**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to notify the physician when a resident experienced ant bites and pain for 1 (Resident #21) of 5 residents reviewed for a notification of a change of condition, in that: RN II did not notify the Physician of Resident #21's change of condition on 08/13/24 when CNA R reported that Resident #21 had indicated experiencing pain to the anterior area of her right elbow to RN II concerns that Resident #21 had suffered ant bites that had resulted in welts on Resident #21's right arm. An Immediate Jeopardy was (IJ) was identified on 08/14/24 at 5:53 PM while the IJ was removed on 08/16/24, the facility remained out of compliance at a severity of No actual harm with a potential for more than minimal harm that is not immediate and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. This deficient practice could place residents at risks of not obtaining the care that was needed, which could lead to a worsening of their condition, hospitalization, or death. Findings Included: Record review of Resident #21's Face Sheet, dated 08/14/2024, revealed a [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #21 had a diagnoses which included the following: Aphasia (cannot speak), Hemiplegia (paralyzed on one side) and Hemiparesis (weakness on one side of the body) following Cerebral Infarction (Stroke) affecting Right Dominant side, Type 2 Diabetes Mellitus (Too much sugar), and Cerebral Infarction due to Thrombosis (blood clots) of Unspecified Cerebral Artery. (Family member #1 was listed as the Responsible Party/POA.) Record review Resident #21's Quarterly MDS Assessment, dated 05/22/24, revealed the resident was rarely/never understood and was cognitively severely impaired. Resident #21 required total or extensive assistance for bed mobility, dressing, toilet use, and personal hygiene. Further review of Resident #21's MDS reflected that Resident #21 was always incontinent of urine and bowel. Record review of Resident #21's Care Plan initiated on 02/22/2022 reflected Resident #21 had an Activities of Daily Living self-care deficit, and the interventions included that Resident #21 required limited-extensive assist to turn and reposition in bed and as necessary. Resident #21 required supervision to eat. Resident #21 required 2 staff for personal hygiene and oral care. The Care Plan reflected that Resident #21 had impaired cognitive function/dementia or impaired thought processes with interventions that included communicating with family family/caregivers regarding her capabilities and needs and to monitor/document/report PRN any changes in cognitive function, specifically changes in: decision making ability, memory, level of consciousness, mental status. The Care Plan reflected that Resident #21 had a communication problem related to Cerebral Vascular Accident. Resident #21 was Aphasic (inability to communicate). Resident #21 smiles when approached and could head/nod to yes and no questions and the interventions included encouraging Resident #21 to continue stating thoughts even if resident is having difficulty and to monitor/document/report as needed any changes in ability to communicate, potential contributing factors for communication problems. The Care Plan reflected that Resident #21 had Diabetes Mellitus and was taking medications per Medical Doctors orders, with interventions that included checking all of body for breaks in skin and treat promptly as ordered by doctor. The Care Plan reflected that Resident #21 had hemiplegia/hemiparesis (paralyzation of one side of the body), with interventions that included discuss with Resident #21's family/caregivers any concerns, fears, issues regarding diagnosis or treatments. Record review of Resident #21's electronic health record revealed that there were no progress notes, skin assessments, treatment for ant bites, follow up treatments, assessments, or record of notifying Resident #21's family or physician in relation to Resident #21 having to temporarily move rooms due to an ant infestation and ant bites. No Situation, Background, Assessment Recommendation Communication Report could be found in relation to Resident #21 being bit by ants, assessment, post treatment or room movement. An interview on 08/12/24 at 1:23 PM with Family Member #1 revealed on 07/14/24 Resident #21 was not in her regular room. CNA R explained on 07/14/24 Resident #21 had been moved to another room because ants and ant bites that were discovered on Resident #21. The family member stated were not notified of the ants or the room move before the family member had asked about it. An interview on 08/12/24 at 1:56 PM CNA R stated that Resident #21 was non-verbal, and that CNA R had worked with Resident #21 for a long time and was familiar with how to communicate with Resident #21 with yes/no questions and pointing. CNA R stated that while delivering Resident #21's breakfast tray, Resident #21 indicated she had pain in her right arm. CNA R stated she reported to RN ii that Resident #21 had indicated pain in her arm around 7:40AM on 07/13/24 and then continued with her morning duties. CNA R stated that when she returned to Resident #21's room around 8:20 AM, she was unsure if RN II had assessed Resident #21 yet. CNA R stated she had discovered ants on Resident #21 on the morning of 7/13/24 around 8:20 AM, while getting Resident #21 ready for a bed bath. CNA R stated that there had been between 20 to 30 small black ants in the crook of Resident #21's arm that Resident #21 had indicated to before. CNA R stated that she immediately reacted and used the gathered bed bath equipment to immediately wipe off Resident #21's arm. CNA R stated that the area on Resident #21's arm where the ants had been present had been welty and red. CNA R stated she then informed RN ii about the ants and then took Resident #21 to a shower where CNA R made sure there were no more ants on Resident #21. CNA R stated that Resident #21 was then temporarily moved to another room from the 100 hall to the 300 hall. CNA R stated that the welts on Resident #21's arm were much less noticeable after the shower and move. CNA R stated that housekeeping had cleaned out Resident #21's room and that Resident #21 had been moved back to Resident #21's original room on 07/16/24 on the 100 hall from the temporary room on the 300 hall. An interview