**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, the facility failed to assess and provide one of 48 sampled residents (R) (R124) with sufficient fluid intake via gastric tube feeding to maintain proper hydration and health. As a result, R124 was admitted to an acute care hospital on [DATE] and died on [DATE] from septic shock, hypoxic respiratory failure, and non-ST elevation myocardial infarction. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the Immediate Jeopardy (IJ) for F692, F710, and F835 on [DATE] at 3:00 pm. The noncompliance related to the IJ was identified to have existed on [DATE]. Based on observations, record reviews, interviews, and a review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice were removed on [DATE]. Findings included:A review of the Notification of Changes Policy dated [DATE] and revised on [DATE] revealed that the purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.A review of the Hydration Policy dated [DATE] and revised on [DATE] revealed that the facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health.A review of the Physician Visits and Physician Delegation Policy dated [DATE] and revised on [DATE] revealed that it is the policy of this facility to ensure the physician takes an active role in supervising the care of residents.1. A review of an admission Record revealed R124 was an [AGE] year-old male admitted to the facility on [DATE] with medical history that included, but was not limited to, dementia, dysphagia, gastric tube, sepsis, urinary tract infection, hypovolemia, hyperosmolality, and hypernatremia, chronic obstructive pulmonary disease, essential hypertension, atrial fibrillation, and seizures. A review of a Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of [DATE], revealed R124 had a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident was dependent for all activities of daily living (ADL) care, required PEG-tube feedings, was bedfast, and was non-verbal.A review of R124's Care Plan included a focus area initiated on [DATE], which indicated the resident required tube feeding (PEG) related to dysphagia. Interventions directed staff to observe/document/report as needed (PRN) any symptoms of aspiration-fever, shortness of breath, tube dislodged, infection at tube site, self-extubation, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration date initiated [DATE].A review of physician orders dated [DATE] revealed R124's facility physician (MM) ordered comprehensive metabolic panel (CMP) labs that revealed R124 had an abnormal blood sodium level of 151 mEq/L. (Normal Sodium 136 - 145 mEq/L)A review of the electronic medical record (EMR) revealed the facility's previous Director of Nursing (DON) reviewed R124's CMP labs on [DATE] at 10:43 am. The previous facility's DON did not notify/follow up with physician MM since interventions were not ordered to correct R124's hypernatremia.A review of the EMR revealed the facility's Nurse Practitioner (NP) reviewed R124's CMP labs on [DATE] at 9:31 pm. No record of notifying the resident's physician or ordering interventions.A review of labs ordered from [DATE] through [DATE] (Eight days) revealed, physician MM did not recheck labs or provide orders for intravenous (IV) fluids as an intervention to correct R124's hypernatremia. Record review of hospital CMP labs on [DATE] revealed R124's sodium level was 161 mEq/L. R124 was admitted to the hospital from [DATE] through [DATE] (24 days).A review of the nurse's progress note dated [DATE] revealed R124 was observed in bed using accessory muscles to breathe, and he was unresponsive. R124's oxygen saturation levels were out of range (no value documented). Oxygen 100% was applied with no improvement. Physician MM was notified, and they gave orders to send R124 to the hospital.A review of hospital CMP labs on [DATE] revealed R124's sodium level was 161 mEq/L. Record review of hospital Medication Administration records revealed R124 was hospitalized for 24 days and administered continuous IV fluids for severe dehydration, weakness, and acute respiratory failure. The resident was discharged from the hospital and returned to the facility on [DATE].A review of facility readmission CMP labs ordered by physician MM on [DATE] revealed R124's sodium level was 142 mEq/L on [DATE].A review of nursing notes dated [DATE] at 2:46 pm revealed, Note Text: (Nurse) Writer called physician MM concerning resident weight. Physician MM stated that she does not totally agree with fluctuating weight. Physician MM recommends that the resident (R124) be re-weighed tomorrow and that RD follow up with weights and tube feeding. Physician MM was made aware of the lab results of [DATE] of hemoglobin of 8.2 compared to 9.5 on [DATE]. Physician MM stated no new orders at this time based on the normal value of MCV, Albumin of 2.3, and per physician MM, the RD can review and recommend supplements. The Responsible Party (RP) was made aware.A review of the facility Registered Dietitian (RD) notes dated [DATE] at 8:48 am revealed, Nutrition Note: [AGE] year-old male recently readmitted from hospital. Upon readmission resident was triggered with significant weight gain, since they had been triggered with significant weight loss. The team reweighed the resident today. Current wt 145.4 lbs. Tube feeding (TF) infusion meets residents' increased needs. (R124) The resident has multiple wounds. Reviewed lab results [DATE]. See RD recommendations below:Height (HT): 71 (5 ft'9 in)Weight (WT): 145.4 lbs.Body Mass Index (BMI): 20.2Significant Weights: [DATE] readmission wt: 159 lbs./-8.5%A review of R124's hospital records on [DATE] revealed a discharge weight of 163 lbs. R124's had a weight loss of 11.6%; 17.6 lbs. in six days.A review of R124's labs revealed that physician MM did not order any new labs related to R124's change in condition noted by the RD on [DATE], nor after the resident was re-weighed on [DATE]. Weight Results: [DATE] at 10:00 am 145.4 lbs. via mechanical lift.A review of R124's labs revealed that Physician MM did not order any new labs related to R124's change in condition noted by the RD on [DATE].A review of nurse progress notes revealed on [DATE], R124 was observed in bed using accessory muscles to breathe, and he was unresponsive. R124's oxygen saturation levels were out of range. (No value documented) 100% oxygen was applied with no improvement. R124's physician, MM, was notified, and they gave orders to send R124 to the hospital.A review of Emergency Medical Services reported R124's oxygen saturation levels were 85% on 15 Liters of oxygen on [DATE].A review of hospital diagnosis for R124 on [DATE] includes hypoxemic respiratory failure, aspiration pneumonia, urinary tract infections (UTI), adult failure to thrive, dehydration, atrial fibrillation, and metabolic dysfunction.A review of R124's Death Certificate lists cause of death as septic shock, hypoxic respiratory failure, and non-ST elevation myocardial infarction. R124 was pronounced dead at the hospital on [DATE] at 7:04 am.During an interview on [DATE] at 12:06 pm, Physician MM confirmed the abnormal CMP lab findings were not addressed in her assessment, and IV fluids should have been immediately started on [DATE]. Also, Physician MM confirmed misinterpreting new hospital discharge nutrition orders provided on [DATE], requiring 8 to 10 glasses of water to be administered daily via R124's tube feedings. These orders were not implemented, nor was clarification requested. These failures resulted in two preventable hospitalizations on [DATE] and [DATE].During an interview on [DATE] at 1:09 pm, the interim DON stated that it is her responsibility to hold nursing staff and the physicians accountable for completing their job duties. The interim DON also stated that audits will be conducted by checking the admissions, pulling out records, and completing the audit check to make sure that nothing is missed. Interim DON further stated that audits for labs will be performed on a weekly or daily basis, depending on what might be going on at that time in the facility.The facility implemented the following actions to remove the IJ: 1. R124 was discharged from the facility. 2. The Chief Clinical Officer (CCO) immediately met with the Administrator and DON to determine the root cause of the deficiencies. We reviewed all policies related to the IJs received; Hydration policy, Physician Visits and Physician Delegation policy, and Notification of Changes policy, and determined that the root cause of the deficient practice was that we failed to follow our policies. The policies did not require updating. 3. On [DATE], the DON and Assistant DONs began reviewing resident admission orders and labs for the past two weeks to ensure that any hydration and enteral hydration orders were ordered correctly and abnormal labs from the last two weeks had physician notification and were addressed to provide adequate hydration as needed. This will be completed by [DATE]. 4. The CCO on [DATE] in-serviced the Administrator, DON, and Assistant DON on the Physician Visits and Physician Delegation policy and Notification of Changes policy, and Hydration policy to ensure that review of labs, notification to providers is done timely and correctly to provide for the hydration and health of the residents. 5. On [DATE] the CCO, DON, Assistant DON and/or Staff Development Coordinator began in-servicing all Licensed nursing staff (Registered Nurses (RNs), Licensed Practical Nurses (LPNs) on the Hydration policy and ensuring all Labs are reviewed with documented notification to the provider when abnormal labs are received, proper hydration is provided to the residents and orders are transcribed correctly with clarification from the provider as needed. At this time, the following Licensed Nursing Staff have been in-service. (10 of 10 RNs, 29 of 36 LPNs) 39 of 46 (85%) of nursing staff were educated. Any Licensed Nursing staff (RNs, LPNs) who have not already completed the in-service will be educated before working their next shift by the DON, Assistant DON, CCO, or the Staff Development Coordinator. 