**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint#: NJ00173566 Based on interviews, record reviews, and a review of the facility's policy titled Residents' Rights Regarding Treatment and Advance Directives, it was determined that the facility failed to ensure the physician's orders matched the resident's documented end-of-life wishes, which resulted in cardiopulmonary resuscitation (CPR) being done on a resident (Resident (R) 17) reviewed for code status out of a total sample of 22 residents. While in the hospital, R17 chose to be a do-not-resuscitate (DNR). However, the facility was unable to provide evidence that they implemented their policy for R17 for Advance Directives upon R17 admission to the facility. On [DATE], when R17 was found unresponsive, the facility performed approximately five rounds of chest compressions on the resident before the emergency medical services (EMS) arrived. EMS intubated [inserted a tube into the windpipe to provide oxygen via ventilator] R17 when they arrived on site and continued CPR via an automatic machine as they departed the facility for the hospital. R17 expired after leaving the facility. This failure resulted in an Immediate Jeopardy identified on [DATE] and was determined to exist on [DATE] at F678: Cardio-Pulmonary Resuscitation (CPR) at a Scope and Severity (S/S) of J. The Administrator was notified of the Immediate Jeopardy on [DATE] at 9:54 PM. The facility submitted an acceptable removal plan on [DATE]. On [DATE], the Surveyors conducted a revisit to verify that the Removal Plan was implemented. The facility implemented the Removal Plan. So, the noncompliance remained on [DATE] as a level D for no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility implemented the removal plan, which included the following: The Regional Director of Clinical Services educated the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on the procedure: ensuring the resident's wishes regarding code status are reflected in the resident's chart, communicating the correct code status to the physician, and interviewing the resident or responsible party regarding completing a POLST form upon admission to the facility. The DON and the ADON or Regional Nurse began re-educating, all nursing and social services staff on ensuring residents wishes regarding code status are reflected in the resident's chart communicating the correct code status to the physician, and interviewing the resident or responsible party regarding completing a POLST form upon admission to the facility. to the hospital, the ambulance transportation company receives the required documents to honor a resident's end-of-life wishes/cold status. The DON or designee initiates audits of new admission and readmission to ensure the nurse(s) completing the admission have reviewed: residents hospital records are reviewed, if they exist the resident's advanced directives is reviewed, the resident's POLST is reviewed, the resident's Living Will is reviewed, and the wishes regarding code status are reviewed with the resident or responsible party and are reflected accurately in the chart and communicated to the physician and that a POLST was offered if one wasn't already in place. Findings include: Review of R17's hospital History and Physical Report, electronically signed by a provider on [DATE], and uploaded on [DATE] into the Misc tab of R17's electronic medical record (EMR), revealed that R17 had a code status of DNR. Review of R17's New Jersey Universal Transfer Form, from the hospital to the facility dated [DATE], and located in the resident's paper chart, revealed R17 came from the hospital to the facility with a DNR code status. Review of R17's Face Sheet, located under the Profile tab of the electronic medical record (EMR), revealed R17 was admitted to the facility on [DATE] from the hospital with diagnoses of Osteomyelitis (bone infection), diabetes mellitus with foot ulcer, and heart failure. Review of an Admission/readmission Note, dated [DATE] at 1:23 AM, and located in the Prog Note tab of the EMR, revealed, Code Status: FULL CODE. Further review of the note revealed no documentation that R17 was asked what his/her wishes were regarding code status or to verify whether R17 had changed his/her code status to a Full Code. Review of R17's Order Summary Report, located in the Orders tab of the EMR, revealed orders dated [DATE] and [DATE] for Full Code. The Medical Director signed both orders on [DATE] at 11:56 AM. Review of the R17's electronic and hard copy closed medical records revealed no documented evidence that the resident or his/her family changed R17's code status from DNR to a Full Code status after he/she was admitted to the facility. Review of a Progress Note, dated [DATE] at 8:30 AM, and located in the Prog Note tab of R17's EMR, revealed, At approx [approximately] [7:45 AM] resident was observed unresponsive to verbal and tactile stimuli. CPR was initiated. 911 called. CPR continued. Patient was transported to [hospital]. Review of the facility-provided, CPR/Code Blue Documentation, dated [DATE], revealed CPR was initiated on R17 at 7:45 AM. At 7:53 AM, R17 was suctioned (fluid removed from the oral cavity via vacuum suction). EMS arrived at 8:00 AM, took over CPR, and intubated R17 at 8:02 AM. Review of R17's Progress Note, dated [DATE] at 5:02 PM, and located in the Prog Note tab of the EMR, documented a follow up call to the hospital revealed R17 had expired. During an interview on [DATE] at 3:43 PM, Family Member (FM)17 revealed that R17 was a DNR in the hospital and wore a DNR wristband from the hospital during his/her stay at the facility. FM17 stated if the facility had asked R17 what his/her end-of-life wishes were, R17 he/she would have chosen to continue to be a DNR. During an interview on [DATE] at 1:22 PM, the Director of Nursing (DON) stated that when a resident was admitted to the facility, the admitting nurse relayed the code status the resident had at the hospital to the Doctor to obtain an order. If there was a discrepancy in the hospital records, the Doctor was likely to order a full code. During a concurrent interview with the DON and Administrator on [DATE] at 2:48 PM, they stated if the hospital records clearly indicated DNR or full code, these were the orders the nurses asked for from the physician when residents were admitted to the facility. During an interview on [DATE] at 6:44 PM, LPN2, the nurse who entered R17's admission orders of a Full Code into the EMR, stated she was agency staff and worked the night shift. LPN2 stated she was not provided with the facility's code status policy. She further stated that other nurses she had worked with instructed her to review the hospital records and request orders from the physician for the code status of the resident in the hospital. LPN2 no longer worked at the facility and could not remember why she entered Full Code as R17's code status. During an interview on [DATE] at 12:26 PM, the Medical Director stated he expected the admitting nurse to attempt to talk to the resident or family about their wishes regarding code status prior to calling the provider for orders. If unable to obtain their input, the Universal Transfer Form could be used for code status until current wishes were verified within 48 to 72 hours after admission to the facility. When asked if he verified what code status R17 wanted before signing the orders, the Medical Director stated he could not remember R17 but that physicians and Nurse Practitioners had an area in the progress notes to document any discussions with the resident or family about code status. Review of the facility's policy titled, Residents' Rights Regarding Treatment and Advance Directives reviewed/revised [DATE], included the following: Under Policy: revealed It is the policy of the facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. Under Definitions: showed Advance directive is a a written instruction, such as a living will or a durable power of attorney for health care . Under: Policy Explanation and Compliance Guidelines: included 1. On, admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive. 2. The facility will provide the resident or resident representative information, in a manner that is easy to understand, . 9. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. NJAC: 8:39-4.1(a)2 NJAC: 8;39-9.6 (b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Complaint#: NJ00173566 Based on interviews, record reviews, and a review of the facility's policy, it was determined that the facility failed to ensure residents code status was documented in the medical records, the Physician's Order for Life-Sustaining Treatment (POLST) reflected the residents' end of life wishes and the proper documentation was completed so that those end of life wishes were honored in the facility and/or during transport. The facility also failed to follow its policies titled Residents' Rights Regarding Treatment and Advance Directives and the Social Services Director Job Description for 8 of 28 residents (Resident (R)2, R10, R13, R17, R24, R25, R26, and R28) reviewed for code status. R17 was admitted to the facility from the hospital with documented evidence that he/she had chosen a Do Not Resuscitate (DNR) code status; however, the facility ordered a Full Code despite no documented evidence the facility verified with the resident and/or family that R17 wishes were not to be a DNR. On [DATE], this failure resulted in Cardiopulmonary Resuscitation (CPR) and Emergency Medical Services (EMS) being initiated when the resident became unresponsive. Additionally, R2, who had a DNR code status, was transferred to the hospital via ambulance; however, the facility failed to ensure the proper documentation was completed and provided to the ambulance transport company for the resident's code status of DNR to be honored. This failure resulted in psychosocial harm to R2 when the ambulance personnel informed the resident that CPR would be required if he/she became unresponsive during transport. Also, during R2's readmission to the facility on [DATE], a physician's order was obtained for a full code from [DATE] until [DATE] without verification if R2 had changed his/her end-of-life wishes from DNR to full code. These failures placed R2, R10, R13, R17, R24, R25, R26, R28, and all other residents who were admitted and/or readmitted to the facility in an Immediate Jeopardy (IJ) situation that the likelihood that their end-of-life code status would not be honored. An Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE], at §483.10 F578: Request/Refuse/Discontinue; Formulate Advance Directives. The Administrator was notified on [DATE] at 7:06 PM of the Immediate Jeopardy. . The IJ ran from [DATE] through [DATE] at 4:30 PM, when the facility submitted an acceptable removal plan. On [DATE], the Surveyors conducted a revisit to verify that the Removal Plan was implemented. The facility implemented the Removal Plan. So, the noncompliance remained on [DATE] as a level E for no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. The facility implemented the removal plan, which included the following: The Regional Director of Clinical Services educated the Director of Nursing (DON) and the Assistant Director of Nursing (ADON)on the procedure, ensuring when residents are transferred from the facility to the hospital, the ambulance transportation company receives the required documents to honor a resident's end-of-life wishes/cold status. The DON and the ADON or Regional Nurse began re-educating, ensuring when residents are transferred from the facility to the hospital, the ambulance transportation company receives the required documents to honor a resident's end-of-life wishes/cold status. The DON or designee initiates audits of transfers to the hospital to ensure that when residents are transferred from the facility to the hospital, the ambulance transportation company receives the required documents to honor a resident's end-of-life wishes/code status. Findings include: 1. Review of R17's Face Sheet, located under the Profile tab of the electronic medical record (EMR), revealed that R17 was admitted to the facility on [DATE] from the hospital with diagnoses of osteomyelitis (bone infection), diabetes mellitus with foot ulcer, and heart failure. Review of R17's hospital History and Physical Report, electronically signed by a provider on [DATE], and uploaded on [DATE] into the Misc tab of R17's electronic medical record (EMR), revealed that R17 had a code status of DNR. Review of R17's New Jersey Universal Transfer Form, dated [DATE] and located in the paper chart, revealed that R17 came from the hospital to the facility with a DNR code status. Review of R17's Order Summary Report, located in the Orders tab of the EMR, revealed orders dated [DATE] and [DATE] for Full Code. The Medical Director signed both orders on [DATE] at 11:56 AM. Review of an Admission/readmission Note, dated [DATE] at 1:23 AM and located in the Prog Note tab of the EMR, revealed, Code Status: FULL CODE. Review of the note showed no documentation that R17 was asked what his/her wishes were regarding code status or to verify a change from a DNR to a Full Code. Review of R17's electronic and hard copy closed medical records revealed no documented evidence that the facility spoke with the resident or his/her family to verify his/her code status and end-of-life wishes after they were admitted to the facility. Review of a Progress Note, dated [DATE] at 8:30 AM, and located in the Prog Note tab of R17's EMR, revealed, At approx [approximately] [7:45 AM] resident was observed unresponsive to verbal and tactile stimuli. CPR was initiated. 911 called. CPR continued. The patient [resident] was transported to [the hospital]. Review of the facility-provided, CPR/Code Blue Documentation, dated [DATE], revealed CPR was initiated on R17 at 7:45 AM. At 7:53 AM, R17 was suctioned. EMS arrived at 8:00 AM, took over CPR, and intubated [tube inserted into the windpipe to provide oxygen via a ventilator] R17 at 8:02 AM. Review of R17's Progress Note, dated [DATE] at 5:02 PM, and located in the Prog Note tab of the EMR, documented a follow up call to the hospital revealed R17 had expired. During an interview on [DATE] at 3:43 PM, R17's Family Member (FM17) revealed that the resident was a DNR in the hospital and wore a DNR wristband from the hospital during his/her stay at the facility. FM17 stated that if the facility had asked R17 what his/her end-of-life wishes were, R17 would have been verified and chosen to be a DNR. During an interview on [DATE] at 1:38 PM, Licensed Practical Nurse (LPN) 1 stated that the facility received code status orders from the provider when a resident was admitted . According to LPN1, the nursing staff verbally spoke to residents about their wishes and relayed them to the provider. Nurses were not allowed to have the resident sign a POLST (Practitioners Orders for Life Sustaining Treatment). LPN1 stated, Someone else did that. However, LPN1 was uncertain about who ensured the POLST forms were signed. During an interview on [DATE] at 2:10 PM, Unit Manager (UM)1 stated the Nurses reviewed the admitting resident's hospital papers to determine what their code status was in the hospital. UM1 stated that nurses did not ask the residents what their wishes were regarding code status. Instead, they relayed the resident's code status in the hospital to the physician and obtained the same orders. During a concurrent interview with the DON and Administrator on [DATE] at 2:48 PM, they stated the following facility's process: if the hospital records clearly indicate DNR or full code, these