**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to ensure one (#7) of six residents reviewed for quality of care out of seven sample residents, received treatment and care in accordance with professional standards of practice.IMMEDIATE JEOPARDYResident #7 was admitted on [DATE] with diagnoses of Parkinson's disease (a progressive disease that causes symptoms such as tremors, stiffness and slow movement), epilepsy without status epilepticus (seizure lasting longer than five minutes, or two or more seizures without the resident gaining consciousness in between them), chronic respiratory failure, dependence on supplemental oxygen and cognitive communication deficit.On 6/26/25, Resident #7 experienced seizure activity that lasted longer than 30 minutes. During the seizure activity, the resident was observed to be having seizures by several staff members. The nurse practitioner (NP) was notified three times, by three different staff members, during the resident's seizure activity, however the NP did not ask staff to obtain vital signs or conduct any assessment of the resident. The NP did not give staff a physician's order to send Resident #7 to the emergency department (ED) until the resident had been experiencing seizure activity for over 30 minutes.When emergency medical services (EMS) arrived at the facility, Resident #7's airway was compromised, and he required an artificial airway placement (a medical device inserted into the trachea (windpipe) to maintain or restore a patient's airway, especially when they cannot breathe effectively on their own). Resident #7 was admitted to the intensive care unit (ICU) and placed on a ventilator.On 6/26/25, Resident #7 experienced a situation of serious harm. The facility's failure to implement a plan to ensure staff were trained on how to monitor residents for seizure activity, how to identify seizure activity and respond timely and appropriately when a resident was experiencing seizures to ensure the incident did not reoccur created the potential for serious harm to Resident #7 and other residents with a seizure disorder if the situation was not immediately corrected. ADDITIONAL FAILURES FOR RESIDENT #7Further review of Resident #7's electronic medical record (EMR) revealed Resident #7 readmitted to the facility following his hospitalization for seizure activity on 7/7/25. On 7/9/25 a physician's order was given for midazolam (an anticonvulsant medication for breakthrough seizure activity), however, the facility failed to ensure the medication was obtained from the pharmacy until 7/15/25, six days after the medication was obtained.Additionally, the facility failed to ensure nursing staff were trained on how to appropriately administer the midazolam medication to Resident #7 in the event the resident experienced another seizure episode.Specifically, the facility failed to:-Provide timely assessment and intervention during a change of condition for Resident #7; and,-Obtain Resident #7's breakthrough seizure medication in a timely manner after a new physician's order was given on 7/9/25 and ensure staff were trained on how to administer the medication to the resident.Findings include:IMMEDIATE JEOPARDYI. Findings of Immediate Jeopardy On 6/26/25, at 1:33 p.m. a care conference was held with the resident's representative. The resident's representative reported to the clinical team that she was concerned whether or not the resident's seizure medications were effective for Resident #7, as he had had several seizures in the last hour. After the care conference conference, around 1:49 p.m., registered nurse (RN) #3 called the NP and received a verbal physician's orders for lab work for Resident #7. -However, RN #3 did not check on the resident and did not assess him for seizure activity. At 2:00 p.m. RN #2 was notified by a dietary staff member of Resident #7's emergency. RN #2 went to Resident #7's room and observed Resident #7 having seizure activity. -However, RN #2 did not complete or document the resident's vital signs or overall condition. RN #2 contacted the same NP a second time, at approximately 2:20 p.m. and reported the seizure activity for Resident #7. The NP said she needed to review the resident's chart and would call back. -However, the NP did not call back within the next 10 minutes. At 2:30 p.m. the NP was called a third time by licensed practical nurse (LPN) #4 to notify the NP about Resident #7's seizure activity that had been occurring for more than 30 minutes. The NP gave a physician's order to send the resident to the hospital via EMS. Resident #7 was admitted to the ICU and placed on a ventilator. The director of nursing (DON) was interviewed on 7/10/25 at 3:20 p.m. The DON said Resident #7 had a history of behaviors. The DON said the resident would stare at the wall and not respond to staff if the staff were not providing his care as he preferred. The DON said Resident #7 had Parkinson's tremors, and when he was first discovered on 6/26/25, he had tremors. The DON said when the staff realized the tremors were worse, they called EMS.Staff interviews on 7/14/25 (during the survey) revealed that staff was not able to recognize the difference between the resident's Parkinson's tremors and seizure activity. The staff said they had not received any recent training on seizure management (see interviews below).During the survey, the facility was unable to find documentation to indicate the licensed nursing staff completed assessments or vitals signs during the time period on 6/26/25 when Resident #7 was experiencing seizure activity (see record review and interviews below).The DON was interviewed on 7/14/25 at 9:50 a.m. The DON said the facility's IDT had not reviewed Resident #7's seizure incident. She said she reviewed the incident and determined facility staff responded appropriately to Resident #7 on 6/26/25. The DON said she was unable to locate documented nursing assessments or vital signs related to the incident. The DON said the staff completed an Hospital Transfer form, which acted as the assessment.The facility failed to provide the licensed nursing staff education regarding seizure activity monitoring and procedures to follow in the event that a resident was experiencing a seizure. On 7/15/25 at 12:40 p.m. the nursing home administrator (NHA) and the DON were notified that the facility's failure to timely assess and intervene appropriately when Resident #7 had a change of condition related to seizure activity and the facility's failure to educate the licensed nursing staff regarding seizure activity monitoring and procedures after the incident on 6/26/25 created the potential for serious harm if the situation was not immediately corrected. B. Facility plan to remove the immediate jeopardyOn 7/16/25 at 3:10 p.m. the NHA provided a plan to remove the immediate jeopardy situation. The removal plan read: Plan of Correction: Beginning 7/11/25 and completed on 7/15/25, the nursing staff were provided seizure-specific education, including types of seizures, management of seizures, and response to seizures.Monitoring for seizure activity would occur every two hours for all residents with a seizure diagnosis, starting 