**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation review, hospital record review, medical transport services record review, and interview, the facility failed to ensure residents remained free from accident hazards for 2 of 5 (Resident #415 and #515) sampled residents reviewed for accident hazards. The facility failed to ensure a vulnerable, non-verbal, cognitively impaired resident who required 2-person assistance with bed mobility and care, remained free from accident hazards as evidenced by failure to provide the required amount of assistance for safe repositioning and/or transfer, resulting in a significant injury and hospitalization for Resident #415. On 3/7/2025 at approximately 11:20 AM, Resident #415, a cognitively impaired Resident who was totally dependent on staff for mobility and required 2-person assistance with activities of daily living (ADLs) was receiving care from Certified Nursing Assistant (CNA) A and CNA B. CNA A and CNA B repositioned Resident #415 in the bed on to her side, CNA B then exited the Resident's room to get more supplies, and left CNA A in the room alone with Resident #415 who was still positioned on her side. According to staff, Resident #415's weight shifted, which caused the Resident to fall from the bed to the floor, and hitting her head which resulted in a large hematoma to the Resident's left side of the forehead. Resident #415 was transported to the emergency room on 3/7/2025 and remained hospitalized until 3/19/2025, with the admitting diagnosis of Focal Hemorrhagic Contusion of Cerebrum (a bruise to the brain caused by a head injury with bleeding and swelling). The facility's failure to provide an environment that was free from accident hazards resulted in an Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) for Resident #415. The facility also failed to provide an environment free from accident hazards when Resident #515, a moderately cognitively impaired resident, who required assistance with mobility, sustained an unwitnessed fall. Resident #515 was found by staff on the floor, reported to staff right leg pain and the inability to move her right leg and asked staff for an x-ray of her leg. Staff assisted the Resident to the bed then used a mechanical lift to move the Resident from the bed to a wheelchair. Staff waited a total of 6 hours and 28 minutes later to call Emergency Transport Services to transport the Resident to the hospital. At the hospital, Resident #515 was diagnosed with a Displaced Subcapital Right Femoral Neck Fracture (hip fracture that occurs when the bone in the neck of the thighbone breaks, and the bone fragments are no longer in proper alignment) which resulted in actual HARM to Resident #515. The Administrator was notified of the Immediate Jeopardy on 5/7/2025 at 4:55 PM, in the Conference Room. The facility was cited at F-689 at a scope and severity of J, which is substandard quality of care. An extended survey was conducted from 5/8/2025 to 5/13/2025. An acceptable Removal Plan which removed the immediacy of the Jeopardy for F-689 was received on 5/9/2025, and the Removal Plan was validated on-site by the surveyors on 5/13/2025 by medical record review, in-service record review, audit review, observation, and staff interviews. The Immediate Jeopardy for F689 began on 3/7/2025 through 5/8/2025, the IJ was removed on 5/9/2025. The facility's noncompliance at F-689 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings included: 1. Review of the facility policy titled, Safety and Supervision of Residents, dated July 2017, revealed .Our facility strives to make the environment as free from accidents and hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities .Safety risks .are evaluated on an ongoing basis through a combination of employee training, employee monitoring and reporting processes .QAPI [Quality Assurance and Performance Improvement] review of safety and incident/accident data .when accident hazards are identified, the QAPI/safety committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards .Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents .Monitoring the effectiveness of interventions shall include the following .Ensuring that interventions are implemented correctly and consistently . Review of the facility policy titled, Repositioning, dated May 2013, revealed .The purpose of this procedure is to provide guidelines for evaluation of resident repositioning needs, to aid in the development of an individual's care plan for repositioning .review the resident's care plan to evaluate for any special needs .assemble the equipment and supplies as needed .encourage the resident to participate if able .two people . Review of the undated facility policy titled, Pain Management, revealed, .most common painful conditions occurring in long-term care residents .Fractures .Effective symptomatic treatment should not be withheld while a definitive diagnosis or cause of pain is identified .The Pain Evaluation prompts the licensed nurse to elicit from the resident or family members' approaches that make the resident's pain better or worse .factors that may increase pain include .Anxiety .Position .Just as the experience of pain is subjective, assessing another in pain is subjective .We must rely on behaviors observations, as well as intuition and personal judgment . 2. Review of the medical record revealed Resident #415 was admitted to the facility on [DATE], with diagnoses including Chronic Respiratory Failure, Cerebral Infarction, Chronic Obstructive Pulmonary Disease, and Dysphagia. Review of the Care Plan revealed .[1/02/2025] .[Resident #415] at risk for falls r/t [related to] unsteady gait .has bladder incontinence r/t limited mobility .has an ADL self-care deficit r/t .cerebral infarct [infarction/stroke] .has bowel incontinence r/t limited mobility .has dx [diagnosis] of Cerebral Vascular Accident [stroke] .impaired cognitive function or impaired thought processes r/t cognitive communication deficit . Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed staff did not perform a Brief Interview for Mental Status (BIMS) score due to Resident #415's severe cognitive impairment. Resident #415 had short and long-term memory problems and cognitive skills for daily decision making indicated the resident had severe cognitive impairment. Resident #415 was dependent on staff for bathing, toileting, and personal hygiene, and was always incontinent of bowel and bladder. Review of the Progress Notes dated 3/7/2025 at 12:17 PM, revealed LPN (Licensed Practical Nurse) G documented .CNA x2 [times 2] was assisting res [Resident #415] with ADLs .res was assisted onto her right side and [had] BM [bowel movement] CNA cleaned BM off of res. res had additional BM after clean linen was applied to bed. one cna [CNA B] stepped out of [the] room to get extra linen/towels. cna [CNA A] that remained in room continued to hold res onto her side. res tilted forwarded and fell onto floor. writer [LPN G] assessed res and noted raised area on left side of res' head. Writer [LPN G] called res' daughter/RP [responsible party] .at 1120 [11:20 AM] to report fall and that res would be transported to hospital foreval [for evaluation]. writer contacted [Medical Transport 1] for res to be transferred to [Named hospital 1] per hospital choice on profile. 1123 [11:23 AM] writer called [responsible party] back to answer additional questions after transportation was called . Review of the Situation Background Assessment and Recommendation (SBAR) Physician/Nurse Practitioner (NP)/Physician Assistant (PA) Communication Tool dated 3/7/2025 at 3:24 PM, revealed Resident #415 fell and was transported to the hospital because of a recent fall. Resident #415 had some confusion, a blood pressure of 172/91, and non-verbal indicators of pain were present. Review of the facility's investigation dated 3/7/2025, confirmed there were 2 staff in the room, 1 staff left the room to retrieve some linen, and Resident #415 fell from the bed, while the second staff member was out of the room. Review of the Hospital Medical Records Radiology results dated 3/11/2025, confirmed Resident #415 had a Traumatic Brain Injury (TBI) with left frontal (lobe of the brain), right temporal (lobe of the brain), parenchymal (the tissue that performs the organ's primary function; indicates damage or problem in the brain tissue) and subarachnoid hemorrhage (bleeding in the space between the brain and covering the tissue in the brain). Review of Hospital #1's HOSPITALIST DISCHARGE SUMMARY dated 3/19/2024, revealed Named Resident #415 was discharged to the facility on 3/19/2025. During a telephone interview on 5/7/2025 at 1:05 PM, CNA B stated, [Named Resident #415] required a 2 person assist on the day of the fall. CNA B confirmed she went to assist CNA A, Resident #415 had a large bowel movement, they did not have enough supplies in the room at that time, and CNA B was asked to go out of the room to get some rags [linens]. CNA B stated, I was in the hallway and CNA A called out 'She fell, she fell'. CNA B stated LPN G was called and nurse LPN G and CNA B went to the room after Resident #415 had fallen from the bed. CNA B stated, Resident #415 was too close to the edge of the bed, I guess. During a telephone interview on 5/7/2025 at 1:45 PM, CNA A stated CNA B exited the room to get supplies because Resident #415 had a bowel movement. CNA A stated she was standing behind Resident #415 when CNA B exited the room. CNA A stated Resident #415 shifted her weight away from her and she couldn't catch Resident #415, and the Resident fell to the floor. CNA A stated the Resident's bed height was waist high. During an interview on 5/13/2025 at 3:58 PM, the Director of Nursing (DON) was asked what occurred when Resident #415 fell out of the bed on 3/7/2025. The DON stated 2 CNAs were providing care to the Resident, they ran out of supplies, and one CNA stepped out of the room to get more supplies. The DON stated that the Resident's weight shifted, and the Resident fell out of bed onto the floor. During an interview on 5/13/2025 at 4:48 PM, the Administrator was asked what they determined the root cause was that resulted in Resident #415 falling out of the bed. The Administrator stated there were 2 CNAs in the Resident's room giving care to Resident #415 and one CNA exited the room to get additional supplies leaving one CNA with the Resident. The Administrator stated Resident #415's weight shifted, and the Resident fell from the bed onto the floor. The facility failed to maintain 2-person assistance while providing care to Resident #415 resulting in a fall with injury which placed the Resident in Immediate Jeopardy. 3. Review of the medical record revealed Resident #515 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Lack of Coordination, Muscle Weakness, and Repeated Falls. Review of the Care Plan dated 12/5/2023, revealed .Focus .[Resident #515] is at risk for falls r/t new and unfamiliar environment, poor safety awareness, unsteady gait, weakness . Review of the admission MDS assessment dated [DATE], revealed Resident #515 had a BIMS score of 11, which indicated moderate cognitive impairment, and she required maximal assistance with ADLs. Review of the Progress Notes dated 1/7/2024 at 4:00 PM, for Resident #515 revealed .Resident in room screaming 'help'. Upon entering room resident observed on floor leaning on left side a few feet from restroom door .Resident c/o [complained of] pain to right hip and leg, requesting X-ray stating 'I can't move this side.' .Resident assisted to w/c [wheelchair] from bed via [by way of] total lift [mechanical device used to lift resident], staff x [times] 2. RP made aware. Unable to reach MD [Medical Director]. PRN [As needed] Tylenol admin [administered] for pain . The Progress Notes revealed the nurse moved Resident #515 using a mechanical lift after she voiced inability to move the right side and complained of pain. Review of the SBAR dated 1/7/2024, revealed .Situation .fall .1/7/2024 .Identify whether the problem/symptom has gotten worse/better/stayed the same since it started .Worse .Recent fall .Resident Reports Pain .Yes .Non-verbal indicators of pain evident .Yes .Describe appearance .in pain post fall . Review of the Progress Notes dated 1/7/2024 at 6:40 PM, revealed .New order per NP to transfer resident to ER [Emergency Room] for eval. Medical transport contacted with 1.5hour ETA [Estimated Time of Arrival]. RP made aware . Review of the Progress Notes dated 1/7/2024 at 10:28 PM, revealed .Resident transferred to [Named Hospital #1] ER for eval. s/p [status post] fall . The Progress Notes revealed the nurse did not make any further calls to other ambulance service transports or call 911 to address Resident #515's immediate needs. Review of the Progress Notes revealed Resident #515 stayed at the facility for 6 hours and 28 minutes before she was transferred to the hospital. Review of the Prehospital Care Report Summary from Medical Transport #2 revealed, .1/07/2024 Call# [number]: 0645 [6:45 PM] .Transport by This EMS [Emergency Management Services] Unit .Initial Patient [Resident #515] Acuity: Critical (Red) .Dispatched: 21:18 [9:18 PM] .Left Scene .22:03 [10:03 PM] .Falls/Back Injuries (Traumatic) .Patient Physical Limitations: Right Leg Paresis [a partial or incomplete loss of muscle function] .distal femur [thighbone] swelling pain 8/10 [pain scale of 1 being lowest and 10 being highest pain level] .unwitnessed fall with injuries Duration: 6 Hours .Extremity Trauma .AOSTF [Arrived on scene to find] [age in years of female] seated in wheelchair by door .stated pain 15 [when asked pain level on scale of 1 to 10] when moving, alert daughter and son-in-law present in pt [patient] room .pt fpund [found] seated in wheelchair, should not be seated until fracture/injury determined . Review of the typed facility investigation for Resident #515 revealed, .On 1/7/24 [2024], [Named Resident #515] was noted yelling for help in her room. Upon the nurse's arrival resident was noted lying on the floor on her left side in front of the bathroom door .MD notified and resident was sent to ER for evaluation per MD orders. 1/8/24 [2024] DON were [was] notified that [Named Resident #515] had sustained a displaced subcapital right femoral neck fracture from the admitting hospital . During an interview on 5/7/2025 at 9:40 PM, the Nurse Practitioner (NP) #1 stated, .I raised up concerns in a recent meeting .I expressed concerns about patient safety .fall education on proper body mechanics .I know of issues with falls with injury . During an interview on 5/12/2025 at 3:23 PM, the MD was asked about Resident #415's fall. The MD stated, .she was supposed to be a 2 person assist someone left to go get supplies and then the resident fell .fall protocol that I expect them [referring to nursing staff] to follow, it hasn't changed, my fall protocol specifically follows what happens after the fall, the resident should not have been left, it would take the 3rd person getting the supplies . MD was asked if the fall was preventable for Resident #415. The MD stated, Yes, never, ever leave the person in the room alone . The MD was asked about Resident #515's fall and what the nurse should have done when she was unable to reach the NP. The MD stated, .we have the call process and text process if they follow those steps, shouldn't be a long period of time to get in contact with me .the nurse should have called me . The MD was asked when Resident #515 had an unwitnessed fall, expressed she was unable to move her leg, and she requested x-rays what would he expect the nurse to do. The MD stated, .expect to send the resident out for x-ray . During a telephone interview on 5/13/2025 at 8:55 AM, Family Member (FM) AA was asked about Resident #515's fall on 1/7/2025. FM AA stated, .Mom kept calling saying she was hurting after she fell .she was calling me on the phone .I got at [to] the facility .I told the nurse she is screaming in pain, I think we need an Xray and sent out to the hospital .the ambulance didn't come quick .I started to call 911 but the nurse told me it wasn't an emergency then we find out at the hospital her leg was broken . FM AA stated, .I stayed at the facility until she was transported out .she was in terrible pain and couldn't move her right leg .she was yelling . During a telephone interview on 5/13/2025 at 12:27 PM, Licensed Practical Nurse (LPN) KK was asked if she recalled a fall which involved Resident #515 on 1/7/2025 when she was on duty and assessed the resident. LPN KK stated, .I don't remember that incident . This surveyor read LPN KK's Progress Notes dated 1/7/2025. LPN KK stated, .now I remember .she was in pain .she kept hollering, eventually got transport to send her out .most times they [referring to the facility] don't want us to use 911 . LPN KK was asked when she would activate 911. LPN KK stated, .if patient was unresponsive . LPN KK was asked why she moved the resident from the floor with the lift. LPN KK stated, .She [Resident #515] wasn't assisting . During an interview on 5/13/2025 at 2:35 PM, the DON was asked if a resident had an unwitnessed fall, voiced the inability to move her leg, and complained of pain after being found on the floor would she expect the nurse to get the resident up. The DON stated, .I would expect the nurse to leave them in place . The DON was asked why she would not want the resident to be moved. The DON stated, .it could cause more injury and possibly cause the resident more pain . During an interview on 5/13/2025 at 5:16 PM, the Administrator was asked if an ambulance transport was unable to arrive for 1.5 hours for a resident who experienced an unwitnessed fall, was unable to move her leg, and experienced pain what would she expect the nurse to do. The Administrator stated, .call 911 . An acceptable Removal Plan which removed the immediacy of the Jeopardy was received on 5/9/2025 at 3:52 PM. The surveyors validated the Removal Plan by record review, review of facility audits, in-service sign-in sheets, observations, and interviews. An Assessment of Compliance (AOC) was conducted on 05/07/2025 to evaluate the appropriate implementation and documentation of 2-person assist with bed mobility at Graceland Rehabilitation and Nursing Center. This assessment included a fall incident audit and a review of care plans and [NAME]'s for accuracy and alignment with residents' current bed mobility needs. The facility immediately educated CNA A and CNA B on 2-person assist with bed mobility and positioning and repositioning the resident while providing care, reviewed all falls, policies, [NAME]'s and care plans to align with each resident's current bed mobility needs. Immediately began in-servicing on Fall Management Program, Safety and Supervision of the Resident and Positioning and Repositioning of the resident for all licensed Nurses, CNAs and Respiratory Therapist. The root cause was CNA B left the room to get more supplies leaving CNA A alone in the room with Resident #415. CNA A and B were aware that resident #415 was a 2-person assist with bed mobility. The facility has implemented Fall audits, Care plan audits, [NAME] audits, Policy audits, and on-going education with Licensed Nurses, CNAs and Respiratory Therapist on 2-person assist with bed mobility to call for help and not leave the room if they need any supplies, skills competency with positioning and repositioning residents with return demonstration to prevent recurrence. The facility is monitoring all falls daily, ensuring all care plans and [NAME]'s are up to date and on-going competencies and education to ensure training is effective. The facility is measuring effectiveness of the in-services by monitoring the falls on a daily basis and observing return demonstrations through competency. Fall Audit: A facility wide fall audit was conducted on 05/07/2025 from 03/07/2025 to current with no major injuries. No fall concerns with 2-person assist with bed mobility. Care Plan Audit: A facility wide care plan audit was conducted on 05/07/2025 to ensure any resident that is a 2- person assist reflects accurately and was found to be up to date. [NAME] Audit: A facility wide [NAME] audit was conducted on 05/07/2025 to ensure all residents had an up-to-date [NAME] and aligning with current care plan with 2-person assist with bed mobility. All [NAME]'s were found to be accurate. Policy Audit: Policies on Fall Prevention Program, Safety and Supervision of Residents, and Repositioning were all reviewed by the Administrator and Director of Nursing on 05/07/2025 with no revisions needed. Education: All licensed Nurses, CNAs, Respiratory Therapist, any nursing agency personnel and any Nurses, CNAs, Respiratory Therapist on Leave of Absence (LOA) will be in-serviced on Fall Prevention, Safety and Supervision of Residents, and Repositioning starting on 05/07/2025. Quality Assurance Improvement Plan (QAPI): The facility is continuing its on-going Quality Assurance Plan to monitor facility performance and compliance with the Fall Prevention Program, Safety and Supervision of Residents, and Repositioning by continuing to monitor falls daily and implementing planned interventions and approaches appropriately. Conclusion: (Named facility) remains committed to ensuring resident safety through proper documentation and adherence to mobility assistance requirements. Continued monitoring and education will be conducted to maintain compliance and prevent future incidents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, job descriptions, medical record review, observation, and interview, the facility failed to provide supervision and monitoring for 1 of 5 (Resident #4) sampled residents reviewed for unwitnessed falls, failed to ensure the resident's right to be free from neglect when the facility failed to provide necessary goods and services and failed to treat residents in a manner that promoted a sense of self-worth, dignity and individuality for 11 of 11 sampled residents (Resident #7, #20, #28, #30, #37, #42, #44, #45, #46, #47 and #48) reviewed for daily hair care, and failed to ensure residents' vital signs were monitored [DATE], February 2024, [DATE] and [DATE], for 20 of 21 (Resident #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #22, #23, and #24 ) sampled residents reviewed on the Crown Unit, a unit with residents that are dependent on ventilators and high acuity care requirements. Resident #4 experienced unwitnessed falls on [DATE], [DATE], [DATE], and on [DATE]. The facility failed to monitor Resident #4's condition post unwitnessed fall per facility policy which resulted in Immediate Jeopardy (IJ) when Resident #4 did not receive neurological (neuro) checks (examination to determine whether the nervous system is impaired affecting the brain), frequent vital signs (measurement of the body's most basic functions) monitoring and supervision after an unwitnessed fall on [DATE] at 2:00 AM. Resident #4 had a decline in condition and was not transferred to the hospital until [DATE] at 2:22 PM, approximately 36 hours after the unwitnessed fall on [DATE]. Resident #4 was admitted to the hospital on [DATE] with Acute on Chronic Subdural hematomas (subdural hematoma is a blood clot collection of blood between the brain and the brain's outer covering, usually with an injury that jolts or shakes the brain) with a right to left midline shift (indicates a significant increase in pressure in the brain pushing the brain to the right or left) and required an emergency craniotomy (Surgery on the brain to treat the bleeding in the brain). The facility's failure to monitor resident's Activities of Daily Living (ADL) care including daily hair care resulted in HARM for 11 of 11 residents (a situation in which the provider's noncompliance resulted in neglect that compromised the residents' ability to maintain and/or reach his/her highest practical physical, mental and psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care and provision of services), cited at a scope/severity of H which is substandard quality of care. Non-compliance of F-600 continues at a scope and severity of H, for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility policy titled, Neurological Assessment, dated 2002, revealed .The purpose of this procedure is to provide guidelines for a neurological assessment .upon physician order .when following an unwitnessed fall .subsequent to a fall with a suspected head injury .when indicated by resident conditions .Neurological assessment are indicated .Following an unwitnessed fall .When assessing neurological status, always, include frequent vital signs. Particular attention should be paid the widening pulse pressure (difference between systolic and diastolic pressure) .This may be indicative of increasing intracranial pressure (ICP) .Any change in vital signs or /neurological status in a previously stable resident should be reported to the physician immediately .perform neurological check [Neuro Checks] with the frequency as ordered or per fall protocol .Observe resident's pattern of speech and speech clarity .Take temperature, pulse, respirations, blood pressure .check pupil reaction .Determine motor ability .Determine sensation in extremities .The date and time the procedure was performed .The name and title of the individual(s) who performed the procedure . Review of the facility policy titled, Assessing Falls and Their Causes, dated 2018, revealed .The purpose of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying cause of the fall .Resident must be assessed upon admission and regularly afterward for potential risk of falls .If a resident has just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine and extremities .Obtain and record vital signs as soon as it is safe to do so .Notify the residents attending physician and family in an appropriate time frame . Review of the facility's undated policy titled, .Abuse Prevention, revealed, .Neglect: A failure of the facility, it's employees, or services provided .to provide goods and services necessary to avoid physical harm, mental anguish, emotional distress, or pain . Review of the facility's undated policy titled, .Activities of Daily Living (ADLs), revealed, .The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate unless deterioration is unavoidable .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene . Review of the facility policy titled, Resident Right, dated 2016, revealed .Federal and state laws guarantee certain basic rights to all resident in this facility .equal access to quality of care . Review of the facility undated policy titled, NOTICE OF RESIDENT RIGHTS, revealed .This facility will protect and promote the rights of each resident .To reside and receive services in the facility with reasonable accommodation of individuals needs and preferences .To have appropriate assessment and management plan . Review of the facility policy titled, Provision Ordered Services, dated 2020, revealed .The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality . Professional Standards of Quality means that care and services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline or in a specific clinical situation or setting . Review of the Director of Nursing Services, Job Description dated [DATE], revealed .The primary purpose of your position is to plan, organize, develop, and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our Facility and as may be directed by the Administrator or the Medial Director to ensure that the highest degree of quality care is maintained at all times .Develop methods for coordination of nursing services with other resident services to ensure the continuity of the residents' total regimen of care .Report absentee call-ins to the Nursing Supervisor and/or Unit Manager .Make daily rounds of your unit/shift to ensure that assigned CNAs [certified nursing assistants] .and other nursing personnel are performing their work assignments in accordance with acceptable nursing standards .Assign a sufficient number of LPNs and RNs for each tour of duty to ensure that quality care maintained . Review of the Unit Manager, Job Description dated [DATE], revealed .Provide the Director of Nursing Services with information relative to the nursing needs of the resident and to the Nursing Services Department's ability to meet those needs .Monitor medication passes and treatment schedules to ensure that medications are being administered as ordered and that treatment are provided as scheduled .Report medication errors to the Director of Nursing Services . Review of the Staffing Coordinator, signed Job Description, revealed .The primary purpose of you position is to ensure adequate and appropriate staffing of the Facility's nursing department to meet the needs of the residents .Complete monthly nursing schedule coordinating requests to ensure appropriate coverage of units .Make written or oral reports and recommendation to the DON concerning staffing and scheduling issues . Review of the Charge Nurse [licensed practical nurse (LPN)] Job Description dated [DATE], revealed .The primary purpose of your position is to provide direct nursing care to the resident, and to supervise the day-to-day nursing activities performed by CNAs [certified nursing assistants] .Report all discrepancies noted concerning physician's orders .charting error .to the Nursing Supervisor .Unit Manger [Manager] .Inform the Nurse Supervisor .Unit Manager of staffing needs when assigned personnel fail to report to work .Nursing Care Functions .Review the resident's chart for specific treatment, medication orders .Use an Automated External Defibrillator .Perform Cardiopulmonary resuscitation (CPR) .Ensure that resident who are unable to call for help ae checked frequently . 2. Review of medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Dysphagia, Heart Failure, Hypertension, Gastrostomy, previous history of Traumatic Subdural Hemorrhage, Anxiety Disorder, and Diabetes. Review of the Fall Incident Report, dated [DATE], revealed .On [DATE] resident [Resident #4] was found sitting on floor by ADON [Assistant Director of Nursing] who summoned nurse to room to assess patient [Resident #4]. Patient was alert and had no visible injuries noted. Was able to move all extremities. Resident stated she was trying to get some water when she got out of bed . There was no documentation staff performed Neuro Checks and frequent Vital signs following the unwitnessed fall on [DATE]. Review of the Physician's Orders dated [DATE], revealed .Eliquis [a blood thinner, bleeding is the most common adverse event related to Eliquis] Oral [by mouth] Tablet 5 MG [milligrams] .give 1 tablet by mouth two times a day for Anticoagulant Therapy . Review of the Fall Incident Report, dated [DATE], revealed .Resident [Resident #4] slid off of low bed onto the floor .I got out of the bed [Residents description]. No injuries observed at time of incident . There was no documentation staff performed Neuro Checks and frequent Vital signs following the unwitnessed fall on [DATE]. Review of the Fall Incident Report, for Resident #4 dated [DATE] at 7:30 AM, revealed .Therapy called writer [Charge Nurse] to [Resident #4's room] .SPL [Speach Language Pathologist] stated to writer resident [Resident #4] on her knees as if she was praying, resident noted holding on the bed rail with both hands .Neuro checks started d/t [due to] unwitness [unwitnessed] . Review of the NEUROLOGICAL ASSESSMENT FLOW SHEET dated [DATE], for the [DATE] fall revealed the neuro checks on [DATE] were only completed at 7:30 AM and at 9:00 AM. There was no documentation of additional neuro checks and vital signs in accordance with the facility policy. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #4 scored a 00 on the Brief Interview for Mental Status (BIMS), which indicated the Resident could not recall the correct answers. Further review of the [DATE] MDS revealed, .Acute Onset mental Status Change . [question] Is there evidence of an acute change in mental status from the resident ' s baseline . No . [question] Was the resident's thinking disorganized or incoherent [rambling or irrelevant conversation, unclear or illogical flow of ideas or unpredictable switching from subject to subject] .Behavior not present . Altered Level of Consciousness .behavior not present . Review of the Social Service Progress Note dated [DATE], revealed .Visited with [Named Resident #4] to conduct a BIMS assessment, resident is severely impaired with BIMS score being a 01 [severely cognitively impaired] [Resident #4] is A&O [alert and oriented], but unable to say the three words correct sock blue and bed; resident said stop blue and bird and she did not know the month, year or day of the week. SW [Social Worker] will continue to assist as needed . Review the Weekly Assessment Note dated [DATE] revealed, . [Resident#4] is alert to self. Answers some questions appropriately with yes and no . Periodically talks about the past times as a child and known for reminiscing . Review of the Progress Note, dated [DATE], revealed . [Resident #4] noted with N/V [Nausea/Vomiting] new order KUB [kidney, ureter, bladder - an X-ray study that assesses the organs of your urinary and gastrointestinal systems] . Review of the facility Fall Incident Report, dated [DATE] at 2:00 AM, revealed LPN Z documented, .Resident [Resident #4] found in sitting position on the floor. [Door side of bed] .Resident Unable to give Description .Resident assessed from head to toe for any injury, none found . Further review revealed LPN Z documented Resident #4 was oriented to person, and had predisposing factors as confused, had a gait imbalance, and immobility. The section for Predisposing Physiological Factors was left blank. Review of the facility's Neurological Check list revealed the neurological checks should be completed every (q) 15 minutes time 4, every 30 minutes times 2, every hour times 2 hours and every 4 hours times 24 hours. Review of the Neurological Check List, for Resident #4's unwitnessed fall on [DATE], revealed the neuro checks were performed on [DATE] as follows: The q 15-minute neuro checks were initiated on [DATE] at 2:00 AM and conducted every 15 minutes until completed at 2:45 AM. Staff documented by each neuro check the Resident was experiencing rambling speech. There were vital signs checked with the neuro checks. The q 30-minute neuro checks were initiated at 3:15 AM and completed at 3:45 AM. Staff documented by each neuro check the Resident was experiencing rambling speech. There were vital signs checked with the neuro checks. The q one-hour neuro checks were initiated at 4:45 AM and completed at 5:45 AM. Staff documented by each neuro check the Resident was experiencing rambling speech. There were vital signs checked with the neuro checks. The q 4-hour neuro checks for 24 hours were only completed at 6:45 AM, 10:45 AM and 2:45 PM. There was no documentation the q 4 hour neuro checks were conducted for 24 hours, and no documentation of vital signs with the neurological checks. Staff documented by each neuro check the Resident was experiencing rambling speech. There were vital signs checked with the neuro checks. Review of the Vitals Summary dated [DATE], revealed Resident #4's Vital signs were checked as follows: On [DATE] at 2:45 AM, and at 10:34 AM. On [DATE] at 11:27 AM and at 1:31 PM. Review of the Situation, Background, Assessment, Recommendation (SBAR) note, (an electronic notification to the physician/practitioner), for Resident #4 dated [DATE] at 2:40 AM, revealed . Mental Status or Neuro Changes .found on floor .She [Resident #4] deny [denies] pain .Instructed to call for asst [assistance] when she [Resident #4] need [needs] something . There was no documentation the physician/practitioner was notified of Resident #4's rambling speech that was documented in the neurological check list. The intervention to instruct Resident#4 to call for assistance was an inappropriate intervention due to BIMS of 01 and the lack of cognitive ability to remember to call for assistance. Review of Progress Note, dated [DATE] at 2:13 PM, revealed .Staff reported resident [Resident #4] not acting like her normal self post fall day 2. Reported changes to [Named Medical Director] at 133p [1:33 PM] and he gave an order to send to the hospital for head ct [Computerized Tomography scan - detailed image of the body] . Review of Nurses Note for Resident #4 dated [DATE], (for the events that occurred on [DATE]), revealed .Went in to assess patient [Resident #4], she was not speaking or answering any questions verbally or nonverbally AAOx0 [Awake Alert Oriented times zero] . This entry was not documented as a late entry. Review of the Emergency Medical Services (EMS) report dated [DATE] revealed EMS received an emergency call on [DATE] at 1:40 PM and arrived at the nursing home at 2:00 PM. The EMS report revealed, .en-route to [Named Facility] .for emergency complaint of altered mental status post-fall .on arrival, pt [Resident #4] was .minimally responsive .Nurse stated pt fell x [times] 2 days ago . ' neuro checks' were started this morning approx [at approximately] 0200 [2:00 AM] .at 2:30 [AM] and had degraded .Pt has hx [history] of trauama [trauma] subdural hematoma .Pt would open eyes to loud verbal stimulus at times pt would not respond unless painful stimulus was applied .pupils were unequal at 4mm [millimeters] on left and 5 mm on right .reactive to lights . EMS left the facility at 2:22 PM, transporting Resident #4 to the hospital Emergency Department (ED). Review of the Hospital Emergency Department (ED) records dated [DATE], revealed Resident #4 presented to the ED on [DATE] at 2:45 PM via EMS. Review of the hospital Triage assessment dated [DATE] at 2:47 PM, revealed . [Resident #4] to triage via [Name of EMS] with cc [chief complaint of] fall x [times] 2 days ago .LKW [Last Known Well] was 0200 [2:00 AM] this morning [[DATE]] .not following commands in triage . The ED Assessment for Resident #4 dated [DATE] at 4:18 PM, revealed .Speech Garbled . Review of the Hospital ED History & Physical for Resident #4 dated [DATE] at 4:41 PM, revealed .Last known well: Date/time [DATE] 02:30:00 [2:30 AM] . According to the EMS NH [Nursing Home] staff noticed that the patient [Resident #4] is experiencing altered mental status around 2:30 AM [approximately 12 hours prior to arriving to the ED] when they started neuro checks on her and noticed declining mental status . Review of the Hospital ED Physician Consultation for Resident #4 dated [DATE] at 4:58 PM revealed, .Acute on chronic right subdural hematoma as well as a left acute on chronic subdural hematoma XXX[AGE] year-old female with a past medical history of hypertension, diabetes, thyroid disease and previous subdural hematoma, status post craniotomy in 2019 .She presents today after a fall at her nursing home .The patient has had a progressive decline in her mental status which prompted a presentation to the emergency department for further evaluation. CT [Computerized Tomography] scan demonstrates a large right subdural hematoma with mass effect [increasing pressure within the skull and potentially causing midline shift or deadly brain herniation] and midline shift for which Neurosurgery has been consulted .We will take the patient emergently to the operating room for a right craniotomy for subdural hematoma evacuation . Review of the Hospital Records for Resident #4 dated [DATE], revealed .As per the patient's daughter patient was at her baseline alert oriented x [times] 3 walking with assistance on Monday of last week [[DATE]], her granddaughter went to see her on Tuesday and Wednesday [[DATE] and [DATE]] when she noticed that she [Resident #4] is becoming confused and the family were informed by the NH [Nursing Home] that the patient fell down on Tuesday [[DATE]] and again on Friday [[DATE]] . Initial CT head reports an acute moderate to large sized right subdural hematoma [Acute subdural hematomas commonly form because of a severe head injury] with 1.5 cm [centimeter] right to left midline shift. She [Resident #4] was taken to the OR [Operating Room] by NSY [Neurosurgery] and underwent R [Right] FT [Frontal] craniotomy for evacuation of SDH [Subdural Hematoma] . Patient was admitted to ICU [Intensive Care Unit] for closer monitoring and critical care management. She is now s/p [Status/Post] craniotomy on [DATE] [2024]. Patient on AED [anti-epileptic drugs .as a prophylactic factor for post-traumatic seizures] prophylaxis. Repeat CTH [CT of the head] is stable .CONSULTATION XXX[DATE] .REASON FOR CONSULTATION . Acute on chronic right subdural hematoma as well as a left acute on chronic subdural hematoma .The patient will need intensive care unit level of care, q.1 h. [every one hour] neurological checks . The Post surgery CT Scan results for Resident #4 on [DATE] revealed, . Mild improvement in leftward midline shift, now measuring 5 mm [millimeter] compared with 7 mm previously when measured at the foramen of [NAME] [an anatomical structure in the human brain that plays a significant role in cerebrospinal fluid circulation and brain imaging]. Ventricles are unchanged in size and configuration . Patient was admitted to ICU [Intensive Care Unit] for closer monitoring and critical care management. She is now s/p [Status/Post] craniotomy on [DATE] [2024]. Patient on AED [anti-epileptic drugs .as a prophylactic factor for post-traumatic seizures] prophylaxis. Repeat CTH [CT of the head] is stable .CONSULTATION XXX[DATE] .REASON FOR CONSULTATION . Acute on chronic right subdural hematoma as well as a left acute on chronic subdural hematoma .The patient will need intensive care unit level of care, q.1 h. [every one hour] neurological checks . During a telephone interview on [DATE] at 11:13 AM, Family Member #4 was asked about Resident #4's recent falls in the facility. Family Member #4 stated, .It started off ok .my mom keep on falling .she [Resident #4] here at the hospital with that fall [[DATE]] she [Resident #4] been here at [Named Hospital] for the past 2 weeks .on [DATE] she had surgery, on Wednesday [[DATE]] she [Resident #4] started throwing up .no one called and told us .my daughter was there and said grandmom is throwing up .so I called the unit manager [Name Unit Manager on [NAME]] .she [Unit Manager] said she don ' t know why she [Resident #4] is throwing up they [staff] are going to order an US [Ultra Sound] and they [staff] will me let know the results .on Thursday [[DATE]] when my daughter of [Family member #4's daughter] was up there [at the facility] mom [Resident #4] was confused .they [facility staff] did not call and let me know that either .she [Resident #4] had 2 Blood clots on her brain and had [a] stroke that [that's] how she [Resident #4] ended up in the nursing home .Friday [[DATE]] got a call from [Named LPN Z] at 6:59 AM said my mom [Resident #4] fell and he [LPN Z] did not know if she [the Resident] hit her head or what .he [LPN Z] said when he found [Resident #4] she was on her butt [on the floor] .I found out from the nurse on Saturday [[DATE]] [Named Registered Nurse (RN) FF] she [Resident #4] was not eating, she [RN FF] called the doctor and he said send to the ER [Emergency Room] .look [looks] like she need [needs] a CT [computerized tomography - a detailed image of the brain] scan .we wanted her [Resident #4] sent [to Named Hospital #2] .her BP [blood pressure] was 180/100 [when the Resident arrived at hospital] rushed her [Resident #4] to do a CT scan and told me they had to do emergency surgery, a craniotomy [surgery to cut a bony flap from the skull to access the brain and treat the bleeding in the brain] .she [Resident #4] had a bleed that shifted her brain .