Based on observations, record review, and staff and Medical Director interviews, the facility failed to ensure staff were trained and competent in following manufacturer's guidelines for cleaning and disinfecting a shared glucometer for 1 of 1 observed (Resident #34). On 8/20/25 Nurse #1 was observed obtaining Resident #34's blood glucose (sugar) level followed by the nurse cleaning the glucometer with an alcohol wipe that was not an Environmental Protection Agency (EPA)-registered disinfectant. Nurse #1 revealed she worked at the facility since March of 2025, had always used an alcohol wipe to clean the glucometer, had not been trained on how to disinfect the glucometer, and was unaware an EPA-registered disinfectant needed to be used. The Infection Preventionist revealed she was unsure what the manufacturer's guidelines were for cleaning and disinfecting a shared glucometer. Resident #34 resided on the locked unit and this shared glucometer was utilized for 2 other residents (Residents #92 and #97) who resided on that unit. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to ensure staff are trained and competent to disinfect a shared glucometer in accordance with the manufacturer's instructions has the high likelihood to expose residents to bloodborne pathogens. There were no residents with a blood-borne pathogen in the facility at the time of the investigation. The deficient practice was identified for 1 of 3 nursing staff members (Nurse #1) reviewed for glucometer disinfection competency. Immediate Jeopardy began on 8/20/25 when Nurse #1 failed to demonstrate competency to disinfect a shared glucometer per manufacturer's instructions. Immediate jeopardy was removed on 8/22/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the completion of education is completed and monitoring systems put into place are effective. Findings included:A continuous observation of Nurse #1 was conducted on 8/20/25 from 12:36 PM through 12:51 PM revealed the following: On 8/20/25 at 12:36 PM, Nurse #1 was standing by the medication cart in the day room of the locked unit with Resident #34 standing next to her. Nurse #1 took the glucometer out of the top left drawer of the cart where it had been stored. Nurse #1 put the glucometer on top of the cart, gathered supplies and obtained Resident #34's blood glucose. The Nurse was observed to clean the glucometer with a small alcohol wipe for less than one minute and place the glucometer back into the top left drawer of the medication cart. In an interview with Nurse #1 during the observation that began on 8/20/25 at 12:36 PM she stated the glucometer was used on all residents in the locked unit that had orders for blood glucose testing. Nurse #1 further stated she had worked in the facility since March of 2025 and had always used an alcohol wipe to clean the glucometer. Nurse #1 indicated she had not been trained on how to disinfect the glucometer with an EPA-registered germicidal wipe. A follow-up interview was conducted with Nurse #1 on 8/20/25 at 1:37 PM. She revealed there was only one resident (Resident #34) who required blood glucose monitoring at lunchtime. Nurse #1 indicated she had completed three blood glucose checks before breakfast on 8/20/25 and used an alcohol wipe to clean the glucometer between each resident (Resident #34, Resident #92 and Resident #97). An interview on 8/20/25 at 12:54 PM with the Infection Preventionist (IP), who was also the Director of Nursing (DON) revealed each medication cart in the facility had one glucometer to be used for all residents on that hall that require blood glucose testing. The IP/DON indicated nurses should be cleaning and disinfecting the glucometers per manufacturer's instruction and facility policy. She stated that she had only been at the facility for three weeks and was unsure when the last in-service/training on glucose monitor disinfection was conducted. The IP further stated she was unsure what the facility policy or manufacturer's instructions for glucometer cleaning and disinfecting instructed. She indicated she was aware that improper disinfection of a shared glucometer could lead to blood-borne pathogens being transferred from one resident to another. A follow-up interview was conducted on 8/20/25 at 2:03 PM with the IP/DON. She stated there were no residents with known blood-borne pathogens in the facility. In an interview with the Administrator on 8/20/25 at 1:08 PM she indicated Nurses should be disinfecting glucometers per manufacturer's instructions between each resident and before use if it is stored with other items such as in the medication cart drawer. The Administrator was unsure when the last in-service training was conducted on the cleaning and disinfecting of glucose monitors. A telephone interview was conducted on 8/21/25 at 8:50 AM with the Medical Director who stated all nursing staff should be educated regarding the cleaning and disinfecting of glucose monitoring before their first shift at the facility. The facility was unable to provide documentation that Nurse #1 was educated on cleaning and disinfecting glucose monitors. They were also unable to provide documentation regarding any in-services that trained nursing staff on cleaning and disinfecting glucometers. The Administrator was notified of immediate jeopardy on 8/21/25 at 9:30 AM. The facility provided the following credible allegation of immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On 8/20/25, Nurse #1 removed a glucometer from the 500-hall medication cart drawer. Nurse #1 performed the blood glucose check on Resident #34 then wiped the glucometer with an alcohol wipe and placed the glucometer back into the medication cart drawer. Nurse #1 stated she was not aware to use an Environmental Protection Agency (EPA) germicidal approved wipe and was not trained regarding the facility's policy/procedures for glucometer disinfection, or which product was approved to disinfect the glucometer. On 8/20/25, the Facility Consultant completed a medical record audit of all residents, including Resident #34, Resident #92, and Resident #97, who received blood glucose checks. This audit was to identify any diagnosed blood-borne pathogen infections to ensure there were no infections related to improper cleaning and disinfecting of glucometers. No residents were identified with a blood-borne pathogen. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: On 8/21/25, the accounts payable will audit all nurses and Medication Aide employee files to verify education and completion of skills checklist to validate competency for disinfecting shared glucometers according to manufacturer's instructions upon hire. The Director of Nursing will ensure all nurses and Medication Aides without education and/or a completed skills checklist will have it completed prior to the employee starting their next scheduled shift.On 8/21/25, the Nurse Consultant educated the Administrator and Director of Nursing regarding the requirements to ensure all facility and agency nurses, and Medication Aides are educated on the policy and procedures for cleaning and disinfecting a glucometer and complete a skills checklist with observation of a return demonstration to validate competency during orientation. On 8/20/25, the Director of Nursing, Assistant Director of Nursing, Treatment Nurse and Unit Managers initiated, in person, education with all nurses to include Nurse #1 and medication aides regarding the importance of following facility and manufacturer's instructions for cleaning and disinfecting a shared glucometer including (1) using a EPA registered germicidal disposable cloth/wipes (2) exposure times (3) dry time (4) the policy/procedure for cleaning and disinfecting glucometers (5) germicidal instructions for cleaning and disinfecting a glucometer are located on the container of the germicidal wipes (6) the risk factors of not properly cleaning shared glucometers (7) approved products for disinfecting a glucometer (8) proper storage of glucometers to prevent cross contamination. The in-service will be completed by 8/20/25. The Director of Nursing will monitor the completion of staff in-services. After 8/20/25, any nurse or medication aide who has not worked or received the in-service will receive the education prior to the next scheduled work shift. All newly hired nurses or medication aides including agency, will be in-serviced by the Director of Nursing, Assistant Director of Nursing or Unit Managers during orientation regarding the importance of following facility and manufacturer's instructions for cleaning and disinfecting a shared glucometer.On 8/20/25, the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Unit Managers initiated in-person return demonstrations of properly cleaning and disinfecting glucometers with all nurses to include Nurse #1 and all medication aides including agency. The purpose of the return demonstrations is to ensure that staff demonstrate knowledge and understanding of the glucometer cleaning and disinfecting procedures, including adhering to the manufacturer's instructions. Staff will be immediately retrained for any identified areas of concern. The return demonstrations will be completed by 8/20/25. Any nurse or medication aide who does not successfully pass the return demonstration will be immediately re-educated and will be required to repeat the return demonstration until successful demonstration is achieved. The return demonstrations were completed by 8/20/25 for all nurses and medication aides who worked. The Director of Nursing will monitor the completion of the glucometer cleaning return demonstrations. After 8/20/25, staff who have not completed the return demonstrations will complete it prior to their next scheduled work shift. On 8/20/25, the Director of Nursing, Assistant Director of Nursing and Unit Managers initiated in person quizzes with all nurses to include Nurse #1 and medications aides, including agency to validate knowledge and understanding of the importance of following facility and manufacturer's instructions for cleaning and disinfecting a shared glucometer. The quizzes included (1) how often do you need to clean a glucometer (2) what should you use to clean and disinfect a glucometer? (3) why is it important to follow the manufacturer's instructions to clean and disinfect a shared glucometer? (4) how do you know the exposure time for the disinfectant you are utilizing? Any nurse or medication aide that does not successfully pass the quiz will be immediately re-educated and will be required to retake the quiz at the time of administration until a successful passing score is achieved. The quizzes were completed by 8/20/25 for all nurses and medication aides who worked. The Director of Nursing will monitor the completion of staff quizzes. After 8/20/25, any nurse or medication aide who has not completed the quiz will complete it prior to their next scheduled work shift. Alleged immediate jeopardy removal date: 8/22/25. Validation of the immediate jeopardy removal plan was conducted on 8/22/25. The facility had compiled a list of nursing staff that were responsible for blood glucose monitoring. All staff were educated on the glucometer disinfection process before being allowed to work. The facility provided an immediate in-service for Nurse #1 with a return demonstration provided. All staff members responsible for blood glucose monitoring also completed a skills validation with return demonstration to the Director of Nursing, Assistant Director of Nursing or Unit Manager. An observation was conducted of glucose disinfection while onsite. The staff member cleaned the glucometer according to manufacturer instructions. Nursing staff interviews revealed they had received education on the disinfection of glucometers.The immediate jeopardy removal date of 8/22/25 was validated.