7/15/25.Resident #7's midazolam rescue inhaler was received on 7/15/25 and placed in the Main Hall medication cart. The charge nurse on duty, RN #2, for Resident #7 was educated on the proper use of medication on 7/16/25.On 7/15/25 the facility identified additional residents with a seizure condition based on medical diagnosis and history and physical.Starting 7/15/25 the identified residents with a seizure diagnosis would have physician's orders in place to monitor seizure activity and the number of seizures every shift, with a note to contact the physician if seizure activity was observed.Beginning 7/16/25 all residents with a seizure diagnosis would be reviewed every morning by the interdisciplinary team (IDT). The residents' medication administration records (MAR) and plan of care would be reviewed daily with the IDT to ensure that new findings (such as seizure activity) were communicated to the physician. The IDT would ensure there was physician feedback documented in the resident's medical records.On 7/15/25 the care plans for all residents with a seizure diagnosis had been updated to reflect seizures and monitoring.On 7/15/25 Resident #7's Kardex (staff directive tool utilized to provide personalized resident care) was reviewed to ensure documentation was listed as indicated to reflect seizures and monitoring.On 7/15/25 physician's orders for parameters were placed in all residents' charts with a seizure diagnosis that read For seizure lasting greater than five minutes, despite interventions or if airway compromised, call 911 and send to ED (emergency department).On 7/15/25 a physician's order was added to Resident #7's CPO for differentiation of tremors versus seizures. This would be assessed by pulse oximetry (a non-invasive method used to measure the oxygen saturation level in the blood) per the physician. Oxygen saturations (level of oxygen in the blood) would be monitored every shift.C. Measures implemented to prevent recurrenceOn 7/16/25 the medical director (MD) initiated seizure-specific training to the nursing staff.On 7/11/25 the staff development coordinator (SDC) began educating the nursing staff on types of seizures and seizure management, as specified by the physician's orders, the residents' Kardex and the care plans. Each nurse would receive the training before the beginning of their next shift.On 7/11/25 all nursing staff would be educated by the SDC on appropriate documentation of emergency situations, changes in condition and physician notification. Each nurse would receive the training before the beginning of their next shift.D. Removal of immediate jeopardyOn 5/16/25 at 5:50 p.m. the NHA was notified that the immediate jeopardy situation was removed, based on the facility's plan and evidence of its implementation. However, deficient practice remained at a G level, actual harm that is not immediate jeopardy, isolated.II. Professional referencePotter, P. A., & [NAME], A. G. (2023). Fundamentals of Nursing E-Book (11th ed., pp. 824-834). Elsevier Health Sciences was reviewed and included instructions for nurses for managing seizure activity as follows: Call 911 if a person has repeated seizures, if a seizure lasts five minutes or longer, or if seizures occur closer together than usual for that person. When a seizure begins, note the time, track the duration of the seizure, and notify the provider immediately. Time the seizure from the beginning to the end of the active seizure. Turn the person onto their side if they are not awake or aware, with the mouth pointing toward the ground. Prolonged or repeated seizures indicate status epilepticus, a medical emergency that requires intensive monitoring and treatment. It is important that you observe the patient carefully before, during, and after the seizure so that you can document the episode accurately. Seizure precautions encompass nursing interventions to protect a patient from traumatic injury, to position for adequate ventilation and drainage of oral secretions, and to provide privacy.III. Facility policy and procedureThe Change in a Resident's Condition or Status policy and procedure, dated February 2021, was received from the DON on 7/14/25 at 12:01 a.m. It read in pertinent part, Our facility promptly notifies the resident, the attending physician, and the resident's representative of the resident's medical condition and status. The nurse will notify the resident's attending physician when there has been a significant change in the resident's physical condition. A significant change is a major decline in the resident's status that will not normally resolve itself without intervention by staff and is ultimately based on the judgment of the clinical staff. Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's status. The nurse will record in the resident's medical record information relative to changes in the resident's status.IV. Resident #7A. Resident statusResident #7, age greater than 65, was admitted on [DATE], discharged to the hospital on 6/26/25 and readmitted on [DATE]. According to the July 2025 computerized physician's order (CPO), diagnoses included Parkinson's disease, epilepsy without status epilepticus, chronic respiratory failure, dependence on supplemental oxygen, and cognitive communication deficit. The 6/19/25 minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of 11 out of 15. Resident #7 was dependent on staff assistance for all activities of daily living (ADL). The MDS assessment identified Resident #7 had a seizure disorder or epilepsy and was prescribed midazolam. B. Resident #7's representative interviewResident #7's representative was interviewed on 7/14/25 at 3:41 p.m. The representative said that on 6/26/25 at approximately 12:30 p.m., she arrived at the facility to visit Resident #7. The representative said that between 12:30 p.m. and 1:30 p.m., she observed Resident #7 experience three seizures. She said each seizure lasted a few minutes, in which Resident #7 had tremors, his body was stiff and he was unable to respond. She said each seizure lasted longer than the previous seizure and the third seizure was not normal for Resident #7 because it lasted longer and he did not recover as quickly from the seizure. The representative said she was scheduled to attend a care conference for Resident #7 on 6/26/25 at 1:30 p.m. The representative said when she arrived for the care conference, she reported to the staff that she was concerned that the resident's recent medication changes were causing seizures and that she wanted the medication stopped. The representative said the care conference ended promptly due to Resident #7 having seizure activity. The representative said when she returned from the care conference to Resident #7's room, he was not responsive and was experiencing a seizure. The representative said nurses went to the resident's room to check on Resident #7. She said she did not recall what actions the nurses took, but said she heard a discussion and was aware the provider was contacted. The representative said the nurse never left Resident #7's room and did not administer any medications to stop the seizure activity. The representative said she heard the nurses