6. On [DATE], the CCO in-serviced the DON and the Assistant DON on the process of reviewing Labs and admission orders in Morning Clinical Meetings, Monday through Friday. In the Morning Clinical, the DON and Assistant DON will review all labs from the previous day and any stat labs that have resulted in abnormal levels. The DON will ensure that all abnormal labs have documentation of notification to the providers and measures have been taken to provide for proper hydration as needed. The DON and Assistant DON will also review admission orders from the previous day to ensure orders for hydration have been transcribed and followed through with correctly. Any issues found with the labs or admission orders will be addressed immediately by the DON. 7. We have no agency staff currently. 8. The Ad Hoc Quality Assurance Process Improvement (QAPI) meeting was completed on [DATE] for policy review, and root cause analysis determined that staffing education was needed. No changes to the policies were needed. Attendees to the meeting were the CCO, DON, Assistant DON, and the Administrator. The Medical Director (MD) was notified by phone on [DATE]. 9. Corrective actions will be completed by [DATE] with the Alleged date of IJ removal of [DATE]. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. A review of progress notes revealed that R124 was discharged from the facility to the hospital on [DATE]. 2. A review of the Notification of Changes Policy dated [DATE] and revised on [DATE]. Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. A review of the Hydration Policy dated [DATE] and revised on [DATE]. Policy: The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. A review of the Physician Visits and Physician Delegation Policy dated [DATE] and revised on [DATE]. Policy: It is the policy of this facility to ensure the physician takes an active role in supervising the care of residents. 3. A review of 85 residents' labs audited by the Director of Nursing (DON) and Assistant Director of Nursing (ADON) for abnormal findings. All physicians were notified that hydration interventions were needed. 4. A review of the facility's Inservice Attendance Signature Sheet (dated [DATE]) revealed that the instructor of the in-service was the CCO. The staff members in attendance (as verified with their signatures) included the DON, the Administrator, and the facility's three Assistant DONs. The topics discussed during the in-service included the Notification of Change policy (revision date of [DATE]), Hydration Policy (revision date of [DATE]), and the Physician Visits and Physician Delegation policy (revision date of [DATE]). A review of the policy titled Notification of Changes Policy, (dated [DATE] and revised on [DATE]) revealed that, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. A review of the policy titled Hydration Policy (dated [DATE] and revised on [DATE]) revealed, The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. A review of the policy titled Physician Visits and Physician Delegation Policy (dated [DATE] and revised on [DATE]) revealed, It is the policy of this facility to ensure the physician takes an active role in supervising the care of residents. During an interview on [DATE] at 1:09 pm, the DON stated that it is her responsibility to hold nursing staff and the physicians accountable for completing their job duties. The DON also stated that audits will be conducted by checking the admissions, pulling out records, and completing the audit check to make sure that nothing is missed. DON further stated that audits for labs will be performed on a weekly or daily basis, depending on what might be going on at that time in the facility. 5. Interviews were conducted on [DATE] through [DATE] with the following employees and revealed that they received education and were able to provide appropriate answers related to the in-service: [DATE] at 1:09 pm DON; [DATE] at 1:17 pm Administrator; [DATE] at 5:04 pm Physician PP; [DATE] at 11:18 am ADON HH ; [DATE] at 11:22 am Medical Director NN; [DATE] at 11:41 am ADON II; [DATE] at 12:01 pm LPN JJ; [DATE] at 1:06 am LPN AA; [DATE] at 1:40 am LPN CC; [DATE] at 1:55 am LPN BB; [DATE] at 2:10 am LPN DD; [DATE] at 11:00 am LPN EE; [DATE] 11:15 am LPN FF; and [DATE] at 12:44 pm Physician MM. 6. A review of the Inservice sheet dated [DATE] revealed the CCO provided in-services on the process of reviewing labs and adequate hydration. During an interview on [DATE] at 1:03 pm, the CCO confirmed providing several in-services to the staff regarding revision of labs and hydration to the nursing staff. During an interview on [DATE] at 1:09 pm, the DON confirmed receiving in-services from the CCO regarding the process of reviewing Labs and admission orders in their daily Morning Clinical Meetings. The DON continued that if the DON is not available to facilitate the meetings and review labs, the Assistant DONs will be responsible for reviewing those labs in the morning clinical meeting. The DON continued that since there are three Assistant DONs, they will alternate facilitating the meetings in the event the DON is out of the facility. Interviews were conducted on [DATE] through [DATE] with the following employees and revealed that they received education and were able to provide appropriate answers related to the in-service: [DATE] at 1:09 pm DON; [DATE] at 11:18 am Assistant DON HH; [DATE] at 11:41 am Assistant DON II. 7. During an interview on [DATE] at 12:43 pm, the DON stated they do not employ agency staff at the facility. A review of the facility's active employee list revealed that there was no agency staff listed. 