[Named RN FF] said he [Staff Licensed Practical Nurse (LPN) Z] was doing neuro checks on your mom [Resident #4] like she [the Resident] was alert oriented . During a telephone interview on [DATE] at 2:07 PM, CNA L was asked if she was aware Resident #4 had a fall. CNA L stated, .No, not until Saturday [[DATE]] .the nurse relayed the message to me .[Named RN FF] .she told me that morning .I went and told her [the nurse] [Named Resident #4] was not saying anything .so for breakfast she was not eating and acting the same [Resident #4 was not acting as she usually/normally does] .so she [Named RN FF] said let me go and check the notes .said she [Resident #4] had a fall . I reported that she [Resident #4] did not eat her breakfast and is not talking .I told her [RN FF] again at lunch she [Resident #4] did not eat and did not say anything to me .she [RN FF] came in and checked on her [Resident #4] and a little later she [RN FF] told me she was going to send her [Resident #4] out [to the hospital] . I knew it was a change for her [Resident #4] .a significant change .she [Resident #4] talks all day, and she [Resident #4] always eats . During an interview on [DATE] at 8:49 AM, the Director of Nursing (DON) reviewed each Resident #4 fall incident and was asked how she identified who performed the Neuro checks on [DATE]. The DON stated, .There is no name on the forms .you can't tell . The DON was asked to review the fall incident for Resident #4 on [DATE] and on [DATE] and asked if the falls were witnessed or unwitnessed falls. The DON stated, Unwitnessed Fall . The DON was asked if the nursing staff should have documented and started Neuro checks and vital signs following the [DATE] and [DATE] falls. The DON stated, .Yes, ma'am . The DON was asked to review the fall incident for Resident #4 which occurred on [DATE] and asked if the Neuro Checks were complete. The DON stated, No it's [the neuro checks] not . The DON was asked to review the unwitnessed fall for Resident #4 which occurred on [DATE] and asked if the Neuro Checks and Vital Signs were completed according to the facility policy. The DON stated, .No, ma ' am . The DON was asked how the Neuro checks, and frequent vital signs should be taken. The DON stated, .Every 15 minutes times 4, every 30 minutes time 2, every hour times 2, and every 4 hours times 24 hours . During an interview on [DATE] at 1:10 PM, the Medical Director was asked if he would expect the staff to complete Neuro checks and vital signs to identify potential neurological problems and inform him when a resident who was on anticoagulants experienced an unwitnessed fall. The Medical Director stated, .Absolutely and let me know .if unwitnessed and don't know if they hit their head .I send them out for a CT right away . The Medical Director was asked what caused a subdural hematoma (bleeding in the brain). The Medical Director stated, .It comes from trauma . During an interview on [DATE] at 9:12 AM, LPN CC was asked about Resident #4's fall on [DATE]. LPN CC stated, .It was the therapy person who found her [Name Therapy Staff Member] .it was change of shift .I was still here .it was around 7:30 AM . I just assessed her [Resident #4] .she said she was not hurting .no pain or discomfort . LPN CC was asked what was completed when a resident experienced an unwitnessed fall. LPN CC stated, .We do the neuro sheet . LPN CC was asked to review the Neurological Assessment Flow Sheet and if it was complete. LPN CC stated, .No its not complete .I documented at 7:30 AM the first neuro check . LPN CC was asked when you have a resident with an unwitnessed fall that is on an anticoagulant, what do you do. LPN CC stated, .Notify the doctor and 9 times out of 10 they will send them [the resident] out to the hospital . During a telephone interview on [DATE] at 8:11 AM, LPN Z was asked about Resident #4's fall. LPN Z stated, .the CNA told me .she [Resident #4] had a fall .I was on the other end of the hallway helping a man in [named room number] .she [Resident #4] was on the floor .she [Resident #4] had her back against the bed .I asked her how she got down there .she [Resident #4] just looked and did not say anything .I don't remember her telling me anything .I assessed her and asked her if she was hurting .she shook head no .she had no injuries .the bed was in the floor position .we put her back to bed . LPN Z was asked if the fall was a witnessed or unwitnessed fall. LPN Z stated, .As far as I know it was unwitnessed .the CNA did not tell me she saw her [Resident #4] fall . LPN Z was asked what the process was for an unwitnessed fall. LPN Z stated, .we fill out the incident report, the SBAR [Situation, Background, Assessment, Recommendation], and start neuro checks .I notify doctor and family . LPN Z was asked if Resident #4 had a fall on Tuesday [DATE]. LPN Z stated, No. LPN Z was asked what else was documented besides the neuro checks. LPN Z stated, .All we do is the regular neuro checks .document and monitor the rest of the night .the new neuro system .we have to do vital signs every time we do the neuro checks .sign and put our name on it [Neuro check form] . LPN Z was asked if he signed the neuro check sheet for Resident #4. LPN Z stated, .No .there was no place for a signature on the sheet anywhere . LPN Z was asked what rambling speech meant for Resident #4. LPN Z stated, .She [Resident #4] is aways confused .when ask a question .she talks about something else .that's the way her conversations went . LPN Z was asked what did Resident #4 look like at the end of the shift. LPN Z stated, .she was fine .she laid there the rest of the night just looking around .I was still doing the neuro checks .it's so busy for one nurse .I was trying to do the best I can . In summary, Resident #4 had a history of a Subdural Hematoma with craniotomy and was on a medication with a potential side effect of increased bleeding. The facility had a history of not completing the neurological checks for Resident #4's previous unwitnessed falls. Resident #4 had an unwitnessed fall on [DATE] at 2:00 AM, the facility initiated neurological checks at 2:00 AM through 2:45 PM on [DATE]. The facility failed to complete the neurological checks for the 24-hour period and did not document the resident's vital signs with each neurological check in accordance with the facility's policy. The neurological checks that were performed revealed Resident #4's speech was rambling. The neurological checklist was dated [DATE] at 2:00 AM, the nurse reported to EMS the neurological checks were initiated on [DATE] at 2:00 AM. The facility reported to EMS on [DATE] at 2:00 PM (when EMS arrived) Resident #4 had degraded (declined) since 2:30 AM and did not notify the Medical Director or seek emergency treatment until approximately 12 hours later. Resident #4 had a decline between [DATE] (after the last neurological check was performed) at 2:45 PM and when the Medical Director was notified on [DATE] at 2:13 PM, almost 36 hours after the unwitnessed fall on [DATE]. 3. Review of the medical record revealed Resident #7 was initially admitted on [DATE], and readmitted after hospitalization on [DATE], with diagnoses including Chronic Respiratory Failure with Hypoxia, Anoxic Brain Damage, Tracheotomy Status, Gastrostomy Status, Type 2 Diabetes, Chronic Pain, Seizure Disorder, and Con[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of the American Heart Association Provider Manual, medical record review, observation, and interview, the facility failed to initiate and provide Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR - perform measures to assist the person with breathing and to stimulate a heart rate) for 2 of 3 sampled residents (Resident #5 and #6) reviewed in accordance with the professional standards of care related to basic life support for healthcare providers. Resident #5 who resided on the ventilation unit called the Crown Unit was found unresponsive and not breathing by Certified Nursing Assistant (CNA) B on [DATE] at 2:45 AM and was a full code (to receive CPR). Resident #6 who resided on the [NAME] Unit was found unresponsive on [DATE] at 3:50 AM by CNA H and was a full code. The facility failed to immediately initiate CPR according to the professional standard of practice for a healthcare provider and in accordance with the facility policy. The facility's failure to immediately provide basic life support placed Resident #5 and #6 in an environment detrimental to their health, safety, and wellbeing. The Chief Operating Officer, Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for of F-678 on [DATE] at 1:01 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F678 at a scope and severity of J which is Substandard Quality of Care. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F-678 was received on [DATE] and an acceptable Removal Plan. The Removal Plan was validated onsite by the surveyors on [DATE] through policy review, medical record review, observation, review of education records, and staff interviews. The IJ for F678 began on [DATE] through [DATE], the IJ was removed on [DATE]. Non-compliance of F678 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility's policy titled, Medical Emergency Response (Named Facility) Rehabilitation and Nursing Center, dated 2019, revealed .It is the policy of this facility to respond to medical emergencies for residents .The employee who first witnesses or is first on the site of a medial emergency, that are trained, will initiate immediate action, including CPR as appropriate, basic first aid and summon for assistance .A nurse will: a. Assess the situation and determine the severity of the emergency. b. Stay with the resident. c. Designate a staff member to announce a Code Blue [overhead call for staff to come to and assist with CPR], if necessary, notify the physician and call 911 as needed .A Code Blue will be announced over the intercom system .All available staff will respond to the emergency accordingly .The RN [Registered Nurse] supervisor or Charge Nurse of the unit will take the Emergency Cart to the code site, ensure accurate documentation of the event and delegate any other duties or tasks needed .This will continue until emergency personnel arrive and resident is transported to the emergency room by the EMS [Emergency Medical System] .Current certified staff must maintain CPR-Certification for Healthcare Providers through a CPR provider . Review of the American Heart Association Basic Life Support Provider Manual dated 2020, revealed .No breathing or gasping, pulse not felt .Start CPR .Use AED [Automated External Defibrillator] as soon as it is available .The first rescuer who arrives .check the victim for responsiveness .should send another rescuer to activate the emergency response system and get the AED .Make sure the victim is face up on a firm flat surface .Perform chest compressions .Provide Breaths .Give breaths, watching for chest rise and avoiding excessive ventilation [oxygenation during cardiac arrest] .Early defibrillation increases the chance of survival for cardiac arrest . 2. Review of medical record revealed Resident #5 was admitted to the Crown/vent unit on [DATE], with diagnoses of Dysphagia, Tracheostomy, Hypertension, Chronic Respiratory Failure, and Gastrostomy. Review of the Post Form (a form used to notify staff if an individual would like CPR in the event it's needed) dated [DATE], for Resident #5 revealed .Resuscitate (CPR) .Full Treatment . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #5's Brief Interview for Mental Status (BIMS) was blank, which indicated the Resident was severely impaired. Review of the Respiratory Therapy Progress Note for Resident #5 dated [DATE] at 12:36 AM, revealed Respiratory Therapist (RT) #1 documented .Resident is alert and appears comfortable saturations [measure of oxygen in the blood stream] 96% [percent] and heart rate 89 bpm [beats per minute] on Airvo [a humidifier with integrated flow generator that delivers warmed and humidified respiratory gases to spontaneously breathing patients] . RR [respirations] 16. Resident received oral and trach care; BS [breath sounds] was coarse before suctioning. Resident's secretions were thick and pale in color. BS improved after suctioning . Review of the Respiratory Therapy Progress Note, dated [DATE] at 2:30 AM, revealed Respiratory (RT) #1 documented .CNA [CNA B] found the resident [Resident #5] unresponsive. [CNA B] told me immediately after finding the resident. I check [checked] the resident pulse and for breath sounds. After not finding either, I instructed the CNA to call 911, find the other RT [Respiratory Therapist] and tell her that we had a code blue, along with finding a nurse to help conduct CPR because there was not one on our floor [Crown Unit], while I grabbed a O2 [oxygen] tank and started CPR [Cardiopulmonary Resuscitation] . EMS [Emergency Medical Services/Paramedic and emergency medical technician (EMT)] took over at approximately 0257 [2:57 AM] and left with the resident around 0307 [3:07 AM] for [Named Hospital #1] . Review of the Nursing Progress Note for Resident #5 dated [DATE] at 3:19 AM, revealed LPN JJ documented .Resident [Resident #5] noted per cna [CNA B] at 0245 [2:45 AM] to be unresponsive and informed this nurse on Delta [another unit separate from the Crown Unit]. Nurse [Delta Nurse who was not CPR certified at the time of the code] assessed [Resident #5] and immediately respiratory [therapist] started cpr. This nurse immediately called 911 and firefighters [Paramedic and EMT] arrived [continued cpr]. Contacted and informed [Named Family Member #6] . of [Resident #5] current status and after firefighters left with resident enroute to [Named Hospital #1]. RR [Resident Representative] asked why they didn't go to [Named Hospital #2] .Nurse informed her in emergency cases/possible cardiac arrest the nearest hospital is first option. She stated she would call them. Nurse expressed wishes for the best outcome and call ended. Informed DON [Director of Nursing] and NP [Nurse Practitioner] . RT #1's progress note revealed Resident #5 was found unresponsive at 2:30 AM. LPN JJ's progress note revealed Resident #5 was found unresponsive at 2:45 AM. The Fire Department report revealed the 911 call to dispatch was at 2:36 AM; and the last known time the Resident was checked with no problems was reported by the facility as 2:35 AM. The facility to failed ensure accurate documentation of the CPR event, in accordance with facility policy. Review of the Fire Department Prehospital Patient Report dated [DATE], revealed they were dispatched to the nursing home on [DATE] at 2:36 AM, arrived at the nursing home at 2:47 AM, and arrived at Resident #5's bedside at 2:50 AM. The report revealed, .Last know well [Resident #5 had no problems] XXX[DATE] .02:35 [2:35 AM] . [Unit Number of named Fire Department] dispatched to cardiac arrest. [Unit number of Named Fire department] arrived on scene to find a 43 yo [year old] female lying on the bed. Pt [patient/Resident #5] was unresponsive, GCS [Glasglow Coma Scale used to measure the consciousness of patients] of 3 [Severe trauma to the brain], cc [Chief Complaint] of cardiac arrest . [facility staff] on scene stated that pt [patient/Resident #5] was last seen normal approximately 30 minutes before [Fire Department] arrived. [Facility Staff] . on [the] scene [and] initiated CPR prior to [Unit number Fire department] .arrival. [Unit number Fire Department] assisted . with CPR and interventions . ALS [Advanced Life Support] procedure, interventions, and medications. Pt [Resident #5] was placed onto stretcher, secured by straps and rales, and placed into unit. Paramedic .rode in with unit crew. Unit crew assisted paramedic .with pt care during transport to hospital .Pt [Resident #5] was transferred to hospital ED [Emergency Department] and offload into [ED Room number]. Pt care was transferred to ED staff . The Fire Department report revealed they left the facility with Resident #5 at 3:08 AM and arrived at the hospital emergency department (ED) at 3:12 AM. Resident #5 had a Rhythm of PEA (Pulseless electrical activity-is a condition where your heart stops because the electrical activity in your heart is too weak to make your heartbeat). Resident #5 was pronounced as deceased in the ED on [DATE]. 3. During a telephone interview on [DATE] at 2:42 PM, Respiratory Therapist #2 (RT) was asked how she found out about Resident #5's code on the Crown Unit. RT #2 stated, .the CNA came and found both [RTs], I went in there immediately and started CPR .did chest compression and [Named RT #1] was bagging [ambu bags are kept in each room on the ventilator unit used to administer breaths to Residents who are not breathing] . RT #2 was asked what type of equipment was in the room. RT #2 stated, .oxygen tank . crash cart .had suctioning in the room .I think [Resident #5] was on oxygen she was not my patient . RT #2 was asked if the AED [Automated External Defibrillator] was in use. RT #2 stated, .We never used it . EMS came in they put her on their monitor .to be honest I don't know . [if the AED was in the room] I'm prn [as needed] there . I work 3 days out of the month .I still don't know how to do things there [at the nursing home] .before anyone brought the crash cart in the room .we were there for 5 minutes . RT #2 was asked if she remembered if the facility had called the code overhead .RT #2 stated, .No . no one called a code overhead .I was in [Named Resident #1's] room and one of the CNAs came running and grabbed me . RT #2 was asked if she knew what time of night it was when Resident #5 needed CPR. RT #2 stated, .I don't remember the time .a nurse came in there [Resident #5's room] .a female [LPN JJ] .a guy [LPN Z] came in there [Resident #5's room] . another CNA [CNA H] did . During a telephone interview on [DATE] at 4:21 PM, RT #1 was asked how she found out about the Code for Resident #5 on the Crown Unit. RT #1 stated, .The CNA went in and found her [found Resident #5 unresponsive] .I had just been there [Resident #5's room] 30 minutes before it happen .[Named Resident #23] heart rate was 148 .we did not have a nurse on crown [the Crown/Vent unit] .I had to keep my eye on her [Resident #23] . RT #1 was asked who was the CNA who came and got her. RT #1 stated, she [CNA B] has natural hair .the same CNA [CNA B] when doing my rounds .she [CNA B] came in the office and said she [Resident #5] was not responding .I ran down there [to Resident #5's room] .I felt for a pulse .no pulse grabbed the oxygen mask and the oxygen tank .told her [CNA B] to get the other RT .call for any nurse available .call code blue .[RT #2] got there before the nurse .she [RT #2] started compression .I was bagging her [Resident #5] with ambu bag [a method for providing a person with immediate air ventilation using a self-inflating bag ] .the nurse said need to grab crash cart .I asked for a board [a board to place under a resident's back in order to perform CPR for accurately] first .we took turns on compression and bagging until EMS got there .I had to put her [Resident #5] trach back in . EMS [emergency medical services] tried to move her [Resident #5] and I had to put trach back in . EMS step [stepped] out the room . RT #1 was asked if they used the AED. RT #1 stated, .We did not use the AED .the EMS used theirs .by time crash cart came into play . EMS put there monitor on her [Resident #5] .first just the 2 of us [RT #1 and RT #2] doing CPR .I assumed when the nurse came into play .they [nurses would] get the AED it did not come into play . RT #1 was asked what time the Code happened. RT #1 stated, . I'm not sure . RT #1 was asked who recorded the times and the event of the code. RT #1 stated, .Nobody . RT #1 was asked how she would know who did what, when, and where during the code if not documented. RT #1 stated, .I don't .normally the nurse would run the code .but there was no nurse on the floor [Crown Unit] it was a lot going on with no nurses on the floor .getting new patient in .patient died .it was a lot going on .and still trying to take care of patients still there on Crown .we did not have a nurse all night .all we had was RT [Respiratory Therapy] and a CNA .every place I went [worked] they have a recorder, and it will be the nurse . RT #1 was asked what did LPN JJ do during the Code in Resident #5's room. RT #1 stated, .the dark skin short lady [LPN JJ- who did not have a current CPR certification] .she was on the computer trying to get everything ready [paperwork] after she left, she sat down to try to write a note about what happen . RT #1 was asked if the 11-7 AM nurse came in to work. RT #1 stated, .I don't think so .at 12:00 AM and 1:00 AM .I said there's still no nurse here on the floor .we were telling the nurse who came at 7:00 AM what happened .there was no nurse on the hall [Crown/Vent unit] all night . During a telephone interview on [DATE] at 5:17 AM, CNA H was asked about the code on the Crown Unit in Resident #5's room. CNA H stated, .All I know is they called Code over the speaker .I did go down there to the hall [Crown Unit] to assist .I got the dinamap [used to measure blood pressure] to get some vital signs .and the pulse oximeter [use to measure blood oxygen] .I put the pulse oximeter on her finger .I put the pulse oximeter on [Resident #5's] finger to see if I could get a reading [there was no documented reading] .I left the room .I was just in there briefly . During a telephone interview on [DATE] at 5:26 AM, LPN Q was asked if she attended the Code on the Crown Unit for Resident #5. LPN Q stated, .No .I did not .I have a bad wrist .I would not be no good . During a telephone interview on [DATE] at 5:40 AM, Staff LPN JJ was asked about the code on the Crown Unit for Resident #5. LPN JJ stated, .I was working on Delta unit and CNA [CNA D] came to get me .when she came and got me she told me there is a Code on the Crown Unit, when I got to room [Resident #5's room], RT [Respiratory Therapy] was there. I went and got the crash cart, they [nurse] took the crash cart .I got on the phone and called 911, they [EMS] got here quickly . LPN JJ was asked if she went back to Resident #5's room. LPN JJ stated, .I did not go in the room .EMT [Emergency Medical Technician] was in the room .I went to the desk .paged Code again .I was in charge of getting EMT and fire department there .when I finished getting paper work .EMT was there I did not get chance to do CPR .there was enough people in the room . LPN JJ was asked did she chart in the nursing notes that she had assessed the Resident #5 for vital signs. LPN JJ stated, .I checked for a pulse .no chest rise and falling .I tried to get her [Resident #5] to response .her eyes were fixated .told them I'm going to call 911 . LPN JJ was asked when was the last time that Resident #5 had been checked prior to requiring CPR. LPN JJ stated, .There was no nurse on the Crown unit .I went in her [Resident #5] room at 12:30 AM .I went to change her feeding bag out .put water in her bag .if a nurse has to leave .they will come to me and I would take the keys .nobody gave me the keys that night .the CNA came over said there is no nurse on Crown unit .when I got over there was no nurse .that is when I found out .I came back to my hall to complete my work . LPN JJ was asked if she called the manager on call to inform them there was no nurse on Crown Unit. LPN JJ stated, No. LPN JJ was asked if she called the DON. LPN JJ stated, .No .I got here around 11:00 PM .that nurse on Crown left early .[Named LPNV] left early .[Named LPN W] left .I did not get this information until later .I was on my hall doing my work .I was behind on my hall, I have 40 plus patients [residents] on my hall . LPN JJ was asked if anyone notified the DON. LPN JJ stated, .Yes .I texted her .it was around 3:16 AM .I don't recall talking to her the [DON] . Review of LPN Staff JJ's employee file revealed there was a CPR certification card with an issue date of [DATE]. The facility was unable to provide information that LPN JJ was CPR certified during Resident #5's Code on [DATE], LPN JJ failed to maintain CPR certification in accordance with the facility policy. During a telephone interview on [DATE] at 6:14 AM, CNA D was asked about the Code with Resident #5. CNA D stated, .The CNA [CNA B] called my name .I was in the patients [residents] room next door visiting when the CNA she called me in the hallway .she [CNA B] asked if she thought she [Resident #5] was breathing .I went to [Name Resident #5's] room .then I left the room to called Code in the building . CNA D was asked where she went when she left the room. CNA D stated, .Down the hall to let another nurse know .told them I'm going to direct the ambulance and to let them [ambulance] in . CNA D was asked if there was a nurse on the Crown Unit. CNA D stated, .There was not a nurse .there was no nurse on Crown . CNA D was asked if she knew when the next nurse would come in [NAME] work n the Crown Unit. CNA D stated, Around 6:30 to7:00 AM the next morning . CNA D was asked if she saw any nurse pass medication to residents on the Crown Unit. CNA D stated, .I was not working that hall that night .all I know is [Named CNA B] was the CNA . During a second interview on [DATE] at 3:07 PM, CNA D was asked how the staff was notified of the Code on the Crown unit for Resident #5. CNA D stated, .I went to call a Code .she [CNA B] left to get the RT . there was no nurse for that hall .so we had to go get the nurse for my hall [Delta unit] .I was running and tell people by mouth . CNA D was asked if she should have used the call light that night and requested help. CNA D stated, .I did not push the light .there was no nurse on the hall [the Crown unit] .she was the only one [CNA B] . CNA D was asked if she checked for a pulse for Resident #5. CNA D Stated, .No . I did not feel her pulse .but I did look to see if her chest was rising or falling . CNA D was asked if CNA B checked for a pulse. CNA D stated, .I don't know .she asked me if she was breathing .she was warm .I looked at her chest .no she don't look like she is breathing .after [afterwards] I called a Code .I did not go back into the room .I went to get the door, to guide the Fire Department in . RT #1 was in the office at the nursing station down the hall . CNA D was asked if she was certified in CPR. CNA D stated, .No, it had expired, to my knowledge . During a second telephone interview on [DATE] at 8:50 AM, CNA H was asked if he went to Resident #5's Code on the Crown Unit. CNA H stated, .Yes ma'am .I went in the room .RT was doing compressions .the second RT was bagging .I got the dinamap [machine to measure vital signs] .took in the room and put the cuff on arm and pulse oximeter [machine to measure oxygen in the blood] on the finger for vital signs .checked the oxygen .from that point I stepped out the room let them do their job . During a telephone interview on [DATE] at 8:11 AM, LPN Z was asked about Resident #5's Code on [DATE]. LPN Z stated, .I went there .they [RT's] were doing CPR .we don ' t have a crash cart .I went to the desk and brought it back .continued with compression and bagging until fire department get there .they wanted the pulse oximeter she did not have one on .[Named LPN JJ] came .[Named LPN Q] she did not come .[Named JJ] she came in the room everybody was doing CPR .she went to the desk to do the paperwork . LPN Z was asked if he was aware there was no nurse working on the Crown Unit that night. LPN Z stated, .Yes. LPN Z was asked if management told them to wrap the building [divide the building equally]. LPN Z stated, .No . they [management] did not tell anyone to wrap that night .if they did .I'm not aware of it .I have 53 -56 resident on my hall . In summary, the facility failed to ensure a RN or unit Charge Nurse documented an accurate account of the CPR, failed to ensure a nurse stayed with the resident who required CPR, failed to ensure the certified CPR staff member (CNA B) initiated immediate action-including CPR, failed to ensure the nurse (LPN JJ) who came from another unit was CPR certified at the time of Resident #5's code on [DATE], in accordance with the facility policy. Staff was unable to determine how long it took to initiate CPR after Resident #5 was found unresponsive. Staff had to go to a separate unit and find someone to start CPR. The facility failed to immediately initiate CPR or use the AED as soon as it was available, first rescuer who arrived should send another rescuer to activate the emergency response system and get the AED in accordance with the American Heart Association Basic Life Support Provider Manual to increase the chance of survival for cardiac arrest. Resident #5 was in arrest and had a PEA rhythm when EMS left the facility and was pronounced dead in the Emergency Department. 3. Review of medical record revealed Resident #6 was admitted on [DATE], with a readmission on [DATE], with diagnoses of Heart Failure, Hypertension, Chronic Pain, Acute Hepatitis C, Dysphagia, and Diabetes. Review of the quarterly MDS dated [DATE], revealed Resident #6 with a BIMS score of 14 which indicated the Resident was cognitively intact. Review of the Nurses' Progress Notes dated [DATE] at 3:50 AM, revealed LPN Z documented .Resident found unresponsive by her CNA [CNA H]. CPR begun and 911 called .[ Named Fire Department] arrived at 4am [4:00 AM] and took over with CPR .[Named Fire Department] pronounced [declared the Resident deceased ] resident [Resident #6] At 410 am [4:10 AM]. [Named [NAME] Department] here @ [at] 415am [4:15 AM] and did report .All 3 family members notified @ 430 am [4:30 AM] with no answer form [from] anyone .Sons wife [Named Family Member #7] returned call to Facility @ 650am [6:50 AM] and was notified and states she will notify the rest of the family .Family asked to hold up on calling [Named ] Funeral until all the family arrive here. mssg [message] passed on to day nurse .Nurse Progress Note dated [DATE] at 10:23AM [Named] Funeral here to receive. Family sighned [signed] personal inventory sheet . There was no documentation of the time that Resident #6 was found unresponsive, and the time immediate CPR was initiated by the facility staff. Review of the Named Fire Department Prehospital Patient Report for Resident #6 dated [DATE], revealed .Chief [Primary] .Cardiac arrest/obvious death .Primary impression .Obvious death .Summary of Events . [Truck Number] arrived on scene and found 62 yof [year old female] laying supine in a bed unresponsive at a nursing home. Staff was performing cpr on the pt. Upon the arrival of [named Truck] the pt was pulseless and cold to the touch in a warm environment. Pt abdomen was very distended. A 3 lead was placed on the pt and asystole was the first monitored rhythm and was confirmed in leads I [one] II [two] and III [three]. The 3 lead was transmitted to the epcr [electronic patient care report] and a picture was uploaded. Nursing home staff last saw the pt alive at 1 am [1:00 AM]. Staff stated the pt was asleep but breathing when they last checked on her. No staff was able to tell [Named Truck number] when the last time they actually spoke to the pt. The crew [Fire Department crew] felt that with the assessment finding above and unknown downtime that resuscitation attempts were considered futile. Pt noted to not have vital signs compatible with life notes at 0410 [4:10 AM]. [Name Police Department] arrived on scene and was turned over to [Named Police Department] .Unit disp .0:358 [3:58 AM] .En route 04:05 [4:05 AM] .At Patient .04:07 [4:07 PM] .Reason CPR Discontinued .Obvious Signs of Death .Medical Assessment .Eye Assessment .Left .Non-Reactive .Right .Non-Reactive .Mental Status Assessment .Unresponsive .Skin Assessment .Cold . During an interview on [DATE] at 1:45 PM, CNA G was asked if he attended the Code for Resident #6. CNA G stated, .I went to the room .the nurse .2 CNAs [Named CNA H] .a female aide, [Named LPN Z] was his hall .other people came along with me .another nurse called 911 . CNA G was asked if Resident #6 had anything coming out her mouth. CNA G stated, .Yes, it looked like black BM [bowel movement]. CNA G was asked if Resident #6 was dirty/soiled. CNA G stated, .When I walked in .they were cleaning her up . CNA G was asked if anyone was doing CPR. CNA G stated, ' No. CNA G was asked if Resident #6 was breathing. CNA G stated, .No . she was a full code .we were short that night . [Named CNA H] was the aide on the hall .it appeared he [CNA H] did not do a round .I had to go and get another crash cart something was missing on the first crash cart . CNA G was asked if during the Codes was there and AED in the room. CNA G stated, No. CNA G was asked if he knew how to use the AED. CNA G stated yes .I was educated when I got certified . During a telephone interview on [DATE] at 8:11 AM, LPN Z was asked about Resident #6's Code on [DATE]. LPN Z stated, . [Named CNA H] he found her .I was down the hall, and he got me .I immediately went to her [Resident #6] room and found her [the Resident] unresponsive . LPN Z was asked if he checked for a pulse. LPN Z stated, Yes .we started CPR .told aide in the room to tell the nurse to call the code . LPN Z was asked who started chest compressions. LPN Z stated, .I did .one of aides brought the crash cart down . LPN Z was asked who bagged Resident #6. LPN Z stated, .I don't remember . LPN Z was asked if they had to get another crash cart. LPN Z stated, Yes .there was something missing on the crash cart .a suction tubing .we had to suction her and cleaned her up . LPN Z was asked if they [staff] suctioned her [Resident #6] and cleaned her [the Resident] up during the code. LPN Z stated, Yes. LPN Z was asked if Resident #6 appeared as if she had been laying there for a while dirty with urine and bowel movement. LPN Z stated, .Yes .from looking at the pads and the bed .yes .I don't think it just happen [her being dirty] . LPN Z was asked what Resident #6 looked like when he entered the room. LPN Z stated, .She looked like herself .but not breathing . LPN Z was asked how often the aides made rounds. LPN Z stated, .They [CNAs] supposed to check them [Residents] every 2 hours . LPN Z was asked when the last time Resident #6 was checked. LPN Z stated, .When I come in at 11:00 PM .I checked everybody .I have [a] list of stuff to do to get started .I had to make out the assignments .look at MARs [Medication Administration Records] for medications .it takes me a minute .I have to stop and start all night long . LPN Z was asked what time he had started his medication pass. LPN Z stated, .At midnight . LPN Z was asked when was the last time he checked on Resident #6 before she was found unresponsive at 3:50 AM. LPN Z stated, .It had to be around 1:30 AM or 2:00 AM, before I went to the Code on the Crown Unit [for Resident #5 ' s code] . LPN Z was asked if the AED was in the room during each code for Residents #5 and #6. LPN Z stated, .No, we didn't [have the AED] . LPN Z was asked if other nurses came to the Code for Resident #6. LPN Z stated, .No other nurse came .they suppose to come, but that night neither one come to the Code .I went to the desk and worked on the paperwork . LPN Z was asked at any time did he tell or ask staff if they could handle the Code and that you were going to do the paperwork. LPN Z stated, .No .I did not leave until fire department relieved me . During a telephone interview on [DATE] at 8:50 AM, CNA H was asked what happened when he found Resident #6 unresponsive on [DATE], and when the last time he checked on the Resident. CNA H stated, .It was around 1:00 AM .I do my first round about 1:00 AM .I just went in and saw she [Resident #6] was asleep [did not verify she was breathing] .I went to check on the other patients [residents] .I round on the patients every 2 hours .in between checking the patients .I make sure they are okay .that night I had [Named Resident #6] . At 3 something .3:30 AM .I went to room . [room of Resident #6] to check on the patient .3:40 AM I found [Named Resident #6] unresponsive .when I found her .I called her [Resident #6] name .she [Resident #6] did not respond .I checked her pulse .she did not have a pulse .I ran to get [Named LPN Z] the nurse and he came in .we tried to find pulse .she was still unresponsive .he [LPN Z] did go to the nursing station and called the Code . CNA H was asked if Resident #6 was breathing. CNA H stated, .No ma'am. CNA H was asked what they did next. CNA H stated, .I left and got the crash cart .he [LPN Z] came back to the room and started bagging .another CNA came and did compression [Named CNA A, who was CPR certified] . CNA H was asked if Resident #6 had something coming out of her mouth. CNA H stated, Yes she did .she had thrown up when I found her .the emesis, I saw a little on the floor and a little on her .when [CNA H] tried to bag her it was coming out of her mouth . CNA H was asked if he thought to push the call light for help. CNA H stated, .No ma'am .I did not .when I saw she was unresponsive I went and got the nurse . CNA H was asked if he was CPR certified. CNA H stated, .Yes, ma'am I am . CNA H was asked if you find a resident with no pulse what should you do first. CNA H stated, .We are taught to do a sternal rub .I did that .I checked her pulse .I called her name and went and got [Named LPN Z] . CNA H was asked if he thought to start CPR and chest compression. CNA H stated, .I did not think to do chest compression .in that moment I wanted to go get the nurse . CNA H was asked who attended the Code. CNA H stated, [Named CNA A] . [Named LPN Z] . [Named CNA G ] . went to the nurse station . CNA H was asked if they were left alone in the room without a [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, daily staffing records, medical record review, observation, and interview, the facility failed to ensure a sufficient number of licensed staff was available to provide care and services to all residents based on physician orders when there was no nurse to provide readmission assessments and services for 1 of 3 sampled residents (Resident #1) readmitted to the Crown Ventilation Unit on 4/4/2024 and failed to administer significant and other medications for 20 of 21 (Resident #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #22, #23, and #24 ) sampled residents reviewed on the Crown Unit. The facility failed to ensure sufficient qualified nursing staff at all times to meet the residents ' needs safely and promote each resident's well-being when there were not a licensed nurse on the Crown Unit on 13 of 90 days (1/1/2024, 1/2/2024, 1/3/2024, 1/6/2024, 1/22/2024, 1/27/2024, and 1/28/2024 on the 11:00 to 7:00 AM shift, 1/6/2023 on the 3:00 PM to 11:00 PM shift, 3/13/2024, 3/18/2024, 3/25/2024, 3/26/2024 on the 11:00 PM to 7:00 AM shift, and 4/4/2024 from the 8:00 PM to 7:00 AM) reviewed for staffing. Medications were not administered as ordered for all residents residing on the Crown Unit. This failure had the potential for serious harm and/or death. The facility's failure to ensure staffing was sufficient to provide oversight of the residents and ensure timely assessments and medications were administered resulted in Immediate Jeopardy. