**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure residents received treatment and care consistent with professional standards of practice. This affected five (#1, #2, #5, #6 and #7) of six residents out of eight total sample residents. RESIDENT #1 Resident #1 was admitted to the facility from the hospital on [DATE]. His diagnoses included long-term use of anticoagulants (blood thinner). Orders included the anticoagulant Lovenox by injection, started 10/10/24 and discontinued 11/7/24, and Apixaban (Eliquis) an oral anticoagulant for deep vein thrombosis, started 11/7/24, discontinued 11/13/24, and ordered again on 11/13/24 to 11/28/24. A review of the treatment administration record (TAR) revealed the November orders, starting 10/16/24, read in part, Anti-coagulation medication monitoring: monitor every shift for signs and symptoms of bleeding (black tarry stools, increased or new bleeding of gums, blood in urine, etc). If complications notify MD . -However, this order was discontinued on 11/13/24, and there was no documentation of anticoagulant monitoring on the resident's TAR from 11/13/24 to 11/28/24 - 26 shifts over 13 days. There was no documentation explaining why monitoring was discontinued and, the resident's care plan did not address anticoagulant therapy - the risks, signs/symptoms of bleeding, or monitoring expectations found on the TAR. In addition, the resident's record did not contain consent for the use of the anticoagulant medication Eliquis. On 11/27/24 at around 6:00 p.m., a certified nurse aide (CNA) found the resident with coffee-colored emesis and a dark bowel movement. The CNA reported the findings to the licensed practical nurse (LPN #1) who worked the night of 11/27/24 and the early morning of 11/28/24. In an interview, the LPN stated Resident #1 had not previously had a dark bowel movement or coffee-colored emesis. The LPN called the assistant director of nursing (ADON) (the interim DON at the time). The ADON requested the registered nurse (RN) do a full assessment. After receiving the RN's report, the ADON contacted the physician around 10:30 p.m. and a decision was made to monitor the resident. -However, there was no documentation of the RN's full assessment in the electronic medical record or a change of condition assessment form. Per the nursing home administrator (NHA), no RN assessment note was completed. Further, there was no documentation explaining why the resident was not sent to the hospital which was the expectation for evidence of a new bleed per the ADON. Moreover, although the resident's primary care physician (PCP) documented the resident's MOST form (Medical Orders for Scope of Treatment) was revised on 11/26/24 and record review revealed an order entered that day for do not resuscitate (DNR), the revised MOST form could not be located during the survey, and the resident's care plan still read full code, initiated 11/13/24. Resident #1 expired at the facility early in the morning on 11/28/24. According to a note dated 11/28/24 at 4:47 a.m., the resident was checked at 4:00 a.m. and found without respirations or heart tones. The cause of death, according to the death certificate, was a presumed gastrointestinal bleed. RESIDENTS #2, #5, #6, AND #7 Record review and interviews revealed the facility failed to complete a change in condition assessment form when Resident #2 experienced low oxygen levels and was unresponsive; failed to care plan Resident #5, #6, and #7's anticoagulant use, and failed to have physician orders monitoring their anticoagulant use. Further, the facility failed to have documentation that consent was obtained for Resident #6's anticoagulant medication. SUMMARY The facility failed to properly address Resident #1's significant change of condition when the resident, who was receiving anticoagulant medication, began bleeding internally. The facility's failure to assess and monitor the resident's anticoagulant medication use and change in condition, failure to document changes, and failure to seek medical treatment, contributed to serious harm for Resident #1. The failures also created the potential for further serious resident harm if the facility's system for assessing, monitoring, and communicating changes was not immediately corrected. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy A review of Resident #1's anticoagulant use, monitoring records, and staff interviews revealed the facility failed to take steps, consistent with professional standards of practice, to promote Resident #1's well-being both before and upon the discovery of the resident's coffee-colored emesis and dark bowel movement on 11/27/24. There was no evidence the facility thoroughly investigated the 11/27/24 incident to uncover and address why the nurses did not recognize the resident's change in condition, complete accurate assessments, and seek appropriate treatment. -Record review revealed no documentation of anticoagulant monitoring on Resident #1's treatment administration record (TAR) from 11/13/24 to 11/28/24 - 26 shifts over 13 days. Further, the resident's care plan did not address anticoagulant therapy - the risks, signs/symptoms of bleeding, or monitoring expectations found on the TAR. -Record