**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and the facility's policy titled Notification of Changes, the facility failed to ensure Resident Identifier (RI) #497's physician was notified when RI #497 experienced a change in condition on 01/04/2025 at 1:24 PM when RI #497 had an elevated heart rate (HR) of 142 beats per minute (bpm). The facility further failed to notify the physician on 01/04/2025 at 9:22 PM when RI #497's heart rate continued to be elevated at 120 bpm. As a result of RI #497's physician not being notified upon the change in condition, no additional treatment or interventions were implemented which resulted in delayed treatment that was likely to result in serious injury, serious harm, impairment, or death. On 01/05/2025 at 4:10 AM RI #497's HR continued to be elevated between 120-150 bpm and RI #497 complained of chest pain and difficulty breathing and requested to be transferred to the emergency room. RI #497 was sent to the local emergency room and was treated in the Intensive Care Unit. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) was cited in reference to 483.10 Resident Rights. On 02/01/2025 at 8:00 PM, the Administrator, the Director of Nursing (DON), the Executive [NAME] President of Operations, two Regional Director of Health Services nurses, the Regional Assessment Compliance Coordinator and the Chief Clinical and Regulatory Officer were provided a copy of the Immediate Jeopardy (IJ) template and notified of the finding of immediate jeopardy in the area of Resident Rights at F 580-Notify of Changes (Injury/Decline/ Room, Etc.). The IJ began on 01/04/2025 and continued until 02/01/2025 when the facility implemented corrective action to remove the immediacy. On 02/02/2025 the immediate jeopardy was removed, F 580 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This affected RI #497, one of six residents sampled for notification of change. This deficiency was cited as the result of the investigation of complaint/report number AL00049932. Findings include: Cross-Reference F 684 and F 658. A review of a policy titled, Notification of Changes, dated 12/31/2024 documented: Policy: The purpose of this policy is to ensure the facility promptly . consults the resident's physician; . when there is a change requiring notification . Definitions: Life-Threatening Conditions: Examples -Heart Attack or Stroke. Clinical Complications: - Examples- Development of stage 2 pressure injury, recurrent episodes of delirium, recurrent UTIs or onset of depression. Need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences . or commence a new form of treatment to deal with a problem . Compliance Guidelines: The facility must . consult with the resident's physician . when there is a change requiring such notification. Circumstances requiring notification include: . 2. Significant change in the resident's physical . condition such as deterioration in health . status, mental or psychosocial status. This may include: a. Life-threatening conditions, or b. Clinical complications . 3. Circumstances that require a need to alter treatment. This may include: a. New treatment. RI #497's admission RECORD indicated that RI #497 was admitted to the facility on [DATE], with diagnoses to include Chronic Obstructive Pulmonary Disease Respiratory Disorders in Diseases and Unspecified Atrial Fibrillation. The record indicated RI #497's Primary Physician was the Medical Director (MD). RI #497's Weight and Vitals Summary flow sheet, documented: . Pulse Summary . 12/27/2024 19:57 (7:57 PM) 60 bpm . 01/03/2025 14:01 (2:01 PM) 99 bpm . 01/03/2025 14:53 (2:53 PM) 99 bpm . 01/04/2025 13:24 (1:24 PM) 142 bpm (Irregular - chronic) 01/04/2025 21:22 (9:22 PM) 120 bpm . A review of RI #497's Progress Notes revealed a note electronically signed by Registered Nurse (RN) #14 dated 01/04/2025 at 11:56 AM. RN #14 documented that RI #497 had . Difficulty breathing noted. Shortness of breath noted. Registered Nurse (RN) #14 was interviewed on 01/31/2025 at 9:59 PM. During the interview, RN #14 was questioned regarding the medical documentation dated 01/04/2025, in which she recorded that RI #497 experienced shortness of breath. RN #14 could not remember if she notified anyone of RI #497's shortness of breath and indicated that there was no record of any notification being made. She acknowledged that she should have contacted either the doctor or the nurse practitioner. When asked about the potential concern, she stated that the resident might be at risk for a stroke or other medical conditions. On 01/30/2025 at 4:49 PM an interview was conducted with the Director of Nursing (DON). The DON said Licensed Practical Nurse (LPN) #16 documented RI #497's HR on 01/04/2025 at 9:22 PM. The DON said RI #497's HR was 120 bpm and she did not see that LPN #16 notified anyone. An interview was conducted on 01/30/2025 at 6:03 PM, with Certified Nurse Practitioner (CRNP) #15. The CRNP was asked if she assessed RI #497 on 01/04/2025. CRNP #15 replied that she saw RI #497 around 10:00 AM and she was fine. CRNP #15 reported that she had been contacted on 01/04/2025 regarding RI #497's heart rate of 142 bpm, at which point she instructed the staff to assess the patient, perform a manual heart rate check, and transfer the patient to the hospital for further evaluation if the heart rate did not decrease. CRNP #15 stated she did not receive a follow-up call after providing those instructions. CRNP #15 said she was not informed of RI #497's heart rate of 120 bpm at 9:22 PM on 01/04/2025. CRNP #15 was asked if she should have been contacted at 9:22 PM and she replied that the on-call provider should have been contacted, but she had already given an order for RI #497 to be sent to the hospital if his/her heart rate did not go down. CRNP #15 said she did not know why RI #497 was not transferred to the hospital until around 4:00 AM on 01/05/2025. An interview was conducted on 01/31/2025, at 6:05 PM with the Director