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, or impairment, or death of a resident. The Chief Operating Officer, Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for of F-725 on 4/23/2024 at 11:34 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F725 at a scope and severity of K which is Substandard Quality of Care. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F-725 was received on 4/25/2024 and an acceptable Removal Plan. The Removal Plan was validated onsite by the surveyors on 4/30/2024 through policy review, medical record review, observation, review of education records, and staff interviews. The IJ for F684 began on 1/1/2024 through 4/30/2023, the IJ was removed on 5/1/2024. Non-compliance of F-725 continues at a scope and severity of E, for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the Unit Manager, Job Description dated 5/15/2023, revealed .As Unit Manager you are delegated the administrative authority, and accountability necessary for carrying out your assigned duties .Assist in the development of Nursing Services in obtaining staffing information that must be posted on a daily basis .Provide the Director of Nursing Services with information relative to the nursing needs of the resident and to the Nursing Services Department's ability to meet those needs .Ensure that rooms are ready for new admission .Monitor mediation passes and treatment schedules to ensure that medications are being administered as ordered and that treatment are provided as scheduled .Report mediation errors to the Director of Nursing Services . Review of the Staffing Coordinator, signed Job Description, dated 10/11/22023, revealed .The primary purpose of you position is to ensure adequate and appropriate staffing of the Facility's nursing department to meet the needs of the residents .Report to Director of Nursing Services (DON) when scheduling with excess tardiness or absenteeism, in accordance with Facility policy .Complete monthly nursing schedule coordinating requests to ensure appropriate coverage of units . Review of the Charge Nurse [Licensed Practical Nurse (LPN], Job Description dated 5/26/2020, revealed .The primary purpose of your position is to provide direct nursing care to the resident, and to supervise the day-to-day nursing activities performed by CNAs . and other nursing personnel .ensure that the highest degree of quality care is maintained at all times .Cooperate with other resident services when coordinating nursing services to ensure that the resident's total regimen of care is maintained .Admit .residents as required .Perform administrative duties such as completing medical forms .charting .as necessary .Report all discrepancies noted concerning physician's orders .charting error .to the Nursing Supervisor .Unit Manger [Manager] .Prepare and administer medication as ordered by the physician .Inform the Nurse Supervisor .Unit Manager of staffing needs when assigned personnel fail to report to work .Nursing Care Functions .Review the resident ' s chart for specific treatment, medication orders . Review of the facility policy titled, Medication Errors (Named Facility) Rehabilitation and Nursing Center, dated 2016, revealed .The facility shall ensure mediations will be administered as following .According to physician's orders .In accordance with accepted standards and principles which apply to professionals providing services . Review of the facility policy titled, Staffing, dated 2007, revealed .Our facility provides adequate staffing to met needed care and services for our resident population .Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services . Review of the Facility Assessment, dated 2/28/2024, revealed .The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Use this assessment to make decisions about your direct care staff needs, as well as your capabilities to provide services to the residents in your facility. Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being .residents on ventilators .the facility assessment [NAME] be reviewed and updated to address how the facility staff, resources, physical environment .meet the needs of those residents and any areas requiring attention .Awareness of any limitations of administrating medications Administration of medication that residents need . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE],with diagnoses including Chronic Kidney Disease, Dependence on Ventilator, Diabetes, Dysphagia, Hypertension, and Gastrostomy tube (a tube inserted into the stomach) for nutrition and medication administration. Review of Physician's Orders dated 12/1/2023, revealed .Apixaban Oral Tablet 5 MG [milligrams] .Give 1 tablet .two times a day related to .THROMBOSIS [a blood clot that forms and and enters the bloodstream] give in morning and HS [hour sleep] .amLODIPine .Oral Tablet 10 MG .Give 1 tablet .one times a day related to .HYPERTENSION .levETIRAcetam Oral Tablet 750 MG .Give 2 tablet .two times a day related to .SEIZURES .give in morning & [and] at HS .Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML [milliliter] .3 ml .every 6 hours as needed for wheezing .Liquid Protein supplement two times a day for wounds . Review of Physician Orders dated 12/6/2023 revealed .HumaLOG [to treat blood glucose levels] Injection Solution 100 UNIT/ML [milliliters] .Inject subcutaneously every 8 hours . Review of Physician Orders dated 12/21/2023, revealed .Ipratropium-Albuterol Inhalation Solution 0.5-2.5 .MG [milligram]/3ML .3 ml [milliliters] .every 4 hours as needed for wheezing and 3 ml every 6 hours for Shortness of Breath . Review of Physician Orders dated 3/14/2024, revealed .Famotidine Oral Tablet 20 MG .Give 1 tablet .two times a day related to GASTRO-ESOPHAGEAL REFLUX DISEASE .cloBAZam Oral Tablet 20 MG .Give 1 tablet .two times a day related to .SEIZURES .Apixaban Oral Tablet 5 MG .Give 1 tablet .two times a day related to .CEREBRAL INFARCTION [ A stroke is a medical emergency that occurs when the blood supply to part of the brain is blocked or reduced] .Valproic Acid Oral Solution 250 MG/5ML .Give 15 ml .three times a day related to .SEIZURES .levETIRAcetam [Keppra] Oral Tablet 1000 MG .Give 1 tablet .two times a day related to .SEIZURES .Lacosamide Oral Solution 10 MG/ML .Give 30 ml .every 12 hours related to .SEIZURES .Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML .3 ml via trach every 6 hours as needed for SOB or wheezing .amLODIPine Besylate Oral Tablet 10 MG .Give 1 tablet .one time a day related to .HYPERTENSION .metFORMIN .Oral Tablet 500 MG .Give 1 tablet .two times a day related to DIABETES .Polyethylene Glycol 3350 Powder .Give 17 gram .two times a day related to CONSTIPATION . Scopolamine Transdermal Patch 72 Hour 1 MG/3DAYS .Apply 1 patch transdermal one time a day every 3 day(s) for secretions and remove per schedule .Arginaid Oral Packet (Nutritional Supplements) .Give 1 packet via PEG-Tube two times a day for supplement . Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed the Brief Interview for Metal Status (BIMS) score for Resident #1 was left blank, which indicated the resident was severely impaired and never/rarely made decisions. Review of Physician Orders dated 3/21/2024, revealed . Linezolid Intravenous Solution 600 MG/300ML . 600 mg [milligram] intravenously two times a day related to BACTERIAL PNEUMONIA . Review of Physician Orders dated 3/22/2024, revealed .Ascorbic Acid .Give 500 mg .two times a day for [wound] Healing for 14 Days . Review of the January 2024 Medication Administration Record (MAR) revealed the following medications, treatments, and services were not administered as prescribed in the physician's orders: a. Apixaban on 1/6/2024 at 9:00 PM. b. Famotidine on 1/6/2024 at 9:00 PM. c. Keppra on 1/6/2024 at 9:00 PM. d. Lacosamide on 1/6/2024 at 9:00 PM. e. Liquid Protein on 1/6/2024 at 9:00 PM. f. Metformin on 1/6/2024 at 9:00 PM. g. Valproate on 1/6/2024 at 5:00 PM. h. Atorvastatin on 1/6/2024 at 9:00 PM. i. ipratropium-Albuterol inhalation treatment on 1/2/2024, 1/6/2024, 1/14/2024, 1/21/2024, 1/28/2024, 1/29/2024, 1/30/2024 at 6:00 AM; on 1/8/2024, 1/17/2024, 1/22/2024 at 12:00 PM, 1/17/2024 at 6:00 PM; and on 1/28/2024 at 12:00 AM. Review of the February 2024 MAR revealed the following medications, treatments, and services were not administered as prescribed in the physician orders: a. Amlodipine on 2/6/2024 at 9:00 AM. b. Atorvastatin on 2/6/2024 and 2/8/2024 at 9:00 PM. c. Doxazosin on 2/6/2024 and 2/8/2024 at 9:00 PM. d. Apixaban on 2/6/2024, 2/8/2024, and 2/17/2024 at 9:00 PM. e. Famotidine on 2/6/2024 and 2/8/2024 at 9:00 PM. f. Keppra on 2/6/2024, 2/8/2024, and 2/17/2024 at 9:00 PM. g. Lacosamide 10 mg on 2/6/2024, 2/8/2024, and 2/17/2024 at 9:00 PM. h. Lacosamide 150 mg on 2/6/2024 at 9:00 PM. i. Liquid protein on 2/6/2024 and 2/8/2024 at 9:00 PM. j. Metformin on 2/6/2024 at 9:00 AM, 2/6/2024, 2/8/2024, and 2/17/2024 at 9:00 PM. k. Valproate on 2/6/2024 at 9:00 AM, 1:00 PM and on 5:00 PM. l. Ipratropium-Albuterol inhaler on 2/8/2024 and 2/16/2024 at 12:00 AM; on 2/3/2024, 2/4/2024, 2/8/2024, 2/11/2024, 2/15/2024, and 2/19/2024 at 6:00 AM; on 2/2/2024, 2/15/2024, 2/17/2024 and 2/19/2024 at 12:00 PM; and on 2/7/2024, 2/8/2024, and 2/14/2024 at 6:00 PM. Review of the March 2024 MAR revealed the following medications, treatments, and services were not administered as prescribed in the physician orders: a. Atorvastatin on 3/23/2024 at 9:00 PM. b. Apixaban on 3/23/2024 at 9:00 PM. c. Clobazam on 3/23/2024 at 9:00 PM. d. Arginaid nutritional supplement on 3/23/2024 at 9:00 PM. e. Famotidine on 3/23/2024 at 9:00 PM. f. Lacosamide on 3/23/2023 at 9:00 PM. g. Levetiracetam on 3/23/2024 at 9:00 PM. h. Linezolid on 3/23/2024 at 9:00 PM. i. Metformin on 3/23/2024 at 9:00 PM. j. Polyethylene on 3/23/2024 at 9:00 PM. k. Vitamin C on 3/23/2024 at 9:00 PM. l. Valproic Acid on 3/23/2024 at 5:00 PM. m. Vital signs were not checked on the evening shift on 3/23/2024 and on 3/18/2024 on the night shift. n. Scopolamine patch every 72 hours on 3/5/2024, 3/8/2024, and 3/11/2024. Review of the facility Admission/readmission form for Resident #1 revealed the Resident was readmitted to the facility on [DATE] to the Crown/Vent Unit. There was no documentation the Resident received a readmission assessment, or the condition, needs and status of Resident #1. Review of the facility's Named Rehabilitation and Nursing Center Midnight Census Report. dated 4/4/2024, On the Crown Unit revealed there was no nurse from 8:00 PM - 7:00 AM on the Crown Unit and the facility had a total of 3 Licensed Practical Nurses (LPNs) on the 11:00 PM to 7:00 AM shift. The Crown unit had a total census of 21 resident and a total facility census of 171 residents. On 4/5/2024 at 7:40 PM, LPN P completed the paperwork for Resident #1's 4/4/2024 readmission. During a telephone interview on 4/5/2024 at 2:18 PM, the Paramedic was asked to explain about the night Resident #1 returned to the facility for readmission. The Paramedic stated, . [Resident #1] was discharged from [Named Hospital] ICU [intensive care unit] at to 2136 [9:30 PM] to [Named Nursing home] in [named room number on the Crown/ Vent Unit] .I [Paramedic] could not find anyone on the halls .there was no staff .I went down the hallway .went into the room there was just a bed frame no mattress .I was not expecting that . The Paramedic was asked if the hospital had called a report to the facility. The Paramedic stated, .Yes, they called at 2:00 PM [on 4/4/2024] in the afternoon .they [facility] should have had the room ready .it was a return patient .finally found someone at the desk RT [Respiratory Therapist] and CNA [certified nursing assistant] .when the RT came in [the room for Resident #1] I said [the Resident] is a vent [Ventilator] patient . [the Paramedic asked] what can I do with a bed with no mattress .the RT went and found a mattress .then the RT left and came back . she [the RT] was trying to figure out how to set up the vent .I told her [the RT] you may want to go next door to see what the other vent setups look like .while she [the RT] was gone we put patient [Resident #1] in the bed .he had a catheter .a PEG tube .padded booth .the CNA came back in [Resident #1'sroom] and said 'We cant receive the patient .the nurse left .walked out .so we have no nurse . ' I [the Paramedic] called the dispatch and told them we going to be here till we get things settle .I spent 30 additional minutes there until the RT got the vent working right . [the Paramedic] went to the nursing desk [Named LPN Q] I gave her the folder with all the paperwork .went out the door with my partner and told him had to report this .these people [facility staff] are not trained to take care of the patients [residents on the Crown/Vent unit] . During an interview on 4/5/2024 at 5:30 PM, LPN V was asked about the staffing on the night shift on 4/4/2024. LPN V stated, .I was in the middle get things ready for the shift .the other nurse there was [Named LPN W] . he [LPN W] came back to the nursing station and said I can't do this .I quit .I asked him what is wrong .he said .well one of the family member he had was asking him question about the resident's clothes and stuff in her room .and now she [resident's family member] in there crying and I'm yelling . [LPN W stated] ' I can't do it ' .he put the keys on the counter and he left .I [LPN V] got an admission at 6:20 PM shortly after that . LPN V was asked who did she give the keys to after LPV W left. LPN V stated, . [Named LPN U] on Delta [another unit of the nursing home] . During an interview on 4/5/2024 at 5:44 PM, the Lead RT was asked to explain about the training of the new RTs. The Lead RT stated, .We have training on hire .monthly meeting we go over positioning, suctioning .how to setup the vents .when they [new RT] come in and give them a week or 2 training . The Lead RT was asked if she was aware Resident #1 was coming back to the facility on the night of 4/4/2024. The Lead RT stated, .Yes, I got report on [Name Resident #1] that he was coming around 12:30 PM or 1:00 PM .most of his equipment .it should have been in the room . The Lead RT was asked if she checked the room to ensure the Resident's room was ready and the ventilator was setup. The Lead RT stated, No when the patient goes out .we throw the old items away and disinfect the equipment [vent] and bag the supplies needed . During an interview on 4/10/2024 at 10:21 AM, LPN P was asked when a resident who is readmission to the facility on the ventilator unit when should the assessment be completed. LPN P stated, . [Named Resident #1] assessment it was not done .I notice it was not done, and it had to be done within 24 hours . LPN P was asked what the process was receiving a readmission. LPN P stated, .Get the admission sheet .go by the sheet .do the note .put the medications in .when they first come in .do the vital signs .a head to toe assessment .look at the orders verify the orders .do a skin assessment .its normally done immediately when they first get here . During an interview on 4/10/2024 at 10:24 AM, the Pulmonologist was asked when you have a resident on the ventilator that is readmitted to facility what should be done on readmission. The Pulmonologist stated, .The nurse and RT go in and admit the resident .usually should be a routine admission .they get the vital sign, write a nurse note .do a full exam .they are assessed by the nurse and RT .if any abnormal finding they would notify me by phone .the Nurse Practitioner [NP] will see them as well .I will see them within a week of admission/readmission .the NP will see them with 24 hours . The Pulmonologist was asked if it was acceptable to not assess the resident on a ventilator on readmit. The Pulmonologist stated, .They should be assessed immediately within hours of the patient's arrival to the facility . During an interview on 4/10/2024 at 3:35 PM, CNA E was asked if she was working when Resident #1 was readmitted on [DATE]. CNA E stated, .Yes . I worked the 3:00 PM to 11:00 PM shift .he [Resident #1] came back some time after 9:00 PM .I went in there [the Resident's room] when the EMS [emergency medical services] came .I was coming back from my break .the nurse was [Named LPN W] that night .when he [Named Resident #1] came in the building there was not a nurse on the floor [Crown Unit] .the paramedic came and asked me who is the nurse .I told him I'm not sure who the nurse is .I don ' t see a nurse .I went to the 800 hall to get [Name LPN U] .I told him there was new patient who came, the paramedic came and asked for signature .he [the Paramedic] said he was going to call the DON [Director of Nursing] .I went to [Named Resident #1's] room to see how he [the Resident] was doing .I told the paramedic the nurse on the 800 hall was checking into it .the nurse [LPN Q] on [NAME] [another unit of the facility] signed for it [paperwork] . CNA E was asked where was the nurse on the Crown Unit. CNA E stated, .I'm not sure .the only nurse I saw after 7:00 PM was [Named LPN V] and from that point on we did not have a nurse on crown . CNA E was asked if any other nurses came to help out on Crown Unit. CNA E stated, .the only one with concerns about the new admit was the one on [NAME] [Named LPN Q] .the only thing I saw was [LPN W] walking towards the front with his things .I asked [Named LPN V] what happened, and she told me he left . During a telephone interview on 4/10/2024 at 4:16 PM, RT #1 was asked about the night Resident #1 was readmitted back to the facility on 4/4/2024. RT#1 stated, .on Thursday [4/4/2024] .[Name Resident #1] came back to the facility .I went to get a mattress for the bed .there was not a mattress on the bed and a vent [ventilator] setup in the room .with every case I have the vent is always setup and preset up .I did not realize the vent was not setup .I put the mattress on the bed .I went got everything for the vent except one piece I did to realize I needed .it was a filter .normally the filter it comes with everything .it was my first time setup a vent .I had to leave the room again to get a filter .there was no nurse on the hall [Crown Unit] to receive him [Named Resident #1] . RT #1 was asked if she knew what happened to the nurse on the Crown Unit. RT #1 stated, .I'm not aware .not sure all I know they did not have a nurse that night on crown .if nurses don ' t come to work .I continue to do my job .I asked the CNA what we do with no nurse .she said 'the people up front can sign for them [the residents] .we [RT] could not sign for them' .EMS took the paperwork up to the front .20 minutes later someone came and asked for paperwork . RT #1 was asked if there was a nurse the rest of the night on 4/4/2024. RT #1 stated, .I did not see a nurse on my shift the CNA said she [Name LPN V] left around 7:30 .she said [Name LPN W] was there . the CNA said he [Named LPN W] walked out . 3. Review of medical record revealed Resident #2 was admitted on [DATE], with diagnoses including Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease, Tracheostomy Status, Dysphagia, Heart Failure, Hypertension, and Gastrostomy tube for nutrition and medication administration. Review of Physician Orders dated 4/2/2024, revealed .Apixaban [used to prevent serious blood clots from forming] Oral Tablet 2.5 MG .Give 1 tablet via PEG-Tube two times a day .Metoprolol Tartrate Oral Tablet 100 MG . Give 1 tablet via PEG-Tube two times a day related to TACHYCARDIA .Sennosides-Docusate Sodium Oral Tablet 8.6-50 MG .Give 1 tablet via PEG-Tube at bedtime related to CONSTIPATION .Midodrine HCl Oral Tablet 5 MG . Give 1 tablet . every 8 hours related to HYPOTENSION .Mirtazapine Oral Tablet 15 MG .Give 1 tablet via PEG-Tube at bedtime for appitite [appetite] .Losartan Potassium Oral Tablet 100 MG .Give 1 tablet .one time a day related to .HYPERTENSION . Review of Physician Orders dated 4/2/2024, revealed .Budesonide Inhalation Suspension 0.5 MG/2ML .0.5 mg via [by] vent two times a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE .Pravastatin Sodium Oral Tablet 80 MG .Give 1 tablet .at bedtime related to HYPERLIPIDEMIA . Review of the April 2024 MAR revealed the following medications, treatments, and services were not administered as prescribed in the physician orders: a. Losartan Potassium on 4/5/2024 at 9:00 AM. b. Mitazapine on 4/4/2024 at 9:00 PM. c. Pravastatin on 4/5/2024 at 9:00 PM. d. Senosides on 4/4/2024 at 9:00 PM. e. Apixaban on 4/4/2024 at 9:00 PM. f. Budesonide inhalation on 4/7/2024 at 9:00 PM and 4/8/2024 at 9:00 AM. g. Metoprolol on 4/3/2024 and 4/5/2024 at 9:00 AM, and 4/4/2024 at 9:00 PM, h. Midodrine on 4/4/2024 at 10:00 PM, and 4/5/2024 at 6:00 AM and 2:00 PM. Review of the admission MDS dated [DATE], revealed Resident #2 scored a BIMS of 3, which indicated she was severely cognitively impaired 4. Review of medical record revealed Resident #3 was admitted on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes, Dysphagia, Tracheostomy, Anxiety Disorder, and Gastrostomy tube for nutrition and medication administration. Review of Physician Orders dated 4/2/2024, revealed .Apixaban Oral Tablet 5 MG .Give 1 tablet by mouth two times a day related to PERIPHERAL VASCULAR DISEASE .Arformoterol Tartrate [is used as a long-term (maintenance) treatment to prevent and decrease wheezing and shortness of breath caused by breathing problems] Inhalation Nebulization Solution 15 MCG/2ML .Budesonide Inhalation Suspension 0.5 MG/2ML .2 ml inhale orally two times a day related to ACUTE AND CHRONIC RESPIRATORY FAILURE .Senna-Docusate Sodium Oral Tablet 8.6-50 MG .Give 1 tablet by mouth two times a day related to CONSTIPATION .Melatonin Oral Tablet 3 MG .Give 3 tablet by mouth at bedtime related to INSOMNIA .Lactulose Oral Solution 10 GM/15ML .Give 15 ml by mouth two times a day related to CONSTIPATION .Insulin Lispro Injection Solution .Inject subcutaneously every 8 hours related to .DIABETES .Ipratropium-Albuterol Inhalation Solution 0.5-2.5 .MG/3ML .3 ml inhale orally every 8 hours related to ACUTE AND CHRONIC RESPIRATORY FAILURE .Vital assessment every shift . Review of Physician Orders dated 4/6/2024, revealed . Spiriva Respimat Inhalation Aerosol Solution 2.5 MCG [micrograms] .2 puff inhale orally one time a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE . Review of the admission MDS dated [DATE], revealed Resident #2 scored a BIMS of 13, which indicated he was cognitively intact. Review of the April 2024 MAR revealed the following medications, treatments, and services were not administered as prescribed in the physician orders: a. Melatonin on 4/4/2024 at 9:00 PM. b. Spiriva inhalation on 4/8/2024 at 9:00 AM. c. Apixaban on 4/4/2024 at 9:00 PM. d. Arfomoterol inhalation on 4/4/2024 at 9:00 PM. e. Budesonide inhalation on 4/4/2024 and 4/9/2024 at 9:00 PM. f. Lactulose on 4/4/2024 at 9:00 AM. g. Senna-Docusate on 4/4/2024 at 9:00 PM. h. Ipratropium - Albuterol inhalation on 4/4/2024 at 10:00 PM and 4/5/2024 at 6:00 AM. 5. Review of medical record revealed Resident #5 was admitted on [DATE], with diagnoses including Dysphagia, Tracheostomy, Hypertension, Chronic Respiratory Failure, and Gastrostomy tube for nutrition and medication administration. Review of Physician Orders dated 3/1/2024, revealed .Metoprolol Tartrate Oral Tablet 50 MG .Give 2 tablet via PEG-Tube two times a day for HTN [hypertension] .Juven [to support wound healing by enhancing collagen formation] Oral Packet .Give 1 packet via [by] PEG-Tube two times a day .LevETIRAcetam Oral Solution 100 MG/ML .Give 10 ml via PEG-Tube two times a day for Seizures . Review of Physician Orders dated 3/4/2024, revealed .Rosuvastatin Calcium [used to lower bad cholesterol] Oral Tablet 10 MG .Give 1 tablet via PEG-Tube at bedtime for .Senna Oral Tablet 8.6 MG .Give 2 tablet via PEG-Tube every night shift for Constipation .Proteinex [Protein Supplement] Oral Liquid .Give 30 ml via PEG-Tube two times a day . Review of the admission MDS dated [DATE], revealed Resident #5's BIMS was blank, which indicated the Resident was severely impaired. Review of the March 2024 MAR revealed the following medications, treatments, and services were not administered as prescribed in the physician orders: a. Rosuvastatin on 3/16/2024 at 9:00 PM. b. Senna on 3/16/2024 at 9:00 PM. c. Juven on 3/16/2024 at 9:00 PM. d. Levetiracetam on 3/16/2024 at 900 PM. e. Metoprolol on 3/16/2024 at 900 PM. f. Protinex on 3/16/2024 at 900 PM. Review of the April 2024 MAR revealed the following medications, treatments, and services were not administered as prescribed in the physician orders: a. Rosuvastatin on 4/4/2024 at 9:00 PM. b. Senna on 4/4/2024 at 9:00 PM. c. Juven on 4/4/2024 at 9:00 PM. d. Levetiracetam on 4/4/2024 at 9:00 PM. e. Metoprolol on 4/4/2024 at 9:00 PM. f. Protinex on 4/4/2024 at 9:00 PM. 6. Review of closed medical record revealed Resident #7 was admitted on [DATE], with a readmission on [DATE], with diagnoses including Chronic Respiratory Failure, Tracheostomy, Hypertension, Dysphagia, Acute Kidney Failure, and Gastrostomy tube for nutrition and medication administration. Review of Physician Orders dated 11/28/2023, revealed .Sodium Polystyrene .Give 60 ml .related to HYPERKALEMIA [high potassium levels in the blood which can lead to heart problems] . Review of Physician Orders dated 2/1/2024, revealed .Atorvastatin Calcium Oral Tablet 40 MG .Give 1 tablet .at bedtime related to HYPERLIPIDEMIA [high levels of fat in the blood] . Review of the admission MDS dated [DATE], revealed Resident #7's BIMS score was blank, which indicated the Resident was severely impaired. Review of Physician Orders dated 2/27/2024 revealed .Atorvastatin Calcium Tablet 80 MG Give 1 tablet .at bedtime related to HYPERLIPIDEMIA [high levels of fat in the blood] . Review of Physician Orders dated 2/28/2024 revealed .Atorvastatin Calcium Oral Tablet 40 MG .Give 40 mg .at bedtime related to HYPERLIPIDEMIA . Review of Physician Orders dated 3/6/2024, revealed .Colace [for constipation] Oral Capsule 100 MG .Give 1 tablet .two times a day for Bowels . Review of the February 2024 MAR revealed the following medications, treatments, and services were not administered as prescribed in the physician orders: a. Atorvastatin on 2/6/2024 at 9:00 PM. b. Eliquis on 2/6/2024 at 9:00 PM. c. Polyethylene on 2/6/2024 at 9:00 PM. Review of the March 2024 MAR revealed the following medications, treatments, and services were not administered as prescribed in the physician orders: a. Atorvastatin on 3/15/2024 at 9:00 PM. b. Polyethylene on 3/15/2024 at 9:00 PM. c. Colace on 3/15/2024 at 9:00 PM. d. Eliquis on 3/15/2024 at 9:00 PM. Review of the April 2024 MAR revealed the following medications, treatments, and services were not administered as prescribed in the physician orders: a. Atorvastatin on 4/4/2024 at 9:00 PM. b. Polyethylene on 4/4/2024 at 9:00 PM. c. Colace on 4/4/2024 at 9:00 PM. d. Eliquis on 4/4/2024 at 9:00 PM. at 9:00 PM. 7. Review of medical record revealed Resident #8 was admitted on [DATE], with a readmission on [DATE], with diagnoses including Chronic Respiratory Failure, Tracheostomy, Colostomy, Diabetes, Hypertension, Colostomy, and Gastrostomy tube for nutrition and medication administration. Review of Physician Orders dated 1/3/2024, revealed Arginaid Oral Packet .Give 1 packet .two times a day for [wound] Healing for 30 Days .Systane Ophthalmic Solution .Instill 1 drop in both eyes every 4 hours for eye lubricant .Ipratropium-Albuterol Inhalation Solution .3 ml via vent every 6 hours related to CHRONIC RESPIRATORY FAILURE .Apixaban Oral Tablet 2.5 MG .Give 1 tablet .two times a day related to ACUTE EMBOLISM .Protein Oral Liquid .Give 30 ml .two times a day for Wound Healing for 30 Days .Moxifloxacin HCl Ophthalmic Solution 0.5 % .Instill 1 drop in both eyes every 4 hours for eye infection for 1 Week . Review of Physician Orders dated 2/29/2024, revealed .Ciprofloxacin HCl Ophthalmic Solution .Instill 1 unit in both eyes every 2 hours for infection . Review of Physician Orders dated 3/4/2024, revealed .Arginaid Oral Packet .Give 1 packet .two times a day for [wound] Healing for 30 Days . Review of the significant change MDS dated [DATE], revealed Resident #8's BIMS was blank, which indicated she was severely imp[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to ensure residents were free from significant medication errors for 25 of 26 sample residents (Resident #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #22, #23, #24, #35, #36, #38, #40, and #41) reviewed for medication administration. The facility's failure resulted in Immediate Jeopardy (IJ) when the residents' medications were not administered as prescribed for December 2023, January 2024, February 2024, March 2024, and April 2024, and had the likelihood to cause serious adverse outcomes. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, or impairment, or death of a resident. The Chief Operating Officer, Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for of F760 on 4/23/2024 at 11:34 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F760 at a scope and severity of K which is Substandard Quality of Care. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F760 was received on 4/25/2024 and an acceptable Removal Plan. The Removal Plan was validated onsite by the surveyors on 4/30/2024 through policy review, medical record review, observation, review of education records, and staff interviews. The IJ for F760 began on 1/1/2024 through 4/30/2023, the IJ was removed on 5/1/2024. Non-compliance of F760 continues at a scope and severity of F, for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility's policy titled Medication Administration dated 2021, and revised April 2024, revealed .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice .Sign MAR [Medication Administration Record] after administered .If medication is a controlled substance, sign narcotic book .Correct any discrepancies and report to nurse manager .Medication timing .BID [abbreviation for twice daily] 9 am, 9 pm .HS [abbreviation for at bedtime] 9 pm QD [abbreviation for every day] .Q 4H [abbreviation for every 4 hours] 6 am, 10 am, 2 pm, 6 pm, 10 pm, 2 am .Q8H [abbreviation for every 8 hours] 6 am, 2 pm, 10 pm . Review of the facility's policy titled Medication Errors dated 2019, revealed .It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services in an environment free of significant medication errors .Significant medication error means one which causes the resident discomfort or jeopardizes his/her health and safety . Review of the facility policy titled, Obtaining a Fingerstick Glucose Level, dated 2011, revealed .The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level .record the following information in the resident's medial record .The blood sugar results .The signature and title of the person recording the data . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with a readmission on [DATE], with diagnoses including Chronic Kidney Disease, Dependence on Ventilator, Diabetes, Dysphagia, Hypertension, and Gastrostomy tube (a tube inserted into the stomach) for nutrition and medication administration. Review of Physician's Orders dated 12/1/2023, revealed .Apixaban Oral Tablet 5 MG [milligrams] .Give 1 [one]tablet .two times a day related to .THROMBOSIS [a blood clot that forms and and enters the bloodstream] give in morning and HS [hour sleep] .amLODIPine .Oral Tablet 10 MG .Give 1 tablet .one times a day related to .HYPERTENSION .levETIRAcetam Oral Tablet 750 MG .Give 2 tablet .two times a day related to .SEIZURES .give in morning & [and] at HS . Review of Physician's Orders dated 12/6/2023 revealed .HumaLOG [to treat blood glucose levels] Injection Solution 100 UNIT/ML [milliliters] .Inject subcutaneously every 8 hours . Review of Physician's Orders dated 12/21/2023, revealed .Ipratropium-Albuterol Inhalation Solution 0.5-2.5 .MG [milligram]/3ML .3 ml [milliliters] .every 4 hours as needed for wheezing AND 3 ml .every 6 hours for Shortness of Breath . Review of the January 2024 Medication Administration Record (MAR) revealed the following medications, were not administered as prescribed in the physician orders: a. Apixaban on 1/6/2024 at 9:00 PM. b. Keppra on 1/6/2024 at 9:00 PM. c. Lacosamide on 1/6/2024 at 9:00 PM. d. Blood sugar (glucose) checks were not performed, and insulin administered per sliding scale On 1/2/2024 at 6:00 AM. On 1/3/2024 at 2:00 PM. On 1/3/2024, 1/6/2024, 1/16/2024, 1/21/2024, 1/22/2024, 1/23/2024, 1/24/2024, 1/26/2024, 1/28/2024, 1/29/2024 and 1/30/2024 at 6:00 AM. On 1/6/2024 at 9:00 PM. e. Valproate on 1/6/2024 at 5:00 PM. f. ipratropium-Albuterol inhalation treatment on 1/2/2024, 1/6/2024, 1/14/2024, 1/21/2024, 1/28/2024, 1/29/2024, 1/30/2024 at 6:00 AM; on 1/8/2024, 1/17/2024, 1/22/2024 at 12:00 PM, 1/17/2024 at 6:00 PM; and on 1/28/2024 at 12:00 AM. Review of the February 2024 MAR revealed the following medications were not administered as prescribed in the physician's orders: a. Amlodipine on 2/6/2024 at 9:00 AM. b. Apixaban on 2/6/2024, 2/8/2024, and 2/17/2024 at 9:00 PM. c. Keppra on 2/6/2024, 2/8/2024, and 2/17/2024 at 9:00 PM. d. Lacosamide 10 mg on 2/6/2024, 2/8/2024, and 2/17/2024 at 9:00 PM. e. Lacosamide 150 mg on 2/6/2024 at 9:00 PM. f. Blood sugar checks were not performed, and insulin administered by sliding scale: On 2/1/2024. 