on 08/13/24 at 1:54 PM RN II stated that she did not remember if she had written any progress notes about the ants on Resident #21 or if she had contacted the ADON face to face or had contacted the ADON via phone. RN II stated she had not contacted the MD or Resident #21's family member/Power of Attorney about the ants or the room move. An interview on 08/13/24 ADON stated that there were no messages about Resident #21 moving rooms or being bitten by ants. The ADON stated that the facility uses a phone messaging app to make sure that all nursing staff are informed of developments with residents and that information is passed. The ADON stated that if there was no evidence of any message being passed and that she had not been informed that it would have been up to RN II to contact the MD and the family of Resident #21. The ADON stated that she could find no evidence of an initial assessment, after treatment for ant bites notification of any room movements, notifications or new orders from the MD or skin assessments. The ADON stated that she was not on the schedule on 07/13/24 and that the facility did not have a DON from 07/07/24 to 07/22/24. In an interview on 08/14/24 at 10:03 AM the DON stated that she had started employment at the facility on 07/22/24 and that she had not known about Resident #21 had been bitten by ants, but that it should have been reported to head nursing staff so that Resident #21 could have been properly assessed and treated for ant bites, the MD should have been notified and the family should have been notified and they had not been informed. The DON stated that there could have been medical complications or undue pain caused to Resident #21 by not being properly treated for ant bites. In an interview on 08/14/24 at 11:33 AM The MD stated that he was not informed that Resident #21 had suffered ant bites or had moved rooms. The MD stated that he could find no evidence that Resident #21 had been issued any new orders for topical ointments for ant bites or evidence of any assessment or post assessments of Resident #21 related to ant bites. The MD stated that it was important that he should have been informed about the ant bites on Resident #21 because of the risk of complications depending on Resident #21's morbidities and that Resident #21 may have missed care that Resident #21 might have needed. A record review of the facility's policy titled Change of Condition and Physician/Family Notification, dated January 2023, reflected Purpose: To ensure that resident's family and/or legal representative and physician are notified of resident changes that fall under the following categories: . A significant change in resident's physical, mental, or psychosocial status. (See below for examples). A need to significantly alter treatment. Transfer of the resident from the facility. Procedures: When any of the above situations exist, the licensed nurse will contact the resident's family and their physician . Each attempt will be charged as to time the call was made, who was spoken to, and what information was given to the physician . This failure resulted in an identification of an Immediate Jeopardy on 08/14/2024 at 5:53 PM. The Administrator was informed and provided the IJ template on 08/14/2024 at 5:55 PM and a Plan of Removal (POR) was requested. The Plan of Removal reflected: Per the information provided in the IJ template given on 8/14/24, the facility failed to take proper action in notification of resident change of condition. Facility failed to further notify executive administration, and/or resident family member. Per template, on 07/13/24, CNA discovered ants on resident with noticeable welts on resident right arm. CNA notified charge nurse, who advised to bathe and relocate resident to different room. Charge nurse failed to take further action in obtaining order for medical treatment, and notification of resident change to physician, administration, and family. The MD, was notified of IJ on 8/14/24 at 06:00p.m. DON and ADON initiated In-service with nursing staff (CNA, CMA, LVN, RN) 8/14/24 on identifying when to conduct assessment on residents and where to document assessments. This in-service will be completed by 8.15.24. DON and ADON initiated in-service with nursing staff (CNA, CMA, LVN, RN) on 8/14/24 regarding when to provide treatment and/or care to residents. This in-service will be completed by 8.15.24. DON and ADON initiated in-service with nursing staff on 8/14/24 (CNA, CMA, LVN, RN) regarding when to communicate with nursing supervisor, administrative team, physician, and family. This in-service will be completed by 8.15.24. This in-service will be completed by 8.15.24. ADON initiated in-service when nursing staff (CNA, CMA, LVN, RN) on 8/14/24 regarding when to report significant changes in resident's condition. This in-service will be completed by 8.15.24. In-service initiated with all staff (Facility Wide) on 8/14/24 regarding notification of observed pest(s) by ADON or ADM. This in-service will be completed by 8.15.24. Each department to provide in-service to every employee, prior to working next assigned shift. To be completed by 8.15.24. If staff member(s) are present for in-person training, training will be conducted by appropriate department head (Director of Culinary Services. Director of Environmental Services. ADON and DON. Director of Rehab. ADM for monitoring of Department Heads). To be completed by 8.15.24. If staff member(s) unavailable for in-person training, phone call will be performed as witnessed phone call with ADM and DON. Phone call dialogue will provide pre-test to employee, followed by in- service education, finishing with post-call test. To be completed by 8.15.24. If staff member(s) do not answer/return phone call, notification will be given to scheduling manager (ADON. Director of Culinary Services. Director of Environmental Services. Director of Rehab. ADM department head monitoring), to place hold on staff member shift availability until complete. Monitoring of understanding by clinical staff to be performed by DON. Monitoring to include daily review of 24-hr log with follow-up of employee to ensure notification appropriately made. Monitoring will also include educational pre/post-test to be administered by 8.15.24. Pre/Post Test with correlating policy will also be added to new-hire