of Nursing (DON). When asked who the staff should notify in the event of a resident's change in condition, the DON indicated that either the CRNP or the Medical Director should be contacted. Upon further questioning regarding the policy on this matter, she stated that it states the physician must be informed. RI #497's HISTORY AND PHYSICAL from the local hospital documented: .Date of Service 01/05/2025 . HPI (History of Present Illness): . was recently discharged from our service on 12-27-2024 after an admission of A-fib/RVR (Atrial Fibrillation/Rapid Ventricular Response) . he/she presents to ER today with 2 day of worsening dyspnea and heart palpitations . EKG (electrocardiogram) shows a-fib/RVR . PLAN: -Admit to ICU . -Diltiazem gtt (cardiac medication administered by IV drip) . -Cardiology consult . A Progress Note from the local hospital dated 01/06/2025 documented: . SUBJECTIVE: . He/She reports breathing much better and denies any palpitations. Currently requiring 2 L (liters) of oxygen by nasal cannula . ASSESSMENT AND PLAN: . Patient has been admitted to the hospital and to the intensive care unit because of atrial fibrillation with RVR . ************************************************************ On 02/02/2025, the facility submitted an acceptable removal plan, which document: ************************************************************ F-580-Resident Rights/Notify of Changes. The facility failed to ensure that RI#497's physician was notified when RI #497 experienced a change in condition on 1/4/2025 at 1:24 PM when he/she had an elevated heart rate of 142 bpm. The facility further failed to notify the physician on 1/4/2025 at 9:22 PM when RI#497's heart rate continued to be elevated at 120 bpm. A. Immediate action(s) taken for the resident(s) found to have been potentially affected include: 1. RI #497 was transferred to the ER on [DATE] at 0410. 2. The Director of Nursing (DON) provided 1:1 in-service with the licensed nurse who failed to notify the physician; on physician notification when resident experiences change in condition and notification parameters on vital signs on 02-01-25. B. Identification of other residents having the potential to be affected: 1. All residents in house most recent vital signs were reviewed by the DON, Regional Director of Health Services and Regional Assessment Coordinator for any change of condition as well as vital signs outside parameters that were set forth by the Medical Director on 1-28-25. 2. Any resident with a change of condition or vital signs outside the parameters, the provider was notified by DON, Unit Manager or Charge nurse for any additional orders or treatment on 2-1-25. C. Actions taken/systems to be put into place to reduce the risk of future occurrences include: 1. All licensed nurses, which are 31 in total, were educated on notification to the provider for change in condition, to include vital signs outside the parameters given on 2-1-25 by the DON and Staff Development Coordinator. Any licensed nurse who did not receive the in-service on 2-1-25 will not be allowed to work until the in-service has been provided. There is 1 LPN pending (on medical leave) and the DON is responsible to ensure they are educated before working *********************************************************** After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 02/02/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of Resident Identifier (RI) #497's medical records, and hospital record review, the facility failed to ensure: 1.) licensed staff followed standards of practice when Licensed Practical Nurse (LPN) #10 failed to completely and accurately transcribe an order. Specifically, on 01/04/2025 at 1:24 PM RI #497's HR was 142 beats per minute (bpm). LPN #10 notified Certified Registered Nurse Practicioneer (CRNP) #15 and received orders to check the resident's heart rate (HR) manually twice per day and send RI #497 to the emergency room (ER) if RI #497's HR did not decrease. LPN #10 entered into the electronic system for the manual HR assessment to begin at 8:00 PM and failed to transcribe the order to send the resident to the ER if the HR did not decrease. LPN #10 failed to manually assess RI #497's heart rate and RI #497's HR was not re-checked until 9:22 PM at which time it was 120 bpm. The facility did not implement any new interventions or take action to treat RI #497's elevated HR until 01/05/2025 at 4:10 AM when RI #497 requested to be transferred to the ER, complained of chest pain, and difficulty breathing. RI #497's HR continued to be elevated between 120 to150 bpm. 2.) Further the facility failed to have a system in place to ensure RI #497's HR was assessed per standards of practice before administering Digoxin. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) was cited in reference to 483.21, Comprehensive Resident Centered Care Plan. On 02/01/2025 at 8:00 PM, the Administrator, the Director of Nursing (DON), the Executive [NAME] President of Operations, two Regional Director of Health Services nurses, the Regional Assessment Compliance Coordinator and the Chief Clinical and Regulatory Officer were provided a copy of the Immediate Jeopardy (IJ) template and notified of the finding of immediate jeopardy in the area of Comprehensive Resident Centered Care Plan at F658-Services Provided Meet Professional Standards. The IJ began on 01/04/2025 and continued until 02/01/2025 when the facility implemented corrective action to remove the immediacy. On 02/02/2025 the immediate jeopardy was removed, F 658 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This affected RI #497 one of six residents sampled for change in condition. This deficiency was cited as the result of the investigation of complaint/report number AL00049932. Findings include: Cross-Reference F 580 and F 684. 