2/3/2024, 2/8/2024, 2/11/2024, 2/12/2024, 2/19/2024 and 2/21/2024 at 8:00 AM. On 2/6/2024, and 2/14/2024 at 2:00 PM. On 2/4/2024, 2/6/2024, 2/8/2024, and on 2/17/2024 at 10:00 PM. g. Valproate on 2/6/2024 at 9:00 AM, 1:00 PM and on 5:00 PM. h. Ipratropium-Albuterol inhaler on 2/8/2024 and 2/16/2024 at 12:00 AM; on 2/3/2024, 2/4/2024, 2/8/2024, 2/11/2024, 2/15/2024, and 2/19/2024 at 6:00 AM; on 2/2/2024, 2/15/2024, 2/17/2024 and 2/19/2024 at 12:00 PM; and on 2/7/2024, 2/8/2024, and 2/14/2024 at 6:00 PM. Review of Physician's Orders dated 3/14/2024, revealed .cloBAZam Oral Tablet 20 MG .Give 1 tablet .two times a day related to .SEIZURES .Apixaban Oral Tablet 5 MG .Give 1 tablet .two times a day related to .CEREBRAL INFARCTION [A stroke is a medical emergency that occurs when the blood supply to part of the brain is blocked or reduced ] .Valproic Acid Oral Solution 250 MG/5ML .Give 15 ml .three times a day related to .SEIZURES .levETIRAcetam [Keppra] Oral Tablet 1000 MG .Give 1 tablet .two times a day related to .SEIZURES .Lacosamide Oral Solution 10 MG/ML .Give 30 ml .every 12 hours related to .SEIZURES .Insulin Lispro [used to lower glucose] Injection Solution .Inject subcutaneously every 8 hours related to helps keep blood sugar under control .amLODIPine Besylate Oral Tablet 10 MG .Give 1 tablet .one time a day related to .HYPERTENSION . Review of the significant change Minimum Data Set (MDS) dated [DATE], revealed the Brief Interview for Metal Status (BIMS) score for Resident #1 was left blank, which indicated the Resident was severely impaired and never/rarely made decisions. Review of Physician's Orders dated 3/21/2024, revealed .Linezolid Intravenous Solution 600 MG/300ML .600 mg [milligram] intravenously two times a day related to BACTERIAL PNEUMONIA . Review of the March 2024 MAR revealed the following medications were not administered as prescribed in the physician's orders: a. Apixaban on 3/23/2024 at 9:00 PM. b. Clobazam 3/23/2024 at 9:00 PM. c. Lacosamide on 3/23/2023 at 9:00 PM. d. Levetiracetam on 3/23/2024 at 9:00 PM. e. Linezolid on 3/23/2024 at 9:00 PM. f. Blood sugar checks were not performed, and insulin administered per sliding scale: On 3/18/2024, and 3/19/2024 at 6:00 AM. On /23/2024 and 3/25/2024 at 10:00 PM. Review of the April 2024 MAR revealed the Blood sugar checks were not performed, and insulin not administered per sliding scale on 4/5/2024 at 6:00 AM. 3. Review of medical record revealed Resident #2 was admitted on [DATE], with diagnoses including Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease, Tracheostomy Status, Dysphagia, Heart Failure, Hypertension, and Gastrostomy tube for nutrition and medication administration. Review of Physician's Orders dated 4/2/2024, revealed .Apixaban [used to prevent serious blood clots from forming] Oral Tablet 2.5 MG .Give 1 tablet via PEG-Tube two times a day .Metoprolol Tartrate Oral Tablet 100 MG .Give 1 tablet via PEG-Tube two times a day related to TACHYCARDIA .Midodrine HCl Oral Tablet 5 MG .Give 1 tablet .every 8 hours related to HYPOTENSION .Losartan Potassium Oral Tablet 100 MG .Give 1 tablet .one time a day related to .HYPERTENSION .Budesonide Inhalation Suspension 0.5 MG/2ML .0.5 mg via [by] vent two times a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE . Review of the April 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Losartan Potassium on 4/5/2024 at 9:00 AM. b. Mitazapine on 4/4/2024 at 9:00 PM. c. Apixaban on 4/4/2024 at 9:00 PM. d. Metoprolol on 4/3/2024 and 4/5/2024 at 9:00 AM, and 4/4/2024 at 9:00 PM, e. Midodrine on 4/4/2024 at 10:00 PM, and 4/5/2024 at 6:00 AM and 2:00 PM. f. Budesonide inhalation on 4/7/2024 at 9:00 PM and 4/8/2024 at 9:00 AM. Review of the admission MDS dated [DATE], revealed Resident #2 scored a BIMS of 3, which indicated the Resident was severely cognitively impaired. 4. Review of medical record revealed Resident #3 was admitted on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease, Diabetes, Dysphagia, Tracheostomy, Anxiety Disorder, and Gastrostomy tube for nutrition and medication administration. Review of Physician's Orders dated 4/2/2024, revealed .Apixaban Oral Tablet 5 MG .Give 1 tablet by mouth two times a day related to PERIPHERAL VASCULAR DISEASE .Arformoterol Tartrate [is used as a long-term (maintenance) treatment to prevent and decrease wheezing and shortness of breath caused by breathing problems] Inhalation Nebulization Solution 15 MCG/2ML .Budesonide Inhalation Suspension 0.5 MG/2ML .2 ml inhale orally two times a day related to ACUTE AND CHRONIC RESPIRATORY FAILURE Insulin Lispro Injection Solution .Inject subcutaneously every 8 hours related to .DIABETES Ipratropium-Albuterol Inhalation Solution 0.5-2.5 .MG/3ML .3 ml inhale orally every 8 hours related to ACUTE AND CHRONIC RESPIRATORY FAILURE . Review of Physician's Orders dated 4/6/2024, revealed .Spiriva Respimat Inhalation Aerosol Solution 2.5 MCG [micrograms] .2 puff inhale orally one time a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE . Review of the admission MDS dated [DATE], revealed Resident #2 scored a BIMS of 13, which indicated the Resident was cognitively intact. Review of the April 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Apixaban on 4/4/2024 at 9:00 PM. b. Arfomoterol inhalation on 4/4/2024 at 9:00 PM. c. Budesonide inhalation on 4/4/2024 and 4/9/2024 at 9:00 PM. d. Ipratropium - Albuterol inhalation on 4/4/2024 at 10:00 PM and 4/5/2024 at 6:00 AM. e. Blood sugar checks were not performed, and insulin administered per sliding scale: On 4/4/2024 and 4/9/2024 at 10:00 PM. On 4/5/2024, 4/8/2024, and 4/10/2024 at 6:00 AM. f. Spiriva inhalation on 4/8/2024 at 9:00 AM. 5. Review of medical record revealed Resident #5 was admitted on [DATE], with diagnoses including Dysphagia, Tracheostomy, Hypertension, Chronic Respiratory Failure, and Gastrostomy tube for nutrition and medication administration. Review of Physician's Orders dated 3/1/2024, revealed .Metoprolol Tartrate Oral Tablet 50 MG .Give 2 tablet via PEG-Tube two times a day for HTN [hypertension] .LevETIRAcetam Oral Solution 100 MG/ML .Give 10 ml via PEG-Tube two times a day for Seizures . Review of the admission MDS dated [DATE], revealed Resident #5's BIMS was blank, which indicated the Resident was severely impaired. Review of the March 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Levetiracetam on 3/16/2024 at 900 PM. b. Metoprolol on 3/16/2024 at 900 PM. Review of the April 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Levetiracetam on 4/4/2024 at 9:00 PM. b. Metoprolol on 4/4/2024 at 9:00 PM. 6. Review of the medical record revealed Resident #7 was initially admitted on [DATE], and readmitted on [DATE], with diagnoses including Chronic Respiratory Failure with Hypoxia, Anoxic Brain Damage, Tracheostomy Status, Gastrostomy Status, Type 2 Diabetes, Chronic Pain, Seizure Disorder, Contracture of Right Hand and Left Hand. Review of a Physician's Orders with a start date of 11/29/2023, and discontinued on 12/11/2023, revealed Gabapentin (a controlled substance used to treat seizures - high doses are associated with a 60 percent increased risk of death) 100 milligrams (mg) 1 capsule to be given at bedtime. Review of the Controlled Substances count sheet revealed a Pharmacy label with prescription #4095079 for Gabapentin 100 mg capsule (1) to be given twice daily. Review of the Controlled Substances count sheet revealed Gabapentin 100mg was signed out to Resident #7 twice a day as follows instead of once at bedtime as ordered: a. 11/30/2023 - 1 capsule at 9:00 AM and 9:00 PM. b. 12/1/2023 - 1 capsule at 9:00 AM and 9:00 PM. c. 12/2/2023 - 1 capsule at 9:00 AM and 9:00 PM. d. 12/3/2023 - 1 capsule at 9:00 AM and 9:00 PM. e. 12/5/2023 - 1 capsule at 9:00 AM AND 9:00 PM. f. 12/6/2023 - 1 capsule at 9:00 AM AND 9:00 PM. g. 12/8/2023 - 1 capsule at 9:00 AM AND 9:00 PM. h. 12/9/2023 - 1 capsule at 9:00 AM AND 9:00 PM. i. 12/10/2023 - 1 capsule at 9:00 AM AND 9:00 PM. j. 12/11/2023 - 1 capsule at 9:00 AM AND 9:00 PM. Review of Resident #7's MAR for November 2023 and December 2023 revealed the nursing staff documented the Resident was administered Gabapentin 100 mg (1) capsule at 9:00 PM on 11/30/2023, 12/1/2023, 12/2/2023, 12/3/2023, 12/5/2023, 12/6/2023, 12/8/2023, 12/9/2023, 12/10/2023 and 12/11/2023. There was no documentation on the MAR the Resident received the Gabapentin at 9:00 AM. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 scored a 3 on the Brief Interview for Mental Status (BIMS), which indicated the Resident was severely cognitively impaired. During an interview with the Interim Director of Nursing (DON) on 4/30/2024 at 2:57 PM, when asked if Resident #7 was given Gabapentin as ordered during the months of November and December 2023, the Interim DON reviewed the Controlled Substance count sheet and stated, It's hard to tell. I can't say. Looks like it was given twice . 8. Review of medical record revealed Resident #8 was admitted on [DATE], with a readmission on [DATE], with diagnoses including Chronic Respiratory Failure, Tracheostomy, Colostomy, Diabetes, Hypertension, Colostomy, and Gastrostomy tube for nutrition and medication administration. Review of Physician's Orders dated 1/3/2024, revealed .Apixaban Oral Tablet 2.5 MG .Give 1 tablet .two times a day related to ACUTE EMBOLISM .Moxifloxacin HCl Ophthalmic Solution 0.5 % .Instill 1 drop in both eyes every 4 hours for eye infection for 1 Week .Insulin Aspart Subcutaneous Solution Cartridge 100 UNIT/ML .Inject subcutaneously every 8 hours related to .DIABETES .Inject as per sliding scale .Ipratropium-Albuterol Inhalation Solution .3 ml via vent every 6 hours related to CHRONIC RESPIRATORY FAILURE . Review of the January 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Blood sugar checks were not performed, and insulin administered per sliding scale: On 1/15/2024, 1/16/2024, 1/21/12024, 1/22/2024, 1/23/2024, 1/24/2024, 1/28/2024, and 1/29/2024 at 6:00 AM. On 1/4/2024, 1/7/2024, 1/18/2024,1/21/024, and 1/25/2024 at 2:00 PM. b. Moxifloxacin on 1/4/2024 at 8:00 AM and 12:00 PM, and 1/18/2024 at 1:00 PM. c. Ipratropium-Albuterol inhalation on 1/14/2024, 1/21/2024, 1/22/2024, and 1/29/2024 at 6:00 AM; on 1/3/2024, 1/8/2024, and 1/11/2024 at 12:00 PM; and on 1/6/2024 and 1/17/2024 at 6:00 PM. Review of the February 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Blood sugar checks were not performed and sliding scale insulin not administered: On 2/8/2024 and 2/26/2024 at 6:00 AM. On 2/14/2024 and 2/16/2024 at 2:00 PM; and on 2/6/2024 and 2/8/2024 at 10:00 PM. b. Moxifloxacin eye drops on 2/6/2024 at 5:00 PM and 9:00 PM; on 2/29/2024 at 12:00 AM; and on 2/8/2024 and 2/29/2024 at 4:00 AM. c. Ciprofloxacin eye drops on 2/14/2024 at 2:00 PM. d. Ipratropium-Albuterol inhalation on 2/8/2024 at 12:00 AM; on 2/8/2024 and 2/11/2024 at 6:00 AM; on 2/2/2024, 2/5/2024, 2/10/2024 at 12:00 PM; and on 2/7/2024 and 2/14/2024 at 6:00 PM. Review of Physician's Orders dated 2/29/2024, revealed .Ciprofloxacin HCl Ophthalmic Solution .Instill 1 unit in both eyes every 2 hours for infection . Review of the significant change MDS dated [DATE], revealed Resident #8's BIMS was blank, which indicated the Resident was severely impaired. Review of the March 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Apixaban on 3/6/2024 and 3/15/2024 at 9:00 PM. b. Blood sugar checks were not performed, and sliding scale insulin was not administered: On 3/1/2024, 3/2/2024, and 3/4/2024 at 6:30 AM. On 3/3/2024 at 4:00 PM. On 3/7/2024, 3/10/2024, 3/14/2024, 3/19/2024, 3/26/2024, and 3/27/2024 at 6:00 AM. On 3/6/2024, 3/9/2024, 3/10/2024, 3/13/2024 and 3/25/2024 at 10:00 PM. c. Moxifloxacin eye drop every 4 hours on 3/2/2024, and 3/7/2024 at 4:00 AM. Review of Physician's Orders dated 3/29/2024, revealed .Carboxymethylcellulose .Ophthalmic Gel 1 % .Instill 1 drop in both eyes every 4 hours for infection . Review of the April 2024 MAR revealed the following medications, treatments, and services were not administered as prescribed in the physician orders: a. Apixaban on 4/4/2024 at 9:00 PM. b. Carboxymethylcellulose eye drops on 4/4/2024 at 4:00 PM and 8:00 PM; and on 4/5/2024 and 4/10/2024 at 12:00 AM and 4:00 AM. c. Moxifloxacin eye drops on 4/4/2024 at 5:00 PM. d. Blood sugar checks were not performed and sliding scale insulin not administered: On 4/5/2024 and 4/8/2024 at 6:00 AM. On 4/6/2024 at 2:00 PM. On 4/4/2024 at 10:00 PM. 9. Review of medical record revealed Resident # 9 was admitted on [DATE], with a readmission on [DATE], with diagnoses including Chronic Respiratory Failure, Chronic Kidney Disease, Colostomy, Tracheostomy, Atrial Fibrillation, Peripheral Vascular Disease, and Gastrostomy tube for nutrition and medication administration. Review of Physician's Orders dated 12/20/2023, revealed .Apixaban Oral Tablet 5 MG .Give 5 mg .two times a day for anticoagulant . Review of Physician's Orders dated 1/18/2024, revealed .Apixaban Oral Tablet 5 MG .Give 5 mg .two times a day for anticoagulant .levETIRAcetam Oral Solution 100 MG/ML .Give 1000 mg .two times a day related to EPILEPSY .busPIRone HCl Oral Tablet 5 MG .Give 5 mg .two times a day related to .ANXIETY .Metoprolol Tartrate Oral Tablet 25 MG .Give 25 mg .two times a day related to .HYPERTENSION .Valproic Acid Oral Solution 250 MG/5ML .Give 10 ml .two times a day related to EPILEPSY .NovoLOG Injection Solution 100 UNIT/ML .Inject subcutaneously every 8 hours for .related to .DIABETES .Inject as per sliding scale . Review of the January 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Apixaban on 1/5/2024 at 9:00 PM. b. Buspirone on 1/6/2024 at 9:00 PM. c. Levetiracetam on 1/6/2024 at 9:00 PM. d. Metoprolol on 1/6/2024 at 9:00 PM. e. Valproic Acid on 1/6/2024 at 9:00 PM. f. Blood sugar checks were not performed, and sliding scale insulin not administered: On 1/2/2024, 1/3/2024, 1/6/2024, 1/21/2024, 1/22/2024, 1/23/2024, 1/28/2024, and 1/29/2024 at 6:00 AM. On 1/2/2024, 1/6/2024, and 1/29/2024 at 2:00 PM. On 1/6/2024 at 10:00 PM. Review of the February 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Apixaban on 2/4/2024 and 2/6/2024 at 9:00 PM. b. Buspirone on 2/4/2024, 2/6/2024, and 2/17/2024 at 9:00 PM. c. Levetiracetam on 2/4/2024, 2/6/2024, 2/17/2024, and 2/17/2024 at 9:00 PM. d. Metoprolol on 2/4/2024, 2/6/2024, 2/7/2024, and 2/17/2024 at 9:00 PM. e. Valproic Acid on 2/4/2024, 2/6/2024, and 2/17/2024 at 9:00 PM. f. Blood sugar checks were not performed, and sliding scale insulin not administered: On 2/8/2024, 2/12/2024, 2/19/2024, 2/21/2024, 2/23/2024, 2/25/2024, and 2/29/2024 at 6:00 AM. On 2/14/2024, and 2/29/2024 at 2:00 PM. On 2/4/2024, 2/6/2024, 2/17/2024, and 2/22/2024 at 10:00 PM. Review of the March 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Buspirone on 3/6/2024 at 9:00 PM. b. Levetiracetam on 3/6/2024 at 9:00 PM. c. Metoprolol on 3/6/2024 at 9:00 PM. d. Valproic Acid on 3/6/2024 at 9:00 PM. e. Blood sugar checks were not performed, and sliding scale insulin not administered: On 3/1/2024, 3/2/2024, 3/9/2024, 3/10/2024, 3/19/2024, 3/26/2024, and 3/27/2024 at 6:00 AM. On 3/3/3034 at 2:00 PM, 3/3/2024, 3/4/2024, 3/6/2024, 3/9/2024, 3/10/2024, 3/18/2024, and 3/25/2024 at 10:00 PM. Review of the significant change MDS dated [DATE], revealed Resident #9's BIMS score was blank which indicated the Resident was severely impaired. Review of the April 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Buspirone on 4/4/2024 at 9:00 PM. b. Levetiracetam on 4/4/2024 at 9:00 PM. c. Metoprolol on 4/4/2024 at 9:00 PM. d. Valproic Acid 4/4/2024 at 9:00 PM. e. Blood sugar checks were not performed, and sliding scale insulin not administered: On 4/5/2024, 4/8/2024 and 4/10/2024 at 6:00 AM. On 4/2/2024, 4/4/2024 and 4/9/2024 at 10:00 PM. 10. Review of medical record revealed Resident #10 was admitted on [DATE], with a readmission on [DATE], with diagnoses including Anoxic Brain Damage, Chronic Obstructive Pulmonary Disease, Hypertension, Tracheostomy, Diabetes, and Gastrostomy tube for nutrition and medication administration. Review of Physician's Orders dated 11/8/2023, revealed .Arformoterol Tartrate Inhalation Nebulization Solution 15 MCG/2ML .2 ml via trach two times a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE .Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML .3 ml via trach every 6 hours related to CHRONIC RESPIRATORY FAILURE .Insulin Lispro Injection Solution 100 UNIT/ML .Inject subcutaneously every 8 hours related to .DIABETES .inject as per sliding scale .Apixaban Oral Tablet 5 MG .Give 2 tablet .two times a day related to .CARDIAC ARREST .Give 1 tablet .two times a day related to .CARDIAC ARREST .Phenytoin Oral Suspension 100 MG/4ML .Give 8 ml .three times a day related to SEIZURES .levETIRAcetam Oral Solution 100 MG/ML .Give 15 ml .two times a day related to SEIZURES .Lacosamide Oral Solution 10 MG/ML .Give 20 ml .two times a day related to SEIZURES .OXcarbazepine Oral Tablet 300 MG .Give 1 tablet .two times a day related to SEIZURES . Review of the January 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Apixaban on 1/5/2024 at 9:00 PM. b. Lacosamide on 1/6/2024 at 9:00 PM. c. Levetiracetam on 1/6/2024 at 9:00 PM. d. Oxcarbazepine o 1/6/2024 at 9:00 PM. e. Arformoterol nebulization on 1/3/2024, 1/8/2024, 1/15/2024, 1/17/2024, 1/18/2024, and 1/31/2024 at 9:00 AM; and on 1/11/2024 and 1/17/2024 at 9:00 PM. f. Blood sugar checks were not performed, and sliding scale insulin not administered as follows: On 1/2/2024, 1/3/2024 at 6:00 AM. On 1/6/2024 at 6:00 AM and 6:00 PM. On 1/15/2024, 1/16,2024, 1/21/2024, 1/22/2024, 1/23/2024, 1/24/2024, 1/26/2024, 1/28/2024 and 1/29/2024 at 6:00 AM. g. Phenytoin on 1/6/2024 at 5:00 PM. h. Ipratropium-Albuterol on 1/6/2024, 1/14/2024, 1/21/2024 and 1/29/2024 at 6:00 AM; on 1/3/2024, 1/8/2024, 1/13/2024, 1/15/2024, 1/17/2024, 1/18/2024, 1/22/2024, and 1/31/2024 at 12:00 PM; and on 1/17/2024 at 6:00 PM. Review of Physician's Orders dated 2/7/2024, revealed .Apixaban Oral Tablet 2.5 MG .Give 1 tablet .two times a day for Anticoagulant . Review of the February 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Apixaban on 2/9/2024 at 9:00 AM and 2/17/2024 and 2/22/2024 at 9:00 PM. b. Apixaban on 2/4/2024 and 2/6/2024 at 9:00 PM. c. Lacosamide on 2/4/2024, 2/6/2024, 2/17/2024 and 2/22/2024 at 9:00 PM. d. Levetiracetam on 2/4/2024, 2/6/2024, 2/17/2024 and 2/22/2024 at 9:00 PM. e. Oxcarbazepine on 2/4/2024, 2/6/2024, 2/17/2024 and 2/22/2024 at 9:00 PM. f. Blood sugar checks were not performed, and sliding scale insulin not administered: On 2/1/2024, 2/8/2024, 2/12/2024, 2/18/2024, 2/19/2024, 2/21/2024, 2/23/2024, 2/25/2024, and 2/29/2024 at 6:00 AM. On 2/14/2024, and 2/22/2024 at 2:00 PM. On 2/4/2024, 2/6/2024, 2/7/2024, 2/17/2024, and 2/22/2024 at 10:00 PM. g. Phenytoin on 2/22/2024 and 2/29/2024 at 1:00 PM and 2/6/2024 at 5:00 PM. h. Arformoterol inhalation on 2/15/2025 and 2/28/2024 at 9:00 AM; and on 2/6/2024, 2/7/2024, 2/8/2024, 2/14/2024, 2/21/2024, and 2/22/2024 at 9:00 PM. i. Ipratropium-Albuterol inhalation on 2/8/2024, 2/16/2024, 2/23/2024 and 2/29/2024 at 12:00 AM; on 2/8/2024, 2/16/2024, 2/19/2024, 2/23/2024 and 2/29/2024 at 6:00 AM; on 2/5/2024, 2/6/2024, 2/15/2024, 2/28/2024 at 12:00 PM; and on 2/7/2024, 2/8/2024, 2/14/2024, 2/22/2024, and 2/27/2024 at 6:00 PM. Review of the March 2024 MAR revealed the following medications, treatments, and services were not administered as prescribed in the physician's orders: a. Apixaban on 3/6/2024 at 9:00 PM. b. Arformoterol inhalation on 3/2/2024, 3/7/2024, 3/8/2024, 3/27/2024, and 3/26/2025 at 9:00 AM and 3/3/2024, 3/6/2024, 3/20/2024, and 3/22/2024 at 9:00 PM. c. lacosamide on 3/6/2024 at 9:00 PM. d. Levetiracetam on 3/6/2024 at 9:00 PM. e. Oxcarbazepine on 3/6/2024 at 9:00 PM. f. Blood sugar checks were not performed, and sliding scale insulin not administered: On 3/1/2024, 3/2/2024, 3/4/2024, 3/7/2024,3/9/2024, 3/10/2024, 3/13/2024, 3/14/2024, 3/19/2024, 3/26/2024, and 3/27/2024 at 6:00AM. On 3/3/2024 at 2:00 PM. On 3/3/2024, 3/4/2024, 3/6/2024, 3/9/2024, 3/10. 2024, and 3/25/2024 at 10:00 PM. g. Arformoterol inhalation on 3/2/2024, 3/7/2024, 3/8/2024, 3/27/2024, and 3/26/2025 at 9:00 AM; and on 3/3/2024, 3/6/2024, 3/20/2024, and 3/22/2024 at 9:00 PM. h. Ipratropium-Albuterol inhalation on 3/1/2024, 3/2/2024, 3/4/2024, and 3/27/2024 at 12:00 AM; on 3/1/2024, 3/2/2024, 3/4/2024, 2/14/2024, 3/16/2024, 3/26/2024 and 3/27/2024 at 6:00 AM; and on 3/3/2024, 3/4/2024, 3/6/2024; and 3/10/2024 at 6:00 PM. Review of the significant change MDS dated [DATE], revealed Resident #10's BIMS score was blank which indicated the Resident was severely impaired. Review of the April 2024 MAR revealed the following medications were not administered as prescribed on the physician orders: a. Apixaban on 4/4/2024 at 9:00 PM and 4/5/2024 at 9:00 AM. b. Lacosamide on 4/4/2024 at 9:00 PM and 4/5/2024 at 9:00 AM. c. Levetiracetam on 4/4/2024 at 9:00 PM and 4/5/2024 at 9:00 AM. d. Oxcarbazepine on 4/4/2024 at 9:00 PM and 4/5/2024 at 9:00 AM. e. Blood sugar checks were not performed and sliding scale insulin not administered: On 4/2/2024 and 4/4/2024 at 10:00 PM. On 4/4/5/2024, 4/8/2024, and 4/10/2024 at 6:00 AM. On 4/5/2024 at 2:00 PM. f. Phenytoin on 4/4/2024 at 5:00 PM, and 4/5/2024 at 9:00 AM and 1:00 PM. g. Ipratropium-Albuterol inhalation on 4/4/2024 and 4/10/2024 at 6:00 PM; on 4/8/2024 at 12:00 PM; and on 4/4/2024 at 6:00 PM. 11. Review of medical record revealed Resident #11 was admitted on [DATE] with a readmission on [DATE], with diagnoses of Anoxic Brain Damage, Seizures, Diabetes, Gastroparesis, Dementia, Dependence on Respirator, Hypertension, and Gastrostomy tube for nutrition and medication administration. Review of Physician's Orders dated 2/3/2024, revealed .Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML3 ml inhale orally via nebulizer every 6 hours for Congestion .related to PNEUMONIA .Perampanel Oral Tablet 6 MG .Give 1 tablet .one time a day related to CONVERSION DISORDER WITH SEIZURES .Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3ML3 ml inhale orally via nebulizer every 6 hours for Congestion .related to PNEUMONIA .Acetaminophen Oral Tablet .Give 2 tablet .every 8 hours for pain .Meropenem Intravenous Solution Reconstituted 1 GM .Use 1 gram intravenously every 8 hours related to PNEUMONIA .HumaLOG KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML .Inject subcutaneously every 6 hours related to [lower blood sugar] .inject as per sliding scale .Scopolamine Transdermal Patch 72 Hour 1 MG/3DAYS .Apply 1 patch transdermally every 72 hours for Nausea and Vomiting .Lacosamide Oral Tablet 150 MG .Give 1 tablet .two times a day related to SEIZURES .levETIRAcetam Oral Solution 100 MG/ML .Give 7.5 ml .two times a day related to SEIZURES .amLODIPine Besylate Oral Tablet 10 MG .Give 1 tablet .one time a day for HTN [hypertension] . Review of the February 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Amlodipine on 2/5/2024 at 9:00 AM. b. Perampanel on 2/5/2024 at 9:00 AM. c. Lacosamide on 2/4/2024 at 9:00 PM and 2/5/2024 at 9:00 AM. d. Levetiracetam 2/4/2024 at 9:00 PM and 2/5/2024 at 9:00 e. Acetaminophen on 2/4/2024 at 6:00 AM, 2:00 PM and 10:00 PM and on 2/5/2020 at 6:00 AM and 2:00 PM. f. Meropenem every 8 hours on 2/3/2024 at 2:00 PM and 10:00 PM; on 2/4/2024 at 10:00 PM, and on 2/5/2024 at 6:00 AM and at 2:00 PM. g. Blood sugar checks were not performed and sliding scale insulin not administered on 2/5/2024 at 600 AM and 12:00 PM. h. Ipratropium-Albuterol on 2/3/2024 at 6:00 PM. Review of the 5-day MDS dated [DATE], revealed Resident #11's BIMS score was blank, which indicated the Resident was severely impaired. Review of the March 2024 MAR revealed the following medications were not administered as prescribed in the physician orders: a. Lacosamide on 3/6/2024 at 9:00 PM. b. Levetiracetam on 3/6/2024 at 9:00 PM. c. Acetaminophen on 3/1/2024, 3/2/2024, 3/7/2024, 3/9/2024, 3/14/2024, 3/16/2024, 3/19/2024, 3/26/2024, and 3/26/2024 at 6:00 AM; on 3/3/2024 at 2:00 PM; on 3/4/2024, 3/6/2024, 3/9/2024, 3/10/2024; and on 3/25/2024 [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on job description review, record review, medical record review, and interview, the facility Administration failed to administer the facility in a manner that provided oversight of the care being provided to residents, and ensure staff were sufficient in numbers and competent in their duties to provide care and services per physician orders and to meet the individualized needs of all residents. The facility Administration failed to have a system in place to ensure sufficient licensed nursing staff were available and with the knowledge and skills necessary to ensure residents were free from significant medication errors when medications were not administered as ordered by the physician for 25 of 26 sample residents (Resident #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #22, #23, #24, #35, #36, #38, #40 and #41) reviewed who required medications and treatments. The medications not administered as ordered by the physician included anti-diabetics, anticoagulants, anticonvulsants, antibiotics, antiarrhythmics, hypertensive, and cardiac medications. The facility's failure to administer medications as ordered and provide care and services for residents resulted in Immediate Jeopardy. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Chief Operating Officer, Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for of F-689 on [DATE] at 3:44 PM, in the Conference Room. The Chief Operating Officer, Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for of F-684, F-725, F-760, F-835, and F-867 on [DATE] at 11:34 PM, in the Conference Room. The Chief Operating Officer, Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for of F-678 on [DATE] at 1:01 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-689 on [DATE] at a scope and severity of J which is Substandard Quality of Care. The facility was cited Immediate Jeopardy at F-684, F-725, F-760 on [DATE] at a scope and severity of K which is Substandard Quality of Care. The facility was cited Immediate Jeopardy at F-835, F-867 on [DATE] at a scope and severity of J which is Substandard Quality of Care. The facility was cited Immediate Jeopardy at F-678 on [DATE] at a scope and severity of J which is Substandard Quality of Care. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F-684, F-689, F-725, F-760, F-835 and F-867 was received on [DATE] and an acceptable Removal Plan. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F-678 was received on [DATE] and an acceptable Removal Plan. The Removal Plan was validated onsite by the surveyors on [DATE] through policy review, medical record review, observation, review of education records, and staff interviews. The IJ for F-684, F-725, F-760, F-835, and F-867 began on [DATE] through [DATE], the IJ was removed on [DATE]. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility's Administrator signed Job Description, revealed dated [DATE], revealed .The primary purpose of your position is to direct the day-to-day functions of the Facility in accordance with current federal, state and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our resident at all times .As Administrator you are delegated the administrative authority, responsibility and accountability necessary for carrying out your assigned duties .Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice .Ensure that an adequate number of appropriately trained licensed professional and non-licensed personnel are on duty at all times to meet the needs of the residents .to assure that the residents' need are continually met . Review of the facility's Director of Nursing (DON) Services Job Description dated [DATE], revealed .The primary purpose of your position is to plan, organize, develop, and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our Facility and as may be directed by the Administrator or the Medial Director to ensure that the highest degree of quality care is maintained at all times .you are delegated the administrative authority, responsibility, an accountability necessary for carrying out your assigned duties .Develop methods for coordination of nursing services with other resident services to ensure the continuity of the residents' total regimen of care .Assist in calculating the number of direct nursing care personnel on duty each shift. Report such information to the Administrator or his/her designee to ensure the accurate staffing information is posted .Inform the Nurse Supervisor and/or Unit Manager of staffing needs when assigned personnel fail to report to work .Report absentee call ins to the Nursing Supervisor and/or Unit Manager .Make daily rounds of your unit/shift to ensure that assigned CNAs [certified nursing assistant] .and other nursing personnel are performing their work assignments in accordance with acceptable nursing standards .Determine the staffing needs of the nursing service department necessary to meet the total nursing needs of the residents .Supervise and assist scheduling of employees within established state guidelines .Assign a sufficient number of LPNs [licensed practical nurse] and RNs [registered nurse] for each tour of duty to ensure that quality care maintained . 2. Review of facility policies, medical record review, observation, and interview during the complaint survey revealed Residents #4 experienced an unwitnessed fall on [DATE]. The nursing staff failed to perform neurological checks and vital signs per the facility policy post fall. Thirty-six hours later the Resident experienced a decline in mental status, was sent to the hospital and an emergency craniotomy was performed for a subdural hematoma (bleeding in the brain). Refer to F689. 3. Review of facility policies, medical record review, observation, and interview during the complaint survey revealed nursing failed to administer residents their anticonvulsant medications, insulin, antibiotic, antiarrhythmic medications, antihypertensive medications, antibiotics, anti-platelet medications, antidiuretic medications, and antipsychotic medications, accu-checks, percutaneous endoscopic gastrostomy tube (PEG) care, breathing treatments and nutritional support in accordance with physician orders for 25 of 26 (Residents #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #22, #23, #24, #35, #36, #38, #40 and #41) reviewed for medication administration and care and services per physician orders. Refer to F725, 726 and F760. 4. Review of facility policies, medical record review, observation, and interview during the complaint survey revealed nursing was not readily available to perform cardiopulmonary resuscitation (CPR) measures for Residents #5 and #6. During an interview with the Licensed Practical Nurse (LPN) staff revealed on the evening shift when both Resident #5 and Resident #6 required CPR, there was not a nurse assigned to work on the Crown Unit/Ventilation Unit. Refer to F678. 5. During an interview on [DATE] at 11:17 AM, the Administrator, Director of Nursing (DON) and the Chief Operational Officer (COO) were asked if there were any nursing staffing issues at the facility. The COO stated, .[Named Administrator] calls and texts me with reportable events .major accidents .staffing .family complaints on daily basis . The COO was asked if he was aware of the missed medications and lack of nursing staffing issue on the Crown Unit. The COO asked, they missed medications and stated I did not know about that .I know now . The Administrator was asked if the Medial Director should be informed of missed medications and treatments. The Administrator stated, Yes. The Administrator was asked who performed and monitored the implementation of CPR when required. The Administrator stated, .we had a code team [a group assigned to perform CPR] in the past everyone had an assignment to take care of the patient [resident] .Respiratory Therapy .nurse .at night it could be 2-3 nurses. The Administrator was asked should the staff respond immediately for CPR. The Administrator stated, Yes. The Administrator was asked how often should the crash carts be checked for medications and items needed to perform CPR and who was responsible for checking the crash carts. The Administrator state, .Daily .the managers make sure it is done . The Administrator was asked if the Automated External Defibrillator (AED) should be in use during CPR. The Administrator stated. Yes. The COO was asked who was responsible for the operations in the facility. The COO stated, .the Administrator and the governing body . The Administrator was asked if the facility had a process in place to determine if the residents were receiving the care and services as ordered and needed. The Administrator stated, .Yes .we have 2 morning meeting .we discuss what is going on in the facility .each department heads are in the meeting .I ask, if there are any issue or concerns .the meeting is in 2 part meeting .have a QA [quality assurance] meeting with the unit managers .the ADON [assisted director of nursing] and DON .look at the falls .behaviors .exit seeking .anything identified . The Administrator was asked about staffing issues on the CROWN/ventilation unit. The Administrator stated, .We [Administrator, COO and DON] should have been notified or the DON should have come in .I could have come in to monitor the unit . The Administrator was asked how the facility is staffed when nurses call in and don't report for their shift. The Administrator stated, .we should split the facility equally among the nurses . The Administrator was asked if 2 CNAs should be responsible to take care of all the residents in the entire building. The Administrator stated, No .we would call in help and the nurse was responsible for helping them [CNAs] . During an interview on [DATE] at 11:29 AM Registered Nurse (RN) FF was asked how long they been working as the Unit Manager on the Crown Unit/Ventilation. RN FF stated, .3 month .I started here in August .I became the unit manager in September . RN FF was asked if she was aware there was not a nurse who worked on Crown Unit on several shifts. RN FF stated, Yes .and I let the DON know . RN FF was asked what as done about the lack of nursing staff on the CROWN unit. RN FF stated, .I would get up and come in . sometimes we would not know until the next morning . RN FF was asked if she was aware of the residents on the CVOWN unit had been not receiving all their missed medications. RN FF stated, .That was the days we did not have a nurse on crown [CROWN unit] .I told the DON and said she would take care of it .I told her the medications were still in pill packs on the cart .then I would hear there was no nurse . RN FF was asked if she notified the Medical Director. RN FF stated, .I went to the DON and don't know if she did anything . Refer to F678, F725, 726 and F760. The surveyors verified the Removal Plan by: 1. Corporate Consultant who is a licensed nursing home administrator and RN (Registered Nurse) with Doctoral level education in-serviced the Administrator/DON) Director of Nursing) on [DATE] on the importance of administering the facility in a manner that enabled its resources efficiently and effectively to attain and maintain highest practical well-being of the residents. The surveyors confirmed this by record review and interviews. 2. Administration has ensured oversight of nursing department including staffing, licensed nurses available at all times to administer medications and treatment. The surveyors confirmed this by record review and interviews. 3.The administration has ensured CPR (Cardiopulmonary resuscitation) trained licensed nurses are available for resident emergencies. The surveyors confirmed this by record review and interviews. 4. Administration has ensured licensed nurses are available to perform assessments of all new admits including vent (known as life-support machines) residents. The surveyors confirmed this by record review and interviews. 5. Immediate in-services on medication error, accident supervision and staffing were initiated by staff educator for licensed nurses on [DATE] and will be completed by [DATE]. The surveyors confirmed this by record review and interviews. 6. All licensed staff on leave or agency staff will require to attend the in-service prior to starting their shift. The surveyors confirmed this by record review and interviews. 7. Following systems were put in place to immediately on [DATE] to correct: The surveyors confirmed this by record review and interviews. Staffing coordinator to provide daily staffing to the Administrator/DON/ADON to review for the next day. If additional staff are needed, take appropriate actions such as agency usage, use of overtime, offer bonus/other incentives to meet the staffing needs. Nursing management to assist in last minute call ins. Vent unit has the highest staffing priority based on acuity. Nursing administration to check for medication errors daily and as needed. Nursing administration to ensure CPR Certified nurses are available all three shifts for resident emergencies. 8. The facility Administration will monitor the removal plan daily including weekends in specific areas such as assessments of all new admits by a licensed nurse, emergency management including availability of CPR certified licensed nurses, daily staffing, and review of medication errors. The surveyors confirmed this by record review and interviews. 9. The facility will conduct daily QAPI meetings as part of the morning meeting with the members of the interdisciplinary team to monitor missing medications and effectiveness of the removal plan. The surveyors confirmed this by record review and interviews. 10. All corrective actions will continue until a Plan of Correction is developed. The surveyors confirmed this by record review and interview. The facility is required to submit a plan of correction.

Based on job description review, facility document review, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI /QA) committee failed to ensure a QAPI program that identified, implemented actions, and monitored serious issues affecting facility staffing, quality of care, prescribed care and services, and residents' rights for 20 of 21 (Resident #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #22, #23 and #24 ) sampled residents reviewed for prescribed medications, treatments, care and services during January 2024, February 2024, March 2024 and April 2024. (Resident #4) failed to receive appropriate monitoring after a fall on 3/29/2024 and underwent an emergency craniotomy (a type of brain surgery where a surgeon removes part of your skull to access your brain) on 3/30/2024. Residents #5 and #6) reviewed for the implementation of basic life support were not immediately provided Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR) CPR. The facility failed to provide hair care in a manner that promoted a sense of self-worth, dignity and individuality for 11 of 11 (Resident #7, #20, #28, #30, #37, #42, #44, #45, #46, #47 and #48) sampled residents reviewed who were observed with unkempt, and matted hair. The facility's failure to provide and monitor hair care resulted in HARM for the 11 residents (Harm is a situation in which the provider's noncompliance resulted in a negative outcome that compromised the residents' ability to maintain and/or reach his/her highest practical physical, mental and psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care and provision of services). The failure of the facility's QAPI program resulted in Immediate Jeopardy when the QAPI committee failed to ensure the facility's Administration were accountable to provide oversight, and to monitor and provide a safe environment, and ensure systems and processes were in place which attained and maintained the highest practicable level of functioning for all residents. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Chief Operating Officer, Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for of F-689 on 4/22/2024 at 3:44 PM, in the Conference Room. The Chief Operating Officer, Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for of F-725, F-726, F-760, F-835, and F-867 on 4/23/2024 at 11:34 PM, in the Conference Room. The Chief Operating Officer, Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) for of F-678 on 4/25/2024 at 1:01 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-689 on 4/22/2024 at a scope and severity of J which is Substandard Quality of Care. The facility was cited Immediate Jeopardy at F-725, F-760 on 4/23/2024 at a scope and severity of K which is Substandard Quality of Care. The facility was cited Immediate Jeopardy at F-835, F-867 on 4/23/2024 at a scope and severity of K. The facility was cited Immediate Jeopardy at F-678 on 4/25/2024 at a scope and severity of J which is Substandard Quality of Care. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F-689, F-725, F-760, F-835 and F-867 was received on 4/25/2024 and an acceptable Removal Plan. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F-678 was received on 4/26/2024 and an acceptable Removal Plan. The Removal Plan was validated onsite by the surveyors on 4/30/2024 through policy review, medical record review, observation, review of education records, and staff interviews. The IJ began on 1/1/2024 through 4/30/2024, the IJ was removed on 5/1/2024. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the Administrator job description dated 12/2018 revealed, .Lead and direct the overall operations of the facility in accordance with customer needs, government regulations and company policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives .Essential Duties & [Symbol for and] Responsibilities .Identify and participate in process improvement, initiatives that improve the customer experience, enhance work flow, and/or improve the work environment .management duties including, but not limited to, hiring, training and developing, coaching and counseling, and terminating department staff, as deemed necessary .Lead the facility management staff and consultants in developing and working from the business plan that focuses on all aspects of facility operations, including setting priorities and job assignments .Monitor each department's activities, communicate policies, evaluate performance, provide feedback and assist, observe, coach, and discipline as needed .Oversee regular rounds to monitor delivery of nursing care .and ensure resident needs are being addressed .Responsible for the QA [Quality Assurance] program .Manage turnover and solidify current and future staffing through development of recruiting sources, and through appropriate selection, orientation, training, staff education and development .Consult with department managers concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement of services . 2. Review of the Director of Nursing (DON) job description dated 12/2011 revealed, .to manage the overall operations of the Nursing Department in accordance with Company policies, standards of nursing practices and governmental regulations so as to maintain excellent care of all residents' needs .Identify and participate in process improvement initiatives that improve the customer experience, enhance work flow, and/or improve the work environment. Management duties including, but not limited to, hiring, training and developing, coaching and counseling, and terminating department staff, as deemed necessary .In the absence of the Administrator and Assistant Administrator (if applicable), assume responsibility of the facility .Plan, develop, organize, implement, evaluate and direct the nursing services department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the long-term facility. Assume administrative authority, responsibility and accountability for all functions, activities, and training of the nursing department. Organize, develop, and direct the administration and resident care of the nursing service department. Participate in Department Supervisor Meetings, Resident Care Plan Meetings, Budget Committee Meetings, Safety Committee Meetings, Quality Assessment and Assurance Committee Meetings, In-service Education, Family Council, and any other meeting as directed by the Administrator. Meet monthly with staff on each unit .Participate in coordination of resident services through departmental and appropriate staff committee meetings. Meet monthly with nursing staff regarding Chart Audit and Physician's Orders. Review audit with Medical Records prior to submitting to Administration .Make daily rounds of the nursing department to verify that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards .Provide appropriate departmental in-service education programs in compliance with Corporate, State and Federal guidelines .Perform nursing services and deliver resident care services in compliance with corporate policies and State and Federal regulations. Inform state of any reportable incidents within appropriate time frames. Complete investigative analysis as required .Schedule daily rounds to observe residents and to determine if nursing needs are being met in accordance with the resident's request .Study Infection Control Reports, Medication Incident Reports and Resident Incident Reports for corrective action. Keep Administrator informed on a daily basis of nursing department functions, recommending changes in techniques or procedures for a more efficient operation .Ensure that all nursing service personnel follow established departmental policies and procedures .Assure residents a comfortable, clean, orderly and safe environment .Confirm accurate completion of forms/reports .Review and verify that documentation procedures for nursing are met according to corporate, state and federal guidelines. Review nurses notes to confirm that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to the care, and that such care is provided in accordance with the resident's wishes. Review Quality Indicator reports and submit to [NAME] President of Clinical Services on monthly basis .Participate in monthly QA. Ensure staffing levels are maintained .Along with the Administrator engage the medical director in all department activity . 3. Review of the QAPI documentation dated September 2023 through February 2024 revealed no documentation or evidence of data collection and analysis, documentation demonstrating the development, implementation and evaluation of corrective actions or performance improvement activities. 4. During an interview on 4/16/2024 at 3:58 PM, the Administrator was asked who is over the QA process. The Administrator stated, .The DON . During an interview on 4/16/2024 at 4:02 PM, the Director of Nursing (DON) was asked how often the QA meetings were held. The DON stated, .Once a month . The DON was asked who responsible for QA. The DON stated, .I am over the QA meetings . The DON was asked who attended the QA meeting. The DON stated, all department heads, and [Named Pulmonologist] over [the] Crown Unit [a unit with residents on mechanical ventilators and high acuity level of resident care and services] .[Named Medical Director] . The DON was asked what some of the focus areas has been covered in the meeting. The DON stated, .every department bring their own problem that need to be fixed in their area .the Social Worker brings the grievance log .Activity go over the complaints of the residents .dietary the same .hot food .cold food .address the problem and get it resolved .nursing talk about infections during the month .the falls we had .what unit and the time and day the fall occurred .pharmacy come and talk about the medication audits .they [pharmacy] come monthly .watch one nurse medication pass .go over any problems identified .check medication rooms .check the carts . The DON was asked if she had any audits in place at this current time. The DON stated, No. The DON was asked if she had any Performance Improvement Plans (PIPS) in place at this time regarding staffing and missed medications. The DON stated, .No .we talked about staffing .I don't have it on paper .we have a staffing meeting me the Administrator, and [Named Chief Operational Officer] . 5. In summary the Quality Assurance Performance Improvement (QAPI) meeting minutes reviewed for September 2023 through February 2024 did not contain any documentation of data collection and analysis at regular intervals and of reports demonstrating systematic identification, reporting, investigating, analysis, and prevention of adverse events of missed medications and sufficient staffing. 6. The QAPI committee failed to ensure all residents' right to be free from neglect when the facility failed to provide hair care in a manner that promoted a sense of self-worth, dignity and individuality for 11 of 11 (Resident #7, #20, #28, #30, #37, #42, #44, #45, #46, #47 and #48) sampled residents reviewed that had unkempt, greasy, matted hair, and matted hair that had to be cut off. The facility's failure at F-600 resulted in Harm for the 11 residents, which is Substandard Quality of Care. Refer to F-600. 7. The QAPI committee failed to ensure the facility provided Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR) in accordance with the professional standards of care related to basic life support for healthcare providers and facility policy for 2 of 3 (Resident #5 and #6) sampled residents reviewed. The facility's failure at F-678 resulted in Immediate Jeopardy and Substandard Quality of Care. Refer to F-678. 8. The QAPI committee failed to ensure the facility completed assessments, provided necessary care, services, and treatments for residents as prescribed on the Crown Unit, a unit with residents that are dependent on ventilators and high acuity care requirements. The facility's failure at F-726 resulted in Immediate Jeopardy and Substandard Quality of Care. Refer to F-725, F-726. 9. The QAPI committee failed to ensure the facility provided a safe environment with adequate supervision for 1 of 5 (Resident #4) sampled residents reviewed for unwitnessed falls. On 3/29/2024 Resident #4, with a history for falls, had unwitnessed fall and was sent to the hospital on 3/30/2024 with Acute on Chronic Subdural hematomas (subdural hematoma is a blood clot collection of blood between the brain and the brain's outer covering, usually with an injury that jolts or shakes the brain) with a right to left midline shift (indicates a significant increase in pressure in the brain pushing the brain to the right or left) and required an emergency craniotomy (Surgery to cut a bony flap from the skull to access the brain). The facility's failure at F-689 resulted in Immediate Jeopardy and Substandard Quality of Care. Refer to F-689. 10. The QAPI committee failed to failed to ensure sufficient qualified nursing staff at all times to meet the residents' needs safely and promote each resident's well-being when there was no licensed nurse on the Crown Unit on 13 of 90 days (1/1/2024, 1/2/2024, 1/3/2024, 1/6/2024, 1/22/2024, 1/27/2024, and 1/28/2024 on the 11:00 to 7:00 AM shift, 1/6/2023 on the 3:00 PM to 11:00 PM shift, 3/13/2024, 3/18/2024, 3/25/2024, 3/26/2024 on the 11:00 PM to 7:00 AM shift, and 4/4/2024 from the 8:00 PM to 7:00 AM) reviewed for staffing and to established, monitored, and implemented policies and procedures to ensure adequate staffing on the Crown Unit. Refer to F-725, F-726, F-760. 11. The QAPI committee failed to ensure the facility failed to ensure residents were free from significant medication errors for 25 of 26 sample residents (Resident #1, #2, #3, #5, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #20, #22, #23, #24, #35, #36, #38, #40, and #41) reviewed for medication administration and that the residents were free from significant medication errors when significant medications including antidiabetic, antiarrhythmics, antihypertensive, anticonvulsant, antiplatelets and cardiac medications were not administered as ordered by the physician. The facility ' s failure at F-760 resulted in Immediate Jeopardy and Substandard Quality of Care. Refer to F-725, F-726, F-760. 12. The QAPI committee failed to ensure the facility Administration was administered in a manner to provide oversight, to monitor and provide a safe environment, ensure systems and processes were in place and consistently followed by staff to address quality concerns related to safe individualized resident care and when the facility failed to provide sufficient licensed nursing staff, failed to administer medications as ordered by the physician. The Administration's failure at F-835 resulted in Immediate Jeopardy. Refer to F-835. The surveyors verified the Removal Plan by: 1. The facility conducted an Ad-hoc QAPI (when necessary or needed) meeting on 4/23/2024 and conducted a root cause analysis. Root causes identified included inability to replace last minute call ins, nurses not following facility policies on medication administration, emergency management and accident supervision. The surveyors confirmed this by record review and interviews. 2. QAPI (Quality Assurance Performance Improvement) team members were in-serviced on 4/23/2024 by the Corporate Consultant who is a licensed nursing home administrator and RN with Doctoral level education on how to use a systemic approach to determine underlying causes of problems impacting larger systems. The surveyors confirmed this by record review and interviews. 3. Training also focused on developing and implementing corrective actions to change processes at the systems level to attain and maintain the quality of care, and quality of life. The surveyors confirmed this by record review and interviews. 4. Following systems were put in place to immediately correct: Staffing coordinator to provide daily staffing to the Administrator/DON/ADON to review for the next day. If additional staff are needed, take appropriate actions such as agency usage, use of overtime, offer bonus/other incentives to meet the staffing needs. Nursing management to assist in last minute call ins. Vent unit has the highest staffing priority based on acuity. Nursing administration to check for medication errors daily and as needed. The surveyors confirmed this by record review and interviews. 5. Nursing administration to ensure CPR Certified nurses are available all three shifts for resident emergencies. The surveyors confirmed this by record review and interviews. 6. Non-licensed staff are not required to be CPR (Cardiopulmonary Resuscitation) Certified. The facility will also encourage non-licensed staff to get certified and additional CPR classes will be offered. The surveyors confirmed this by record review and interviews. 7. The facility will staff two licensed nurses for the day shift, two for the evening shift and one for the night shift in the Crown Unit. The surveyors confirmed this by record review and interviews. 8. Administrator/DON (Director of Nursing)/ADON will audit staffing daily for the following day to ensure adequate staff to perform admission assessments, manage emergency procedures, and no medication errors occurred. The surveyors confirmed this by record review and interviews. 9. Any negative findings will be corrected or completed immediately and brought to the next morning QAPI meeting to ensure completion and accuracy of assessments. The surveyors confirmed this by record review and interviews. 10. The facility will conduct daily QAPI meetings as part of the morning meeting with the members of the interdisciplinary team to monitor missing medications and effectiveness of the removal plan. The surveyors confirmed this by record review and interviews. 11. All corrective actions will continue until a Plan of Correction is developed. The facility is required to submit a plan of correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, user instruction manual review, job description review, medical record review, observation, and interview, the facility failed to ensure staff practices to prevent the potential spread of infection were maintained when multi-use blood glucometers were not cleaned and disinfected after/between resident testing to prevent cross-contamination of bloodborne pathogens for 5 of 9 sampled residents (Resident #9, #10, #11, #12, and #13) reviewed for blood glucose monitoring, when 1 of 3 nurses (Licensed Practical Nurse (LPN) A) failed to use appropriate Personal Protective Equipment (PPE) when providing care to Residents #9, #10, #11, #12, #17, and #18, and when staff failed to ensure reusable equipment was cleaned and disinfected when 2 of 2 staff members (Certified Nursing Assistant (CNA) N and CNA M) were observed during transferring Resident #4 with a mechanical lift. The facility's failure to ensure nursing staff properly disinfected the multi-use blood glucose meter that was used for multiple residents without disinfecting after/between resident testing placed residents at risk for contamination with bloodborne pathogens and had the likelihood to cause serious injury, which resulted in Immediate Jeopardy. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Chief Operation Officer, Administrator, and the Director of Nursing (DON) were notified of the Immediate Jeopardy for F-880 on 6/18/2024 at 1:13 PM, in the Conference Room. The facility was cited Immediate Jeopardy for F-880 at a scope and severity of K. The Immediate Jeopardy began on 6/18/2024 through 6/21/2024, the IJ was removed on 6/22/2024. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 6/18/2024 at 4:19 PM. The corrective actions were validated onsite by the surveyors on 6/21/2024 through review of in-service documentation, audits, and staff interviews. The facility's noncompliance at F-880 continues at a scope and severity of E for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility's policy titled, (Named Facility) Glucometer Disinfection, dated 2020, revealed .The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood glucose sampling devices to prevent transmission of blood borne disease to residents .The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use .The glucometers will be disinfected with a wipe pre-saturated with an EPA [Environmental Protective Agency] registered healthcare disinfectant that is effective against HIV [human immunodeficiency virus], Hepatitis C, and Hepatitis B virus [infection of the liver] Glucometer will be cleaned and disinfected after each use and accordance to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use .Obtain needed equipment and supplies .Retrieve (2) disinfectant wipes from container .Use first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer .After cleaning use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions. Allow the glucometer to air dry . Review of the undated [Named Company] User Instruction Manual, for Glucometers revealed .Cleaning & [and] Disinfecting Guidelines .We suggest cleaning and disinfecting the meter between patient use .Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe .Many wipes act as both a cleaner and disinfectant, though if blood is visibly present on the meter, two wipes must be used .use one wipe to clean and the second wipe to disinfect .With all the recommended meter cleaning and disinfecting methods, it is critical that the meter be completely dry before testing a resident's glucose level . Review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Equipment [Named Facility], dated 2022, revealed .Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC [Centers for Disease Control and Prevention] recommendations in order to break the chain of infection .Each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident . Review of the facility's policy titled, Enhanced Barrier Precautions [Named Facility], dated 6/2024, revealed .It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms .An order for enhanced barrier precaution will be obtained for residents with any of the following .Wounds .( .chronic wounds .pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) .indwelling medical devices .(urinary catheters, feeding tubes, tracheostomy/ventilator tubes .) .PPE for enhanced barrier precaution is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident room .High-contact resident care activities .Dressing .Bathing .Transferring .Providing hygiene .Changing linens .Changing briefs or assisting with toileting .Device care or use .central lines, urinary catheters, feeding tubes, tracheostomy/ventilators tubes, hemodialysis catheters, PICC [peripherally inserted central catheter line] lines, midline catheters .Wound care .any skin opening requiring a dressing . Review of the Director of Nursing Services, Job Description signed 5/1/2024, revealed .The primary purpose of your position is to plan, organize, develop, and direct the overall operation of our Nursing Services Department in accordance with current federal, state, and local standards, guidelines, and regulation that govern our Facility and as may be directed by the Administrator or the Medical Director to ensure that the highest degree of quality care is maintained at all times .Plan, develop, organize, implement, evaluate, and direct the nursing service department, as well as its programs and activities .Make daily rounds of your unit/shift to ensure that assigned CNAs and other nursing personnel are performing their work assignment in accordance with acceptable nursing standards . 2. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE], with a readmission on [DATE], with diagnoses including Chronic Respiratory Failure, Diabetes, Gastrostomy, Tracheostomy, and Hypertension. Review of the Physician's Orders dated 4/25/2024, revealed .Insulin Lispro [used to control blood sugar] .Injection Solution 100 UNIT/ML [millimeters] .Inject subcutaneously every 6 hours related to .DIABETES .inject as per sliding scale . The facility failed to obtain Physician's Orders in accordance with the enhanced barrier precautions policy for a resident with a tracheostomy and Peg (Percutaneous endoscopic gastrostomy is a medical device used to provide nutrition and hydration directly into the stomach), tube. Observation at the medication cart on 6/18/2024 at 5:32 AM, revealed Agency LPN A removed the blood glucometer from the top left drawer of the medication cart and placed the blood glucometer on top of the medication cart without a barrier. Agency LPN A gathered her supplies, the blood glucometer, entered Resident #9's room, and placed the blood glucometer and supplies on the resident's bed without a barrier. Agency LPN A pricked Resident #9's finger with the lancet, picked up the blood glucometer, inserted the test strip into the glucometer, placed the blood sample onto the test strip, then placed the blood glucometer back on Resident #9's bed to read the results. Agency LPN A exited Resident #9's room and placed the blood glucometer back on top of the medication cart without a barrier. Agency LPN A failed to don her gown before providing direct care to a resident in enhanced barrier precaution. Agency LPN A failed to clean and disinfect the blood glucometer after/between resident testing. 3. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE], with a readmission on [DATE], with diagnoses including Anoxic Brain, Diabetes, Tracheostomy, Gastrostomy, Hypertension, and Vegetative State. Review of the Physician's Orders dated 4/11/2024, revealed .Check [PEG tube] placement by auscultation and aspiration prior to all medication administration, flush and feeding .every shift .Check Residual Q [every] Shift .every shift . Review of the Physician's Orders dated 5/22/2024, revealed .Insulin Aspart Injection Solution 100 UNIT/ML . Inject 12 unit subcutaneously three times a day related to .DIABETES .Hold for Blood sugar < [less than] 150 . The facility failed to obtain Physician's Orders in accordance with the enhanced barrier precautions policy for a resident with a tracheostomy and PEG tube. Observation in the resident's room on 6/18/2024 at 5:37 AM, revealed Agency LPN A gathered her supplies, entered Resident #10's room, and placed the supplies and blood glucometer on the resident bed without a barrier. Agency LPN A pricked the resident's finger with the lancet, picked up the blood glucometer and inserted the test strip into the glucometer, and placed the blood sample onto the test strip. Agency LPN A placed the blood glucometer back on the resident's bed to read the results. Agency LPN A gathered the supplies and the blood glucometer, removed gloves, exited the resident's room, and placed the blood glucometer back on top of the medication cart without a barrier. Agency LPN A gathered medication for administration via (by) PEG tube, and reentered Resident #10's room placing the medication cup on the nightstand. Agency LPN A administered the medication and when attaching the tip of the enteral tube into the PEG tube, the tip of the tubing dislodged and the tip of the tubbing fell on the floor. Agency LPN A picked up the enteral tubing off the floor, reinserted the tip of the enteral tube into the Peg tube and the tubing dislodged again and hit the floor a second time. LPN A picked up the enteral tube off the floor and reinserted the enteral tube to the PEG tube site. Agency LPN A failed to don her PPE (gown) before providing care to a resident in enhanced barrier precaution and failed to clean and disinfect the blood glucometer after/between resident testing. Agency LPN A failed to change out the contaminated enteral feeding tube that tip fell on the floor. 4. Review the of medical record revealed Resident #11 was admitted to the facility on [DATE], with a readmission on [DATE], with diagnoses including Anoxic Brain, Gastrostomy, Persistent Vegetative State, and Diabetes. Review of the Physician's Orders dated 1/13/2024, revealed .NovoLOG [used to control blood sugar] PenFill Subcutaneous Solution Cartridge 100 UNIT/ML . Inject subcutaneously every 8 hours related to .DIABETES .inject as per sliding scale . The facility failed to obtain Physician's Orders in accordance with the enhanced barrier precautions policy for a resident with a tracheostomy and PEG tube. Observation in the resident's room on 6/18/2024 at 5:57 AM, revealed Agency LPN A entered Resident #11's room, donned her gloves, hung the enteral feeding, exited the resident's room, and gathered the supplies and blood glucometer from on top of medication cart. Agency LPN A reentered Resident #11's room and placed the supplies and blood glucometer on the resident's bed without a barrier. Agency LPN A pricked the resident's finger with the lancet, picked up the blood glucometer, inserted a test strip into the glucometer and placed the blood sample onto the test strip. Agency LPN A placed the blood glucometer back down on the resident's bed to read the results. Agency LPN A removed her gloves, picked up the blood glucometer and supplies off of Resident #11's bed and walked to the opposite side of the resident's bed and picked up a towel off the floor and placed the towel on the resident's chest. Agency LPN A exited the resident's room and placed the blood glucometer on top of the medication cart without a barrier. LPN A failed to don her PPE gown before providing care to a resident in enhanced barrier precautions and failed to clean and disinfect the blood glucometer after/between resident testing. LPN A picked up a dirty towel off the floor and placed it on the resident's chest. 5. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with a readmission on [DATE], with diagnoses including Chronic Respiratory Failure, Hyperglycemia, Methicillin Resistant Staphylococcus Aureus, and Diabetes. Review of the Physician's Orders dated 6/3/2024, revealed .HumaLOG [used to lower the blood sugar] Injection Solution 100 UNIT/ML . Inject subcutaneously every 8 hours related to .DIABETES .inject as per sliding scale . The facility failed to obtain Physician's Orders in accordance with the enhanced barrier precautions policy for a resident with a tracheostomy and PEG tube. Observation at the medication cart on 6/18/2024 at 6:37 AM, revealed Agency LPN A donned her gloves, gathered supplies and the blood glucometer, and then entered Resident #12's room. Agency LPN A placed the supplies and blood glucometer on the resident's bed with no barrier present, administered the eye drops and removed her gloves. Agency LPN A donned her gloved, pricked the resident's finger, picked up blood glucometer and inserted the test strip, obtained a blood sample and placed it on the strip, and placed blood glucometer back down on the resident's bed for the reading. Agency LPN A gathered the supplies and the blood glucometer and exited the resident's room and placed the blood glucometer on top of the medication cart without a barrier. LPN A failed to don her PPE gown before providing care to a resident in enhanced barrier precautions and failed to clean and disinfect the blood glucometer after/between resident testing. Random observation in the resident's room on 6/24/2024 at 4:13 PM, revealed CNA O failed to don PPE when she bathed Resident #12, who was in enhanced barrier precautions. 6. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE], with a readmission on [DATE], with diagnoses including Chronic Respiratory Failure, Diabetes, Hypertension and Anxiety. Review of the Physician's Orders dated 3/8/2024, revealed .Insulin Lispro Injection Solution .Inject subcutaneously every 8 hours for .DM [Diabetes Mellitus] .per sliding scale . The facility failed to obtain Physician's Orders in accordance with the enhanced barrier precautions policy for a resident with a tracheostomy. Observation in the resident's room on 6/18/2024 at 6:30 PM, revealed Agency LPN B donned his gloves removed the blood glucometer from the medication cart, entered Resident #13's room pricked the resident's finger, inserted the strip and obtained a blood sample to check the blood sugar. Agency LPN B failed to clean and disinfect the blood glucometer before use when he removed the blood glucometer from the medication cart. During an interview on 6/18/2024 at 10:34 AM, the Interim Director of Nursing (DON) was asked about the process for checking resident blood glucose levels. The Interim DON stated, Wash hands .get a clean barrier and place it on top of the medication cart .wipe meter [blood glucometer] off with Micro-Kill wipe .wait for a full minute .or whatever the time is on the container .check the blood sugar .remove gloves .wash hands .dispose of supplies in appropriate container .clean the meter again . 7. Review the of medical record revealed Resident #17 was admitted to the facility on [DATE], with diagnoses including Diabetes, Depression, Tracheostomy, Gastrostomy, and Acute Respiratory Failure. Review of the Physician's Orders dated 5/8/2024, revealed .Check [PEG tube] Residual Q [every] Shift . Check placement by auscultation and aspiration prior to all medication administration, flush and feeding . The facility failed to obtain Physician's Orders in accordance with the enhanced barrier precautions policy for a resident with a tracheostomy and PEG tube. Observation in the resident's room on 6/18/2024 at 5:21 AM, revealed Agency LPN A entered Resident #17's room with the resident's enteral feeding formula, donned her gloves, hung the enteral feeding on the intravenous pole, disconnected the old enteral feeding formula tube from the PEG tube and connected a new enteral feeding tube to the PEG tube. LPN A failed to don her PPE gown before providing care to a resident with a PEG tube in enhanced barrier precautions. 8. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE], with a readmission on [DATE], with diagnoses including Gastrostomy, Tracheostomy, Respiratory Failure, Acute Kidney Failure, and Adult Failure to Thrive. Review of the Physician's Orders dated 8/22/2023, revealed .Check placement [of PEG tube] by auscultation and aspiration prior to all medication administration, flush and feeding .every shift . The facility failed to obtain Physician's Orders in accordance with the enhanced barrier precautions policy for a resident with a tracheostomy and PEG tube. Observation in the resident's room on 6/18/2024 at 6:44 AM, Agency LPN A entered Resident #18's room for medication administration via PEG tube. Agency LPN A donned her gloves, raised bed with the remote, administered medication via PEG tube, flushed with 60 cc (centimeters) of water, administered medication and flushed with 30 cc water. Agency LPN A failed to don her PPE gown before providing care to a Resident #18 who had a PEG tube and was in enhanced barrier precaution. Agency LPN failed to remove her gloves and perform hand hygiene after raising the head of the bed with the remote with her gloved hands. Observation and interview on 6/18/2024 at 7:03 AM, after the medication pass, Agency LPN A placed the blood glucometer in the top left drawer of the medication cart after checking Residents #9, #10, #11 and #12's blood glucose. Agency LPN A fail to clean and disinfect the blood glucometer after use on each resident and rolled the mediation cart to the nursing station. Agency LPN A was asked if she was finished with the medication administration. Agency LPN A stated, Yes. 9. During an interview on 6/18/2024 at 10:34 AM, the Interim Director of Nursing (DON) was asked about the process for checking resident blood glucose levels. The Interim DON stated, Wash hands .get a clean barrier and place it on top of the medication cart .wipe meter [blood glucometer] off with Micro-Kill wipe .wait for a full minute .or whatever the time is on the container .gather supplies .take the clean barrier with clean meter to the room .get another clean barrier and place it on bedside table .and place the clean meter on the clean barrier .check the blood sugar .remove gloves .wash hands .dispose of supplies in appropriate container .clean the meter again .place the meter in the medication cart . The Interim DON was asked if the staff members should place the meter and supplies on the resident bed without a barrier. The Interim DON stated, No. The Interim DON was asked if the staff member should go from room to room without cleaning and disinfecting the blood glucometer. The Interim DON stated, No. The Interim DON was asked when the last time was that she educated the staff on the cleaning and disinfection of the blood glucometer. The Interim DON stated, .I have not done it [training] this last past year .I can't tell you when it was done last . The Interim DON was asked when you have an agency staff member coming in to work are they trained on the facility policies. The Interim DON stated, .We do not train the agency staff .they are in-serviced by the agency . The Interim DON was asked should the staff member pick up a dirty towel off the floor and place the towel back on the resident chest. The Interim DON stated, No. The Interim DON was asked if the feeding tube tip is dropped on the floor should the staff member hook it to the Peg tube. The Interim DON stated, No. 10. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE], with diagnoses including Malignant Neoplasm of Prostate, Peripheral Vascular Disease, Hypertension and Rhabdomyolysis. Observation and interview in Resident #4's room on 6/26/2024 at 11:26 AM, CNA M was asked where she got the lift. CNA M stated, .I got the lift from a room on 200 hall and brought the lift to resident's [Resident #4] room . CNA M and CNA N entered Resident #4's room, donned their gloves and placed the lift pad under the resident. CNA M and CNA N transferred Resident #4 to his wheelchair and removed the lift. CNA N exited the resident's room and placed the lift in the hallway. CNA N failed to clean and disinfect the lift after use. During an interview on 6/26/2024 at 1:11 PM, CNA M was asked who cleans the lifts when used for transfer. CNA M stated, .I don't know who cleans the lift when they are used to transfer residents . CNA M was asked when the lifts should be clean when used to transfer residents. CNA M stated, After use. During an interview on 6/26/2024 at 11:46 AM, the Interim DON was asked when the staff members should clean the lift when used for transfer. The Interim DON stated, Before and after use. During an interview on 6/27/2024 at 8:01 AM, Family Nurse Practitioner (FNP) #1 was asked when the staff members should clean and disinfect the blood glucometers. FNP #1 stated, .Between every patient .before and after, and let the meter dry for 2 minutes and proceed to the next patient, and then they should wash their hands . The FNP was asked when the staff members should clean the reusable equipment (lifts). The FNP stated, In between every patient and prior to use .because you don't know if the other [last] person had cleaned it . The surveyors verified the Removal Plan: The surveyors reviewed the in-services and made observations of return demonstration of the cleaning, disinfection of the blood glucometer during blood sugar checks, and interviewed nursing staff on all shifts. 1. LPN A and LPN B who failed to clean the glucometer before and after checking blood sugar between residents #9, #10, #11, #12 and #13 were reported to the staffing agency and not allowed to return to work. 2. The facility Administrator conducted a root cause analysis pertaining to this situation which resulted in an Immediate Jeopardy. The root cause analysis indicated that the agency nurses did not follow the facility's policy on glucometer cleaning.? 3. The facility policy on glucometer cleaning was reviewed, and no changes required. 4. Immediate in-services on glucometer cleaning and disinfecting before and after each resident use was initiated by staff educator for licensed nurses on 6/18/2024 and will be completed by 6/19/2024. 5. All licensed staff on leave or agency staff will be required to attend the in-service prior to starting their shift. DON/ADON (Assistant Director of Nursing)/Staff educator/Unit manager/charge nurse will educate licensed nurses on leave or agency nurses prior to beginning of their shift. This in-service will be ongoing for agency employees at the beginning of all shifts. The facility will conduct competency evaluation on glucometer cleaning by return demonstration prior to beginning of the shift. 6. Education includes: Retrieve (2) disinfectant wipes from container. Using first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. After cleaning, use second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions. Allow the glucometer to air dry. 7. The DON/ADON/Staff educator/unit managers will be responsible to monitor the glucometer cleaning before and after each use and as needed. The DON/ADON/Staff educator/unit managers/charge nurses will?conduct random physical observation of glucometer cleaning on all three shifts. The DON/ADON/Staff educator/unit managers will conduct competency evaluation on licensed nurses for glucometer cleaning by return demonstration. Infection Preventionist to verify the competency of the DON/ADON/Staff educator/unit managers to conduct this competency evaluation related to glucometer cleaning on licensed nursing staff on 06/18/2024. 8. The facility will conduct daily QAPI (Quality Assurance and Performance Improvement) meetings as part of the morning meeting with the members of the interdisciplinary team to monitor glucometer cleaning and effectiveness of the removal plan. 9. All corrective actions will continue until a Plan of Correction is developed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, Board of Examiners of Nursing Home Administrators (BENHA) review, medical record review, observation, and interview, the facility failed to ensure a resident's right to be free from abuse neglect for 1 of 3 sampled residents (Resident #5) reviewed for wandering/elopement behaviors, when Resident #5 exited the COVID 19 isolation area, then exited the facility without staff awareness, walked down a sidewalk. Resident #5 traveled approximately 223 feet. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator, the Director of Nursing (DON), and the Chief Clinical Officer (COO) were notified of the Immediate Jeopardy on 11/10/2033 at 3:44 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-600. The facility was cited at F-600 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 10/30/2022 through 11/17/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 11/14/2022 at 12:44 PM, and was validated onsite by the surveyors on 11/16/2022 and 11/17/2022 through observations, review of audits, meeting minutes, and staff interviews. The findings include: 1. Review of the facility's undated policy titled, .Abuse Prevention, revealed, .Neglect: A failure of the facility, it's employees, or services provided .to provide goods and services necessary to avoid physical harm, mental anguish, emotional distress, or pain .Features of the physical environment that may make abuse and/or neglect more likely to occur, such as secluded areas of the facility .It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatments shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment . Review of the facility's undated policy titled, MISSING RESIDENT/ELOPEMENTS, revealed .The Unit Charge Nurse is responsible for knowing the location of their residents .Missing Resident Guidelines .Determine time and location when last seen . Review of the facility's policy titled, Wandering, Unsafe Resident, revised 8/2014, revealed .The facility will strive to prevent unsafe wandering .The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) .The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering .A missing resident is considered a facility-wide emergency . 2. Review of the BENHA form revealed the Administrator had an employment date of 7/6/2020. 3. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Wernicke's Encephalopathy, Altered Mental Status, Alcohol Abuse, Adult Failure to Thrive, Cerebral Infarction, Cognitive Social or Emotional Deficit following Cerebral Infarction. Review of a physician's order dated 8/16/2022, revealed Resident #5 had an order for a wander guard. Review of an elopement risk assessment dated [DATE] revealed Resident #5 was assessed at risk for elopement. Review of the Care Plan dated 8/16/2022, revealed Resident #5 was at risk for elopement related to poor safety awareness, was at risk for falls, had impaired cognitive function and was at risk for loneliness, anxiety and sadness related to isolation precautions related to COVID 19. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #5 was severely cognitively impaired for daily decision making and required one-person physical assistance with walking in his room or in the corridor. Review of a Progress Note dated 9/30/2022 at 4:30 PM, revealed .resident attempt to exit building .pursued resident and prevented him from exiting building . Review of a physician's order dated 10/28/2022 revealed Resident #5 had an order for contact isolation with droplet precautions related to a positive Covid diagnosis. Review of a Progress Note dated 10/30/2022 at 11:33 AM, revealed .exit seeking x [times] 3 left COVID hall x 2 this am set off the alarm to door on 700 hall x 1 set off alarm on 500 hall door x 2 found in visitor parking lot per staff member . Review of a Progress Note dated 10/30/2022 at 11:33 AM revealed .staff alerted by 700 hall door alarm sounding off. Staff noted resident exiting 700 all [hall] door . Review of a Progress Note dated 10/31/2022 at 8:03 PM revealed .off COVID unit x 1 redirected to room .30-minute checks continue .remains confused at baseline .remains on COVID unit with droplet precautions and contact isolation . During an interview on 11/8/2022 at 12:58 PM, CNA #1 stated, .yes, I was assigned to care for [Resident #5] on 10/30/2022 .he had got out of the unit a couple of times that day .I helped the nurse get him back in the COVID unit about 20 minutes after that I got a phone call from the [Activities Director] telling me he was outside . During an interview on 11/8/2022 at 1:28 PM, the Housekeeper stated, .I was in a resident room on the 800 hall .I didn't hear an alarm sounding .I looked out the window .saw the resident [Resident #5] walking outside on the sidewalk .I didn't see him walk out a door . During an interview on 11/9/22 at 11:10 AM, the Activity Director stated, .I saw him [Resident #5] walking down the sidewalk alone .I called [CNA #1] told her he was outside .I didn't see him walk out the door . During an interview on 11/10/2022 at 10:54 AM, the Administrator confirmed Resident #5 had exited the Covid Unit several times on 10/30/22. The Administrator further confirmed staff had not initiated every 30-minute checks until after the elopement. During a telephone interview on 11/10/2022 at 11:43 AM, LPN #1 stated, .yes, I was [Resident #5's] charge nurse on 10/30/2022, he got off of the Covid Unit several times. Two times he tried to get out on the 500 hall .I escorted him back to the Unit, then the 500 hall [exit] door alarm was sounding .he was trying to go out the door .took him back to the Covid Unit .then I found him at the [exit] door across from the DON office. I tried to get him back to the Unit, but he didn't want to go .so I had to get help from the CNA to get him back in the Covid Unit .I didn't see him go out the door .I didn't see him outside, I didn't see them bring him back in .I was told by staff he was outside . The facility staff assigned direct care for Resident #5 were aware he had exited the Covid Isolation Unit and had attempted to exit the facility several times during their shift. The direct care staff were unaware that he had exited the Covid Isolation Unit and was outside of the facility unsupervised. During a telephone interview on 11/14/2022 at 12:23 PM, Registered Nurse (RN) #1 stated, .I was told about the incident .it was secondhand information .someone alerted me that a resident was outside of the facility. We went outside to search, and when we came back, he was already back in the facility .there were no alarms sounding . During an interview on 12/2/2022 at 10:29 AM, the Administrator stated, .One (1) on 1 supervision would be warranted . Refer to F-609, F-610, F-689, F-725, F-726, F-880, F-835, F-867. The surveyors verified the Allegation of Compliance (AoC) Removal Plan through record review, observations, audit reviews, review of education and sign-in sheets, and interviews for the immediate corrective actions listed below: 1. The facility immediately called an ADHOC (formed for a special and immediate purpose)/Quality Assurance Performance Improvement (QAPI) meeting with department heads and QAPI team members at 4:00 PM on 11/10/2022. During the QAPI meeting a root cause analysis was completed pertaining to the resident that exited the COVID Unit and facility without staff knowledge (Resident #5). Root cause identification included: Resident #5 who was moved to the Covid Unit, was trying to get out of the area. Resident #5 was looking to meet with his brother outside the building. He was a cognitively impaired resident who was moved to a new environment on the Covid Unit. The surveyors reviewed the QAPI meeting sign-in sheet, the minutes of the meeting and interviewed the DON and the Administrator. 2. New elopement assessment on Resident #5, who was identified as being outside without staff supervision was completed on 10/31/2022. The surveyors reviewed the elopement risk assessment. 3. A body audit was completed on 10/31/2022 on Resident #5, who was identified as being outside without staff supervision with no negative findings. The surveyors reviewed the body audit and interviewed the DON. 4. Resident #5, who was identified as being outside without staff supervision was placed on every 30-minute checks. The surveyors reviewed the every-30-minute check log and interviewed the Unit Manager. The every-30-minute checks were initiated at 11:15 AM on 10/30/2022. Every resident who was identified as at-risk for exit-seeking was placed on 30-minute checks on 11/11/2022 at 5:00 PM and continued. The surveyors reviewed the every-30-minute check sheets for residents identified as being at-risk for exit-seeking and interviewed staff. 5. The Care Plan was updated with new interventions for Resident #5, who was identified as being outside without staff supervision. New interventions included: Psychiatric evaluation and consultation. Face time with family member(s), and every 30-minute checks. The Care Plan was reviewed with the new interventions. The Psychiatric Nurse Practitioner was interviewed to verify the consultation was completed. The Psychiatric Nurse Practitioner progress note dated 11/10/2022 was reviewed by the surveyors. 6. Maintenance staff checked all exit doors and alarms for proper functioning on 10/30/2022. The surveyors reviewed the exit door check sheet and interviewed the Director of Maintenance about the process for checking the exit doors. The surveyors verified doors and alarms were functioning properly for the 700 hall door, the 800 hall door, and the 500 hall door. 7. Elopement drills were conducted on following dates with good response. 10/31/2022 at 3:21 PM for the 3-11 evening shift, 11/9/2022 at 11:20 AM for the 7-3 day shift, and 11/14/2022 at 6:18 AM for the 11-7 night shift. The surveyors observed the elopement drill on 11/9/2022 and reviewed the elopement drill sign sheet. 8. The facility conducted QAPI meetings on 10/31/2022 and 11/10/2022 regarding the 10-30-2022 incident on Resident #5, who was identified as being outside without staff supervision. The surveyors reviewed the QAPI minutes and interviewed the DON and the Administrator. 9. Resident #5, who was identified as being outside without supervision, was discharged from the COVID Unit on 11/9/2022 after completing quarantine time. The surveyors verified by observing Resident # 5 in a room on the 800 hall. 10. A psychiatric evaluation on Resident #5, who was identified as being identified outside without supervision, was completed on 11/10/2022. The surveyors interviewed the Psychiatric Nurse Practitioner related to the 11/10/2022 evaluation. 11. All residents that would like to participate in facetime and phone calls on the COVID Unit will be offered these services. Every resident who was currently in the Covid Unit was offered facetime/phone calls on 11/12/2022. Every resident will be offered facetime/phone calls with family members at least weekly and as needed. The Social Worker/Activities staff will visit the resident with an iPad or cell phone and coordinate calls. The surveyors verified through interview with the Social Services Director and review of the form used to ensure residents were offered facetime/phone calls with family members. 12. The facility will ensure sufficient staff and supervision on the COVID Unit for all residents. Staffing needs will be determined based on the census and acuity in the Covid Unit. The goal will be to have at least one nurse for the Unit and one CNA for every 10 residents. The surveyors verified through interview with the Staffing Coordinator, Interim DON, and the Administrator. The surveyors reviewed the updated Covid Unit staffing policy. 13. The facility immediately started in-services and education on neglect and accidents on 10/31/2022 and is ongoing. All facility employees are required to attend in-services/education regarding neglect and accidents. In-service education started 10/30/2022 and will be continued to attain over 100% compliance by 11/15/2022. Employees who are on vacation, family medical leave or as needed (prn) staff will be required to complete the training prior to return to work. The surveyors reviewed the in-service education literature, reviewed the sign in sheets and interviewed staff on all shifts to verify. 14. The facility will audit all exit-seeking/elopement risk residents every shift by conducting every-30-minute checks. The findings will be reviewed in the daily morning meetings. The Charge Nurse/designee will conduct audits for exit-seeking/elopement risk residents. The surveyors interviewed the Charge Nurse and reviewed the audit tool. The facility's noncompliance of F-600 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to report incidents of elopement for 1 of 3 sampled residents (Resident #5) reviewed for wandering and elopement. The facility's failure to report an incident of elopement and neglect to the State Survey Agency resulted in Immediate Jeopardy when Resident #5 exited the facility on 10/30/2022 without staff knowledge or supervision. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 11/16/2022 at 5:19 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-609. The facility was cited at F-609 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 10/30/2022 through 11/22/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 11/18/2022 at 10:13 AM, and was validated onsite by the surveyors on 11/21/2021 and 11/22/2021 through observations, review of audits, meeting minutes, and staff interviews. The findings include: Review of the facility's undated policy titled, .ABUSE PREVENTION, revealed .Alleged violations involving abuse, neglect, exploitation or mistreatment, including injury of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury .to other officials .including State Survey Agency .Report the results of all investigations to the administrator or designated representative and other officials in accordance with state law including State Survey Agency within 5 working days of the incident . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Wernicke's Encephalopathy, Altered Mental Status, Alcohol Abuse, Adult Failure to Thrive, Cerebral Infarction, Cognitive Social or Emotional Deficit following Cerebral Infarction. Review of an elopement risk assessment dated [DATE] revealed Resident #5 was assessed at risk for elopement. Review of a physician's order dated 8/16/2022, revealed Resident #5 had an order for a wander guard. Review of the Care Plan dated 8/16/2022, revealed Resident #5 was at risk for elopement related to poor safety awareness, was at risk for falls, had impaired cognitive function, and was at risk for loneliness, anxiety and sadness related to isolation precautions related to COVID 19. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #5 was severely cognitively impaired for daily decision making and required one-person physical assistance with walking in his room or in the corridor. Review of a Progress Note dated 9/30/2022 at 4:30 PM, revealed .resident attempt to exit building .pursued resident and prevented him from exiting building . Review of a physician's order dated 10/28/2022 revealed Resident #5 had an order for contact isolation with droplet precautions related to a Covid-positive diagnosis. Review of a Progress Note dated 10/30/2022 at 11:33 AM, revealed .exit seeking x [times] 3 left COVID hall x 2 this am set off the alarm to door on 700 hall x 1 set off alarm on 500 hall door x 2 found in visitor parking lot per staff member . Review of a Progress Note dated 10/30/2022 at 11:33 AM, revealed .staff alerted by 700 hall door alarm sounding off. Staff noted resident exiting 700 all [hall] door . During an interview on 11/3/2022 at 11:18 AM, the DON stated, .Sunday [10/30/2022] a resident [Resident #5] left the building, I was notified by the RN [Registered Nurse] supervisor. She said eyes were on him the entire time .Had a QAPI [Quality Assurance Performance Improvement] meeting on Monday [10/31/2022], Activity Director was in the meeting and said nothing when we discussed the incident .determined since staff had eyes on him, it was not reportable at that time . During an interview on 11/3/2022 at 11:25 AM, the Administrator stated, .the incident has not been reported .I notified the COO [Chief Operations Officer] and agreed not reportable since staff had eyes on him . During an interview on 11/8/2022 at 12:58 PM, Certified Nursing Assistant (CNA) #1 stated, .I did not know he was outside of the facility until [Activities Director] called and told me he was outside . During an interview on 11/8/2022 at 1:28 PM, the Housekeeper stated, .I was in a resident room on the 800 hall .saw the resident [Resident #5] walking outside on the sidewalk toward the parking lot .he was by himself . During an interview on 11/9/2022 at 11:10 AM, the Activity Director stated, .I saw him [Resident #5] walking down the sidewalk alone .I called [CNA #1] told her he was outside .I didn't see him walk out the door . The facility was unable to provide evidence that staff saw Resident #5 exit the building on 10/30/2022. He was found outside the facility alone and unsupervised. During an interview on 11/9/2022 at 12:28 PM, the Chief Clinical Officer (CCO) stated, .my understanding was the incident was reported on Wednesday [11/2/2022] . During an interview on 12/2/2022 at 11:53 AM, the Administrator stated .this incident should have been reported earlier . Refer to F-600, F-610, F-689, F-725, F-726, F-880, F-835, F-867. The surveyors verified the Allegation of Compliance (AoC) Removal Plan through record review, observations, audit reviews, review of education and sign-in sheets, and interviews for the immediate corrective actions listed below: 1. The facility conducted ADHOC (formed for a special and immediate purpose)/Quality Assurance Performance Improvement (QAPI) meeting with the management team on 11/16/2022 at 6:00 PM, and completed a root cause analysis. Root cause identification included late reporting and failure to conduct a thorough investigation. The facility received conflicting statements from different employees, which caused a delay in collecting statements and information from employees. The surveyors reviewed the QAPI meeting minutes and sign-in sheet and interviewed the Administrator and the DON. 2. The facility reported the incident to the Tennessee Department of Health on 11/3/2022 regarding the cognitively impaired resident (Resident #5) that was identified as being found outside unsupervised. The surveyors reviewed the Incident Reporting System information sheet and interviewed the DON. 3. The Administrator/DON will review all incidents and accidents for the last 30 days to ensure that any incident that was considered a reportable event by the state and federal regulations was reported appropriately. The surveyors reviewed the audit form and interviewed the Administrator and DON. 4. All incidents will be reported timely to all appropriate agencies within 24 hours of occurrence regarding any incident that could result in harm or death. The Administrator or the DON/designee will be responsible for reporting to all appropriate agencies. Designee by title includes ADON, In-service Coordinator, Unit Managers and Weekend Supervisor. The Weekend Supervisor will be trained in incident investigation and reporting over the weekends by the In-service Coordinator by 11/18/2022. Incident reporting system (IRS) reporting required over the weekends will be completed with assistance from the Administrator, DON or ADON. The ADON, In-service Coordinator and Unit Managers have been assigned days as Manager on Duty (MOD) including holidays to be responsible for thorough investigation and reporting events timely. The surveyors interviewed the Administrator and DON regarding proper reporting timeframes. The surveyors reviewed the Manager on Duty form and interviewed staff responsible for investigation and reporting. 5. The Administrator and DON were trained by the Consultant regarding thorough investigation and reporting to the appropriate agencies timely. The Administrator and DON are responsible for timely reporting in addition to the responsibilities of the Designees. The surveyors interviewed the Administrator and DON regarding investigation and timely reporting of incidents. 6. The facility will ensure that all incidents with major injury will be reported within 2 hours and all other reportable events within 24 hours. The surveyors interviewed the Administrator, the DON and the Unit Managers regarding reporting of incidents. In addition to the Administrator and DON, additional members of the nursing management team including the ADON, the In-service Coordinator, and Unit Managers were also trained on incident investigation and reporting. This training included reporting requirements within two hours and within 24 hours. The Weekend Supervisor will be trained in incident investigation and reporting over the weekends by the In-service Coordinator by 11/18/2022. The surveyors interviewed the ADON and Unit Managers regarding investigation and reporting. The facility added additional users to the incident reporting system (IRS allows maximum 4 users) with the capability for remote accessing and reporting as needed. Additional training on thorough investigation and reporting will be provided to the Administrator, DON, and additional members of the nursing management team including the ADON, In-service Coordinator, and Unit Managers. The surveyors verified through interview with the Administrator, the DON, and the Unit Managers. 7. The Administrator/DON/ADON will be contacted via phone by Nursing Supervisor/Charge Nurse if any incident that required IRS reporting for guidance. The surveyors interviewed Charge Nurses on all shifts. This was verified by interview with the DON and Administrator and review of a facility reported incident that occurred on 11/20/2022. 8. The Administrator/Designee will audit all reportable events daily during morning meetings and report findings to the QAPI committee. Designee by title includes ADON, In-service Coordinator, Unit Manager and Weekend Supervisor. Unit Managers will bring incident information daily to the morning meetings for review by the Administrator. In the absence of the Administrator, the DON will be responsible for reviewing incidents in the morning meetings. If both are unavailable, the chain of command will be the ADON, the In-service Coordinator, Unit Managers and Weekend Supervisor. Responsibilities are assigned specifically. The surveyors interviewed the DON, the ADON, and Unit Managers and reviewed in-service sign in sheets. This was verified by interview, review of a reported incident, review of in-service sheets and interview with facility and agency staff on all shifts. The facility's noncompliance of F-609 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview the facility failed to thoroughly investigate an incident of elopement for 1 of 3 sampled residents (Resident #5) reviewed for elopement and wandering. The facility's failure to thoroughly investigate an incident of elopement resulted in Immediate Jeopardy when Resident #5 eloped from the Covid Unit, exited the facility, and walked unsupervised down a sidewalk toward a parking area. The vulnerable, confused resident ambulated approximately 223 feet from the facility unsupervised. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 11/16/2022 at 5:19 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-610. The facility was cited Immediate Jeopardy at F-610 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 10/30/2022 through 11/22/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 11/18/2022 at 10:13 AM, and was validated onsite by the surveyors on 11/21/2021 and 11/22/2021 through observations, review of audits, meeting minutes, and staff interviews. The findings include: Review of the facility's policy titled, INCIDENT REPORT-DOCUMENTATION, INVESTIGATING, AND REPORTING, revised 9/20/2021, revealed, .all accidents or incidents involving residents .shall be investigated and reported to the administrator . Review of the facility's undated policy titled, Accident & Incident Documentation & Investigation Resident Incident, revealed .The Licensed Nurse assigned at the time of the resident care accident/incident is responsible for conducting an investigation of the circumstances surrounding the accident/incident, and for notifying the Supervisor, Director of Nursing, and/or the Executive Director .The Licensed Nurse .is responsible for initiating/completing the Resident Incident Report, ensuring that all items identified on the form have been completed as applicable to the accident/incident. Review of the facility's undated policy titled, Abuse Prevention, revealed, .The Executive Director and Director of Nursing Services must be promptly notified of suspected abuse or incidents of abuse .if such incidents occur or are discovered after hours, the Executive Director and Director of Nursing Services must be called .and informed of such incident .The facility will initiate at the time of any finding of potential abuse or neglect an investigation to determine cause and effect, and provide protection to any alleged victims to prevent harm during the continuance of the investigation . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Wernicke's Encephalopathy, Altered Mental Status, Alcohol Abuse, Adult Failure to Thrive, Cerebral Infarction, Cognitive Social or Emotional Deficit following Cerebral Infarction. Review of a physician's order dated 8/16/2022, revealed Resident #5 had an order for a wander guard. Review of the Care Plan dated 8/16/2022, revealed Resident #5 was at risk for elopement related to poor safety awareness, at risk for falls, impaired cognitive function and at risk for loneliness, anxiety and sadness related to isolation precautions related to COVID 19. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #5 had severely impaired cognition for daily decision making and required one-person physical assistance with walking in his room or in the corridor. Review of a Progress Note dated 9/30/2022 at 4:30 PM, revealed .resident attempt to exit building .pursued resident and prevented him from exiting building . Review of a physician' order dated 10/28/2022 revealed Resident #5 had an order for contact isolation with droplet precautions related to a Covid positive diagnosis. Review of a Progress Note dated 10/30/2022 at 11:33 AM, revealed .exit seeking x 3 left COVID hall x 2 this am set off the alarm to door on 700 hall x 1 set off alarm on 500 hall door x 2 found in visitor parking lot per staff member . Review of a Progress Note dated 10/30/2022 at 11:33 AM, revealed .staff alerted by 700 hall door alarm sounding off. Staff noted resident exiting 700 all [hall] door . Review of a Progress Note dated 10/31/2022 at 8:03 PM, revealed .off COVID unit x 1 redirected to room .30-minute checks continue .remains confused at baseline .remains on COVID unit with droplet precautions and contact isolation . During an interview on 11/3/2022 at 11:18 AM, the DON and the Administrator confirmed the camera footage had not been reviewed to determine where Resident #5 went out of the facility or what time he was last captured on video in the facility. During an interview on 11/7/2022 at 1:40 PM, the Administrator stated, .we have talked to all of the staff .he was seen by staff outside .eyes on him the whole time he was outside .I have the typed-up account of the reenactment done with the Housekeeper. That is all I have related to the investigation involving [Resident #5] . During an interview on 11/8/2022 at 4:36 PM, the DON confirmed she had not directed the Registered Nurse (RN) supervisor to obtain statements from the facility staff or to complete an incident report. During an interview on 11/7/2022 at 4:50 PM, the Administrator stated, .I did find some pictures on my phone of the incident .not able to save a video of the incident .just able to see still pictures of the camera footage .did not review them until today . On 11/8/2022 the Administrator provided screenshots of Resident #5 inside the facility and outside of the facility. The Administrator confirmed there were no staff outside with Resident #5. During an interview on 11/9/2022 at 11:00 AM, the Administrator stated, .the investigation of the incident is ongoing. We are not finished .the Staffing Coordinator worked that day . During an interview on 11/9/2022 at 11:10 AM, the Staffing Coordinator stated, .I worked that day. I turned the alarm off to the 800 hall exit door .I did not write a statement until today, because they [Administrator and DON] did not know I worked . On 11/9/2022 the Administrator provided still photos of the camera footage. The Administrator stated, We're not able to get a copy of the video, only still photos of the video . The Administrator was not able to provide the photos on a storage device. The Administrator stated, .I'm not able to extract the pictures . During an interview on 11/10/2022 at 10:15 AM, the Administrator confirmed there was no staff outside with the resident. Refer to F-600, F-609, F-689, F-725, F-726, F-835, F-867 and F-880. The surveyors verified the Removal Plan by: 1. The facility conducted ADHOC (formed for a special and immediate purpose)/Quality Assurance Performance Improvement (QAPI) with the management team on 11/16/2022 at 6:00 PM, and completed a root cause analysis. Root cause identification included: Late reporting and not conducting a thorough investigation. The facility received conflicting statements from different employees, creating a delay in collecting statements and information from employees. The surveyors reviewed the QAPI meeting minutes and sign-in sheet, and interviewed the Administrator and the DON. 2. The facility reported the elopement incident to the Tennessee Department of Health on 11/3/2022 regarding the cognitively impaired resident (Resident #5) that was identified as being found outside unsupervised. The surveyors reviewed the Incident Reporting System information sheet and interviewed the DON. 3. The Administrator/DON will review all incidents and accidents for the last 30 days to ensure that any incident that was considered a reportable event by the state and federal regulations was reported appropriately. The surveyors reviewed the audit form and interviewed the Administrator and DON. 4. All incidents will be reported timely to all appropriate agencies within 24 hours of occurrence regarding any incident that could result in harm or death. The Administrator or the DON/designee will be responsible for reporting to all appropriate agencies. Designee by title includes ADON, In-service Coordinator, Unit Managers and Weekend Supervisor. The Weekend Supervisor will be trained in incident investigation and reporting over the weekends by the In-service Coordinator by 11/18/2022. Incident reporting system (IRS) reporting required over the weekends will be completed with assistance from the Administrator, DON or ADON. The surveyors interviewed the Administrator and DON regarding proper reporting timeframes. The surveyors reviewed the Manager on Duty form and interviewed staff responsible for investigation and reporting. Additional training on thorough investigation was provided to the Administrator, DON and additional members of the nursing management team including the ADON, In-service Coordinator and Unit Managers. The ADON, In-service Coordinator and Unit Managers have been assigned days as Manager on Duty (MOD) including holidays to be responsible for thorough investigation and reporting events timely. The surveyors reviewed the Manager on Duty roster and interviewed staff regarding their responsibility when on call. Staff were interviewed related to thorough investigations and reporting of events timely. 5. All missing statements were collected as part of the ongoing investigation by 11/3/2022 concerning Resident #5, who was identified as having exited the facility without staff knowledge. Resident #5 was placed on a every 30-minute checks. A psychiatric evaluation was completed. The Care Plan was updated with new interventions. In-service education to prevent neglect and accidents was completed for all staff members. Record review and observation were included as part of the investigation. The surveyors reviewed the investigation on 11/3/2022 and 12/1/2022. 6. The facility will ensure that all incidents with major injury will be reported within 2 hours and all other reportable events within 24 hours. The surveyors interviewed staff regarding reporting guidelines. In addition to the Administrator and DON, additional members of the nursing management team including the ADON, the In-service Coordinator, and Unit Managers were also trained on incident investigation and reporting. This training included reporting requirements within 2 hours and within 24 hours. The Weekend Supervisor will be trained on incident investigation and reporting over the weekends by the In-service Coordinator by 11/18/2022. The surveyors interviewed the Administrator, the DON, and Unit Managers regarding investigation and reporting. The surveyors reviewed a facility reported incident that occurred on 11/20/2022. The facility added additional users to the Incident Reporting System (IRS allows maximum 4 users) with the capability for remote accessing and reporting as needed. Additional training on thorough investigation and reporting will be provided to the Administrator, DON, and additional members of the nursing management team including the ADON, the In-service Coordinator, and Unit Managers. The surveyors interviewed the Administrator, the DON, the Unit Managers, and the ADON. 7. The Consultant will educate the Administrator and DON regarding proper reporting and thorough investigating which include collecting witness statements timely. The surveyors interviewed the Administrator and DON regarding proper reporting and thorough investigation of incidents. 8. The Administrator/DON/ADON will be contacted via phone by the Nursing Supervisor/Charge Nurse if any incident that required IRS reporting for guidance. The surveyors interviewed Charge Nurses from all shifts, the Administrator, the DON and the ADON regarding reporting. 9. The Administrator/Designee will audit all reportable events daily during morning meetings and report findings to the QAPI committee. Designee by title includes the ADON, the In-service Coordinator, Unit Managers and Weekend Supervisors. Unit managers will bring incident information daily to the morning meetings for review by the Administrator. In the absence of the Administrator, the DON will be responsible for reviewing incidents in the morning meetings. If both are unavailable, the chain of command will be the ADON, the In-service Coordinator, Unit Managers and Weekend Supervisors. Responsibilities are assigned specifically. The surveyors interviewed the Administrator, the DON, the ADON and Unit Managers regarding reportable events audits during morning meetings. The facility's noncompliance of F-610 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation and interview the facility failed to ensure a safe environment to prevent an incident of elopement for 1 of 3 (Resident #5) sampled residents reviewed for elopement and wandering behaviors, which resulted in Immediate Jeopardy (IJ) when a cognitively impaired resident exited the facility without authorization or staff supervision. The facility was unaware the resident had exited the facility until a housekeeper looked out a window and saw the resident walking on the sidewalk outside of the facility toward the parking area. The facility failed to ensure fall risk assessments were completed for 2 of 3 sampled residents (Resident #9 and Resident #2) reviewed for falls. The failure of the facility to implement measurable interventions resulted in actual harm when Resident #9 had a fall with a major injury. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Director of Nursing, and the Chief Clinical Officer were notified of the Immediate Jeopardy on 11/10/2022 at 3:44 PM, in the conference room of the facility. The facility was cited Immediate Jeopardy at F-689. The facility was cited F-689 at a scope and severity of J, which is Substandard Quality of Care. The IJ existed 10/30/2022 through 11/18/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 11/14/2022 and was validated onsite by the surveyors on 11/17/2022 through 11/18/2022 by policy review, medical record review, observation, review of education records, auditing tools, and staff and resident interviews. The findings include: 1. Review of the facility's undated policy titled, MISSING RESIDENT/ELOPEMENTS, revealed, .The Unit Charge Nurse is responsible for knowing the location of their residents .Missing Resident Guidelines .Determine time and location when last seen . Review of the facility's policy titled, Wandering, Unsafe Resident, Revised 8/2014, revealed, .The facility will strive to prevent unsafe wandering .The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) .The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering .A missing resident is considered a facility-wide emergency .When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall .Contact the Attending Physician and report findings and conditions of the resident . Review of the facility's policy titled, Fall Risk Assessment, revised March 2018, revealed, .The nursing staff .will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information .Upon admission, the nursing staff and physician will review a resident's record for a history of falls .nursing staff will ask the resident and his/her family about any history of the resident falling .staff and attending physician will .identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable . 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE], with diagnoses of Wernicke's Encephalopathy, Altered Mental Status, Alcohol Abuse, Adult Failure to Thrive, Cerebral Infarction, Cognitive Social or Emotional Deficit following Cerebral Infarction. Review of the Care Plan dated 8/16/2022, revealed Resident #5 was care planned at risk for elopement related to poor safety awareness related to his admission diagnosis of WERNICKE'S ENCEPHALOPATHY (a degenerative brain disorder). The goal was for Resident #5 to remain safely on facility property until a safe discharge was possible. Interventions included assess/observe patterns of exit-seeking behavior and remove/eliminate triggers when possible, check wander guard placement every shift, consult psychiatric and/or psychology services as ordered by physician, encourage participation and interactions that decrease anxiety and exit seeking, place resident's picture in elopement binders throughout the facility and notify receptionist/security staff, redirect resident away from exits as needed, a wander guard to be placed for resident safety, and avoid leaving Resident #5 unattended or unobserved for long periods of time. Review of an elopement risk assessment dated [DATE], revealed Resident #5 had a score of 2, which indicated he was at risk for elopement. Review of a physician's order dated 8/16/2022, revealed Resident #5 had an order for a wander guard. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #5 had severely impaired cognition for daily decision making and required one-person physical assistance with walking in his room or in the corridor. Review of a physician's order dated 10/28/2022, revealed Resident #5 had an order for contact isolation with droplet precautions related to a positive Covid diagnosis. Review of a Progress Note dated 9/30/2022 at 4:30 PM, revealed, .resident attempt to exit building .pursued resident and prevented him from exiting building . Review of a Progress Note dated 10/30/2022 at 11:33 AM, revealed, .exit seeking x [times] 3 left COVID hall x 2 this am [morning] set off the alarm to door on 700 hall x 1 .set off alarm on 500 hall door x 2 .found in visitor parking lot per staff member . Review of a Progress Note dated 10/30/2022 at 11:33 AM, revealed, .staff alerted by 700 hall door alarm sounding off. Staff noted resident exiting 700 all [hall] door . The cognitively impaired resident (Resident #5) exited the Covid Unit several times prior to exiting the facility (elopement) unsupervised on 10/30/2022. The facility failed to implement interventions that prevented the resident from exiting the facility. Review of a Progress Note dated 10/31/2022 at 8:03 PM, revealed, .off COVID unit x 1 redirected to room .30-minute checks continue .remains confused at baseline .remains on COVID unit with droplet precautions and contact isolation . Observation of the area outside of the 700 hall exit door on 11/8/2022 beginning at 1:45 PM, with the Maintenance Director and the Speech Therapist, revealed a concrete sidewalk around the building, which was noted with several areas of a 3 ½ inch descent to the ground. There was a 3-foot 3 inch ditch running parallel to the sidewalk, and the sidewalk was covered in small round nuts which caused an uneven walking surface. It was approximately 274 feet from the 700 hall exit door to the sidewalk where Resident #5 was seen by the housekeeping staff. There was a sidewalk from the 800 hall exit door to the parking lot. The parking lot was located approximately 223 feet from where the resident was seen by the housekeeping staff, as measured by the Speech Therapist. During a telephone interview on 12/2/2022 at 9:25 AM, the physician stated, .not safe for [Resident #5] to be outside unsupervised .I was not aware of any attempts before this incident . 3. Medical record reviewed revealed Resident #9 was admitted on [DATE], with diagnoses of Cerebral Infarction, Anemia, History of Falling, Metabolic Encephalopathy, Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. Review of the admission fall risk assessment dated [DATE], revealed the assessment was incomplete. Review of the admission assessment dated [DATE], revealed the assessment was not signed until 11/15/2022. Review of the baseline care plan dated 11/4/2022, revealed Resident #9 is at risk for falls related to the new and unfamiliar environment, poor safety awareness, and unsteady gait with weakness. The interventions included anticipate and meet resident's needs as needed and keep the room free of clutter and obstacles that may pose trip hazards. Review of the admission MDS dated [DATE], revealed Resident #9 was assessed by staff as having severe cognitive impairment for decision making, had trouble concentrating, exhibited behaviors including rejection of care and wandering, required one-person limited assistance with activities of daily living, and had a history of falls prior to admission. Review of the Incident Details Report dated 11/10/2022, revealed, .CNA [Certified Nursing Assistant] called for the nurse to come to the resident's room. Resident was found on the floor .resident has right side head injury with a raised area over the eye .hematoma forehead . Resident #9's admission assessment and fall risk assessment was not completed. The baseline care plan did not include person centered measurable interventions to prevent falls. Resident #9 fell on [DATE] and sustained a hematoma to the right side of her face. During an interview on 11/17/2022 at 11:31 AM, the Interim DON stated, .the admission assessment should be completed within 24 hours of admission .fall risk assessments are completed upon admission and when a fall occurs The Interim DON confirmed Resident #9's admission assessment was not completed within 24 hours of admission and the admission fall risk assessment was not completed. 4. Review of a closed medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses of Anemia, Cerebral Infarction, and Esophagitis. Review of the fall risk assessment dated [DATE], revealed Resident #2 was assessed at moderate risk for falls. Review of the admission MDS dated [DATE], revealed Resident #2 was assessed with a BIMS of 11 indicating moderate cognitive impairment for decision making. Resident #2 required assistance with activities of daily living. Review of the Care Plan revised 10/21/2022, revealed fall interventions to anticipate and meet resident's needs, and physical therapy to evaluate and treat as ordered and as needed. Review of the Incidents by Incident Type report dated 8/1/2022 through 12/2/2022, revealed Resident #2 was not listed as having a fall on 10/25/2022. During an interview on 11/16/2022 at 10:54 AM, the DON confirmed Resident #2 had a fall on 10/25/2022. The DON stated, The CNA did not report the fall to the charge nurse .I received the information on 10/26/2022 .in-serviced staff .talked to them about reporting falls .didn't have them sign anything .a fall investigation was completed the next day .a fall risk assessment was not completed after the fall . There were no noted injuries to Resident #2. During a telephone interview on 11/23/2022 at 10:37 AM, CNA #3 stated, .yes [Resident #2] was in the floor I helped [CNA #4 and #5] get her up into the wheelchair .no I did not report it to the nurse . Review of personnel files for CNA #3, CNA #4, and CNA #5 on 11/15/2022, revealed there were no disciplinary actions or education provided related to reporting falls. During an interview on 11/16/2022 at 11:05 AM, the DON confirmed the fall investigation was not signed by the staff completing the investigation. During a telephone interview on 11/21/2022 at 3:40 PM, the Chief Operations Officer stated, .fall investigation should be signed .fall risk assessments should be completed after a fall and on admission .if staff observe a fall and do not report it to the nurse, the staff are educated and disciplined .should be in their personnel record . The surveyors verified the Allegation of Compliance (AoC) Removal Plan through record review, observations, audit reviews, review of education and sign-in sheets, and interviews for the immediate corrective actions listed below: 1. The facility immediately called ADHOC (formed for a special and immediate purpose)/Quality Assurance Performance Improvement (QAPI) meeting with department heads and QAPI team members at 4:00 PM on 11-10-2022. During the QAPI meeting a root cause analysis was completed pertaining to Resident #5 that exited the COVID-19 Unit and facility without staff knowledge. Root cause identification included: Resident who was moved in to the Covid Unit, was trying to get out of the area. The resident was looking to meet with his brother outside the building. He was a cognitively impaired resident and moved to a new environment on the Covid Unit. The surveyors reviewed the QAPI meeting minutes and interviewed the Administrator and the DON. 2. A new elopement assessment on Resident #5 that was identified as being outside without staff supervision was completed on 10-31-2022. The surveyors reviewed the elopement risk assessment. 3. A body audit was completed 10-31-2022 on Resident #5 that was identified as being outside without staff supervision with no negative findings. The surveyors reviewed the body audit and interviewed the DON. 4. The resident that was identified as being outside without staff supervision (Resident #5) was placed on every 30-minute checks. Every 30-minute checks were initiated at 11:15 AM on 10/30/2022. The every-30-minute check sheet was reviewed, and staff was interviewed about the every-30-minute checks. Every resident who was identified as at risk for exit-seeking was placed on 30-minute checks on 11/11/2022 at 5:00 PM, and continued. The surveyors reviewed the 30-minute check sheets for all residents and observed checks being completed. The surveyors interviewed direct care staff regarding the 30-minute checks. 5. The Care Plan was updated with new interventions in place for Resident #5 that was identified as being outside without staff supervision. New interventions included: Psychiatric evaluation and consultation, face time with family member (s) every 30-minute check. The surveyors interviewed the Psychiatric Nurse Practitioner and reviewed the Social Services note regarding the phone call with family member. 6. Maintenance staff checked all exit doors and alarms for proper functioning on 10-30-2022. The surveyors reviewed the exit door checks and interviewed the Maintenance Director. 7. Elopement drills were conducted on following dates with good response: 10/31/2022 at 3:21 PM for the 3-11 evening shift; 11/9/2022 at 11:20 AM for the 7-3 day shift; and 11/14/2022 at 6:18 AM for the 11-7 night shift. The surveyors observed the elopement drill on 11/9/2022 day shift and reviewed the sign in sheet. 8. The facility conducted a QAPI meeting regarding the 10-30-2022 incident on the resident identified as being outside without staff supervision. The surveyors reviewed the QAPI meeting form, the sign-in sheet, and interviewed the Administrator and Director of Nursing. 9. The resident identified as being outside without supervision (Resident #5) was discharged from the COVID-19 Unit on 11-9-2022 after completing quarantine time. The surveyors confirmed the resident was no longer residing in the COVID-19 unit. 10. A psychiatric evaluation was completed on 11-10-2022 on the resident identified as being outside without supervision (Resident #5). The surveyors interviewed the Psychiatric Nurse Practitioner and reviewed the progress note from the 11-10-2022 visit. 11. All residents that would like to participate in facetime and phone calls on the COVID-19 Unit will be offered. Every resident currently in the Covid Unit were offered facetime/phone calls on 11/12/2022. Every resident will be offered facetime/phone calls with family members at least weekly and as needed. Social Worker/Activities staff will visit the residents with an iPad or cell phone and coordinate calls. The surveyors reviewed the log sheet of residents offered and those that participated in a facetime/phone call. The surveyors interviewed the Social Worker and Activities Director regarding facetime/phone calls for residents on the Covid Unit. 12. The facility will ensure sufficient staff and supervision on the COVID-19 Unit for all residents. Staffing needs will be determined based on the census and acuity in the Covid Unit. The goal will be to have at least 1 nurse for the COVID Unit and 1 CNA for every 10 residents. The surveyors interviewed the Staffing Coordinator, Administrator and the Interim Administrator regarding Covid Unit staffing. 13. The facility immediately started in-services and education on neglect and accidents on 10-31-2022 and is ongoing. All facility employees are required to attend in-services/education regarding neglect and accidents. In-service education started 10/30/2022 and will be continued to attain over 100% compliance by 11/15/2022. Employees who are on vacation, family medical leave, or are scheduled as-needed will be required to complete the training prior to return to work. The surveyors reviewed the education, reviewed the sign-in sheets, and interviewed staff on all shifts. 14. The facility will audit all exit-seeking/elopement risk residents every shift by conducting every-30-minute checks. Findings will be reviewed in the daily morning meetings. Charge Nurse/designee will conduct audits for exit-seeking/elopement risk residents. The surveyors reviewed the audit form and interviewed Administration and facility staff regarding audits and morning meetings. The facility's noncompliance of F-689 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on job description review, facility staffing schedules, daily staffing sheet, punched detailed report review, agency time detailed report review, and interview, the facility failed to provide sufficient nursing staff to ensure supervision of residents. The facility's failure to ensure sufficient staffing for adequate resident supervision resulted in Immediate Jeopardy for 1 of 5 sampled residents (Resident #5) when a vulnerable resident with severe cognition impairment with wandering and elopement behaviors, and a positive COVID diagnosis, exited the COVID Unit 3 different times, and then exited the facility and was found by staff in the parking lot unsupervised and without Personal Protective Equipment (PPE) in place. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator, the Director of Nursing (DON), and the Chief Operating Officer (COO) were notified of the Immediate Jeopardy on 11/21/2033 at 4:41 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-725. The facility was cited at F-725 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy was existed from 10/30/2022 through 12/2/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 11/18/2022 at 10:13 PM, and was validated onsite by the surveyors on 11/30/2022 through 12/1/2022 through observations, review of audits, meeting minutes, and staff interviews. The findings include: 1. Review of the Administrator Job Description, signed by the Administrator on 7/6/2020, revealed, .The primary purpose of your position is to direct day-to-day functions of the Facility in accordance with current federal, state and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all time .Personnel Functions .Ensure that an adequate number of appropriately trained licensed professional and non-professional personnel are on duty at all times to meet the needs of the residents. Ensure that appropriate staffing level information is posted on a daily basis. Review and check competence of work force and make necessary adjustments or corrections as required or that may become necessary . Review of the Director of Nursing Services Job Description dated 3/16/2020, revealed, .The primary purpose of your position is to plan, organize, develop, and direct the overall operation of our Nursing Services Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our Facility and as may be directed by the Administrator or the Medical Director to ensure that the highest degree of quality care is maintained at all times .Administrative Function .Assist in calculating the number of direct nursing care personnel on duty each shift. Report such information to the Administrator or his/her designee to ensure that accurate staffing information is posted .Personnel Functions Inform the Nurse Supervisor and/or Unit Manager of staffing needs when assigned personnel fail to report to work .Determine the staffing needs of the nursing service department necessary to meet the total nursing needs of the residents. Supervise and assist scheduling of employees within established state guidelines .Assign a sufficient number of LPN's [Licensed Practical Nurse] and RNs [Registered Nurse] for each tour of duty to ensure that quality care is maintained. Assign a sufficient number of CNAs/GNAs [Geriatric Nurse Aide] as applicable for each tour of duty to ensure that routine nursing care is provided to meet the daily nursing care needs of each resident .Nursing Care Functions .Provide the Administrator with information relative to the nursing needs of the resident and the nursing service department's ability to meet those needs . 2. Review of the Midnight Census Report and Daily Schedule dated 10/30/2022 revealed a total census of 148 residents. A total of 49 residents resided on the 100 and 200 Halls. A total of 49 residents resided on the 300 and 400 Halls, and a total of 30 residents resided on the 500 and 600 Halls (11 residents resided on the COVID Unit, rooms 606-617). A total of 20 residents resided on the 800 Hall. Daily Schedule revealed on the day shift (6:45 AM-3:15 PM) on 10/30/2022, 6 Licensed Practical Nurses (LPNs) were scheduled. 3. Review of the Daily Assignment Sheets dated 10/30/2022, revealed day shift (6:45 AM-3:15 PM) assignments showed 1 Certified Nursing Assistant (CAN) for rooms 500-504 and 600-605; 1 CNA for rooms 505-512 and 811w (window)-817; 1 CNA for (COVID Unit) rooms 606-617; and 1 CNA for rooms 800-811d (door). 4. Review of the Daily Staffing Sheet, Punched Detailed Report, Agency Time Detailed Report dated 10/30/2022, revealed 0700 days 8 CNAs with 1 CNA clocking punch time at 10:05 AM and 1 CNA clocking punched out time at 12:58 PM. 5. During an interview on 11/8/2022 at 4:36 PM, the Administrator stated, .during the QAPI (Quality Assurance Performance Improvement) [meeting] on 10/21[2022], we had a meeting regarding the COVID outbreak .we would have designated staffing in the Covid Unit: 1 nurse, 1 CNA, and 1 housekeeper .the day of the elopement [10/30/22], there should have been designated staff in the COVID Unit .staff had to work outside the Covid Unit picking up other residents .if someone called in, that staff had to cover .there was [were] 11 residents on the COVID Unit that day . The Administrator confirmed that the nurse and CNA had other residents assigned outside of the Covid Unit, and were not designated only to the COVID Unit stating, .we shot ourselves in the foot when we put that in place .with the staffing challenges .the DON should provide the oversight for the staffing, but that wasn't done . During an interview on 11/8/2022 at 1:01 PM, CNA #1 stated, .I was assigned the COVID Unit and provided care to residents assigned outside of the COVID Unit on another hall .it was hard for me to keep eyes on him [Resident #5] .he was up wandering around and going out of the COVID Unit .I brought him back in the unit several times .then I got a call he was out in the parking lot .there was no way I could have watched him closely, because I had other residents outside the COVID Unit . CNA #1 confirmed the assignment sheet was inaccurate, and that due to a call-in, she was assigned other residents outside of the COVID Unit. During an interview on 11/8/2022 at 3:00 PM, the DON stated, .I told the Staffing Coordinator a couple of weeks ago that we need designated staff to staff the Covid Unit only .If someone calls in, then the staff from the Covid Unit will have to cover .there should have been a nurse and CNA assigned to the COVID Unit . During an interview on 11/18/2022 at 1:04 PM, the LPN #1 stated, .I was not aware that there was designated staff for the COVID Unit .I had the COVID Unit and provided care to residents outside of the COVID Unit on another hall .me and the other nurse split the halls .had rooms on the 500 and the 600 hall [COVID Unit] .we were trying to do the best that day we could .it was very hard to manage [named Resident #5]. He kept getting out of the [Covid] Unit .I probably shouldn't have sat him at the desk since he was COVID-positive . During an interview on 12/1/22 at 1:00 PM, the Staffing Coordinator stated, .we had call-outs from staff and agency staff that day [10/30/2022] at the last minute, and staff that had promised to work left their shifts early .we were short [short-staffed] .not sure if the Charge Nurse who made the assignments knew to staff the COVID Unit with designated staff . The Staffing Coordinator confirmed the nurse and CNA were not designated to only the COVID Unit. The Staffing Coordinator confirmed the daily assignment sheet was inaccurate and did not reflect the actual assignments or schedule. The surveyors verified the Removal Plan by: 1. The facility will provide 1 nurse and 1 CNA for every 10 residents in the COVID Unit each shift. Documentation was provided which showed the nurse-to-patient ratio. The Administrator/DON will monitor staffing for the COVID Unit daily to ensure adequate staffing was available. This will be discussed daily during morning meetings, during the day, and again at the end of the day. This was validated by the surveyors through observation and review of the daily assignment sheets. Clinical acuity and the COVID Unit census will be reviewed by Administrator/DON daily and staffed accordingly as follows: 1-5 residents minimum 1 nurse 6-10 residents minimum 1 nurse and 1 CNA 11-20 residents minimum 1 nurse and 2 CNAs 2. Facility initiated every-30-minute checks on Resident #5, who exited the COVID Unit unsupervised. The facility initiated every-30-minute check on all residents with exit seeking behaviors or at elopement risks. This was validated by surveyors through review of the 30-minute check sheets. Unit Managers will monitor and audit every-30-minute checks daily on all exit seeking residents. Findings will be reviewed and reported in the morning meetings daily. Resident added to the wander list since audit started. This was validated by surveyors through review of 30-minute check sheets of all wandering and exit-seeking residents and review of audits and interviews with Unit Managers. 3. All facility staff were educated on incidents/accidents and supervision. This was validated by surveyors through interviews with agency and facility staff conducted on all shifts, and sign-in sheets were reviewed for all staff and agency staff. 4. Administrator/DON/ADON will monitor staffing each morning in the morning meetings to ensure adequate staffing is provided for the COVID Unit specifically and for the facility in general. This was validated by surveyors through review of the COVID Unit census with staffing assignment sheets and observations. 5. Administrator/DON/ADON will review staffing for the following day with the Staffing Coordinator on the previous day before posting to ensure adequate staff members are scheduled daily. This was validated by surveyors through review of daily staff postings and schedules. 6. Administrator/DON and Staffing Coordinator will review daily PPD and take action to replace call outs, including use of agency staff, as-needed (PRN) staff, and management staff to ensure adequate staffing is available for the COVID Unit specifically, and the facility in general, each day in the morning meetings. This was validated by surveyors through review of staff postings and schedules, and interviews. The facility's noncompliance of F-725 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, job description review, staff personnel file review, medical record review, observation, and interview, the facility failed to ensure nursing staff were competent and proficient in practices to maintain residents' highest practical well-being and to prevent elopement, prevent the spread of infectious diseases, prevent significant weight loss, and ensure assessments were done timely and fall interventions were implemented. The failure of the facility to ensure competent nursing staff resulted in Immediate Jeopardy for 1 of 5 sampled residents (Resident #5) reviewed for accidents. Resident #5, a vulnerable resident with severe cognition impairment and a positive COVID-19 diagnosis, exited the COVID Unit barrier 3 times by unzipping the barrier, and then exited the facility unsupervised on [DATE]. Resident #5 was found by staff walking on the sidewalk into the parking lot, approximately 223 feet from the facility. Neither Resident #5, nor staff who interacted with him, were using Protective Personal Equipment (PPE), which had the potential to expose staff and other residents to COVID-19. The failure of the facility to ensure competent nursing staff resulted in actual harm for 1 of 3 sampled residents (Resident #3) reviewed for Social Services. Resident #3, a vulnerable resident with diagnoses of Depression, Dementia and COVID-19, sustained a significant weight loss of 7.8 percent (%) in 1 month, after having suicidal ideations and voiced that he wanted to die and would starve himself. Resident #3 was admitted and isolated in the COVID Unit on [DATE] and voiced to Social Services and his family of wanting to die and had suicidal ideations on [DATE]. Resident #3 frequently refused medications and meals, resulting in significant weight loss in 1 month. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator and Interim Director of Nursing (DON) were notified of the Immediate Jeopardy for F-726 on [DATE] at 4:41 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-726. The Immediate Jeopardy existed [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the jeopardy was received on [DATE] and was validated onsite by the surveyors on [DATE] through [DATE] through policy review, review of education records, medical record review, observation, and staff interviews. The findings include: 1. Review of the facility's undated policy titled, .Personal Protective Equipment, revealed, .To ensure that .PPE .is provided for all staff at the facility, including .facemasks, gloves, gowns, and eye protection .when interacting with COVID-19 suspected or confirmed residents .Prior to entering areas where residents are suspected or confirmed with COVID-19 .Education provided to staff on proper usage, procedure . Review of the facility's undated policy titled, MISSING RESIDENT/ELOPEMENTS, revealed, .The Unit Charge Nurse is responsible for knowing the location of their residents .Missing Resident Guidelines .Determine time and location when last seen . Review of the facility's policy titled, Wandering, Unsafe Resident, Revised 8/2014, revealed, .The facility will strive to prevent unsafe wandering .The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) .The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering .A missing resident is considered a facility-wide emergency .When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall .Contact the Attending Physician and report findings and conditions of the resident . Review of the facility ' s policy titled, Fall Risk Assessment, revised [DATE], revealed, .The nursing staff .will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information .Upon admission, the nursing staff and physician will review a resident ' s record for a history of falls .nursing staff will ask the resident and his/her family about any history of the resident falling .staff and attending physician will .identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable . 2. Review of the Social Worker Job Description revealed, .Ensure that all charted progress notes are informative and descriptive of the services provided and of the resident ' s response to service .review nurses note to determine if the care plan is being followed . Review of the Social Service Director Job Description revealed, .to assure that the medically related emotional and social needs of the resident are met and maintained on an individual basis .make daily rounds to assure that social service personnel are preforming required duties and to assure that appropriate social service procedures are being rendered to meet the needs of the facility .Ensure that all social services personnel are aware of the care plan and that care plans are used in providing daily social service to the residents .review nurses ' notes to determine if the care plan is being followed .communicate with the medical staff, nursing staff . 3. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of [NAME] ' s Encephalopathy, Altered Mental Status, Alcohol Abuse, Adult Failure to Thrive, Cerebral Infarction, Cognitive Social or Emotional Deficit following Cerebral Infarction. Review an elopement risk assessment dated [DATE] revealed Resident #5 had a score of 2 indicating at risk for elopement. Review of a physician ' s order dated [DATE], revealed Resident #5 had an order for a wander guard. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #5 had severely impaired cognition for daily decision making and required one-person physical assistance walking in his room or in the corridor. Review of a physician ' s order dated [DATE] revealed Resident #5 had an order for contact isolation with droplet precautions r/t Covid positive. Review of a Progress Note dated [DATE] at 11:33 AM, revealed .exit seeking x [times] 3 left COVID hall x 2 this am set off the alarm to door on 700 hall x 1 set off alarm on 500 hall door x 2 found in visitor parking lot per staff member . Review of a Progress Note dated [DATE] at 8:03 PM revealed .off COVID unit x 1 redirected to room .30-minute checks continue .remains confused at baseline . During a telephone interview on [DATE] at 9:25 AM, the physician stated, .not safe for [Resident #5] to be outside unsupervised .I was not aware of any attempts before this incident . 4. Review of the medical record review for Resident #3 showed an admission date of [DATE] with diagnoses of Hypertension, Adult Failure to Thrive, Depression, Insomnia, Personal History of Covid-19, Dementia, Anxiety, Mood Disturbance and Psychotic Disturbance. Review of the physician ' s order dated [DATE] showed .Admit .on COVID Unit d/t [due to] + [positive] COVID test .q [every] 15-minute checks (suicidal ideations) . The facility was unable to provide documentation for the every-15-minute checks as ordered. Review of the admission MDS dated [DATE], showed a BIMS score of 7, which indicated severe cognition impairment, had symptoms of feeling depressed, feeling tired or having little energy, poor appetite or overeating, stated that life isn ' t worth living and wished for death or attempted to harm self, required assistance with activities of daily living, weighed 167 pounds, received oxygen therapy and isolation or quarantine for active infectious disease. Review of the Care Plan initiated date [DATE] showed, .exhibits sad moods .saying negative statements of wanting to die .Observe any changes .check throughout the day .making suicidal statements about killing himself .encourage family to visit often .encourage resident to attend activities .Refer to Psychiatric for evaluation as needed . Review of the Social Services note dated [DATE] showed, .resident began expressing suicidal ideations stating he wanted to die and not live anymore. The resident was refusing to eat, refusing meds removing his oxygen and telling his family and staff that he wanted to die. The SW told the family she would ask for a Psychiatric (Psych) referral for the resident .Window visits with daughter . The facility was unable to provide documentation of Social Services follow-up interventions for Resident #3 for Depression with suicidal ideations and refusal of mediations and meals from [DATE] until resident expired [DATE]. Review of the physician ' s order dated [DATE] showed, .psych [Psychiatric]-eval[evaluation] refusing to eat . Review of the [NAMED] PHYSICIANS ORDER FOR PSYMED SERVICES dated [DATE] documented .thoughts of dying .ordering referral for psychiatry services . The Psychiatric Nurse Practitioner did not see Resident #3 until [DATE], 13 days after Resident #3 expressed suicidal ideations and after the physician ordered the psychiatric services. Review of the Care Plan dated [DATE] showed, .at risk for loneliness, anxiety and sadness related to isolation precautions implemented due to COVID 19 .interventions .observe resident for S/S [Signs and Symptoms] of social isolation or .depression .Resident to talk or facetime family/friends as per resident/family request and as needed . Review of the significant change MDS dated [DATE], showed a BIMS score of 6 indicating severe cognition impairment, requires assistance with activities of daily living, weighed 140 pounds with loss of 5% or more in the last month, had 2 stage 2 pressure ulcers, and received antidepressant medication. Review of the physician ' s order dated [DATE], showed, .Palliative Care . Resident #3 expired on [DATE]. 5. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses of Cancer of Larynx, Supraglottis and Pharynx, Dementia, Anxiety, Aphonia, and a History of COVID 19. Review of the quarterly MDS dated [DATE], revealed a BIMs score of 10, indicating moderate cognition impairment, required assistance with activities of daily living, had unclear speech, was sometimes understood, made needs known by pointing and use of electrolarynx, had moderately impaired vision, and had behaviors. Review of the Care Plan dated [DATE], revealed, .has a potential to demonstrate physical aggressive behavior .resident to resident altercation .Psych consult . During an interview on [DATE] at 10:51 AM, the PNP confirmed she did not see Resident #12, and that she was unaware she was supposed to see him. During an interview on [DATE] at 5:00 PM, the Social Services Director (SSD) confirmed she was unaware Resident #12 had not been seen by the PNP until the surveyor asked for the psychiatric note, and that follow-up notes should have been documented. The SSD was unable to provide the Psychiatric referral sheet for Resident #12. The SSD was asked if 2 residents were in an altercation, should Social Services evaluate and document both. The SSD stated, .yes, they should . Resident #12 was involved in a resident-to-resident altercation and hit another resident on [DATE]. The facility failed to provide Social Services monitoring and was unable to provide a psychiatric services referral documentation. 6. Medical record review revealed Resident #9 was admitted on [DATE], with diagnoses Cerebral Infarction, Anemia, History of Falling, Metabolic Encephalopathy, Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. Review of the admission fall risk assessment dated [DATE] revealed the assessment was incomplete. Review of the admission assessment dated [DATE] revealed assessment was not signed until [DATE]. Review of the baseline Care Plan dated [DATE] revealed Resident #9 was at risk for falls related to new and unfamiliar environment, poor safety awareness, unsteady gait and weakness. The interventions were to anticipate and meet resident ' s needs as needed and keep room free of clutter and obstacles that may pose trip hazards. Review of the MDS dated [DATE] revealed Resident #9 had a history of falls prior to admission. Review of the Incident Details Report dated [DATE] revealed, .CNA [Certified Nursing Assistant] called for the nurse to come to the resident ' s room. Resident was found on the floor .resident has right side head injury with a raised area over the eye .hematoma forehead . Resident #9 ' s admission assessment and fall risk assessment were not completed. The baseline care plan did not include person centered measurable interventions to prevent falls. Resident #9 fell on [DATE] and sustained a hematoma to the right side of her face. During an interview on [DATE] at 11:31 AM, the Interim DON stated, .the admission assessment should be completed within 24 hours of admission .fall risk assessments are completed upon admission and when a fall occurs . The Interim DON confirmed Resident #9 ' s admission assessment was not completed within 24 hours of admission and the admission fall risk assessment was not completed. 7. Review of a closed medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses of Anemia, Cerebral Infarction, and Esophagitis. Review of the fall risk assessment dated [DATE], revealed Resident #2 was assessed at moderate risk for falls. Review of the admission MDS dated [DATE], revealed Resident #2 was assessed with a BIMS of 11 indicating moderate cognitive impairment for decision making. Resident #2 required assistance with activities of daily living. Review of the Care Plan revised [DATE], revealed fall interventions to anticipate and meet resident's needs, and physical therapy to evaluate and treat as ordered and as needed. Review of the Incidents by Incident Type report dated [DATE] through [DATE], revealed Resident #2 was not listed as having a fall on [DATE]. During an interview on [DATE] at 10:54 AM, the DON confirmed Resident #2 had a fall on [DATE]. The DON stated, The CNA did not report the fall to the charge nurse .I received the information on [DATE] .in-serviced staff .talked to them about reporting falls .didn't have them sign anything .a fall investigation was completed the next day .a fall risk assessment was not completed after the fall . There were no noted injuries to Resident #2. During a telephone interview on [DATE] at 10:37 AM, CNA #3 stated, .yes [Resident #2] was in the floor I helped [CNA #4 and #5] get her up into the wheelchair .no I did not report it to the nurse . Review of personnel files for CNA #3, CNA #4, and CNA #5 on [DATE], revealed there were no disciplinary actions or education provided related to reporting falls. During an interview on [DATE] at 11:05 AM, the DON confirmed the fall investigation was not signed by the staff completing the investigation. During a telephone interview on [DATE] at 3:40 PM, the Chief Operations Officer stated, .fall investigation should be signed .fall risk assessments should be completed after a fall and on admission .if staff observe a fall and do not report it to the nurse, the staff are educated and disciplined .should be in their personnel record . 8. Observation on [DATE] at 2:15 PM, revealed LPN #3 on 200 hall Nurses ' Station sitting at the computer with her eyes closed and nodding her head asleep at the desk. During an interview on [DATE] at 3:50 PM, the Interim DON stated, .staff should not be sleeping while working here at this facility .I have spoke [spoken] with LPN #3, and she has begged me for another chance . Observation on [DATE] at 1:50 PM, revealed CNA #2 sitting outside of a room on the 800 hall in a chair beside a linen cart with her head slumped over and eyes closed. During an interview on [DATE] at 2:10 PM, CNA #2 stated, .I apologize for sleeping. I ' ve been here since yesterday . During an interview on [DATE] at 12:55 PM, the Administrator stated, .it is not acceptable for staff to be sleeping on duty . The surveyors verified the Allegation of Compliance Removal Plan through record review, observations, audit reviews, review of education and sign-in sheets, and interviews for the immediate corrective actions listed below: 1. The facility will conduct an audit to ensure admission assessments were completed on all new admissions for the past 30 days. This audit will be completed by [DATE]. The DON/ADON/Unit Managers will be responsible. Any missing assessments will be completed immediately. The surveyors reviewed the audit form. The surveyors interviewed the DON, the Assistant Director of Nursing (ADON) and the Unit Managers regarding admission assessments, reviewed Resident #9 ' s assessments to ensure completion. 2. The facility will conduct an audit to ensure fall assessments were completed upon admission and following fall incidents for the past 30 days. This audit will be completed by [DATE]. The DON/ADON/Unit Managers will be responsible. Any missing fall risk assessments will be completed immediately. The surveyors interviewed the DON, the ADON, and the Unit Managers regarding admission fall risk assessments. 3. All employees were educated on incident and accident supervision. All staff have been educated on Incidents and Accidents, and monitoring has been completed. Education included thorough and timely completion of resident assessments, monitoring, and provision of safety for all residents, and thorough investigations of all incidents and accidents to include all potential witness statements in the event of elopement. The surveyors interviewed staff on all shifts, reviewed the in-service education and sign-in sheet. 