**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, hospital record review, review of a facility investigation, review of the facility assessment, policy review, and interview, the facility failed to develop and implement an effective discharge planning process focusing on the safety and total care needs of Resident #23 to ensure the resident was discharged to a safe location with continuity of care post-discharge. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injury, and/or death beginning on 08/12/25 when Resident #23, who had been admitted to the facility with a known diagnosis of alcohol abuse, was discharged from the facility without evidence the resident had a safe location in which to go. Following the resident's discharge, on 08/13/25 the facility was notified by an unidentified bystander that Resident #23 wanted the facility contacted and Assistant Director of Nursing (ADON) #341 informed the unknown caller Resident #23 would have to go to the emergency room. The resident was subsequently admitted to the hospital with diagnoses of suicidal ideation and malnutrition. On 09/11/25 at 1:21 P.M., Regional Director of Operations (RDO) #261, Licensed Nursing Home Administrator (LNHA) #271, Regional Nurse #264, and the Director of Nursing (DON) were notified Immediate Jeopardy began on 08/12/25 when Resident #23 was discharged from the facility without proper assessment, without evidence he had a safe location in which to discharge to and without evidence of coordination of care to ensure the resident's medical and psychosocial needs were met resulting in the resident being hospitalized for malnutrition and suicidal ideation. The Immediate Jeopardy was removed on 09/11/25 when the facility implemented the following corrective actions: Resident #23 exited the facility on 08/12/25 at 6:45 A.M. He did not return to the facility. On 09/11/25 at 9:00 A.M., LNHA #271 and the DON were educated on the facility's discharge against medical advice (AMA) and leave of absence (LOA) policies. On 09/11/25 at 12:00 P.M., an audit was completed by LNHA #271 of current residents with plans to discharge to the community. The audit identified five residents (Residents #16, #42, #101, #114, and #122). All five resident's records were audited to ensure discharge planning was in progress and discharge plans were accurately recorded in each resident's record. On 09/11/25 at 3:30 P.M., Social Services Director (SSD) #312 and LNHA #271 were educated by Regional Director of Clinical Services (RDCS) #263 on ensuring support for residents' psychosocial well-being and providing assistance with discharge needs and requests. Additional education included SSD #312 will complete new admission care conferences within 72 hours of admission which will include screening assessments such as the PHQ-9 depression screening tool. On 09/11/25, the DON provided education to the facility's interdisciplinary team (IDT) and licensed nurses on the facility's policies on discharge AMA and LOA policies. The IDT included LNHA #271, ADON #341, Unit Manager (UM) #347, UM #345, SSD #312, Business Office Manager (BOM) #267, Dietary Manager #269, Activity Director #270, Therapy Director #315, Housekeeping Supervisor #280, Maintenance Director #219, Central Supply Coordinator #205, and Medical Records Coordinator #273. Additionally, 20 Licensed Practical Nurses (LPN) and 11 Registered Nurses (RN) were educated. All education was completed on 09/11/25 by 4:30 P.M. The facility held a Quality Assurance Performance Improvement (QAPI) meeting on 09/11/25 which included completion of a root cause analysis of the event and development of a plan of correction. Participants included Medical Director #450, LNHA #271, DON, RDO #261, RDCS #263, and Regional Nurse #264. The QAPI plan was approved by Medical Director #450 and the IDT on 09/11/25 at 4:30 P.M. On 09/11/25 at 4:45 P.M., Minimum Data Set (MDS) Nurse #343 completed an audit of in-house residents with the diagnosis or history of substance abuse or polysubstance abuse. The audit identified six in-house residents (Residents #3, #17, #58, #78, #89, and #120) with a substance abuse or polysubstance abuse history. On 09/11/25 at 5:00 P.M., the DON provided one-on-one education to Residents #3, #17, #58, #78, #89, and #120 on the facility's leave of absences policy. Ad hoc (not scheduled) education will be provided on an ongoing basis by RDCS #263 or Regional Nurse #264 for any staff member who is not correctly implementing the AMA and/or LOA policies on an as-needed basis. Beginning on 09/11/25, newly hired nurses will be trained on the facility's discharge AMA and LOA policies upon hire by the DON or designee. Beginning on 09/12/25, the DON or designee will provide education to agency staff nurses on the facility's discharge AMA and LOA procedures prior to the agency nurse being able to accept the assignment at the facility. Beginning the week of 09/15/25, LNHA #271 or designee will audit weekly discharges for a duration of four weeks to ensure documentation supports a safe discharge, including a discharge plan that meets the residents' behavioral and psychosocial needs. The results of ongoing audits will be reviewed by the facility's QAPI committee to determine if additional audits or education is needed. Beginning on 09/18/25 at regularly scheduled Utilization Review (UR) meetings, LNHA #271 or designee will discuss upcoming resident discharges and safe discharge planning. The weekly UR meetings will be attended by LNHA #271, DON, Therapy Director #315, BOM #770 (start date 09/15/25), and MDS Nurse #343. Although the Immediate Jeopardy was removed on 09/11/25, the deficiency remained at a Severity Level II (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include:Review of the closed medical record for Resident #23 revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), moderate protein-calorie malnutrition, anemia, alcohol abuse, hypertensive heart disease, adult failure to thrive, chronic viral hepatitis C, osteoarthritis, cutaneous abscess of right lower limb, and multiple myeloma. Emergency contacts included a female friend and the resident's sister. The medical record revealed Resident #23 was discharged on 08/13/25.An admission note dated 05/22/25 at 6:19 P.M. authored by Licensed Practical Nurse (LPN) #221 revealed Resident #23 was admitted to the facility from the hospital via medical transport. Review of the physician orders revealed Resident #23's scheduled medications included amlodipine (antihypertensive) 10 milligram (mg) daily, Vitamin D3 (supplement) 125 micrograms daily, Folic Acid (supplement) one mg daily, magnesium oxide (supplement) 400 mg daily, multivitamin with minerals (supplement) one tablet daily, thiamine (supplement) 100 mg daily, Vitamin E (supplement) one tablet daily, zinc (supplement) 220 mg daily, Acyclovir (antiviral) 400 mg twice a day, ascorbic acid (supplement) 500 mg twice a day, Gabapentin (for nerve pain) 500 mg twice a day and 300 mg once a day, senna (laxative) 8.6 mg twice a day, and melatonin (for insomnia) three mg at bedtime.A plan of care dated 05/22/25 revealed Resident #23 was at risk for falls related to weakness, limited mobility, and COPD. Interventions included educating and encouraging Resident #23 to use the ramp when going off a curb, to call for assistance before transferring, and food/fluids and personal care items within reach.An order dated 05/22/25 at 8:47 A.M., given by Certified Nurse Practitioner (CNP) #425, revealed Resident #23 could go on leave of absence (LOA) without supervision. CNP #425 was aware the resident was not signing out when he went on LOA, but the resident was alert and oriented. No care plan was initiated at the time the order was received to ensure the residents' safety when leaving on LOA.The 5-day Medicare Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact, had no documented behavior and required supervision or touching assistance for ambulating. The MDS also revealed Resident #23 had a venous/arterial ulcer.A nursing note dated 06/06/25 at 7:42 A.M. authored by Nursing Supervisor #311 revealed Resident #23 was found outside in his wheelchair wheeling himself down the road in front of the facility. Resident #23 stated he was going to buy beer. Record review revealed no new interventions were initiated at this time to ensure the resident's safety when leaving on LOA.A nursing note dated 06/14/25 at 3:57 A.M. revealed around 3:30 A.M., Resident #23 called the facility and stated he was at a lady friend's house and would return in the morning. Resident #23 refused to give the address of where he was staying. The DON was notified of the phone call. Record review revealed no new interventions were initiated at this time to ensure the resident's safety when leaving on LOA.A nursing note dated 06/14/25 at 10:31 A.M. revealed the outgoing nurse gave report that Resident #23 went on a LOA the previous day and did not return. Resident #23 called on 06/14/25 around 10:15 A.M. and stated he was stalked on [NAME] Road (no clarification was provided regarding what the resident meant by stalked) at the bus stop and needed someone to pick him up. An activity person (unidentified) went to pick Resident #23 up. Record review revealed no new interventions were initiated at this time to ensure the resident's safety when leaving on LOA.A nursing note dated 06/22/25 at 10:30 A.M. revealed Resident #23 was not in his room during morning medication administration. The outgoing nurse did not give report on Resident #23 and stated she took over the shift at 4:00 A.M. The police arrived at the facility around 10:30 A.M. and stated Resident #23 was found sitting in his wheelchair in the street (location not identified). The Administrator sent someone to pick Resident #23 up. Record review revealed no new interventions were initiated at this time to ensure the resident's safety when leaving on LOA. A nursing note dated 07/02/25 at 11:57 P.M. revealed Resident #23 returned to the facility around 11:30 P.M. The note documented the nurse educated Resident #23 about signing out before leaving the facility. Resident #23 stated he would sign out next time. Record review revealed no new interventions were initiated at this time to ensure the resident's safety when leaving on LOA. A Preadmission Screening and Resident Review (PASRR) identification screen dated 07/07/25 revealed Resident #23 had no mental disorders or substance use related disorders. However, review of the resident's admission diagnoses revealed the resident had a diagnosis of alcohol abuse.A plan of care dated 07/19/25 revealed Resident #23 had the potential