8. A review of the Notification of Changes Policy dated [DATE] and revised on [DATE]. Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. A review of the Hydration Policy dated [DATE] and revised on [DATE]. Policy: The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. A review of the Physician Visits and Physician Delegation Policy dated [DATE] and revised on [DATE]. Policy: It is the policy of this facility to ensure the physician takes an active role in supervising the care of residents. During an interview on [DATE] at 1:09 pm, the DON stated that it is her responsibility to hold nursing staff and the physicians accountable for completing their job duties. The DON also stated that audits will be conducted by checking the admissions, pulling out records, and completing the audit check to make sure that nothing is missed. DON further stated that audits for labs will be performed on a weekly or daily basis, depending on what might be going on at that time in the facility. 9. It was verified that the corrective actions were completed by [DATE]. The removal date of the IJ was [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the physician failed to assess laboratory orders for routine monitoring for two of 48 sampled residents (R) (R124 and R213).On 6/2/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the Immediate Jeopardy (IJ) for F692, F710, and F835 on 6/2/2025 at 3:00 pm. The noncompliance related to the IJ was identified to have existed on 4/2/2025. Based on observations, record reviews, interviews, and a review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice were removed on 6/4/2024.Findings included:1. Record review of the Physician Visits and Physician Delegation Policy dated 3/1/2022 and revised on 3/1/2025. Policy: It is the policy of this facility to ensure the physician takes an active role in supervising the care of residents. Record review of an admission Record revealed R124 is an [AGE] year-old male admitted to the facility on [DATE] with medical history that included but was not limited to dementia, dysphagia, gastric tube, sepsis, urinary tract infection, hypovolemia, hyperosmolality, and hypernatremia, chronic obstructive pulmonary disease, essential hypertension, atrial fibrillation, and seizures. Record review of a Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/24/2025, revealed R124 has a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident is dependent for all activities of daily living (ADLs) and requires PEG-tube feedings, is bedfast, and non-verbal.Record review of R124's Care Plan included a focus area initiated on 2/17/2025, which indicated the resident requires tube feeding (PEG) related to dysphagia. Interventions directed staff to observe/document/report as needed (PRN) any symptoms of aspiration-fever, shortness of breath, tube dislodged, infection at tube site, self-extubation, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration date initiated 2/17/2025.On 2/17/2025, R124's facility physician (MM) ordered comprehensive metabolic panel (CMP) labs that revealed R#124 had an abnormal blood sodium level of 151 mEq/L. (Normal Sodium 136 -145 mEq/L)Record review revealed the facility's previous Director of Nursing (DON) reviewed R124's CMP labs on 2/18/2025 at 10:43 am. No record of notifying the resident's physician.Record review revealed the facility's Nurse Practitioner (NP) reviewed R124's CMP labs on 2/20/2025 at 9:31 pm. No record of notifying the resident's physician or ordering interventions.Record review of physician orders and labs revealed that physician MM provided no orders for IV fluids as an intervention to correct R124's hypernatremia, nor orders to recheck labs. Physician MM failed to monitor R124's condition to prevent serious injury, serious harm, serious impairment, or death.Record review of nurse progress notes dated 2/24/2025, a nurse observed R124 in bed using accessory muscles to breathe, and he was unresponsive. R124's oxygen saturation levels were out of range. 