packet. ADM to monitor compliance of DON. Skin assessments, performed by ADON, and [NAME] President of Clinical Services, completed on every resident, to be completed by 8/15/24. Results to be submitted upon completion. Environmental sweep of hallways, resident rooms, and exterior perimeter performed by Director of Environmental Services, on 8/14/24 with no findings of pest(s). Director of Environmental Services will monitor pest control by daily review of pest binder. Pest Control scheduled twice per month with 3rd party source and PRN for sightings. ADM to monitor compliance of Director of Environmental Services. Summary of IJ and corrective action to be reviewed by QAPI committee weekly x4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Monitoring of the Plan of Removal included: Interviews were conducted on 08/15/24 at 9:18 AM to 08/16/24 at 1:23 PM with 4 RN's, 10 LVN's, 4 MA's, 18 CNA's, 2 Dietary Cooks, 2 HSK's, the ADM, ADON, SW, Director of Environmental Services, Director of Rehab, and Director of Culinary Services, who worked multiple shifts, revealed that they had all been in-serviced on Conducting and Reporting Assessments, Providing Treatment and/or Care to Residents, Communicating with Nursing Supervisor, Administrative Team, Physician and Family, Reporting significant Changes in resident Condition, and Notification of Observed Pest(s). The staff were able to identify examples on who, when, and where to report Assessments, Changes in Condition and Pest(s) sightings. Interviewed staff were knowledgeable on protocols and who they needed to report too. The staff reported verifying their competencies via a pre and post quiz. An interview on 08/16/24 at 11:40 AM [NAME] President of Clinical Services stated that the ADM and DON were in-serviced on all in-service topics and [NAME] president of Clinical Services stated their competency was verified via quizzes. The [NAME] president of Clinical Services stated for the next 30 days [NAME] president of Clinical Services and DON would be monitoring, and stated if they identified any changes, they would contact the MD and family/POA immediately. A record review of in-services titled Conducting and Reporting Assessments, Providing Treatment and/or Care to Residents, Communicating with Nursing Supervisor, Administrative Team, Physician and Family, Reporting significant Changes in resident Condition, and Notification of Observed Pest(s), conducted by the ADM, DON, Director of Rehab, Director of Environmental services and the Director of Culinary services, reflected that all staff were educated on policy and procedures including assessments and notification to MD and Nurse Practitioners regarding change of condition. All Nursing staff were in-serviced and educated on policy and procedures regarding providing treatment and/or care to residents. The ADM and DON were informed the Immediate Jeopardy was removed on 08/16/24 at 1:35 PM. The facility remained out of compliance at a severity of No actual harm with a potential for more than minimal harm that is not immediate and a scope of isolated due to the facility still monitoring the effectiveness of their corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 4 residents (Resident #1) reviewed for quality of care. 1) The facility nurses failed to assess, treat, or monitor ant bites and pain for Resident #21 or seek treatment instructions from the physician. An Immediate Jeopardy was (IJ) was identified on 08/14/24 at 5:53 PM while the IJ was removed on 08/16/24, the facility remained out of compliance at a severity of No actual harm with a potential for more than minimal harm that is not immediate and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. This deficient practice could place residents at risks of not obtaining the care that was needed, which could lead to a worsening of their condition, hospitalization, or death. Findings Included: Record review of Resident #21's Face Sheet, dated 08/14/2024, revealed a [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #21 had a diagnoses which included the following: Aphasia (cannot speak), Hemiplegia (paralyzed on one side) and Hemiparesis (weakness on one side of the body) following Cerebral Infarction (stroke) affecting Right Dominant side, Type 2 Diabetes Mellitus (to much sugar), and Cerebral Infarction due to Thrombosis (blood clots) of Unspecified Cerebral Artery. (Family member #1 was listed as the responsible party/POA.) Record review Resident #21's Quarterly MDS Assessment, dated 05/22/24, revealed the resident was rarely/never understood and was cognitively severely impaired. Resident #21 required total or extensive assistance for bed mobility, dressing, toilet use, and personal hygiene. Further review of Resident #21's MDS reflected that Resident #21 was always incontinent of urine and bowel. Record review of Resident #21's Care Plan initiated on 02/22/2022 reflected Resident #21 had an Activities of Daily Living self-care deficit, and the interventions included that Resident #21 required limited-extensive assist to turn and reposition in bed and as necessary. Resident #21 required supervision to eat. Resident #21 required 2 staff for personal hygiene and oral care. The Care Plan reflected that Resident #21 had impaired cognitive function/dementia or impaired thought processes with interventions that included communicating with family family/caregivers regarding her capabilities and needs and to monitor/document/report PRN any changes in cognitive function, specifically changes in: decision making ability, memory, level of consciousness, mental status. The Care Plan reflected that Resident #21 had a communication problem related to Cerebral Vascular Accident. Resident #21 was Aphasic (inability to communicate). Resident #21 smiles when approached and could head/nod to yes and no questions and the interventions included encouraging Resident #21 to continue stating thoughts even if resident is having difficulty and to monitor/document/report as needed any changes in ability to communicate, potential contributing factors for communication problems. The Care Plan reflected that Resident #21 had Diabetes Mellitus and was taking medications per Medical Doctors orders, with interventions that included checking all of body for breaks in skin and treat promptly as ordered by doctor. The Care Plan