Based on observations, record review, staff and Medical Director interviews, the facility failed to implement their infection control policies and procedures when Nurse #1 did not follow the manufacturer's instructions for cleaning and disinfecting a shared blood glucose meter (glucometer) before and after resident usage for 1 of 1 resident observed whose blood glucose (sugar) level was checked (Resident #34). On 8/20/25 Nurse #1 was observed obtaining Resident #34's blood glucose level followed by the nurse cleaning the glucometer with an alcohol wipe that was not an Environmental Protection Agency (EPA)-registered disinfectant. Nurse #1 then stated that she worked at the facility since March of 2025 and had always used an alcohol wipe to clean the glucometer indicating that she was unaware an EPA-registered disinfectant needed to be used. Resident #34 resided on the locked unit and this shared glucometer was utilized for 2 other residents (Residents #92 and #97) who resided on that unit. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an EPA-registered disinfectant in accordance with the manufacturer's instructions for disinfection of the glucometer potentially exposes residents to the spread of blood-borne pathogens. There were no residents with a blood-borne pathogen in the facility at the time of the investigation. The facility staff also failed to change gloves between cleansing a wound and applying a new dressing and failed to perform hand hygiene between the removal of soiled gloves and the application of clean gloves (Wound Care Nurse). Finally, the facility failed to handle soiled linen in a manner that prevented the potential transmission of pathogenic (disease causing) microorganisms (germs) when Nurse Aide (NA) #2 placed soiled linen directly onto the floor. These deficient practices were identified for 3 of 10 staff members (Nurse #1, Wound Care Nurse, and NA #2) reviewed for infection prevention and control. Immediate Jeopardy began on 8/20/25 when Nurse #1 was observed performing a blood glucose check on Resident #34 using a shared glucometer without disinfecting per manufacturer's instructions. Immediate jeopardy was removed on 8/21/25 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) for findings #2 and #3 and to ensure education is completed and monitoring systems put into place are effective. Findings included:1. The blood glucose meter manufacturer's instructions for cleaning and disinfecting dated 09/2024 indicated the meter should be cleaned and disinfected after use on each patient with EPA-registered product. A list of EPA-registered products was listed in the instructions. Additional instructions were to read the manufacturer's instructions for the use of the EPA-registered cleaning and disinfecting product. Alcohol wipes were not listed as an EPA-registered product. Review of the facility policy “Glucometer Disinfection”, undated, indicated that the objective was to prevent infection due to potential blood-borne pathogen exposure. The equipment and supplies were listed as gloves and germicidal disposable cloth/wipes. The procedure for disinfecting glucometers included: Step 1. Apply gloves Step 2. When visible blood or body fluids are present, clean by wiping the external surfaces to remove any visible organic material. A cloth dampened with soap and water, or a germicidal wipe may be used according to the manufacturer’s instructions and then discard. Step 3. After any visible blood or body fluids have been removed, or if no visible blood or bodily fluids are present: a.) Use EPA-registered germicidal disposable cloth/wipe horizontally and vertically to thoroughly wet the entire external surface of the glucometer according to the manufacturer’s instructions. b.) Allow treated surface to remain wet for the germicidal wipe manufacturer’s recommended exposure time. If needed, utilize a new germicidal wipe to keep the glucometer surface wet. Step 4. After allowing the full amount of exposure time according to manufacturer’s product direction, discard the used cloth/wipe and allow the glucometer to thoroughly air- dry. Step 5. Remove and discard gloves. Perform hand hygiene. Step 6. When glucometer is completely dry, it may be used for the next resident or if not proceeding to another resident, store glucometer in med cart or specified storage area. A continuous observation of Nurse #1 was conducted on 8/20/25 from 12:36 PM through 12:51 PM revealed the following: On 8/20/25 at 12:36 PM, Nurse #1 was standing by the 500-hall medication cart in the day room of the locked unit with Resident #34 standing next to her. Nurse #1 took the glucometer out of the top left drawer of the cart where it had been stored. Nurse #1 put the glucometer on top of the cart, gathered supplies and obtained Resident #34’s blood glucose. The Nurse was observed to clean the glucometer with a small alcohol wipe for less than one minute and place the glucometer back into the top left drawer of the medication cart. An EPA-registered container of wipes that was located on top of the medication cart indicated to disinfect nonfood contact surfaces; thoroughly wet surface, allow treated surface to remain wet for two minutes and let air dry. These wipes were an EPA-registered germicidal wipe and approved for blood-borne pathogen use. In an interview conducted with Nurse #1 during the observation that began on 8/20/25 at 12:36 PM she stated the glucometer was used on all residents in the locked unit that had orders for blood glucose testing. Nurse #1 further stated she had worked in the facility since March of 2025 and had always used an alcohol wipe to clean the glucometer. Nurse #1 indicated she had not been trained on how to disinfect the glucometer with an EPA-registered germicidal wipe. A follow-up interview was conducted with Nurse #1 on 8/20/25 at 1:37 PM. She revealed there was only one resident (Resident #34) who required blood glucose monitoring at lunchtime. Nurse #1 indicated she had completed three blood glucose checks before breakfast on 8/20/25 and used an alcohol wipe to clean the glucometer between each resident (Resident #34, Resident #92 and Resident #97). An interview on 8/20/25 at 12:54 PM with the Infection Preventionist (IP), who was also the Director of Nursing (DON), revealed each medication cart in the facility had one glucometer to be used for all residents on that hall that require blood glucose testing. The IP/DON indicated nurses should be cleaning and disinfecting the glucometers per manufacturer’s instruction and facility policy. The IP/DON stated she was unsure what the facility policy on glucometer disinfection said. She indicated she was aware that improper disinfection of a shared glucometer could lead to blood-borne pathogens being transferred from one resident to another. A follow-up interview was conducted on 8/20/25 at 2:03 PM with the IP/DON. She stated there were no residents with known blood-borne pathogens in the facility. In an interview with the Administrator on 8/20/25 at 1:08 PM she indicated nurses should be disinfecting glucometers per manufacturer’s instructions between each resident and before use if it is stored with other items such as in the medication cart drawer. A telephone interview was conducted on 8/21/25 at 8:50 AM with the Medical Director who stated the danger of not cleaning the shared glucometer per manufacturer’s instructions was that blood-borne pathogens could be transmitted between residents. He indicated that all shared glucometers should be cleaned per manufacturers’ instructions between residents and before use when the glucometer is stored with other items in a medication cart drawer. The Administrator was notified of immediate jeopardy on 8/21/25 at 9:30 AM. The facility provided the following credible allegation of immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: On 8/20/25, Nurse #1 removed a glucometer from the 500-hall (locked unit) medication cart drawer. Nurse #1 performed the blood glucose check on Resident #34 then wiped the glucometer with an alcohol wipe and placed the glucometer back into the medication cart drawer. Nurse #1 stated she was not aware she was to use an Environmental Protection Agency (EPA) germicidal approved wipe. On 8/20/25, the Facility Consultant completed a medical record audit of all residents, including Resident #34, Resident #92, and Resident #97, who received blood glucose checks. This audit was to identify any diagnosed blood-borne pathogen infections to ensure there were no infections related to improper cleaning and disinfecting of glucometers. No residents were identified with a blood-borne pathogen. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: On 8/20/25, the unit managers and the treatment nurse completed the cleaning and disinfecting of all resident glucometers including Resident #34, Resident #92, and Resident # 97, in accordance with the manufacturer’s instructions for cleaning and disinfecting glucometers. The instructions include utilizing an EPA-registered germicidal wipe, allowing full exposure time according to the manufacturer’s product directions, then discarding the used wipe and allowing the glucometer to thoroughly air-dry before using it for the next resident. On 8/20/25, the Director of Nursing, Assistant Director of Nursing, Treatment Nurse and Unit Managers initiated, in person, education with all nurses to include Nurse #1 and medication aides regarding the importance of following facility and manufacturer’s instructions for cleaning and disinfecting a shared glucometer including (1) using a EPA-registered germicidal disposable cloth/wipes (2) exposure times (3) dry time (4) the policy for cleaning and disinfecting glucometers (5) germicidal instructions for cleaning and disinfecting a glucometer are located on the container of the germicidal wipes (6) the risk factors of not properly cleaning shared glucometers. The in-service will be completed by 8/20/25. The Director of Nursing will monitor the completion of staff in-services. After 8/20/25, any nurse or medication aide who has not worked or received the in-service will receive the education prior to the next scheduled work shift. All newly hired nurses or medication aides including agency, will be in-serviced by the Director of Nursing, Assistant Director of Nursing or Unit Managers during orientation regarding the importance of following facility and manufacturer’s instructions for cleaning and disinfecting a shared glucometer. On 8/20/25, the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Unit Managers initiated in-person return demonstrations of properly cleaning and disinfecting glucometers with all nurses to include Nurse #1 and all medication aides including agency. The purpose of the return demonstrations is to ensure that staff demonstrate knowledge and understanding of the glucometer cleaning and disinfecting procedures, including adhering to the manufacturer’s instructions. Staff will be immediately retrained for any identified areas of concern. The return demonstrations will be completed by 8/20/25. Any nurse or medication aide who does not successfully pass the return demonstration will be immediately re-educated and will be required to repeat the return demonstration until successful demonstration is achieved. The return demonstrations were completed by 8/20/25 for all nurses and medication aides who worked. The Director of Nursing will monitor the completion of the glucometer cleaning return demonstrations. After 8/20/25, staff who have not completed the return demonstrations will complete it prior to their next scheduled work shift. On 8/20/25, the Director of Nursing, Assistant Director of Nursing and Unit Managers initiated in person quizzes with all nurses to include Nurse #1 and medications aides, including agency to validate knowledge and understanding of the importance of following facility and manufacturer’s instructions for cleaning and disinfecting a shared glucometer. The quizzes included (1) how often do you need to clean a glucometer (2) what should you use to clean and disinfect a glucometer? (3) why is it important to follow the manufacturer’s instructions to clean and disinfect a shared glucometer? (4) how do you know the exposure time for the disinfectant you are utilizing? Any nurse or medication aide that does not successfully pass the quiz will be immediately re-educated and will be required to retake the quiz at the time of administration until a successful passing score is achieved. The quizzes were completed by 8/20/25 for all nurses and medication aides who worked. The Director of Nursing will monitor the completion of staff quizzes. After 8/20/25, any nurse or medication aide who has not completed the quiz will complete it prior to their next scheduled work shift. Alleged immediate jeopardy removal date: 8/21/25 A validation of immediate jeopardy removal plan was conducted on 8/22/25. The facility had compiled a list of nursing staff that were responsible for blood glucose monitoring. All staff were educated on the glucometer disinfection process before being allowed to work. The facility provided an immediate in-service for Nurse #1 with a return demonstration provided. All staff members responsible for blood glucose monitoring also completed a skills validation with return demonstration to the Director of Nursing, Assistant Director of Nursing or Unit Manager. An observation was conducted of glucose disinfection while onsite. The staff member cleaned the glucometer according to manufacturer instructions. Nursing staff interviews revealed they had received education on the disinfection of glucometers. The immediate jeopardy removal date of 8/21/25 was validated. 2. A review of the facility policy titled “Handwashing Policy” revised 4/2023 provided by the facility revealed in part: “Personnel are required to wash their hands after each direct or indirect resident contact for which handwashing is indicated by acceptable standards of practice. Personnel should wash their hands: … When indicated between tasks and procedures to prevent cross contamination of different body sites.” During observation on 8/20/25 at 11:29 AM the Wound Care Nurse was observed providing wound care to Resident #4. The wound care nurse was observed to perform hand hygiene and don personal protective equipment including gloves. The Wound Care Nurse was observed to cleanse the sacral wound with wound cleanser. After cleaning the wound, with the same gloves she cleansed the wound with, she then cut the xeroform (a non-adhering protective dressing) gauze to the size of the wound and placed the dressing over the wound bed. She then changed gloves, did not perform hand hygiene, and covered the xeroform gauze with a dry dressing. During an interview on 8/20/25 at 11:35 AM the Wound Care Nurse stated after cleansing the wound she should have performed hand hygiene and changed gloves prior to applying the xeroform gauze and dry dressing to prevent cross contamination and did not because she was nervous. During an interview on 8/20/25 at 11:38 AM the Director of Nursing stated hand hygiene, and a glove change should be performed between cleaning a wound and applying a new dressing to not cross contaminate the area being treated. 3. A review of the facility’s policy dated 3/10/2020 titled “Linen Handling Policy” revealed in part “All soiled linen should be considered contaminated. The risk of actual disease transmission from soiled linen with pathogenic (disease causing) microorganisms (germs) is insignificant if it is handled, transported, and laundered in a way that avoids the transfer of microorganisms. Soiled linen should be bagged or placed in containers at the location where it is used.” On 8/18/25 at 2:55 PM soiled linen including towels and a gown were observed directly on the floor of Resident #1’s room. On 8/18/25 at 2:58 PM an interview with Nurse Aide (NA) #2 outside the room indicated the soiled towels and gown where from the bathing she provided to Resident #1 at approximately 2:45 PM that day. She stated she should have placed these soiled items into a bag and not left them directly on the floor, but she did not. She indicated she had bags available and did not know why she had not done this. She reported she had been educated not to place soiled linen directly onto the floor in resident’s room so that any germs on them did not get tracked around. On 8/22/25 at 11:25 AM an interview with the Director of Nursing (DON) indicated she also served as the facility’s Infection Preventionist. She stated she was glad that NA #2 acknowledged that placing soiled linen directly on the floor in a resident’s room was inappropriate, because this should never occur. She reported all soiled linen should be placed in bags. The DON stated this was for infection control purposes to prevent the spread of germs. On 8/22/25 at 11:38 AM an interview with the Administrator indicated soiled linen should be bagged at the time of removal and never placed directly on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and resident, staff, and Medical Director (MD) interviews, the facility failed to provide care in a safe manner. On 6/30/25 Resident #2 rolled off her bed during incontinence care and landed on the floor. Resident #2 sustained a right forearm skin tear and complained of severe pain and was sent to the Emergency Department (ED) for evaluation. The Resident was diagnosed with a closed fracture (the broken bone does not penetrate the skin) at the distal end (just above the knee joint) of the left femur (thighbone) and closed fracture at the distal end of the right femur. In the ED, Resident #2 required intravenous (IV) fentanyl (an opioid drug used to treat severe pain) for pain. The Resident was discharged back to the facility the same day with an immobilizer on her right knee and orders to follow up with orthopedic surgery. Following the incident Resident #2 required oxycodone for pain management with pain levels rated up to a 9 (on a scale of 0 to 10 with 10 being the worst possible pain). On 7/14/25, a new order was entered for methocarbamol (muscle relaxer) for fracture induced muscle spasms. Prior to the incident Resident #2 was getting out of bed daily and attending activities. The Resident stated during interview that she missed attending group activities. This was for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #2).The findings included:Resident #2 was admitted to the facility on [DATE] with diagnoses that included age related osteoporosis, restless leg syndrome, chronic pain and osteoarthritis. Review of a physician's order dated 5/12/2025 revealed an order for Acetaminophen 325 milligram (mg) tablet - Give 2 tablets every 4 hours as needed for general discomfort. A care plan dated 5/13/25 and revealed a focus of Risk for falls characterized by multiple risk factors related to pain and osteoarthritis. The goal was for Resident #2 not to sustain serious injury through the review date. The interventions included: Substantial/maximal assistance with 1 person assistance for bed mobility and toileting hygiene. A care plan initiated 5/13/25 revealed a focus of chronic pain related to osteoporosis, restless leg syndrome. The goal was for Resident #2 to report satisfactory pain control. A care plan dated 5/13/25 revealed a focus of osteoporosis/osteoarthritis: At risk for fractures. The goal was for Resident #2 to remain free from fractures through the next review date. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively intact and had no behaviors. She had no impairment of her upper or lower extremities and used a wheelchair for mobility. Resident #2 requires substantial maximal assistance with 1 staff physical assistance for rolling left and right. She was always incontinent of bowel and bladder. Resident #2 was coded as on a scheduled pain medication regiment within the past five days. Resident #2 denied pain during the pain assessment. Resident #2's activity assessment found it somewhat important to do things with a group and she enjoyed participating in religious services or practices. Review of a physician's order dated 6/5/2025 with an end date of 7/5/25 revealed an order for Acetaminophen 325 mg tablet - Give 2 tablets two times a day for acute toe pain. The investigational summary written by the Administrator dated 6/30/25 revealed Nurse Aide (NA) #1 entered Resident #2's room to provide incontinent care. NA #1 was standing on the resident's left side. NA #1 grasped the draw sheet and pulled Resident #2 towards her. NA #1 told Resident #2 to grab the bed rail to turn over. NA #1 was straightening the draw sheet to get ready to place the brief beneath Resident #2. NA #1 indicated Resident #2 grabbed the bed rail with her left hand and rolled over to her right side. NA #1 stated she noticed Resident #2 had crossed her leg over the edge of the bed and continued to roll onto the floor. NA #1 reported she attempted to catch Resident #2 by grabbing her arm but was unsuccessful. Resident #2 landed on her left side on the floor on her left side with her legs slightly bent at the knees and Resident #2 was propping her upper body up with the left arm. Resident #2 complained of pain in her legs. Resident #2 was sent to the emergency department where x-rays and CT (computed topography) scans revealed she had severe osteopenia and diagnoses of fracture to the right and left distal femurs. A nursing progress note dated 6/30/25 and written by Nurse #1 revealed NA#1 stated she was assisting Resident #2 with incontinence care when resident turned to grab bedside rail and resident's legs began to swing off the bed and resident fell off the bed onto the floor. NA #1 came out of Resident #2's room and called a code green. (Code used by the facility to indicate an emergency). Nurse #1 entered Resident #2's room and on visual assessment observed the resident lying on the floor on her left side and holding her upper body up with her left elbow. Resident #2 complained of severe left hip and left ankle pain. Nurse #1 noted a skin tear to Resident #2's right forearm and applied a dressing. 