1.) RI #497 was admitted to the facility on [DATE], with diagnoses to include Chronic Obstructive Pulmonary Disease (COPD), Respiratory Disorders in Diseases, Essential Hypertension, Obstructive Sleep Apnea, and Unspecified Atrial Fibrillation. RI #497's admission Minimum Data Set assessment, with an Assessment Reference Date of 12/31/2024, identified RI #497 to score a 15 of 15 on the Brief Interview for Mental Status which indicated that RI #497 had intact cognition. RI #497's Weight and Vitals Summary flow sheet documented the following: . Pulse Summary . 12/27/2024 19:57 (7:57 PM) 60 bpm . 12/28/2024 07:41 (7:41 AM) 76 bpm . (12/29/2024 - 01/02/2025 No documented HRs) . 01/03/2025 14:01 (2:01 PM) 99 bpm . 01/03/2025 14:53 (2:53 PM) 99 bpm . 01/04/2025 13:24 (1:24 PM) 142 bpm (Irregular - chronic) . 01/04/2025 21:22 (9:22 PM) 120 bpm . No additional vital signs or pulse was documented. The facility's physician orders for RI #497's revealed a verbal order dated 01/04/2025 at 1:57 PM for vital signs and to check RI #497's pulse manually twice per day. This order was created by Licensed Practical Nurse (LPN) #10. On 01/31/2025 at 10:38 AM, an interview was conducted with LPN #10, the LPN assigned to care for RI #497 on 01/04/2025 on the 6 AM to 6 PM shift. LPN #10 said she reported RI #497's HR of 142 on 01/04/2025 at 1:24 PM to CRNP #15. LPN #10 said she did not see in RI #497's medical record that she reassessed RI #497's HR before she left. LPN #10 said not assessing RI #497 could put RI #497 at risk for a heart attack. On 01/31/2025 at 5:10 PM, a follow-up interview was conducted with LPN #10. LPN #10 said she entered the order for RI #497's HR to be checked twice a day to start at 8:00 PM. LPN #10 said she did not recall if she notified her relief (LPN #16) of the need to obtain RI #497's HRs manually. When asked since she had another four hours on her shift did she feel she needed to check RI #497's HR before she left, LPN #10 said she just put the order in for twice a day and the next HR check was for 8:00 PM. LPN #10 said she should have entered a progress note to inform the oncoming staff and others of RI #497's status, but did not. LPN #10 said the concern of not documenting in RI #497's progress notes about RI #497's care and HR was no one would know that a problem had occurred. LPN #10 said the concern of her not taking RI #497's HR after the order was given was RI #497's HR could have gone up a lot more. On 01/30/2025 at 11:55 AM, an interview was conducted with CRNP #15. CRNP #15 confirmed that nursing staff had contacted her when RI #497 had a HR of 142. CRNP #15 said she instructed staff to assess the resident, recheck the HR manually twice a day, and if the HR did not go lower to send RI #497 to the hospital. CRNP #15 said she did not know why RI #497 was not sent to the hospital until around 4:00 AM. On 01/30/2025 at 6:30 PM, a follow-up interview was conducted with CRNP #15. CRNP #15 said there should have been another assessment of RI #497's HR after she was informed of RI #497's HR was 142 and gave the order to check it manually twice a day. On 01/30/2025 at 6:09 PM, a telephone interview was conducted with the Medical Director (MD). The MD said RI #497 should have been sent out for the HR of 142 if RI #497 was symptomatic. RI #497's Progress Notes, dated 01/05/2025 at 12:36 AM, documented: . Difficulty breathing noted. Nurse reported labored breathing . This note was written by LPN #16. On 01/31/2025 at 5:49 PM, a telephone interview was conducted with LPN #16, the LPN providing care to RI #497 on 01/04/2025 on the 6 PM to 6 AM shift. LPN #16 said more than likely she assessed RI #497's HR on 01/04/2025 at 9:22 PM, but she did not remember what was done for RI #497's elevated HR until he/she was sent to the ER. The document titled EHM (Eastern Hospital Medicine) providerLink conversation which was initiated on 01/05/2025 at 3:51 AM by LPN #16 and sent to CRNP #30, documented the following: . Chest pain. Dyspnea. Pulse 120-150. Can't breath. Copd. Sending to ER per resident request . RI #497's Progress Notes dated 01/05/2025 at 4:10 AM electronically signed by LPN #16, revealed the following: . Sent to (name of local hospital) per resident request . on call CRNP aware . Resident is dyspneic. Unable to catch (his/her) breath. Unable to talk. Pulse 120-150 . 2.) RI #497's Order Summary Report (Physicians Orders) revealed RI #497 had a Physicians Order for Digoxin Oral Tablet 125 MCG (micrograms) Give 125 mcg by mouth one time a day every other day. This order had a start date of 12/28/2024. Davis's Drug Guide identifies Digoxin as a high-risk medication. The Guide includes assessment instructions to monitor apical pulse for one full min before administering and to hold the dose if pulse rate is less than 60 bpm in an adult. A review of RI #497's December 2024 electronic Medication Administration Record (eMAR) revealed RN #14 administered RI #497's Digoxin at 8:00 AM on 12/30/2024. There was no evidence RI #497's HR had been checked before he/she received the Digoxin. On 02/01/2025 at 5:52 PM, an interview with was conducted with RN #14 who said the standard of practice nurses use before administering Digoxin was to follow the doctor's orders. RN #14 said she did not check RI #497's HR on 12/30/2024 because there were no doctor's orders to check the HR. RN #14 said there was no place to document the HR on the December 2024 eMAR. A review of RI #497's January 2025 eMAR revealed LPN #28 administered RI #497's Digoxin at 8:00 AM on 01/01/2025. There was no evidence RI #497's HR had been checked before he/she received the Digoxin. On 02/02/2025 at 1:23 PM, a telephone interview was conducted with LPN #28, the LPN assigned to care of RI #497 on 01/01/2025. LPN #28 said the standard of practice nurses use before administering Digoxin was to check the apical pulse. LPN #28 said evidence she had checked RI #497's pulse on 01/01/2025 would be on the January eMAR. On 02/01/2025 at 4:55 PM, an interview was conducted with the Director of Nursing (DON). The DON said the standard of practice for administering