100% oxygen was applied with no improvement. R124's physician, MM, was notified of the resident's change in condition, and physician MM gave orders to send R124 to the hospital.Record review of hospital CMP labs dated 2/24/2025 revealed R124's abnormal blood sodium level had progressed to 161 mEq/L. R124 was hospitalized for 24 days on continuous IV fluids for severe dehydration, weakness, and acute respiratory failure.Record review of facility readmission CMP labs ordered by MM on 3/19/2025 revealed R124's sodium level was 142 mEq/L on 3/21/2025.Record review of nursing notes dated 3/25/2025 at 2:46 pm revealed, Note Text: (Nurse) Writer called physician MM concerning resident weight. Physician MM stated that she does not totally agree with fluctuating weight. Physician MM recommends that the resident (R124) be re-weighed tomorrow and that RD follow up with weights and tube feeding. Physician MM was made aware of the lab results of 3/21/2025 of hemoglobin of 8.2 compared to 9.5 on 2/17/2025. Physician MM stated no new orders at this time based on the normal value of MCV, Albumin of 2.3, and per physician MM the RD can review and recommend supplements. The Responsible Party (RP) was made aware.Record review of R124's labs revealed that physician MM did not order any new labs related to R124's change in condition noted by the RD on 3/26/2025, nor after the resident was re-weighed on 3/26/2025. Weight Results: 3/26/2025 at 10:00 am 145.4 lbs. via mechanical lift.Record review of nurse progress notes revealed on 4/1/2025, a nurse observed R124 in bed using accessory muscles to breathe, and he was unresponsive. R124's oxygen saturation levels were out of range. (No value documented) 100% oxygen was applied with no improvement. R124's physician (MM) was notified, and they gave orders to send R124 to the hospital.Record review of hospital diagnosis for R124 on 4/1/2025 includes hypoxemic respiratory failure, aspiration pneumonia, urinary tract infections (UTI), adult failure to thrive, dehydration, atrial fibrillation, and metabolic dysfunction.Record review of R124's Death Certificate lists cause of death as septic shock, hypoxic respiratory failure, and non-ST elevation myocardial infarction. R124 was pronounced dead at the hospital on 4/2/2025 at 7:04 am.In an interview with physician MM on 5/29/2025 at 12:06 pm, she admitted the abnormal CMP lab findings were not addressed in her assessment, and IV fluids should have been immediately started on 2/17/2025. Also, physician MM admitted misinterpreting new hospital discharge nutrition orders provided on 3/20/2025, requiring 8 to 10 glasses of water to be administered daily via R124's tube feedings. These orders were not implemented, nor was clarification requested. These failures resulted in two preventable hospitalizations on 2/24/2025 and 4/1/2025. During an interview on 6/3/2025 at 1:09 pm, the interim DON stated that it is her responsibility to hold nursing staff and the physicians accountable for completing their job duties. The interim DON also stated that audits will be conducted by checking the admissions, pulling out records, and completing the audit check to make sure that nothing is missed. Interim DON further stated that audits for labs will be performed on a weekly or daily basis, depending on what might be going on at that time in the facility.2. Resident 213 (R213) is a [AGE] year-old female admitted to the facility on [DATE] with a medical history of metabolic encephalopathy, Human Immunodeficiency Virus Disease (HIV), Thrombocytopenia, Dependence on renal dialysis, and chronic kidney disease.Record review revealed facility physician (MM) was notified on 4/16/2025 at 2:08 PM of R213 HgB levels being seven (7) g/dL (grams per deciliter). (Normal H Range 12.0-16.0)MM gave new orders for Complete Blood Count (CBC) with differential, iron saturation, total iron-binding capacity, ferritin level iron level on 4/17/25.Record review revealed R124's CBC lab dated 4/17/2025, reviewed by Assistant Director of Nursing (ADON) 1 documented Hgb Seven (7). g/dL (grams per deciliter) and Platelet Count 80 (Normal H Range 12.0-16.0)Record review revealed the facility physician (MM) was notified on 4/18/25 at 1:50 PM of Complete Blood Count (CBC) with differential iron saturation, total iron-binding capacity, ferritin level iron level. MM provided no orders for intervention to correct R213's low hemoglobin levels.Interview with MM on 5/29/2025 at 2:39 pm, MM stated only send residents to the hospital when their Hgb is below 7. MM stated R213 attended dialysis three times a week, where their Hgb was monitored. MM stated they would expect dialysis to notify nursing staff if there were concerns with R213's Hgb levels.Interview with Dialysis Manager (DM) on 5/30/2025 at 9:01 am, DM confirmed they do monitor dialysis residents' Hgb. DM stated they are open three days a week, so their critical lab notifications would be relayed late to nursing staff if there was a concern. Follow-up interview with MM on 5/30/2025 at 9:33 am, MM stated they planned on monitoring R213 by putting in an order to do another CBC within a week. MM stated forgot to follow up and could not remember if they told the nurses to enter an order for a follow-up CBC.Record review of Hospital Clinical Paperwork dated 4/26/2025 revealed R213 presented at the hospital today with her G tube pulled out and was found to be bradycardic and hypothermic in the hospital, as well as Hgb 5.9 and K of 2.9. R213 received a blood transfusion.The facility implemented the following actions to remove the IJ: 1. On 4/2/2025, R124 was discharged from the facility. 