911 was called due to a resident's complaint of severe pain and Resident #2 was transported to the hospital emergency department for evaluation and treatment. During an interview with NA #1 on 7/14/25 at 4:30 PM she revealed she was familiar with Resident #2 and had taken care of her multiple times. NA #1 stated on 6/30/25 during the night shift, she walked into Resident #2's room and announced herself and explained that she was there to provide incontinent care. NA #1 stated she was standing on Resident #2's left side and used the draw sheet to pull the resident closer to her. NA #1 stated she instructed Resident #2 to grab the bed rails. NA #1 stated Resident #2 grabbed the bed rail with her left hand and pulled herself over. NA#1 stated Resident #2's legs continued to roll. NA #1 stated she tried to catch Resident #2 but was unsuccessful. NA#1 stated Resident #2 was still holding on to the bed rail when she landed on the floor. NA#1 stated Resident #2 complained of pain in her legs and ankle. NA #1 stated Resident #2 required one-person physical assistance for turning before she fell. Multiple attempts to interview Nurse #1 who was assigned to Resident #2 at the time of the fall on 6/30/25 were unsuccessful. A review of the Hospital Emergency Department (ED) note dated 6/30/25 revealed Resident #2 had pain in her left ankle and diffusely through her right leg. The ED assessment further revealed Resident #2 was tender over the upper and lower left leg. The Discharge summary dated [DATE] indicated Resident #2 was seen in the emergency department after the fall and found to have a closed fracture at the distal end of the left femur and closed fracture of the distal end of the right femurs and skin tear to right forearm without complications. Resident #2 was evaluated by an Orthopedic surgeon and no surgical interventions were recommended. Resident #2 required intravenous (IV) Fentanyl for pain at the hospital. Resident #2 was placed on non-weight bearing status and prescribed a short course of Oxycodone (an opioid pain medication). Resident #2 was discharged back to the facility with an immobilizer on her right knee and she was to follow up with orthopedic surgery. A nursing progress note written by Nurse #3 dated 6/30/25 at 4:48 PM revealed Resident #2 returned to the facility with an immobilizer intact to her right lower extremity. Review of a physician's order dated 6/30/2025 revealed an order for Oxycodone HCl 5 MG (milligram) oral tablet- Give 5 mg by mouth every 6 hours as needed for moderate pain until 07/03/2025. Review of a physician's order dated 7/2/25 revealed an order for Oxycodone HCl 5 MG oral tablet- Give 5 mg by mouth every 6 hours as needed for moderate pain until 7/5/2025. Review of Resident #2's Medication Administration Record from 6/30/25 to 7/5/25 revealed the following: -On 6/30/25 at 5:35 PM Resident #2 rated her pain at 7/10 and received Acetaminophen 650 mg. Medication effective.-On 6/30/25 at 9:00 PM Resident #2 rated her pain at 5/10 and received scheduled Acetaminophen 650mg. Medication effective.-On 7/1/25 at 7:30 AM Resident #2 rated her pain at 3/10 and received Oxycodone 5mg. Medication effective.-On 7/1/25 at 9:00 AM Resident #2 rated her pain at 3/10 and received scheduled Acetaminophen 650 mg. Medication effective.-On 7/1/25 at 9:00 PM Resident #2 rated her pain at 0/10 and received scheduled Acetaminophen 650 mg. Medication effective.-On 7/2/25 at 9:00 AM Resident #2 rated her pain at 4/10 and received scheduled Acetaminophen 650 mg. Medication effective.-On 7/2/25 at 2:21 PM Resident #2 rated her pain at 7/10 and received Oxycodone 5mg. Medication effective.-On 7/2/25 at 9:00 PM Resident #2 rated her pain at 5/10 and received scheduled Acetaminophen 650 mg. Medication effective.-On 7/2/25 at 11:05 PM Resident #2 rated her pain at 9/10 and received Oxycodone 5mg. Medication effective.-On 7/3/25 at 9:00 AM Resident #2 rated her pain at 5/10 and received scheduled Acetaminophen 650 mg. Medication effective.-On 7/3/25 at 9:00 PM Resident #2 rated her pain at 5/10 and received scheduled Acetaminophen 650 mg. Medication effective.On 7/4/25 at 12:07 AM Resident #2 rated her pain at 8/10 and received Oxycodone 5mg. Medication effective.-On 7/4/25 at 9:00 AM Resident #2 rated her pain at 3/10 and received scheduled Acetaminophen 650 mg. Medication effective.-On 7/4/25 at 9:00 PM Resident #2 rated her pain at 1/10 and received scheduled Acetaminophen 650 mg. Medication effective.-On 7/5/25 at 9:00 AM Resident #2 rated her pain at 4/10 and received scheduled Acetaminophen 650 mg. Medication effective. A review of the Orthopedic Surgery follow-up visit note dated 7/7/25 revealed Resident #2 was seen in the office and rated her pain as 4 out of 10 at its worst level. Resident #2 indicated she had been taking Acetaminophen for pain. She described her pain as on and off achy pain that increased with motion of the knees. Resident #2 also reported she had increased pain with transfers. Orthopedic surgery recommended resident continue with the immobilizer to right knee and recommended an immobilizer for left knee to keep the knees in extension and prevent motion that was painful. The significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #2 was cognitively intact. Resident #2 had bilateral lower extremity impairment with a diagnosis of fracture. She was assessed as having pain frequently that interfered with her sleeping at night and interfered with performance of daily activities. She described her pain as 10 on a scale of 1 through 10. Resident #2 was coded as having limitations to her daily activities. A physician's progress note dated 7/14/25 revealed Resident #2 was seen for pain control and new onset of muscle spasms related to the bilateral femur fractures. Review of a physician's order dated 7/14/25 revealed an order for Oxycodone HCl 5 MG oral tablet- Give 1 tablet by mouth every 8 hours for bilateral distal femur fracture. Review of a physician's order dated 7/14/25 revealed an order for Methocarbamol (a muscle relaxant) 500 MG Oral Tablet - Give 1 tablet by mouth every 8 hours for fracture induced muscle spasms. An observation of incontinence care conducted on 7/14/25 at 12:55 PM revealed Resident #2 required the assistance of 2 staff for turning and repositioning. Resident #2 was positioned in the middle of the bed after care was rendered. During an interview with Resident #2 on 7/14/25 at 1:30 PM she revealed on 6/30/25 she was awakened in the middle of the night when NA #1 came to assist her with incontinence care. Resident #2 stated NA #1 was standing on the left side of the bed and she was instructed to turn over. Resident #2 stated when she went to roll over to the right, she continued to roll and ended up on the floor. Resident #2 stated the fall happened so fast that before she knew it, she was on the floor. Resident #2 stated she was holding on to the rails when she slid down. Resident #2 stated her left ankle was hurting and her right ankle was bent in an awkward position. Resident #2 stated she was transferred to the hospital emergency department and told both of her lower thigh bones were broken. Resident #2 stated she was now taking strong pain medication for pain to her lower thighs. Resident #2 also stated she had recently received a new medication for spasm to her thigh muscles. Resident #2 stated she had not been taking medication for pain prior to the fall. Resident #2 further stated she missed getting up to the chair daily and going out to activities. Resident #2 stated she had not begun working with therapy yet and movement was very painful. During an interview with Nurse #2 on 7/15/25 at 11:14 AM. Nurse #2 stated she was familiar with Resident #2 and worked with her over the past couple of months. Nurse #2 stated she had been made aware of Resident #2's fall. Nurse #2 reported Resident #2 required only one person assistance for turning in bed prior to the fall. She indicated Resident #2 now required two-person physical assistance for turning and positioning in bed. Nurse #2 stated Resident #2 was not receiving any pain medication prior to the fall. Nurse #2 further stated Resident #2 did get up daily to the chair and participated in group activities prior to the fall but had not been to group activities since the fall due to her non weight bearing status. During an interview with Nurse Aide #2 on 7/15/25 at 11:22 AM she stated Resident #2 was able to assist with turning herself in bed using the handrails prior to the fall on 6/30/25. Nurse Aide #2 stated the resident required 1 staff for assistance with incontinent care before the fall. NA #2 stated she had worked with Resident #2 on multiple occasions and indicated Resident #2 had been participating in activities prior to the fall. NA #2 stated Resident #2 was currently on non-weight bearing status and complained of pain with movement. During an interview with the Medical Director on 7/15/25 at 11:40 AM he stated he was made aware Resident #2 had fallen from the bed and had fractures on her right and left lower femur. The Medical Director stated he felt that Resident #2's fractures were caused by fragility due to her diagnosis of severe osteoporosis. The Medical Director stated he did not feel there was anything the facility could have done differently to prevent the fall. During an interview with the Activities Director on 7/15/25 at 1:30 PM she stated Resident #2 got up to the reclining chair in her room daily and participated in group activities prior to going out to the hospital this last time. The Activity Director stated Resident #2 experienced a lot of pain with movement, so she had not been attending out of room activities. The Activity Director stated Resident #2 had been doing self-directed activities in her room. During an interview with the Director of Nursing on 7/18/25 at 9:02 AM she stated that residents were to be assessed by the nurse after a fall and the physician notified. The DON stated the nurse would follow the orders given by the physician. The DON further stated she was not the DON at the facility when Resident #2 fell. She stated that all resident falls should be investigated, and interventions put into place. The DON stated she expected all care provided to residents would be conducted in a safe manner and immediate education was provided. During an interview with the Administrator on 7/18/25 at 9:05 AM she stated the DON should be contacted when a resident falls and emergency medical services were notified if there was something acute going on. An investigation including statements was initiated and root cause analysis completed. Education was conducted with staff and interventions were put in place. The Administrator was notified of immediate jeopardy on 7/15/25 at 3:03 PM. The facility provided the following corrective action plan with a completion date of 7/7/25. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #2 is alert and oriented with a brief interview mental status (BIM) score of 15/15, indicating the resident is cognitively intact. Diagnoses include osteoporosis, high blood pressure, depression, restless leg syndrome, chronic pain, hypothyroidism and coronary artery disease. On 6/30/25 at approximately 3:00 am Nursing Assistant (NA) #1 entered Resident #2's room to provide incontinent care. NA #1 turned on the light and woke the resident up. Resident #2 was lying on her back in the center of the bed with the head of bed slightly elevated. NA #1 gathered supplies and then lowered the head of the bed to a flat position. NA #1 was standing on the resident's left side. NA #1 grasped the draw sheet and pulled the resident towards the left side. NA #1 then instructed Resident #2 to grasp the bed rail to turn over. Resident #2 grasped the bed rail with her left hand and rolled over to the right side. NA #1 observed Resident #2 continue to roll off the side of the bed. NA #1 attempted to stop the roll by grasping the resident by the arm but was unsuccessful. Resident #2 landed on the left side on the floor still holding on to the bed rail with her legs slightly bent at the knees and the upper body propped up with her left arm. NA #1 immediately notified the nurse. At approximately 3:17 am, the nurse entered the room and assessed the resident. Resident #2 complained of pain to her left ankle and bilateral lower extremities. A skin tear was noted to resident's right forearm. The nurse applied a dressing to the skin tear. The nurse notified emergency medical services (EMS). Resident #2's resident representative was notified of the fall. At approximately 3:29 am, EMS arrived, and Resident #2 was transferred to the emergency room for further evaluation and treatment. At approximately 3:44 am, the provider was made aware by the nurse of Resident #2's emergency transfer. At approximately 4:48 pm Resident #2 returned to the facility with a new diagnosis of bilateral femur fractures and a new order for pain medication every six hours as needed. An immobilizer was present to the right lower extremity. An appointment with orthopedics was scheduled for 7/7/25. At approximately 5:00 pm, the Director of Nursing interviewed Resident #2 upon return to the facility. Resident #2 stated as she rolled herself over, she just kept going, it happened so fast.On 6/30/25, the Administrator completed a root cause analysis for Resident #2's fall from bed. During the investigation it was determined that Resident #2 grasped the bed rail as instructed by NA #1 and independently rolled over in a forward motion away from NA #1 to assist in care. This forward motion positioned the resident out of the center of the bed and further toward the right side of the bed causing the resident to fall. As a result, the facility identified the root cause of the incident to be, ensuring appropriate safety measure are in place to support the resident while self-positioning during care. Address how the facility will identify other residents having the potential to be affected by the same deficient practice.On 6/30/25, the Director of Nursing (DON), Unit Managers, Assistant Director of Nursing (ADON) and/or Staff Development Coordinator initiated an audit, through observation, of all residents positioning in bed. This audit was to identify any resident who was not positioned in the center of bed and away from the edge of bed during care. There were no additional areas of concern. The audit was completed by 7/6/25. On 6/30/25, the Social Workers (SW) initiated resident questionnaires with all alert and oriented residents with BIMs of 13 or higher regarding turning and positioning in bed during care. This questionnaire was to identify any concerns related to turning and positioning during care. There were no additional concerns. The questionnaire was completed by 7/6/25.On 6/30/25, the Director of Nursing (DON), Unit Managers, Assistant Director of Nursing (ADON) and/or Staff Development Coordinator Initiated staff questions with all nurses, nursing assistants to include NA #1 and therapy staff related to turning and repositioning. The audit is to identify any safety concerns during care to include turning and positioning. The Director of Nursing (DON), Unit Managers, Assistant Director of Nursing (ADON) and/or Staff Development Coordinator addressed all areas of concern identified during the audit to include therapy referrals when indicated and initiate interventions for resident safety. The questionnaires were completed by 7/6/25. The Director of Nursing monitored the completion of staff questionnaires. After 7/6/25, any nurse, nursing assistant or therapy staff who have not completed the questionnaire will complete it upon the next scheduled work shift.On 6/30/25, the Director of Nursing (DON) completed an audit of all falls for the past 30 days. This audit is to identify any incidents related to safety concerns during care to include turning and positioning in bed. There were no identified areas of concern. The audit was completed by 6/30/25. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.On 6/30/25, the Director of Nursing (DON), Unit Managers, Assistant Director of Nursing (ADON) and/or Staff Development Coordinator initiated an in-service, in person, with all nurses, nursing assistants to include NA #1, agency staff and therapy staff regarding (1) Turning and Positioning During Care with emphasis on checking the care guide and providing care according to care plan/care guide for safety, technique for turning and positioning resident when providing care to include pulling the resident toward the side nearest staff prior to turning, positioning resident back in the center of the bed following care after turning and positioning to prevent falls/injury and (2) Safe Handling with emphasis on checking/following care guide when providing care even after a fall to include transfer method. The in-service included a return demonstration to validate staff knowledge and understanding of the education to include technique for turning and positioning and ensuring resident safety during care and how to check care guide on iPad. In-service with return demonstration was completed by 7/6/25. The Director of Nursing monitored the completion of the in-service and return demonstrations. After 7/6/25 any nurse, nursing assistant or therapy staff that has not received the in-service/return demonstration will complete it prior to the next scheduled work shift. All newly hired nurses, nursing assistants, agency staff and therapy staff will be in-serviced by the Staff Development Coordinator (SDC) during orientation regarding turning and positioning during care.Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.On 6/30/25, the decision was made by the Administrator to monitor the plan for ensuring safety during care to include turning and positioning and presented to the Quality Assurance Performance Improvement (QAPI) committee to include the Administrator, Director of Nursing, Assistant Director of Nursing, Unit Managers, Staff Development Coordinator, Medical Records, Social Worker, and Minimum Data Set Nurse on 6/30/25. On 6/30/25, the decision was made by the Administrator for the Director of Nursing (DON), Unit Managers, Assistant Director of Nursing (ADON) and/or Staff Development Coordinator to complete 10 Resident Care Audits-Turning and Positioning/Safe Handling, through observation, weekly x 4 weeks then monthly x 1 month utilizing the Resident Care Audits-Turning and Positioning tool. This audit will be completed during various shifts and various days including weekends. This audit is to ensure staff review care guides prior to providing care, use proper technique for turning and positioning during care and residents are positioned in the center of the bed during care. The Director of Nursing (DON), Unit Managers, Assistant Director of Nursing (ADON) and/or Staff Development Coordinator will address all concerns identified during the audit to include repositioning the resident and re-education of the staff. The Director of Nursing (DON) will review Turning and Positioning/Safe Handling audit tools weekly x 4 weeks then monthly x 1 month to ensure all areas of concern are addressed. The Director of Nursing (DON), Unit Managers, Assistant Director of Nursing (ADON) and/or Staff Development Coordinator were made aware of this responsibility by the Administrator on 6/30/25.The Administrator or Director of Nursing will present the findings of the Turning and Positioning/Safe Handling audit tools to the Quality Assurance Performance Improvement (QAPI) committee monthly for 2 months to review and to determine trends and/or issues that may need further interventions and the need for additional monitoring.Alleged IJ removal date: 7/7/25The corrective action plan was verified on 7/15/25 as evidenced by staff interviews. Staff education was initiated on 6/30/25 regarding (1)Turning and Positioning during Care with emphasis on checking care guide and providing care according to care plan guide for safety, techniques for turning, positioning resident back in center of bed following care after turning and positioning to prevent falls/injury (2) Safe Handling with emphasis on checking and following care guide when providing care even after a fall to include transfer method. All staff interviewed (nurses, nursing assistants and therapy staff) stated they had been educated to check the care guide to review techniques for turning and positioning residents, resident transfers, as well as positioning residents in the center of the