reflected that Resident #21 had hemiplegia/hemiparesis (paralyzation of one side of the body), with interventions that included discuss with Resident #21's family/caregivers any concerns, fears, issues regarding diagnosis or treatments. An interview on 08/12/24 at 1:23 PM with Family Member #1 revealed on 07/14/24 Resident #21 was not in her regular room. CNA R explained on 07/14/24 Resident #21 had been moved to another room because ants and ant bites that were discovered on Resident #21. The family member stated were not notified of the ants or the room move before the family member had asked about it. In an interview on 08/12/24 at 1:56 PM CNA R stated that they had discovered ants on Resident #21 on the morning of 07/13/24 while getting Resident #21 ready for a bed bath. CNA R stated that there had been between 20 to 30 small black ants in the crook of Resident #21's right arm in the anterior of the right elbow. CNA R stated she immediately reacted and used the gathered bed bath equipment to immediately wipe off Resident #21's arm. CNA R stated that the area on Resident #21's arm where the ants had been present had been welty and red. CNA R stated she did not see an ant trail leading to the bed, she then informed RN II about the ants and then took Resident #21 to a shower where she (CNA R) made sure there were no more ants on Resident #21. CNA R stated that Resident #21 was then temporarily moved to another room from the 100 hall to the 300 hall. CNA R stated that the welts on Resident #21's arm were much less noticeable after the shower and move. CNA R stated that housekeeping had cleaned out Resident #21's room and that Resident#21 had been moved back to Resident #21's original room on 07/16/24 on the 100 hall from the temporary room on the 300 hall. In an interview on 08/13/24 at 1:54 PM RN II stated that there had been no DON working on 07/13/24 but that RN II had told the ADON about the ants on Resident #21 and she had been told to move Resident #21 to another room and she had done a skin assessment and found no ant bites on Resident #21. She stated that she was unsure if she notated the skin assessment anywhere. RN II stated she assumed that the ADON had informed the DON about the ants on Resident # 21. RN II stated they did not remember if she had written any progress notes about the ants on Resident #21 or if she had contacted the ADON face to face or had contacted the ADON via phone. In an interview on 08/13/24 at 2:07 PM the ADON stated that there were no messages about Resident #21 moving rooms or being bitten by ants. The ADON stated that the facility used a phone messaging app to make sure that all nursing staff were informed of developments with residents and that information was passed. The ADON stated that if there was no evidence of any message being passed and that she had not been informed that it would have been up to RN II to contact the MD and the family of Resident #21. The ADON stated that she could find no evidence of an initial assessment, after treatment for ant bites notification of any room movements, notifications or new orders from the MD or skin assessments. The ADON stated she was not on the schedule on 07/13/24 and that the facility did not have a DON from 07/07/24 to 07/22/24. Record review of the facility pest sighting log of the last 6 months revealed that ants were sighted in Resident #21's room on 07/15/24 and treated by the pest control on 07/25/24. Record review of the facility's Incident Accident log dated 06/01/24 to 08/12/24 revealed that there were no incidents listed regarding any resident being bitten by ants or having to move rooms. Record review of Resident #21's progress notes from 06/01/24 to 08/12/24 revealed that there were no notes regarding Resident #21 having been bit by ants or having been discovered with ants on Resident #21's body. No notes were discovered that indicated that Resident #21's MD or Resident #21's family members had been notified that Resident #21 had been bitten by ants or that Resident #21 had received any post treatment for ant bites or pain resulting from ant bites. In an interview on 08/14/24 at 9:57 AM the ADM stated she had never been told that Resident #21 had been bitten by ants until the investigator informed her on 08/13/24. The ADM stated that Resident #21's family member had spoken to her on 07/14/24 about Resident #21 being moved to another room but that Resident #21's family member had not mentioned ants or ant bites. In an interview on 08/14/24 at 10:03 AM the DON stated she had started employment at the facility on 07/22/24 and she had not known about Resident #21 being bitten by ants, but that it should have been reported to head nursing staff so that Resident #21 could have been properly assessed and treated for ant bites; the MD should have been notified and the family should have been notified and they had not been informed. The DON stated that there could have been medical complications or undue pain caused to Resident #21 by not being properly treated for ant bites. In an interview on 08/14/24 at 11:33 AM the MD stated he had been unaware that Resident #21 had suffered ant bites or had moved rooms. The MD stated that he could find no evidence that Resident #21 had been issued any new orders for topical ointments for ant bites or evidence of any assessment or post assessments of Resident #21 related to ant bites. The MD stated that it was important he be informed about the ant bites on Resident #21 because of the risk of complications depending on Resident #21's morbidities and that Resident #21 may have missed care that Resident #21 might have needed. In an interview on 08/14/2024 at 2:32 PM Resident #21 was observed supine. Resident #21 indicated through hand gestures that she was fine. Resident #21 indicated through nodding her head that she had been bitten by ants on her right arm and indicated through nodding her head that the ant bites had caused her pain. In an interview on 08/14/24 at 4:25 PM the Director of Environmental Services stated that Pest control came to the facility twice a month and could be called in for extra visits. Director of Environmental services stated she did external rounds of the building to direct pest control services to active ant mounds near the building and that all staff were directed to note any insects in the facility