Digoxin was to administer medication as ordered. The DON said the facility's protocol for assessing a resident's HR was done per doctor's order. When asked how would the staff know when to assess the HR of residents before administering Digoxin, the DON said it would be on the physician's orders and eMAR. On 02/01/2025 at 3:33 PM, a telephone interview was conducted with the Medical Director (MD). The MD said it was standard of practice to check the HR of a person receiving Digoxin before administering the medication. The MD said if an order had not been written to check the heart rate before administering the Digoxin he would have written one, but it was just standard or practice for the nurse to assess resident's HR before administering Digoxin. A review of RI #497's Weight and Vitals Summary flow sheet and RI #497's Progress Notes revealed there was no evidence RI #497's HR had been checked on 12/30/2024 or on 01/01/2025 before RI #497 was administered the Digoxin. ******************************************************** On 02/03/2025 the facility submitted an acceptable removal plan, which documented: A. Immediate action(s) taken for the resident(s) found to have been potentially affected include: 1. The facility failed to ensure licensed staff followed standards of practice and completely and accurately transcribed an order received from a CRNP to send RI#497 to the emergency room if heart rate did not go down. The nurse also did not communicate the order to the oncoming nurse. The nurse further failed to re-assess RI #497's heart rate at the time the order was provided to ensure RI#497 did not need to be transferred to the ER. The facility further failed to ensure process was in place to ensure resident's HR was checked prior to administration of digoxin. 2. RI #497 was transferred to the ER on [DATE] at 0410. 3. The Director of Nursing (DON) provided 1:1 education to the licensed nurse that took the verbal order, and did not communicate to the oncoming nurse on 2-1-25. Education included completely and accurately transcribing an order received from a physician or CRNP, following up on an order and communicating new orders to the oncoming nurse that require follow up, and assessing residents heart rate prior to administering digoxin. B. Identification of other residents having the potential to be affected: 1. This has the potential to affect all residents that reside in the facility on 2-1-25. 2. On 2-1-25, the DON reviewed all current in-house residents last recorded vital signs to identify any resident with vital signs outside the parameters set forth by the Medical Director. Any resident identified with vitals signs outside the parameters, the provider was notified, and any new orders as indicated. 3. All residents in house on Digoxin (and amiodarone, clonidine) were reviewed by the DON, Regional Director of Health Services (RDHS) and Pharmacist on 2-1-25 to ensure heart rate/blood pressure documentation was included on the Medication Administration Record with parameters for Digoxin (and amiodarone, clonidine). There were 13 residents reviewed. There were no other residents that did not have documentation of HR/BP on MAR. 4. Beginning on 02/01/2025, the nurse that transcribes the order will be responsible for ensuring HR/BP as indicated documentation is included for any residents with new digoxin (and amiodarone, clonidine) orders. The clinical meeting (M-F) by the DON and Nurse Managers will verify HR/BP documentation will be included with any new Digoxin orders. 5. The process to ensure the MAR includes vital sign monitoring/parameters for ALL medications which require monitoring of vitals before administration per standards of practice will be: i. On 02/01/2025 MD and Facility Pharmacist determined on 2-1-2025 the following medications require VS monitoring preadministration: Clonidine-hold if systolic BP <90 or diastolic BP <55 and notify MD/NP ; Amiodarone-hold if pulse < 55bpm or systolic BP <100 or diastolic BP <60 and notify MD/NP; Digoxin-hold if pulse <60bpm and notify MD/NP. ii. The DON/ Regional Director of Health Services/ Facility Pharmacist completed an audit of residents' medications to ensure all medications with an established standard of practice to check vitals pre-administration are identified and the monitoring is included on the MAR. If residents. The audit was completed on 2-1-2025, there were 13 residents reviewed, and 8 residents required updates on the MAR. Specifically, we updated the VS parameters as set forth by the Medical Director on 2-1-25 for Digoxin, Clonidine and Amiodarone. iii. During the clinical meeting (M-F) the DON and Nurse Managers will verify all new orders for medications requiring VS monitoring include the required monitoring and documentation on the MAR. iv. The nurses will know the thresholds for VS, HR monitoring for newly ordered digoxin and HR and blood pressure for Amiodarone and blood pressure monitoring for Clonidine because it was posted at the nurses station on 1-28-25 by the DON, additionally the specific instructions are included on the MAR to notify the MD/NP if the VS are out of the parameters. C. Actions taken/systems to be put into place to reduce the risk of future occurrences include: 1. Vital Sign threshold alerts were updated to the electronic medical record for all residents by the DON and RDHS on 2-1-25. 