were the orders the Nurses asked for from the physician when residents were admitted to the facility. On admission or the day after, nursing asked residents if they wanted a consultation with the palliative nurse practitioner to discuss code status. When asked what the expectation was regarding the discussion of code status, the DON and Administrator stated the expectation was that residents were asked what their wishes were regarding code status. It was expected that a nurse practitioner or physician had a conversation with residents regarding code status and that the nurses followed the physician's orders. If residents did not want a discussion about code status, then their code status was whatever the doctor confirmed based on hospital records. In the same interview, the DON stated she expected a conversation to be documented in EMR for code status changes. The Administrator stated if code status changed from the hospital to the facility, she expected documentation of that either in a nurse's assessment, a progress note, or verification with the physician's order. When asked for documentation that R17 had changed her code status from DNR to Full Code, a social service progress note was provided as documentation. Review of the social service progress note, Social Services Assessment and Documentation, dated [DATE], revealed no documentation that code status was discussed with R17 or that R17 had changed her code status from DNR to Full Code. During an interview on [DATE] at 8:20 PM, the Certified Social Worker/Social Services Director (SSD) stated social services did not ask residents what their wishes for code status were when they were admitted . According to the SSD, within 72 hours of the resident's admission, social services asked residents if they had any advanced directive or living will and provided information regarding filling out an advanced directive or POLST if they wished. If a resident expressed interest in filling out a POLST, the SSD assisted but did not otherwise ask residents what their wishes were. During an interview on [DATE] at 6:44 PM, LPN2, the nurse who entered R17's admission orders for a Full Code into the EMR, stated she was agency staff and worked the night shift. LPN2 stated that she had not been trained concerning the facility's code status policy. LPN2 stated that other nurses instructed her to review the hospital records and request orders from the physician for the code status the resident had in the hospital. If the records were unclear or did not mention the code status, full code orders were requested and entered into the EMR. LPN2 stated she was told by other nursing staff that the facility did not want the nurses asking residents for their code status, so she did not ask about their end-of-life wishes. During an interview on [DATE] at 12:26 PM, the Medical Director stated he expected the admitting nurse to attempt to talk to the resident or family about their code status wishes before calling the provider for orders. If unable to obtain their input, the Universal Transfer Form could be used for code status until current wishes were verified. The Medical Director stated there were many opportunities to discuss code status with the resident by the admitting provider, the palliative nurse practitioner, nursing, or a social worker. In addition, the Medical Director further stated, We [the facility] need to make sure we close the loop. The Medical Director further stated he expected code status to be clarified within 48 to 72 hours after admission to the facility but was uncertain who ensured this was done. 2. Review of R2's undated admission Record, located in the EMR under the Profile tab, revealed the resident was admitted to the facility on [DATE] and most recently readmitted on [DATE]. The undated admission Record also documented under the Advance Directive section, R2 was DNR-DO NOT RESUSCITATE/DNI-DO NOT INTUBATE [insertion of a tube into the windpipe to provide oxygen through a ventilator]. A review of R2's untitled hospital record dated [DATE] and located in the resident's EMR under the Misc [Miscellaneous] tab revealed on the second-page order of DNR/DNI. The order documented, .I am attending, or I conferred with the attending physician prior to placing this order .Discussed with Patient . The print date of the document was [DATE] at 4:40 PM. Review of R2's physician Order Summary Report (POS), dated [DATE] through [DATE] and provided by the facility, revealed an order dated [DATE] of DNR/DNI. The order summary report did not have any physician signatures, nor did it have what provider gave the order. Review of R2's admission Agreement, dated [DATE] (four days after the resident was admitted to the facility), revealed . Facility Representative Documentation on Advance Directives: Resident has executed a Living Will [marked 'Yes'] . Resident has executed a Medical Order for Life Sustaining Treatment [nothing marked] .Resident has executed a Do Not Resuscitate (DNR) [nothing marked] . Review of R2's nursing Progress Note, dated [DATE] and located in the resident's EMR under the Progress Notes tab., revealed .at 1700 [5:00 PM], patient's son and his/her daughter .requested that [the] patient [be] transferred out to the hospital. 1810 [6:10 PM] Patient transferred to hospital via stretcher by [name of ambulance transport company] . Review of R2's New Jersey Universal Transfer Form, dated [DATE] and provided by the facility, revealed .CODE STATUS: DNR [marked], DNI [marked] .19. Attached Documents: .Code Status [marked] . The New Jersey Universal Transfer Form, dated [DATE], was completed by Licensed Practical Nurse (LPN) 3. No documents were attached to the facility provided New Jersey Universal Transfer Form, dated [DATE]. R2 was readmitted to the facility on [DATE] and even though the facility was aware the resident was a DNR, R2 was ordered a Full Code status until the next day. Review of the admission Record for R2 readmission with a print date of [DATE], provided by LPN1 and located in the resident's Paper Medical Record adjacent to the 200 nurses' station, revealed that R2 was readmitted to the facility on [DATE] and under the Advance Directive section it was documented Full Code. Review of R2's nursing Progress Note, dated [DATE] and located in the resident's EMR under the Progress Notes tab, revealed an admission/readmission note of [R2's Name] arrived at the facility on 11/15/ [at] 6:15 PM from a hospital via stretcher .Code Status: FULL CODE . Review of R2's Order Recap Report, revealed an order dated [DATE] of Full Code. The order for the resident to have a Full Code status ended on [DATE] when the order was changed to DNR Do Not Resuscitate. A review of R2's physician's Progress Note, dated [DATE] as a late entry and located in the resident's EMR under the Progress Notes tab, revealed .plan of care discussion had with family and patient's CODE STATUS was changed to DNR/DNI . During an interview on [DATE] at 6:13 PM, R2 stated that during the transfer to the hospital on [DATE], prior to leaving the facility, the ambulance transport staff informed him/her that the facility could not find the correct paperwork for them to take with them to verify that he/she was a DNR. The resident stated he/she, and the nurse told the ambulance staff he/she was a DNR code status. The resident stated that he/she had been a DNR since admission to the facility. According to the resident, the ambulance staff told him/her that if he/she was to code during transfer to the hospital, they would be required to perform CPR. The resident stated this made him/her very upset. During an interview on [DATE] at 9:23 AM, LPN3 stated on [DATE] that he was the nurse who had completed R2's transfer to the hospital. When asked if there were any concerns with R2's transfer to the hospital, LPN3 stated