in the pest sighting log. The Director of Environmental services stated that there had been no reports made that any residents had been bitten by ants and that staff cleaned rooms every day to make sure that pests like ants were not attracted to resident rooms. A record review of the facility's policy titled Change of Condition and Physician/Family Notification, dated January 2023, reflected Purpose: To ensure that resident's family and/or legal representative and physician are notified of resident changes that fall under the following categories: . A significant change in resident's physical, mental, or psychosocial status. (See below for examples). A need to significantly alter treatment. Transfer of the resident from the facility. Procedures: When any of the above situations exist, the licensed nurse will contact the resident's family and their physician . Each attempt will be charged as to time the call was made, who was spoken to, and what information was given to the physician .Prior to notifying the physician or health care provider, the nurse will make detailed observations and gather relevant and pertinent information to the provider, including (for example information prompted by the Situation, Background, Assessment Recommendation Communication Form . A record review of the facility's policy titled Requesting, Refusing and/or Discontinuing Care or Treatment, dated May 2017, reflected .Treatment is defined as services provided for purposes of maintaining/restoring health, improving functional level, or relieving symptoms . This failure resulted in an identification of an Immediate Jeopardy on 08/14/2024 at 5:53 PM. The Administrator was informed and provided the IJ template on 08/14/2024 at 5:55 PM and a Plan of Removal (POR) was requested. The Plan of Removal reflected: Per the information provided in the IJ template given on 8/14/24, the facility failed to take proper action in notification of resident change of condition. Facility failed to further notify executive administration, and/or resident family member. Per template, on 07/13/24, the CNA discovered ants on a resident with noticeable welts on the resident right arm. The CNA notified the charge nurse, who advised to bathe and relocate the resident to different room. The charge nurse failed to take further action in obtaining orders for medical treatment, and notification of a resident change to the physician, administration, and family. The MD, was notified of IJ on 8/14/24 at 06:00p.m. The DON and ADON initiated an in-service with nursing staff (CNA, CMA, LVN, RN) 8/14/24 on identifying when to conduct assessment on residents and where to document assessments. This in-service will be completed by 8.15.24. The DON and ADON initiated an in-service with nursing staff (CNA, CMA, LVN, RN) on 8/14/24 regarding when to provide treatment and/or care to residents. This in-service will be completed by 8.15.24. The DON and ADON initiated in-service with nursing staff on 8/14/24 (CNA, CMA, LVN, RN) regarding when to communicate with nursing supervisor, administrative team, physician, and family. This in-service will be completed by 8.15.24. This in-service will be completed by 8.15.24. The ADON initiated in-service when nursing staff (CNA, CMA, LVN, RN) on 8/14/24 regarding when to report significant changes in resident's condition. This in-service will be completed by 8.15.24. In-service initiated with all staff (Facility Wide) on 8/14/24 regarding notification of observed pest(s) by the ADON or ADM. This in-service will be completed by 8.15.24. Each department to provide in-services to every employee, prior to working next assigned shift. To be completed by 8.15.24. If staff member(s) are present for in-person training, training will be conducted by appropriate department head (The Director of Culinary Services. The Director of Environmental Services. The ADON and DON. The Director of Rehab. The ADM for monitoring of Department Heads). To be completed by 8.15.24. If staff member(s) are unavailable for in-person training, phone call will be performed as witnessed phone call with the ADM and DON. Phone call dialogue will provide a pre-test to employee, followed by in- service education, finishing with a post-call test. To be completed by 8.15.24. If staff member(s) do not answer/return phone call, notification will be given to scheduling manager (The ADON. The Director of Culinary Services. The Director of Environmental Services. The Director of Rehab. The ADM department head monitoring), to place hold on staff member shift availability until complete. Monitoring of understanding by clinical staff to be performed by the DON. Monitoring to include daily review of the 24-hr log with follow-up of the employee to ensure notification appropriately made. Monitoring will also include educational pre/post-test to be administered by 8.15.24. Pre/Post Tests with correlating policy will also be added to new-hire packet. The ADM to monitor compliance of DON. Skin assessments performed by the ADON, and [NAME] President of Clinical Services, completed on every resident, to be completed by 8/15/24. Results to be submitted upon completion. Environmental sweep of hallways, resident rooms, and exterior perimeter performed by the Director of Environmental Services, on 8/14/24 with no findings of pest(s). The Director of Environmental Services will monitor pest control by daily review of pest binder. Pest Control scheduled twice per month with 3rd party source and PRN for sightings. The ADM to monitor compliance of Director of Environmental Services. Summary of the IJ and corrective action to be reviewed by QAPI committee weekly x4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. Monitoring of the Plan of Removal included: A record review of in-services dated 8/14/2024, titled Conducting and Reporting Assessments, Providing Treatment and/or Care to Residents, Communicating with Nursing Supervisor, Administrative Team, Physician and Family, Reporting significant Changes in resident Condition, and Notification of Observed Pest(s), conducted by the ADM, DON, Director of Rehab, Director of Environmental services and the Director of Culinary services, reflected that all staff were educated on policy and procedures including assessments and notification to MD and Nurse Practitioners regarding change of condition. All