discussing facility protocol and procedure, and the agency nurse (LPN #4) asked the facility staff what the facility protocol and procedure were for emergencies. The representative said before EMS arrived, she heard Resident #7 having gurgling sounds when he was breathing. C. Record review1. Care planThe neurological status care plan, initiated on 6/24/18, revealed the resident had an altered neurological condition related to a seizure disorder and Parkinson's disease with a history of antipsychotic medication use. Pertinent interventions included assessing Resident #7 for effects of psychotropic medications, involuntary dystonia (muscle spasms), akinesia (restlessness), akinesia (difficulty with voluntary movements), rigidity, and tremors (initiated 6/27/18), placing the resident on his side, maintaining an open airway and removing obstacles to ensuring a safe environment if seizure activity occurred (initiated 6/27/18), notifying the physician if the resident had a seizure (initiated 6/27/18), following seizure precautions, including not leaving the resident alone, protecting the resident from injury removing or loosening tight clothing (initiated 6/27/18), providing medications for breakthrough seizures as ordered and monitoring for side effects and effectiveness (initiated 7/14/25), monitoring for seizure activity every shift (initiated 7/14/25), monitoring for tremors, rigidity, changes in level of consciousness and slurred speech every shift (initiated 7/14/25), notifying the physician in the event of seizure activity (initiated 7/14/25) and providing visual checks every two hours and as needed for signs and/or symptoms of seizures (initiated 7/14/25).2. EMS documentationThe 6/26/25 EMS documentation was provided on 7/18/25 at 10:05 a.m. from the EMS company. The EMS documentation, dated 6/26/25 at 2:41 p.m., revealed Resident #7 was unresponsive. The resident's blood pressure was 140/80 millimeters of mercury (mmHg), his heart rate was 160 beats per minute (BPM -normal adult range is 60 to100 BPM), and had premature ventricular contractions (abnormal heart rhythm). The resident's respirations were 20 breaths per minute and his breathing was labored. His blood sugar was 170 milligrams per deciliter (mg/dl) and his body temperature was 102 degrees Fahrenheit (F). The EMS staff administered an injection of Versed (a medication to slow down brain activity), placed the resident on high-flow oxygen with a non-rebreather mask and suctioned Resident #7's airway. The EMS staff noted Resident #7 did not have an intact airway and the resident was not taking adequate breaths. The EMS staff removed the non-breather oxygen mask and inserted an artificial airway. The EMS staff provided respiration assistance to the resident using a bag, valve and mask technique with suction. 3. NP documentationThe Summary of Episode note, dated 6/27/25 at 7:39 p.m., written by the NP, was received from the DON on 7/15/25 at 3:34 p.m. The episode summary documented Resident #7's respiratory rate was 18 breaths per minute, his blood pressure was 118/78 mmHg, his body temperature was 98.2 F, his rate rate was 77 BPM, his oxygen saturation level was 82% (percent) and his blood sugar level was 122 mg/dl.-However, the vital signs documented in the episode summary note were the vital signs that had been documented in Resident #7's EMR on 6/25/25 at 8:31 p.m. (the night before the resident's seizure episode), with the exception of the resident's blood sugar level which was documented on 6/14/25, 12 days prior to the seizure episode. -The NP's episode summary note did not include documentation of the verbal telephone orders for lab work that were provided to RN #3 at 1:49 p.m. or the telephone calls RN #2 and LPN #4 made to the NP. -There were no additional provider progress notes documented in the EMR until 7/7/25, when Resident #7 returned from the hospital.4. Change in condition assessmentThe 6/26/25 2:45 p.m. Hospital Transfer form documented at 2:45 p.m. was provided by the DON on 7/15/25 at 3:34 p.m. The Hospital Transfer form documented Resident #7's respiratory rate was 18 breaths per minute, his blood pressure was 118/78 mmHg, his body temperature was 98.2 F, his rate rate was 77 BPM, his oxygen saturation level was 82% (percent) and his blood sugar level was 122 mg/dl.-However, the vital signs documented in the Hospital Transfer form were the vital signs that had been documented in Resident #7's EMR on 6/25/25 at 8:31 p.m. (the night before the resident's seizure episode), with the exception of the resident's blood sugar level which was documented on 6/14/25, 12 days prior to the seizure episode.-Review of Resident #7's EMR revealed there were no additional vital signs obtained or documented in the resident's EMR after the resident's representative reported seizure activity and the facility staff observed the resident with seizure activity on 6/26/25. -The Hospital Transfer form documented that Resident #7 had a risk for seizures but did not include information about the 6/26/25 seizure activity on the form.5. Progress notes-There was no documentation to indicate RN #3 notified the NP about the seizure activity before the care conference.The 6/26/25 at 2:32 p.m. nursing progress note, documented by RN #2, revealed RN #2 was called to Resident #7's room at 2:00 p.m. where he observed Resident #7 with seizure activity. Resident #7 was unconscious and had involuntary movement which lasted longer than 30 minutes. -However, there was no documentation in Resident #7's EMR to indicate that RN #2 assessed Resident #7, recorded what time the NP was contacted, the NP's response, or what time emergency services were contacted.The 6/26/25 at 3:07 p.m. nursing progress note, documented by LPN #4, revealed LPN #4 revealed that the NP was called a third time, and informed that Resident #7 had continued seizure activity for 30 minutes. The note revealed that a physician's order was obtained from the NP to transfer Resident #7 to the ED. -However, there was no documentation in Resident #7's EMR to indicate that LPN #4 assessed Resident #7, what time the NP was contacted, the NP's response, or what time emergency medical services were contacted. -Review of Resident #7's EMR revealed there was no documentation to indicate an assessment was conducted by a licensed nurse during Resident #7's seizure activity on 6/26/25.D. Staff interviewsRN #2 was interviewed on 7/10/25 at 3:00 p.m. RN #2 said nurses could provide several interventions to manage residents' seizure activity. RN #2 said if a resident had seizure activity, they should be placed on their side and the provider should be notified. He said if the resident had medications for breakthrough seizures ordered the medications should be administered when the resident was experiencing a seizure.The DON was interviewed on 7/10/25 at 3:20 p.m. The DON said Resident #7 had a history of behaviors. The DON said the resident would stare at the wall and not respond to staff if the staff were not providing his care as he preferred. The DON said Resident #7 had Parkinson's tremors, and when he was first discovered on 6/26/25, he had tremors. The DON said when the staff realized the