to be discharged . Resident #23 desired to be discharged to home. Interventions included discussing any special equipment needs and to facilitate obtaining the equipment needed prior to discharge, make referrals to other community agencies as needed, and to talk with Resident #23, allowing the resident to express feelings regarding discharge. A nursing note dated 07/22/25 at 6:42 P.M. authored by Agency LPN #900 revealed the DON notified the nurse Resident #23 had left the building without signing the LOA book. Agency LPN #900 had no knowledge of Resident #23 leaving the building without signing the LOA book. Record review revealed no new interventions were initiated at this time to ensure the resident's safety when leaving on LOA.A plan of care dated 07/23/25 revealed Resident #23 had a history of substance seeking behavior alcohol and had the potential for complications such as substance abuse, withdrawal symptoms, and mood and/or behavioral disturbances (not identified in the medical record). Resident #23 does sign himself out to go drink. Interventions include to discuss behavioral limits and expectations with Resident #23, if Resident #23 returned from leave of absence and appeared to be impaired, the doctor should be notified for directions regarding administration of regularly scheduled medications and observe for indications the resident may be storing drugs or alcohol in room or on person. The doctor should be notified if drugs or alcohol were found. A nursing note dated 08/09/25 at 6:41 A.M. authored by Agency LPN #901 revealed Resident #23 insisted on leaving the facility to go to the mall around 6:00 A.M. The nurse informed Resident #23 that the mall was usually closed at that time, but Resident #23 stated he was leaving anyway. Several staff attempted to redirect Resident #23 without success. The nursing supervisor on call was made aware of Resident #23 leaving the facility. Record review revealed no new interventions were initiated at this time to ensure the resident's safety when leaving on LOA.A social service note dated 08/11/25 at 2:50 P.M. authored by SSD #312 revealed the writer met with Resident #23 to discuss discharge planning. The note included Resident #23 wanted to discharge on ce his therapy goals were met and he was safe to reside on his own. Resident #23 was unclear if he would be able to return to his previous apartment because he had been late on his rent prior to going to the hospital and had made no attempt to pay the rent. Record review revealed no evidence of any social service follow-up or information related to the resident's progress with therapy goals or ability to safely reside on his own.A nursing note dated 08/12/25 at 7:12 A.M. authored by LPN #902 revealed Resident #23 refused a shower after multiple attempts by the Certified Nursing Assistant (CNA). The note included Resident #23 left the building around 6:45 A.M. and failed to comply with signing the LOA book. There was no additional information related to the circumstances surrounding why Resident #23 left and/or what his condition was at the time he left. Record review revealed no evidence the resident's physician, CNP #425 or responsible party were notified the resident had left at this time.Review of the resident's medical record revealed there was no evidence the resident was offered or provided any type of mental health services. There was no evidence of counseling or behavioral health services while the resident resided in the facility.Review of hospital records revealed on 08/12/25 at 6:45 P.M. Resident #23 entered the emergency department at Ohio State University and then left. On 08/13/25 at 11:43 A.M. a follow up note revealed Ohio State University Hospital did not have a bed available for the resident.A nursing note dated 08/13/25 at 8:48 A.M. and authored by LPN #903 revealed Resident #23 was at the hospital (no additional information was provided in the note).A nursing note dated 08/14/25 at 8:18 A.M. authored by RN #235 revealed Resident #23 was at the hospital.The last nursing note in the medical record dated 08/15/25 at 8:00 A.M. authored by RN #235 revealed Resident #23 was hospitalized . Review of hospital records from (Hospital #1) revealed Resident #23 arrived on 08/13/25 at the emergency department on 08/13/25 at 1:32 P.M. Resident #23 had complaints of a headache and lack of housing. Resident #23 stated he had pressure at the top of his head and rated the pain an eight out of ten (on a 0-10 pain scale with zero meaning no pain and 10 being the worst pain the resident has experienced) and described the pain as crushing. The pressure was slow in onset and progressed throughout the day. Resident #23 stated he got headaches infrequently but had headaches like this before. Resident #23 stated he had been outside most of the day and was homeless. Resident #23 denied any trauma and was not sure if he had been under a lot of stress. Resident #23 was discharged (from Hospital #1) on 08/13/25 at 7:35 P.M. (location not identified).Review of hospital records revealed on 08/15/25 at 9:36 P.M. Resident #23 entered Mount Carmel emergency department. An emergency department note dated 08/15/25 from [NAME] Health/Mount Carmel revealed Resident #23 was found in the middle of the road in his wheelchair. Resident #23 admitted to drinking alcohol. Review of hospital records revealed on 08/19/25 at 2:19 P.M. Resident #23 entered Riverside emergency department. An emergency department provider note dated 08/19/25 at 3:44 P.M. revealed Resident #23 had come to the emergency department with concerns for left foot pain and swelling. Resident #23 reported he was ambulatory and walked around a lot. Resident #23 reported he drank some alcohol today and reported suicidal ideation. Resident #23 stated he could not disclose his plan for harming himself. Resident #23 appeared somewhat disheveled and intoxicated and had bilateral lower extremity pitting edema that was 2+ (indentation is three to four millimeters deep and rebounds in less than 15 seconds) with pain overlying erythema (redness) and some venous stasis (where blood flow in the veins slows down or stops) changes. Resident #23's lower extremities would be treated for cellulitis, suspect cellulitis versus venous stasis dermatitis. The first dose of Keflex (antibiotic) would be given. Hospital notes dated 08/19/25 revealed Resident #23 reported he was suicidal and had been since he was at the skilled nursing facility (Sapphire). When asked if Resident #23 had a plan, he stated there was not a building tall enough in Columbus. Resident #23 stated the building would need to be as tall as the Empire State building. Resident #23 reported he had been having suicidal thoughts for months and wanted to stop the misery. Resident #23 was not able to say when he left the skilled facility but stated it was the second time he had left the same facility (he had a prior admission in April 2025). Resident #23 reported he had not really eaten much in the past two weeks. Resident #23 described his sleep as volatile and reported nightmares and used alcohol to mitigate these symptoms. Resident #23 struggled with homelessness and received an eviction notice prior to hospitalization in May 2025. Resident #23 reported sleeping wherever it was safe. Resident #23 had poor hygiene, and his hair was overly long and matted in the back. Further review of the hospital record revealed an emergency department social worker behavioral health initial assessment completed on 08/19/25 at 8:26 P.M. revealed Resident #23 was currently homeless and stayed wherever is safe. Resident #23 stated there was no one to call for a contact person. An emergency social worker behavioral health updated assessment dated [DATE] at 12:05 P.M. revealed Resident #23 had current severe episode of major depressive disorder with psychotic features. Resident #23 continued to endorse thoughts of suicide with a plan to jump from a building. Resident #23 felt he would be better off dead and knows he was not able to manage his medical needs and should have stayed at the skilled nursing facility where he was sent in May. When asked why he left, he admitted to leaving to get a beer. On 08/21/25 at 2:09 P.M., Resident #23 was discharged from Riverside (and transferred to another hospital).Review of hospital records from Hospital #3 revealed Resident #23 was admitted on [DATE] at 2:11 P.M. from another medical center. Resident #23's principal diagnosis included other specified depressive disorder (dysphoria in the context of alcohol use disorder, multiple medical co-morbidities, and psychosocial stressors). Resident #23 had other diagnoses listed that included alcohol use, tobacco use, cannabis use, recent failure to thrive, multiple myeloma, right groin lymphadenopathy, hypertension, coccyx wound, bilateral lower extremity edema (suspected cellulitis versus venous stasis dermatitis, hyponatremia, and limited mobility wheelchair bound). The note included Resident #23 presented to the emergency department at Hospital #3 on 08/19/25 via emergency medical services reporting foot pain/swelling, alcohol use, and suicidal ideation (SI) with thoughts to jump off a building but stated there was not a tall enough structure in Columbus. Resident #23 described SI for months and wanted to stop the misery. Resident #23 was medically stabilized and transferred to Hospital #2 on 08/21/25 for further care. Hospital records revealed Resident #23 was treated for failure to thrive in May of 2025 and then transferred to Sapphire Rehabilitation (Rehab) on 05/22/25. The note included Resident #23 left the facility in search of beer so the staff at Sapphire Rehab told him he could not return. Resident #23 reported he had not eaten in two weeks, had poor sleep and drank alcohol to cope with nightmares. Upon initial evaluation, Resident #23 shared he had been struggling with homelessness and physical health issues. Resident #23 stated he left Sapphire Rehab due to a desire for beer. Resident #23 was amendable to re-referral to skilled nursing facility and indicated he would remain until formally transferred or discharged . Resident #23 was agreeable with transfer to the medical surgical unit for ongoing physical health stabilization and referral to a skilled nursing facility. A nutrition care initial assessment dated [DATE] at 12:19 P.M. revealed Resident #23 had an unintentional weight loss of more than seven pounds in the last month. Resident #23 had a body mass index of less than 23 and was underweight. A behavioral medicine note dated 08/24/25 at 9:02 P.M. revealed Resident #23 stated his mood was not good. Resident #23 