2. The RDHS revised the New Admit/Readmit Checklist on 2-1-25 to include setting the vital sign parameter thresholds set forth by the Medical Director and Pharmacist related to Clonidine, Amiodarone, and digoxin orders have heart rate and or BP parameters for monitoring, holding of medication and notification of MD/NP. 3. All licensed nurses (31 licensed nurses), were provided with education by the DON and Staff Development Coordinator on 2-1-25. Any licensed nurse who did not receive this education will not be allowed to work until the education has been provided (there is 1 pending nurse on medical leave and the DON is responsible to ensure they are educated before working). Education included completely and accurately transcribing an order received from a physician or CRNP, following up on an order and communicating new orders to the oncoming nurse that require follow up, and assessing residents' heart rate and or BP prior to administering Clonidine, Amiodarone and Digoxin, the updated procedures including entering the order for assessment and documentation of HR monitoring for newly ordered digoxin and HR and blood pressure for Amiodarone and blood pressure monitoring for Clonidine. The nurses were educated that the thresholds for VS was posted at the nurses station on 1-28-25 by the DON, additionally the specific instructions are included on the MAR to notify the MD/NP if the VS are out of the parameters. The facility requests for the IJ removal plan to be effective on 2-2-25. This plan was written by the Executive VP of Operations and the Regional Director of Health Services. ***************************************************** After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 02/02/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and resident record reviews the facility failed to ensure: 1) a system was in place to ensure newly admitted residents vital signs were assessed at a frequency expected by the Physician/Certified Registered Nurse Practitioner (CRNP); and 2) resident specific vital sign parameters were established including when the physician should be notified of abnormal values. Specifically, RI #497 was admitted to the facility on [DATE] after being admitted to the hospital on [DATE] with Atrial Fibrillation with RVR (Rapid Ventricular Response). The facility's orders indicated RI #497's vitals were to be assessed every month and no parameters were established. The physician/CRNP reported they expected vitals to be assessed at least daily for newly admitted residents. On 01/04/2025 at 1:24 PM RI #497's heart rate (HR) was 142 beats per minute (bpm). The CRNP was notified and gave an order to send him/her to the hospital if his/her HR did not decrease. On 01/04/2025 at 9:22 PM RI #497's HR was 120 bpm. No action was taken until the RI #497 complained of chest pain, shortness of breath, and requested to be transferred to the hospital. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death. The Immediate Jeopardy (IJ) was cited in reference to 483.25, Quality of Care. On 02/01/2025 at 8:00 PM, the Administrator, the DON, the Executive [NAME] President of Operations, two Regional Director of Health Services nurses, the Regional Assessment Compliance Coordinator and the Chief Clinical and Regulatory Officer were provided a copy of the Immediate Jeopardy (IJ) template and notified of the finding of substandard quality of care at the immediate jeopardy level in the area of Quality of Care, F 684. The IJ began on 01/04/2025 and continued until 02/01/2025 when the facility implemented corrective action to remove the immediacy. 02/02/2025 the immediate jeopardy was removed, F 684 was lowered to the lower severity of no actual harm with a potential for more than minimal harm that was not immediate jeopardy, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance. This affected RI #497 one of six residents sampled for change in condition. This deficiency was cited as the result of the investigation of complaint/report number AL00049932. Findings include: Cross-Reference F 580 and F 658. RI #497's hospital DISCHARGE SUMMARY dated 12/27/2024 included REHAB ORDERS which documented that RI #497 was to have routine vital signs. RI #497 was admitted to the facility on [DATE] with diagnosis to include Chronic Obstructive Pulmonary Disease, Atrial Fibrillation, and Essential Hypertension. A review of RI #497's Order Summary Report revealed on 12/27/2025, an admission order was input for RI #497's vital signs to be checked once a month and as indicated. There were no parameters given at this time as to when the Physician or CRNP were to be notified when the resident's vital signs were out of normal range. A review of RI #497's Weights and Vitals Summary flow record indicated there was no evidence RI #497's vital signs were assessed on 12/29/2024, 12/30/2024, 12/31/2024, 01/01/2025, nor 01/02/2025, five of ten days RI #497 was a resident at the facility. RI #497's pulse was documented on 01/04/2025 at 1:24 PM as 142 bpm and on 01/04/2025 at 9:22 PM 120 bpm. During an interview on 01/30/2025 at 6:29 PM with Registered Nurse (RN) #25, the nurse who entered RI #497's admission orders, RN #25 said the standard for checking vital signs on new admissions should be every shift until discharged . An interview was conducted on 01/30/2025 at 10:46 AM with the RN/Unit Manager (UM) #8. She was asked how often vital signs were to be assessed for RI #497 and she stated as often as prescribed, per orders. She further stated that she entered an order on 01/03/2025 for vital signs every shift for blood pressure, heart rate, and oxygen sats every shift for three days. On 01/30/2025 at 6:29 PM an interview was conducted with RN #25, House Supervisor. RN #25 reported that newly admitted residents should have vitals assessed each shift until discharged . During an interview with the Director of Nursing (DON) on 01/30/2025 at 4:49 PM, the DON stated RI #497's orders were entered on 12/27/2024 for RI #497's vitals to be assessed once a month. The DON stated newly admitted residents should have vital signs assessed at least daily. The DON said there was no evidence that RI #497's vital signs were assessed from 12/29/2024 through 01/02/2025. During an interview with CRNP #15 on 01/30/2025 at 1:15 PM the CRNP stated the standing order was for vital signs to be assessed each shift for newly admitted residents. CRNP #15 said vital signs were assessed once per month for long-term residents who were stable. On 01/30/2025 the DON presented a Vital Signs Parameter guideline implemented on 