review revealed no documentation of the RN's full assessment in the electronic medical record or a change of condition assessment form. Per the nursing home administrator (NHA), no RN assessment note was completed. There was no documentation explaining why the resident was not sent to the hospital which was the expectation for evidence of a new bleed per the assistant director of nursing (ADON). The facility's failure to implement an immediate and comprehensive review of the facility's system of anticoagulation management and of response to resident changes in condition, including the response to Resident #1's coffee-colored emesis and dark bowel movement, placed residents at risk for serious harm if the situation was not immediately corrected. B. Facility notice of immediate jeopardy On 2/11/25 at 4:30 p.m., the NHA, chief operating officer (COO), and director of nursing (DON) were notified that the facility's failure to identify and respond to Resident #1 change in condition created an immediate jeopardy situation. C. Facility plan to remove immediate jeopardy On 2/12/25 at 11:04 a.m. the facility submitted a final plan for removal of the immediate jeopardy situation. The plan read: The facility immediately completed the following: 1. Resident-centered care plan was created on 02/11/2025 for all residents who currently received anticoagulant medications and will be completed by 02/12/2025. 2. Orders for on-going monitoring for anticoagulant medications were obtained from the providers on all residents who do not have orders on 02/11/2025. 3. An in-service was completed on 02/11/2025 by the DON/designee to all licensed nursing staff who were in the building (phone call education for staff who were not in the building) to ensure that the facility performs adequate physical assessments for change of conditions, recognize changes and how to accurately and timely communicate the assessment findings to the physician on call. 4. An in-service was completed on 02/11/2025 by the DON/designee to all licensed nursing who were in the building (phone call education for staff who were not in the building) to ensure that they analyze the situations for when to send residents to the hospital, with background information, assessments and recommendations with a timely, consistent and accurate process. 5. Education will be provided to all nursing staff prior to the start of their shift. All residents have the potential to be affected by this alleged deficiency. All residents in the building were reviewed for change of condition and none of the other residents were affected by this deficient practice. The DON or their designee will oversee the compliance with the resident-centered care plan and ensure continuous monitoring of anticoagulant therapy. This monitoring will include staff performance of thorough physical assessments for changes in resident conditions, timely recognition of these changes, and the accurate and prompt communication of assessment findings to the on-call physician. Additionally, the monitoring process will ensure that nursing staff appropriately analyze situations where hospitalization may be necessary, including completing timely and accurate background information, assessments, and recommendations. Monitoring will start on 02/11/2025 and will follow the schedule below: Daily for one week, Weekly for four weeks, Monthly for two months, or until substantial compliance is achieved. D. Removal of immediate jeopardy Based on the facility's plan above and evidence of its implementation, the immediate jeopardy situation was removed on 2/12/25 at 12:40 p.m. However, the deficient practice remained at a G level, isolated actual harm. II. Professional references and facility expectations A. Professional references - Anticoagulant risks 1. The National Library of Medicine, Anticoagulant Safety, updated 10/6/24, retrieved on 2/18/25 at Amaraneni A, Chippa V, [NAME] J, et al. Anticoagulation Safety. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519025/, read in pertinent part: Millions of patients rely on oral anticoagulants to decrease the risk of ischemic stroke and other thromboembolic events, underscoring the importance of understanding their safety profiles. However, these medications rank among the leading causes of emergency department visits and hospital admissions among older adults, prompting classification as high-alert medications by the Institute of Safe Medication Practices and a focus on harm reduction in The Joint Commission's National Patient Safety Goals. Still, the benefits outweigh the overall risks for most patients. The initial weeks of oral anticoagulant use pose the highest risk of adverse effects, particularly during transitions from hospital to home care, necessitating careful management as patients recuperate. Despite their efficacy in preventing and treating thromboembolism, all anticoagulants elevate the risk of bleeding. Clinicians must carefully assess each agent's risks and benefits, tailoring medication choices accordingly. Adverse effects often stem from concurrent use of antiplatelet medications, dosing errors, or inadequate monitoring, underscoring the importance of healthcare professionals' knowledge about potential