tremors were worse, they called EMS.The DON was interviewed again on 7/14/25 at 9:50 a.m. The DON said the facility's IDT had not reviewed Resident #7's seizure incident. The DON said she was unable to locate documented nursing assessments or vital signs related to the incident. The DON said the staff completed a Hospital Transfer form, which acted as the assessment.Certified nurse aide (CNA) #1 was interviewed on 7/14/25 at 1:00 p.m. CNA #1 said she did not remember receiving any training regarding seizure monitoring or seizure protocol. She said if she noticed a resident having abnormal movement, she would notify the nurse on duty. She said Resident #7 had mild tremors to his right arm because he had Parkinson's disease. She said Resident #7 was always able to answer questions and respond appropriately. CNA #2 was interviewed on 7/14/25 at 1:20 p.m. CNA #2 said she did not know who she needed to monitor residents for seizure activity because that was the nurse's job. She said her nurse manager never told her that she needed to monitor residents for seizure activities and she was not trained to do so. LPN #1 was interviewed on 7/14/25 at 2:00 p.m. LPN #1 said it was her first day working at the facility. LPN #1 said she did not receive any facility-specific training before the start of her shift. She said if she noticed a resident having continuous seizures for more than one minute, she would reach out to the physician for emergency medication orders. She said if a seizure was noted to last more than five minutes, she would immediately call 911 for medical transfer to the hospital. She said additionally, she would complete a progress note to document the event details because the facility did not have a seizure-specific documentation assessment.RN #1 was interviewed on 7/14/25 at 2:10 p.m. RN #1 said if a resident was having a seizure, he would protect the resident from injury by making sure their limbs did not hit any bed rails and he would turn the resident's head to the side so they did not aspirate. RN #1 said that if a resident had a seizure for more than three minutes, he would call 911. RN #1 said he did not know if that was the facility's protocol, but that was what he would do, based on his years of experience as a bedside nurse. RN #1 said typically, the DON would do the education for the staff regarding what to monitor for resident seizure activity. RN #1 said he thought he received education on seizures, but he was not sure.LPN #3 was interviewed on 7/14/25 at 2:17 p.m. via telephone. LPN #3 said she looked at the residents' care plans for interventions on how to monitor a resident with a history of seizures. She said she would also check the physician's orders for rescue medication to stop the seizure if it exceeded five minutes in duration. She said immediate action would include assessing the resident's vital signs, documenting the type and duration of the seizure and notifying the physician immediately. She said it was important to follow these steps because if a seizure lasted more than five minutes, it could cause brain damage or death. She said she started working at the facility four months ago. LPN #3 said she did not remember receiving any type of training on seizure protocol.The NP was interviewed on 7/15/25 at 10:00 a.m. The NP said she remembered the events of that day (6/26/25). The NP said she received a total of three calls from the staff regarding Resident #7. The NP said the first call was regarding a medication change and she ordered STAT labs. She said about 20 minutes later, she received a second call from a nurse saying that Resident #7 was having active prolonged seizures. The NP said during the second call, she told the nurse on the phone that she would review Resident #7's EMR and give him a call back. The NP said she did not ask for vital signs or a resident assessment and the staff did not provide her with information obtained from a resident assessment. She said she received the third call a few minutes later, from a different nurse, indicating that Resident #7 needed to go to the hospital. The NP said she did not ask for Resident #7's assessment or vital signs during the third phone call. She said she gave a verbal physician's order to the third nurse to send the resident to the hospital. The medical director (MD) was interviewed on 7/15/25 at 10:30 a.m. The MD said he often had issues with the nurses at the facility not completing assessments on residents in emergency situations. The MD said he was not notified the day that Resident #7 had a seizure (6/25/25). The MD said if he was notified of the seizure activity, he would have asked the nurses to do a complete assessment in order to help him correctly treat the acute issue. The MD said based on the severity and the resident's medical history, a prolonged continuous seizure lasting in excess of 30 minutes could cause harm to a resident.E. Facility follow-upOn 7/14/25 at 8:15 a.m. (during the survey) the DON provided a written statement from RN #2. The statement, dated 7/13/25, read in pertinent part, This writer (RN #2) and LPN #4 assessed Resident #7 for Parkinson's disease signs and symptoms due to the resident always having involuntary upper arm movement, while monitoring oxygen saturation and vital signs. -However, review of Resident #7's EMR did not reveal additional documentation of the resident's vital signs after the vital signs that were taken on 6/25/25 at 8:31 p.m. (see record review above).RN #3 sent an email communication to the DON on 7/15/25 at 2:07 p.m. (during the survey). The email was provided by the DON on 7/15/25 at 3:34 p.m The email documented that RN #3 had attended the care conference for Resident #7 on 6/26/25 at 1:33 p.m. via telephone. RN #3 said she notified the NP that Resident #7's representative was concerned about the resident's medications after the resident had a couple of episodes of staring into space for a few seconds on 6/26/25, before the care conference. RN #3 said she informed the representative that she would notify the physician of the concerns and that the facility would see if there was a different medication for Resident #7. RN #3 documented in the email that she notified the NP on 6/26/25 at 1:49 p.m. of the staring episodes. RN #3 said the NP ordered STAT (immediate, without delay) labs for the resident. RN #3 documented in the email that she informed RN #2 about the lab work.