Nursing staff were in-serviced and educated on policy and procedures regarding providing treatment and/or care to residents. Interviews were conducted on 08/15/24 at 9:18 AM to 08/16/24 at 1:23 PM with 4 RNs , 10 LVNs, 4 MAs, 18 CNAs, 2 Dietary Cooks, 2 HSKs, the ADM, ADON, SW, Director of Environmental Services, Director of Rehab, and Director of Culinary Services, who worked multiple shifts, revealed that they had all been in-serviced on Conducting and Reporting Assessments, Providing Treatment and/or Care to Residents, Communicating with Nursing Supervisor, Administrative Team, Physician and Family, Reporting significant Changes in resident Condition, and Notification of Observed Pest(s). The staff were able to identify examples on who, when, and where to report Assessments, Changes in Condition and Pest(s) sightings. Interviewed staff were knowledgeable on protocols and who they needed to report too. The staff reported verifying their competencies via a pre and post quiz. In an interview on 08/16/24 at 11:40 AM the [NAME] President of Clinical Services stated that the ADM and DON were in-serviced on all in-service topics and they stated their competency was verified via quizzes. The [NAME] president of Clinical Services stated for the next 30 days they and the DON would be monitoring, and stated if they identified any changes, they would contact the MD and family/POA immediately. The ADM and DON were informed the Immediate Jeopardy was removed on 08/16/24 at 1:35 PM. The facility remained out of compliance at a severity of No actual harm with a potential for more than minimal harm that is not immediate and a scope of isolated due to the facility still monitoring the effectiveness of their corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure a resident with urinary incontinence, based on the resident's comprehensive assessment, who enters the facility with an indwelling catheter received appropriate treatment and services for 1 (Resident #1) of six residents reviewed for quality of care, in that: LVN A, DON, and ADON failed to follow-up with physician after leaking was reported to the suprapubic catheter on 06/16/24 until 06/29/24 when surveyor intervened. An Immediate Jeopardy (IJ) was identified on 06/30/24. The IJ template was provided to the facility on [DATE] at 4:30 PM. While the IJ was removed on 07/01/24, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. This deficient practice placed residents at high risk of, or the likelihood of, serious injury or harm by not receiving treatment, developing complications such as injury to the urinary tract, and the development of sepsis. Findings included: Record review of Resident #1's admission Record revealed a [AGE] year-old male, who admitted to the facility on [DATE] with the following diagnoses: Hemiplegia (refers to complete paralysis), affecting right dominant side; CKD, stage 2 (mild); retention of urine (a condition in which you are unable to empty all the urine from your bladder); and Down Syndrome. Record review of Resident #1's Annual MDS assessment, dated 05/08/24, revealed a BIMS score of 12 which suggested Resident #1 had a moderate cognitive decline. Resident #1's functional status required one-person substantial/maximal assistance with ADLs. Resident #1 was always incontinent of bowel and had a suprapubic indwelling catheter (a flexible tube inserted into the bladder, through a cut in the abdomen, and remains in place for continuous drainage of urine into a drainage bag). Resident #1's clinical physician orders reflected on the June 2024 Nurse Treatment Administration Record (nTAR) that each order was being performed as ordered: - Order date - 05/05/23: Catheter care with soap and water every shift and as needed. Every shift. - Order date - 09/23/23: Suprapubic output every shift. - Order date - 03/04/24: Change Suprapubic catheter with 16F (size of tubing) catheter with 10 cc balloon every 4 weeks along side with bed side bag. Every night shift every 4 weeks on Sunday. - Order date - 06/10/24: Clean and change dressing at catheter insertion site in the morning [04:00 AM - 06:00 AM] - Order date - 06/16/24: Barrier cream to Suprapubic catheter PRN every 6 hours as needed for skin irritation of skin every 6 hours as needed for skin irritation. [Discontinued 06/16/24] The orders to flush urinary catheter with 30 cc normal saline as needed to maintain patency every 8 hours as needed to keep catheter patent [order date: 05/09/23 - discontinued] did not reflect on the June 2024 nTAR. Record review of the Order Summary Report reflected an order written, 05/09/24, to Flush urinary catheter with 30 cc normal saline as needed to maintain patency. Every 8 hours as needed to keep catheter patent. The order status was discontinued. Review of Resident #1's progress notes indicated: - Nurse's Note Effective Date: 06/16/24 at 6:32 PM, LVN A entered, SEE SBAR FOR SUPRAPUBIC CATH - Nurse's Note Effective Date: 06/29/24 at 4:25 PM, the DON entered, just spoke with [family member] . requesting resident go to [2 hospital choices] . EMT present. - Nurse's Note Effective Date: 06/29/24 at 11:33 PM, LVN D entered, [Resident #1] return back to facility . suprapubic [SPC] replaced, no leakage noted . new order for cefdinir 300 mg capsule (antibiotic) for infection. Record review of SBAR documentation reflected LVN A notified the PCP on 06/16/24 at 6:19 PM that Resident's #1 SPC was not draining, brief was soaked with urine, and [LVN A] recommendation was for Resident #1 to see Urologist. No new orders. A review of Resident #1's hospital medical records dated 06/29/24 reflected [Resident #1] arrived at the ER on [DATE] at 5:10 PM. Review of the interpretation of the urinalysis collected 06/29/24 at 6:07 PM indicated Resident #1 had a urine infection. Resident #1's suprapubic catheter was changed in the ER and Resident #1 was discharged back to the facility with a prescription for an antibiotic to be administered for 7 days. During an observation and interview on 06/29/24 at 10:10 AM, accompanied by CNA B, Resident #1 was observed in bed. [Catheter] Tubing dangled loosely from the right side of bed, attached to drainage bag. A cloudy yellow haze with white specks settled in the loop of the tubing and a scant amount of yellow cloudy urine was in the drainage bag. CNA B assisted by pulling back the