catheter, pyelonephritis, and the urinary stent. The MDS Nurse had not been aware that when Resident #49 returned to the facility from the hospital on 4/26/24 she was supposed to follow up with urology in a week. She said it was after the MD had given her the order for the urology follow up on 6/4/24 that she realized that Resident #49 had not followed up with urology when she returned to facility as specified on the hospital discharge summary. The MDS Nurse stated the urology appointment for Resident #49 had been made for 6/14/24 but that she was not sure what had come of that appointment. A telephone interview was conducted with NP #1 on 7/10/24 at 12:03 PM. NP #1 said when she saw Resident #49 on 6/29/24 and had placed in her progress note she needed to be seen by urology ASAP, she had also entered the order for a urology referral into the electronic computer system. NP #1 stated she had also verbally let the staff know. NP #1 was certain she had discussed Resident #49 needing to be seen by the urologist for follow up with Unit Manager (UM) #1 and the Director of Nursing (DON). NP #1 indicated she had also told UM #3. NP #1 stated she had not given a time frame that Resident #49 needed to be seen, but that she expected that Resident #49 to be seen as soon as the urology office could get her in. NP #1 stated she had wanted Resident #49 to be seen ASAP for follow up of the stent and evaluation of the urinary catheter because Resident #49 had another UTI, and the current UTI had a greater resistance pattern to antibiotics. NP #1 was concerned if Resident #49 developed another UTI in between her completion of the antibiotic for her current UTI and her going to the urologist it could have a higher antibiotic resistance and required Resident #49 to go back to the hospital to be treated. NP #1 did not know that Resident #49 had missed her other urology appointments but that the appointments for follow up being scheduled a month later was too long. NP #1 stated she did not usually see the urology office being booked out and unable to fit someone in for an appointment. An interview was conducted on 7/10/24 at 12:16 PM with Unit Manager (UM) #1. UM #1 did not remember the NP #1 speaking to her about Resident #49's indwelling catheter, urinary stent, UTTs, or needing to be seen by urology for follow up as soon as possible. UM #1 had not been aware of NP #1's note from 6/29/24 that specified Resident #49 needed to be seen by urology ASAP. UM #1 explained appointments listed on the hospital discharge summary were given to the Transportation Aide and that the Transportation Aide scheduled the appointments. UM #1 said in-house appointment referrals were entered into the electronic computer system by the provider. She said the UMs would go through orders each morning and if there was an order for an appointment/ referral they printed it out and would give it to the Transportation Aide to schedule. UM #1 said the appointment date/ time was not entered into the electronic computer system. UM #1 explained appointment dates/ times were in the appointment book kept at the reception desk. She said the Transportation Aide made a copy of appointments for the week and put the list out at the nurse's station for the current week. She stated the only way to know when a resident had an appointment would be for someone to look at the weekly list of appointments for the current week located at the nurse's station or to call the Transportation Aide. UM #1 explained the facility MD/ NP would not know when a resident had a specialty appointment scheduled unless it was on the current weeks appointment list at the nursing station, because it did not show up in the electronic computer system anywhere that they could see. UM #1 said the Transportation Aide was not clinical and would not know if an appointment was medically necessary versus a routine appointment. She did say the Transportation Aide asked for clinical decision-making support from nursing management when he was unsure. UM #1 stated if a residents appointment needed to be moved because another resident had an urgent appointment need, the Transportation Aide should call that day and re-schedule the appointment for as soon as possible. UM #1 said she thought a cancelled appointment would need to be re-scheduled for within a week if possible. UM #1 stated she had started working at the facility on June 10th and was unaware that Resident #49 was supposed to follow up with urology in a week after her hospital discharge on [DATE] and had not been seen. An Interview was conducted with UM # 2 on 7/10/14 at 12:38 PM. UM #2 indicated she had never been approached by the Transportation Aide about an appointment that needed to be moved or changed. UM #2 said she did not always review the providers notes after they had seen a resident because they did not put the notes into the electronic computer system right away. UM #2 did not remember why Resident #49 did not go to her urology appointment scheduled on 5/17/24. UM #2 said she did not know that Resident #49's appointment on 6/14/24 had to be moved because another resident had an urgent appointment need. UM #2 stated she remembered a patient that needed to have an urgent appointment but that she did not tell the Transportation Aide to bump or move Resident #49's urology appointment to take the other resident. UM #2 said she would tell the Transportation Aide if a resident needed to be seen urgently but that the Transportation Aide did not ask her whose appointment to move or bump to fit in the appointment. She stated if the Transportation Aide had asked her, she would have asked the MD/NP which appointment could be moved or bumped to a later date if that needed to happen. UM #2 did not remember NP #1 discussing Resident #49's urinary issues with her or that Resident #49 needed to be seen by the urologist as soon as possible. UM #2 had not been aware of the NP #1's note on 6/29/24 indicating Resident #49 needed to be seen by urology ASAP. UM #2 indicated Resident #49 needing to be seen by the urologist had been discussed during a clinical meeting but that she did not remember the date of the meeting. UM #2 had known the urology appointment for Resident #49 had been scheduled but had not known that the date had been changed, and that the appointment had been pushed out so far to the end of July. UM #2 had known Resident #49 had received antibiotics for treatment of UTIs but had not attributed that to be a concern. She could not say if Resident #49's UTIs could have been prevented if she had followed up with the urologist sooner. An interview was conducted with UM #3 on 7/10/24 at 1:09 PM. UM #3 stated she had worked at the facility for 6 weeks. UM #3 did not remember NP #1 speaking to her about Resident #49's indwelling catheter, urinary issues, or that she needed to be seen by urology as soon as possible. She said orders and appointments that were needed were discussed in the morning stand up meetings but that she did not remember Resident #49 being discussed. UM #3 stated there was not a good communication flow at the facility about when appointments were scheduled. An interview was conducted with the NP #1 on 7/10/24 at 8:18 AM. NP #1 stated she had been working at the facility for approximately 5 weeks. She said Resident #49 had her indwelling catheter placed when the urinary stent was placed during her hospitalization in April. NP #1 explained she had seen Resident #49 last week and had been trying to find an appropriate diagnosis or medical need to keep the indwelling catheter in place. NP #1 stated she had wanted to remove Resident #49's indwelling catheter due to her having another UTI but wanted to check with urology first. NP #1 explained she had entered a referral for Resident #49 to be seen by urology for follow up of the indwelling catheter and urinary stent. NP #1 stated she had not been aware that Resident #49's hospital discharge summary from 4/26/24 had included for her to follow up with urology in a week. NP #1 explained she knew Resident #49 needed to be seen by urology because she had a stent placed. NP #1 did not know why Resident #49 had not gone to the urologist but knew she needed to be seen. NP #1 stated she felt Resident #49's most current UA with C&S that had a colony count of 30,000-40,000 needed to be treated with antibiotics because of her history of pyelonephritis with sepsis. NP #1 said Resident #49 should have been seen by urology for follow up the week after her hospital discharge. NP #1 stated it was hard to say if her following up with urology when she was supposed to would have prevented her from developing the 2 additional UTI's. She said Resident #49's urinary catheter was an indwelling device and because it was invasive it increased the risk of bacteria growth. NP #1 stated she did not know if Resident #49 needed the surgical procedure to break up her renal stones. NP #1 stated that if Resident #49 had been seen by urology when she was supposed to be seen they could have done the surgical procedure to break up the renal stones sooner if she needed it. NP #1 said Resident #49 should be seen by urology sooner than 7/31/24. NP #1 was worried that when Resident #49's current antibiotics ended that she could potentially develop another UTI that was resistant to everything because Resident #49's most recent UTI showed the growth of two organisms which had a greater resistance to antibiotics. She said Resident #49 needed to be sooner, preferably by next week because Resident #49 would be at high risk of developing another UTI between the time, she completed her current ordered antibiotics and the appointment scheduled on 7/31/24. NP #1 said that it would put Resident #49 at high risk for sepsis or returning to the hospital if she developed another UTI. A telephone interview was conducted on 7/9/24 at 4:45 PM with the MD. He stated Resident #49 should have been seen the week after her hospital discharge by urology for follow up. The MD thought she was doing okay and that there was not a negative impact to Resident #49, but that she should be seen soon for follow up by the urologist. The MD said Resident #49 should be seen sooner than 7/31/24 and it would be preferable to move the appointment up. An interview with the MD on 7/10/24 at 4:30 PM revealed he did not specifically remember giving the order dated 6/4/24 for Resident #49 to follow up with urology. An interview was conducted with the Director of Nursing (DON) on 7/10/24 at 1:55 PM. She stated that appointments were given to the Transportation Aide to schedule. She said once the Transportation Aide made an appointment, he put the appointment date/ time into the appointment book. The DON explained a weekly list of appointments was distributed to the nursing stations and administrative staff. She said if someone wanted to know when an appointment was scheduled further out than the current week, then they would have to look in the appointment book. She said the appointment book was located downstairs at the reception desk. The DON was unsure if everyone knew where the appointment book was located. The DON said she had been at the facility for 6 weeks and was not sure why Resident #49 had been hospitalized in April or why she had an indwelling catheter. The DON stated she was aware that Resident #49 had been treated for two UTIs since she returned from the hospital. The DON did not know that Resident #49 was supposed to have followed up with the urologist in a week when she returned from the hospital on 4/26/24. The DON only recalled one urology appointment in June that had to be rescheduled because another resident needed to go to an appointment. The DON stated no one had approached her to ask if it was medically appropriate to move Resident #49's urology appointment in June. The DON did not remember NP #1 speaking to her about Resident #49's urinary issues or telling her that she needed to be seen by urology ASAP. The DON said that they reviewed physician orders and appointments during the morning meetings and did not remember discussing Resident #49 during the morning meetings. She stated that if the urology office had an appointment that was earlier than 7/31/24 then Resident #49's appointment should have been scheduled sooner. She stated Resident #49 not following up with urology when she was supposed to, could have contributed to her infections. She said Resident #49 should have followed up with the Urologist within a week after her hospital discharge if possible. The DON was unsure where the break in the appointment process was that caused Resident #49's urology appointment to be pushed out so far to the end of July. A follow up telephone interview was conducted with the MD on 7/10/24 at 4:30 PM. The MD

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and interviews with resident, staff and the Medical Director, the facility failed to notify a medical provider of significant changes in a resident's condition (Resident #8) who was observed to be unresponsive to painful stimuli, having low oxygen saturation level and pupil constriction. Nurse #14 suspected drug overdose and administered one dose of Naloxone, also known as Narcan (a medication used to rapidly reverse opioid overdose in an emergency situation) on [DATE] at 9:34 AM and an additional dose at 9:54 AM without notifying a medical provider. Resident #8 responded temporarily to the Narcan doses but at 3:50 PM, he was observed with no heart rate or respiratory rate and was pronounced dead. In addition, the facility failed to notify the Guardian after a resident (Resident #6) tested positive for tetrahydrocannabinol (THC - a compound found in cannabis/marijuana plants). This deficient practice affected 2 of 3 residents reviewed for notification of changes (Resident #8). Immediate jeopardy began on [DATE] when the facility failed to notify a medical provider of significant changes in Resident #8's condition suggestive of a possible drug overdose. The immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. Example #2 is out of compliance at a level of D. The findings included: 1. Resident #8 was admitted to the facility on [DATE]. A progress note dated [DATE] at 9:36 AM by Nurse #14 in Resident #8's medical record indicated: Resident #8 was given Narcan per order. Oxygen saturation 68% (normal value 95% or higher), resident not responding to painful stimuli, pupils constricted. Narcan given in each nostril. Resident now 95% on oxygen. Blood pressure 128/72 (normal value less than 120/80), heart rate 84 (normal value 60 to 100 beats per minute), respirations 18 (normal value 12 to 18 breaths per minute) and regular. Another progress note dated [DATE] at 9:47 AM by Nurse #14 in Resident #8's medical record indicated: Resident #8 now resting with eyes closed. Oxygen saturation 98%. No signs/symptoms of pain or shortness of breath. A phone interview with Nurse #14 on [DATE] at 10:56 AM revealed she was working as the weekend supervisor on [DATE] when Agency Nurse #20 alerted her. Nurse #20 told her that she had no idea what to do about Resident #8. When Nurse #14 came into Resident #8's room, he was very sweaty and was not responding. Resident #8 was sitting in his wheelchair at his bedside, and he was slumped over. Nurse #14 stated that she was afraid Resident #8 might fall forward off his wheelchair, so Nurse Aide (NA) #20 helped her put him back in bed. Nurse #14 stated that she administered two doses of Narcan to Resident #8 to try to get him to wake up because she suspected that he might have overdosed from medications he took by himself. Nurse #14 further stated after she gave Resident #8 the two doses of Narcan, he perked up. Nurse #14 said she thought Nurse #20 spoke with the on-call provider while she was busy taking care of Resident #8. Nurse #14 also stated that she did not think to call 911 because it seemed like the two doses of Narcan worked, and she noted on the physician's order that she could give another dose after 10 minutes if the first one did not work. After Nurse #14 administered the second dose, she observed that Resident #8's oxygen saturation was within normal limits, and he was talking to her although he said that he was tired and just wanted to lay there in the bed. Nurse #14 stated that Nurse #20 told her that she had called the doctor, and she thought that Nurse #20 had also called 911. Nurse #14 stated that she knew this was Nurse #20's first day working at the facility. A progress note dated [DATE] at 10:00 AM by Nurse #20 in Resident #8's medical record indicated: Resident #8 was sitting up in wheelchair, very difficult to arouse. Oxygen saturation was 71% on oxygen via nasal cannula. Resident #8 was placed back to bed with head of bed elevated. Somewhat more responsive but continued to nod off. Oxygen saturation increased to the low 80% with deep breaths. Narcan administered by Nurse #14. Narcan somewhat effective, more alert and verbal. Morning medications held. A second progress note dated [DATE] at 12:58 PM by Nurse #20 in Resident #8's medical record indicated: Resident #8 difficult to arouse at this time. Responds to sternal rub (application of painful stimulus with the knuckles of closed fist to the center chest of a patient who is not alert and does not respond to verbal stimuli) with mumbles. Oxygen on per order via nasal cannula. BiPAP (bilevel positive airway pressure which is a form of non-invasive ventilation therapy used to help you breathe) placed on. More verbal and alert at this time. A third progress note dated [DATE] at 3:50 PM by Nurse #20 in Resident #8's medical record indicated: Upon observation, no heart rate or respiratory rate noted. Responsible party aware. Nurse Practitioner aware, order to release body to the funeral home received and noted. Funeral home contacted per family request. A phone interview with Nurse #20 on [DATE] at 12:26 PM revealed NA #21 alerted her that Resident #8 was lethargic. When Nurse #20 checked Resident #8's oxygen saturation, it was dropping so she asked Nurse #14 for help. Resident #8 woke up somewhat after he received the two doses of Narcan. Nurse #20 explained that [DATE] was her very first day working at the facility as an agency nurse and she did not have access at the time to the clinical messaging platform that the facility used to contact the on-call providers. Nurse #20 stated that she did not think about calling the on-call provider because she thought that Nurse #14 took over Resident #8's care when she gave him the Narcan. Nurse #20 explained that during this incident, she was still trying to get her medication pass done, and she thought Nurse #14 was going to take care of Resident #8. Nurse #14 stated she did not recall telling Nurse #14 whether she called the provider or not because she thought Nurse #20 was going to do it. A phone interview with the former Social Worker (SW) on [DATE] at 12:45 PM revealed she was the manager on duty on [DATE]. The former SW stated that when she came in that morning around 9:30 AM, Nurse #14 told her that Resident #8's pupils were pinpoint, and that they needed help to put him back into bed. The former SW stated she observed Resident #8 slumped over in his wheelchair and she thought he was going to die right there. Resident #8's eyes were pinpoint, and she watched Nurse #14 give Resident #8 two doses of Narcan. The former SW further stated that she told Nurse #14 that the facility's policy was to immediately call EMS, call the doctor and send the resident to the hospital after the resident was given Narcan. The former SW stated that she told Nurse #14 to call EMS right after Nurse #14 administered the Narcan to Resident #8. A joint interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on [DATE] at 1:11 PM. The ADON stated that she did not know if Nurse #14 notified the provider, but said she would have called the doctor if she was at the facility. An interview with the Medical Director (MD) on [DATE] at 10:21 AM revealed he last saw Resident #8 on [DATE] when he visited him after he had just gotten back from the hospital for COPD and CHF, and he seemed to be doing fine during the visit. The MD stated that he was not notified when Resident #8 died but he found out about it the next day he visited the facility. The MD stated that he did not know that they administered Narcan to Resident #8, and he was not familiar with the facility policy for Narcan. The MD stated that if the policy indicated for staff to notify EMS when administering Narcan, then they should have followed that. The MD confirmed that low oxygen saturation and pupil constriction were signs of overdose, and that Resident #8 should have been sent out to the hospital on [DATE]. The MD added that if an on-call provider was notified about the Narcan doses, then there would be a note in Resident #8's chart and they would have ordered to send him out to the hospital. The Administrator was notified of immediate jeopardy on [DATE] at 2:50 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 notify the medical provider of the suspected drug overdose of Resident #8 who was observed unresponsive to painful stimuli, had low oxygen saturation, and pupil constriction, and received 2 doses of Narcan on [DATE] at 9:34 AM and 9:54 AM. The guidelines for notifying physicians of clinical problems to ensure 1) medical care problems are communicated to the medical staff in a timely, efficient, and effective manner and 2) all significant changes in resident status are assessed and documented in the medical record was not followed in the administration to Resident #8 by Nurse #14. The facility notified the medical provider of the suspected drug overdose of Resident #8 who was observed unresponsive to painful stimuli, low oxygen saturation, and pupil constriction receiving 2 doses of Narcan on [DATE] at 9:34 AM and 9:54 AM on [DATE] by the Director of Nursing Services (DNS). A facility look-back audit of 30 days was completed by the Nurse Consultant on [DATE] to ensure that for any resident that was administered Narcan, the medical provider was notified. The audit did not identify any other residents who were administered Narcan. An audit will be completed by [DATE] by the Nurse Consultant on the number of residents who use opioids, which will include residents that have a diagnosis of opioid abuse disorder that do not have a scheduled or prn opioids. The audit identified 3 residents who have a diagnosis of opioid dependence, one resident has scheduled pain management, and two residents have prn pain management per physician order. 