bed following care to prevent falls. Staff return demonstrations on checking the care guide and technique for turning and repositioning residents during care were initiated on 6/30/25. Observations of residents during incontinence care revealed correct turning and positioning techniques and positioning of the resident in the center of the bed after care. Audit reports of resident falls for the past 30 days were reviewed. Audits of care plans for turning and positioning in bed, and staff and resident questionnaires were reviewed and completed 7/6/25. Quality Assurance Resident Care Audits to ensure staff reviewed care guide prior to providing care, proper technique for turning and positioning during care and positioning of residents in the center of the bed following care for the dates of 7/8/25 and 7/9/25 were reviewed. The facility's IJ removal date and corrective action plan compliance date of 7/7/25 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews with family, staff, Physician Assistant, and Physician the facility failed to monitor and assess a resident's neurological status (an assessment of motor and sensory response to determine if the nervous system is impaired) after an unwitnessed fall for a resident on an anticoagulant (Coumadin) and to recognize the seriousness of a change in condition and immediately seek emergent medical care. On [DATE] at approximately 9:30 AM Resident #1 was found in her room sitting on the floor and was unable to report what happened. At approximately 1:55 PM the resident was identified with lethargy, a change in mental status, and later developed unclear speech. The resident's family requested a transfer to the emergency room (ER) and 911 was called at 5:28 PM. A computerized tomography (CT) revealed multiple abnormalities including a large (9.4 centimeter [cm]) hemorrhagic contusion (bleeding within the skull) and a subdural hematoma (buildup of blood on the surface of the brain) with a 9-millimeter (mm) left-to-right midline shift (displacement of brain tissue along the center of the brain). Resident #1's injury was a life ending event, she was changed to comfort care, and expired on [DATE]. This deficient practice was for 1 of 3 residents reviewed for falls (Resident #1). The findings included: Resident #1 was admitted into the facility on [DATE] with diagnoses of hypertension, non-Alzheimer's dementia, disorder of bone density and structure, anxiety disorder, long term use of anticoagulant, fracture of the superior rim (upper end) of the left pubis (one of the three smaller bones that make up the hip bone), and presence of a prosthetic heart valve. A review of Resident #1's quarterly Minimum Data Set, dated [DATE] included that Resident #1 was severely cognitively impaired, had clear speech, was able to express ideas and wants, and was able to understand verbal content. She received both scheduled and as needed pain medication and her pain assessment indicated she was frequently in pain with pain rating a 7 on a scale of 0 to 10 with 0 meaning no pain at all and 10 meaning very severe pain. It also included that she was taking an anticoagulant medication. A physician order dated [DATE] indicated to keep the order for Coumadin 2.5 milligrams (mg) daily for an International Normalized Ratio (INR) (a test that determines how long it takes blood to clot) of 3.1 and to recheck the INR in 2 weeks. The normal range INR range for a person with atrial fibrillation is 2.0-3.0. An increased INR makes a person more prone to bleeding. Resident #1's medical record indicated on [DATE] Resident #1's INR was 4.4 and orders were received to decrease the dose of her anticoagulant medication to 2.0 mg and to draw the next lab on [DATE]. A physician order dated [DATE] indicated that Resident #1's order for Coumadin was decreased from 2.5 mg to 2 mg. An interview conducted on [DATE] at 3:15 PM with Nurse #3 indicated that the normal protocol for neurological checks were to complete as follows: every 15 minutes x 1 hour, every 30 minutes x 1 hour, every hour for 4 hours and then every 4 hours for 24 hours. An incident report dated [DATE] at 9:30 AM by Nurse #3 indicated that the nurse was called to the room and noted Resident #1 sitting on the floor. Resident #1 was alert, verbal and was assisted to the chair. Resident #1 stated she did not know what to do. There were no injuries observed at the time of the incident and Resident #1's mental status was confused. There were no witnesses to the fall. A progress note by Nurse #1 on [DATE] at 9:30 AM indicated Resident #1 had an unwitnessed fall and Nurse #1 was called to the room and noted the resident was sitting on the floor, was alert and verbal, was assisted to the chair, and stated she did not know what to do. During a telephone interview with Nurse #1 on [DATE] at 10:45 AM she indicated she completed an initial neurological check on Resident #1 when she assessed her after the fall on [DATE]. The results were within normal range except for limited movement to hips which was not abnormal for the resident due to her fractured pubis. A neurological assessment was documented by Nurse #1 on [DATE] at 9:35 AM and was within normal range except for extremity movement indicated limited range of motion to hips. During a telephone interview with Nurse #1 on [DATE] at 10:45 AM she was asked about the timing of the neurological assessments since she had documented one at 9:35 AM which was 5 minutes after the time of her first neurological assessment. She was unable to explain the time but stated that she completed this neurological assessment per protocol. Additional progress notes for Resident #1 dated [DATE] completed by Nurse #1 indicated the following: - At 10:00 AM the neurological assessment was within normal range except for extremity movement of limited range of motion to her bilateral hips. - At 10:15 AM the neurological assessment was within normal range. - At 11:09 AM the neurological assessment was within normal range except for extremity movement: limited range of motion to hips. - At 12:10 PM the neurological assessment was within normal range except for extremity movement was limited range of motion to hips. - At 1:51 PM Nurse #1 documented she had given Resident #1 Oxycodone hydrochloride (opioid pain medication) 2.5 milligrams by mouth for complaints of pain to her hips (this order had been in place since [DATE]). - At 1:55 PM Nurse #1 documented Resident #1 was noted to be lethargic with altered mental status, she was assisted to bed, peri care provided, and noted to be complaining of pain, as needed pain medication was given orally. - At 2:05 PM Nurse #1 documented she had called the Physician Assistant and informed her that Resident #1 was lethargic and complained of pain to her hips. The Physician Assistant stated that the Physician should be there soon and to make sure he sees her. - At 2:47 PM Nurse #1 documented Resident #1 was resting in bed with both eyes closed, bed in lowest position and call bell in reach. A review of Nurse #1's witness statement obtained [DATE] revealed on [DATE] around 9:15 AM an aide hollered that Resident #1 was on the floor and she went and assessed her. Resident #1 stated she didn't know what she was doing, she was alert and verbal and stated she was fine. The nursing assistants put Resident #1 back to bed and Nurse #1 initiated neurological checks which were normal until 1:55 PM. Resident #1 was up in the chair, and she had given Oxycodone, Resident #1 appeared lethargic, and she completed the neurological checks. Resident #1 was able to squeeze Nurse #1's hands equally and Resident #1's pupils were equal and reactive to light. She called the Physician Assistant. Nurse #1 indicated she thought Resident #1 was just sleepy since she was leaning and slow to respond but after incontinence care she seemed better, but she called the Physician Assistant anyway. The Physician Assistant stated that the physician would be there shortly and would assess her (Resident #1) when he got there. The nursing assistants put her (Resident #1) to bed and Nurse #1 reported the events of the day to the next shift. She stopped and checked on Resident #1 on her way off the unit at 3:00 PM and she was in bed with her eyes closed. A telephone interview was conducted on [DATE] with Nurse #1 at 10:45 AM. She stated that she had assessed Resident #1 after the fall and had started neurological assessments which were normal. She then notified the Physician Assistant of the fall and anticoagulant medication and also notified the responsible party of the fall. She stated that later around 2:00 PM Resident #1 had been in the dining room, and she was sleepy and in pain so herself, the therapist, and Nursing Assistant #2 put her bed and provided incontinence care. She then gave Resident #1 pain medication, Oxycodone 2.5 mg, for pain in her hips and notified the Physician Assistant of her findings. She stated that it wasn't unusual for Resident #1 to receive a pain pill due to her fractured pubis and there were times the medication made Resident #1 tired. The Physician Assistant told her the physician would be in later to see Resident #1. She gave a report to the oncoming shift and when she left her shift Resident #1 was resting quietly in her bed with her eyes closed. Nurse #1 indicated that the normal procedure for an unwitnessed fall was to complete neurological checks per protocol. A review of Nurse Assistant #2's witness statement obtained on [DATE] indicated on [DATE] around 9:15 AM he responded to a fall and saw Resident #1 on the floor, sitting on her buttocks with her legs out in front of her. She was alert and verbal and just saying her hips hurt like she always does. Her head was not anywhere near anything she could have hit her head on. The nurse assessed her (Resident #1) and Nurse Assistant #2, Nurse Assistant #1, and Nurse #1 assisted her off the floor and back in bed. Around lunch time, Resident #1 seemed to be a little out of it like she was tired, and Nurse Assistant #2 told Nurse #1 when touching her (Resident #1) leg she (Resident #1) acted like she was in pain and wasn't acting right. The other aide and Nurse Assistant #2 took her (Resident #1) to her room via wheelchair and assisted her to bed. When he (Nurse Assistant #2) left at 3:00 PM, Resident #1 was still in bed with her eyes closed and appeared to be sleeping. A telephone interview was conducted on [DATE] with Nursing Assistant #2 at 10:15 AM he stated couldn't remember a lot about Resident #1 on [DATE], but knew at lunch she seemed tired and out of it so she was put into bed. A telephone interview was conducted on [DATE] with the Physician Assistant at 2:28 PM. She revealed that she was aware of the fall on [DATE] and that Resident #1 was on an anticoagulant medication. She stated that the standard with a fall was that if the resident was at baseline and neurological checks were