covers to show the Suprapubic catheter (SPC) insert site at the lower abdomen above the pubic area. There was a 4x4 gauze placed over the site with one piece of paper tape horizontally placed across the top of the gauze, initialed and dated. The gauze flapped up and down as the covers were pulled back. There was leakage around the SPC insert site. CNA B detached the tape that secured the brief and pulled back between Resident #1's legs. The brief flopped down on the bed from the weight of the urine that filled the brief. The inner lining of the brief appeared squishy with yellow fluffy material that absorbed urine and had a strong odor. Resident #1 's pubic area was distended that indicated fullness from urine retention. There was a stat lock placed on Resident #1's right upper thigh to keep the catheter tubing from being pulled that appeared dirty and was pulled away from the skin. Resident #1 denied pain at the site but could not hold a meaningful interview due to his impaired cognition. During an interview on 06/29/24 at 10:38 AM, CNA B said she was familiar with Resident #1's care needs. CNA B said that she reported to LVN A the past 2 weekends (June 15 and 16; June 22 and 23) that Resident #1's brief was filled with urine and none in the drainage bag. CNA B said that LVN A acknowledged and informed that she notified the PCP. CNA B said that she notified LVN A because a urine filled brief was not normally seen with residents who had [urine] catheters. CNA B said that it was her responsibility to prevent skin breakdown by making sure Resident #1 was maintained clean and dry. During an interview on 06/29/24 at 3:43 PM, the DON said that she was familiar with Resident #1 and indicated Resident #1 recently had his [SPC] catheter replaced on or about May 26, 2024, when Resident #1 was sent to the hospital due to leaking around the insert site. The DON was informed by the surveyor the observation findings (06/29/24 at 10:10 AM). The DON said she had not been informed by LVN A or reviewed in the 24-hour reports about any change of condition since then related to Resident #1's urinary catheter. The DON said that she expected nurses to notify the MD, ADON, DON and NFA of any resident change in condition, the cause of decline and how the cause was determined. The DON said that she would expect the nurse to report to the MD, signs and symptoms, interventions, effectiveness, and to document communication with the MD. The DON said that she would expect the nurse to follow up with the MD if she did not get a reply within thirty minutes and notify the oncoming nurse to follow up as needed. The DON said that the nurse should maintain awareness of the resident's condition to be able to recognize changes and be knowledgeable of nursing interventions. During an outbound call on 06/30/24 at 4:30 PM, the FMD indicated vaguely recalled being notified about Resident #1's SPC leaking. Notifications were sent via a group text phone app. The FMD recalled an order was given to replace the SPC with a larger tubing and the resident ended up being sent out to the hospital (this incident occurred the end of May 2024 and was not relevant to the incident that occurred on 06/16/24). During an interview and record review on 07/01/24 at 12:03 PM, the ADON said she was familiar with Resident #1. The ADON described Resident #1's care needs as one person assist with ADLs and had a SPC. The ADON said that the nurses performed catheter care per shift to assess for any issues, such as leaking or drainage around insert site, cracks in the tubing, urine output and characteristics. The ADON indicated that the CNA also checked the catheter during incontinent care for any concerns that should be reported to the nurse. The ADON said that it was the nurse's responsibility to ensure catheter care was provided during their shift and as needed. The ADON said that the assigned nurse must ensure proper catheter care and the catheter must remain patent. Patency was maintained by flushing the catheter with 30 cc normal saline. The ADON indicated that catheter flushing was part of urinary catheter care batch orders. The ADON described a change in condition as anything outside of what was normal for the resident, not eating or sleeping more than usual. The ADON said that the nurse should assess the resident to determine the cause of change in condition, immediately notify the MD, then document findings. The ADON said that the SNF used a secured messaging app to notify the MD about resident clinical status and send pictures if needed. The ADON said that she, the DON, and NFA were included on MD notifications via the messaging app. The ADON reviewed the messaging app and saw that there was a message on 06/16/24 about Resident #1's SPC leaking and urine-soaked brief, without a reply from the MD. The ADON said that her expectation was that every nurse be responsible for the assignment given and for nurses to inform leadership when they were busy and needed assistance. An outbound phone call to LVN A on 06/29/24 at 12:40 PM, 06/30/24 at 1:10 PM and 07/01/24 at 6:15 PM were unanswered. LVN A did not return the phone calls. An outbound phone call to speak with Resident #1's RP on 06/29/24 at 12:54 PM was not answered. Record review of the facility's Suprapubic Catheter Care policy, revised October 2010, reflected the purpose of the procedure was to prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract. General Guidelines reflected: Observe the resident's urine level for noticeable increases or decreases. Should the resident indicate that his or her bladder is full or needs to void, report immediately to your supervisor. Observe the resident for signs and symptoms of urinary tract infection and urinary retention. Report findings to your supervisor. Notify the physician of any abnormalities in the skin assessment or the character of urine. Report other information in accordance with facility policy and professional standards of practice. Record review of the facility's Change in a Resident's Condition or Status policy, revised May 2017, reflected the purpose to ensure resident's family and physician are notified of changes that fall under: - an accident resulting in injury that has the potential for needed physician interventions - a significant change (example given: Abnormal lab results) - a need to significantly alter treatment - transfer of the resident from the facility Record review of the facility's Acute Condition Changes - Clinical Protocol policy, reviewed December 2022, reflected assessment and recognition, cause identification, treatment/management, monitoring and follow-up: 1. During the initial assessment, the physician will help identify individuals with a significant risk for having acute changes of condition during their stay; for example, and individual with an indwelling urinary catheter who has had recurrent symptomatic UTIs, someone with unstable VS, or recurrent pneumonia. 