he could not locate R2's Practitioner Orders for Life-Sustaining Treatment (POLST) form. LPN3 stated the POLST had R2's code status on it and was supposed to go with the resident to the hospital. LPN3 revealed that because he could not locate R2's POLST, the ambulance transport company told him and the resident they would have to make her a Full Code while being transported. LPN3 also stated he and R2 both verbally told the ambulance personnel that R2 was a DNR; however, the ambulance personnel stated they needed either a copy of the POLST form or a copy of a signed physician's order for the DNR. LPN3 further stated he completed the New Jersey Universal Transfer Form, dated [DATE], and indicated the resident was a DNR on the form. In addition, LPN3 stated he sent a copy of R2's Order Summary Report, which indicated the resident had a physician's order for a DNR code status. When asked if R2's Order Summary Report had either a physician's signature or a physician's electronic signature on the report, LPN3 stated it did not. During a record review on [DATE] at 2:00 PM, LPN1 reviewed R2's Paper Medical Record, located adjacent to the nurses' station, and verified the resident's medical record did not contain a signed physician's order for a DNR status or a POLST form. During an interview on [DATE] at 2:55 PM with the DON and the Administrator, the DON stated when a resident was transferred to the hospital from the facility, the facility sends, at a minimum, the resident's order summary report and verbal report of the resident's code status is given to the ambulance company. The Administrator stated a POLST form was not required to be completed; they (the facility) just recommended that it be completed to ensure the residents' wishes are honored. The DON stated it was her expectation for residents to be offered a POLST form, and if the resident declined to complete a POLST form, the declination should be documented in the record. During a subsequent interview on [DATE] at 11:54 AM, R2 was further asked about his/her transfer to the hospital on [DATE]. R2 stated when the ambulance staff told him/her since the facility did not have the required document (completed POLST or signed physician's order) for his/her DNR status and if he/she coded on the way to the hospital, they would be required to do CPR, he/she became very upset and started crying. R2 stated all he/she could think about was the conversation his/her granddaughter had with him/her related to not being a full code at his/her age. The resident stated he/she pictured in his/her mind the tears coming down his/her granddaughter's face when he/she was having this conversation with him/her. R2 stated he/she did not want to be a vegetable and feared that it would happen if he/she coded on the way to the hospital. R2 stated even though his/her transfer to the hospital was not an emergency; the ambulance driver knew he/she was upset and transported him/her with the lights and siren on like it was an emergency to get there quicker. R2 was teary while relaying the incident to the surveyor. During an interview on [DATE] at 4:36 PM, when asked if there were documents that were required to be attached to the New Jersey Universal Transfer Form, the DON stated the Medication Administration Record/Treatment Administration Record (MAR/TAR), physician order summary (POS), face sheet, labs, and if the resident had a POLST. The continued interview revealed that when the POS (order summary report) was printed out for a transfer, the orders had been approved by the physician, whether verbal or signed. The DON verified that the POS did not have a physician's signature/electronic signature (which was required by the EMS to be a valid order). 3. Review of R10's undated admission Record, provided by the facility, revealed the resident was admitted on [DATE] and most recently readmitted on [DATE]. The admission Record documented the resident's code status as DNR/DNI. Review of R10's EMR and paper medical record revealed no documented evidence that the resident's record included a POLST form or a copy of a signed physician's order for DNR/DNI, which EMS required. 4. Review of R13's undated admission Record, provided by the facility, revealed the resident was admitted on [DATE] and most recently readmitted on [DATE]. The admission Record documented the resident's code status as DNR/DNI. Review of R13's EMR and Paper Medical Record revealed no documented evidence the resident's record included a POLST form or a copy of a signed physician's order for DNR/DNI, which EMS required. 5. Review of R24's undated admission Record, provided by the facility revealed the resident was admitted to the facility on [DATE] and documented the resident's code status as DNR/DNI. Review of R24's EMR and Paper Medical Record revealed no documented evidence that the resident's record included a POLST form to document the code status of DNR/DNI, so that the resident's end of life wishes would be honored by the ambulance staff during transport. During a record review and interview on [DATE] at 2:00 PM, LPN4 verified that R24's medical records did not contain a POLST form or a copy of a signed physician's order for DNR/DNI, which EMS required. 6. Review of R25's undated admission Record, provided by the facility, revealed the resident was admitted on [DATE] and most recently readmitted on [DATE]. The admission Record documented the resident's code status as DNR/DNI. Review of R25's EMR and Paper Medical Record revealed no documented evidence that the resident's record included a POLST form or a copy of a signed physician's order for DNR/DNI, which EMS required. 7. Review of R26's undated admission Record, provided by the facility revealed the resident was admitted to the facility on [DATE] and documented the resident's code status as DNR/DNI. Review of R26's EMR and Paper Medical Record revealed no documented evidence the resident's record included a POLST form or a copy of a signed physician's order for DNR/DNI, which EMS required. 8. Review of R28's undated admission Record, provided by the facility revealed the resident was admitted to the facility on [DATE] and documented the resident's code status as DNR/DNI. Review of R28's EMR and Paper Medical Record revealed no documented evidence the resident's record included a POLST form or a copy of a signed physician's order for DNR/DNI, which EMS required. During a record review and interview on [DATE] at 2:08 PM, Unit Manager (UM) 1 stated a POLST form should be completed and placed in the residents' chart. UM1 verified that R10, R13, R24, R25, R26, and R28's Paper Medical Record and EMR did not include a POLST form or a copy of a signed physician's order for DNR/DNI, which EMS required. Review of the facility's Social Services Director Job Description, updated [DATE], revealed, The Social Services Director will oversee the process of Advance Care Planning for each resident upon admission, and make sure that any Advance Directives are reviewed with the resident/resident representative on a regular basis. The Director will ensure that staff members are made aware of the resident's code status and end-of-life wishes and will assist with informing and educating residents and their representatives about health care options and ramifications. Review of the facility's policy titled, Residents' Rights Regarding Treatment and Advance Directives, revised [DATE] revealed Policy: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate and advance directive .Policy Explanation and Compliance Guidelines: .9. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care . A review of the NEW JERSEY PRACTITIONER ORDERS FOR LIFE-SUSTAINING TREATMENT (POLST), form dated [DATE] revealed DIRECTIONS FOR HEALTHCARE PROFESSIONAL .POLST orders are actual orders that transfer with the person and are valid in all settings in New Jersey. It is recommended that POLST be reviewed periodically, especially when: The person is transferred from one care setting or care level to another .Any incomplete section of POLST implies full treatment for that section .Section D. Make a selection for the person's preferences regarding CPR . Review of Section D revealed a selection of Attempt CPR or Do not attempt resuscitation/DNAR Allow Natural Death . Continued review of the POLST revealed on the front page at the bottom is a signature line for the resident/representative to sign confirming I have discussed this information with my physician/APN/PA [advanced practice nurse/physician assistant]. The POLST also had a signature line for the physician/APN/PA to sign, making the POLST document an order. NJAC: 8:39-9.6

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of R57's undated admission Record, provided by the facility, revealed the resident was admitted to the facility on [DATE]. Review of R57's Medical Diagnoses, located in the resident's EMR under the Med Diag tab, revealed the resident was admitted to the facility with diagnoses which included chronic respiratory failure and obstructive sleep apnea. On 11/01/23 the diagnosis of acute on chronic congestive heart failure was added. Review of R57's quarterly Minimum Data Set (MDS), with an ARD of 11/17/23, located in the resident's EMR under the MDS tab, revealed the facility assessed R57 to have a BIMS score of 14 out of 15 which indicated the resident was cognitively intact. During an interview on 01/04/24 at 9:40 AM, R57 stated back in October 2023, he started having swelling with water. R57 stated he requested an appointment with a cardiologist because of the swelling; however, the facility did not take him seriously. R57 also stated the swelling was so bad, he touched his right leg and the skin split open. R57 stated he finally got an appointment with the cardiologist who sent him directly to the hospital where he had about 60 pounds of fluids drained from him. Review of R57's Physician Note, dated 02/06/23, located in the resident's EMR under the Progress Notes tab, revealed .Chief Complaints chf [congestive heart failure], right knee pain, cardiomegaly .58 yo [year old] male .pt [patient] evaluated today for monitoring of his sob [shortness of breath] .pt completed his ct [CT scan] of his chest .PLAN heart failure seen on ct [.] fu [follow up] with [Cardiologist Name] not available until august [.] will monitor pt currently on diuretics .pt counseled on his high risk of death due to his morbid obesity . Review of R57's Progress Note, dated 10/02/23, revealed Pt complained of r [right] sided swelling. MD [Medical Doctor] notified will be evaluated tomorrow. The nursing progress notes lacked assessment information related to R57's edema (swelling). Review of R57's Physician/Practitioner Progress Note, dated 10/04/23, revealed Note Text: MEDICAL PROGRESS NOTE .chief complaints .chf [congestive heart failure], cardiomegaly .pt is resting, in bed, noted to have ongoing Left side swelling and pain, pt being treated with increased dose of diuretic [fluid pill] .CT chest ordered STAT .Care plan reviewed with pt and nursing [.] vitals reviewed will cont. [continued] to monitor. The note was completed by Nurse Practitioner (NP) 1. NP1's note did not document the extent of the edema or what signs or symptoms nursing was to monitor for the CHF and edema Review R57's Radiology Note, dated 10/04/23, located in the resident's EMR under the Progress Notes tab, revealed Procedure: .Findings: There is moderate congestive heart failure. There is moderate interstitial edema [fluid in the interstitial spaces of the lung], cardiomegaly, and pulmonary vascularredistribution [sic] . Review of a nursing progress note, dated 10/11/23, revealed PT [patient] c/o having trouble breathing. SPO2 [oxygen level]=95%. Will continue to monitor. There was no documented evidence that the resident's physician was notified. Review of R57's Progress Note, dated 10/21/23 revealed small open area to RLE [right lower extremity] weeping measuring about 1.7x2 medi honey applied and covered with CDD [clean dry dressing] NP made aware follow up with podiatry on Monday morning. There was no documented evidence of any intervention to address the CHF and edema that caused the resident to sustain an open area. Review of R57's Progress Note, dated 10/21/23 revealed .Pt complained of shortness of breath O2 @ 94%. I sat resident up and placed O2 @ 2 liters throughout the evening until replaced by C-PAP for sleep. Review of the Progress Notes, dated 10/04/23 through 10/23/23 and located in the EMR Progress Notes tab, revealed no documentation of monitoring for signs and symptoms of CHF for R57. Review of R57's Progress Note, dated 10/23/23 revealed [resident name] left unit with medical transport Mon [DATE]:30 for a Cardiology. Review of R57's Progress Note, dated 10/23/23 revealed Patient confirmed to have been sent from Cardio appt w. [Dr. Name] to [hospital name] and admitted with Dx. CHF. This was 21 days after R57 first complained of swelling and 19 days after an x-ray revealed CHF with no consistent monitoring by nursing and no other treatment than an oral diuretic. During an interview on 01/04/24 at 2:32 PM, LPN 6 was asked if she remembered back in October 2023 when R57 had some swelling. LPN6 started to cry and stated she remembered the resident had so much swelling she called and told NP1 that it looked like he was going to bust open all over his body. LPN6 stated NP1 came into the facility, assessed the resident, and wanted to send the resident to the hospital for IV diuretics; however, the prior Director of Nursing (PDON) told the NP no because of the facility's census numbers. LPN6 stated the NP increased the resident's Lasix medication; however, it continued to worsen. LPN6 further stated his swelling got so bad, the resident's right leg busted open from so much swelling. LPN6 with tears in her eyes stated she thought the resident was going to die. During an interview on 01/05/24 at 10:33 AM, NP1 stated when she assessed R57, she recommended the resident to be sent out to the hospital; however, the facility wanted to treat the resident in house. NP1 stated she ordered a CT scan and increased the resident's diuretic; however, the CT was not able to be completed due to the resident's weight and they had to find a place for him to be able to have the CT completed which caused a delay in treatment. NP1 stated prior to sending out a resident to the hospital, the former DON would have to approve. NP1 stated she wanted to send R57 out to the emergency room because he was already on a high dose diuretic by mouth, so she wanted to send him for IV diuretics. NP1 stated R57 having 45 pounds of fluid drained off was a lot and it was concerning the DON not wanting the resident sent out. NP1 stated a possible negative outcome would have been respiratory failure. During an interview on 01/05/24 at 11:11 AM, the prior Director of Nursing (PDON) stated she did not remember NP1 wanting to send R57 to the hospital due to excess edema. The PDON confirmed the facility's practice was that she would be notified prior to sending any resident to hospital; however, she stated she would not have requested the resident to be treated in the facility and not be sent out. When asked what her expectation was related to the monitoring of R57's edema, the PDON stated it meant to monitor and assess the resident; however, she did not expect the nurses to document the monitoring. During an interview on 01/05/23 at 12:35 PM, the prior Administrator stated the facility's practice was for nurses and providers to notify the PDON prior to sending any residents out of the facility to the hospital. The prior Administrator stated the PDON and provider