**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and staff, Nurse Practitioner (NP), responsible party, and Resident interviews, the facility failed to notify the physician and responsible party of changes in condition for of 1 of 1 resident (Resident #7). Resident #7 had intact cognition and a history of stroke and on 10/21/24 at approximately 9:00 PM he reported to a nurse aide (NA) he had pain and numbness in his left arm and leg. The NA aide reported this to the nurse. On the next shift at approximately 6:00 AM Resident #7 informed another NA he could not feel his left side. The NA reported this to the nurse. On 10/22/24 between 7:00 and 7:15 AM Unit Manager (UM) #1 was called to the room by an NA and assessed Resident #7 and found his speech was slurred, his left arm and leg did not have any feeling, and they did not have any muscle tone. The Nurse Practitioner was in the facility and assessed Resident #7 and had him transferred to the Emergency Department (ED) for evaluation of stroke symptoms. There were no nursing progress notes entered on 10/21/24 or 10/22/24 regarding notification of the physician or responsible party regarding the change in Resident #7's condition until the note entered by UM #1 on 10/22/24 at 8:25 AM. Resident #7 presented to the Emergency Department (ED) with new onset vision changes and inability to use his left upper and lower extremities. Diagnoses included cerebral vascular accident (CVA- ischemic stroke) with following cognitive deficits and dysphagia (difficulty swallowing) post CVA. It was noted Resident #7 was outside of the window for the administration of Alteplase (tPA) which is a medicine that dissolves blood clots used to treat ischemic strokes. Resident #7 was admitted to the critical care stroke unit and was discharged on 10/29/24. Immediate jeopardy began on 10/21/24 for Resident #7 he reported his left arm and leg were numb and a medical provider and responsible party were not notified. Immediate jeopardy was removed on 11/02/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems are in place and are effective. Findings included: Resident #7 was admitted to the facility on [DATE], with diagnoses of history of right hemiparesis/hemiplegia (partial or complete paralysis of one side) with right side weakness related to a stroke and Type 1 diabetes mellitus. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #7's cognition was intact. An interview with NA # 5 at 10/29/24 4:33 PM revealed she worked the 3:00 pm to 11:00 PM shift on 10/21/24 and did first rounds with Resident #7 at 6:30 PM and he did not have any concerns. When she did her second round at 9:00 PM, the resident told her he had pain and numbness in his left arm and leg. NA #5 indicated she went to tell Nurse #5 Resident #7 had numbness and pain, and Nurse #5 nodded to NA #5. NA #5 stated Nurse #5 did not go in to check on Resident #7, that she was aware of. An interview with Nurse # 5 on 10/29/24 at 6:06 PM revealed she worked the 3:00 PM to 11:00 PM shift on 10/21/24. Nurse #5 went to Resident #7's bedside to take his blood sugar at 5:00 PM. The Resident did not mention he was having any issues. Nurse #5 did not recall NA #5 telling her Resident #7 was having any change in condition. An interview with NA #4 on 10/29/24 at 5:05 pm revealed at 6:00 AM (on 10/22/24) Resident #7 stated, I can't feel my left side. NA #4 went to tell Nurse #6 and Nurse #6 wrote something down but did not come with NA #4. NA #4 further stated she went back to the room and told Resident #7 she reported his symptoms to Nurse #6 and went on with her assignment. An interview with Nurse #6 on 10/30/24 at 12:47 PM revealed on 10/21/24 at around 6:00 AM NA #4 reported to her that Resident #7's left side wasn't feeling right. Nurse #6 stated that she did an assessment when she gave Resident #7 his medication and checked his blood sugar at around 6:00 AM. She stated she briefly spoke with him while doing the blood sugar and Resident #7 did not indicate anything was wrong at that time. Nurse #7 stated she had not been given any kind of report from the prior shift that anything was going on with Resident #7. An interview with NA #8 on 10/29/24 at 4:25 PM revealed she worked the 7:00 AM to 3:00 PM shift on 10/22/24 and had taken breakfast to the resident around 7:15 am and asked Resident #7 how he was doing. He said, I am not well and I haven't felt well since last night and he couldn't feel his left side, and this had started after dinner. Resident #7 further revealed that his vision was blurred on the left side, and he was numb and could not feel anything on the left side. NA #8 stated she noticed his speech was slurred too. A review of the medical record revealed there were no nursing progress notes entered on 10/21/24 notification to the family or physician regarding a change in Resident #7's change in condition. An interview with Unit Manager (UM) #1 on 10/29/24 at 11:40 AM revealed she was requested by NA #8 to come to Resident #7's room as soon as possible at 7:15 AM (on 10/22/24). Upon arrival, she found Resident #7 with left-sided paralysis, including the left arm and left leg. UM #1 further revealed Resident #7 stated he had been unable to move his left side since last night after dinner. UM #1 stated she began her assessment and called for the Nurse Practitioner (NP). UM #1 stated Resident #7's left arm and leg were flaccid, dropping to the bed when she raised them up. The NP arrived, assessed Resident #7 and asked for EMS to be called because Resident #7 had had a stroke. A phone interview on 10/29/24 at 4:48 PM with the family member/responsible party revealed she was called by NA #8 around 8:15 AM (on 10/22/24) and was told that Resident #7 had been sent to the hospital for a stroke. A phone interview with Resident #7 on 10/30/24 at 5:30 PM revealed after dinner on 10/21/24 he could not feel