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 specific actions the facility will take to alter the system failure to prevent a serious outcome from reoccurring are: * Re-education to licensed nursing staff, including agency nurses on ensuring the medical provider has been notified of any resident receiving Narcan and activating EMS per physician orders by the Director of Nursing Services/Assistant Director of Nursing (designee) by [DATE]. Licensed nursing staff that are not available on or before [DATE] will not be scheduled until the education has been completed. * Facility wide audit completed by Nurse Consultant by [DATE] to determine if for any resident who received Narcan, the medical provider has been notified. The audit identified 3 residents who have a diagnosis of opioid dependence, one resident has scheduled pain management, and two residents have prn pain management per physician order. * The actions the facility will take to ensure the nurses notify the medical provider of administration of Narcan by the DNS reviewing the 24-hour report on a daily basis for appropriate notification documentation in the Electronic Medical Record (EMR). Agency licensed nurses working at the facility will receive education on notification to the medical provider on administration of Narcan for a suspected overdose by the Director of Nursing Services and/or the Assistant Director of Nursing Services, Unit Managers, and Supervisors. * If the Director of Nursing Services is unavailable the Assistant Director of Nursing will assume this responsibility of reviewing the 24-hour report. * Agency licensed nurses working at the facility will receive education on notification to the medical provider on administration of Narcan for a suspected overdose prior to working their first shift by the DNS/Assistant Director of Nursing (designee). The alleged date of immediate jeopardy removal is [DATE]. The credible allegation for the immediate jeopardy removal was validated on [DATE] with a removal date of [DATE]. A review of in-service education records dated [DATE] indicated education was provided to nurses including agency nurses on ensuring the medical provider has been notified of any resident receiving Narcan and activating EMS per physician orders. Interviews with the nursing staff including agency nurses revealed they had been educated on notifying the medical provider of any resident who receives Narcan for suspected overdose. The audit completed by the Nurse Consultant on [DATE] was reviewed. All residents identified as having orders for Narcan administration had notification of medical providers added to the Narcan order. The facility's date of immediate jeopardy removal of [DATE] was validated. 2. Resident #6 was admitted to the facility on [DATE]. The nurse's progress notes dated [DATE] revealed Resident #6 was found to have slurred speech and unable to sit, stand, or keep his eyes opened at around 8:45 PM. He could not answer questions from the staff but was making the comment I feel good and high. Around 9:00 PM, a urine specimen was obtained per the on-call provider's order for a drug screening. On [DATE] at 1:30 AM, the results from the urine drug screening were obtained and faxed to the on-call provider. A review of medical records indicated Resident #6 had a 12-Panel urine drug screening conducted on [DATE] and was positive for THC. A review of medication administration records (MARs) from [DATE] through [DATE] revealed Resident #6 was not ordered to receive any medications containing THC. During an interview conducted on [DATE] at 3:30 PM, Resident #6 stated he would not take drugs from anyone except nurses in the facility. He attributed the incident to the medications he received from the nurses in the facility prior to the incident. A phone interview was conducted with Nurse #2 on [DATE] at 4:15 PM. She stated she worked second shift from 7 PM to 7 AM on [DATE] evening and was providing care for Resident #6 in 300 Hall. At around 8:45 PM, Resident #6 was brought to her by a staff member from the rehab department with altered mental status, impaired movements, and slurred speech. She contacted the on-call provider immediately and was told to monitor Resident #6's vital signs and collect urine specimen for a drug screening. After obtaining Resident #6's urine specimen, she ordered one of her nurse aides (NA) to bring it to the local hospital immediately and waited for the results. At around 1:30 AM, the results from the urine drug screening confirmed Resident #6 was positive for THC. She faxed the results to the on-call provider immediately and was ordered to report the results to the Director of Nursing (DON). She did not notify Resident #6's Guardian after she received the drug screening results as it was late and non-urgent. She explained after she notified DON and Unit Manager (UM) #2 in the morning, she assumed either one of them would notify the Guardian. During an interview conducted on [DATE] at 10:30 AM, Resident #6's Guardian stated he did not know that Resident #6 was tested positive for THC on [DATE] morning and confirmed none of the staff in the facility had notified him about the drug screening results after the incident. It was his expectation for the facility to notify him within 24 hours after the incident occurred. During an interview conducted on [DATE] at 11:52 AM, UM #2 stated Nurse #2 reported the incident to her on [DATE] in the morning. However, she did not specifically ask her to notify Resident #6's Guardian before leaving for the shift, and she assumed the notification had been made. An interview was conducted with the DON on [DATE] at 12:54 PM. She stated the hall nurse (Nurse #2) was responsible for notifying the Guardian after Resident #6 was tested positive for THC. The UM would be the back-up if the hall nurse was unable to do it. It was her expectation for the hall nurse and the UM to communicate with each other to ensure the Guardian was notified as soon as possible. An interview was conducted with the MD on [DATE] at 1:53 PM. He stated he was being notified of the incident on [DATE] in the morning and expected the Guardian to be notified in a timely manner as well. During an interview conducted on [DATE] at 3:28 PM, the Administrator stated it was her expectation for the facility to notify Resident #6's Guardian regarding the incident in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #8 was admitted to the facility on [DATE] with diagnosis that included chronic obstructive pulmonary disease (COPD), acute respiratory failure, shortness of breath and anxiety. A review of Resident #8's comprehensive care plan revealed an activities of daily living plan of care dated [DATE] which included the following interventions: - The resident requires assistance by staff with personal hygiene. - The resident requires assistance by staff with toileting. - The resident requires assistance by staff to move between surfaces. An Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact and was independent for transfers and hygiene. The assessment indicated Resident #8 was independent and continent of bowel and bladder, had no behaviors or rejection of care. A review of Resident #8's physician's order revealed the following: - [DATE] consult for Hospice services for end stage COPD. - [DATE] Morphine Sulfate (concentrate) 20 mg (milligrams)/ mL (milliliter)- administer 0.4 ml every 2 hours for pain or shortness of breath (SOB); hold if sedation. - [DATE] Morphine Sulfate (concentrate) 20 mg (milligrams)/ mL (milliliter)- administer 0.5 ml every 2 hours for pain or shortness of breath (SOB); hold if sedation. - [DATE] Morphine Sulfate (concentrate) 20 mg (milligrams)/ mL (milliliter)- administer 0.75 ml every 2 hours for pain or shortness of breath (SOB); hold if sedation. - [DATE] Morphine Sulfate (concentrate) 20 mg (milligrams)/ mL (milliliter)- administer 1.0 ml every 2 hours for pain or shortness of breath (SOB); hold if sedation. A nurse progress note written on [DATE] at 4:00 AM by Nurse #2 read as follows: Resident is noted to be very busy. He is constantly messing with anything in reach. Objects have been removed for his safety. He is not keeping his O2 (oxygen) in place. Easily anxious with neb (nebulizer) treatments and removes from face. Needs supervision to maintain his O2 placement. Not wanting to take scheduled and routine meds but then easily upset if meds are not given. See MARS (medication administration records) for med administration. Hallucinations off and on. Asking to wear a brief (adult incontinence product) to assist with no movement due to exertion and SOB (shortness of breath). Drinking well. Frequent rounds made. Resident will use call bell at times then he yells out! Call bell is in reach. An interview with Nurse #2 on [DATE] at 4:54 PM revealed she was assigned to care for Resident #8 on night shift from 7:00 PM on [DATE] until 7:00 AM on [DATE]. Nurse #2 indicated Resident #8 was very anxious on that night and she recalled him hallucinating which she assessed to be related to his recent increase in opioid medications. Nurse #2 said although Resident #8 was at baseline continent of bowel and bladder and independent to supervision assistance with toileting, he was more confused that night and staff had convinced him to wear a brief to help him with comfort and to conserve his exertion of him having to get up and down from the bed causing him increase shortness of breath. Nurse #2 stated Resident #8 remained anxious during her shift and she reported these changes to the oncoming nurse at 7:00 AM who she believed to be Nurse #3. A nurse progress note written on [DATE] at 11:47 AM by Nurse #3 read as follows: Res (Resident) is up on side of bed unable to eat lunch due to confusion as well as hallucinations res had a hard time this am with taking breathing treatments writer had to sit with res and hold res hand as well as hold the mask to talk with res due to res felt as if the breathing treatment was suffocating res. Res is crying and tearful due to seeing cats and cars, Res is also wearing a brief at this time due to decline in health status res has made a choice to be comfort measures staff have checked in on resident multiple times this shift. Res is digging through draws (drawers) and making room in disarray as staff walk in throughout checks res is unsure of what he is doing res has had one dose of Morphine (opioid medication used to control pain and aid in breathing during air hunger) this shift as well as morning medications. Staff will continue to check on resident throughout shift. An additional progress note written on [DATE] at 4:43 PM by Nurse #3 read as follows: Res was noted to be laying on the bedroom floor res has a gash noted to the left upper arm res also has pain and discomfort noted to the left hip and femur res is unable to move leg or hip area res is in pain and discomfort res on call provider is notified as well as POA (power of attorney) is notified res is sent to ER (emergency room) for treatment and evaluation at this time. DON (Director of Nursing) is notified for the fall. A review of Resident#8's hospital emergency room report dated [DATE] indicated Resident #8 arrived at the hospital via ambulance status post an unwitnessed fall with complaints of pain to his left hip. Resident #8 was comfort care with some confusion noted but expressed desire to have his hip fixed due to worsening pain when he moved. The report includes a radiological report from a left hip and pelvis x-ray which resulted in a foreshortened subcapital left femoral neck fracture (most common fracture in the elderly population where the fracture line extends through the junction of the head and neck of the femur) and 4 cm (centimeter) laceration to his left upper arm which required 2 layered repair with sutures. The ER report further detailed he had an increase in lethargy (sluggish) and hypoxia (low levels of oxygen in the blood) in the emergency department and as a result was admitted to the intensive care unit. Resident #8 was readmitted to the facility on [DATE] with diagnoses that included an unspecified intracapsular left hip fracture and chronic respiratory failure with hypoxia. An interview with Nurse #3 on [DATE] at 12:19 PM revealed she was assigned to care for Resident #8 on day shift on [DATE] from 7:00 AM to 7:00 PM. Nurse #3 indicated she recalled Resident #8 being very agitated and anxious in the first portion of the shift. Nurse #3 said staff had convinced him to allow assistance to get back in the bed and allow assistance for incontinence by use of wearing a brief to decrease exertion from increase movement and fidgeting. Nurse #3 said she provided him with his medications during the shift but had not provided any incontinence care during her shift. Nurse #3 stated Nurse Aide #18 was assigned to Resident #8 and would have provided him with incontinence care. Nurse #3 said she was standing at her medication cart sometime after her afternoon medication pass was completed and was alerted by Resident #6 (Resident #8's roommate) that she needed to come to the room because Resident #8 had fallen to the floor. Nurse #3 explained she rushed down to Resident #8's room to find him lying on the floor on his side and face facing towards the floor, a heavily soiled brief located around his knees and lying in a puddle of urine. Nurse #3 said he had multiple cuts and gashes on his body, and he was complaining of severe pain in his left hip. Nurse #3 said she recognized the hip was fractured and immediately initiated calling the emergency medical services 9-1-1 line for transport for evaluation and treatment. Nurse #3 stated she sent Resident #8 to the hospital; she was not aware NA #18 had not provided him with incontinence care and she had not assigned his care to another nurse aide on the unit. An interview with Nurse Aide (NA) #18 on [DATE] at 3:38 PM revealed she was assigned to Resident #8 on [DATE] during day shift (7:00 AM to 7:00 PM). NA #18 stated she had gone in to see Resident #18 at approximately 9:00 AM for incontinence care. NA #18 indicated during that care, Resident #8 became very upset and had threatened her to say he would beat her a**. NA #18 said after completing the incontinence care she left the room and told Nurse #3 about the interaction and that she had concerns about providing him with further care. NA #18 stated Nurse #3 gently reminded her that the behaviors Resident #8 was currently exhibiting were not his morning baseline and if he were himself, he would apologize for what he said that he didn't mean any of it. NA #18 indicated this had not reassured her since his threat had caused her to have flashbacks from personal traumas of her past and therefore, she did not provide any further incontinence care to Resident #8 that day. NA #18 stated she periodically stepped in the room to verify that he was breathing until she was called to his room by Nurse #3 stating he had fallen, and she needed assistance. NA #18 said when she arrived at Resident #18's doorway, she saw Resident #8 on the floor with blood on him and the floor, his soiled brief halfway down his legs around his knees and laying in a puddle of urine with his wheelchair resting upon him. NA #18 said this made her feel guilty that she had not provided him with incontinence care, and he had attempted to go by himself as a result. NA #18 said she did not tell Nurse #3 at the time she had not provided him with incontinence care after 9:00 AM that morning. An interview with Nurse Aide (NA) #20 on [DATE] at 9:22 AM revealed that he was not assigned to Resident #8 on that morning ([DATE]) but had gone in to provide him his breakfast tray about 8:00 AM and retrieved a pitcher of tea, a pitcher of water, and a pitcher of ice for Resident #8 upon request at the time of the breakfast delivery. NA #20 said he did not return to Resident #8's room until he was summoned by Nurse #3 shortly after 4:00 PM that afternoon when he was alerted that Resident #8 had fallen. NA #20 indicated he approached Resident #8's room to find him lying on the floor on his side with his brief which was visibly saturated located around his knees and a puddle of urine surrounding him on the floor. NA #20 said Resident #8 was complaining of terrible pain and after initial assessment was sent to the emergency room for evaluation. NA #20 said he was not asked to provide assistance with incontinence care to Resident #8 on [DATE]. An interview with the Director of Nursing on [DATE] at 12:03 PM revealed she had not been aware NA #18 had not provided incontinence care to Resident #8 on [DATE] from 9:00 AM until he fell around 4:00 PM. The DON stated incontinence care should be provided to Resident #8. Based on record reviews, and interviews with staff and the Medical Director, the