would have discussions about treating the residents in house by increasing their Lasix first, redoing labs stat, and other options. The prior Administrator also stated they [the facility] just wanted to do everything here at the facility that they could, but it was ultimately up to the provider. During an interview on 01/04/24 at 12:50 PM, the Medical Director stated after the provider was notified on 10/02/23 about R57's edema, the provider should have started an intervention at that time. The Medical Director also stated if the provider stated they were going to be in the next day to evaluate the resident, then the provider should have come in. The Medical Director reviewed some of R57's medical record with the surveyor. The Medical Director further stated after the Xray results came back, the provider should have completed a follow up with the resident, reassessed the resident, monitored the resident, and ensured the nursing staff was monitoring the resident including daily weights. The Medical Director further stated, the provider should not have waited until the resident's cardiology appointment on 10/23/23 for the resident to receive treatment for the edema and CHF. Continued interview revealed the Medical Director stated R57 could have gone into respiratory distress. Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised July 2023, revealed, . An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur . Written procedures for investigations include . Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations . Reporting of all alleged violations to the . state agency, adult protective services and to all other required agencies . Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse . NJAC 8:39- 4.1 (a) 5 NJAC 8:39-5.1 (a) NJAC 8:39-27.1 (a) Complaints: NJ00157215, NJ00161186, NJ00161762, NJ00162457, NJ00162827, NJ00167295, NJ00168400, NJ00168545, NJ00168603, NJ00169368 Based on observation, interview, record review, and facility policy review, the facility failed to protect one resident's (Resident (R) 38) right to be free from physical abuse by staff and failed to protect two residents' (R37 and R57) right to be free from neglect out of a total sample of 65 residents. An allegation was reported that R38 was found with adhesive paste inside his ileostomy stoma. It was reported the stoma adhesive paste was in an amount sufficient to obstruct R38's stoma. The facility failed to identify the alleged incident as an allegation of abuse, failed to report the allegation to the state agency, failed to conduct a thorough investigation, and failed to protect residents during the investigation. R37 received Eliquis, an anticoagulant medication, suffered an unwitnessed fall, and the facility neglected to monitor for changes in level of consciousness. R37 was sent to the hospital, and it was recorded that she had a traumatic brain injury. R57 had diagnoses including congestive heart failure (CHF) and exhibited signs and symptoms of an exacerbation of CHF. The facility neglected to obtain a cardiologist appointment as requested by the resident, neglected to monitor daily weights, neglected to notify the physician when R57 had shortness of breath, and neglected to intervene when providers did not provide care and services necessary for a resident having an exacerbation of CHF. R57 was admitted to the hospital and had 45 pounds (lbs) of fluid drained from his body. The failures to identify allegations of abuse, monitor for changes in level consciousness, and provide care and services for a resident having an exacerbation of CHF resulted in an Immediate Jeopardy (IJ) at F600-L; Freedom from Abuse, Neglect, and Exploitation due to the increased likelihood of serious harm or impairment, up to and including death. The facility provided an acceptable removal plan on 01/9/24. The removal plan included assessments of all residents with stomas and educating all nursing staff, including agency nurses, on ostomy management. The removal plan included reviewing all residents receiving anticoagulants and any falls to determine if monitoring and educating nursing staff, including agency nurses, on monitoring residents on anticoagulants who fall, monitoring residents for changes in condition, timely physician notification, accurate documentation, and sending residents to outside providers per physician orders. The removal plan included assessing all residents with a diagnosis of heart failure and educating nursing staff, including agency nurses, of signs and symptoms of CHF and evaluating residents with CHF. On 1/17/2024, the surveyors conducted a revisit and verified that the Removal Plan was fully implemented. The noncompliance remained on 1/17/2024 at a Level F for no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy. Findings include: 1. Review of R38's admission Record, provided by the facility, revealed R38 was admitted to the facility on [DATE] with diagnoses that included surgical aftercare following surgery on the digestive system, ileostomy (surgical opening and attachment of the small intestine to the abdomen where waste is collected in a bag attached to the outside of the abdomen) status, and other intestinal obstruction. Review of R38's Physician Orders, dated 12/06/23 and located under the Orders tab of the electronic medical record (EMR), revealed R38's ostomy wafer and ostomy bag were to be changed daily on the 11-7 shift. Review of R38's admission Minimum Data Set (MDS), located under the MDS tab of the EMR and with an Assessment Reference Date (ARD) of 12/12/23, revealed R38 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated R38 was cognitively intact. Review of R38's undated Care Plan, provided by the facility, documented a focus problem related to R38's ileostomy. It was recorded to change the wafer as ordered and when indicated, to change/empty the ostomy bag after each bowel episode or when full, and to place a proper-fitting wafer around the ostomy site. Review of R38's Progress Notes, dated 01/01/24 through 01/04/24, revealed no documentation of any concerns related to R38's ileostomy. On 01/04/24 at 6:00 PM, R38's family member (F) 6 stated that on the morning of 01/02/24, F7 had started to change R38's ostomy bag, and when F7 removed the bag, F7 found stoma adhesive paste inside of R38's stoma. F6 showed the surveyor a photo of what appeared to be a stoma with a yellow-colored substance occluding the opening of the stoma. F6 reported that the Director of Patient Relations and two nurses had been informed of the incident. F6 stated she believed the photo had been forwarded to staff members. On 01/04/24 at 6:25 PM, the Administrator and Director of Nursing (DON) were asked if they were aware of the alleged incident. The Administrator stated she had been informed on 01/03/24, and she had opened a grievance regarding the allegation. The Administrator confirmed a state reportable incident report had not been sent to the state survey agency. The Administrator stated she had seen the photo but had not enlarged it for closer inspection. The DON stated she had not seen the photo. The Administrator identified two staff members, Registered Nurse (RN) 4 and RN2, as working with R38 on the 11-7 shift from 11:00 PM on 01/01/24 through 7:00 AM on 01/02/24. The Administrator stated RN2 had been suspended because she would not return their call and that RN4 was coming to provide a statement before his shift on 01/04/24. The Administrator did not identify any nurse aides that had worked with R38 on the shift in question. The Administrator confirmed she had not identified the allegation as an allegation of abuse and had not started an investigation of the alleged incident. On 01/04/24 at 6:58 PM, the Administrator provided documentation concerning the allegation. Included in the documentation were R38's admission Record, Order Summary Report, and a Grievance/Concern Form, where it was recorded, . 