-However, review of Resident #7's EMR did not reveal any documentation regarding RN #3's conversation with the resident's representative or her phone call with the NP, where physician's orders were obtained for lab work. V. ADDITIONAL FAILURES FOR RESIDENT #7A. Facility policy and procedureThe Administering Medications policy, dated April 2019, was provided by the DON on 7/15/25 at 10:06 a.m. The policy read in pertinent part, Medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted may prepare, administer, and document the administration of medications. The director of nursing services (DON) supervises and directs all personnel who administer medications and/or have related functions. Medications are administered by prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: - Enhancing the optimal therapeutic effect of the medication; -Preventing potential medication or food interactions; and-Honoring resident choices and preferences, consistent with their care plan. The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the medication administration record (MAR) space provided for that drug and dose. The individual administering the medication signs the resident's MAR on the appropriate line after giving each medication and before administering the next ones. As required or indicated for a medication, the individual administering the medication records in the resident's medical record:-The date and time the medication was administered;-The dosage;-The route of administration;-The injection site (if applicable);-Any complaints or symptoms for which the drug was administered;-Any results achieved and when those results were observed; and,-The signature and title of the person administering the drug.B. Resident #71. Record reviewA review of Resident #7's July 2025 CPO revealed the following physician's order:Midazolam nasal solution solution 5 mg/0.1ml. Administer one spray in the left nostril every 24 hours as needed for breakthrough seizure activity. Administer one spray to the left nostril for one dose, repeat dose in the other nostril for one dose in ten minutes, if needed, ordered 7/9/25 at 2:11 p.m. -However, the midazolam medication was not delivered until 7/15/25 at approximately 8:00 p.m. (see DON interview below).C. Staff interviews RN #2 was interviewed on 7/10/25 at 3:00 p.m. RN #2 said if a resident had medications for breakthrough seizures ordered the medications should be administered when the resident was experiencing a seizure. RN #2 said emergency medications were available in the emergency medication kit which was stored in the medication room, however, he said he was unaware if there were emergency medications for seizures available in the facility.The DON was interviewed on 7/14/25 at 4:52 p.m. The DON said she was unaware that the midazolam medication was not available for Resident #7. The DON said the nurses should have monitored the status of the resident's midazolam until it was delivered from the pharmacy. The DON was interviewed again on 7/16/25 at 3:00 p.m. The DON said Resident #7's Midazolam medication ordered for seizures on 7/9/25 was delivered on 7/15/25 at approximately 8:00 p.m.The DON said it was the responsibility of the licensed nurses to follow up with the pharmacy when they realized a medication was not delivered promptly. The DON said this was concerning because Resident #7 could have had another seizure and there was no medication available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure one (#1) of three residents out of eight sample residents received treatment and care in accordance with professional standards of practice. The facility failed to identify and respond to Resident #1's non-pressure related skin condition resulting in the development of osteomyelitis (bone infection), hospitalization and amputation of his left great toe. Resident #1, diagnosed with heart disease with heart failure and type 2 diabetes mellitus, was admitted to the facility 12/14/21. The facility failed to follow standards of practice in identifying, documenting, reporting to physicians and providing treatment per physician orders. The facility responded by educating nursing staff on the appropriate protocol for wound identification, management, condition changes and notification to appropriate parties. The education proved to be ineffective when the nurses were interviewed and revealed they were not able to identify when a skin condition should be reported to the doctor and documented. The plan was not comprehensive enough and had not included those who were diabetic and dependent with mobility. In addition, the licensed practical nurse (LPN) #4 who had completed the skin assessment on Resident #1 on 10/3/23 had documented there were no wounds. Hospital records revealed it resulted in the distal aspect of Resident #1's left great toe to be necrotic (death of cells or tissue) with an open wound down to bone. The x-ray series of the left foot showed the osteomyelitis of the left great toe with destruction of the distal aspect of the phalanx (bones in toe). Resident #1 required evaluation and treatment at the emergency department (ED), eight days of hospitalization from 10/6/23 to 10/13/23 with amputation of the great left toe. The facility's failure to implement an immediate and comprehensive review of the facility's system and response to Resident #1's non-pressure related skin condition, placed residents at risk for serious harm if not immediately corrected. Findings include: I. Immediate Jeopardy A. Findings of immediate jeopardy Review of the investigation of the resident's skin breakdown on 10/6/23 for Resident #1, observations conducted from 10/12/23 through 10/17/23 and staff interviews revealed the facility failed to take immediate and comprehensive steps following discovery of Resident #1's left great toe necrosis and opened wound down to bone on 10/6/23. There was no evidence the facility thoroughly investigated the incident to uncover and address root cause analysis and uncover why the nurses completed inaccurate assessments. B. Facility notice of immediate jeopardy On 10/12/23 at 4:15 p.m. the nursing home administrator (NHA) was notified that the facility's failure to identify and respond to preventable skin conditions created an immediate jeopardy situation. C. Facility plan to remove immediate jeopardy On 10/16/23 at 5:59 p.m. the facility submitted a final plan for the immediate jeopardy. The plan read: On 10/12/23 facility will immediately assess all residents who are bed fast, diabetic, dependent with toileting, dependent with transfers and dependent for bathing and are at risk for developing wounds and implement interventions to prevent the development of wounds. Their care plans will be reviewed and updated to ensure interventions are in place Beginning 10/12/23 and completed 10/15/23 the facility assessed all residents currently residing at community for developing wounds and implemented interventions to prevent the development of wounds. Residents identified in this full house skin sweep as having skin breakdown their care plans were reviewed and updated to ensure interventions are in place by 10/15/23. Beginning 10/12/23 100% of Nursing staff ( RN's [Registered nurses], LPN's [licensed practical nurses] and C.N.A's [certified nurse aides]) will be educated before they work their next shift until completed to ensure they can identify and respond appropriately to skin condition concerns (including infections, pain, etc) with any other residents. IDENTIFICATION Residents will receive the care and services necessary to prevent the development of additional wounds and /or worsening wounds. The facility will ensure the tracking of all wounds is accurate, consistent, and complete. In addition, the facility will ensure residents with risk for skin breakdown are identified utilizing the admission data collection tool, the RAI (resident assessment instrument) care planning process, and the Braden