2. In addition, the nurse shall assess and document/report the following baseline information: VS; neurological status; current level of pain, and any recent changes in pain level; LOC . 3. Direct care staff, including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the nurse. 6. Before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the Physician; for example, history of present illness and previous and recent test results for comparison. a. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident's current symptoms and status. b. Nurses are encouraged to use the SBAR Communication Form and Progress note as a tool to help gather and organize information before notifying the Physician. the purpose to ensure resident's family and physician are notified of changes that fall under: - an accident resulting in injury that has the potential for needed physician interventions - a significant change (example given: Abnormal lab results) - a need to significantly alter treatment - transfer of the resident from the facility The NFA was notified of an Immediate Jeopardy (IJ) on 06/30/24 at 4:30 PM, due to the above failures and the IJ template was provided. The facility's Plan of Removal (POR) was accepted on 07/01/24 at 1:54 PM and included: Per the information provided in the IJ template given on 6/30/24, the facility failed to ensure that all nursing staff had training on foley catheter care and prevention of UTI/CAUTI. Facility failed to ensure a resident with urinary incontinence based on the resident's comprehensive assessment who entered the facility with an indwelling catheter received appropriate treatment and services to prevent UTI. 1. The medical director was notified of IJ on 6/30/24 at 04:35p.m. 2. Review completed by DON of all residents with catheters in facility to assure appropriate monitoring and treatment orders are in place. 3. Chart audits initiated by the DON and ADON on 6/29/24 for all residents with catheters to ensure documentation was noted in the chart. 4. DON, ADON, and clinical leadership-initiated education with nurses and CNAs on monitoring catheters, catheter care, and UTI/CAUTI prevention. 5. Inservice training and education will include determining significant changes, reporting s/s of change in condition, and communicating with department heads and MD/NP changes in condition. 6. Clinical corporate leadership provided education to DON on 6/30/24. 7. All licensed nurses will start competency skills checkoffs on catheter care starting on 6/30/24. 8. All CNAs will complete competency on catheter care initiated on 6/30/24. 9. This training and competencies will be completed in-person with all staff prior to the start of their next shift. Staff will not be allowed to work until they have completed the training and competency skills checkoffs. This training will be included upon new hire orientation and for PRN staff. 10. A QAPI meeting will be held 7/1/24 regarding the items in the IJ template that will include the following attendees: Medical Director, DON, ADON, Executive Director, Clinical Resource, and additional IDT members. The QAPI meeting will include the plan of removal items and interventions. 11. All residents with catheters will be reviewed during the weekly clinical meetings and the medical director will be consulted for any recommendations or suggestions as necessary. Meeting attendees will include the DON, ADON, Rehab Director, MDS 12. Coordinator. The DON and Executive Director will be responsible for ensuring this meeting is held weekly and all residents with catheters are reviewed. 13. Summary of IJ and corrective action to be reviewed by QAPI committee weekly x4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. On 07/01/24 the surveyor began monitoring if the facility implemented their plan or removal sufficiently to remove the IJ by: Record review of QAPI meeting minutes dated 07/01/24 revealed the QAPI team met to discuss the facility's failure to ensure nursing staff had received training on catheter care and prevention of UTI/CAUTI and steps the facility were taking to address the concern. During an interview and record review on 07/01/24 at 2:49 PM, the DON indicated that she conducted surveillance rounds to visualize each resident's (six residents) urinary catheter site for s/s of infection and patency. The DON indicated that she performed a chart audit on each of the six residents with a urinary catheter to assure appropriate monitoring and treatment orders were in place. Record review of order summaries for the six residents revealed treatment orders were entered and nTAR reflected orders were performed. Interviews conducted with nurses and CNAs scheduled on the 6A - 2P shift [RN F, CNA L, CNA J, MA M, LVN G, CNA I, and CNA N], on the 2P - 10P shift [LVN C, CNA O, CNA P, and CNA Q], and 10P - 6A shift [RN R] indicated they participated in an in-service training about recognizing change in condition, s/sx of UTIs, physician notification, and ANE. The topic of discussion included physician notification, documentation, and follow up orders. Each nurse stated in their own words the procedure was to notify physicians immediately about resident change in condition, verbalized steps taken to notify physician, entering and implementing new orders. Record review of in-services conducted by the DON and ADON dated 06/30/24 - 07/01/24 titled Flushing Supra-pubic Catheter (and irrigation) and Catheter Care - Infection Control, including pre-/post-test were on-going to achieve 100% nursing dept participation. On 06/30/24, an Immediate Jeopardy was identified. The NFA was notified and provided an IJ template on 06/30/24 at 4:30 PM. While the IJ was lowered on 07/01/24, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.