facility failed to protect a resident's right to be free from neglect when they failed to provide care and services to a resident experiencing a medical emergency. The facility failed to activate emergency response for Resident #8 who was observed to be unresponsive to painful stimuli, having low oxygen saturation level and pupil constriction. Nurse #14 administered two doses of Naloxone, also known as Narcan (a medication used to rapidly reverse opioid overdose in an emergency situation) on [DATE] at 9:34 AM and 9:54 AM, with positive response, for suspicion of drug overdose. At 3:50 PM, Resident #8 was observed with no heart rate or respiratory rate and was pronounced dead. In addtion, on [DATE] the facility neglected to provide incontinence care to Resident #8 who was cognitively intact but experienced mental status changes with new onset of hallucination and confusion and required increased assistance with toileting. Resident #8 had a fall on [DATE] while attempting to go to the bathroom without assistance. Resident #8 was hospitalized with a left hip fracture requiring surgical repair and a four centimeter laceration to the left upper extremity which required two-layer suture repair. This deficient practice affected 1 of 4 residents reviewed for abuse and neglect (Resident #8). Immediate jeopardy began on [DATE] when staff found Resident #8 slumped over, non-responsive with constricted pupils and impaired respiration and administered two doses of Narcan for suspected drug overdose, was not provided emergency medical services, and subsequently died. Immediate jeopardy was removed on [DATE] when the facility implemented a credible allegation of immediate jeopardy removal. Example #2 is out of compliance at a level of G. The findings included: 1. The first example for this tag is cross-referred to: F580 - Based on record reviews, and interviews with resident, staff and the Medical Director, the facility failed to notify a medical provider of significant changes in a resident's condition (Resident #8) who was observed to be unresponsive to painful stimuli, having low oxygen saturation level and pupil constriction. Nurse #14 suspected drug overdose and administered one dose of Naloxone, also known as Narcan (a medication used to rapidly reverse opioid overdose in an emergency situation) on [DATE] at 9:34 AM and an additional dose at 9:54 AM without notifying a medical provider. Resident #8 responded temporarily to the Narcan doses but at 3:50 PM, he was observed with no heart rate or respiratory rate and was pronounced dead. In addition, the facility failed to notify the Guardian after a resident (Resident #6) tested positive for tetrahydrocannabinol (THC - a compound found in cannabis/marijuana plants). This deficient practice affected 2 of 3 residents reviewed for notification of changes. F684 - Based on record reviews, and interviews with staff and the Medical Director, the facility failed to initiate emergency medical services for symptoms of a drug overdose. Resident #8 was slumped over, non-responsive with constricted pupils and impaired respiration. Resident #8 was observed by a facility staff member with no heart rate or respiratory rate and was pronounced dead on [DATE] at 3:50 PM. This deficient practice affected 1 of 3 residents reviewed for quality of care. F726 - Based on record reviews, and staff interviews, the facility failed to ensure nursing staff were trained and competent with responding to medical emergencies, activating emergency procedures with emergency medical services, and notifying medical providers for 1 of 4 residents (Resident #8) reviewed for neglect. Nursing staff failed to notify a medical provider of significant changes in a resident's condition who was observed to be unresponsive to painful stimuli, having low oxygen saturation level and pupil constriction, and failed to immediately initiate emergency procedures with 911. Resident #8 expired on [DATE]. This was for 2 of 2 staff members reviewed for competency (Nurse #20 and Nurse #14). The Administrator was notified of immediate jeopardy on [DATE] at 10:37 AM. 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 neglected to activate emergency response for Resident #8 after Nurse #14 administered Narcan on [DATE] at 9:34 [NAME], again at 9:54 AM with positive response for suspicion of drug overdose. In addition, the nurse supervisor did not activate emergency response. All residents who use opioid medications are at risk of overdose and may be subject to the need for Narcan administration and emergency response. An audit will be completed by [DATE] by the Nurse Consultant on the number of residents who are prescribed opioid medication, which will include residents that have a diagnosis of opioid abuse disorder that do not have a scheduled or prn opioids. 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 specific actions the facility will take to alter the system failure to prevent a serious outcome from reoccurring are: * The licensed nursing staff who neglected to activate emergency response were Nurse #14 and Nurse #20. * The facility has filed a report of the neglect to the health care personnel registry on [DATE]. * Education on the facility policy for Abuse and Neglect Prevention was presented to all facility staff beginning [DATE] by the Administrator, Director of Nursing and Assistant Director of Nursing. This educational in-service included the policy and implementation of procedures to prevent abuse and neglect. Included in this education was a review of staff training expectations on preventing, identifying, reporting abuse and neglect. * The facility has filed a report of the neglect to the licensing agency on [DATE]. * The facility has re-educated the licensed nursing staff on the use of Narcan and activation of the emergency response per physician orders by [DATE]. * The actions the facility will take to ensure the nurses have activated the emergency response as indicated in the physician's orders on the administration of Narcan is the DNS will review the 24-hour report on a daily basis for appropriate activation of the emergency response. Feedback will be provided by the DNS addressing any challenges or barriers. * Agency licensed nurses working at the facility will receive education on notification to the medical provider on administration of Narcan for a suspected overdose by the DNS/ Assistant Director of Nursing (designee). * The nurse who responds to the suspected overdose will direct another staff member to activate the emergency response system which is denoted in the revised Narcan Administration Policy [DATE]. The alleged date of immediate jeopardy removal is [DATE]. The credible allegation for the immediate jeopardy removal was validated on [DATE] with a removal date of [DATE]. A review of in-service education records dated [DATE] to [DATE] indicated education was provided to all facility staff including contract staff on the policy for Abuse and Neglect Prevention which included staff training expectations on preventing, identifying, and reporting abuse and neglect. Education was also provided to nurses including agency nurses on the activation of emergency response upon administration of Narcan, and ensuring the medical provider has been notified of any resident receiving Narcan and activating EMS per physician orders. Interviews with staff revealed they had been educated on the facility policy for preventing abuse and neglect. Interviews with the nursing staff including agency nurses revealed they had been educated on activating EMS and notifying the medical provider of any resident who receives Narcan for suspected overdose. The nurses including agency nurses stated they received education on medical emergencies and activation of the emergency response. A review of the revised Narcan administration policy dated [DATE] indicated the nurse who responds to the suspected overdose will direct another staff member to activate EMS. The facility's date of immediate jeopardy removal of [DATE] was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and interviews with staff and the Medical Director, the facility failed to initiate emergency medical services for symptoms of a drug overdose. Resident #8 was slumped over, non-responsive with constricted pupils and impaired respirations. Resident #8 was observed by a facility staff member with no heart rate or respiratory rate and was pronounced dead on [DATE] at 3:50 PM. This deficient practice affected 1 of 3 residents reviewed for quality of care (Resident #8). Immediate jeopardy began on [DATE] when the facility failed to initiate emergency medical services. Immediate jeopardy was removed on [DATE] when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education and monitoring systems put into place are effective. The findings included: Resident #8 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure, congestive heart failure (CHF), obstructive sleep apnea, anxiety disorder, and panic disorder. Effective [DATE] per physician's order, Resident #8's code status was Do Not Resuscitate (DNR). Resident #8's care plan initiated on [DATE] indicated the resident had COPD related to history of smoking, had chronic and acute respiratory failure, BiPAP (non-invasive ventilation) at night for obstructive sleep apnea, and oxygen via nasal cannula. Interventions included to monitor for difficulty breathing on exertion, signs and symptoms of acute respiratory insufficiency, and anxiety, and oxygen as ordered. Resident #8 also had a care plan initiated on [DATE] that he was on pain medication therapy related to chronic pain, COPD, and severe breathing problems. Interventions included to administer analgesic medications as ordered by physician, monitor/document side effects and effectiveness every shift, monitor for respiratory depression and for increased risk of falls. There was no mention of opioid or Narcan use in Resident #8's care plans. Resident #8 did not have an end of life care plan. A review of the physician's orders in Resident #8's medical record indicated an order for BiPAP with mode/settings: Inspiratory positive airway pressure (IPAP) 22, Expiratory positive airway pressure (EPAP) 18 - Apply at bedtime and remove in morning upon awakening for obstructive sleep apnea. This order started on [DATE] and was discontinued to [DATE] per recommendations from a pulmonologist as Resident #8 could not tolerate it and the resident wanted to be comfortable. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #8 was cognitively intact, had no behaviors, had range of motion impairment to one side of the lower extremities, and used a wheelchair. He required supervision to partial/moderate assistance with all activities of daily living (ADL). The MDS further indicated that Resident #8 received both scheduled and prn (as needed) pain medications for complaints of frequent pain at a level of 8 (on a scale of 1-10 with 1 being minimal pain and 10 being severe pain). He had shortness of breath or trouble breathing with exertion, when sitting at rest, and when lying flat, and used tobacco. He received anti-anxiety, antidepressant, antibiotic, diuretic, and opioid medications. He also received oxygen therapy but was not coded for receiving hospice care. A physician's order dated [DATE] in Resident #8's medical record indicated Naloxone (also known as Narcan) liquid 4 milligrams (mg)/0.1 milliliter (ml) 0.1 ml in nostril every 24 hours as needed for opioid depression/suspected opioid depression (overdose). CALL 911 TO ACTIVATE EMERGENCY RESPONSE. Naloxone liquid 4 mg/0.1 ml in alternate nostril from first dose if no response from first dose. Validate 911 emergency response activated. Nasal Narcan order - Call 911- May repeat dose every 10 minutes as needed for opioid depression/suspected opioid depression (overdose). A history and physical note documented by the Medical Director on [DATE] in Resident #8's medical record indicated Resident #8 was a long-term care resident who mobilized with wheelchair and was sitting in the hallway. Resident #8 endorsed no complaints of anxiety at this time. He recently was admitted to the hospital for treatment of COPD/CHF exacerbation, and stated he was feeling better after returning to the facility. Review of systems was negative except for cough and shortness of breath. Assessment and plan included COPD - improved since admission to hospital, and CHF - plan to give (diuretic) twice a day for 10 days. A review of Resident #8's Medication Administration Record for [DATE] indicated he received the following medications: * Buspirone (anxiolytic) 5 milligrams (mg) on [DATE] at 8:00 PM by Nurse #2 * Trazodone (antidepressant and sedative) 25 mg on [DATE] at 9:00 PM by Nurse #2 * Alprazolam (sedative use to treat anxiety and panic disorder) 1 mg on [DATE] at 9:00 PM by Nurse #2 * Hydroxyzine (antihistamine used to treat anxiety) 25 mg intramuscularly on [DATE] at 9:29 PM by Nurse #2 and [DATE] at 3:37 AM by Nurse #2 * Oxycodone-Acetaminophen (narcotic used to treat moderate to severe pain) 5-325 mg on [DATE] at 9:26 PM by Nurse #2 and [DATE] at 6:28 AM by Nurse #2 * Lorazepam (sedative) 1 mg on [DATE] at 9:25 PM by Nurse #2 and [DATE] at 6:29 AM by Nurse #2 * Naloxone liquid 4 mg in nostril on [DATE] at 9:34 AM and 9:54 AM by Nurse #14 A progress note dated [DATE] at 3:01 AM by Nurse #2 in Resident #8's medical record indicated: Resident #8 had been restless just about the entire shift. He wanted to argue about everything. He was so easily exerted with just movement. He was wearing oxygen via nasal cannula. He would not rest in the bed, and sat up on the side of the bed with feet hanging off. Both lower legs and feet were noted to be very edematous. Resident #8 was non-compliant with care. Staff not able to reason with this resident. He was using call bell constantly. See Medication Administration Record for all prn medications and scheduled medications given. A phone interview with Nurse #2 on [DATE] at 4:54 PM revealed she worked with Resident #8 on the night before he died. Nurse #2 stated that he rested occasionally but then he would wake up with breathing problems and would quickly be in a panic. Resident #8 had chronic breathing problems, and he wanted his medications given frequently. Nurse #2 shared that she gave all his medications that she could give that night, but nothing seemed to help his air hunger and he was very anxious. Resident #8 was independent with ADL and was able to go in and out of bed by himself. A phone interview with Nurse Aide (NA) #24 on [DATE] at 3:22 PM revealed she worked with Resident #8 on the night before he passed away. NA #24 stated that Resident #8 had increased shortness of breath that night, and he was very anxious. Resident #8 came to the nurses' station that night and then eventually went back to bed in the early morning. A progress note dated [DATE] at 9:36 AM by Nurse #14 in Resident #8's medical record indicated: Resident #8 was given Narcan per order. Oxygen saturation 68% (normal value 95% or higher), resident not responding to painful stimuli, pupils constricted. (Small pupils or constricted pupils are common symptoms of opioid overdose.) Narcan given in nostril. Resident now 95% on oxygen. Blood pressure 128/72 (normal value less than 120/80), heart rate 84 (normal value 60 to 100 beats per minute), respirations 18 (normal value 12 to 18 breaths per minute) and regular. Another progress note dated [DATE] at 9:47 AM by Nurse #14 in Resident #8's medical record indicated: Resident #8 now resting with eyes closed. Oxygen saturation 98%. No signs/symptoms of pain or shortness of breath. A phone interview with Nurse #14 on [DATE] at 10:56 AM revealed she was working as the weekend supervisor on [DATE] when Agency Nurse #20 alerted her. Nurse #20 told her that she had no idea what to do about Resident #8. When Nurse #14 came into Resident #8's room, he was very sweaty and was not responding. Resident #8 was sitting in his wheelchair at his bedside, and he was slumped over. Nurse #14 stated that she was afraid Resident #8 might fall forward off his wheelchair, so NA #20 helped her put him back in bed. Nurse #14 stated that she administered two doses of Narcan to Resident #8 to try to get him to wake up because she suspected that he might have overdosed from medications. Nurse #14 further stated she gave him the two doses of Narcan which perked him up. Nurse #14 said she thought Nurse #20 spoke with the on-call provider while she was busy taking care of Resident #8. Nurse #14 also stated that she did not think to call 911 because it seemed like the two doses of Narcan worked, and she noted on the physician's order that she could give another dose after 10 minutes if the first one did not work. After Nurse #14 administered the second dose, she observed that Resident #8's oxygen saturation was within normal limits, and he was talking to her although he said that he was tired and just wanted to lay there in the bed. Nurse #14 stated that Nurse #20 told her that she had called the doctor, and she thought that Nurse #20 had also called 911. Nurse #14 commented that she thought Nurse #20 was going to call 911 because Resident #8 was Nurse #20's resident, and after giving Resident #8 the two doses of Narcan, Nurse #14 went back to the other side of the building. Nurse #14 stated that she knew this was Nurse #20's first day working at the facility. She denied having been told by the Social Worker to call EMS after she gave him Narcan. Nurse #14 stated she did not think she needed to call 911 because Resident #8 responded to the Narcan doses, and he was DNR. Nurse #14 further stated that she was not familiar with the facility's policy for Narcan administration and had not received training on how to administer Narcan. She found out later around 2:00 PM that Resident #8 took a turn for the worse but because the ADON told her that morning after she gave him Narcan that Resident #8 was DNR, and that he was dying, she didn't think there was anything else she should have done. A progress note dated [DATE] at 10:00 AM by Agency Nurse #20 in Resident #8's medical record indicated: Resident #8 was sitting up in wheelchair, very difficult to arouse. Oxygen saturation was 71% on oxygen via nasal cannula. Resident #8 was placed back to bed with head of bed elevated. Somewhat more responsive but continued to nod off. Oxygen saturation increased to the low 80% with deep breaths. Narcan administered by Nurse #14. Narcan somewhat effective, more alert and verbal. Morning medications held. A second progress note dated [DATE] at 12:58 PM by Nurse #20 in Resident #8's medical record indicated: Resident #8 difficult to arouse at this time. Responded to sternal rub (application of painful stimulus with the knuckles of closed fist to the center chest of a patient who is not alert and does not respond to verbal stimuli) with mumbles. Oxygen on per order via nasal cannula. BiPAP (bilevel positive airway pressure which is a form of non-invasive ventilation therapy used to help you breathe) placed on. More verbal and alert at this time. A third progress note dated [DATE] at 3:50 PM by Nurse #20 in Resident #8's medical record indicated: Upon observation, no heart rate or respiratory rate noted. Responsible party aware. Nurse Practitioner aware, order to release body to the funeral home received and noted. Funeral home contacted per family request. A phone interview with Nurse #20 on [DATE] at 12:52 PM revealed she took care of Resident #8 on the day he died. Nurse #20 stated Resident #8 was not alert and was unresponsive, so she got Nurse #14 to come in his room to see him and they took his vital signs which were