1/3/23 [sic] [F6] stated that that [sic] whomever on the 11-7 shift did not change bag/care for colostomy properly . It was documented that the Director of Public Relations filled out the form. There was no documentation of the allegation that stoma adhesive paste was found in R38's stoma. On 01/05/24 at 7:53 AM, the Administrator provided documentation of her investigation of the alleged incident with R38. The documentation included an untitled document, dated 01/04/24, that recorded, . The resident was interviewed by the DON and he stated that there was stoma paste on his stoma. The investigation documentation included a statement from RN4 where it was noted RN4 did not provide care for R38 on 01/02/24, a statement from Licensed Practical Nurse Supervisor (LPNS), and a statement from Licensed Practical Nurse (LPN) 5. It was recorded LPN5 was asked what care he provided to R38 on 01/02/24. It was recorded LPN5 stated he did not change the ostomy bag and did not note any concerns with the ostomy bag. There was no documentation LPN5 was asked any questions specific to the allegation of stoma adhesive paste being inside R38's stoma. On 01/05/24 at 6:55 PM, the Regional Clinician (RC) stated she had been informed a family member had found stoma adhesive paste inside R38's stoma and she had reported it immediately. The RC stated she had seen the photo and F6 had told staff that the substance was stoma adhesive paste. The RC stated R38 had a high output ileostomy, and the facility was using different processes to determine what was the best method for changing and maintaining R38's ileostomy bag. The RC stated staff and family members had been changing R38's ileostomy system two to three times per shift because of leakage. The RC reported that RN2 had tested positive for COVID-19, and that was why she had not been answering the facility's calls. On 01/05/24 at 2:00 PM, F7, who was the family member that allegedly found the stoma adhesive paste in R38's stoma, reported that on 01/02/24 when he arrived at the facility, R38's ostomy bag was clean. F7 stated he found that unusual and began to change R38's ostomy bag. F7 stated when he removed the bag, he found what looked to be stoma adhesive paste inside the stoma. F7 stated, It looked like someone squirted it [adhesive paste] in there. F7 reported he inserted a Q-tip into the stoma three quarters to one inch and pulled out approximately one to one and a half inches of adhesive. F7 reported he began to clean around the stoma, and the pressure caused three additional pieces of adhesive to come from the stoma. F7 reported that after the last piece of adhesive came out, bowel movement began coming out. On 01/06/24 at 10:00 AM, the surveyor observed ostomy supplies, including two tubes of Adapt ostomy adhesive paste, were noted on R38's bedside table. The ostomy adhesive paste was noted to be yellow in color. On 01/06/24 at 10:36 AM, the Unit Manager (UM) stated nurses changed and emptied ostomy bags and aides emptied the ostomy bags. On 01/06/24 at 11:35 AM, the Administrator provided an update to her investigation of the alleged incident with R38. Included a document dated 01/02/24 which recorded Certified Nurse Aide (CNA) 4 had been assigned to R38 on 01/02/24. There was no documentation of an interview with CNA4 included in the documents provided to the surveyor. A statement from CNA3, who was the other CNA assigned to R38's unit, was included in the documentation. The Administrator stated RN4 and RN2 had been interviewed and neither worked with R38 on the shift in question. The Administrator reported that LPN5 had been assigned to R38 on the shift in question and that he had been interviewed and denied any concerns. The Administrator provided documentation of interviews with three other residents where the residents were asked How would you describe your overall care and Do you have any concerns at all that you want to express. There was no documentation the residents were asked questions specific to abuse. There was no documentation a statement had been obtained from F7. The Administrator stated the investigation was ongoing and confirmed the incident did occur. The Administrator was asked if all the aides assigned to R38 on that shift had been interviewed. She stated, No. The Administrator was asked how the facility was protecting residents during the investigation. The Administrator stated residents were being protected with general rounds and observing and monitoring R38's stoma. The Administrator reported she did not know if there were any other residents with stomas in the facility. No further documentation was provided to the surveyor by the end of the survey on 01/09/24 at 12:30 PM. 2. Review of R37's hospital Active Meds sort by Name, located under the Misc (Miscellaneous) tab of the EMR, revealed R37 received 5 milligrams (mg) of apixaban (Eliquis, an anticoagulant) at the hospital on [DATE] at 9:00 AM. Review of R37's admission Record, provided by the facility, revealed R37 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation (irregular heartbeat). Review of R37's Physician Orders, located under the Orders tab of the EMR, revealed R37 was to receive Eliquis 5mg twice daily for atrial fibrillation. Review of R37's Fall Risk Evaluation, dated 06/15/23 at 3:11 AM, revealed documentation R37 was assessed to have behaviors of an altered level of consciousness continuously. The evaluation did not indicate what behaviors R37 exhibited. It was also recorded R37 was ambulatory and incontinent, walking did not occur, and R37's vision was adequate. The Licensed Practical Nurse Supervisor (LPNS) electronically signed the form. Review of R37's Nurses Notes, dated 06/15/23 at 3:22 AM and located under the Progress Notes tab of the EMR, revealed, . @ 0300 [3:00 AM] [R37] was overheard calling out. Upon entering her room, she was noted lying on the floor with only a diaper on (diaper was dry) and was on her left side. Full body assessment revealed no bruised [sic], marks, or contusions. She was assisted back intobed [sic] and [family member] and primary physician were notified, and neurochecks [sic] were initiated . Review of R37's Progress Notes, dated 06/15/23 and located under the Progress Notes tab of the EMR, revealed no documentation to show R37's level of consciousness was monitored from 3:00 AM through 7:00 AM. Review of R37's Nurses Notes, dated 06/15/23 at 8:30 AM and located under the Progress Notes tab of the EMR, revealed, . after reporting on my shift the night nurse said they received a patient [R37] who at the moment was sedated. Patient did not respond at all for entire shift. She had moments of confusion about 3.00am [sic] while they were going round the staff found patient on the floor. they [sic] assessed her and picked her up. They started neuro status. around [sic] 8.30 am [sic] i [sic] walked to the room i tried to call the patient but could respond with mubling [sic]. on the sheet was yellow vomit as if the patient had thrown up. i took her vital signs bp [blood pressure], 159/81, p [pulse]: 161, oxygen 93%, Temp [temperature]: 97.8, and BS [blood sugar]: 251, patient could not obey the command and while i was there patient threw up again. Informed the supervisor, NP [nurse practitioner] and Doctor informed, they decided to evaluate her for few hrs [hours] and then send her out . This was five and one-half hours after R37's fall. Review of R37's Medication Administration Records (MARS), dated 06/15/23 and located under the Orders tab of the EMR, revealed no documentation R37 had been administered a sedative or any medication known to cause sedation. It was documented R37 had received Eliquis, 5 mg at 9:00 AM on 06/15/23. Review of R37's Assessments, Progress Notes, and