complications like intracranial and gastrointestinal bleeding, hematoma formation, and available reversal agents. Accurate assessment of bleeding risks and prescribing appropriate doses is essential for maximizing clinical benefit. Symptoms of significant bleeding vary by site, and early symptoms include epistaxis, gum bleeding, heavy menstrual bleeding, or excessive bruising. Airway-related hematomas may cause sore throat, painful or difficult swallowing, nosebleeds, shortness of breath, or hemoptysis. Extremity involvement may manifest as pain, swelling, weakness, or limited motion. Intraabdominal bleeding can lead to pain and distension, while intracranial bleeds may cause severe headaches, vomiting, dizziness, or seizures. Ocular bleeding may result in vision changes. Gastrointestinal bleeding may present as melena, hematochezia, or hematemesis. Gastrointestinal signs: Patients may have evidence of hypovolemia manifesting as tachycardia and hypotension, visible or occult blood in the stool, and pain on abdominal examination. Healthcare professionals must swiftly determine the severity and location when assessing bleeding complications in patients taking oral anticoagulants. A comprehensive history and medication review are crucial, documenting the anticoagulant regimen, last dose timing, and potential overdose risk. In addition, exploring the history of renal or hepatic disease, bleeding disorders, thrombocytopenia, and medications affecting hemostasis is necessary. Understanding the anticoagulation indication and thrombosis risk aids treatment decisions. Enhancing patient-centered care, outcomes, safety, and team performance in anticoagulation management requires a multifaceted approach involving physicians, advanced practitioners, nurses, pharmacists, and other healthcare professionals. Physicians and advanced practitioners should demonstrate strong clinical skills in risk assessment, medication selection, and dosage determination while effectively communicating with patients to involve them in treatment decisions. Nurses play a crucial role in monitoring patients, educating them about adherence and lifestyle changes, and promptly recognizing and managing complications. Pharmacists contribute by conducting medication reviews, assessing drug interactions, and ensuring appropriate care transitions. Effective interprofessional communication, supported by clear documentation, is essential for coordinating care and minimizing errors. Care coordination involves developing standardized protocols, guidelines, and pathways for anticoagulation management across various settings, ensuring seamless transitions and optimizing patient outcomes. By leveraging their skills, communication, and coordination, healthcare teams can collectively enhance anticoagulation safety and improve patient care and outcomes. 2. Eliquis package insert (April 2021) was retrieved on 2/17/25 from chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/202155s034lbl.pdf. It revealed in pertinent part, Eliquis increases the risk of bleeding and can cause serious, potentially fatal bleeding. Advise patients of signs and symptoms of blood loss and to report them immediately or go to an emergency room. B. Facility expectations The facility's Change of Condition policy, reviewed 4/2/24, was provided by the NHA on 2/11/25 at 12:36 p.m. It read in pertinent part: As part of the evaluation the nurse will help identify individuals for having any changes of condition during their stay or if a patient has a fall. In addition, the nurse shall evaluate and document/report the following: Vital signs; Difficulty speaking; Difficulty understand(ing) speech; neurological abnormalities; recent labs; all active diagnoses; cognitive and emotional status; change in mental status and LOC (level of consciousness). Direct care staff to notify nurse if they notice subtle, but significant changes in the patient: For example: Decrease in food intake; Increase confusion/agitation; Change in vital signs etc; Change in balance; Injury from fall; Change in neuro's (neurological findings). The nursing staff will notify the physician if any of the above signs and symptoms are identified. The physician will indicate if patient requires additional evaluation/ treatment at the facility or if patient needs to be sent out to the hospital. Nurse to also notify family if requested by patient or family is listed to contact in case of an emergency. III. Resident #1 A. Resident status Resident #1, age [AGE], was admitted on [DATE] and discharged on 11/28/24 due to death. According to the November 2024 computerized physician orders (CPO), diagnoses included encephalopathy, cerebral infarction, acute pancreatitis, type 2 diabetes mellitus, chronic kidney disease, and long-term and current use of anticoagulants (blood thinners). The 10/20/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of 6 out of 15. He was dependent on assistance with eating, bathing, upper and lower body dressing, personal hygiene, bed mobility, and transfers. The record revealed no documented discussion with the resident/resident representative concerning hospice or palliative care. Further record review revealed no Medical Orders for Scope of Treatment (MOST) form, identifying the type of treatments and interventions the resident/representative wanted but may be unable to express. However, the care plan read Full code (life-saving measures if respiratory/cardiac arrest), initiated 11/13/24. Orders revealed the resident was administered anticoagulants. A review of a 10/10/24 physician note revealed Resident #1 was started on Lovenox (an anticoagulant) by injection at the hospital and continued after admission until 11/7/24 when, per the November 2024 CPO, Lovenox was discontinued due to a site reaction to the injections. The anticoagulant Apixaban (Eliquis) an oral anticoagulant, 2.5 MG (milligram) was ordered for administration by mouth two times a day for DVT (deep vein thrombosis). This order was discontinued on 11/13/24 at 8:12 a.m., and Apixaban oral tablet 2.5 MG by mouth two times a day for DVT was ordered (start date site of 11/13/24 at 9:00 p.m.). A review of the TAR revealed an order for anti-coagulation medication monitoring: monitor every shift for signs and symptoms of bleeding (black tarry stools, increased or new bleeding of gums, blood in urine, etc). If complications notify MD. P = Problems, 0 = No Problems. Start date 10/16/24, and discontinued date 11/13/24. B. Change in status/goals after admission 1. Record review revealed documentation of the resident's primary care provider (PCP) follow-up visit to discuss goals of care on 11/26/24 at 8:45 a.m. It read in part: -Resident #1's hospitalization history: admitted to the hospital on [DATE] with global weakness and dysarthria. The patient was then discharged from the hospital to the skilled nursing facility on 10/14/24. The patient transferred to the emergency room (ER) on 11/13/24 for concerns of developing sepsis, diagnosed with COVID, and sent back to the facility. The resident transferred to the ER on [DATE] for liver function testing, increasing lethargy, and worsening pulmonary symptoms. Urinary tract infection (UTI) diagnosed in the ED (emergency department). The resident was transferred to the ER on [DATE] and 11/18/24 due to feeding tube issues. The feeding tube was unclogged and the patient was sent back to the facility. -Goals of care discussion held 11/26/24 with the resident and his wife through an interpreter over the phone who speaks Chuukese (arranged per facility administration). Explained in detail numerous medical issues that the patient was currently dealing with. Explained in detail that given the multitude of issues as well as progressive worsening in weakness and failure to improve with therapy that it was unlikely that patient will improve from a therapeutic standpoint in regards to his stroke. Explained that he will likely never swallow again, he will likely never walk again, and will be dependent on others for the remainder of his life. Also explained given the multitude of issues affecting multiple organ systems that further worsening of such is likely to occur and that rehospitalization was certain in his future. -We discussed CPR (cardiopulmonary resuscitation) at length, what it entails, what that would look like for Resident #1 and possible outcomes of such. After answering questions, the wife decided that CPR/intubation would not likely be in the patient's best interest and instead DNR would be more appropriate. New MOST form filled out and filed. A bedside nurse was present in the room for the entire discussion. All questions answered. 2. Events 11/27/24 and 11/28/24 An 11/27/24 nursing progress note revealed Resident #1 was changed at the beginning of the shift (6:00 p.m.) by a certified nurse aide (CNA). When Resident #1 was rolled to his right side, the resident had vomited coffee ground emesis. Resident #1 was cleaned up and the nurse was notified. Resident #1's brief was changed and found to have a dark bowel movement. A call was made to the DON. A full assessment was completed by the registered nurse (RN) in the building and notified the DON of the results. The DON called the provider and he gave the following orders: One time order of 30ML of first-lansoprazole oral suspension 3 MG/ML (Lansoprazole) (a medication that reduces acid in the stomach). Vital signs every four hours and if systolic blood pressure was less than 100 or heart rate greater than 100 to call the provider. The 11/28/2024 at 4:47 a.m. death note revealed the DON had called the provider at approximately 10:30 p.m. and he gave the following orders: One time order of 30ML of First-Lansoprazole Oral Suspension 3 MG/ML (Lansoprazole.) Vital signs every four hours. If Systolic is less than 100 or HR (heart rate) is greater than 100 call the provider. Vitals just after midnight: Blood pressure 109/68, Temperature 98.1, Pulse 100, Respirations 19, O2 (oxygen saturation) 90%. The resident was checked on at 2:00 a.m. and had no changes to note. At 4:10 a.m. the staff went in to check on the resident and complete vital signs and the patient had no respirations or heart tones. Eyes were fixed and dilated. RN assessed patient for the final outcome. The patient was a DNR. Time of pronouncement of death: 4:10 a.m. per on-call physician. Body not sent anywhere at this time. Wife in room and would gather belongings. Skin condition upon death: intact. Responsible party notification: Wife in attendance in room. MD Notification: On-call notified at 4:20 a.m. C. Record review and interviews revealed the facility failed to ensure Resident #1 received treatment and care consistent with professional standards of practice. The DON was interviewed on 2/10/25 at 5:28 p.m. The technician at the local county coroner's office was interviewed on 2/11/25 at 10:08 a.m. Resident #1's PCP was interviewed on 2/11/25 at 10:19 a.m. The ADON was interviewed on 2/11/25 at 1:11 p.m. The NHA was interviewed on 2/11/25 at 2:47 p.m. and LPN #1 was interviewed on 2/11/25 at 5:42 p.m. 1. Failure to properly manage Resident #1's anticoagulant therapy a. Record review Although the resident's TAR revealed an order for anti-coagulation medication monitoring every shift for signs and symptoms of bleeding (see above), this order was discontinued on 11/13/24. There was no explanation for discontinuing monitoring for evidence of bleeding, and a review of the TAR and the resident's electronic medical record revealed no documentation of anticoagulant monitoring from 11/13/24 to 11/28/24 - 26 shifts over 13 days. Although there are significant risks to resident safety from anticoagulants (see references above), a review of the resident's care plan revealed it did not address anticoagulant therapy - the risks, signs/symptoms of bleeding, or monitoring expectations found on the TAR. Finally, the resident's record did not contain consent for the use of the anticoagulant medication Eliquis. b. Interview ADON: The assistant director of nursing (ADON) said if a resident is on an anticoagulant, the nurses should be monitoring for signs and symptoms of bleeding, evaluating the resident if signs of bleeding are reported by staff, and documenting the evaluation. The ADON said it was important to monitor if a resident uses anticoagulant medication for the very reason with Resident #1 of a gastrointestinal bleed. The ADON said without monitoring, there could be abnormal labs, leading up to and including death. The ADON said there should be a care plan for all residents using an anticoagulant medication so that staff providing care were aware. PCP: The PCP said if a resident was on an anticoagulant medication such as Eliquis, there should be monitoring and documentation of symptoms of bleeding. The PCP said it went without saying how important it was because healthcare providers worry about the ongoing risk of hemorrhage. 2. Failure to properly manage Resident #1 change of condition a. Interviews DON: The DON, who assumed her position on 12/27/24, said she did not know why Resident #1 was not sent to the hospital when he had signs and symptoms of a gastrointestinal bleed. ADON: The ADON said she was the nurse on-call and acting as the interim DON during the evening on 11/27/24 and early morning on 11/28/24. She said it was her understanding that Resident #1's bleeding was not new and that he had gone to the hospital multiple times with the same issue. She said this was reported to her from the staff that evening. She said on the night of 11/27/24, she got a call from LPN #1 and she spoke to the RN in charge who made it sound like, and confirmed, that the resident had gone out to the hospital multiple times for the same issue (coffee ground emesis and dark stool) and it sounded like a recurrent issue in the way it was presented. She said typically, if it was a new bleed, the resident would be sent out immediately and per protocol, a change of condition assessment form completed. The ADON confirmed she did not have an RN assessment for Resident #1 or a completed change of condition assessment form. The ADON said she called the on-call physician and told him it was reported the resident had abdominal distension, that the resident had received both doses of his anticoagulant, and that the resident had coffee-ground emesis and dark-colored bowel movement. She said the physician was made aware of the bleeding, but told it was a frequent event, not a new event. He was informed the resident's status had changed to DNR, the wife was at the bedside and it was reported to her the wife did not push to send the resident to the hospital but did not say either way. The ADON said the action decided on by the physician was to give Prevacid (a medication that reduces acid in the stomach), check vitals every four hours with parameters of when to notify the provider, and ordered a CBC but not stat (right now). It was not obtained before the resident expired. The ADON said at the time of the incident she agreed with the provider, but with what she knew now, that the bleeding was a new issue, her decision would have been different and she would have recommended sending Resident #1 to the hospital. PCP: The PCP said if there was a change in condition, such as increased bleeding, nose bleeds, vomiting blood, or gastrointestinal bleeding, she would want to be notified. The PCP said the facility should know to contact her or call 911. The PCP said if there was no documentation stating otherwise, a resident with new significant bleeding should be sent to the hospital for further monitoring and evaluation. The PCP said she saw Resident #1 on 11/26/24 before taking time