01/28/2025, which was signed by the Medical Director (MD). The parameter for the Pulse indicated a pulse of 110 was considered High. Documented on the form were instructions to Please call MD (Medical Director)/NP (Nurse Practitioner) when vital signs are out of parameters. ********************************************************************** On 02/03/2025 the facility submitted an acceptable removal plan, which documented: 1. Immediate action(s) taken for the resident(s) found to have been potentially affected to include: A. The facility failed to ensure: 1) A system was in place to ensure newly admitted residents vital signs were assessed at a frequency expected by the physician/CRNP. 2) Resident specific vital sign parameters were established including when the physician should be notified of abnormal values. B. The Director of Nursing contacted the Medical Director on 01-28-25 for guidance on updating vital sign thresholds for notification. C. On 2-1-25, the Medical Director was contacted by the DON on his expectations on vital sign monitoring. 2. Identification of other residents having the potential to be affected: A. All newly admitted residents have the potential to be affected B. The Regional Director of Health Services (RDHS), Director of Nursing (DON), and Regional Assessment Coordinator reviewed all vital signs on all residents newly admitted to the facility in the last 30 days had an order to monitor vital signs per the Medical Directors expectations. This was completed on 2-1-25. 3. Actions taken/systems to be put into place to reduce the risk of future occurrences include: A. An updated New Admit/Readmit Checklist was implemented to ensure vital sign frequency and parameters are established at the time of admission. Completed on 2-1-25. B. The vital sign monitoring policy was updated on 2-1-25 by the RDHS to require at least daily vital signs for all newly admitted or readmitted residents for 2 weeks. The changes to the VS Monitoring Policy were based on discussion and recommendation of The Medical Director on 2-1-2025. C. The Director of Nursing contacted the Medical Director on 1-28-25 for guidance on updating vital sign thresholds for notification. D. On 2-1-25, the Medical Director was contacted by the DON on his expectations on vital sign frequency. E. Vital sign parameter thresholds and frequency were updated for all newly admitted or readmitted residents over the last 30 days, vital sign orders on 2-1-25 by the RDHS and DON. The facility parameters were discussed with The Medical Director on 2-1-2025 and were updated. In addition, it was noted by The Medical Director that there will be residents that may require specific parameters based on clinical need. F. The Daily Clinical Meeting form was revised on 2-1-25 by RDHS to include review of vital signs outside physician ordered parameters with follow up documentation. G. The DON and Staff Development Coordinator on 2-1-2025 provided education for licensed staff on the updated VS Monitoring Policy, monitoring residents' vital signs at least daily for 2 weeks following an admission or re-admission and vital signs thresholds that require physician notification, and process to document vitals, notification, and physician recommendations. The facility requests for the IJ removal plan to be effective on 2-2-25. This plan was written by the Executive VP of Operations and the Regional Director of Health Services. ***************************************************** After review of the information provided in the facility's Removal Plan, in-service/education records, as well as staff interviews, and observations, the survey team determined the facility implemented the immediate corrective actions as of 02/02/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, the facility's VERIFICATION OF INVESTIGATION, a review of the Alabama Department of Public Health Online Incident Reporting System, a review of facility's policies titled Resident Elopement, and Resident-Missing the facility failed to ensure adequate supervision was provided to Resident Identifier (RI) #1 to prevent and identify elopement. On 09/14/2023 around 5:35 PM, RI #1, a resident with cognitive deficits, eloped from the facility. Certified Nursing Assistant (CNA) #5 identified that RI #1 was not in his/her room around 6:00 PM and did not act to locate RI #1, but assumed he/she had discharged home. At 8:47 PM, Licensed Practical Nurse (LPN) #8 identified that RI #1's whereabouts were unknown and initiated action to locate RI #1. At 8:57 PM, RI #1 was found by local law enforcement at a grocery store located 1.9 miles away. The deficient practice affected RI #1, one of three residents reviewed for elopement. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (d) Free of Accident Hazards/Supervision/Devices at a scope and severity of J. On 05/17/2024 at 12:43 PM, the Administrator and the Corporate Nurse were provided a copy of the Immediate Jeopardy Template and notified of the findings of substandard quality of care at the Immediate Jeopardy level in the area of Quality of Care, at F 689-Free of Accident Hazards/Supervision/Devices. The IJ began on 09/14/2023 and continued until 09/18/2023 when the facility implemented corrective actions with ongoing monitoring; thus, immediate jeopardy was cited at Past Non-Compliance. The deficiency was cited as a result of complaint/report number AL00045611. Findings include: A review of facility policy titled Resident Elopement-Risk Of with a revised date of 07/12/2001 revealed: Purpose To identify those residents ar risk for elopement. Policy The facility will have procedures in place to assess each resident for their elopement potential and to minimize the potential for elopement. Procedure . 4. Residents shall be monitored for early warning signs of elopement which include: a. Statements from resident such as I want to go home b. Wandering aimlessly . 