Misc tabs of the EMR revealed no documentation of neuro checks or monitoring for R37 after her fall. Review of R37's Nurses Notes, dated 06/15/23 at 1:28 PM and located under the Progress Notes tab of the EMR, revealed, . patient was sent out for evaluation due to change of mental status, vomiting, and previous history of fall . Review of R37's Physician/Practitioner Progress Note, dated 06/15/23 at 1:59 PM, revealed, . Nursing states patient had a fall last night. Nursing states patient had 3 episodes of vomiting this morning and is lethargic. Patient seen in bed with eyes closed with minimal response to sternal rub. Due to mental status change, new onset of vomiting, and unwitnessed fall on Eliquis sending patient out for CT to r/o [rule out] bleed . Review of R37's Nurses Notes, dated 06/15/23 at 6:53 PM and located under the Progress Notes tab of the EMR, revealed, . [Hospital name withheld] nurse called at 18:30 [6:30 PM] to ask when was the last time [R37] had Eliquis. Eliquis was las [sic] given at 09:00 [9:00 AM], Diagnosis traumatic brain injury . During an interview on 01/04/24 at 2:35 PM, Registered Nurse (RN) 1 stated neuro checks were supposed to be documented on paper and then placed in the resident's hard chart. RN1 stated she did not remember anything about R37. During an interview on 01/04/24 at 4:41 PM, the Administrator and DON provided a copy of R37's incident report for the fall on 06/15/23. Review of the incident report, dated 06/15/23 and prepared by LPNS, revealed, . heard resident call out for help. Staff entered room and observed her lying on her r [right] side on the floor near the bath [unable to read the rest of this sentence] . was last seen in bed. Resident ambulated without asking for assistance and lost balance . It was recorded R37 was alert and oriented to person and situation. The Administrator and DON were asked if the incident report recorded any neuro checks for R37. They stated no. During an interview on 01/05/24 at 7:58 AM, RN4, who was the nurse responsible for R37 on 06/15/23, stated when R37 was found in the floor, the house supervisor was notified, an assessment was completed, and neuro checks were started. RN4 stated the physician was notified via the on-call system and no call back from the physician was requested. RN4 stated he did not request a return call because R37 did not have any injuries. RN4 stated he did review R37's medications but did not inform the physician that R37 was receiving Eliquis. RN4 stated his call to the physician was just a notification of a fall. RN4 stated he documented the neuro checks, including vital signs, on a neuro check log sheet. RN4 stated after neuro checks were completed, the log sheet was given to the Unit Manager (UM). RN4 stated he did not note any changes in R37's neurological status or vital signs. RN4 stated he believed he did notify the physician R37 was receiving Eliquis. RN4 was reminded he had previously stated he did not notify the physician of this. RN4 then stated, I believe I did. On 01/05/24 at 8:57 AM, the facility provided an investigative summary of R37's fall. The investigative summary included a neuro check sheet and statements from RN4, LPNS, and RN1. Review of the investigative summary revealed: a. Review of R37's Neurological Check Flowsheet, dated 06/15/23, revealed no documentation that R37's level of consciousness had been monitored by RN4 from 06/15/23 at 3:00 AM through 06/15/23 at 7:00 AM. It was documented by RN1 that R37 was alert from 7:00 AM until 11:00 AM on 06/15/23. It was documented R37's BP was 152/70 and pulse rate was 78 at 8:30 AM. This was inconsistent with the documentation included in the Nurses Note dated 06/15/23 at 8:30 AM where RN1 had documented R37's BP was 159/81 and her pulse rate was 161. b. Review of RN4's Accident/Incident Investigation Statement Report, dated 06/15/23, revealed, . I overheard [R37] yelling [and] went into room. I called [LPNS] into the room [and] we assessed her body [and] did neuro checks. The assessment showed no injuries, marks, or contusions. I offered Tylenol for pain [and] [patient] refused. Neuro checks continued to show no change from base line to the last one, between 0630 [6:30 AM] [and] 0645 [6:45 AM]. Pt left in bed in low position [and] encouraged her to stay in bed [and] she stated she understood . c. Review of LPNS's Accident/Incident Investigation Statement Report, dated 06/15/23, revealed, . Around 3 am assigned nurse and myself heard a noise from pt's room so we went in to check on her, upon entering room we found pt laying [sic] on the floor. Pt was assessed and helped back to bed. VS [vital signs] was [sic] stable no visible sign swelling around the head and no injury noted at the time. Pt was talking and was alert, denies any pain. Mentation was within normal limits. Monitored throughout night with no change. Before 8am pt was in bed sleeping and no s/s [signs and symptoms] of distress noted . This was inconsistent with R37's Fall Risk Evaluation, dated 06/15/23 at 3:11 AM, where it was recorded R37 had an altered level of consciousness present continuously. d. Review of RN1's typed statement from the facility provided fall investigative summary revealed, . 6/15/2023 I arrived for my 7am shift on 6/15/2023. I received report about [R37] having a fall overnight and that there were no apparent injuries. The nurse gave me the neuro-check sheet. I rounded on all my residents. [R37] was in bed sleeping. Her bed was low. Her call bell was in reach. Her neuro-checks were within normal limits. I rounded around 8:30am and observed her in bed with a small amount of yellow fluid on her sheet. She was alert but confused and mumbling. I took her vital signs and called the provider. Her vital signs were 159/81, p:61, oxygen 93%, Temp: 97.8 and BS: 251. The provider said to continue monitoring her. We continued to monitor her. Around 11am, the Director of Nursing spoke with the nurse practitioner and received an order to send her to the hospital for an evaluation due to a change in mental status . The form contained RN1's signature. The information in the statement was inconsistent with the Nurses Note, dated 06/15/23 at 8:30 AM, where it was documented R37 was sedated and had not responded at all on the previous shift. The statement did not address R37 vomiting while RN1 was completing her assessment or R37 being unable to obey commands as was documented in the progress note on 06/15/23 at 8:30 AM. On 01/05/24 at 8:59 AM, the surveyor attempted to contact RN1 by telephone. A voice message was left, but no return phone call was received by the end of the survey. During an interview on 01/05/24 at 9:06 AM, Nurse Practitioner (NP) 2 stated she was notified of R37's fall on 06/15/23 at approximately 9:30 AM when she arrived at the facility for her morning rounds. NP2 stated she was not notified when R37 fell. NP2 stated she assessed R37 after being told she had suffered a fall, found the resident unresponsive, and immediately sent her to the hospital. NP2 reviewed R37's EMR and stated she would look at her call reports. NP2 stated she was not at the facility at 3:00 AM and did not receive a call from the facility. NP2 opened a Word document on her computer. The document was headed, Wednesday 6/14/2023. Five nursing homes, including Spring Hills [NAME], were listed on the document. Under each nursing home was a line list containing resident names and specific communication for each resident listed. Under Spring Hills [NAME], R37's name was listed. The specific communication for R37 was recorded as new admit. Continuing with the interview on 01/05/24 at 9:11 AM, NP2 stated she assessed R37 at approximately 9:30 AM. This was six and one-half hours after R37's fall. NP2 stated R37 was unresponsive, had vomited three times, and was on Eliquis, so she had R37 sent to