the same vital signs recorded by Nurse #14 in her 9:36 AM progress note. Nurse #20 stated that Resident #8's oxygen saturation level was very low. She could not recall the exact numbers, but she remembered it being in the 70s. Nurse #20 said that Nurse #14 administered Narcan to Resident #20. Nurse #20 further stated she was not sure why EMS (Emergency Medical Services) was not notified, and she did not know at the time that EMS was supposed to be notified when Narcan was administered. Nurse #20 shared that she did not look at the order for Narcan because she was not the one who administered it to Resident #8. Nurse #20 recalled Resident #8's pupils being very pinpoint, and he was very lethargic on the day that he died but because Nurse #14 told her that Resident #8 was DNR and that there was nothing else they could do for him, she did not think about calling EMS. Nurse #20 stated she was not familiar with Narcan and had never given it before. She also did not receive training on Narcan administration at the facility prior to her working there. A follow-up phone interview with Nurse #20 on [DATE] at 12:26 PM revealed NA #21 alerted her that Resident #8 was lethargic. When Nurse #20 checked Resident #8's oxygen saturation, it was dropping so she asked Nurse #14 for help. Resident #8 woke up somewhat after he received the two doses of Narcan. During the interview, Nurse #20 stated that she was very nervous because she thought that she might be in trouble. Nurse #20 explained that [DATE] was her very first day working at the facility as an agency nurse and she did not have access at the time to the clinical messaging platform that the facility used to contact the on-call providers. Nurse #20 stated that she did not think about calling the on-call provider because she thought that Nurse #14 took over Resident #8's care when she gave him the Narcan. Nurse #20 explained that during this incident, she was still trying to get her medication pass done, and she thought Nurse #14 was going to take care of Resident #8. Nurse #20 further shared that she asked Nurse #14 if they needed to send Resident #8 to the hospital, but Nurse #14 told her no, and that they were not going to do anything for Resident #8 because he was DNR. Nurse #20 clarified that the progress note she documented in Resident #8's chart at 10:00 AM was entered late and that she referred to this note about what happened to Resident #8 before receiving the two Narcan doses. Nurse #20 confirmed that Resident #8 was somewhat more responsive after the two doses of Narcan, but she was not familiar with him because this was her first time taking care of Resident #8, so she did not know what was normal for him. Resident #8 stayed in bed asleep, and his oxygen saturation went up a little, but he got worse in the afternoon when he became lethargic and unresponsive with no heart rate and no breathing. She notified Nurse #14 but again Nurse #14 told her there was nothing they could do for Resident #8. Nurse #20 stated she could not remember why she did not send Resident #8 to the hospital after he received the two doses of Narcan. She did not think of administering the Narcan again and did not think about calling 911. She further shared that she had never administered Narcan before which was why she asked for help from Nurse #14. A phone interview with Nurse Aide (NA) #21 on [DATE] at 11:03 AM revealed on the day that Resident #8 passed away, he was very lethargic, and she told Nurse #20 that he was unresponsive. NA #21 stated that this was not normal for Resident #8 because he was usually up and about and could get around by himself. NA #21 stated that they tried to wake him up multiple times, but he had extremely low oxygen saturation level according to what Nurse #14 and Nurse #20 told her. He was wheezing and although she could not recall the exact oxygen saturation, she stated that it was in the 70s based on what she remembered Nurse #20 telling her. NA #21 further stated that they tried to sit him up but over the next few hours, he did not get any better. NA #21 shared that Resident #8 briefly opened his eyes after receiving the Narcan doses but within 20 to 30 minutes he was back to being lethargic. Resident #8 was able to answer questions, but he acted tired and went back to sleep. He continued to have wheezing and a few hours later he was actively dying based on what Nurse #14 told her. She reported this to Nurse #20, and she placed Resident #8 on BiPAP which was at the bedside. NA #21 stated she went on to take care of the other residents on the hall so NA #20 could sit with Resident #8. Then they provided postmortem care to Resident #8. A phone interview with NA #20 on [DATE] at 9:22 AM revealed he took care of Resident #8 when he died. NA #20 stated that it was the most horrific experience he had ever had. Resident #8 sat in his wheelchair and had his head down on the rolling table. Resident #8 was slumped over, and he was jerking in and out of consciousness, so they put him back into bed. NA #20 stated that Resident #8 was not able to speak that day. He was very short of breath. NA #20 reported that Resident #8 usually complained of shortness of breath, but he was always alert and oriented, and he was able to move around in his room by himself. NA #20 said that he told Nurse #14 that Resident #8 was not responding and was lethargic. After Nurse #14 gave Resident #8 the Narcan, he woke up for a few minutes and then after a brief period he was back to being unresponsive. NA #20 added that he continued to tell Nurse #20 and Nurse #14 that something was not right with him because his eyes were pinpoint and glazed over even when his head was laid on the pillow. His head was floppy, and his limbs were flaccid. NA #20 further shared that Resident #8 had severe edema in his lower extremities which was worse than usual. He said he attempted to check a pedal pulse on Resident #8 because his legs were so swollen, but he was unable to obtain a pedal pulse for the remainder of the day. He stated that he did not check a pulse anywhere else on Resident #8's body. NA #20 stated that Nurse #14 told him that Resident #8 was actively dying and that there was nothing to be done because he was DNR. NA #20 stated that he stayed with Resident #8 holding his hand because he had known previously that he was afraid of dying alone, and then Resident #8 got quiet and then NA #20 realized that he had passed away. NA #20 hollered for Nurse #20 at approximately 3:50 PM and they came to check on Resident #8 who was pronounced dead. NA #20 provided postmortem care with NA #21 before the funeral director got Resident #8's body. A phone interview with the former Social Worker (SW) on [DATE] at 12:45 PM revealed she was the manager on duty which meant she was in charge of the facility in the absence of the Administrator on [DATE]. The former SW stated that when she came in that morning around 9:30 AM, Nurse #14 told her that Resident #8's pupils were pinpoint, and that they needed help to put him back into bed. The former SW stated she observed Resident #8 slumped over in his wheelchair and she thought he was going to die right there. Resident #8's pupils were pinpoint, and she watched Nurse #14 give Resident #8 two doses of Narcan. The former SW further stated that she told Nurse #14 that the facility's policy was to immediately call EMS, call the doctor and send the resident to the hospital after the resident was given Narcan. The former SW explained that she was training an activity staff member that day, so she left the room after Resident #8 received the two doses of Narcan and she said she thought Nurse #14 was going to send Resident #8 out to the hospital afterwards, but she did not. Later that day, around 2:00 PM, Nurse #14 reported to her that Resident #8 took a turn for the worse, so the former SW asked Nurse #14 if she was going to send Resident #8 out. Nurse #14 did not answer her and just looked at her. The former SW stated that she thought Nurse #14 should know what she was supposed to do because she was the nurse. The former SW stated that she did not want to interfere with nursing because she worked in another department, and she could not tell them what they were supposed to do. The former SW stated that she tried to call the Administrator to alert her as to what was happening in the facility, but she could not get her on the phone. An initial joint interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on [DATE] at 1:11 PM. The DON stated that she was not at the facility when Resident #8 died so she did not remember anything that went on that day. The DON stated that she would have to look back at the notes, but she knew that the former Social Worker and Nurse #14 were at the facility on [DATE]. The ADON stated that she knew Resident #8 passed away, but it was expected that he was going to die because he had end-stage COPD and respiratory failure. The ADON stated that from what she remembered, Resident #8 was found unresponsive, but she denied knowing any details regarding Resident #8 receiving Narcan. The ADON shared that each resident had a standby order for Narcan especially if they had opioid medications in cases of opioid overdose, but she was not sure whether the order indicated that they were supposed to call 911 when administering Narcan. The DON stated that if it was specified on the Narcan order to call EMS, the nurses should have followed what was specified on the order. A follow-up interview with Nurse #14 on [DATE] at 8:32 AM revealed she talked to the ADON after she gave two doses of Narcan to Resident #8 and the ADON told her that it was fine, and that she didn't have to do anything else because Resident #8's code status was DNR. Nurse #14 further stated that if the ADON had told her to call 911, she would have called 911, but because he was DNR, the ADON told her they did not need to do anything. Nurse #14 also shared that around 2:00 PM on [DATE] when Resident #8's condition was getting worse, she asked the former Social Worker if she needed to send him out to the hospital. Nurse #14 claimed that the former Social Worker told her that she didn't have to send him out to the hospital because he was DNR. Nurse #14 further shared that Resident #8 had improved after the first dose of Narcan, but she did not know the reason for the persistent lethargy even while he was in bed, so she gave her another dose of Narcan. A follow-up phone interview with the former SW on [DATE] at 11:18 AM revealed she did not say to Nurse #14 not to send Resident #8 to the hospital because he was DNR. The former SW stated that it was not her call. She added that Nurse #14 was the nurse on the floor, and she should have taken care of Resident #8. A follow-up interview with the ADON in the presence of the DON on [DATE] at 3:29 PM revealed that the ADON could vaguely remember if she called or texted Nurse #14 on [DATE] after Nurse #14 gave the two Narcan doses to Resident #8. The ADON stated that she couldn't remember when her conversation with Nurse #14 was and what time, but that the ADON was not surprised that Resident #8 had died but she was surprised that Nurse #14 had given him Narcan. The ADON stated she questioned Nurse #14 why she gave Resident #8 Narcan when he was expected to die. The ADON explained that she was doing verbal education to the staff to help them understand how sick he was. Whenever Resident #8 had issues with his breathing, he wanted to go to the hospital where they would just give him a rescue BiPAP and intravenous diuretics, and then send him back to the facility. The ADON stated she did not remember her exact response to Nurse #14 about the two Narcan doses, but she recalled Nurse #14 telling her that Resident #8 responded a little bit to the Narcan dose. The ADON further explained that she remembered telling Nurse #14 that Resident #8 was unresponsive because he was actively dying. The ADON recalled Nurse #14 told her Resident #8 responded a little bit after she gave him Narcan. An interview with the Medical Director (MD) on [DATE] at 10:21 AM revealed he last saw Resident #8 on [DATE] when he visited him after he had just gotten back from the hospital for COPD and CHF, and he seemed to be doing fine during the visit. The MD stated that Resident #8 was a long-term care resident and his plan of care included providing assistive care and managing his chronic medical issues. The MD stated that he was not notified when Resident #8 died but he found out about it the next day he visited the facility. The MD stated that he did not know that they administered Narcan to Resident #8, and he was not familiar with the facility policy for Narcan. The MD stated that if the policy indicated for staff to notify EMS when administering Narcan, then they should have followed that. The MD confirmed that low oxygen saturation and pupil constriction were signs of overdose, and that Resident #8 should have been sent out to the hospital on [DATE]. The MD added that if an on-call provider was notified about the Narcan doses, then there would be a note in Resident #8's chart and they would have ordered to send him out to the hospital. Resident #8's death certificate indicated date of death was [DATE] and the immediate cause of death was myocardial infarction (heart attack) with the following diagnoses listed as underlying causes: coronary artery disease and congestive heart failure. A follow-up phone interview with the MD on [DATE] at 11:39 AM revealed he put myocardial infarction (MI) on Resident #8's death certificate because that was the most likely cause of his death but if he had known that the nurses had to give him Narcan, he probably would not have put MI without doing further investigation into the cause of his death. The MD stated that he could not put possible overdose on Resident #8's death certificate, and that he would need to have a toxicology report done but this was rarely done unless the family member requested for one to be done. The MD stated that a toxicology report could verify the cause of death but since they did not do this anymore, he said he didn't know what he would have put as the cause of death without investigating further. The MD explained that Narcan was just a temporary fix, and it did not fix or correct the cause of the lethargy. Narcan also had a tendency to wear off quickly which was why it could be given every 10 minutes or so, but it would be nice to have EMS around in case the resident went back into depression. The MD added that Narcan was only used in cases of emergency and any resident who received it needed to be observed and monitored closely. The MD further explained that a positive response from Narcan meant that the Narcan was working in terms of reversing whatever caused the unresponsiveness, but it was only effective up to a certain extent. A phone interview with the Administrator on [DATE] at 11:55 AM revealed she was not aware of Resident #8's passing until the Monday when she came in. The Administrator stated Resident #8 had been having repeated respiratory issues, and she knew that he had been advancing with his COPD and that he was end-stage which meant there was not a lot they could do for him. She stated that she knew Resident #8 had just been through two previous hospitalizations for respiratory distress where he received treatment. The Administrator stated that she did not know the specific date that she found out about Resident #8 having been given Narcan without guessing. She could not say whether Resident #8 should have received emergency treatment after receiving the two Narcan doses. The Administrator was notified of immediate jeopardy on [DATE] at 12:00 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 activate emergency response for Resident #8 after Nurse #14 administered two doses of Narcan on [DATE] at 9:34 AM and 9:54 AM with positive response for suspicion of drug overdose. The facility has re-educated the licensed nursing staff on the use of Narcan and activation of the emergency response per physician orders by [DATE]. Licensed nursing staff that are not available on or before [DATE] will not be scheduled until the education has been completed. The actions the facility will take to ensure the nurses have activated the emergency response as indicated in the physician's orders on the administration of Narcan is the DNS will review the 24-hour report on a daily basis for appropriate activation of the emergency response. Feedback will be provided by the DNS to the licensed nurse addressing any challenges or barriers in the use of Narcan and/or the activation of the emergency response. Re-education was provided to licensed nursing staff about the activation of the emergency response when Narcan is administered. * Agency licensed nurses working at the facility will receive education on activating emergency response when administration of Narcan for a suspected overdose by the DNS/ Assistant Director of Nursing (designee). 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 specific actions the facility will take to alter the system failure to prevent a serious outcome from reoccurring are: * The facility has re-educated the licensed nursing staff on the use of Narcan and activation of the emergency response per physician orders by [DATE]. * The actions the facility will take to ensure the nurses have activated the emergency response as indicated in the physician's orders on the administration of Narcan is the DNS will review the 24-hour report on a daily basis for appropriate activation of the emergency response. Feedback will be provided by the DNS addressing any challenges or barriers. * Agency licensed nurses working at the facility will receive education on notification to the medical provider on administration of Narcan for a suspected overdose by the DNS/ Assistant Director of Nursing (designee). * The nurse who responds to the suspected overdose will direct another staff member to activate the emergency response system, which is denoted in the revised Narcan Administration Policy [DATE]. The alleged date of immediate jeopardy removal is [DATE]. The credible allegation for the immediate jeopardy removal was validated on [DATE] with a removal date of [DATE]. A review of in-service education records dated [DATE] revealed education was provided to nurses including agency nurses on the activation of emergency response upon administration of Narcan, and ensuring the medical provider has been notified of any resident receiving Narcan and activating EMS per physician orders. Interviews with the nursing staff including agency nurses revealed they had been educated on activating EMS and notifying the medical provider of any resident who receives Narcan for suspected overdose, and the revised Narcan administration policy. A review of the revised Narcan administration policy dated [DATE] indicated the nurse who responds to the suspected overdose will direct another staff member to activate EMS. The facility's date of immediate jeopardy removal of [DATE] was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #1 was admitted to the facility on [DATE] with diagnoses that included dementia with agitation, bipolar disorder, anxiety disorder, insomnia, history of falling, difficulty walking, unsteadiness on feet, muscle weakness, panic disorder, schizoaffective disorder, and cognitive communication deficit. A review of the facility floor plan revealed Resident #1 resided on the 200 hall unit near the 100/200 hall nurses station and approximately 7 resident rooms from the 200 hall emergency exit door. An elopement risk assessment was completed on the following dates prior to her recent readmission: [DATE] and 11/26/23. Resident #1 was determined to be at risk for elopement on both assessments. A review of Resident #1's Admission/readmission Nursing assessment dated [DATE] revealed she had risk alerts for falls and may attempt to exit with wandering listed under mood and behaviors. A review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had moderate cognitive impairment. Resident #2 was not coded with wandering behaviors during the 7-day lookback and required supervision for ambulating 50 feet and make 2 turns. A review of Resident #1's care plan revealed the care plan was initiated on 7/19/23. She was care planned for exit seeking behaviors and elopements and read in part; It is unsafe for me to leave this facility; however, I may attempt to do so. 8/1/23-trying codes on exit doors and the following interventions implemented: 1) When you find me trying to leave, please check to see if I am looking for a specific place or thing. If appropriate, help me to find it. If it is not appropriate, distract me. 2) Perform an elopement assessment on me quarterly and as needed should my cognitive or physical situation change 3) Make sure that my picture is in the elopement book on every floor and in the main lobby. 