had a flat affect. When asked the reason for the resident's mood, Resident #23 stated I am a homeless man I have no idea what I'm going to do when I get out of here.Review of a facility investigation related to Resident #23's discharge, undated, revealed the investigation documented the resident had left the facility Against Medical Advice (AMA). The investigation included Resident #23's face sheet, care plan, progress notes, recent physician orders, and an AMA form signed by the DON and ADON #341 that was not included in the resident's medical record during the investigation. An AMA Informed Signature form that was privileged and confidential (not part of the medical record) dated 08/13/25 at 1:32 P.M. (this was the same time the resident was at Hospital #1) completed by ADON #341 under Nursing Description revealed Resident #23 returned to the facility after a LOA and refused to sign the LOA book. Resident #23 was asked to sign the LOA book. Resident #23 was educated again on signing the LOA book and Resident #23 stated he would not sign the book. Resident #23 was informed that if he refused to abide by facility policies he may not be permitted to return due to insurance authorization (insurance would not pay due to the resident going on LOA). Resident #23 stated he would just leave and refused to sign the LOA book or AMA form. Resident #23 stated Get the (expletive) out of my way. CNP #425 was notified. A note added at the end of the form revealed Resident #23 returned from LOA and stated he was leaving again. The DON and ADON #341 spoke with Resident #23 regarding the LOA and the need to sign out. Resident #23 refused. Resident #23 was educated on the need to sign out LOA for safety. Resident #23 became agitated and stated he would just leave. Resident #23 was alert and oriented. An attempt was made to educate Resident #23 on AMA. Resident #23 stated Get the (expletive) out of my way and refused to sign. Resident #23 left the facility in a wheelchair, and the AMA form was signed by two nurses (DON and ADON #341). ADON #341 was notified on 08/13/25 that Resident #23 had been found outside a hospital and he asked a bystander to call the facility (no clarification as to why the bystander called the facility). The nurse explained to the caller that Resident #23 had left the facility and would need to go to the emergency department for evaluation. Resident #23's girlfriend then came to the facility on [DATE] and stated she could not find Resident #23. The girlfriend was notified where Resident #23 had been taken (hospital information provided since that was near where the unidentified bystander called the facility) and Resident #23 had left. Resident #23's girlfriend/female friend declined to take Resident #23's belongings. The investigation revealed the facility was waiting for further information from the hospital regarding authorization for readmission. There were no staff or resident statements obtained as part of the investigation.During an interview on 08/25/25 at 12:36 P.M., Resident #23's female friend that was listed on the contact list revealed Resident #23 had mental health issues and the facility staff did not care. The friend stated she had located Resident #23, and he was currently at the hospital on a locked behavioral unit. Resident #23 had been living on the streets and was dirty. Resident #23's phone had been shut off and the friend stated she had filed a missing person report because no one knew where Resident #23 was after he left the facility. The friend stated Resident #23 left to get a beer. Resident #23 could not stop drinking and would leave the facility to get beer but always went back to the facility. Resident #23 could not walk very well and had a sore on his bottom when he went to the hospital. During an interview on 08/27/25 at 1:43 P.M., the DON stated Resident #23 liked to leave the facility and not sign the LOA book. The DON reported Resident #23 had left the facility and then come back on 08/13/25 and then wanted to leave again. The DON stated she assumed Resident #23 subsequently went to the hospital because someone called from the area near the hospital at the request of the resident. The DON stated central admissions for the facility was handled offsite, so the DON was not aware if Resident #23 had wanted to return to the facility or where Resident #23 had been discharged to (if discharged ) from the hospital. During an interview on 09/02/25 at 3:24 P.M., the DON verified there was no notification to the police, adult protective services or a home healthcare agency when Resident #23 left the faciity on [DATE]. The DON stated she considered Resident #23 an AMA discharge since he said he was leaving. The DON revealed Resident #23 made bad decisions but always knew to come back to the facility. When asked about the content and thoroughness of the facility investigation related to the incident, the DON revealed the facility did not complete much investigation into the incident because they didn't think it was an issue.During an interview on 09/03/25 at 9:25 A.M., the DON verified Resident #23 did not receive any type of services for substance abuse or mental health while residing at the facility. The DON stated she believed Resident #23 refused services but verified there was no documentation of Resident #23 being offered any services or refusing services. She also verified there was no discharge planning noted in the medical record such as contacting outside resources or looking into alternate places for the resident to live after the resident voiced, he had lost his apartment. The DON verified the resident did have a care plan for anticipated discharge to home but stated it was never followed.During an interview on 09/03/25 at 10:19 A.M., SSD #312 stated she was unsure what her responsibility was when Resident #23 left the faciity on [DATE] because the resident had left on an LOA and never returned. SSD #312 revealed she did contact the police about Resident #23 being missing after his female friend reported she was unable to locate Resident #23. SSD #312 stated she got report that following the resident leaving the facility he was at one hospital, discharged to the community and then was back at a different hospital. During an interview on 09/03/25 at 1:33 P.M., CNP #425 revealed she had not been notified immediately on 08/12/25 when Resident #23 left the facility. CNP #425 was later told Resident #23 had left the facility and would not be returning. During an interview on 09/08/25 at 12:39 P.M., the DON verified Resident #23 left the faciity on [DATE] at 6:45 A.M. and did not return. She verified the resident's medical record contained no documentation supporting the resident verbalized he wanted to leave the facility against medical advice and there was no evidence the resident had any behaviors to support him wanting to leave against medical advice. The DON verified the facility considered the resident leaving the facility an AMA discharge because the resident did not return when he left.During an interview on 09/11/25 at 10:20 A.M., Regional Nurse #264 stated Resident #23 had lost his housing and the facility did not know where the resident went when he left the faciity on [DATE].During an interview on 09/11/25 at 10:20 A.M., LNHA #271, the DON, and Regional Nurse #264 revealed they were unable to provide information as to why the police, APS, Ombudsman and/or the resident's female friend were not notified when Resident #23 left the faciity on [DATE]. Lastly, the DON and Regional Nurse #264 verified Resident #23 was alert and oriented but made unsafe decisions when he wanted alcohol.An attempt to reach the resident's physician (Physician #450) was made on 09/11/25 at 10:48 A.M. The attempt was unsuccessful. A message was left asking the physician to return the call; however, no return call was received.Further review of the medical record revealed no AMA form located within the medical record regarding the resident requesting to leave the facility AMA, no assessment of the resident's ability to safely leave the facility due to potential decision-making impairment related to alcohol use, no communication or attempts to contact the hospital regarding the resident's status and no behaviors documented. Facility staff continued to document through 08/15/25 the resident remained hospitalized (no hospital identified) with no mention the resident had refused to sign an AMA form and left the facility or make mention the resident had discharged from the facility. The facility policy titled Resident Leave of Absence, dated 12/2024, revealed that all residents leaving the facility must have orders for supervised or unsupervised leave of absence. Residents leaving the facility on leave of absence must sign out when leaving. Prior to opening the door to allow a resident to leave, the nurse would verify the leave of absence order and would communicate the leave of absence with the receptionist. Staff observing a resident leaving the premises and having doubts about the resident being properly signed out, should notify their supervisor at once. The nurse would document in a progress note the time the resident leaves the facility and if known, the purpose. Review of the Facility Assessment Tool dated 07/31/25 revealed the number/average or range of residents with behavioral health needs was four to five residents, and those with active or current substance use disorders were four to five residents. The assessment revealed the facility managed the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/post-traumatic stress disorder, and other psychiatric diagnoses, intellectual or developmental disability. Emotional support and mental well-being and support with helpful coping mechanisms would be provided. The facility would identify hazards and risks for residents. Behavioral and mental health providers were available to provide services to residents.This deficiency represents noncompliance investigated under Complaint Number 2596080.