10. Staff shall be aware of the facility's list of potential elopement residents. The facility's policy titled Resident-Missing with a revised dated of 07/12/2001 revealed: Purpose To report and investigate all reports of missing residents. Procedure 1. In the event a resident is suspected of being missing from the facility, or for any reason can not be readily located, the Charge Nurse on the wing, which the resident resides, shall be notified immediately. a. The Charge Nurse shall designate an employee to do a complete head count . b. Search the outside areas of the building IMMEDIATELY . RI #1 was admitted to the facility on [DATE] for rehabilitation services and had a diagnoses that included Dementia without behavior, Encephalopathy, and Alcohol abuse. RI # 1's admission Minimum Data Set (MDS) with an Assessment Reference Date on 08/27/2023 revealed a Brief Interview of Mental Status (BIMS) score of five of 15 which indicated severe cognitive deficits. RI #1's Care Plan included: Care Plan Description Wants to return home .Start Date 8/30/2023 . The facility submitted an initial report on 09/15/2023 at 4:39 PM to the Alabama Department of Public Health Online Incident Reporting System. The initial report indicated RI #1 had eloped from the facility on 09/14/2023 at 5:30 PM. The facility's VERIFICATION OF INVESTIGATION signed by the Previous Administrator on 09/21/2023 indicated that . (RI #1) went to a doctor's appointment at 9 am on 9/14/23 . and returned at 3:03 PM. (RI) #1 was eating supper at approximately 4:45 PM in the dining room on the unit. At 5:27 PM per facility cameras, (RI #1) walks out the front door and sits on the porch. At 5:30 PM the patient is seen standing in the parking lot. At 5:35 PM patient is walking in the back parking lot. After this, (RI #1) was not seen on camera. At 8:47 PM, (This is the time he/she was due for his/her medications) the charge nurse (LPN #8) contacts Director of Nursing (DON) and asked if patient discharged early (Patient was supposed to discharge on [DATE]) . Nurse . was on the phone with RI #1's (spouse) 8:57 pm . police were at (spouse's) house reporting to them that RI #1 was found by . police at the (name of grocery store) . RI #1 was not monitored in the building on 09/14/2023 from 5:31 PM to 8:57 PM . On 05/15/2024 at 3:29 PM an interview was conducted with CNA #10. The CNA said RI #1 was a little confused and walked around the facility but was not a resident who was identified as being at risk for wandering. CNA #10 said she was assigned to RI #1's care on 09/14/2023, but her shift ended before RI #1 returned from his/her appointment. CNA #10 said RI #1 was talking about going home that day and was anticipating discharge. On 05/15/2024 at 4:24 PM an interview was conducted with CNA #11 who said RI #1 would make comments that he/she was ready to go home, and he/she had to go to work. CNA #11 said RI #1 had periods of confusion. CNA #11 said on 09/14/2023 she last saw RI #1 at the nurses' station around dinnertime, around 4:45 to 5:00 PM . CNA #11 said that she redirected RI #1 from the nurses' station to the dining room for dinner. During an interview on 05/16/2024 at 9:16 AM, CNA #5 revealed she was working with RI #1 on 09/13/2023 and 09/14/2023. CNA #5 said on 09/13/2023 RI #1 talked about going home soon. On 09/14/2023 when making her initial rounds between 6:00 PM and 6:30 PM, she went into RI #1's room and she did not see RI #1. It was at that time that CNA #5 went to LPN #8 and made a comment to LPN #8 that RI # 5 must have been discharged because he/she was not in the room. CNA #5 said that around 8:30 PM or 9:00 PM, LPN #8 came to her and said that RI #1 was still in the computer system. It was at this time that the staff began to search for RI #1. During an interview on 05/16/2024 at 5:48 PM, LPN #8 said she was the night shift nurse on 09/14/2023. LPN #8 said when she arrived for the shift, it was busy, and she relieved a travel agency nurse who did not give her a report. LPN #8 said the travel nurse and she should have done a walk through together and she should have received a report from the travel nurse. LPN #8 said that during the evening medication pass she noticed RI #1 was not in his/her room. LPN #8 said he/she did not know how long it had been since RI #1 had last been seen or observed. LPN #8 said RI #1 could have been struck by a vehicle while crossing the busy highway. On 05/16/2024 at 10:49 AM an interview with the Previous Director of Nursing (PDON) said she was notified that RI #1 was missing by LPN #8 during medication pass. The PDON said that after reviewing the facilities camera footage, it was determined RI #1 was seen exiting the front door. The PDON confirmed RI #1 was last seen during dinner time around 4:45 PM. The PDON said residents should be checked every two hours. The PDON said the nurses and CNAs should have checked on RI #1 during that three-hour time period. The PDON said the concern with RI #1 being found at the grocery store 1.9 miles away from the facility was injury or harm to RI #1 from walking in such a high traffic area. On 05/16/2024 at 3:15 PM the previous Administrator (PADM) was interviewed. The PADM said the frequency in which staff checked on residents depended on the individual resident's acuity, but generally residents should be checked on by staff every 30 minutes to two hours depending on the resident's care needs. He said it was unacceptable for staff not to check on a resident over a three-hour period due to risk of injury and overall safety of the resident. The PADM noted the concern with RI #1 not being supervised by facility staff was the safety of the resident, risk of elopement, and risk of harm or serious injury from crossing a busy six lane highway in the evening hours. On 05/15/2024 at 6:15 PM an interview with RI #1's Responsible Party (RP) was conducted. The RP said RI #1 was admitted for rehabilitation after breaking his back. RI #1 had a doctor's appointment the morning on 09/14/2023. The RP reported the family returned RI #1 to the facility around 2:30 or 3:00 PM that same day. At 9:12 PM that night the RP said local law enforcement informed him/her that RI #1 had been found at a local grocery store. The RP said it was extremely frightening that RI #1 walked all the way to the grocery store on a busy road. **************************************************************************************************************************** Once the facility became aware of RI #1's elopement from the facility on 09/14/2023, the following corrective actions were implemented: 1. The resident was located nearby by local law enforcement and taken to the emergency room for an evaluation upon family request. No injuries noted. The resident discharged home with the RP after the ER visit. This was completed on 09/14/23. 