scale, and review of comorbidities and will provide treatment interventions associated with those risks and monitoring of wounds to prevent wounds from declining. On 10/12/23 the facility immediately evaluated all residents' skin who are at risk for developing wounds and implemented interventions to prevent the development of wounds. Residents identified in this full house skin sweep as having skin breakdown their care plans were reviewed and updated to ensure interventions are in place by 10/15/23. SYSTEMIC CHANGES Beginning 10/12/23 100% of Nursing staff ( RNs , LPNs, C.N.As) prior to working their next shift will be educated until completed to ensure they can identify and respond appropriately to skin condition concerns (including infections (including osteomyelitis and sepsis), pain, etc) with any other residents. Residents will be reviewed for their risk of skin breakdown on admission utilizing the Braden and the admission skin assessment, weekly times four weeks after admission, quarterly, annually, and with significant changes in status, which includes development of wounds. Licensed nurses communicate any newly identified wounds to the IDT (interdisciplinary team) via the 24 hour communication report. Residents with wounds will be reviewed and progress will be evaluated weekly with corresponding documentation. All of the residents residing at the facility will have a total skin evaluation completed weekly by a licensed nurse, which is documented in the treatment administration record on (medical record system). Immediate action to include treatment orders and notification of MD (medical doctor)/family will be provided for any issues noted. The care plans will be reviewed/revised/updated as indicated at that time. Beginning 10/12/23 completed 10/15/23, 100% of all licensed nursing staff and C.N.A's will be inserviced on the system above as well as identification, treatment, and prevention of wounds according to policy and procedure and required actions when a wound is identified. Those who didn't attend education will be provided 1:1 (one-to-one) education prior to their next working shift. Any agency staff will be educated prior to working their scheduled shift. MONITORING The Nurse Managers will review the resident's treatment records for completion of the weekly skin assessments as well as ordered treatment documentation three times a week for one month, and then weekly for one month, then monthly and prn (as needed) until a pattern of compliance has been met. (Medical record system) telephone orders will be reviewed in the morning meeting (stand-up) to review new orders and follow up as needed. Quality of care rounds will be completed by the DON/MDS/designee weekly for three months and then prn to ensure care planned interventions for residents with wounds are in place. Issues identified will be corrected at that time with on-the-spot reeducation. The completed quality of care rounds will be reviewed by the QAPI (quality assurance and performance improvement) team recommendations will be addressed as needed to ensure continued compliance. Results of treatment sheet reviews will be reviewed by the QAPI committee. Recommendations will be addressed as needed to ensure continued compliance. Identified issues will be reported to the monthly QAPI committee to ensure the plan has been implemented, achieved, sustained and evaluated for its effectiveness. D. Removal of immediate jeopardy Based on the facility's plan above, the immediate jeopardy was removed on 10/16/23 at 5:59 p.m. However, deficient practice remained at a G scope and severity. II. The facility failed to identify and respond to Residents #1's non-pressure related skin condition A. Professional reference [NAME], J. L. L., [NAME], Y. G. et al. (2019). Optimal management of diabetic foot osteomyelitis. Diabetes Metabolic Syndrome and Obesity. National Library of Medicine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6593692/ retrieved on 10/13/23. Diabetic foot osteomyelitis (DFO) is the most frequent infection associated with diabetic foot ulcer, occurs in >20% of moderate infections and 50-60% of severe infections and is associated with high rates of amputation. DFO represents a challenge in both diagnosis and therapy, and many consequences of its condition are related to late diagnosis, delayed referral, or ill indicated treatment. B. Facility policy and procedure The Pressure Ulcers/Skin Breakdown Clinical Protocol policy and procedure, revised April 2018, was provided by the DON on 10/12/23 at 3:19 p.m. It read in pertinent part, Assessment and recognition: The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). In addition, the nurse shall describe and document/report the following: full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue; pain assessment; resident's mobility status; current treatments, including support surfaces; and all active diagnoses. The Acute Condition Changes Clinical Protocol policy and procedure, revised March 2018, was provided by the DON on 10/12/23 at 3:19 p.m. It read in pertinent part, Assessment and recognition: 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. C. Resident #1-risk of skin breakdown 1. Resident status Resident #1, age [AGE], was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), the diagnoses included heart disease with heart failure and type 2 diabetes mellitus. The 9/21/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He was totally dependent with the assistance of two people for transfers, the extensive assistance of one person for bed mobility, dressing, toileting, personal hygiene and supervision with set up assistance with eating. He did not have any pressure wounds, venous or arterial wounds or diabetic foot wounds. He was at risk for pressure ulcer/injury. His Braden scale for predicting pressure sore risk assessment was conducted 8/1/23 and revealed a score of 14 indicating a moderate risk. 2. Review of 10/6/23 incident On 10/12/23 at 11:56 a.m. the DON provided the investigation of the resident's skin breakdown on 10/6/23. The report revealed the following in pertinent part: Wound chart audit: Resident #1 current wound left great toe. Medication/orders: left great toe status post twice a day 3/30/22 to 4/13/22; collagen 3/23/22 to 3/30/22; Right great toe: xeroform dressing 3/12/22 to 3/16/22; 3/10/22 to 3/12/22. Wound history: On 10/6/23 showered by CNA after dinner, noted left great toe open. 4/13/22 left great toe vascular resolved. 3/23/22 left great toe stable. 3/16/22 left toe improved. 3/9/22 right toe 'error' is left toe. 3/2/22 antibiotics initiated left toe infection, mild infection. Braden: 8/1/23 score 14. Pain 6 (scale 1-10). Labs: 10/2/23 white blood counts within normal limits. Skin evaluation dates: 10/3/23 LPN #4 no new wounds; 9/26/23 LPN #4 no new wounds; 9/19/23 LPN #4 no new wounds; 9/12/23 LPN #4 no new wounds; 9/5/23 LPN #1 no new wounds; 9/3/23 LPN #5 no new wounds; 8/28/23 LPN #5 no new wounds; 8/22/23 LPN #4 one new wound but no note; 8/20/23 LPN #1 no new wounds; 8/13/23 LPN #5 no new wounds; 8/8/23 LPN #4 no new wounds; 8/1/23 LPN #4 no new wounds; 7/25/23 LPN #3 no new wounds. Nurses notes: 7/7/23 podiatrist no areas of concern; 4/7/23 podiatrist no areas of concern. Add foot cradle to bed, chart review, staff interviews. Interviews conducted by DON: 10/6/23 CNA #1: Last night after giving him a shower. There was already a bandaid on it. It's been awhile since I've worked with him. LPN #4: Noticed for a couple months. Was on the list for wound cleanser and bandaid. No order in chart. 