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, staff interviews, Emergency Medical Technician (EMT) interview, review of Emergency Medical Services (EMS) run report, review of the tracheostomy handbook, and review of the facilities policies and procedures, the facility failed to ensure the proper respiratory support was provided to a resident who was experiencing respiratory distress. This resulted in Immediate Jeopardy and serious life-threatening harm and/or negative health outcomes when Resident #199, who had a tracheostomy (a small surgical opening through the skin and into the windpipe), was not administered respiratory support including suctioning the tracheostomy, administering an as needed breathing treatment which was ordered for shortness of breath, changing the inner cannula of the tracheostomy to ensure its patency or attaching an Ambu (also known as a bag 0 valve-mask resuscitator) to the residents tracheostomy to provide breaths. The lack of providing respiratory support during this emergency resulted in Resident #199 experiencing shortness of breath, loss of consciousness, loss of respirations, loss of pulse and was subsequently pronounced deceased in the emergency room. This affected one (Resident #199) of two residents reviewed for tracheostomy care. The facility does not currently have any residents with tracheostomies. The facility census was 93. On [DATE] at 2:50 P.M., the Administrator, Director of Nursing (DON), and Regional Director of Clinical Operations (RDCO) #306 were notified of Immediate Jeopardy that began on [DATE] between 2:30 P.M. and 3:00 P.M., when Resident #199 had complaints of shortness of breath which led to unconsciousness, loss of respiration and pulse. On [DATE], Resident #199 complained of shortness of breath when Assistant Director of Nursing (ADON) #157 proceeded to check all oxygen tubing connections to ensure there was no leakage and increased Resident #199 ' s oxygen being delivered from 4 to 5 liters per minute. Resident #199 was noted to show no improvement, so ADON #157 left the residents ' room to call 911 (EMS) and prepare this resident ' s medical paperwork for transfer to the hospital. Licensed Practical Nurse (LPN) #303 was to remain in the room with Resident #199. EMS was noted to arrive at the facility at 3:08 P.M. where upon entering Resident #199 ' s room, the resident was found to be alone with no staff at bedside, face appeared pale, and hands and feet appeared cyanotic (bluish) in color. Resident #199 was noted to be laying in a semi-Fowler ' s position (when a person lies on their back with their head and upper body raised 30 - 45 degrees) with no supplemental oxygen in place. EMT ' s were noted to check Resident #199 ' s carotid arteries on both sides of her neck where no pulse was detected. Cardiopulmonary resuscitation (CPR) was immediately initiated with no detectable pulse ever noted. Resident #199 was transported to the local emergency room where she was pronounced deceased . The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: • On [DATE], Resident #199 was transferred to the hospital via EMS. • On [DATE], the DON audited charting over the last seven days to see if any other residents reported respiratory distress with no findings. The DON or designee will complete a weekly audit for the next 30 days regarding residents reporting respiratory concerns and ensure appropriate interventions are put in place. • On [DATE] at 4:30 P.M., the Administrator validated no residents currently reside in the facility with tracheostomies. • On [DATE] at 5:38 P.M., the facility completed a Quality Assurance and Performance Improvement (QAPI) meeting which included a root cause analysis of the event and developed a plan of correction. Participants included Medical Director #300, the Administrator, the DON, Unit Manager #117, Unit Manager #41 and RDCO #306. The QAPI plan was approved by Medical Director #300 and the Interdisciplinary Team (IDT) on [DATE]. • On [DATE], a new Emergency Tracheostomy Care Policy was put into effect. • On [DATE], a Code Blue Competency Drill was conducted by RDCO #306 and the DON. The drill also included education on responding to respiratory distress, suctioning, and monitoring of residents in respiratory distress and education on the Emergency Tracheostomy Care Policy. The Code Blue Competency and education was held on day and night shift on [DATE]. The DON completed the day shift Code Blue Competency Drill at 5:12 P.M. on [DATE] and ADON #157 completed the night shift Competency Drill at 7:18 P.M. on [DATE]. • At this time, the facility does not have a resident with a tracheostomy; however, if the facility admits a resident with a tracheostomy, the resident will be interviewed three times weekly regarding quality of respiratory care. Staff will also be interviewed three times a week for responding to respiratory distress, suctioning, and monitoring of residents in respiratory distress and education on the Emergency Tracheostomy Care Policy. These audits will continue for the next 30 days after admission. • On [DATE] at 6:00 P.M., the Administrator electronically delivered RN/LPN education to all licensed nurses regarding emergency tracheostomy care via the One Call delivery system. • On [DATE], all facility staff in Environmental Services, Dietary, Administration, Maintenance, Therapy, and Activities departments were educated on responding to respiratory distress by the Administrator. • The DON/designee will educate all agency staff prior to taking an assignment on the Emergency Tracheostomy Care Policy and will ensure they receive competency validation on tracheostomy care at the start of their shift. The DON or designee will ensure on going education with All Agency Nurses. Any nurse who did not complete the training above will not be permitted to take an assignment until completed. • The DON and/or designee will perform three staff interviews five times a week, across all shifts times 4 weeks to ensure all LPNs and RNs are knowledgeable in responding to situations of respiratory distress and steps to take to maintain oxygenation. • The QAPI committee will review the results of these audits and processes to determine if additional audits or education is needed. Although the Immediate Jeopardy was removed on [DATE], the deficiency remains at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the closed medical record for Resident #199 revealed an admission date of [DATE] and a discharge date of [DATE]. Diagnoses included acute respiratory failure with hypoxia (absence of enough oxygen in the tissue to sustain bodily function) and hypercapnia (occurs when there is too much carbon dioxide [CO2] in the bloodstream), bacterial pneumonia, morbid obesity, and tracheostomy status. Review of the admission Assessment for Resident #199 dated [DATE] at 2:41 P.M. revealed this resident admitted to this facility from a local hospital with an admission diagnosis including acute hypoxic/hypercapnic respiratory failure. Resident #199 was noted to have a full code status indicating if this patient ' s heart stops or they stop breathing, all possible medical interventions, including CPR, intubation, and defibrillation will be used to try and revive them. Resident #199 ' s respiratory assessment revealed clear bilateral lung sounds with no abnormal sounds noted and shortness of breath was experienced when Resident #199 was laying flay. Resident #199 was noted with a non-productive cough. Resident #199 was noted to be alert and orientated to person, place, time, and situation and able to make needs known and understood others. Resident #199 was noted to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating an intact cognition for daily decision-making abilities. Review of the care plan for Resident #199 failed to identify a plan to provide respiratory or tracheostomy (trach) care. Review of physician orders for Resident #199 revealed the following: -Elevate the head of bed to prevent shortness of breath related to Asthma. -Trach care every shift and as needed. -Change oxygen tubing filters and humidification bottle every week and as needed on Sunday night. -Supplemental oxygen continuously via trach at 4 liters per minute every shift for Chronic Obstructive Pulmonary Disease (COPD) -Albuterol Sulfate Nebulization Solution (2.5 milligrams [mg]/3 milliliter [ml]) 0.083% Inhale 3 ml orally via nebulizer every 6 hours as needed for shortness of breath. -Clonazepam oral tablet, 0.5 mg. Give 1 tablet by mouth every 12 hours as needed for anxiety for 14 days. Review of the medication administration record revealed no administration of the ordered nebulizer treatment on [DATE] for shortness of breath. Review of the nursing progress note dated [DATE] at 3:30 P.M., created by LPN #303, revealed Resident #199 requested to be suctioned due to reported difficulty clearing secretions. This nurse obtained assistance from another nurse (ADON #157) to perform suctioning. Procedure was completed with a moderate amount of mucus suctioned. After suctioning resident requested to be changed, while this nurse and aids were assisting resident with repositioning, resident began complaining of shortness of breath, appearing in acute respiratory distress with labored breathing and cyanosis noted. Pulse oximeter (non-invasive equipment used to measure the percent of oxygen in a person ' s blood) applied and oxygen saturations were found critically low fluctuating between 50-20%, heart rate dropped rapidly. Resident #199 maintained a weak pulse initially. 911 was immediately called by an assisting nurse (ADON #157). The face sheet, medication list and necessary documentation were printed and prepared for EMS. Upon EMS arrival the resident lost pulse, and CPR was initiated by the EMT. The resident was transported to a local hospital for further evaluation and treatment. On call clinical staff were notified and provided full report. Power of Attorney (POA) contacted and informed of the incident and resident transfer to hospital. Review of the EMS run report dated [DATE] revealed the 911 call from the facility was received at 3:02 P.M. for Resident #199 who was unconscious, Medic Unit #72 was notified of the dispatch at 3:03 P.M., Medic Unit #72 was enroute to the facility at 3:04 P.M. and arrived at the facility at 3:08 P.M. Resident #199 was found lying in her bed unconscious and not breathing. Primary assessment of Resident #199 when medics arrived was cardiac arrest which was noted prior to any EMS arriving. No vitals were able to be obtained due to this patient ' s condition. Continued reviews indicated that no CPR was being performed by facility staff prior to EMS arriving at the facility. Medic Unit was noted to leave the facility at 3:26 P.M. and arrived at the local hospital at 3:32 P.M. Interview on [DATE] at 2:56 P.M. with ADON #157 revealed she has worked at this facility for about six years and over the years they have had multiple trach patients. ADON #157 stated that on [DATE] she came in just to grab some paperwork and that was when LPN #303 asked her if she could just help with suctioning Resident #199. LPN #303 stated she knew how to do it but was busy. ADON #157 stated that while she set up the sterile suctioning kit, she had placed the pulse