4. The Administrator/DON have been consulted regarding proper reporting in a timely manner per state regulation and conducting thorough investigations with all Incidents and Accidents. The ADON/Unit Managers were educated on proper monitoring and supervision, incidents and accidents, proper investigating and reporting. Unit Managers were educated on proper and thorough assessments to be completed in a timely manner. The surveyors interviewed the Administrator, the DON, the ADON and the Unit Managers regarding proper reporting, investigation, supervision, and monitoring. 5. DON/ADON/Unit Managers will audit and review any uncompleted assessments daily in the clinical meetings. The findings will be reported to the monthly QAPI committee meetings for follow-up. The surveyors interviewed the Administrator, the DON, the ADON and the Unit Managers regarding proper reporting, investigation, supervision and monitoring. The facility's noncompliance of F-726 continues at a scope and severity of E for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on the Board of Examiners of Nursing Home Administrators (BENHA) review, job description review, medical record review, and interview, the facility Administration failed to provide supervision and oversight to prevent the potential for serious injury when Resident #5 exited the Covid Unit and eloped from the facility on 10/30/2022. Resident #5 walked outside the facility, and down the sidewalk toward a parking lot approximately 223 feet from the facility and was unsupervised for approximately 6 minutes. Administration failed to identify breaches in Infection Control practices when Licensed Practical Nurse (LPN) #1 and Certified Nurse Assistant (CNA) #1 were not wearing Personal Protective Equipment (PPE) when providing care for Resident #5, who was Covid Positive. Administration failed to identify incomplete admission and fall risk assessments, failed to ensure measurable and person-centered interventions were in place to prevent falls, and failed to provide in-service education for facility staff related to fall reporting for 2 of 3 sampled residents (Resident #9 and #2) reviewed for falls. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Interim Director of Nursing (DON), and the Chief Operating Officer (COO) were notified of the Immediate Jeopardy on 12/2/2022 at 8:52 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-600, F-609, F-610, F-689, F-725, F-726, F-835, and F-867. The facility was cited Immediate Jeopardy at F-600, F-609, F-610, and F-689 at a scope and severity of J, which is Substandard Quality of Care. The facility was cited an Immediate Jeopardy at a J on 8/30/2021 for deficiencies related to F-600, F-610, F-689, F-725, F-726, F-835 and F-867. The facility was cited an Immediate Jeopardy at a J on 2/10/2020 for deficiencies related to F-600, F-610, F-689, F-835 and F-867. The Immediate Jeopardy was existed from 10/30/2022 through 12/2/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 11/14/2022 at 12:44 PM, and was validated onsite by the surveyors on 12/1/2022 - 12/2/2022 through observations, review of audits, meeting minutes, and staff interviews. The findings include: Review of the BENHA revealed the Administrator had an employment date of 7/6/2020. Review of the Administrator job description, signed by the Administrator on 7/6/2020, revealed, .The primary purpose of your position is to direct the day-to-day functions of the Facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times .As Administrator, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties .Administrative Functions .Plan, develop, organize, implement, evaluate, and direct the Facility's programs and activities in accordance with guidelines issued by the VP [Vice President] of Operations .Develop and maintain written policies and procedures and professional standards of practice that govern the operation of the Facility .realize the importance of teamwork .Review the Facility's policies and procedures at least annually and make changes as necessary to assure continued compliance with current regulations .Ensure that all employees, residents, visitors, and the general public follow the Facility's established policies and procedures .Represent the Facility in dealings with outside agencies, including governmental agencies .Participate in state/federal surveys of the facility .Assist in providing survey team members with additional information during the survey .Review deficiencies noted during the exit conference .Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies .Consult with department directors concerning the operation of their departments to assist in eliminating and correcting problem areas .Ensure that an adequate number of appropriately trained licensed professional and non-licensed personnel are on duty at all times to meet the needs of the residents .Review and check competence of work force and make necessary adjustments or corrections .Inform the Medical Director of all suspected or known incidents of resident abuse .Ensure the building and grounds are maintained in good repair .Review accident/incident reports .Monitor to determine the effectiveness of the facility's risk management program .Specific Requirements .Must have a thorough knowledge of OBRA [Omnibus Budget Reconciliation Act] regulations, the survey process, survey tag numbers, and quality measures .Must be able to communicate policies, procedures, regulations, reports .to government agencies and personnel . Review of the Director of Nursing Services job description, signed by the DON on 3/16/2020, revealed .The primary purpose of your position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our Facility .you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. In the absence of the Medical Director, you are charged with carrying out the resident care policies established by the Facility .Plan, develop, organize, implement, evaluate, and direct the nursing service department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the nursing care facilities .Develop, implement, and maintain an ongoing quality assurance program for the nursing service department .Assist the Quality Assessment & [and] Assurance Committee (QAPI) in developing and implementing appropriate plans of action to correct identified deficiencies .Make daily rounds of your unit/shift to ensure that assigned CNAs [Certified Nursing Assistants] .and other nursing personnel are performing their work assignments in accordance with acceptable nursing standards .Make changes to assignments based upon resident needs .Determine the staffing needs of the nursing service department necessary to meet the total nursing needs of the residents .Assign a sufficient number of LPNs [Licensed Practical Nurses] and RNs [Registered Nurses] for each tour of duty to ensure that quality care is maintained .Assign a sufficient number of CNAs for each tour of duty to ensure that routine nursing care is provided to meet the daily nursing care needs of each resident .Review nurses' notes to ensure that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to the care .Develop and participate in the planning, conducting, and scheduling of timely in-service training classes that provide instructions on how to do the job, and ensure a well-educated nursing service department .Monitor nursing service personnel to ensure that they are following established safety regulations in the use of equipment and supplies .Review and revise care plans and assessments as necessary .Report all allegations of resident abuse .Must be knowledgeable of nursing and medical practices and procedures, as well as laws, regulations, and guidelines that pertain to nursing care facilities . During an interview on 11/3/2022 at 11:17 AM, the DON stated, .I was notified the day [Resident #5] exited the facility .the investigation wasn't started until 10/31/2022, and it has not been reported . During an interview on 11/3/2022 at 11:17 AM, the Administrator stated, .the investigation started on 10/31/2022 after the morning meeting .I notified the [Chief Operating Officer] and was told to continue the investigation and collect statements .the COO agreed it was not a reportable incident at this point . During an interview on 11/8/2022 at 4:36 PM, the DON stated, .I did not direct the RN [Registered Nurse] Supervisor to gather statements the day she notified me of the incident . During and interview on 11/9/2022 at 11:00 AM, the Administrator confirmed staffing concerns had not been investigated until 11/8/2022. During an interview on 11/9/2022 at 12:27 PM, the COO stated, .I was notified of the incident on [10/31/2022] and directed them [Administration] to continue the investigation and collect statements .I spoke with Administrator on Wednesday [11/22/2022] and directed them to report the incident into [Incident Reporting System]. I assumed they had reported it that day . During an interview on 11/10/2022 at 10:54 AM, the Administrator stated, .the DON should have come in .gave directions about getting staff statements .the investigation was not started immediately .on Monday [10/31/2022] the only information we had was RN #1's statement that was based on what she was told .Monday I told the DON an incident report and a head-to-toe assessment needed to be completed . During an interview on 11/21/2022 at 3:30 PM, the COO stated, .incidents should be reported to the DON then to the Administrator .the DON took it upon herself to not report the incident to the Administrator .statements should be obtained immediately .incident reports should be completed by the charge nurse . During an interview on 11/22/2022 at 3:40 PM, the Administrator stated, .this is the 3rd elopement for us .this is the same thing that happened last year [2021]. The [DON] failed to notify me about the incident when it happened .I am supposed to be notified of these incidents .did not report it timely because did not think it was reportable since staff had their eyes on him .now were are finding out statements and assessments that should have been done but were not .and I'm just finding out about them . During an interview on 11/22/2022 at 3:50 PM, the Interim DON stated, .admission assessments should be completed within 24 hours of admission .fall risk assessments are completed upon admission .and after a fall . The facility's noncompliance of F-835 continues at a scope and severity of E for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

Based on policy review, Quality Assurance Performance Improvement (QAPI) Committee meeting review, job description review, and interview, the QAPI committee failed to ensure an effective QAPI program that identified opportunities for improvement related to resident safety and infection control, and failed to implement performance improvement activities in order to provide a safe environment for residents, prevent the spread of infections, and ensure systems and processes were in place and were consistently followed by staff and administration. The QAPI committee failed to provide oversight that established and implemented policies and procedures to ensure the facility was administered in a manner to use its resources effectively and efficiently. The failure of the QAPI committee to ensure systems and processes were in place and consistently followed by staff and administration placed Resident #5, a COVID-positive resident with exit-seeking behaviors, in Immediate Jeopardy when he exited the COVID Unit barriers 3 times, and then exited the facility unsupervised. Staff was unaware Resident #5 was missing from the facility until he was seen by a staff member walking outside the facility, down the sidewalk and into the back parking lot approximately 223 feet from the 800 hall exit door. Contact isolation was not maintained, which had the potential to spread COVID-19 infection to staff and residents. The failure of the QAPI committee to ensure systems and processes were in place and consistently followed by staff and administration resulted in actual harm for Resident #3, who sustained a 7.8 percent weight loss in 1 month. Resident #3 admitted with Depression, Dementia and a positive COVID diagnosis. He was admitted to the COVID Unit in contact isolation and voiced suicidal ideations 3 days after admission by stating he wanted to die and would starve himself. The facility was unable to provide documentation of follow-up by Social Services for Resident #3. Resident #3 was not provided needed psychiatric services for days after expression of suicidal ideations. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Director of Nursing (DON), and the Chief Operating Officer (COO) were notified of the Immediate Jeopardy on 12/2/2022 at 8:52 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-600, F-609, F-610 and F-689, F-725, F-726, F-835, and F-867. The facility was cited Immediate Jeopardy at F-600, F-609, F-610, and F-689, at a scope and severity of J, which is Substandard Quality of Care. The facility was cited an Immediate Jeopardy at a J on 8/30/2021 for deficiencies related to F-600, F-610, F-689, F-725, F-726, F-835 and F-867. The facility was cited an Immediate Jeopardy at a J on 2/10/2020 for deficiencies related to F-600, F-610, F-689, F-835 and F-867. The Immediate Jeopardy existed 10/30/2022 through 12/2/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 12/2/2022 at 8:52 PM. The Removal Plan for QAPI was validated by the surveyors with additional education put in place on 12/2/2022 and the removal of the F600, F609, F610, F689, F725, F726, F835, and F880 IJs. The findings include: Review of the facility policy titled, QA [Quality Assurance] Committee-Role of the Quality Assessment and Assurance Coordinator, revised 11/2010, revealed, .Duties and responsibilities of the Quality Assessment and Assurance Program include, but are not limited to: .Meeting with the Quality Assessment and Assurance Committee monthly to review all assessment tools designed, all data collection reports, and all activities regarding quality assessment and assurance as carried out by departments, services, or committees which have a direct impact on resident care and safety .planning developing, organizing, implementing, coordinating, and directing the Quality Assessment and Assurance program designed to enhance the quality of resident care, in accordance with current rules, regulations, and guidelines that govern the long-term care facility .Evaluating programs and effecting changes as necessary to improve programs and assuring compliance with regulatory requirements .Assisting department directors in developing and implementing appropriate plans of action to correct identified deficiencies .Scheduling committee meetings and notifying members of such meetings .Assisting in developing follow-up procedures for monitoring identified problem areas . Review of the facility's policy titled, Wandering, Unsafe Resident, revised 8/2014, revealed, .The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) .The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering .When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall .Complete and file an incident report; and Document relevant information in the resident's medical record . Review of the Administrator Job Description, signed by the Administrator on 7/6/2020, revealed, .The primary purpose of your position is to direct day-to-day functions of the Facility in accordance with current federal, state and local standards guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care can be provided to our residents at all times .Committee Functions Serve on various committees of the Facility (i.e. Infection Control, Quality Assurance and Assessment, etc. and provide written and oral reports of such committee meetings to the VP [Vice President] of Operations .Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies. Evaluate and implement recommendations from the Facility's committee as necessary . Review of the Director of Nursing Services Job Description, signed by the Director of Nursing on 3/16/2020, revealed, .The primary purpose of your position is to plan, organize, develop, and direct the overall operation of our Nursing Services Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our Facility and as may be directed by the Administrator or the Medical Director to ensure that the highest degree of quality care is maintained at all times .Duties and responsibilities .Plan, develop, organize, implement, evaluate, and direct the nursing services department, as well as its programs and activities in accordance with current rules, regulations, and guidelines that govern the nursing care facilities .Develop, implement, and maintain an ongoing quality assurance program for the nursing service department .Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified deficiencies . Review of the QAPI meeting minutes provided by the Administrator, revealed a QAPI Committee meeting was held on 10/21/2022, to address a COVID-19 outbreak in the facility, and a recommendation was made for designated staffing for the COVID Unit to reduce further spread of the virus with staff and residents. The designated staff should consist of 1 nurse, 1 certified nursing assistant (CNA) and 1 housekeeper on the COVID Unit. On 10/30/2022, this was not followed, as staff assigned to the COVID Unit also cared for residents outside the COVID Unit on other halls. The QAPI meeting held on 10/31/2022, did not address designated staffing of the COVID Unit. There was no immediate action taken by the QAPI Committee to staff the COVID Unit with designated staff until 11/10/2022. During an interview on 11/9/2022 at 12:27 PM, the COO stated, .when I was notified, I told them [Administrator and DON] on 10/31/22 .They told me that a resident was found outside .told them to continue the investigation and get statements .on Wednesday [11/2/2022] I told them to report it, and I was under the assumption it was reported Wednesday [11/2/2022] . During an interview on 11/8/2022 at 4:36 PM, the Administrator stated, During our QAPI [meeting] on 10/21 [2022], we had a meeting regarding the COVID outbreak. We decided that we would have designated staffing in the Covid Unit: 1 nurse, 1 CNA, and 1 housekeeper . The Administrator was asked if the designated staff assigned to the COVID Unit also had to work outside the Covid Unit on the day of the elopement [10/30/2022]. The Administrator stated, .I don't think so .the staff had redirected the resident [Resident #5] several times that day and prevented him from getting out. The Administrator confirmed she had not reviewed the staff assignments for 10/30/2022. The Administrator was asked what the root cause analysis was determined for Resident #5's elopement incident during the QAPI meeting on 10/31. The Administrator stated, He [Resident #5] wanted to exit the facility to go see his brother. The root cause analysis for QAPI on 10/21 was staffing due to outbreak [COVID-19] .We were to have some people work the Unit [Covid Unit] designated only to COVID [Unit] unless call ins. During an interview on 11/8/2022 at 4:36 PM, the DON stated, .to be honest with you, we hadn't looked at the staffing .I told the Staffing Coordinator a couple of weeks ago that we need designated staff to staff the Covid Unit only .The DON was asked if the fact that Resident #5 was positive for COVID should not have been considered an incident [of potential COVID-19 exposure]. The DON was asked if the Supervisor should have collected statements when Resident #5 got out of the door. The DON confirmed that Resident #5's exit from the COVID Unit and exit from the facility should have been considered an incident. The DON stated, .I can see where you are coming from . The DON confirmed the Registered Nurse (RN) Supervisor (RN #1) should have gotten statements. During an interview on 11/21/2022 at 3:40 PM, the Chief Operating Officer (COO) stated, .fall investigation should be signed .fall risk assessments should be completed after a fall and on admission .if staff observe a fall and do not report it to the nurse, the staff are educated and disciplined .should be in their personnel record . Interview on 12/2/2022 at 5:20 PM, the Interim DON confirmed there were some issues with the psychiatric referrals that were identified yesterday [12/1/2022]. The DON stated, .We are finding out that the orders are written, but they are not being seen immediately after the order is written .there is a delay in services . The QAPI committee failed to maintain oversight, establish, and implement policies and procedures to ensure adequate staff supervision to protect vulnerable residents from neglect and unsafe elopement episodes. Refer to F600. The QAPI committee failed to maintain oversight, establish and implement policies and procedures to ensure incidents of elopement and neglect were reported to the State Survey Agency. Refer to F609. The QAPI committee failed to maintain oversight, establish, and implement policies and procedures to ensure incidents of elopement were thoroughly investigated. Refer to F-610. The QAPI committee failed to maintain oversight, establish, and implement policies and procedures to ensure elopement incidents were prevented, identified, and thoroughly investigated. Refer to F-689. The facility failed to provide sufficient nursing staff to adequately supervise a vulnerable resident with severe cognition impairment, wandering and elopement behaviors, a positive COVID diagnosis from exiting the COVID Unit 3 different times, and then exited the facility unsupervised and without Personal Protective Equipment (PPE) in place. Refer to F725. The facility failed to ensure licensed nurses had the competencies and skill sets necessary to perform assessments and complete fall risk assessments for residents with impaired safety awareness. According to the investigation, Resident #5, who was positive for COVID-19 exited the COVID Unit barrier 3 times by unzipping the barrier, and then exited the facility unsupervised on 10/30/2022. Resident #5 was found by staff walking on the sidewalk into the parking lot, approximately 223 feet from the facility. Neither Resident #5, nor staff who interacted with him, were using Protective Personal Equipment (PPE), which had the potential to expose staff and other residents to COVID-19. The facility's failure to ensure staff had the competencies and skill sets necessary to ensure residents having immediate needs for psychiatric services, received such services in a timely manner. This failure resulted in actual harm when Resident #3, a vulnerable resident with diagnoses of Depression, Dementia and COVID-19, sustained a significant weight loss of 7.8 percent (%) in 1 month, after having suicidal ideations and voiced that he wanted to die and would starve himself. Resident #3 was admitted and isolated in the COVID Unit on 8/9/2022. Resident #3 voiced to Social Services and his family of wanting to die and had suicidal ideations on 8/12/2022. Resident #3 refused medications and meals, resulting in significant weight loss in 1 month. The facility was unable to provide documentation for Social Service monitoring or follow-up. The facility's failed to ensure licensed nurses had the competencies and skill sets necessary to perform and complete admission assessments and fall risk assessments on admission for Resident #9 and Resident #2. Refer to F726. The QAPI committee failed to maintain oversight, failed to establish and implement policies and procedures to ensure effective social services to maintain the highest practicable physical, mental, and psychosocial well-being for residents were provided. The facility's QAPI Committee failed to identify the systemic issues of psych services referrals not being processed timely and the social services system failure to include documentation, visits, referrals and meeting the needs of residents with agitation and suicidal threats. Refer to F745. The QAPI Committee failed to maintain oversight, failed to establish and implement policies and procedures, failed to ensure Administration consistently followed policies and procedures, failed to provide oversight of nursing staff, failed to identify the root cause of concerns identified in the facility, and failed to ensure systems and processes were developed and consistently followed by facility staff. Refer to F835. The QAPI committee failed to maintain oversight, establish, and implement policies and procedures to ensure staff maintained appropriate transmission-based precautions for infectious diseases, and failed to ensure staff used proper PPE when caring for residents with known infectious COVID-19. The facility's QAPI Committee failed to identify, investigate, analyze and evaluate the incident of Resident #5 (a COVID positive resident) exiting the COVID Unit multiple times and having the potential to expose other residents and staff when the resident eloped. Refer to F-880. The surveyors verified the Removal through observations, review of audits, meeting minutes, and staff interviews as follows: 1. All employees including QAPI team members were in-serviced on 11/11/2022 on how to properly identify residents who were wanderers/exit-seekers and elopement risk along with review on wanderers, exit-seekers and residents at risk for elopement, incidents and accidents, and thorough investigation and reporting. The Administrator/DON/ADON were consulted on 11/17/2022 regarding incidents and accidents, adequate and through investigation and proper reporting to the proper agencies in a timely manner. All employees, including QAPI team members, were in-serviced on 11/11/2022 on who to report to if a resident was identified as going out of the facility unsupervised, and how and when to start an investigation. Administrator/DON/ADON to go over daily staffing the day before with the Staffing Coordinator (SDC), and each morning with the QAPI team members to ensure adequate and competent staff facility-wide, including the COVID Unit, based on acuity and census. Administrator/DON/ADON check staffing daily to ensure there is dedicated staff members on the COVID Unit to reduce the risk of exposure to other residents and staff for COVID 19. Administrator consulted DON/ADON/Social Services on prompt procedure regarding psychiatric referrals and residents being seen by psychiatric services in a timely manner. All non-emergent behavioral referrals and residents being seen by psychiatric services within the week and all emergency cases will be attended by Primary Care Provider (PCP). Psychiatric service providers will be notified via telephone regarding transfers to hospitals. 2. The DON in serviced ADON/SDC and Unit Managers on 12/01/2022 regarding completion of all new admissions, readmissions and any assessments that are warranted per resident change of condition. 3. The facility immediately reviewed policies and procedures with all staff regarding incidents and accidents, thorough investigation and reporting to proper authorities in a timely manner on 11/11/2022. DON/ADON put a monthly calendar in place to ensure that a Manager on Duty is in place including weekends and holidays. In the event that there is any change of condition or occurrences concerning any residents at the facility, it will be thoroughly investigated and reported timely. Administrator/DON/Unit managers review all occurrences, change of condition, and all assessments, including new admissions, readmissions and any assessments warranted by change of condition or occurrences in the morning QAPI meetings. DON/ADON/SW/UM will review all psychiatric referrals in the morning QAPI meetings to ensure all referrals are processed and residents are seen by psychiatric services in a timely manner. Any negative findings will be corrected or completed immediately and brought to the next morning QAPI meeting to ensure completion and accuracy of assessments. The facility's noncompliance of F-867 continues at a scope and severity of E for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, video surveillance review, observation, and interview the facility failed to maintain Contact Isolation with Droplet Precautions for 1 of 11 (Resident #5) Covid-positive residents reviewed for infection control. Resident #5 exited the COVID-19 isolation unit, attempted to exit the 500 hall door twice, was then placed at a nursing station outside of the COVID Unit by staff; Resident #5 was observed out of the COVID Unit walking on the 700 hall, and on the sidewalk outside the building without personal protective equipment (PPE). Three (3) of 3 staff members, (Certified Nursing Assistant (CNA) #1, Licensed Practical Nurse (LPN) #1 and #2) failed to wear PPE when providing care for Resident #5. The facility failure to contain COVID-19 and prevent exposure potentially affected other residents and staff on the 500 hall, 700 hall, and 800 hall. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator, the Interim Director of Nursing (DON) were notified of the Immediate Jeopardy on 11/22/2022 at 3:57 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-880. The facility was cited at F-880 at a scope and severity of J, which is Substandard Quality of Care. The Immediate Jeopardy existed from 10/30/2022 through 12/2/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 11/29/2022 at 11:16 AM, and was validated onsite by the surveyors on 11/30/2022 -12/2/2022 through observations, review of audits, meeting minutes, and staff interviews. The findings include: 1. Review of the facility's undated policy titled, Policies and Practices-Infection Control, revealed, .This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections .2. The objectives of our infection control policies and practices are to .Prevent, detect, investigate, and control infections in the facility . Review of the facility's undated policy titled, COVID-19 Management of Suspected or Confirmed Residents, revealed .Restrict residents with respiratory infections .to their rooms .If they leave the room, resident should be encouraged and assisted to wear a facemask . Review of the facility's undated policy titled DISCONTINUATION OF TRANSMISSION BASED PRECAUTION RELATED TO COVID -19, revealed .all residents tested positive .will be monitored closely to prevent spread of infection related to COVID-19 .PURPOSE: To protect all residents and staff and to keep all residents and staff away from contracting COVID-19 virus . Review of the facility's undated policy titled, .Personal Protective Equipment (PPE), revealed .To ensure that .PPE .is provided for all staff at the facility, including .facemasks, gloves, gowns, and eye protection .when interacting with COVID-19 suspected or confirmed residents .Prior to entering areas where residents are suspected or confirmed with COVID-19 .Education provided to staff on proper usage, procedure . Review of the facility's undated policy titled, .Contact Precautions, revealed .Transmission Based Precautions are designed for residents documented or suspected to be infected or colonized with highly transmissible or epidemiologically important pathogens for which additional precautions beyond stand precautions are needed to interrupt transmission . Review of the facility's undated policy titled .Personal Protective Equipment (PPE), revealed .Personnel will be trained on our infection control policies and practices caring for or encountering a COVID+ [positive] or COVID suspected or COVID unknown resident .FACE SHIELD OR GOGGLES .GLOVES .FIT-TESTED N95 RESPIRATOR .GOWN . 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses of Wernicke's Encephalopathy, Altered Mental Status, Alcohol Abuse, Adult Failure to Thrive, Cerebral Infarction, and Cognitive Social or Emotional Deficit following Cerebral Infarction. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #5 had severely impaired cognition for daily decision making. Review of the Care Plan dated 8/16/2022, revealed Resident #5 was at risk for elopement related to anxiety and sadness related to isolation precautions related to COVID-19. Review of a physician's order dated 10/28/2022, revealed Resident #5 had an order for contact isolation with droplet precautions related to a positive COVID test. Review of a Census Report dated 10/28/2022, revealed Resident #5's room was changed to the COVID Unit. Review of the facility's camera footage dated 10/30/2022 at 11:00 AM, revealed 2 staff members, LPN #1 and CNA #1, and Resident #5 standing in the hallway beside an exit door without full PPE. Review of a Progress Note dated 10/30/2022 at 11:33 AM, revealed .exit seeking x [times] 3 left COVID hall x 2 this am .on 700 hall x1 .on 500 hall door x 2 .found in .parking lot . Observation in the COVID Unit located on the 600 Hall on 11/7/2022 at 4:48 PM, revealed the Covid Unit had plastic barriers with zippers to provide Contact and Droplet Precaution isolation for COVID-positive residents. The barriers were located beginning at room [ROOM NUMBER] and ended at room [ROOM NUMBER] and at the exits to the 500 and 700 hall. During an interview on 11/8/2022 at 12:58 PM, Certified Nursing Assistant (CNA) #1 stated, .Resident #5 kept getting out of the COVID Unit .I had to assist to bring him back in .he was unzipping the plastic to go out of the unit, and I found him at the 500 hall exit door twice .I would go get him from the door and bring him back to the unit .once he got out and was found by a nurse walking around on the 700 hall .I don't know which way he got out of the unit that time, because I didn't see him .I did see him unzipping the barrier trying to get out . CNA #1 was asked if Resident #5 should have been out of the COVID Unit. She stated, .No, he should have stayed on the unit, but I couldn't keep my eyes on him. I had other residents . During an interview on 11/18/2022 at 1:04 PM, Licensed Practical Nurse (LPN) #1 stated, I was the nurse on the COVID Unit. He [Resident #5] had gotten out .found him out of the COVID Unit attempting to get out the exit door across from the DON's office on the 500 hall .we would take him back in the unit, and before you knew it, he was out again .we were doing our best to keep him on the unit .I sat him at the desk for a short time just to keep an eye on him .but I could not keep a watch on him. That's when I sat him at the desk, after he had gotten out of the Covid Unit .I probably shouldn't have .but I did . During an interview on 11/21/2022 at 3:00 PM, the Interim DON/Infection Control Preventionist stated, .we had an outbreak of COVID-19 after staff and a large number of residents tested positive on 10/21/22 .we were trying to maintain the unit with designated staff to work only in the COVID unit . She was asked if a COVID-positive resident should be out of the COVID Unit without PPE walking the halls. She stated, .absolutely not .he should have remained isolated . should not be outside of the COVID Unit wandering around in patient areas on different halls . She was asked if a COVID-positive resident should be sitting at the desk with staff outside the COVID Unit. She stated, .no .a COVID-positive resident on COVID isolation precautions should not have been at the nurses' station outside of the Covid Unit .There should have been designated staff in the Covid Unit and not taking care of other residents outside of the Covid Unit. She confirmed staff should be wearing full PPE when caring for a COVID-positive resident in the Covid Unit or in contact with a COVID-positive resident. During a telephone interview on 11/22/2022 at 3:15 PM, LPN #2 stated, .I was sitting at the desk, and I saw him [Resident #5] walking. He did not have a mask on. He was coming from the 700 hall .I gave him a mask and assisted him back to the COVID Unit .I was the nurse on the other side .don't know which way he came from .I knew he was supposed to be on the COVID Unit . Refer to F-689, F-609, F-610, F-726, F-725, F-835 and F-867. The surveyors verified the Allegation of Compliance (AoC) Removal Plan through record review, observations, audit reviews, review of education and sign-in sheets, and interviews for the immediate corrective actions listed below: 1. Resident #5, who was wandering out of Covid Unit, had completed his quarantine period as per facility protocol and discharged from the COVID Unit on 11/9/2022 with no signs and symptoms of COVID-19. Resident #5, who wandered outside the COVID Unit unsupervised was monitored closely for signs and symptoms of COVID and none reported. The surveyors verified on site by interview with the DON and Administrator 2. As of 11/23/2022, the facility had no Covid positive residents residing in the Covid Unit. All residents completed required quarantine period and were discharged out of Covid Unit. No new residents tested positive for Covid-19 and required isolation. This was validated onsite by surveyors through observation and census review. 3. If any residents test positive in the future, the Administrator/DON will review census and clinical acuity and staff accordingly. The Administrator/DON will monitor staffing for the COVID Unit daily to ensure adequate staffing on the COVID Unit. Clinical acuity and the COVID Unit census will be reviewed by the Administrator/Don daily and staffed accordingly as follows: 1-5 residents minimum 1 nurse, 6-10 residents minimum 1 nurse and 1 CNA, 11-20 residents minimum 1 nurse and 2 CNA'S. Nurses/CNAs will ensure that all residents residing on the COVID Unit will follow the facility's protocol on PPE usage. The facility initiated every-30-minute checks on all residents at risk for elopement/wandering. This was validated onsite by surveyors through review of the COVID Unit census with the staffing assignment sheets, observation, and interviews. 4. The facility will ensure that adequate supervision for the residents including wandering residents residing on the COVID Unit are monitored closely by Nurses/CNAs designated to the COVID Unit to reduce the risk of exposure to COVID outside of the COVID Unit. Staff will monitor by every-30-minute checks on all residents at risk for elopement/wandering risk residents. Nursing staff will be in-serviced on additional infection control and transmission-based precautions by staff educator with a completion date of 11/23/2022. This was validated onsite by surveyors through review of COVID Unit census with staffing assignment sheets, review of in-service sign-in sheets, observation, and interviews. 5. The facility will ensure residents with active wandering behaviors residing on the COVID Unit are monitored and transmission-based precautions are maintained to ensure residents and staff are not exposed. Nurses/CNAs will ensure that all residents residing on the COVID Unit will follow the facility's protocol on PPE usage. The Administrator/DON will monitor staffing for the COVID Unit daily to ensure adequate staffing on the COVID Unit to reduce the risk for active wandering residents leaving the COVID Unit unsupervised. This was validated by review of the COVID Unit census with staffing assignment sheets, review of in-service sign-in sheets, observation, and interviews conducted with facility staff, agency staff, DON, Staffing Coordinator and Administrator. The facility's noncompliance of F-880 continues at a scope and severity of E for monitoring of the effectiveness of the corrective actions. The facility is required to submit a plan of correction.