'I think there was, seriously you have to check. It has been intact, didn't question wound rounds or need to report.' One-to-one education. LPN #3: Last I saw it, it was just a scab. LPN #4 was doing treatment on days. Last saw it as scab four days ago. Education on scab versus eschar. Podiatrist debrided eschar, resulting in exposed wound. Skin evaluations, started 10/6/23 for residents with a Braden score of 12 and less and if history of skin impairment. -However, Resident #1 had a score of 14 (see Braden scale above) which identified him at moderate risk but he would not have been included in the skin evaluations based on this criteria. 3. Record review-steps taken after the resident's skin breakdown identified on 10/6/23. The 10/3/23 total body skin assessment, conducted weekly, was reviewed. It revealed the skin assessment was conducted by LPN #4. It documented Resident #1 had no new wounds. 10/6/23 at 4:05 a.m. Health status note: Resident's shower provided by female CNA after dinner, noted his left great toe open area, toe red and warm to touch. Cleansed area with wound cleanser, pat dried and covered with bandaid temporarily. To notify the wound nurse when she comes early this morning. Podiatrist visit 10/6/23 revealed, Left great toe distally has a wound that is palpable to bone. The bone feels as if it has deteriorated and is infected. The distal phalanx appears to be destroyed distally. X-rays three views, augmentin 875 mg bid until patient can get into the hospital. Patient should be transferred to (hospital name) today for evaluation and treatment of the left toe pending approval from vascular. 10/6/23 at 12:08 p.m. Social services note: Resident was seen by the podiatrist today. Podiatrist recommended resident be sent out to the hospital for treatment of osteomyelitis of the L (left) big toe on the L foot. Podiatrist did explain to resident that he will likely need the toe amputated. Podiatrist spoke with the resident's nurse. Nurse is calling resident's doctor and POA (power of attorney). 10/6/23 at 1:37 p.m. Infection note type and location of infection: Left great toe. Osteomyelitis. Current Signs and Symptoms: Inflammation of bone caused by infection. Adverse Reactions: none. Treatment/Response: Vital signs within normal limits: 101/69 (blood pressure),70 (heart rate), 16 (respiration), 91% Room Air (oxygen saturation), 97.5 (temperature). Alert and Oriented x3 (person, place, and time) baseline. Podiatrist visited with resident and ordered that he be sent to the ER (emergency room) for vascular consult, and treatment. Resident is Full Code and agreed to go to the ER for treatment. Hospital notes Resident #1 was admitted to hospital on [DATE] at 2:15 p.m. Emergency department encounter noted in pertinent part, The distal aspect of his left great toe is necrotic with open wound down to bone. X-ray series of the left foot shows the osteomyelitis of the left great toe with destruction of the distal aspect of the phalanx. Patient summary in pertinent part, Nursing home resident sent to hospital by nursing home podiatrist for admission on [DATE] for suspect osteomyelitis of left great toe with open painful wound, elevated CRP (for tracking infections). Interval history: Left great toe remains sore. Says he has been receiving care for this at the skilled nursing facility (SNF) where he stays. -However, the facility had no physician orders for wound care to the left toe, the nursing staff had not documented there was a wound, the nurses were applying wound cleanser and a bandaid. Hospital assessment and plan: Diabetic foot infection left great toe, likely osteomyelitis. Ceftrianone and vancomycin (antibiotics) initiated in the ED 10/6/23 and have been continued. Open wound with frank drainage, toe appears necrotic. Reason for continued hospitalization: IV(intravenous) antibiotics and surgical intervention for left great toe. Surgery 10/8/23, pre and postoperative diagnosis: Left great toe infection. Principal procedure: Left great toe amputation with primary closure. Resident #1 was discharged back to the facility on [DATE] at 4:24 p.m. Operative procedure performed: Amputation left great toe. III. Staff interviews LPN #1 was interviewed on 10/12/23 at 11:25 a.m. She said she was the wound care nurse that rounded with the wound physician once a week. She said skin assessments were scheduled and done during shower day by the CNAs and nurses. She said if a skin issue was identified they would notify her by text message right away and she would follow up with the resident and include those residents in the wound care physician rounds. She said she had not been notified by the staff that Resident #1 had a scab. She said skin issues and skin assessments were documented on the skin assessment form in the resident's medical record and there was a check off box on the treatment assessment record (TAR) that a skin assessment was completed. The wound care physician would come in once a week for residents that were identified with skin issues or wounds. She said she was not able to follow up with Resident #1's scab since the nursing staff had not notified her. The DON was interviewed on 10/12/23 at 11:30 a.m. She said that Resident #1 was not on wound care physician rounds. She said LPN #3 notified her on 10/6/23 that Resident #1 had a wound on the left great toe. She said she notified the podiatrist on 10/6/23 and he came in, assessed the wound and recommended Resident #1 be transported to the hospital for evaluation and treatment for osteomyelitis of his left great toe wound. She said there was no documentation on the skin assessment forms of new wounds and no prior notification by nurses of an existing wound. She had been told by nurses during interviews they had known about the scab on Resident #1's left great toe. She said they conducted an investigation and had interviewed nurses and began auditing every resident with a Braden score of 12 or less. They were in the process of educating staff on how to identify wounds and what to do after a wound had been identified. She said the cause of the wound was due to the resident's immobility and diabetes diagnosis. The medical director (MD) was interviewed on 10/12/23 at 1:36 p.m. He said he was a wound care certified physician. He said he became aware on 10/6/23 that Resident #1 had developed a wound on his foot and ended up in the hospital that required an amputation. He said Resident #1 was in bed all the time and never got out of bed. He said Resident #1 was difficult to reposition. He said Resident #1 was a high risk of developing wounds on his feet and losing more toes. He said Resident #1 had issues with arterial insufficiency. He said a protective boot would have helped prevent the formation of the wound. He said for someone who had