oximeter on Resident #199 ' s finger to see what her oxygen saturations were, and they were in the high 90s and her pulse per what she remembered was fine. ADON #157 reported that she placed the suction catheter in once and there were not a lot of secretions noted. The resident requested to be suctioned again so she waited about 5 minutes and then did it again all while the pulse oximeter was in place and her sats were still at baseline and good. After the second time suctioning, Resident #199 requested to be pulled up in bed, which she assisted with. Then she said she needed to be changed. As the Certified Nursing Assistants (CNAs) were coming in to do this care, Resident #199 started to complain she could not breathe, ADON 157 noticed her pulse and oxygen level started to decline. Resident #199 was already receiving 4 liters of oxygen, so she bumped it up to 5 liters with no positive outcome. ADON #157 stated she called 911 and the EMS arrived quickly. All during this time, the primary nurse (LPN #303) remained at bedside and this resident was still alert and had a pulse during this time. EMS took this resident to the hospital. Interview on [DATE] at 6:38 P.M. with Agency LPN #303 reported Resident #199 requested to have her tracheostomy suctioned and ADON #157 was at the facility so she figured the resident would be more comfortable with a full-time staff member doing this care instead of her, so she asked ADON #157 to complete this care. After this care was completed twice, this resident requested to be changed. When Resident #199 ' s head of bed was lowered to provide care, she started to complain of shortness of breath. Her head was raised up and ADON #157 increased her oxygen level from 3 to 4.5 or 5, she could not remember the exact number. Resident #199 did not appear to be any better, so ADON #157 went to call 911 and get the residents ' paperwork ready. During this time, she remained with the resident until EMS arrived. The pulse oximeter remained in place and while she could not recall the patient ' s pulse, she remembered her oxygen saturations reading in the low 80%. Until EMS arrived at the facility, her oxygen saturation was in the low 80s and then it suddenly dropped to about 25% but again she could not recall the pulse because she was more focused on her respiration and oxygen saturations. LPN #303 claimed Resident #199 ' s head of bed was raised high, and she was receiving oxygen support via trach mask when EMS arrived. LPN #303 confirmed that no one attempted to suction the patient, did not administer as needed breathing treatment for shortness of breath, did not change the inner trach cannula nor did they attempt to attach an Ambu bag for breathing assistance. An interview was conducted on [DATE] at 2:45 P.M. with EMT #308 and Battalion Chief #310. EMT #308 revealed he has been a medic for two years now. He stated he was the lead of Medic Unit #72 who responded to this facility for Resident #199 who was reported in respiratory distress. The station received the call at 3:02 P.M., and they arrived at the facility at 3:08 P.M. When they walked through the facility ' s ambulance entrance her room was right there. EMT #308 reported they walked into her room and no staff members were in the room, and the patient was laying in a semi-Flowers position and had no supplemental oxygen on. Her face was pale, and her hands and feet were blue. He immediately checked both carotid arteries and felt no pulse. Chest compressions were immediately started, and he then instructed another Medic to obtain an airway. This was when they realized this patient had a trach but due to how she was laying and her size, they could not see it. They were able to obtain an airway with her trach and CPR continued. Epinephrine was administered, which is a medication used during CPR which acts as adrenaline to stimulate the body ' s sympathomimetic system or the Fight-or-Flight response. Medic #308 stated CPR was started within 60 seconds of arriving at the facility. He could not recall if there was a pulse oximeter on her finger or not, but she did not have a pulse per his assessment. Per Medic #308 and Battalion Chief #310, per the appearance of this patient, her pulse had not just stopped when they entered the facility. Each patient is different in the way they decline but the pale face and blue feet and hands do not happen immediately. Further interview revealed they cannot say for sure what the facility did or did not do but they strongly feel not all respiratory measures were taken to help this patient with respiratory distress. Interview on [DATE] at 4:25 P.M. with CNA #191 revealed she did work the day shift on [DATE] but was not Resident #199's primary caregiver. CNA #191 stated she assisted the other CNAs with changing her that morning. After this, Resident #199 requested to be suctioned so they told the nurse. CNA #191 reported Resident #199 pulled her call light multiple times during the day requesting to be suctioned and the nurse would say okay but would not do it. Around 2:00 P.M. on [DATE] when she came into Resident #199 ' s room she was upset and looking on the Internet for different facilities for her to transfer to, claiming she did not feel safe. CNA #191 stated she gave the patient the Administrators number for her to contact him and let him know what was going on. The patient was claiming that she had not been suctioned since she arrived at the facility. Review of the undated Smiths Adult trach handbook the facility provided revealed that during an emergency, a bag ventilation device is used when resident is not able to breathe with ease or has stopped breathing. Using the bag allows you to assist his/her breathing or to completely take over breathing for him/her. This is to be used with CPR if the resident is not breathing and you cannot find a pulse. It may also be used to help resident breathe whenever there is difficulty or shortness of breath. Review of the facility policy titled, Lower Airway (tracheostomy tube) Suctioning dated [DATE] revealed, the purpose was to remove secretions, maintain a patent airway, and prevent infection to the lower respiratory tract. Review of facility policy titled, Advanced Directives dated [DATE] revealed under the section titled Full Code, when a resident is identified as a full code the facility staff will provide emergent measures in an attempt to resuscitate the patient. This may involve chest compressions, electric shocks, and emergency medications that act to temporarily keep blood moving to essential organs such as the brain. The facility staff must continue any resuscitative efforts until EMS arrives and takes over. This deficiency represents noncompliance under Complaint Number OH00164689.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital discharge summaries, resident and staff interviews, and facility policy review, the facility failed to ensure Resident #58 was administered diabetic medication as ordered. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, injuries, and/or death on [DATE] when Resident #58 was readmitted to the facility from the hospital with orders for Lantus (a long-acting insulin) and Humalog (a fast-acting insulin) and Resident #58 was not administered any diabetic medications or insulin on [DATE] or [DATE]. On [DATE] at approximately 11:30 A.M., Resident #58 was sent back to the hospital when Resident #58's blood sugar was checked and showed high. Resident #58's blood sugar was 624 milligrams per deciliter (mg/dL) at the hospital and Resident #58 was treated for hyperglycemia and diabetic ketoacidosis (DKA). Resident #58 remained in the hospital until [DATE]. This affected one (Resident #58) of six residents reviewed for unnecessary medication and/or diabetic medications. The census was 87. On [DATE] at 4:50 P.M., the Administrator #149 and Director of Nursing (DON) #163 were notified that Immediate Jeopardy began on [DATE] when Resident #58 returned to the facility at approximately 1:00 P.M. with orders for the following medications: Lantus (a long-acting insulin) 14 units every morning and Humalog (a fast-acting insulin) per corrective scale three times a day before meals. Resident #58 was not administered any insulin or diabetic medications from [DATE] at approximately 1:00 P.M. through [DATE] at approximately 11:30 A.M., and there was no evidence Resident #58's blood sugar levels were checked from [DATE] at approximately 1:00 P.M. until [DATE] at approximately 11:30 A.M. when Resident #58's blood sugar level measured high, and Resident #58 was sent back to the hospital. Resident #58's blood sugar level at the hospital was 624 mg/dL (A normal blood glucose before a meal for someone with Diabetes is 80 to 130 mg/dL and a normal blood glucose one to two hours after beginning a meal is less than 180 mg/dL per the American Diabetes Association) and Resident #58 was treated for hyperglycemia and DKA (a serious diabetes complication where the body produces excess blood acids or ketones that occurs when there is not enough insulin in the body). Resident #58 remained in the hospital until [DATE]. The Immediate Jeopardy was removed on [DATE] when the facility completed the following corrective actions: • On [DATE], Resident #58 returned to the facility from the local hospital. • On [DATE], the facility began reviewing all new admissions for the last seven days to ensure orders were entered correctly and timely. Resident #58 was included in the audit. Any concerns identified in the admission audit were corrected at that time. This was completed by the Traveling Director of Nursing #242 on [DATE] at 11:00 A.M. • On [DATE], Administrator #149 sent a one call education to all nurses regarding the input of resident admission orders. This education was initiated and completed on [DATE]. • On [DATE], Medical Director (MD) #218 received the facility Quality Assurance and Performance Improvement (QAPI) plan which reviewed the facility plan to correct and determine the root cause of the incidents. The QAPI plan findings revealed the root cause was agency staff, nurse education, poor understanding of the admission process, timely completion of new admissions, and difficulty navigating hospital paperwork. The plan included education to nurses on the Facility admission checklist which includes reviewing the after-visit summary and discharge summary by the admitting nurse and follow up audits by the Unit Managers. These audits will be reviewed by the Director of Nursing or designee. MD #218 responded via email on [DATE] and indicated she approved of the plan with no additions. • On [DATE], the DON or designee-initiated