4) Divert to activity 5) Check on me often and when you do your hourly safety rounds. 6) 15-minute checks until behaviors stops 7) 1:1 until behaviors stops or discharge. An interview with Nurse #10 on 4/24/24 at 8:38 AM revealed she recalled working with Resident #1 on the night of 1/27/24 from 7:00 PM to 1/28/24 at 7:00 AM. Nurse #10 said that although Resident #1 did not exit the facility on that evening she did recall her pulling the fire alarm and pushing on the emergency exit door in an attempt to at one point to exit the facility but was unsuccessful to open the door and redirected by staff. A nurse progress note dated 2/2/24 at 6:06 AM written by Nurse #11 indicated Resident #1 had shown behaviors where she expressed the desire to go outside and stated, Satan was coming after her if she didn't go outside right now. The note indicated staff attempted to redirect Resident #1 by notifying her it was too cold to go outside at the time but Resident #1 continued to go into other resident's rooms to ask them to take her outside. A telephone interview with Nurse #11 on 4/26/24 at 4:21 PM revealed she recalled working with Resident #1 on 2/2/24 when Resident #1 expressed her need to go outside due to Satan coming after her. Nurse #11 stated Resident #1 frequently referred to Satan coming to get her or someone being outside and her need to go outside but had not exited the facility during her shift on 2/2/24. A review of the incident report logs dated 1/1/24 through 4/23/24 revealed no elopement reports for Resident #1 documented. A telephone interview with Visitor #1 on 4/22/24 at 4:55 PM revealed he had arrived at the facility the morning of 2/20/24 at approximately 7:05-7:10 AM to visit a resident at the facility. Visitor #1 stated when he arrived that morning before sunrise (documented sunrise was 7:14 AM), he noticed a female walking and stopping at the front of the facility holding a large handful of mail and wearing nothing but a short-thin cotton night gown, he described as It was hardly fit for sleeping indoors, and no shoes. Visitor #1 stated he immediately thought about how frigid the temperatures were outside, thought she looked cold, and he stopped his automobile near the female and Visitor #1 said he attempted to ask Resident #1 where she was trying to go. Visitor #1 recalled Resident #1 told him she was attempting to go to Asheville, (which was approximately 55 miles away) so he asked her to get in his vehicle to wait with him until Transportation Aide #1 arrived at the facility that morning so she would not freeze to death and maybe [Transportation Aide #1] could take her. Visitor #1 stated Resident #1 willingly entered the front seat of Visitor #1's car and he turned on the heater as high as possible to warm her back up after being in the cold air for an unknown amount of time. Visitor #1 said Resident #1 sat in his car talking until Transportation Aide #1 arrived between 7:25-7:30 AM that morning to let them in the building. Visitor#1 said when the transportation aide arrived that morning, he recalled telling Transportation Aide #1 that he had found the resident alone outside holding the mail from the mailbox. Visitor #1 said he remembered saying, [Transportation Aide], I stopped and let her in before she froze to death out here. Visitor #1 stated he offered to escort Resident #1 upstairs to her room for the transportation aide because he was going that way, but Transportation Aide #1 asked him to stand with her while he clocked in, then they both escorted Resident #1 upstairs. Visitor #1 said Resident #1 stood with him and Transportation Aide #1 at the 300/400 hall nurses' station while they spoke to the nurses (Nurse #2 and Nurse #3); then he left and went to visit his family member who resided in the facility and left Resident #1 with Transportation Aide #1. A review of the recorded weather on AccuWeather for the area of the facility during the night of 2/19/24 for the facility revealed the temperatures was approximately 23 degrees Fahrenheit around 7:00 AM without precipitation on the morning of 2/20/24 when Resident #1 was returned to the facility. A telephone interview with Transportation Aide #1 on 4/22/24 at 5:14 PM revealed he arrived at the facility on 2/20/24 at approximately 7:25 AM. He stated he was always the first staff member to arrive in the front entrance to the facility and he unlocked the door each morning and allows Visitor #1 to enter daily to visit his family. Transportation Aide #1 stated on the morning of 2/20/24, he quickly gathered his belongings to get to the door, but as he approached the front entrance, he noticed a female exiting the passenger side door of Visitor #1's automobile and was bent over gathering something from the front seat wearing a short mini skirt and her legs shining. The Transportation Aide stated he stood there initially startled because Visitor #1 did not usually have anyone accompany him to the facility but within moments the female turned around and looked at him, yelled out [Transportation Aide], I got your mail. The Transportation Aide stated she began walking towards him carrying an arm full of mail and handed it to him. The Transportation Aide said he asked Visitor #1 what occurred, and Visitor #1 had informed him that when he arrived that morning, he noticed Resident #1 was in front of the facility carrying the mail with a limited amount of clothes on and he was concerned she would freeze so he stopped his car and had her get in until someone arrived. The Transportation Aide stated he and Visitor #1 escorted Resident #1 back into the facility and upstairs where he then took Resident #1 back to her unit and asked a nurse aide (he could not recall her name) if she was missing anyone? He then informed the nurse aide Visitor #1 had located Resident #1 outside near the front entrance and had her in his car until the Transportation Aide arrived. The Transportation Aide said he asked the nurse aide if she looked outside for any residents, and she said NA #3 looked around but did not see any residents outside and was unsure if a resident had exited the facility at the time. A handwritten statement dated 2/24/24 written by Nurse Aide (NA) #1 read as follows: the door alarms on 200 hall started going off I want to say between 7:05 AM and 7:15 AM. NA#2 and I walked to the end of the hall to see why the alarm was going off. As we got to the end of the hall, we didn't see anyone near the door and NA #3 came down the hall probably a minute later because we couldn't turn the alarm off. She (NA #3) asked if anyone went outside and checked, and we (NA #1 and NA #2) said no, and NA #3 cut the alarm off. NA #2 walked right (I'm not sure how far right) then she walked left to the dining room and stated she didn't see anyone. NA #3 and I walked back up to the front and that was the end of what happened until [Transportation Aide #1] brought Resident #1 up at about 7:30 AM-ish. An interview with Nurse Aide (NA) #1 on 4/22/24 at 3:58 PM revealed she was scheduled to work on the 200 hall where Resident #1 resided on the night of 2/19/24 from 7:00 PM to 7:00 AM the morning of 2/20/24. NA #1 stated she was an agency NA and began working in November or December of 2023 and had recently transitioned to be a facility employee. She stated she was familiar with Resident #1, she knew Resident #1 had a history of exit seeking behaviors, Resident #1 frequently said she needed to leave the facility for various surgeries and most recently breast surgery, and believed her family was outdoors to transport her to her appointments. She said around shift change (7:00 AM) she heard an alarm going off and she and NA #2 followed the sound and located it to be the emergency exit door at the end of the 200 hall. NA #1 said neither she nor NA #2 knew the code to turn off the alarm that was sounding so another nurse aide (NA #3) came down the hall about that time from another unit and asked if anyone went out the door. NA #1 said both she and NA #2 had not seen anyone exit from that door so they both said No. NA #3 turned off the alarm. NA #1 said NA #3 told NA #2 to check to make sure no resident had gotten outside even if she had not seen anyone exit by taking a quick look outside. NA #1 said she recalled NA #2 being reluctant but went outside and walked briefly to the right of the emergency exit door and to the left and quickly returned into the facility though the cafeteria door (emergency exit door in the kitchen/dining room area which required a key pad code for entry) and said she did not see anyone outside. NA #1 said NA #3 then left the facility as her shift was completed and she said she was getting ready to leave herself at approximately 7:30 AM when she heard staff paged to come to the 300/400 hall nurses' station. NA #1 said she stayed on the hall with the residents and NA #2 responded to the page. NA #1 said she was asked to continue to work on the 200 hall until 11:00 AM when NA #2 abruptly returned to the unit and said she was leaving the facility and would not be returning to work and therefore she continued to work with Resident #1 until 11:00 AM on 2/20/24. NA #1 said later in the shift she was asked to write a statement of what occurred with the alarm at shift change. NA #1 stated shortly following the page on the intercom, Transportation Aide #1 escorted Resident #1 onto the 200-hall unit wearing a short green cotton night gown and said Resident #1 needed to be watched closer because she had exited the facility and Visitor #1 had found her outside the facility. NA #1 said around that time (7:30 AM-7:45 AM), Nurse #5 had arrived on the unit for her shift and was walking towards them and Transportation Aide #1 explained to Nurse #5 what occurred. NA #1 said Nurse #5 then took Resident #1 from Transportation Aide #1 and took her to her room. NA #1 said Resident #1 was initially placed on every 15 minutes checks; however, she continued to attempt to exit the facility and wander off the unit at times. NA #1 said she was difficult to redirect and had increase agitation the remainder of her shift. A telephone interview with NA #2 on 4/24/24 at 11:08 AM revealed she was no longer employed with the facility and had not worked at the facility since 2/20/24. NA #2 stated she thought she heard an alarm sounding when she arrived to work on the morning of 2/20/24 at shift change (7:00 AM) as she had approached the nurses' station at the 100/200 hall desk, and she sat her bag down. NA #2 said she looked around and no other staff seemed alarmed so she initially thought it must be the alarm on the back door where staff entered and exited and continued to obtain shift to shift report from the night shift nurse aide (NA #1). NA #2 said after approximately 30-60 more seconds she continued to hear the noise, she and NA #1 looked at each other and realized the alarm was not coming from the staff exit (a designated locked door in the rear of the facility where staff enter and exit the facility) but another door and proceeded towards the 200 hall and towards its emergency exit door. NA #2 said she and NA #1 quickly reached the 200-hall emergency exit door and attempted to disarm the alarm but did not know the code to turn off the alarm. NA #2 said she did not see any residents in the general proximity of the door on the interior or exterior of the facility from the door while trying to disarm the alarm. NA #2 explained around that time, NA #3 approached them and asked if anyone went outside. NA #2 said both she and NA #1 said they had been giving reports and had not seen anyone near the door and did not see anyone outside. NA #2 said she was asked to go outside and take a look around. NA #2 stated NA #3 opened the door and let her out the door and she said when she exited the 200 hall emergency exit door she walked towards the right side of the facility to the 300/400 hall storage area (a covered awning used on the exterior of the building to store unused furniture and equipment) which was approximately 25-50 feet from the exit door to the right and located in the direction of the front of the facility, then returned towards the staff parking lot (across from the exit door) and returned into the facility through the dining room entrance at the rear of the facility (approximately 50 feet to the left of the 200 hall exit door). NA #2 stated she did not see any residents while she was outside and therefore believed the alarm had sounded faulty from the wind as had occurred before (alarm would sound when door had not been fully opened due to excessive suction from the wind which forced a crack in the door enough to set off the maglock system) until she overheard staff announce to come to the 300/400 hall for a meeting. NA #2 said she told NA #1 to stay on the 200-hall unit and she would respond to the page, so she left the unit and proceeded to the 300/400 hall unit as requested. NA #2 said when she arrived at the 300/400 hall nurses' station, she learned that Resident #1 had exited the facility and been found outside the facility by Visitor #1. NA #2 said Resident #1 was at the 300/400 hall nurses' station with Transportation Aide #1 when she arrived in a short green cloth gown but was then taken to the 200-hall unit during the meeting. A handwritten statement dated 2/20/24 at 8:45 AM written by Nurse Aide #3 (NA #3) read as follows: 7:05 AM- leaving at the end of my shift 300 hall going to the time clock- when I reached the conference room, I heard a door alarm and a screamer (small battery powered alarm which sounds like a siren when activated) going off. I reached the 100/200 hall desk at the same time as NA #4 did coming from the opposite direction. She (NA #4) and I together turned down to 200 to see NA #2 and NA #1 attempting to silence both alarms. As I am coming towards them, I am yelling and motioning for them both to go outside to see if someone had gone out. NA #2 hesitated, then said Really and I stated yes. I watched her exit and turn right, walk a distance, turn back left, walk a distance, and come back towards the door shrugging her shoulders. By now I had the screamer turned off and the door alarm and motion for her to go around the building to come back in. I then asked NA #4 and NA #1 whose rooms were in this back corner and NA #4 stated [Resident 7]. I asked if she thought he could have pushed the door and she replied no, and NA #1 follows by saying I thought it was Resident #1 but she's in the TV room. I made it back to the 100/200 hall desk now and see Nurse #1 walking on 200 hall side of the desk I believe her to being aware and I clocked out and left. I left honestly believing it was a fault in the door. There have been several occasions that 400 hall door has popped open just enough from wind to sound the door alarm. Having personally watched NA #2 outside looking seeing no one and NA #1's statement that Resident #1 was in the TV room I clocked out thinking it was a fault in the door as I've experienced on 400 hall. A telephone interview with Nurse Aide (NA #3) on 4/24/24 at 8:55 AM revealed she was assigned to work the 400 hall on the night shift (7:00 PM of 2/19/24 to 7:00 AM of 2/20/24). NA #3 stated on the morning of 2/20/24 she gave report to the day shift nurse aide and both she and NA #4 had retrieved their belongings and were walking along the corridor between the wings that separate the 300/400 hall from the 100/200 and lead to the staff exit at the back of the facility. NA #3 stated when they had reached the conference room area on the hall, she heard a noise that sounded like an alarm, so she continued to walk towards the 100/200 hall until she realized the noise was an alarm sounding from an emergency exit door on the 200 hall. NA #3 said when she reached the opposite end of the 200 hall where the door was located, she saw both NA #1 and NA #2 at the opposite end of the 200 hall near the door attempting to disarm the alarm, but neither were successful, so she proceeded towards them. NA #3 said when she approached NA #1 and NA #2 she asked them if anyone had exited the facility through that door and they looked at one another and both answered by shaking their heads no. NA #3 said she asked if any of the residents who resided near the exit door could have opened the door and said she recalled asking about Resident #1 specifically and was told by NA #1 she had saw her earlier in the shift with another resident reading the Bible in the activity room on the unit. NA #3 said she told NA #2 to go outside just to make sure a resident had not gone outside, and she would disarm the emergency exit alarm for her. NA #3 said NA #2 then exited the facility and proceeded outdoors as far as she could see towards the right and then came back in front of her to the left and back in the facility through the dining room door shrugging her shoulders and said she did not see anyone out there. NA #3 said she thought the alarm may have sounded faulty (alarm would sound when door had not been fully opened due to excessive suction from the wind which forced a crack in the door enough to set off the maglock system) as had occurred in the past and she left the facility since her shift was completed. NA #3 said a little later that morning she was contacted by Social Worker #1 where she learned Resident #1 had eloped from the facility and she was asked to return to write a written statement of what she recalled that morning, so she returned to the facility to write the statement at around 8:45 AM. A handwritten statement dated 2/20/24 written and signed by NA #4 read in part as follows: I was at the desk giving NA #2 report and heard a loud noise. We didn't know what it was because we had never heard it before, but we followed the sound and seen it was the unit 200 hall exit door. NA #1 and NA #2 ran down to the door as I waited on NA #3 who was walking toward me, and we went down to give the girls the code as NA #3 was the only one who knew it that was right there. NA #2 walks out to the right and didn't see anybody and then walked to the left to the parking lot to come inside through the dining room. As me, NA #1 and NA #3 were coming back up the hall we were thinking someone pushed the door; even joked that [resident not on the sample] did it because it was so quick, and we didn't see anyone. Even mentioned Resident #1's name as we walked by and observed her door still closed as it was left on the last round but never thought she had gotten out and