normal then the resident was monitored, with the expectation that the neurological checks were continued per facility policy. She further revealed that she was under the impression when Nurse #1 had called regarding lethargy that Resident #1 was lethargic related to the pain medication being given, she was not aware that Resident #1 was lethargic prior to receiving the pain medication. She stated that all the conversations with Nurse #1 left her feeling that the resident was at baseline and just tired due to receiving pain medication. Resident #1's progress notes dated [DATE] completed by Nurse #2 indicated the following: - At 3:22 PM Nurse #2 documented she received in report that Resident #1 was lethargic today and that the resident had a fall this morning. The 7AM-3PM nurse reported she contacted the Physician Assistant and made her aware and the Physician Assistant stated that the Physician will see her today. The resident was noted resting in bed, eyes closed, respirations even and non-labored. - At 4:30 PM Nurse #2 documented Resident #1's speech was noted unclear at times. Vital signs were normal except her blood pressure was 145/81 (normal is top number less than 120 and bottom number less than 80). Her respirations were even and non-labored, no signs or symptoms or complaints of pain or discomfort noted status post fall. The Physician was made aware and reported he would come and assess. - At 5:30 PM Nurse #2 documented the Physician was in to assess Resident #1, her family was at bedside requesting resident to be sent to the emergency room. The Assistant Director of Nursing called 911 and the writer called and gave report to the emergency room nurse. An interview was conducted on [DATE] at 10:57 AM with Nurse #2. Nurse #2 worked the 3PM-11PM shift on [DATE]. She indicated that she was told by Nurse #1 in report that Resident #1 was lethargic (which was not normal for Resident #1), she had a fall that morning, and she had received a pain pill which wasn't unusual due to her fractured pubis. She was also told by Nurse #1 that the Physician Assistant had been notified twice and the physician would see her that evening. Nurse #2 stated she had seen her at the beginning of the shift and Resident #1 was resting quietly with no signs of pain, in bed with her eyes closed. At 4:30 PM she was checking on Resident #1 and noticed her speech was unclear/slurred at times which was not normal for her. The Physician was in the building at the time so she and the Medication Aide went and told him of the change, and he stated he would be over to see Resident #1. At 5:30 PM Nurse #2 was notified by the Medication Aide that the family of Resident #1 was at the facility and wanted Resident #1 to be sent to the emergency department. Nurse #2 and the Physician went to the room where the family was waiting, and the Physician said to send her to the emergency department. Emergency medical services were called. A review of Nurse Assistant #3's witness statement obtained on [DATE] indicated that around 3 PM on [DATE] the Medication Aide brought to his attention that Resident #1 did not seem right. He (NA #3) went to Resident #1, she was incoherent, she was babbling and not making much sense, and she (Resident #1) was alert but seemed drowsy. He believed that the Medication Aide told the Nurse because the Medication Aide was in the room. An interview was conducted on [DATE] at 3:45 PM with Nursing Assistant #3 who was assigned to Resident #1 on [DATE] for the 3PM-11PM shift. He stated that he was told by the Medication Aide that Resident #1 had fallen that day. He stated that the Medication Aide was in Resident #1's room around 4:00 PM and had him come in. He reported he noted Resident #1 was pale and her speech was muffled which wasn't normal for her (Resident #1). The Medication Aide notified Nurse #2 and they notified the physician. An interview was conducted on [DATE] at 3:29 PM with the Medication Aide who was assigned to Resident #1 on [DATE] for the 3PM-11 PM shift. She indicated that during report, it was told that Resident #1 had fallen and was sleeping soundly. She stated that around 4-4:30 PM something told her to go check on Resident #1 and she noted her (Resident #1) color was bad she was very pale, her mouth was weird (she couldn't explain it other than using the term weird), and she was not talking right. She indicated by then the family was there and a staff member (unable to recall who) had gone to get the Physician. The family member was upset because of the way Resident #1 looked and was acting which was not normal for Resident #1 and the physician had not been there yet. When the physician came around 5:30 PM Resident #1 was sent to the Emergency Room. A telephone interview was conducted on [DATE] at 9:11 AM with Resident #1's family member, Family Member #1. She stated that when she and another family member (Family Member #2) walked into the door of the facility on [DATE] around 4:15-4:30 PM they could hear someone groaning and realized it was Resident #1. When they walked into Resident #1's room there was no staff present and Resident #1's head and her body was contorted on her right side, and it appeared Resident #1 was about to fall out of bed. Family Member #2 went to Resident #1 to keep her from falling and spoke to Resident #1, but she did not give any acknowledgement. Family Member #1 stated that Resident #1 was staring straight ahead with her right eye wide open but blank and the left eye shut. She revealed that Resident #1 was pulling on her clothes and exposing her top half which the resident would never do especially in front of Family Member #2 (male relative). The resident wouldn't or couldn't talk to her or Family Member #2. Family Member #1 stated that while Family Member #2 was holding Resident #1, she (Family Member #1) went down the hall saying, call 911 call 911. Family Member #1 stated she looked at the Medication Aide and said, call 911, [Resident #1] isn't right and the Medication Aide told her she was going to go get the physician. Family Member #1 stated that she believed about 20 minutes passed, the physician had not appeared, so she went to Nurse Assistant #3 and said to call 911. Nurse Assistant #3 told her the Medication Aide went to go get the physician. The family told Nurse Assistant #3 I know this, but something is very wrong with [Resident #1] and you need to call 911. Family Member #1 stated she then went back into Resident #1's room and finally the physician came, took one step into the room and said call 911 and she never saw the physician again. Family Member #1 stated that when the facility had called her at 11:00 AM they told her Resident #1 was fine but babbling which was unusual for the resident to do and if she had known the extent of the change, she would have told them then to send the resident to the emergency department. The Emergency Medical Service (EMS) record dated [DATE] revealed the call to 911 was received at 5:28 PM. When they arrived at the facility at 5:36 PM Resident #1 was not alert with uneven pupils and non-responsive to verbal only painful stimuli. EMS was informed Resident #1 had fallen earlier around 9:00 AM and had had altered mental status since then. The physician came to check on Resident #1 when the family insisted Resident #1 be taken and seen at the emergency department. Resident #1's hospital record dated [DATE] revealed Resident #1 presented to the emergency department on [DATE] after she was found unresponsive at her skilled nursing facility. Earlier in the day the resident was found on the floor noted to have an unwitnessed fall. After this the resident spent the majority of the time in bed, however later in the day she was found to be difficult to arouse and unresponsive. A computerized tomography of the head was performed which demonstrated multiple abnormalities including multicompartment intracranial hemorrhages most notable for a 9.4 centimeter (cm) x 5.2 cm x 4.3 cm hemorrhagic contusion in the left temporal lobe (area in the brain near temples and ears) with a 9-millimeter left-to-right midline shift in the brain and trace subfalcine (brain tissue is displaced to the other side) and left uncal (occurs from rising pressure in the brain causing brain tissue to move from one compartment to another) herniations, subdural hematoma. It was also revealed that during the physical examination of Resident #1 a parietal scalp contusion. This was discussed with neurosurgery and trauma surgery at tertiary center (higher level of care) and deemed a life altering/ending event. Resident #1 was made comfort care at this time. After approximately 48 hours she was pronounced deceased . An interview was conducted on [DATE] with the Physician at 4:12 PM. He indicated that Resident #1 could have been sent out earlier on [DATE], but it would not have made a difference in the outcome. He thought that there was nothing the facility could have done differently and with her comorbidities of micro abrasions (tiny blood vessel damage) in her frontal lobe (the area of the brain behind the forehead), microvascular ischemic changes (narrowing of small blood vessels in the brain) and parenchymal atrophy (pathological loss of brain functional tissue in the brain) and infarction of the left thalamus (ischemic strokes [a blood clot blocks an artery leading to the brain] that affect the subcortical grey matter [play an essential role in cognitive and motor function]) not to mention anticoagulant therapy that the bleed would have happened regardless of when she was sent to the hospital resulting in the same outcome. An interview was conducted on [DATE] at 2:42 PM with the Director of Nursing. She stated that from her investigation related to the fall that occurred on [DATE] involving Resident #1 that the nurses may have a different perspective regarding urgency or seriousness when a change is noted in a resident's condition. She further stated that the nurses had contacted the Physician Assistant or the Physician and followed orders. The Administrator was notified of Immediate Jeopardy on [DATE] at 5:25 PM. The facility presented the following corrective action plan: Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice: Resident #1 has a diagnosis of acute kidney failure, chronic atrial fibrillation (abnormal heart rhythm), edema, gastroesophageal reflux disease, long-term use of anticoagulants (medications to prevent blood clots), fracture of the right ulna (right lower arm), disorders of bone density and structure, malignant neoplasm (cancer) of the large intestine, thrombocytopenia (low level of platelets that help blood to clot), vitamin D deficiency, allergic rhinitis (inflammation of the lining of the nose), cognitive social or emotional deficit following cerebrovascular disease (stroke), left hip fracture, anxiety disorder, insomnia (difficulty sleeping), muscle weakness, presence