2. On 6/2/2025, the DON and Assistant DON began reviewing resident labs for the past two weeks to ensure that any abnormal labs from the last two weeks had physician notification and were addressed to provide adequate hydration as needed. This will be completed by 6/3/2025. 3. On 6/2/2025, the DON contacted Physician MM to provide in-service on ensuring that labs are ordered and followed up on, and proper interventions are put in place to provide for proper hydration. 4. On 6/2/2025, the DON and/or Assistant DON began contacting all of the Attending Physicians to in-service them on the importance of ensuring that labs that are ordered are followed up on and proper interventions are put in place to provide for proper hydration. This will be completed by 6/2/2025. Four of four (100%) Primary Physicians were educated.) 5. The Ad Hoc QAPI meeting was completed on 6/2/2025 for policy review, and root cause analysis determined that staffing education was needed. No changes to the policies were needed. Attendees to the meeting were the Chief Clinical Officer (CCO), DON, Assistant DON, and Administrator. The Medical Director (MD) was notified by phone on 6/2/2025. 6. Corrective actions will be completed by 6/3/2025 with the Alleged date of IJ removal of 6/4/2025. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. A review of the progress notes for R124 revealed that the resident was discharged from facility to the hospital via Emergency Medical Services (EMS) on 4/1/2025. 2. Record review of 85 residents' labs audited by the DON and Assistant DON for abnormal findings. All physicians were notified that hydration interventions were needed. 3. Record review of Lab Review Order dated 6/2/2025, instructed by the Regional Nurse for Physician MM via phone. 4. Record review of Lab Review Order MD/Mid-Level Providers dated 6/2/2025, instructed by the Regional Nurse. Six providers were in attendance; two in person and four via phone. Physician MM, Physician NN, Physician OO, and Physician PP were interviewed on 6/5/2025. 5. Record review of the Notification of Changes Policy dated 10/1/2022 and revised on 4/1/2024. Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification. Record review of the Hydration Policy dated 3/1/2022 and revised on 3/1/2025. Policy: The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health. Record review of the Physician Visits and Physician Delegation Policy dated 3/1/2022 and revised on 3/1/2025. Policy: It is the policy of this facility to ensure the physician takes an active role in supervising the care of residents. 6. It was verified that the corrective actions were completed by 6/3/2025. The removal date of the IJ was 6/4/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview and record review, the facility's previous Director of Nursing (DON) failed to administer the facility in a manner that enabled the use of resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of one of 48 sampled residents (R) (R124). The facility's systemic failure to notify R124's physician of abnormal laboratory results, assess, and provide R124 with sufficient intravenous (IV) fluids, interventions/fluid intake to maintain proper hydration and health, placed the resident at risk. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation caused or had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility's Administrator was informed of the Immediate Jeopardy (IJ) for F692, F710, and F835 on [DATE] at 3:00 pm. The noncompliance related to the IJ was identified to have existed on [DATE]. Based on observations, record reviews, interviews, and a review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice were removed on [DATE]. Findings included:Record review of the Notification of Changes Policy dated [DATE] and revised on [DATE]. Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.Record review of an admission Record revealed R124 is an [AGE] year-old male admitted to the facility on [DATE] with medical history that included but was not limited to dementia, dysphagia, gastric tube, sepsis, urinary tract infection, hypovolemia, hyperosmolality, and hypernatremia, chronic obstructive pulmonary disease, essential hypertension, atrial fibrillation, and seizures. Record review of a Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of [DATE], revealed R124 has a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident was dependent for all activities of daily living (ADL) care, required PEG-tube feedings, was bedfast, and was non-verbal.Record review of R124's Care Plan included a focus area initiated on [DATE], which indicated the resident requires tube feeding (PEG) related to dysphagia. Interventions