down the hill that fast! Multiple attempts to interview Nurse Aide #4 during the investigation were unsuccessful. A telephone interview with Nurse #2 on 4/23/24 at 5:22 PM revealed she had been assigned to work 300/400 hall during night shift (7:00 PM to 7:00 AM) on the night of 2/19/24 into the morning of 2/20/24. Nurse #2 stated she recalled on the morning of 2/20/24 around 7:30 AM, she was providing shift to shift report to Nurse #3 at the 300/400 hall nurses' station (opposite side of the building from the 200 hall) when she looked up to notice Visitor #1, Transportation Aide #1 and Resident #1 get off the elevator and approach the nurses' station. Nurse #2 indicated Visitor #1 began to explain that he arrived at the facility to see his family member, but this morning he noticed Resident #1 was standing outside alone. Nurse #1 stated Visitor #1 told her and Nurse #3 that he noticed she was not dressed appropriately for the weather and was concerned for her safety since she appeared confused when he spoke to her. Nurse #2 said Visitor #1 had explained he convinced Resident #1 into sitting in his car where it was warm until Transportation Aide #1 arrived to let them in the building that morning. Nurse #2 said she did not appear injured, so she immediately began attempting to call the facility administration beginning with the Director of Nursing (DON), who did not answer. Nurse #2 said she then attempted to contact the Assistant Director of Nursing (ADON) and could not reach her. Nurse #2 said she made a second attempt to reach both the DON and the ADON without success before reaching out to Social Worker #1 who answered the phone immediately. Nurse #2 said Social Worker #1 told her to make sure Resident #1 was safely returned to her unit and have nurses complete a full facility headcount. Nurse #2 said that Social Worker #1 said she would attempt to contact the Administrator who was at a conference and would come to the facility as soon as possible. Nurse #2 said once she hung up with Social Worker #1, both she and Nurse #3 called staff over the intercom to the 300/400 hall nurses' station to request they begin conducting a headcount for resident accountability and to see if anyone may possibly know how Resident #1 had gotten out of the building. Nurse #2 said when staff arrived at the 300/400 hall nurses' station, she learned that an alarm had sounded on the 200-hall unit around shift change. A telephone interview with Nurse #3 on 11/23/24 at 11:04 AM revealed she was assigned to work the 400 hall on day shift (7:00 AM to 7:00 PM) on 2/20/24. Nurse #3 said she had arrived at work that morning and began shift to shift report with Nurse #2 when Visitor #1 and Transportation Aide #1 approached the floor from the elevator escorting Resident #1. Nurse #3 explained when she saw Resident #1, she was wearing a short green cotton gown and thin socks on her feet and carrying an arm full of what appeared to be mail. Nurse #3 said Visitor #1 immediately asked her and Nurse #2, Who is responsible for this woman? He was referring to Resident #1 and began telling both Nurse #2 and Nurse #3 he found her when he arrived at the facility that morning (2/20/24) between 7:05 AM and 7:10 AM and stopped to ask her what she was doing outside. Nurse #3 went on to say both she and Nurse #2 had asked Visitor #1 where he had found Resident #1. She indicated Visitor #1 told them he found her down the road and kept her safe in his car until Transportation Aide #1 arrived at the facility to let them in the facility. Nurse #3 explained Visitor #1 thought she appeared cold and said he had to warm her up because he didn't want her to freeze to death in the bitter cold air outside. Nurse #3 said when Resident #1 did not appear injured from being outside, they instructed Transportation Aide #1 to take Resident #1 back to her room and make her nurse (Nurse #5) aware she had exited the facility and needed monitoring more closely to ensure she did not get out again. Nurse #3 said Transportation Aide #1 escorted Resident #1 back to her unit at that time while both she and Nurse #2 tried to contact the facility's administrative team to let them know what occurred. Nurse #3 said both she and Nurse #2 attempted to contact both the Director of Nursing (DON) and Assistant Director of Nursing (ADON) multiple times without success and tried contacting the Administrator once via telephone unsuccessfully before they reached out to Social Worker #1. Nurse #3 said Social Worker #1 instructed her and Nurse #2 to start conducting a head count to determine if all residents were accounted for in the facility and she would be to the facility in about half an hour or so since staff were unable to reach the DON and ADON. Nurse #3 said after hanging up the phone with Social Worker #1, both she and Nurse #2 called staff over the intercom to the 300/400 hall nurses' station to initiate a headcount. Nurse #3 indicated she and Nurse #2 had begun interviewing staff about their knowledge of what happened on that morning (2/20/24) and learned an alarm sounded on the 200 hall emergency exit door around shift change (7:00 AM). A telephone interview with the Social Worker #1 on 4/23/24 at 12:07 PM revealed she was no longer employed at the facility. She explained she was familiar with Resident #1 and initiated the investigation conducted on 2/20/24 after Resident #1 exited the facility through the 200-hall emergency exit on the unit. Social Worker #1 indicated she was contacted via telephone around 7:30 AM on 2/20/24 by Nurse #2 and Nurse #3 who informed her that Resident #1 had somehow exited the facility and was found by Visitor #1 outside near the front of the building in the cold and he returned her to the facility when Transportation Aide #1 arrived at the facility that morning. Social Worker #1 said she immediately told Nurse #2 and Nurse #3 to begin a headcount of all residents in the building to make sure no other residents had exited the building at the same time and she would be to the facility in about 30 minutes. Social Worker #1 said she arrived at the facility at approximately 8:00 AM that morning and began to collect statements from staff who were present in the facility. Social Worker #1 said when the administrative nurses (DON and ADON) arrived later in the morning between 8:30 AM - 9:00 AM, they assisted in the investigation at that time. Social Worker #1 indicated she contacted the Administrator and notified her of Resident #1's exit from the facility on the morning of 2/20/24. A telephone interview with Maintenance Director #1 on 5/5/24 at 5:50 PM revealed he was no longer employed by the facility; however, he recalled the events on 2/20/24 regarding Resident #1 exiting the facility. Maintenance Director #1 stated he learned of the elopement on the morning of 2/20/24 when a member of the nursing administration team (identified by Maintenance Director #1 to be the Assistant Director of Nursing) communicated an alert on 2/20/24 at 7:48 AM via an external social media communication application called WhatsApp used by facility staff. Maintenance Director #1 stated after he arrived at the facility on the morning of 2/20/24, he checked all emergency exit doors to ensure the alarms were functioning properly and assisted with in-service training by initiating education on the screamer alarms. He said he was able to provide education to available members of staff on day shift. Maintenance Director #1 said he had previously expressed concerns to administration that he had noticed staff ignored alarms. Maintenance Director #1 indicated he had performed an external audit of the external perimeter of the facility where Resident #1 would have traveled from the 200 hall emergency exit door to the front of the facility where the mailbox was located which he described as approximately 150-200 yards and included a steep declining roadway leading to the front parking lot which he was sure Resident #1 had traveled on the morning of 2/20/24 and stated it would have been almost impossible for Resident #1 to have traveled to the front of the facility through the grassy as due to the grade of the hills and uneven surfaces required. A review of the electronic screenshot messages of the alert provided by Maintenance Director #1 was reviewed and revealed the following messages: - Huge problem girls .We had an elopement! [Resident #1] got out 200 hall door no one checked to see if someone went out just turned alarm off .and [Resident #1] was walking down the road. Family member picked her up outside and brought her back in. - It's 24 degrees outside and [Resident #1] was wearing just a shirt. - She's prolly going to need 1:1 until Bx [behavior] stops. She knows how to get out now. - [Assistant Director of Nursing] call me. On 4/23/24 at 7:55 AM, accompanied by Transportation Aide #1, an observation of the area surrounding the 200 hall emergency exit door revealed immediately upon exit of the 200 hall emergency exit door was a paved walkway approximately 10 feet that connects to an adjacent road which lead to a staff parking lot or down a steep hill with a blind curve area leading into the lower parking lot and lead out the road exiting the facility to the main road at the highway. The area where Resident #1 was found by Visitor #1 was at the front of the facility. A concrete area which contained a flagpole, and a mailbox were observed which were next to the road that served as the facility ambulance entrance, staff parking lot, and was along the road entrance into the facility with a posted speed limit sign of 25 miles per hour. An observation and demonstration of the emergency exit door alarm system accompanied by Maintenance Director #2 on 4/22/24 at 2:30 PM revealed a metal door at the end of the hallway. The door was equipped with a maglock system which allowed the door to open after pressing on the handle which was located approximately waist high for 15 seconds. This caused the door to release with an audible but low decimal pitch alarm. Once the door was fully opened, a second alarm was activated, a high pitch siren type alarm began to sound until the door was closed and a code was pressed into the key pad located above the top of the left side of the door. The alarm systems were not electronically wired into an enunciator panel elsewhere in the facility and must be manually disarmed by a staff member. An interview with Nurse #1 on 4/22/24 at 4:20 PM revealed she was the Unit Manager for the 100/200 halls. Nurse #1 stated she had counted narcotics and received report from Nurse #7 at around 6:45 AM when Nurse #7 had to leave her shift early on 2/20/24. Nurse #1 assumed the responsibility for 200 hall until Nurse #5 arrived around 7:30 AM. She said she was in charge of Resident #1's care at the time of the elopement but said she could not recall any residents in the hallway nor had she heard any alarms sounding on the morning of 2/20/24. Nurse #1 said between 7:30 AM- 7:45 AM she heard the intercom page staff to the 300/400 hall and was approached by NA #1 around the same time who informed her that Resident #1 had exited the facility and been found by Visitor #1 that morning. Nurse #1 said following being notified that Resident #1 had exited the facility, she did a head count of her unit to ensure the residents on the 100-hall unit were all visualized. Nurse #1 said after she counted all her residents, she noticed Nurse #5 near the 200 hall emergency exit door and an alarm was going off, but the sound was very faint and was barely loud enough to be heard at the 100 hall nurses' station. Nurse #1 said the alarm could not be heard until she began to approach Nurse #5 on the 200-hall unit. Nurse #1 described the alarm as a low-pitched humming sound and only be[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and staff interviews, the facility failed to ensure nursing staff were trained and competent with responding to medical emergencies, activating emergency procedures with emergency medical services, and notifying medical providers for 1 of 4 residents (Resident #8) reviewed for neglect. Nursing staff failed to notify a medical provider of significant changes in a resident's condition who was observed to be unresponsive to painful stimuli, having low oxygen saturation level and pupil constriction, and failed to immediately initiate emergency procedures with 911. Resident #8 expired on [DATE]. This was for 2 of 2 staff members reviewed for competency (Nurse #20 and Nurse #14). Immediate jeopardy began on [DATE] when nursing staff did not demonstrate competency in responding to a medical emergency. The immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective for ensuring all staff are trained and competent before caring for residents in the facility. The findings included: A review of the employee file for Nurse #20 indicated verification of an active license to practice in the state, and a checklist entitled, Agency Staff Facility Orientation. The checklist was initialed and signed by Nurse #20 on [DATE]. Included in the checklist were emergency codes, Narcan, and code blue. A review of the employee file for Nurse #14 indicated she was hired on [DATE] as a charge nurse. A new-hire orientation checklist was completed on [DATE] and verification of an active license to practice in the state was done. The checklist dated [DATE] indicated Nurse #14 was checked off on the location of fire alarms, location and operation of emergency exits, location of fire extinguishers, fire plan, evacuation procedure, emergency telephone numbers, door alarms, and emergency generators. The Nurse Supervisor job description was signed by Nurse #14 and the Director of Nursing on [DATE]. Included in the job description were to assist the charge nurse in monitoring seriously ill patients, and to notify the attending physician and next-of-kin when there is a change in the resident's condition. A progress note dated [DATE] at 9:36 AM by Nurse #14 in Resident #8's medical record indicated: Resident #8 was given Narcan per order. Oxygen saturation 68% (normal value 95% or higher), resident not responding to painful stimuli, pupils constricted. (Small pupils or constricted pupils are common symptoms of opioid overdose.) Narcan given in nostril. Resident now 95% on oxygen. Blood pressure 128/72 (normal value less than 120/80), heart rate 84 (normal value 60 to 100 beats per minute), respirations 18 (normal value 12 to 18 breaths per minute) and regular. Another progress note dated [DATE] at 9:47 AM by Nurse #14 in Resident #8's medical record indicated: Resident #8 now resting with eyes closed. Oxygen saturation 98%. No signs/symptoms of pain or shortness of breath. A progress note dated [DATE] at 10:00 AM by Agency Nurse #20 in Resident #8's medical record indicated: Resident #8 was sitting up in wheelchair, very difficult to arouse. Oxygen saturation was 71% on oxygen via nasal cannula. Resident #8 was placed back to bed with head of bed elevated. Somewhat more responsive but continued to nod off. Oxygen saturation increased to the low 80% with deep breaths. Narcan administered by Nurse #14. Narcan somewhat effective, more alert and verbal. Morning medications held. A second progress note dated [DATE] at 12:58 PM by Nurse #20 in Resident #8's medical record indicated: Resident #8 difficult to arouse at this time. Responds to sternal rub (application of painful stimulus with the knuckles of closed fist to the center chest of a patient who is not alert and does not respond to verbal stimuli) with mumbles. Oxygen on per order via nasal cannula. BiPAP (bilevel positive airway pressure which is a form of non-invasive ventilation therapy used to help you breathe) placed on. More verbal and alert at this time. A phone interview with Nurse #20 on [DATE] at 12:52 PM revealed she took care of Resident #8 on the day he died. Nurse #20 stated Resident #8 was not alert and was unresponsive, so she got Nurse #14 to come in his room to see him and they took his vital signs which were the same vital signs recorded by Nurse #14 in her 9:36 AM progress note. Nurse #20 stated that Resident #8's oxygen saturation level was very low. She could not recall the exact numbers, but she remembered it being in the 70s. Nurse #20 said that Nurse #14 administered Narcan to Resident #20. Nurse #20 further stated she was not sure why EMS (Emergency Medical Services) was not notified, and she did not know at the time that EMS was supposed to be notified when Narcan was administered. Nurse #20 shared that she did not look at the order for Narcan because she was not the one who administered it to Resident #8. Nurse #20 recalled Resident #8's pupils being very pinpoint, and he was very lethargic on the day that he died but because Nurse #14 told her that Resident #8 was DNR (Do Not Resuscitate) and that there was nothing else they could do for him, she did not think about calling EMS. Nurse #20 stated she was not familiar with Narcan and had never given it before. She also did not receive training on Narcan administration at the facility prior to her working there. A follow-up phone interview with Nurse #20 on [DATE] at 12:26 PM revealed that [DATE] was her very first day working at the facility as an agency nurse and she did not have access at the time to the clinical messaging platform that the facility used to contact the on-call providers. Nurse #20 stated that she did not think about calling the on-call provider because she thought that Nurse #14 took over Resident #8's care when she gave him the Narcan. Nurse #20 explained that during this incident, she was still trying to get her medication pass done, and she thought Nurse #14 was going to take care of Resident #8. Nurse #20 further shared that she asked Nurse #14 if they needed to send Resident #8 to the hospital, but Nurse #14 told her no, and that they were not going to do anything for Resident #8 because he was DNR. Nurse #20 confirmed that Resident #8 was somewhat more responsive after the two doses of Narcan, but she was not familiar with him because this was her first time taking care of Resident #8, so she did not know what was normal for him. Resident #8 stayed in bed asleep, and his oxygen saturation went up a little, but he got worse in the afternoon when he became lethargic and unresponsive with no heart rate and no breathing. She notified Nurse #14 but again Nurse #14 told her there was nothing they could do for Resident #8. Nurse #20 stated she could not remember why she did not send Resident #8 to the hospital after he received the two doses of Narcan. She did not think of administering the Narcan again and did not think about calling 911. She further shared that she had never administered Narcan before which was why she asked for help from Nurse #14. The interview further revealed that Nurse #20 started as an agency nurse on [DATE] and later signed a contract with the facility. Nurse #20 stated she received no orientation prior to working at the facility because agency staff did not receive orientation. Nurse #20 stated that she was only given an orientation packet and was asked to sign a checklist, but she did not have time to read over the material before she started working on the floor on [DATE]. Nurse #20 also stated she was not familiar with the facility's policy regarding the administration of Narcan. She further stated that she was not sure how to notify an on-call provider for the facility if needed during a medical emergency. Nurse #20 explained that she did not receive any training from the facility regarding emergency procedures. A phone interview with Nurse #14 on [DATE] at 10:56 AM revealed she was working as the weekend