of prosthetic heart valve, and severe dementia without behavioral disturbances. The resident was receiving warfarin sodium 2mg to prevent blood clots. On [DATE] at approximately 9:15 am, Resident #1 was observed in the room on the floor next to the bed. The resident was noted to be alert and verbal. Neurological checks were initiated and within normal limits with no signs of head injury at the time of the incident. The physician's assistant was initially contacted by the nurse and notified of the fall and the resident's condition which was at baseline. There were no new orders received. The family was contacted and notified of the fall. At 9:15 am, 9:35 am, 9:55am, 10 am, 10:15am, 11am, and 12:10pm, neurological checks were completed and within normal limits for the resident. At approximately 1:55pm, Resident #1 was up in the chair and noted by the nurse to be lethargic (a state of tiredness or sleepiness) and leaning to the side. The nurse completed a neurological assessment. The resident was able to squeeze the nurse's hands equally and pupils were equal and reactive to light. The physician's assistant was notified of the resident's change in condition. Due to the resident receiving narcotic pain medication, the physician assistant stated to the nurse, the physician was enroute to the facility and would assess the resident upon arrival to determine the course of action. At approximately 3:15 pm, Resident #1 was observed in the room with incoherent speech and appeared drowsy. At approximately 4 pm, vital signs were stable. The resident appeared lethargic but was responsive to tactile and verbal stimuli. The resident did not appear to be in any distress or pain. Pupils were equal, round, and reactive to light/accommodation. The nurse made the physician aware of Resident #1's change of condition. At approximately 5 pm, the physician assessed Resident #1. The resident's family was in the room with the resident at that time and requested the resident be sent out to the hospital for evaluation. The resident was transferred out of the facility via emergency medical services. A hospital CT scan revealed multicompartment intracranial hemorrhages most notable for a 9.4 cm x 5.2 cm x 4.3 cm hemorrhagic contusion in the left temporal lobe, associated mass effects were notable for a 9 mm left-to-right midline shift and trace subfalcine and left uncal herniations. The resident was changed to comfort care and expired on [DATE]. A root cause analysis was completed on [DATE] by the Director of Nursing and determined that the nurse failed to continue neuro checks and identify an emergent acute change after a resident displayed lethargy, altered mental status, and unclear speech following a fall. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. On [DATE], the Assistant Director of Nursing initiated a head-to-toe assessment of all residents including residents with recent falls who are on blood thinners for signs and symptoms of acute change in condition. This audit is to ensure the resident was assessed, interventions initiated as appropriate to include neuro checks or emergent medical treatment, the physician notified for further recommendations, and the resident representative notified with documentation in the electronic record. There were no additional concerns identified during the audit. The audit was completed by [DATE]. On [DATE], the Assistant Director of Nursing reviewed all progress notes for the past 30 days to identify any resident with an acute change including residents with recent falls who are on blood thinners. The purpose of the audit is to ensure the resident was assessed, interventions initiated as appropriate to include neuro checks or emergent medical treatment, the physician was notified for further recommendations and the resident representative was notified with documentation in the electronic record. The Assistant Director of Nursing will address all concerns identified during the audit. The audit was completed by [DATE]. On [DATE], the Assistant Director of Nursing reviewed the past 30 days of fall incident reports to include residents on blood thinners. This audit is to ensure the resident was assessed, interventions initiated as appropriate to include neuro checks or emergent medical treatment, the physician notified for further recommendations, and the resident representative notified with documentation in the electronic record. If the acute change continued, the resident did not improve or the physician was not on-site during an emergency situation, the physician was notified again for further recommendations, or the resident was sent out to the hospital for further evaluation. There were no additional concerns identified during the audit. The audit was completed by [DATE]. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On [DATE], the Assistant Director of Nursing initiated an in-service with all nurses to include the agency regarding Acute change with emphasis on 1) assessing changes in condition to include neurological checks, obtaining vital signs, initiating interventions for the acute change, notification of the physician for further recommendations and notifying the resident representative with documentation in the electronic record. 2) If acute change continues, the resident does not improve or the physician is not on-site during an emergent event, the resident should be sent to the emergency room for further evaluation and treatment with notification of the physician and resident representative with documentation in the electronic record. The in-services will be completed by [DATE]. After [DATE], the Director of Nursing monitored staff completion and any nurse who has not worked or received the in-service will complete it before the next scheduled work shift. All newly hired nurses will be educated during orientation by the Director of Nursing regarding Acute Changes. The Administrator confirmed this responsibility with the Director of Nursing on [DATE]. On [DATE], the Assistant Director of Nursing initiated an in-service with all CNAs to include agency staff regarding Notification of Acute Changes with emphasis on immediately reporting to the nurse any change in condition to include but not limited to a decreased level of consciousness. The in-service will be completed by [DATE]. After [DATE], the Director of Nursing monitored staff completion and any nursing assistant who has not worked or received the in-service will complete it before the next scheduled work shift. All newly hired nursing assistants will be educated during orientation. All newly hired nursing assistants will be educated during orientation by the Director of Nursing regarding Notification of Acute Changes. The Administrator confirmed this responsibility with the Director of Nursing on [DATE]. On [DATE], the ADON initiated an in-service with all nurses regarding Incidents with emphasis on investigating all incidents thoroughly including obtaining statements and completion of investigative folder, assessment of the resident to include neuro checks for suspected head trauma to include residents prescribed blood thinners, initiating intervention based on root cause, updating care plans for new safety interventions and notification of MD/RR. The in-services will be completed by [DATE]. After [DATE], the Director of Nursing monitored staff completion and any nurse who has not worked or received the in-service will complete it before the next scheduled work shift. All newly hired nurses will be educated during orientation by the Director of Nursing regarding Incidents. The Administrator confirmed this responsibility with the Director of Nursing on [DATE]. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; and The decision to monitor the system for residents with acute changes through review of incident reports and progress notes was made on [DATE] by the Administrator and Director of Nursing and presented to the Quality Assurance (QA) Committee on [DATE]. The facility's interdisciplinary team (IDT) including the Administrator, Director of Nursing, Assistant Director of Nursing, and Unit Managers will review progress notes and incident reports 5 times per week x 4 weeks to identify residents with an acute change including residents with falls prescribed blood thinners utilizing the Acute Change Audit Tool. This audit is to ensure the resident was assessed, interventions initiated as appropriate to include neuro checks or emergent medical treatment, the physician notified for further recommendations, and the resident representative notified with documentation in the electronic record. If the acute change continued, the resident did not improve or the physician was not on-site during an emergent situation, the physician should be notified again for further recommendations and notify the resident representative with documentation in the electronic record. The unit managers will address all concerns identified during the audit including but not limited to an assessment of the resident, initiating interventions as appropriate to include neuro checks or emergent medical treatment, notification of the physician for further recommendations, notification of the resident representative with documentation in the electronic record, and/or re-training of staff. The Director of Nursing or Assistant Director of Nursing will review the Change in Condition audits weekly x 4 weeks to ensure all areas of concern were addressed appropriately. The Administrator or Director of Nursing will present the findings of the Acute Change Audit Tools to the Quality Assurance Performance Improvement (QAPI) committee monthly for 1 month to review and to determine trends and/or issues that may need further interventions and the need for additional monitoring. Alleged date of immeidate jeopardy removal and corrective action completion: [DATE] The corrective action plan was validated on [DATE] by reviewing the audit tools used by the facility for all residents who were on anticoagulants and had falls were assessed for acute changes in condition, progress notes were reviewed for the past 30 days for any residents with acute changes to ensure the resident was assessed, interventions initiated as appropriate to include neuro checks or emergent medical treatment, the physician was notified for further recommendations and the resident representative was notified with documentation in the electronic record, and the past 30 days of fall incident reports to include residents on blood thinners. This audit is to ensure the resident was assessed, interventions initiated as appropriate to include neuro checks or emergent medical treatment, the physician notified for further recommendations, and the resident representative notified with documentation in the electronic record. All audits were completed [DATE]. The nursing staff were educated on regarding Acute change with[TRUNCATED]