diabetes or was compromised, a wound would take at least a week to develop. LPN #3 was interviewed on 10/12/23 at 2:10 p.m. She said skin assessments were done from head to toe scheduled weekly during the resident's showers. She said when nursing staff identified any new wound issues they were reported to the wound nurse and the DON. She said any new or existing skin wound or issue should be documented under the skin assessment in the resident's medical record. She said a new scabbed area was reported depending on whether it looked like it was healing, if it appeared to be healing then it was not a problem and reporting was not needed. She said if a scabbed area looked like it was getting worse then it would be reported. She said Resident #1 had a scabbed area on his left great toe for approximately three weeks and had looked like it was dried blood and appeared to be healing. She said she was called on 10/5/23 after Resident #1's shower and the scab had come off the left great toe and it was bleeding and the toe was red. She placed a bandaid on it at that time and notified the wound nurse and the DON on 10/6/23 in the morning. LPN #4 was interviewed on 10/12/23 at 2:44 p.m. She said skin assessments were done during shower time once a week. She said that if a new skin issue was identified a skin risk assessment was done and the doctor, the DON and the wound nurse was called in order for there to be follow-up with the wound doctor. She said skin conditions should be reported and assessed were moisture associated skin damage, new open areas, abrasions and scabbed areas that were new. She said she was aware of the wound on Resident #1's left great toe and said an evening nurse had noticed it approximately two weeks ago. She said it had not been documented in the medical record and it had not been reported to the physician, wound nurse or DON. She said staff had thought he had just hit his foot on the footboard of his bed. IV. Facility follow-up Documentation was received from the DON on 10/12/23 at 3:19 p.m. The action plan for wounds read in pertinent part, Compliance plan Pressure injuries. Through the facility's own quality monitoring and QAPI plan the facility has self identified some deficient practices pertaining to the pressure injury system, those include but are not limited to: Action plan: All residents Braden reviewed for risk. Any resident that has a Braden of 12 or less a complete skin assessment to be completed. Any areas of concern that are noted during assessment will be documented, physician will be notified, and treatment will be implemented. Residents found with wounds that indicate an assessment need from the wound MD will be added to the rounding list. All CNAs and nurses will be educated on the appropriate protocol for wound identification, management, and condition changes. Education will also include notification to appropriate parties. Correction: Residents will receive the care and services necessary to prevent the development of additional pressure injuries and/ or worsening pressure injuries. The Facility will ensure the tracking of pressure injuries is accurate, consistent, and complete. In addition, the facility will ensure residents with risk for skin breakdown are identified and will provide treatment interventions associated with those risks and monitoring of pressure injuries to prevent pressure injuries from declining. Identification: On or before 10/9/23 DON/designee will review records of those residents residing at the facility, specifically the most recent Braden risk score, to identify those residents at low, medium, and high risk for development of pressure injuries. The care plans will be reviewed/revised/updated as indicated to ensure interventions are in place to address identified risks at that time and identify any resident whose care plan may not appropriately address resident's risk. The DON/designee will meet along with IDT to evaluate all residents currently with pressure injuries to review current care plan interventions (including mattress and cushion) to evaluate effectiveness. Care plan will be revised if indicated. Systemic changes: Residents will be reviewed for their risk of skin breakdown on admission, weekly times four weeks after admission, quarterly, annually, and with significant changes in status, which includes development of new pressure injuries. Licensed nurses communicate any newly identified pressure injuries to the IDT via the 24 hour communication report. Residents with pressure injury will be reviewed daily and pressure injury progress will be evaluated weekly with corresponding documentation. All of the residents residing at the facility will have a total skin evaluation completed weekly by a licensed nurse, which is documented in the treatment administration record. Immediate action to include treatment orders and notification of MD/family will be provided for any issues noted. The care plans will be reviewed/revised/updated as indicated at that time. Prior to 10/23/23 all licensed nursing staff will be inserviced on the system above as well as prevention of pressure injury according to policy and procedure and required actions when a pressure injury is identified. An attendance sheet will be kept and reconciled with an active roster of licensed nursing staff and those unable to attend will be provided with 1:1 reeducation. Prior to 10/23/23 all CNA's will be inserviced on prevention of pressure injuries. An attendance sheet will be kept and reconciled with an active roster of CNA's and those unable to attend will be provided with 1:1 reeducation. Monitoring: The nurse managers will review the resident's treatment records for competition of the weekly skin assessments as well as ordered treatment documentation three times a week for one month, and then weekly for one month, then monthly and prn until a pattern of compliance has been met. Telephone orders will be reviewed in the morning meeting (stand-up) to review new orders and follow up as needed. DON and/or designee will facilitate. Quality of care rounds will be completed by the DON/MDS/designee weekly for three months and then prn to ensure care planned interventions for residents with pressure injuries are in place. Issues identified will be corrected at that time with on the spot reeducation. The completed quality of care rounds will be reviewed by the QAPI team Recommendations will be addressed as needed to ensure continued compliance. Results of treatment sheet reviews will be reviewed by the QAPI committee. Recommendations will be addressed as needed to ensure continued compliance. Identified issues will be reported to the monthly QAPI committee to ensure the plan has been implemented, achieved, sustained and evaluated for its effectiveness. Compliance 10/31/23. -However the plan had not included a complete skin assessment for those who were diabetic and for those who were dependent with functional mobility. It had included a plan to screen residents with a Braden score of 12 or less however Resident #1 had a score of 14 and would have been missed using this criteria. The nurse staff education did not include a written test to assess knowledge base.