off. When she returned to work, she asked what happened in reference to the resident's death. The PCP said she thought Resident #1 should have been sent to the hospital. She said that although she was not the provider who was covering that day, whenever she heard about a gastrointestinal bleed and the resident was on an anticoagulant medication, they should go to the hospital. NHA: The NHA said Resident #1 spoke a rare language, Chuukese (a language spoken in the Federated States of Micronesia). The NHA said the resident had been sent out to the hospital a couple of times in November 2024. The NHA said his understanding about what had occurred with Resident #1 was that the resident's wife had said no - the resident did not want to be sent out. He said the ADON called and told him the resident's clinical indicators were decreasing and told him they were going to send the resident out but the wife said no. The NHA said an interpreter was not present. The resident's wife spoke some English; however, he acknowledged there was no documentation of the resident's wife saying no to hospitalization. He said he found out that Resident #1 had passed away the next morning. LPN #1: LPN #1 said she had worked at the facility for one year and was the nurse who was working on the night of 11/27/24 and early morning of 11/28/24 with Resident #1. LPN #1 said that Resident #1 had a lot going on and the doctor during the day came in and that was the report she got. LPN #1 said Resident #1 had a lot of congestion going on and breathing was loud. LPN #1 said when she first checked on him, his tube feeding was going and he was sitting up. LPN #1 said the CNA told her of Resident #1's dark bowel movement and coffee-colored emesis but the CNA did not show it to her. LPN #1 said Resident #1 had not had a dark bowel movement or coffee-colored emesis before. LPN #1 said the RN had come up to the third floor from the second floor to assess him. LPN #1 said the bleeding was new as far as she was concerned. LPN #1 said she did not speak to the doctor. She called the ADON (interim DON at the time) who said to have the RN do a full assessment and call her back and then she (ADON) would call the doctor. LPN #1 said after that, the RN called the ADON back to give her a report. LPN #1 said she did not remember what the RN said after the assessment. LPN #1 said basically, the RN found nothing wrong and she asked the RN if she thought Resident #1 should be sent out and the RN said no, that she had talked with the ADON. LPN #1 said she was told to call the ADON with any change of condition, and before calling a provider or sending a resident out to the hospital. LPN #1 said she had tried to call the daughter but she had not answered. LPN #1 said she felt that Resident #1 should have gone to the hospital but she deferred to the RN and ADON (interim DON at that time). County coroner technician (CCT): The technician at the local county coroner's office said Resident #1's actual cause of death as listed on the death certificate was presumed gastrointestinal bleed caused by gastric ulcers as recorded by Resident #1's PCP. b. Record review There was no documentation of the RN's full assessment on 11/27/24 in the electronic medical record or a change of condition assessment form, and, per the NHA, no RN assessment note was completed. There was no documentation why the resident was not sent to the hospital, which was the expectation for a new bleed per the ADON. On 2/11/25 at 12:21 p.m., the RN assessment for the 11/27/24 event was requested. On 2/11/25 at 1:50 p.m., the NHA responded that an RN assessment note was not completed and the RN had been terminated. The Change of Condition policy (see above) was not reviewed or revised following the events on 11/27/24 that revealed nursing staff failed to fully evaluate, document, and report Resident #1's change in condition. A review of the policy revealed it was last reviewed 4/2/24, per the Change of Condition document provided by the NHA. Printed on the Change of Condition policy document was the issuing date (7/1/18), a revised date (2/8/21), a revised date (8/20/22), and a reviewed date (4/2/24). (Department of Nursing) A review of the electronic medical record revealed there were no physician orders to send Resident #1 to the hospital. 3. Failure to take steps to clarify Resident #1 and their representative's goals for care to ensure a response consistent with their goals. a. Record review The 11/26/24 PCP follow-up visit to discuss goals of care (see above) indicated a new MOST form that documented Resident #1 would be a DNR (do not resuscitate) was filled out and filed. Further, the resident's record revealed an order was written with a start date of 11/26/24 that read Resident #1 was a DNR (do not resuscitate)/No code. -Notwithstanding the PCP note and order above, the new MOST form (or copy), requested from the NHA on 2/10/25 at 4:22 p.m., could not be located as of 2/13/25 according to the NHA. -Notwithstanding the PCP note and order above, a review of Resident #1 care plan was not updated and read the resident was a full code, initiated on 11/13/24. b. Interviews DON: The DON said she did not recall anything about Resident #1's M[TRUNCATED]