education for all nurses present in the building. • On [DATE], the DON or designee completed medication administration audits for all nurses working and the audits will continue before any nurse starts a shift. The education was initiated on [DATE]. Medications must be entered into the system during the shift of admission and medications must be administered per doctor's orders. The education was completed by the Administrator via automated phone calls on [DATE]. • On [DATE], all residents were audited to ensure their medication orders were accurate and complete. This audit was completed on [DATE] by the DON or designee. • On [DATE], the medication order policy was reviewed by the Interdisciplinary Team (IDT) and no changes were recommended. • On [DATE], a one call education for the nurses was completed. The education included medication orders and follow up appointments for all new and current residents must be entered into the system timely after admission or the order is received. Medications must be administered per physician orders. Medications must be entered by the admitting nurse and then audited during the next nurse shift. • All new licensed nurses and licensed agency nurses have been included in all education and will continue to be educated on medication orders before working with residents. Education was also sent out to the four agencies in order to educate their staff prior to working at the facility by Staffing Coordinator #107 on [DATE]. The education was added to the facility's agency education binder. • The DON or designee will complete random audits daily for the next 30 days to ensure new admission orders are entered timely and accurately. These audits will continue for the next 30 days and will be reviewed by the QAPI committee to see if additional education or interventions are necessary. • Interviews on [DATE] from 3:48 P.M. through 3:55 P.M. revealed Assistant Director of Nursing #179, Licensed Practical Nurse (LPN) #113, and LPN #121, were knowledgeable regarding ensuring residents receive medications as ordered, ensuring medications are entered appropriately upon admission/readmission, and reviewing appropriate forms from the hospital when a resident is admitted or re-admitted . Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #58 revealed an initial admission date on [DATE] and a readmission date on [DATE]. Resident #58's medical diagnoses included metabolic encephalopathy, Type one Diabetes Mellitus with ketoacidosis without coma, and long-term use of insulin. Review of the census report for Resident #58 revealed Resident #58 was hospitalized from [DATE] to [DATE] and from [DATE] to [DATE]. Review of the care plan, dated [DATE], revealed Resident #58 was at risk for adverse outcomes from potential hypoglycemic or hyperglycemic episodes due to a diagnosis of Type one Diabetes Mellitus. Interventions for Resident #58 included Accu-check blood sugar testing as ordered and administer insulin as ordered. Review of the Medicare Five Day Minimum Data Set (MDS) 3.0 assessment, dated [DATE], revealed Resident #58 had intact cognition and scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #58 required extensive assistance to total dependence from one to two staff to complete Activities of Daily Living (ADLs). Resident #58 received daily insulin injections and had insulin orders changed one time during the review period. Review of physician orders, dated [DATE], revealed Resident #58 did not have any insulin orders or diabetic medication orders entered on [DATE] and [DATE]. Resident #58 had an order to send to the emergency room (ER) for observation dated [DATE]. Review of the Medication Administration Record (MAR), dated [DATE], revealed Resident #58 was not administered any insulin on [DATE] or [DATE]. Review of the blood sugar results for Resident #58, dated from [DATE] through [DATE], revealed Resident #58 did not have any blood sugar levels entered on [DATE] and the only blood sugar level entered on [DATE] showed a reading of 1.0 (1.0 was entered due to being unable to enter high) at 4:55 P.M. Review of progress notes, dated from [DATE] to [DATE], revealed on [DATE] at 4:53 A.M., Resident #58 reported having chest pain and shortness of breath. Resident #58 was sent out to the hospital for an evaluation and was admitted to the hospital. On [DATE] at 1:11 P.M., an agency nurse (Agency Nurse #260) noted Resident #58 arrived at the facility from the hospital. On [DATE] at 2:00 P.M., LPN #137 noted Resident #58 arrived at the facility via transport. Resident #58 was provided lunch. Resident #58's medications were verified with the physician and entered into the electronic medical record for delivery via the pharmacy. Resident #58's representative was notified of Resident #58's arrival. On [DATE] at 11:25 A.M., LPN #135 noted she was notified by the aide and therapy that Resident #58 was not at baseline. Resident #58's vital signs were stable. Resident #58's blood sugar was high, with trembles and Resident #58 was disoriented. Certified Nurse Practitioner (CNP) #215 was notified and a verbal order was received to send Resident #58 to the emergency room for an evaluation. Resident #58's responsible party was notified. On [DATE] at 12:35 P.M., Resident #58 was readmitted to the facility from the hospital. Review of the Discharge summary, dated [DATE] and included in Resident #58's electronic medical record, revealed Resident #58 was admitted to the emergency room on [DATE] at 3:47 P.M. Resident #58 presented with shortness of breath. Resident #58's metformin (diabetic medication) was stopped. Resident #58's Lantus insulin (long-acting insulin) was reduced from 18 units to 14 units on [DATE] due to hypoglycemia. Resident #58's new medications at discharge included Lantus insulin with instructions to inject 14 units under the skin every morning and Resident #58's continued medications included Humalog insulin (short acting insulin) with instructions to inject three units under the skin three times a day before meals plus corrective scale insulin. Review of the Discharge summary, dated [DATE], revealed Resident #58 was admitted on [DATE] with hyperglycemia and found to have DKA. The discharge summary revealed Resident #58 reported the facility ran out of insulin and he was not administered any insulin for one day. Resident #58's blood glucose was 642 milligrams per deciliter (mg/dl), Anion Gap (AG) was 23 (a normal anion gap is typically 4 to 12 millimoles per liter (mmol/L)), and Beta-Hydroxybutyrate (BHB) was seven (normal BHB levels are less than or equal to 0.3 mmol/L and are typically greater than 2.0 mmol/L in patients with ketoacidosis). A continuous insulin infusion protocol was started for Resident #58. Resident #58 was transitioned to subcutaneous (under the skin) insulin on [DATE]. Resident #58 was discharged back to the facility on [DATE]. Interview on [DATE] at 6:07 P.M. with Resident #58 revealed there was a mix-up with obtaining his insulin at the facility and his blood sugar level increased to over 600. Resident #58 stated he was sent to the emergency room (ER) on [DATE] after he did not receive any insulin injections for one to one and a half days. Resident #58 stated he typically received insulin injections early in the morning and with meals as needed. Resident #58 stated he did not receive any insulin injections and had to stay in the hospital for a couple of days. Interview on [DATE] at 4:39 P.M. with Agency Licensed Practical Nurse (ALPN) #240 confirmed Resident #58 did not have any insulin orders entered in the medical record on [DATE] and [DATE]. Interview on [DATE] at 10:55 A.M. with Regional Nurse (RN) #235 confirmed there was a medication error that occurred when Resident #58 returned to the facility on [DATE]. RN #235 stated the floor nurse who was present when Resident #58 returned to the facility was an agency nurse (Agency Nurse #260) and failed to enter all of Resident #58's medication orders into the medical record. RN #235 confirmed Resident #58 did not receive any insulin from [DATE] at approximately 1:00 P.M. when Resident #58 returned to the facility through [DATE] at approximately 11:30 A.M. when Resident #58 was sent out to the hospital. RN #235 also confirmed Resident #58's blood sugar levels were not checked during the same timeframe. Interview on [DATE] at 11:06 A.M. with LPN #137 revealed when a resident was readmitted to the facility following a hospital stay, the floor nurse was responsible for gathering information and entering the resident's medication orders into the electronic medical record. LPN #137 stated the progress note she entered on [DATE] at 2:00 P.M., was incorrectly dated. LPN #137 stated she completed an admission audit of Resident #58's medical record on [DATE], not [DATE], and no medication orders were entered until [DATE]. LPN #137 stated an agency nurse (Agency Nurse #260) was the floor nurse who was present when Resident #58 arrived back at the facility from the hospital on [DATE]. Interview on [DATE] at 12:20 P.M. with CNP #215 revealed she was on-site at the facility on [DATE] when Resident #58 returned to the facility from the hospital. CNP #215 stated she verified Resident #58's medication orders. CNP #215 stated Resident #58 returned with orders to discontinue the sliding scale insulin, Humalog, and to reduce Resident #58's Lantus insulin to 14 units in the morning. CNP #215 stated she used a discharge summary from Resident #58's hospital chart that was dated [DATE] to verify Resident #58's medication orders. CNP #215 stated the staff called her on [DATE] at 4:55 P.M. (over 24 hours after Resident #58 was readmitted to the facility and after Resident #58 had already been sent back out to the hospital) to verify Resident #58's sliding scale insulin. CNP #215 confirmed she would expect Resident #58's blood sugar levels to be checked at least in the morning at a minimum and with a sliding scale insulin order, should be checked prior to administering any sliding scale insulin to confirm the correct amount of insulin was administered. Review of the Discharge summary, dated [DATE] and received from CNP #215 via email on [DATE] at 3:29 P.M., revealed Resident #58 had orders for Lantus insulin with instructions to inject 14 units under the skin every morning and Humalog insulin with instructions for corrective (sliding) scale three times a day before meals. The prandial (insulin taken at mealtime) insulin was discontinued. Review of the facility policy, Medication Orders Non-Controlled Medication Orders, dated 12/2012, revealed the policy stated Written transfer orders (sent with a resident from a hospital or other health care facility), implement a transfer order without further validation if it is signed and dated by the resident's current attending physician, unless the order is unclear or incomplete or the date signed is different from the date of admission. If the order is unsigned or signed by another prescriber or the date is other than the date of admission, the receiving nurse verifies the order with the current attending prescriber before medications are administered. The nurse documents verification on the admission order record by entering the time, date, and signature. The nurse who transcribes the orders to the physician order sheet and/or Medication Administration Record (MAR) documents on the admission form the date, the time, and by whom the orders were noted. Orders are transmitted to the pharmacy with any additional information required for new admission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital records, review of dental records, staff interview, and facility policy review, the facility failed to ensure one resident (Resident #72) was provided dental care in a timely manner. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm and/or medical emergency on 03/30/23 when Resident #72 was re-admitted to the facility from the hospital where Resident #72 had been treated with three antibiotics for sepsis (the body's extreme response to an infection) caused by several abscessed teeth. Resident #72 was discharged from the hospital with an order to follow-up with a dentist as soon as possible (ASAP) for tooth extractions. Resident #72 did not receive any follow-up with a dentist and was re-admitted to the hospital on [DATE] due to septic shock (the most severe stage of sepsis) which was most likely due to Resident #72's abscessed teeth. Resident #72 received oral surgery in the hospital to extract the several abscessed teeth. This affected one (Resident #72) out of three residents reviewed for dental services. The facility census was 87. On 06/14/23 at 4:50 P.M., the Administrator #149 and Director of Nursing (DON) #163 were notified that Immediate Jeopardy began on 03/30/23 when Resident #72 was discharged from the hospital where he received treatment for sepsis due to several abscessed teeth. Resident #72 was discharged with an order to follow-up with a dentist ASAP for tooth extractions. Resident #72 did not receive any dental follow-up services for tooth extraction between 03/30/23 and 05/12/23. Resident #72 was re-admitted to the hospital on [DATE] and was treated for septic shock with symptoms of significant hypothermia (a significant and potentially dangerous drop in body temperature), leukopenia (low white blood cell count), hypotension (low blood pressure), and a short-term course of vasopressor support (a serious intervention that can only be done in the intensive care unit (ICU) and usually means someone has a critical medical condition). A Computerized Tomography (CT) scan of the maxillofacial area (face, head, neck, and jaw) on 05/13/23 showed several large dental caries (cavities), several periapical teeth lucencies (holes in bone formed as a result of inflammation under the root of the tooth), suspicious for odontogenic abscesses (infections that originate in the teeth and/or their supporting tissues), and soft tissue swelling at the base of the tongue. Resident #72 was moved to the Medical Intensive Care Unit (MICU) due to worsening confusional episodes, hypothermia, and hypotension. Resident #72 was treated with intravenous (IV) antibiotics for the infection and received oral surgery to extract the several abscessed teeth. The Immediate Jeopardy was removed on 06/15/23 when the facility completed the following corrective actions: • On 05/18/23, Resident #72 was readmitted to the facility from the hospital after having his teeth extracted in the hospital. • On 06/14/23, all residents had their oral health assessed by DON #163, Assistant Director of Nursing (ADON) #179, Clinical Manager #137, Clinical Manager #164, Wound Nurse #153, Infection Preventionist #135, and Traveling Director of Nursing (TDON) #242. Residents were interviewed regarding their oral health. Residents who expressed concern or were unable to answer due to impaired cognition had an oral assessment by a licensed nurse. All residents who were identified were communicated to the facility contracted dental provider on 06/15/23 by the Regional Director of Nursing (RDON) #235 via email. All new admissions and residents returning to the facility will be interviewed regarding their oral health and have an oral assessment completed by licensed nursing staff. The DON or designee will weekly randomly review these assessments for accuracy and completion. These audits will continue for the next 30 days and will be reviewed by the Quality Assurance and Performance Improvement (QAPI) committee where the facility will determine if additional audits or education are needed. • On 06/14/23, Social Services #146 completed an audit of all residents in order to see when they were last seen by dental services. Residents who were not signed up for dental services had that option reviewed with them or their representative. This was completed on 06/14/23 by Social Services #146. • On 06/14/23, education was initiated for all scheduled nurses to ensure dental services were provided. Nurses were educated that all new admissions and current residents that receive consultations for dental services must be scheduled by the facility for follow up. Residents with concerns regarding their oral health must be assessed for their oral health and have follow up documented. The education was initiated by the DON via in-person education on 06/14/23. The education was completed by Administrator #149 via automated phone calls on 06/15/23. • On 06/14/23, MD #218 received the facility QAPI plan which reviewed the facility plan to correct and determined the root cause of the incidents. The QAPI plan findings revealed the root cause was agency staff, nurse education, poor understanding of the admission process, timely completion of audits for new admissions, and difficulty navigating the hospital paperwork. MD #218 responded via email on 06/14/23 and indicated she approved of the plan with no additions. • On 06/15/23, the dental services policy was reviewed by the Interdisciplinary Team (IDT) with no revisions recommended. • On 06/15/23, education was initiated for State Tested Nurse Aides (STNAs) by TDON #242 and was sent out by the Administrator via automated phone call on 06/15/23 and all STNAs were verified to have completed the education on 06/15/23. • All new direct care staff and direct care agency staff will be educated on dental services prior to starting their shift. On 06/15/23, Facility Staffing Coordinator #107 sent out education to the four agencies utilized by the facility in order for them to educate their staff prior to coming to the facility. The education was added to the facility agency education binder. • All new admissions and residents returning to the facility will be interviewed regarding their oral health and will have an oral assessment completed by licensed nursing staff. The DON or designee will randomly review these assessments weekly for accuracy and completion. These audits will continue for the next 30 days and will be reviewed by the QAPI committee. The QAPI committee will determine if additional audits or education are needed. Although the Immediate Jeopardy was removed on 06/15/23, the facility remained out of compliance at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Findings include: Review of the medical record for Resident #72 revealed an initial admission date on 02/15/21 with readmission dates on 03/30/23 and 05/18/23. Resident #72's medical diagnoses included encephalopathy, severe sepsis with septic shock, respiratory arrest, periapical abscess without sinus, cellulitis and abscess of mouth, encounter for surgical aftercare following surgery on the teeth or oral cavity, and periodontal disease. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 01/03/23, revealed Resident #72 had severely impaired cognition and scored a three out of 15 on the Brief Interview for Mental Status (BIMS) assessment. There were no dental issues noted on the assessment. Review of the Summary Report for dental care, dated from 02/01/22 through 06/14/23, revealed Resident #72 was seen by a dentist on 02/01/22 and 02/09/23. Resident #72 had not been seen by a dentist since 02/09/23. On 02/09/23, Resident #72 was seen for a periodic examination, no x-rays were taken, and there were no complaints. Review of Resident #72's progress notes dated 03/21/23, revealed Resident #72 was seen by Certified Nurse Practitioner (CNP) #215 for altered mental status. Resident #72 had a change in mental status, would not leave his room, was not eating, and displayed garbled speech. CNP #215 ordered for Resident #72 to be sent to the hospital for an evaluation to rule out stroke. Review of the hospital records, dated 03/30/23, revealed Resident #72 was admitted to the hospital on [DATE]. On 03/24/23, Resident #72 was seen by Infectious Disease (ID) #223 who noted Resident #72 had one positive blood culture identified as Actinomyces (a type of bacteria commonly found in the mouth). Resident #72 was hypothermic with a white blood cell count of 4,000. Vancomycin, Cefepime, and Ampicillin (three different antibiotics) were initiated. ID #223 noted there was a relatively high suspicion for dental source as the cause of the infection based on the Computed Tomography (CT) scan showing periodontal disease and tooth infection. ID #223 ordered for Resident #72 to start penicillin (an antibiotic) for possible Actinomyces bacteremia. On 03/26/23, Resident #72 was seen by Physician #220 who was called by the nurse for worsening encephalopathy and recurrent hypothermia (sudden drop in body temperature). The nurse reported Resident #72's mentation had been worsening all day with increased lethargy (lack of energy) and Resident #72 was now unresponsive and required the [NAME] again (warming blankets that bring heat close to the patient's body to help increase blood flow). An oral and maxillofacial surgery consult note, dated 03/27/23, revealed Resident #72 had overall poor dentition due to neglect. A blood culture was done and showed actinomyces (a type of bacteria usually found in the mouth and/or around teeth) in the face of multiple carious (cavities) teeth. The current hospital medications included Penicillin G Potassium (an antibiotic) 12 million units in sodium chloride 0.9% (normal saline) 500 milliliters (mL) intravenous (IV) every 12 hours. A CT scan of the maxillofacial area with contrast showed dental caries (cavities) and scattered apical lucency/abscess and paranasal sinus disease. A CT scan of the head and neck showed scattered dental caries and periodontal disease/tooth infection. Review of the After Visit Summary (AVS), dated 03/30/23, stated Handoff to Primary Care Physician (PCP), PCP to address the following: dental visit as soon as possible (ASAP) to remove remaining teeth. Resident #72 was to receive oral Augmentin (an antibiotic) through 04/05/23. The AVS noted Resident #72 had a positive blood culture, was hypothermic with a temperature of 93 degrees Fahrenheit (F), leukopenia with white blood cells of 3,000 on admission, and acute encephalopathy. A urinalysis (UA) was done and was without signs of infection. Resident #72 was to see an outpatient dentist ASAP for removal of remaining teeth. Infectious Disease was following, and Resident #72 received intravenous (IV) Penicillin G while hospitalized then transitioned to Augmentin on discharge with a stop date of 04/05/23. Review of the physician orders dated March 2023 revealed Resident #72 had an order for Augmentin oral tablet 875-125 milligrams (mg), give one tablet by mouth two times a day for six days for urinary tract infection. The order had a start date of 03/30/23 and an end date of 04/05/23. Review of Resident #72's physician orders from 03/30/23 through 05/12/23 revealed there were no orders for Resident #72 to have a tooth extraction completed. Review of Resident #72's progress notes dated 03/30/23 at 3:53 P.M., revealed Resident #72 returned from the hospital by ambulance. Resident #72's vital signs were within normal limits. Resident #72 had no signs or symptoms of pain or distress. The physician and family were made aware of the resident's return. Review of Resident #72's progress notes dated 04/01/23 at 6:57 A.M, revealed Resident #72 was noted to be on antibiotics for a urinary tract infection (UTI). Review of Resident #72's progress notes dated 04/04/23, revealed Resident #72 was seen by CNP #215 as a follow up for Resident #72's muscle weakness and recent altered mental status. There was no indication that Resident #72 was on antibiotics or that Resident #72 was treated for sepsis due to abscessed teeth and had an order to follow-up with a dentist as soon as possible to have teeth extracted. Review of Resident #72's progress notes dated 04/05/23, revealed Resident #72 was seen by Physician #218 for a regular visit and follow-up on blood pressure. There was no indication that Resident #72 was on antibiotics or that Resident #72 was treated for sepsis due to abscessed teeth and had an order to follow-up with a dentist as soon as possible to have teeth extracted. Review of Resident #72's progress notes dated 04/05/23 at 1:22 P.M., revealed Resident #72 was reviewed for readmission by Registered Nurse (RN) #250 to the facility on [DATE]. Resident #72 was noted to have readmitted to the facility on [DATE] status post (s/p) sepsis and continued on antibiotics through 04/05/23 for a UTI. Review of the care plan for Resident #72, revised 05/03/23, revealed Resident #72 needed ancillary services such as dental. Interventions included to coordinate with Social Services for scheduling of Resident #72's need to see in-house specialty physicians, educate Resident #72 to communicate the need for an appointment with nursing and social services in order to be set-up as needed, notify the specialty physician and responsible party of any changes or concerns regarding appointments, obtain consent from Resident #72 and/or responsible party prior to consulting the in-house specialty physician, and review progress notes from specialist and communicate with Primary Care Physician (PCP) any recommendations/changes to medication or treatment plan. Review of the dental note, dated 05/08/23, revealed Resident #72 was seen by a dental hygienist only and was not seen by a dentist. The dental hygienist looked in Resident #72's mouth but Resident #72 was not cooperative outside of that. No prophylaxis was completed however oral hygiene instructions were provided. Review of Resident #72's progress notes dated 05/10/23 at 2:07 P.M., revealed Resident #72 was noted to have been seen by the dentist on 05/08/23. Review of Resident #72's progress notes dated 05/12/23, revealed Resident #72 was seen by CNP #215 due to Resident #72 having no urine output for 24 hours. Staff were unable to straight catheterize Resident #72 for urine. Resident #72's abdomen was firm and distended. Resident #72 was sent to the hospital for further evaluation and was admitted to the hospital. Review of the hospital records, dated 05/12/23, revealed Resident #72 was admitted to the Medical Intensive Care Unit (MICU) on 05/12/23 at 3:15 P.M. Physician #227 saw Resident #72 on 05/12/23 at 8:14 P.M. in the MICU due to confusional episodes, significant hypothermia, leukopenia, and subsequent hypotension. Resident #72 was treated with a low dose of norepinephrine (a medication to increase alertness, arousal, and attention). Physician #227 agreed to continue intravenous Vancomycin and Zosyn (antibiotics) to treat septic shock. Review of the hospital records dated 05/14/23 at 3:23 P.M., revealed Resident #72 was seen by Dentist (DDS) #225 in the hospital. Resident #72 had generalized poor dentition with multiple decayed and abscessed teeth. A CT scan revealed multiple decayed teeth with periapical abscesses present. The plan was to send Resident #72 to the operating room on 05/15/23 for extraction of the multiple decayed and abscessed teeth that were a potential source of the sepsis. Review of the hospital records dated 05/15/23 at 5:24 A.M., revealed Resident #72 was seen by Physician #231 in the MICU for septic shock, acute on chronic encephalopathy, and actinomyces bacteremia. Resident #72 was treated for septic shock presumptively from a dental source as Resident #72 previously grew actinomyces and had a very similar presentation. Resident #72 needed extensive dental extractions to minimize the source of infection. Physician #231 noted Resident #72 needed a minimum of six months of antibiotic therapy in Physician #231's opinion. Review of the hospital records dated 05/15/23 at 7:07 A.M., revealed Resident #72 was seen by CNP #234 in the hospital who noted Resident #72 was treated for septic shock which was suspected to be secondary to oral abscesses. A urine culture on 05/12/23 was negative. A CT scan completed on 05/13/23 showed several large dental caries (cavities), several periapical teeth lucencies which were suspicious for odontogenic abscesses, and soft tissue swelling at the base of the tongue. At prior hospitalization, Oral and Maxillofacial Surgery (OMFS) recommended follow up with an outpatient dentist ASAP for removal of remaining teeth. Resident #72 did not follow up for dental extractions. Review of the hospital records dated 05/15/23 at 7:36 P.M., revealed during Resident #72's hospitalization, Resident #72 underwent a surgical procedure to extract multiple abscessed teeth by DDS #225. Review of the hospital records dated 05/18/23, revealed Resident #72 was discharged from the hospital back to the facility. Review of Resident #72's progress notes dated 05/19/23 at 1:13 P.M., revealed Resident #72 was reviewed by LPN #137 for readmission to the facility on [DATE] following extraction of an infected tooth and encephalopathy. Resident #72 was prescribed Amoxicillin (an antibiotic) 500 mg every eight hours for ten days for s/p tooth extraction. Review of the quarterly MDS 3.0 assessment, dated 05/21/23, revealed Resident #72 had severely impaired cognition and scored a 99 on the BIMS assessment signifying the resident was unable to complete the assessment. Resident #72 required extensive assistance from one to two staff to complete ADLs. Resident #72 was noted to have mouth or facial pain, discomfort, or difficulty with chewing. Interview on 06/14/23 at 11:19 A.M. with RDON #235 confirmed Resident #72 had not been seen by a dentist since 02/09/23. RDON #235 stated the facility received two AVS's from Resident #72's hospitalization in March 2023 and only one of them indicated the need for Resident #72 to follow up with a dentist. RDON #235 confirmed Resident #72's discharge summary showed the need for Resident #72 to follow-up with a dentist ASAP for tooth extractions and had been received by the facility. RDON #235 stated they used the AVS and did not usually review the entire discharge summary. Interview on 06/20/23 at 3:55 P.M. with LPN #121 revealed as part of the admission process, nurses review the hospital after visit summary and discharge summary for follow up needs. The nurses are supposed to look at what appointments have been made or need to be made and enter that information into the electronic medical record as well as fill out a transportation request form for the transport to the appointments. Interview on 06/21/23 at 1:41 P.M. with Social Worker (SW) #146 and Corporate Director of Social Services (CDSS) #280 revealed the social worker is responsible for scheduling routine follow up visits with the contracted dental provider. SW #146 stated she was not aware Resident #72 needed any dental follow up after his hospitalization in March 2023. SW #146 stated the contracted dental provider rotates every three to six months between a hygienist visit and a dentist visit. Resident #72 was seen by a dentist in February 2023 and then by a hygienist in May 2023. SW #146 stated the nursing staff was responsible for scheduling outside dental appointments and if a tooth extraction was needed, Resident #72 would need to be sent out to an outside dentist for treatment. The contracted dentist had not been back to the facility since May 2023. If a resident needed treatment in between the regular routine visits, then the resident would need to be scheduled for an outside dentist appointment and nursing would be responsible for making those arrangements. Review of the facility policy titled Dental Services, dated 11/15/17, revealed the policy stated, the purpose of this policy is to ensure the Center assists patients/residents in obtaining routine and 24-hour emergency dental care. It is the responsibility of the clinical team to monitor, assess and recommend interventions to maintain the highest practicable dental care for all patients/residents. Upon admission or during a patient/resident's stay if it is determined a patient/resident is in need of routine and/or emergency dental care the Center will have available a means to provide routine and/or emergency dental care.