directed staff to observe/document/report as needed (PRN) any symptoms of aspiration-fever, shortness of breath, tube dislodged, infection at tube site, self-extubation, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration date initiated [DATE].Record review of physician orders dated [DATE] revealed R124's facility physician (MM) ordered comprehensive metabolic panel (CMP) labs that revealed R124 had an abnormal blood sodium level of 151 mEq/L (hypernatremia - high blood sodium level). (Normal Sodium 136 - 145 mEq/L)Record review revealed the facility's previous DON reviewed/audited R124's CMP labs on [DATE] at 10:43 am. The DON failed to take immediate action after reviewing R124's abnormal CMP labs on [DATE] at 10:43 am; they did not notify/follow up with physician MM to request interventions to prevent serious injury, serious harm, serious impairment, or death.Record review of nurse progress notes dated [DATE], a nurse observed R124 in bed using accessory muscles to breathe, and he was unresponsive. R124's oxygen saturation levels were out of range. 100% oxygen was applied with no improvement. R124's physician, MM was notified of the resident's change in condition, and physician MM gave orders to send R124 to the hospital.Record review of hospital CMP labs dated [DATE] revealed R124's abnormal blood sodium level had progressed to 161 mEq/L. R124 was hospitalized for 24 days on continuous IV fluids for severe dehydration, weakness, and acute respiratory failure. This failure resulted in a preventable hospitalization on [DATE].During an interview on [DATE] at 1:09 pm, the interim DON stated that it is her responsibility to hold nursing staff and the physicians accountable for completing their job duties. The interim DON also stated that audits will be conducted by checking the admissions, pulling out records, and completing the audit check to make sure that nothing is missed. Interim DON further stated that audits for labs will be performed on a weekly or daily basis, depending on what might be going on at that time in the facility.The facility implemented the following actions to remove the IJ: 1. R124 was discharged from the facility on [DATE]. 2. On [DATE], the DON and Assistant DON began reviewing resident labs for the past two weeks to ensure that any abnormal labs from the last two weeks had physician notification and were addressed to provide adequate hydration as needed. 3. The Chief Clinical Officer (CCO) on [DATE] in-serviced the DON and Assistant DON on the Notification of Changes policy and Hydration policy to ensure that review of labs, notification to providers are done timely and correctly to provide for the hydration and health of the residents. 4. On [DATE], the CCO in-serviced the DON and the Assistant DON on the process of reviewing Labs and admission orders in Morning Clinical Meetings, Monday through Friday. In the Morning Clinical Meeting, the DON and Assistant DON will review all labs from the previous day and any stat labs that resulted in abnormal levels. The DON will ensure that all abnormal labs have documentation of notification to the providers and measures have been taken to provide for proper hydration as needed. Any issues found with the labs or admission orders will be addressed immediately by the DON. 5. On [DATE], the job descriptions of the DON and Administrator were reviewed by the CCO. The DON and Administrator were educated and voiced an understanding of responsibilities and job duties. 6. We have no agency staff currently. 7. An AD Hoc Quality Assurance Process Improvement (QAPI) meeting was completed on [DATE] for policy review, root cause analysis was determined, and staffing education was needed. No changes to the policies were needed. Attendees to the meeting were the CCO, DON, Assistant DON, and Administrator. The Medical Director (MD) was notified by phone on [DATE]. 8. Corrective actions will be completed by [DATE] with an alleged date of IJ removal of [DATE]. The State Survey Agency (SSA) validated the facility's written IJ Removal Plan as follows: 1. Review of R124's EMR revealed R124 was transferred to the emergency room (ER) on [DATE]. Review of the Hospital Record revealed R124 was admitted on [DATE] at 10:59 pm and expired at the hospital on [DATE] at 7:04 am. 2. Record review of 85 residents' labs audited by the DON and Assistant DON for abnormal findings. All physicians were notified that hydration interventions were needed with no concerns noted. 3. Record review of the facility's Inservice Attendance Signature Sheet (dated [DATE]) revealed that the instructor of the in-service was the CCO. The staff members in attendance (as verified with their signatures) included the DON, the Administrator, and the facility's three ADONs. The topics discussed during the in-service included the Notification of Change policy (revision date of [DATE]), Hydration Policy (revision date of [DATE]), and the Physician Visits and Physician Delegation policy (revision date of [DATE]). During an interview on [DATE] at 1:09 pm, the DON stated that it is her responsibility to hold nursing staff and the physicians accountable for completing their job duties. The DON also stated that audits will be conducted by checking the admissions, pulling out records, and completing the audit check to make sure that nothing is missed. DON further stated that audits for labs will be performed on a weekly or daily basis, depending on what might be going on at that time in the facility. 