2. A.) A one-time head count to verify all current residents were inside the facility was completed by the charge nurse on duty, on 09/14/2023. All residents were accounted for. B.) All facility exits were verified by the Administrator and DON to be locked and alarms functional. This was completed on 09/14/2023. C.) On 09/15/2023, DON/Social Worker completed a new elopement risk User Defined Assessment for all current residents to identify any resident who may have had a change in condition deeming them at risk for elopement. Any residents found to be newly at risk will have their care plan reviewed and revised as indicated. D.) The front door will be monitored until all reassessments have been completed. This was completed on 09/15/2023. E.) All staff will be interviewed to ascertain if there are any residents with wandering behavior that may not be documented. If residents are identified with wandering behavior not previously identified, their assessment and care plan will be updated to reflect the wandering. This was completed on 09/15/2023. F.) A discharge communication form will be instituted to reflect scheduled discharges each day indicating discharge date /time to effectively communicate between discharge planner and direct care staff. The discharging nurse will sign acknowledging when discharge occurs. This was initiated on 09/15/2023. 3. A.) Facility front door was locked and/or supervised. This was completed on 09/15/2023. Facility changed the door system to remain locked at all times with keypad code required for entry/exit. Residents and family members notified and educated of change in entry/exit process by resident council meeting and family notifications by phone and written notification. This was completed on 09/18/2023. B.) Staff re-educated by DON/Designee, on 09/15/2023-09/16/2023 regarding reporting of new behaviors such as wandering and elopement policy. Staff also reeducated on steps to take if a resident displays wandering behavior. Charge nurses reeducated regarding documentation of behaviors, specifically wandering with the need to obtain an order for a Wander guard Bracelet if indicated. This was completed on 09/16/2023. C.) 24-hour report/Nurse-to-nurse communication process updated to a more efficient method of communicating changes from shift to shift. A 24-hour notebook will be utilized rather than 24-hour report form. This new process was initiated on 09/15/2023. Staff education was initiated on 09/15/2023. Staff education on the new process for 24-hour report was completed on 09/18/2023. D.) The facility will utilize elopement risk assessment in Electronic Medical Record that scores residents on a scale of 0-10 according to elopement risk level. This was completed on 09/15/2023. E.) Staff educated regarding discharge communication form initiated by discharge planner to communicate with direct care staff the scheduled discharges each day. The discharging nurse will sign acknowledging the discharge is complete and return to the DON. This was completed in person and by telephone on 09/15/2023. 4. A.) Facility doors will be checked daily x 1 week and then weekly x 4 weeks to verify that all doors are secured and functioning properly. This was initiated on 09/15/2023. B.) The facility Interdisciplinary Team (IDT) will review nurse's 24-hour report information and discuss new or worsening behaviors in daily clinical meetings 5 x weekly. If a new behavior is reported or documented, IDT will verify that care plan and orders reflect interventions as indicated. DON/Designee will also interview 5 staff members to verify reporting and documentation of any new wandering behaviors. The interviews will be weekly x 4 weeks, then monthly x 2 months. This was initiated on 09/15/2023. C.) 24-hour report/Nurse-to-nurse communication process monitored daily in clinical meeting 5 x weekly X 4 weeks to verify the 24-hour notebook is being utilized and report is thorough. This was initiated on 09/15/2023. D.) Elopement risk assessments (that score residents on a scale of 0-10 according to elopement risk level) will be reviewed on all new admissions X 3 months to verify that assessment is complete, interventions in place and care planned if appropriate. This was initiated on 09/15/2023. E.) The facility IDT will review the discharge communication forms from the previous day to verify each discharge occurred as scheduled and will initiate a new discharge communication form listing the discharges scheduled for the day and will provide the form to direct care nurses on each unit. This was initiated on 09/15/2023. F.) An emergency Quality Assessment Program Improvement (QAPI) meeting was conducted on 09/15/2023, attendance included the Medical Director. Date of compliance: 09/18/2023. After review and verification of the information provided in the facility's corrective action plan, in-service/education records, monitoring tools, and facility investigation, as well as staff interviews, the survey team determined the facility implemented corrective actions from 09/14/2023-09/18/2023, with ongoing monitoring implemented; thus, immediate jeopardy past non-complaint was cited.