supervisor on [DATE] when Nurse #20 alerted her about Resident #8 being unresponsive. Nurse #14 stated that she administered two doses of Narcan to Resident #8 to try to get him to wake up because she suspected that he might have overdosed from medications. Nurse #14 said she thought Nurse #20 spoke with the on-call provider while she was busy taking care of Resident #8. Nurse #14 further stated that Nurse #20 told her that she had called the doctor, and she thought that Nurse #20 had also called 911. Nurse #14 commented that she thought Nurse #20 had called 911 because Resident #8 was Nurse #20's resident, and after giving Resident #8 the two doses of Narcan, Nurse #14 went back to the other side of the building. Nurse #14 stated that she knew this was Nurse #20's first day working at the facility, and that she was supposed to monitor Nurse #20, but she was also busy on another hall. Nurse #14 stated she did not think she needed to call 911 because Resident #8 responded to the Narcan doses, and he was DNR. Nurse #14 further stated that she was not familiar with the facility's policy for Narcan administration, and had not received training on how to administer Narcan. She found out later around 2:00 PM that Resident #8 took a turn for the worse but because the Assistant Director of Nursing (ADON) told her that morning after she gave him Narcan that Resident #8 was DNR, and that he was dying, she didn't think there was anything else she should have done. During a follow-up interview with Nurse #14 on [DATE] at 8:32 AM, Nurse #14 stated she started as the weekend supervisor on [DATE], but she did not get orientation on her job responsibilities. Nurse #14 stated she remembered signing a job description, but she did not receive formal training on what she needed to do as the weekend supervisor. Nurse #14 also stated that she was the nurse who had been at the facility the longest and she had worked previously as a supervisor nine years ago. A joint interview with the Director of Nursing (DON) and the ADON on [DATE] at 2:34 PM revealed agency nurses who worked per diem received an orientation packet while agency nurses who signed a contract with the facility received at least one shift of orientation while working with another nurse. The DON stated Nurse #20 started as a per diem agency nurse so she would not have gotten a shift orientation before she worked on the floor. The Human Resources Director usually reviewed the packet with agency nurses prior to them working, but Nurse #14 should have monitored Nurse #20 since it was her first day working at the facility, and it was on a weekend. The ADON further stated that Nurse #14 did not get training as a supervisor, and they were not sure whether she used to be supervisor. The DON stated Nurse #14 was expected to read her job description and that they went over her responsibilities with her as a team. An interview with the Administrator on [DATE] at 4:34 PM revealed they put agency nurses through an onboarding list. Nursing went over with them the review of the medication carts. The Administrator stated that typically when agency nurses started, they came in with the knowledge on how to do their job while receiving monitoring from administrative staff. Nurse #14 had worked as a charge nurse, as a Unit Manager, and as the Director of Nursing before at the facility. The Administrator was notified of immediate jeopardy on [DATE] at 10:54 AM. 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 ensure nursing staff were trained and competent in responding to medical emergencies, activating emergency response, and notifying medical providers for Resident #8 who received two doses of Narcan on [DATE] at 9:34 AM and 9:54 AM, with positive response, for suspicion of drug overdose. All residents who use opioid medications are at risk of overdose and may be subject to the need for Narcan administration and emergency response. 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 facility needs to have a system in place to provide training and verify competencies for nurses related to responding to medical emergencies, medical provider notification and activation of emergency response. The facility continues to employ agency nurses without providing orientation and training prior to providing care to the residents. * An audit was completed by [DATE] by the Nurse Consultant on the number of residents who are prescribed opioid medication, which will include residents that have a diagnosis of opioid abuse disorder that do not have a scheduled or prn opioids. * The Director of Nursing/Assistant Director of Nursing (designee) has re-educated the licensed nursing staff on medical emergencies and emergency activation response per physician orders on [DATE]. * The actions the Director of Nursing/ Assistant Director of Nursing (designee) will take to ensure the nurses have activated the emergency response as indicated in the physician's orders on the administration of Narcan is the DNS will review the 24-hour report on a daily basis for appropriate activation of the emergency response. Feedback will be provided by the DNS addressing any challenges or barriers, which can require re-education if needed. * Agency licensed nurses working at the facility will receive education on medical emergencies and activation of the emergency response by the DNS/Assistant Director of Nursing (designee). * Licensed nursing staff, including agency staff that are not available on or before [DATE] will not be scheduled until the education has been completed. The Director of Nursing/Assistant Director of Nursing (designee) will provide education on medical emergencies, medical provider notification, and activation of emergency response for the nursing staff unavailable after [DATE] before they start the shift. * The nurse who responds to the suspected overdose will direct another staff member to activate the emergency response system which is denoted in the revised Narcan Administration Policy [DATE]. * The facility will initiate Mock Medical Emergencies Drills on each shift weekly x 4 weeks, and then ongoing monthly upon completion of the licensed nursing education. The first drill took place [DATE]. The DNS and/or the ADNS will critique the drill denoting areas in need of improvement. The alleged date of immediate jeopardy removal is [DATE]. The credible allegation for the immediate jeopardy removal was validated on [DATE] with a removal date of [DATE]. A review of in-service education records dated [DATE] revealed education was provided to nurses including agency nurses on the activation of emergency response upon administration of Narcan, and ensuring the medical provider has been notified of any resident receiving Narcan and activating EMS per physician orders. Interviews with the nursing staff including agency nurses revealed they had been educated on activating EMS and notifying the medical provider of any resident who receives Narcan for suspected overdose. The nurses including agency nurses stated they received education on medical emergencies and activation of the emergency response. Interviews with staff confirmed a mock medical emergency drill was conducted on [DATE] and [DATE] where the nursing staff initiated emergency response and notified the doctor of a suspected drug overdose. The audit completed by the Nurse Consultant on [DATE] was reviewed. All residents identified as having orders for Narcan administration had notification of medical providers added to the Narcan order. A review of the revised policy for Narcan Administration dated [DATE] indicated that the nurse who responds to the suspected overdose will direct another staff member to activate the emergency response system. The facility's date of immediate jeopardy removal of [DATE] was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff, friend, Physician Assistant (PA), and Medical Director (MD) interviews, the facility failed to prevent a resident with severe cognitive impairment and a history of wandering and exit seeking behaviors, from exiting the facility unsupervised and without staff knowledge for 1 of 3 sampled residents (Resident #2). During the evening hours on 08/11/23, the Business Office Manager observed Resident #2 approximately 150 yards from the facility walking in the direction of a two-lane main road approximately 100 yards away. The Business Office Manager was able to intercept and escort Resident #2 back to the facility before he reached the two-lane main road which was located on a blind curve and directly across the two-lane road was a wooded area. The posted speed limit sign on the main road was 35 miles per hour (mph) and in the blind curve the posted speed limit was 25 mph. Immediate jeopardy began on 08/11/23 when Resident #2 exited the facility unattended and wandered approximately 150 yards from the facility exit door. Immediate jeopardy was removed on 09/08/23 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 of D (no actual harm with more than minimal harm that is not immediate jeopardy) to ensure monitoring systems are in place and the completion of staff education. The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses that included early onset Alzheimer's disease, non-Alzheimer's dementia, and depression. A review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 had severe cognitive impairment. Resident #2 was not coded with wandering behaviors during the 7-day lookback but indicated he ambulated in his room and in the corridor. Review of Resident #2's care plan revealed he was care planned for wandering and read in part; It is unsafe for me to leave this facility; however, I may attempt to do so. I wander without purpose. I sometimes wander into others' rooms or will attempt to get on the elevator. 8/11/23- exited facility, 8/14/23- trying exit doors two times, 8/23/23-Trying exit door. The care plan was initiated on 07/24/2023 and last updated 08/23/23. An Elopement Evaluation was completed dated 07/20/23, Resident #2 scored not at risk for elopement. Two separate Elopement Evaluations forms dated 08/02/23 were started for Resident #2 but were incomplete. Review of a nurse's progress noted dated 08/3/23 at 6:06 PM, read the patient continues with wandering, urinating / defecating in inappropriate places. He has wandered today and has been exit seeking. Patient redirected as able. Will continue to observe and note behaviors as they occur. Will redirect patient as able during times of these behaviors and provide hygiene and safety measures as necessary. The note was written by Nurse #4. Review of a nurse's progress note dated 08/9/23 at 12:37 AM read, wandering, urinating /defecating in inappropriate places. Resident resting in bed with eyes closed. Wandering on and off unit, not in any inappropriate areas noted so far this shift. The note was written Nurse #6. Review of a nurse's progress note dated 08/11/23 at 12:00 PM, read patient has been wandering hallways per usual. The resident had no abnormal urination or defecation and was not noted to be in places he should not be. However, he does have bladder incontinence then walks through the hallways. Staff redirects the patient to toilet, then incontinence care. No complaints or complications noted. No exit seeking behaviors currently. The progress note was written by Nurse #4. Review of an Incident Report dated 08/11/23 at 6:33 PM, revealed that Resident #2 was found outside of the building, and he was returned to the building and assessed. No other information or details were provided about the elopement. The incident report was completed by the Unit Manager. Review of the recorded weather on 08/11/23 for the facility revealed at 6:00 PM, it was 80 degrees Fahrenheit with fair skies and winds at 3 miles per hour. Source - weatherunderground.com. On 08/24/23 at 9:00 AM an observation of the area where Resident #2 eloped on 08/11/22 was located revealed a gravel/dirt path that descended towards the main road. This path was also used as the ambulance/emergency pick-up location. From the top of the path where the hallway 400 doors open, was approximately 250 yards to the two-lane main road which was located on a blind curve and directly across the street was all a large, wooded area. The posted speed limit sign on the main road was 35 miles per hour (mph) and on the blind curve the posted speed limit was 25 mph. A continuous observation on 08/23/23 from 10:44 AM to 10:59 AM of Resident #2 was made and revealed he was walking around all the hallways alone and stopped at various exit doors to look outside. Resident #2 appeared to be inspecting the door and would bend down to look at the door jam and various structures associated with the exit door. In an interview on 08/24/23 at 9:42 AM with the Business Office Manager, he reported that since April 2023, when he started working at the facility, Resident #2 had been a wanderer but hadn't tried to get outside until about 2 weeks ago and was becoming more aggressive in his attempts to exit the building. He stated he recalled that on 08/11/23 it was a hot day and around 6:00 PM - 6:01 PM and he was getting into his car to go home. He stated he saw Resident #2 walking down the gravel/dirt pathway on the 400-hall side of the building. He stated Resident #2 was approximately 150 yards from the exit doors and approximately 100 yards from the main road when he called out to Resident#2 and had to move quickly to intercept Resident#2 as he was a fast walker. He stated there were no staff members following behind him. He stated Resident #2 was wearing pants, t-shirt, tennis shoes, and carrying a coffee cup. He stated he was at the bottom of the pathway, and he yelled out to Resident #2 asking him where he was going. He stated Resident #2 pointed towards the main road, which was about 100 yards away and he kept walking at a fast pace towards the road. The Business Office Manager stated he went to Resident #2 and was able to re-direct him and walked him back into the main entrance and took him up the elevator back to the 200 hallway and he notified the nursing staff. An interview on 08/23/23 at 2:33 PM with Nurse #4, she stated she worked on the 100-200 hallway and took care of Resident #2 almost every day. She stated she was Resident #2's nurse and worked on 08/11/23 when he eloped. She recalled the Business Office Manager brought Resident #2 back to the 200 - hallway from outside and told everyone at the nurses' desk where he found Resident #2. She stated they did not know Resident #2 had gotten out of the building until the Business Office Manager brought him back to the floor. The Director of Nursing and Unit Manager came to the desk and were told about the elopement. The Director of Nursing and Unit Manager stated Resident #2 would be a 1:1 for a while. She stated nothing seemed different about his behavior that day before he exited the building. In an interview on 08/23/23 at 3:40 PM with Nurse Aide (NA) #1, she stated they discussed the residents who were elopement risks in report before their shifts started. She stated she worked the day Resident #2 exited the building on 08/11/23. She stated she didn't know how he got outside without being seen. She stated the permanent NAs knew the residents well but not all the agency NAs knew the residents as well. She stated she tried her best to keep an eye on the at-risk residents, but it was hard because she was so busy completing her patient care duties. An interview with the Unit Manager on 08/23/23 at 1:15 PM revealed Resident #2 had been wandering for a long time, but just started trying to get outside about 2 months ago and he was getting worse. She stated he roamed all day/night, and all the staff knew to watch out for him. She stated they had started him on new medications less than a week ago and hoped it would help with his wandering and agitation behaviors. She stated the elevator and stairwell, that led down to the lobby were next to the 300 nurses' station and were secured. She stated the elevator was key controlled and the key was kept in a drawer on the 300 nurses' station. The Unit Manager stated the stairwell was code pad controlled and they had to push 2 numbers at one time and then a single number which made it harder to manipulate. She stated all their exit/emergency doors that led outside had a regular alarm and an extra loud screamer alarm. She stated if anyone pushed the door push bar the first alarm would go off, and if the door was pushed open the screamer alarm would go off. She stated their Social Worker was trying to find Resident #2 placement at a facility with a locked unit. The Unit Manager stated Resident #2 had gotten out of the building on 08/11/23, and he left the building through the 400 exit/emergency door which was on the same floor as his room. She stated after Resident #2 exited through the 400-hallway door he walked down a gravel path when the Business Office Manager saw Resident #2 walking down the path. She stated they had an elopement book at each nurse's station, and all the departments discussed at the beginning of each shift which residents were elopement risks, so everyone knew who to keep an eye on. She stated after Resident #2 got outside on 08/11/23, they put him on 1:1 supervision and they continued that until his behaviors were under control and then they started every 15-minute safety checks. The exit/emergency door alarm went off, but the screamer alarms were not in place until after he eloped. An interview with Resident #2's friend on 08/23/23 at 2:31 PM explained that Resident #2 was an avid hiker/walker and had been his whole life. He was very agile and walked or hiked frequently before coming to the facility and loved being in the woods. An interview with the facility's Social Worker on 08/23/23 at 2:49 PM stated that Resident #2 was an avid hiker and walked constantly. She stated that she had been looking for alternate placement for Resident #2 on a locked unit but had been unsuccessful at this time. An interview was conducted on 08/23/23 at 12:52 PM with Nurse #3 who stated she usually worked the day shift on the 100-200 hallway and cared for Resident #2 frequently. She stated Resident #2 was known for always walking around in the halls, but the exiting behaviors had just started recently. She stated the permanent staff knew him well and watched him closely. An observation was made on 08/23/23 at 3:27 PM when the Social Worker and a nurse started running to the 400 hallway to see why the alarms for the exit/emergency doors at the end of the 400 hallway were going off. The Activities Assistant came out of the activity room which was directly next to the exit doors and told the Social Worker and nurse that she heard the alarm and came out of the activity room and found Resident #2 standing at the 400 hallway doors pushing the door push bar which sounded the alarm. She stated the doors never opened and he never went outside. She stated she had re-directed Resident #2, and he went back down the hall in the opposite direction. In an interview with the Director of Nursing on 08/24/23 at 1:43 PM, she stated although she had not been working at the facility for very long, she was familiar with Resident #2. The Director of Nursing stated he was a wanderer and exit seeking resident. She stated she was aware he had gotten out of the facility a few weeks ago and knew they placed him on 1:1 supervision until the exit seeking behaviors ceased which she thought was a for a few days. The Director of Nursing stated his behaviors of going to the exit doors or standing by the elevator, had slowed down so now he was on every 15-minute safety checks. She stated she was not aware he pushed the 400-hallway