4. During a record review of the in-service packet dated [DATE], revealed that the CCO provided an in-service on the topics of reviewing labs and adequate hydration. During an interview on [DATE] at 1:03 pm, the CCO confirmed providing several in-services to the staff regarding reviewing labs and hydration to the nursing staff.During an interview on [DATE] at 1:09 pm, the DON confirmed receiving in-services from the CCO regarding the process of reviewing labs and admission orders during their daily morning clinical meetings. The DON stated that if the DON is not available to facilitate the morning meetings and review labs, it is the responsibility of the ADONs to facilitate the morning meetings and review any current labs during the morning clinical meeting. The DON also stated that since there are three ADONs, the responsibility of facilitating the meetings will be alternated. During interviews conducted from [DATE] at 1:09 pm through [DATE] at 11:41 pm with the DON, ADON HH, and ADON II revealed that they received education reviewing labs and admission orders. All staff interviewed were able to provide appropriate answers related to the information provided from the in-service packet. 5. During a record review of the In-Service Attendance sheet (dated [DATE]) revealed that the in-service topic was revealed to be Job Descriptions. Review of the attendance also revealed staff in attendance to include the Administrator and DON. The in-service was provided by the CCO of the facility. During an interview on [DATE] at 1:03 pm, the CCO revealed that during the in-service (dated [DATE]), he reviewed the job descriptions of the DON and the Administrator with the DON and the Administrator. CCO stated that for the in-service, he reiterated to the administrator and the DON that their roles included being responsible for ensuring that clinical staff, direct-care staff, and individuals who are providing care to the residents are following through with orders and care according to policies and procedures. CCO also stated that the Administrator and the DON are responsible for ensuring the labs are conducted as ordered and reviewed. CCO further stated that the facility is in the process of implementing a new clinical process to ensure that labs are reviewed to catch anything that may have been missed by physicians. During an interview on [DATE] at 1:09 pm, the DON confirmed that the CCO reviewed the DON job description with her. The DON stated that part of her job duties includes the continuous oversight of the clinical department and ensuring that follow-ups are being completed. The DON also stated that it is her duty to hold the clinical staff, including physicians, accountable and to complete their job duties as assigned. The DON further stated that ensure accountability of the clinical staff by performing weekly or daily audits, which include pulling patient records and reviewing labs. During an interview on [DATE] at 1:17 pm, the Administrator confirmed that the CCO provided several in-services in the last couple of days including review of the Administrator's job description, he stated, I learned that obviously I'm over the whole facility, my role is to make sure that I'm abreast of everything that's going on, the department heads are supposed to relay information to me. 6. During an interview on [DATE] at 12:43 pm, the DON stated the facility does not employ agency staff at the facility. A review of the facility's active employee list revealed that there was no agency staff listed. 7. A review of the Quality Assurance Performance Improvement AD HOC committee meeting minutes dated [DATE] revealed that F692, F710, and F835 were reviewed. The attendees included the Administrator, the DON, the CCO, the third-floor ADON, and the second-floor ADON. The fourth-floor ADON and the Medical Director were in-service via phone. During an interview on [DATE] at 1:17 pm, the Administrator confirmed that the CCO provided several in-services in the last couple of days including review the Administrator's job description, I learned that obviously I'm over the whole facility, my role is to make sure that I'm abreast of everything that's going on, the department heads are supposed to relay information to me. In regard to tracking and trending in future QAPI meetings, the Administrator stated they meet quarterly and will discuss how to track and trend critical labs with the staff. 8. It was verified that the corrective actions were completed by [DATE]. The removal date of the IJ was [DATE].