exit/emergency doors push bar yesterday (08/23/23), and she did not hear the alarms. She stated they had realized that many of the staff members did not know about Resident #2's exit seeking behaviors as well as some other at-risk for elopement residents. She stated she has started elopement in-services today that would be presented to all departments. In an interview on 08/23/23 at 3:35 PM with Nurse #2, she stated she was working on the hallway 300-400 medication cart. She stated they had discussed residents who were elopement risks in morning report, and she was aware Resident #2 was an elopement risk. She stated she tried to keep her eye on him, however, she was passing medications throughout the day and did not see him go to the 400 hallway doors today and hit the push bar. She stated they did have a good view of the 400 exit doors from the nurse's station, but she was not usually at desk. She stated she must have been doing something else when Resident #2 went to the 400 hallway doors. She stated the NA # 2 who was working with her had also been very busy taking care of residents. She stated it was difficult to manage a patient care assignment and watch wandering residents as well. In an interview on 08/24/23 at 11:38 AM with the Central Supply-Maintenance Manager, he stated all the exit/emergency doors had their own alarms. He stated when the door push bars were pushed on all exit/emergency doors the regular alarms would sound at 15 seconds and the regular alarm were not very loud. He stated after Resident #2 exited the 400 hallways exit/emergency doors, he suggested they add screamer alarms, in addition to the regular alarms, to all the exit/emergency doors. He stated the screamer alarms had now been put into place on all the exit/emergency doors and they were loud at 120 decibels (sounded like a siren on an emergency vehicle), and they would sound off the minute the door opened. Observation on 08/23/24 at 11:50 AM with the Central Supply-Maintenance Manager, revealed the regular alarm on hallway 400 exit/emergency doors worked after 15 seconds of pushing the door push bar, but when the door was opened the screamer alarm did not work. The Central Supply-Maintenance Manager noticed that the screamer alarm was not set. The Central Supply-Maintenance Manager then re-set the alarm so it would sound off if the doors were opened. The Central Supply-Maintenance Manager was unable to state when the door alarm was last checked because daily logs were not kept. He stated the batteries and alarms were to be checked by the Manager on Duty on the weekends, after any elopement, and a minimum of once a week. He stated he just developed and initiated a log for the alarm checks to be documented. He stated education about checking the screamers and how to set them to the ready to activate had been by word of mouth, but he was going to put together some formal education. During an interview on 08/23/23 at 3:52 PM with the Activities Assistant, she revealed that she knew a few of their residents were elopement risks but could not recall their names or describe them. She stated she was not aware there was an elopement notebook with pictures of the residents who were at risk for elopement. She stated she really didn't know exactly what she was personally supposed to do when an alarm went off, but she knew they would have to figure out if a resident got outside and then find them. Observation on 08/24/23 at 11:30 AM revealed Resident #2 was standing around the elevator and stairwell area next to the 300-400 nurse's station. The elevator key which was attached to a large rectangular piece of brown wood was unsecured on the top corner of the nurses' station counter corner closest to the elevator. An observation on 08/23/23 at 2:50 PM of Resident #2, revealed he was walking to the end of the 300 hallway, when he got to the exit/emergency doors he stopped, stared, and lightly touched the doors for approximately 3 minutes. Resident #2 then turned and walked away and went down the main facility hallway. The staff at the 300 nurse's station desk, Nurse # 2, and Nurse Aide # 2, were not watching him as they were busy with tasks. In a phone interview on 08/28/23 at 9:30 AM with the lobby receptionist, she reported she would watch when people came off the elevator or out of stairwell to ensure no residents were coming down to the lobby unattended. She stated she had an elopement notebook with pictures of the residents who were at high risk of eloping at her desk. She stated she knew they had some residents who would try to escape out of the building, and she was able to name several residents including Resident #2. She stated she recalled Resident #2 came down the elevator about 3 months ago with family members of another resident. She stated she received a call from someone upstairs, she thought it might have been their previous Director of Nursing and was told Resident #2 had gotten on the elevator before they could stop him, and he was on his way down. She stated she was ready and met him and re-directed so he didn't go outside. She stated she could not remember who came down and took Resident #2 back upstairs. She stated all the Administration and Nursing staff were aware of the incident because everyone was talking about it. She thinks the Administrator came out to the lobby when Resident #2 was there, but she was not sure. A phone interview was conducted on 08/28/23 at 4:23 PM with the previous Director of Nursing and she stated that in early June 2023, Resident #2 absolutely did get on the elevator with family members of another resident and got down to the lobby unattended. She stated she could not remember the exact time, but it was after lunch and before 3:00 PM. She stated all the Administration team, and all the department heads, were aware of the event because they discussed it on the same day of the event during their 3:00 PM stand-down daily meeting. She stated no one saw Resident #2 get on the elevator, but he must have been hanging around the elevator and slipped on when another resident's family got on the elevator. She stated he made it down to the lobby. The previous Director of Nursing stated the receptionist in the lobby called up to the floor and reported that Resident #2 was in the lobby. She stated she did not think he made it outside and could not recall who brought Resident #2 back up to the floor. She stated this event must have occurred between June 1, when the Administrator started working at the facility, and June 8, the last day she worked in the facility. She stated there were no changes or interventions put in place after Resident #2 made it down to the lobby. She stated they were not allowed to have enough staff, especially Nurse Aides, and could not have possibly watched all the wanderers adequately to ensure their safety. In a phone interview with a previous Social Worker on 08/28/23 at 4:55 PM, she confirmed that Resident #2 did get in the elevator and made it to the lobby unattended in early June 2023. The former Social Worker also reported Resident #2 had done the same thing in January 2023 when she first started working at the facility. She stated she could not recall much about the January 2023 occurrence because she had just started her job, but she knew Resident #2 had gotten on the elevator and made it to the lobby on his own. She stated the first time he got to the lobby via elevator she thinks the other Social Worker went to the lobby and brought Resident #2 back to the floor, and the second time the receptionist brought him back to the floor. She recalled on the second occurrence, someone from the lobby called up to the floor and said Resident #2 had come down the elevator and was in the lobby. She stated she was concerned about several of their wanderers and worried that they would elope because they did not have enough staff to watch those residents as closely as they needed to be watched. She stated she recalled after the second occurrence of Resident #2 getting down to the lobby, it was discussed on that same day in their stand-down meeting with the Administrator, Director of Nursing, and all other department heads. She stated it was a big discussion but does not recall any plans or interventions put in place for Resident #2's safety. In an interview with the administrator on 08/28/23 at 5:45 PM, she stated she had no recollection or knowledge of Resident #2 ever getting on the elevator and making it down to the lobby on his own. She stated Resident #2 had tried to get on the elevator at times, but he had never been successful which was why they started using an elevator key 2 years ago. In a phone interview on 08/25/23 at 5:15 PM with Physician Assistant #2, she stated she did not recall being notified that Resident #2 had eloped. She stated she had no documentation of his elopement in her notes, and she felt confident that she would have written a note and/or remembered if he had eloped. She stated Resident #2 was not safe to be outside unattended because he had progressive dementia and would not know how to get back to the facility if he wandered off. She stated if he wandered away, he would be in danger because he would not have his medications, someone may hurt him or take advantage of him, he could get hit by a car on the main road which was very close to the building, and there were many other bad things that could have happened to him. She stated she would like to see the staff watch him more closely and perhaps move him to a room furthest from the exits and closest to the nurse's station. Additionally, Physician Assistant #2 stated she felt Resident #2 needed 1:1 supervision. She stated she was going to review his medication for any adjustments that could possibly help. She stated she was going to reach out to the Medical Director on Monday for more assistance. She said she wished they could keep only permanent staff because agency staff came and went so frequently, and they didn't know the residents and that brought so much risk with no continuity of care. A phone interview was conducted on 08/28/23 at 5:41 PM with the Medical Director. She stated that the day after the elopement, the Director of Nursing had called her to report the elopement and they discussed changing medications and possible care plan interventions. The Medical Director stated Resident #2 would not be safe outside unattended as he could be injured or much worse, and an elopement was no small thing. The Administrator was notified of Immediate Jeopardy on 11/13/23 at 4:26 PM. The facility provided the following immediate jeopardy removal plan: The entity's removal plan must: o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; On 8-11/23 upon reentering the facility, the charge nurse completed a clinical assessment of Resident#2 to ensure that there were no injuries. None were noted. The Director of Nursing, (DON), initiated a head count of all residents to assure all residents were present in the facility. All residents were present. This action was completed on 8-11-23 by the clinical nursing staff, certified nursing assistants, the Unit Nurse Manager, and the Director of Nursing. Notifications were made to the facility Medical Director, (MD) and the responsible party of the event involving Resident #2. The Administrator notified the Social Worker on 8/11/23 of the responsibility for updating the elopement binders with any new admissions that are identified as elopement risk and to remove information for discharged residents from the elopement binders on a weekly basis this was completed on 09/08/23. The Clinical nursing staff began providing 15-minute checks upon Resident#2's reentry into the building on 8-11-2023 to 08/14/23. Then due to the continued exit seeking behavior of Resident #2, the clinical nursing staff were directed to assign 1:1 staffing with Resident #2 from 08/15/23-08/17/23 to ensure that this resident received constant supervision to ensure safety. 15 minutes were resumed on 08/18/23 and continue. This action was initiated on 8-11-23 after observation of continued exit seeking was noted by the clinical nursing staff. The Administrator also directed the Director of Maintenance to complete a facility door audit to ensure that all facility doors were functioning as designed. An audit was conducted on 8-11-2023. All exit doors were found to be in proper working order. In addition, the Director of Maintenance installed screamer alarms to the facility exit doors. The screamer alarms were placed on the exit doors on 8-11-2023 by the Maintenance Director. The Maintenance Director and Assistant Maintenance Director confirmed proper functioning of the screamer alarms on 8/11/23 at the time of installation. The residents care plan was reviewed and modified by the Minimum Data Set (MDS) Nurse on 8/14/23 to include additional interventions to ensure the resident's safety. Interventions implemented: 1) 1:1 supervision, 2) Divert me to an activity, 3) Offer me snacks. The Nurse Unit Manager notified the direct care staff of the modified care plan on 8-11-2023. The facility acknowledges that all residents that are cognitively impaired are at risk of this alleged deficient practice. On 8/11/23 the Nursing Unit Manager reviewed all resident's elopement risk assessments and made a list of those residents who were determined to be at risk for elopement. The list was shared with the Director of Social Work who then confirmed that each of those residents' information (resident face sheet and photograph) was current and in the Elopement Risk binder. This was started on 08/11/23 and completed on 09/08/23. The elopement books were placed at each nursing station by the Social Worker. o Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete The Administrator notified the Nurse Unit Manager on 8/11/23 of the need to provide education of the facility's elopement policy and procedures and the staff expectations for any exit seeking resident. On 8/11/23 the Administrator notified the Nurse Unit Manager and Director of Nursing of the need began in-services for all facility staff including (full time, part time, and contract agency staff) by the Nurse Unit Manager, Director of Nursing and Administrator on 8-11-2023. The education was provided by various methods including one on one, verbally through phone calls as well as group in-services. The educational in-service covered the content of increasing the awareness and knowledge of the staffing expectations and techniques when intervening with residents that are exhibiting exit seeking behaviors as well as the purpose of the elopement binders, where they are located (each nursing station and reception areas), the placement of screamers/alarms on the exit doors and how to operate them. The in-services were completed on 08/30/23. The educational material used included: 1) Elopement book protocol, 2) Code [NAME]/Elopement Protocol, 3) Emergency Door and Screamer Alarms. Validation of understanding was confirmed verbally during the in servicing, 4) Elopement Policy/Procedure. The Nurse Unit Manager and Director of Nursing were notified on 8/11/23 of the need to provide this education by the Administrator. The Nurse Unit Manager developed the educational material, and the in-services were provided by both the Unit Manager and Director of Nursing and Administrator. The Nurse Unit Manager, Director of Nursing and Administrator provided in-services to the night shift staff as they reported for duty for their 7:00 pm to 7:00 am shift. Weekend staff were educated by the Nurse Unit Manager while she was in the facility performing her Weekend Nurse Supervisor duties. On 8-11-23 the Administrator notified the Corporate Nurse Consultant to add the educational material described above to the new hire orientation packet. The Director of Human Resources tracked to see what employees had been educated by running an employee listing and as each of them in-serviced the staff, they checked those staff members off the list. Any staff that did not receive the education by 8/11/23 will not be allowed to work until they receive the education. The following process for identifying residents at risk for elopement is outlined below. The nursing staff were educated by the Nurse Unit Manager and Administrator on this process as part of the educational and in-services that began on 8/11/23. Elopement risk assessments are completed on admission by the licensed nurses on admission, quarterly and if a significant change in residents occurs. If the resident is assessed as an elopement risk, this information is communicated to the Leadership Team (Administrator, Director of Nursing, MDS Nurse, Social Worker) during daily clinical meetings. The Social Worker then completes the process of placing the information in the elopement book. The information is also included in the resident care plan by the MDS Nurse, who also updates the Kardex (care guide for staff). The Nurse Unit Manager and Administrator monitored and tracked the nursing staff to cross reference the scheduled staff that received in-services and compared to the staff that were not scheduled. The Nurse Unit Manager maintained a list of staff that required education prior to reporting to work. The Nurse Unit Manager was notified of this task on 8-11-2023 by the Administrator. The Elopement Policy and Procedure was added to the new hire orientation packets by the Administrator on 8-11-2023. The Administrator notified the Social Worker on 8/11/23 of the responsibility for updating the elopement binders with any new admissions that are identified as elopement risk and to remove information for discharged residents from the elopement binders on a weekly basis. The Social Worker will also review the information in the elopement books at that time to ensure the information and pictures are up to date. On 8/11/23 The Administrator reiterated to the Minimum Data Set (MDS) nurse the need to ensure that all residents identified as an elopement risk has a proper care plan initiated with the proper interventions noted and kept current and any significant changes will reflect the accurate interventions as it related to interventions to prevent any potential elopements. To ensure any agency staff that did not receive the in-service/education above, the Unit Manager notified the Charge Nurses on 8/11/23 of their responsibility to ask the Agency staff when they report for duty if they have received the education related to (expectations and techniques when intervening with residents that are exhibiting exit seeking behaviors as well as the purpose of the elopement binders, where they are located (each nursing station and reception areas), the placement of screamers/alarms on the exit doors and how to operate them prior to beginning work). If they report no, then the staff person will be educated prior to beginning work. Direct care staff and basic supervision of residents at risk is achieved through care delivery daily by staff using the process outlined above. On 2-21-2023 and 8-14-2023 the Social Worker began contacting other long term care facilities with secured units for possible placement of Resident # 2. IJ removal date is 09/08/23 Validation of the facility's credible allegation of IJ removal for supervision to prevent accidents was conducted on 11/21/23. The initial assessment of Resident #2 was reviewed, as was his care plan that was updated after his elopement on 08/11/23. Resident #2 was placed on every 15-minute check but his exit seeking behavior worsened so he was placed on 1:1 supervision until the exit seeking behaviors decreased. The 1:1 supervision and every 15-minute check logs were reviewed with no [TRUNCATED]