his left arm and left side when the nurse aide was trying to change him. He could not help due to the lack of movement. NA #5 and NA #9 (3:00 pm to 11:00 pm shift) helped him because one person couldn't do it. He further stated he usually could position himself on his side with the use of the bed rails and a push on his hip to the turning side. This was when he noticed he couldn't move his left side. Nurse #5 came in and he told her he couldn't move his left arm or left leg, and he did not know what was going on. Resident #7 further stated Nurse #5 did not respond. Resident #7 indicated Nurse #5 should have checked him and called the doctor. Resident #7 explained his condition stayed the same until NA #4 came in on third shift and he told NA #4 he could not feel his left side and she went and told Nurse #6. Nurse #6 came into his room around 6:00 am or so and gave him his medicine. Resident #7 indicated Nurse #6 did not assess him or ask if anything was wrong. When the first shift NA (NA #8) came in with breakfast at 7:15 AM, Resident #7 told her he was not himself and she asked what was going on. Resident #7 told her he could not move his left side, and NA #8 immediately called Unit Manager #1. NP #1 came in and assessed him then sent him to the local hospital. An interview with the NP on 10/29/24 at 4:40 pm revealed she was called by the Unit Manager #1 on 10/22/24 because Unit Manager #1 thought Resident #7 had a stroke, and that UM #1 called EMS. NP #1 stated neuro-checks should have been done when his symptoms started on the evening of 10/21/24 and he should have been sent out to the ED on 10/21/24. She further indicated if Resident #7 had been assessed when he first was having numbness (after dinner), and nursing staff had called our on-call provider, we would have instructed them to send Resident #7 to the hospital where his condition could have been managed. NP #1 confirmed Resident #7 had been admitted to the local hospital with a left side stroke. An interview with DON 10/29/24 4:07 PM revealed that when the NA tells the nurse that something was wrong with a Resident, the nurse goes in and does an assessment and notifies the provider, she then notifies the party responsible. The Emergency Department (ED) note dated 10/22/24 indicated Resident #7 had a medical history significant for congested heart failure, chronic renal insufficiency, coronary artery disease, and prior stroke with left-sided deficits. Resident #7 presented to the Emergency Department with new onset vision changes and inability to use his left upper and lower extremities. Stroke code was called upon arrival. A National Institute of Health Stroke Scale (NIH) was documented as an 8 which indicated a mild to moderately severe stroke. Resident #7 reported he was unable to move his arm or leg at 6:00 PM on 10/21/24, which was new for him. The computed tomography (CT) scan showed a right posterior frontal lobe hypodensity concerning edema which could be related to an acute/subacute infarct. It was noted Resident #7 was outside of the window for the administration of Alteplase (tPA) which is a medicine that dissolves blood clots used to treat ischemic strokes. Resident #7 was admitted to neurology stroke service. Resident #7's vitals were blood pressure 162/59, pulse rate 60, temperature 98.5, and oxygen saturation 90%. The clinical impression after evaluation findings were Cerebral vascular accident (CVA) with following cognitive deficits and dysphagia (oropharyngeal phase) post CVA. Resident #7 was released to a skilled nursing facility on 10/29/24. The Administrator was notified of the immediate jeopardy 10/29/24 at 2:15 PM. The facility provided the following credible allegation of IJ removal: (1) Identify those recipients who have suffered, or are likely to suffer a serious adverse outcome as a result of the noncompliance: Resident #7, who has a history of a prior stroke with left sided weakness, reported to Nursing Assistant (NA) #7 on 10/21/24 at 9:00 PM he was experiencing pain and numbness to his left side. Nursing assistant #7 reported to the nurse who did not identify any acute changes, did not complete a neurological assessment, obtain vital signs, did not notify healthcare provider or, initiate emergency medical services. On 10/21/24 at 11:30 PM the resident reported to NA #4 he was moving slowly and could not move his left arm. Nursing assistant #4 reported to the nurse who did not identify any acute changes, did not complete a neurological assessment, obtain vital signs, did not notify healthcare provider, or initiate emergency medical services. The resident reported further symptoms to NA #4 on 10/22/24 at 6:00 AM about being unable to move his left side who then reported to the nurse who did not identify any acute changes, did not complete a neurological assessment, obtain vital signs, did not notify healthcare provider, or initiate emergency medical services. NA took Resident #7 his breakfast tray on 10/22/24 between 7 and 7:15 AM, the resident had slurred speech and was unable to move his left side. The CNA immediately reported the change in condition to Unit Manager #1. Unit Manager #1 assessed the resident and found his left side to be flaccid. The Resident was also complaining of blurry vision. Resident stated that he had been able to move his left side since last night after dinner. The Nurse Practitioner then assessed the resident and directed the resident to be sent out to the hospital via Emergency Medical Services because he had had a stroke. The resident was admitted to the hospital with an acute stroke on 10/22/24. An audit to determine if any residents had reported any new change in condition that was not reported to the healthcare provider by a licensed nurse of residents with a brief interview for mental status (BIMS) score of 13 or higher was completed by the Administrator on 10/25/2024. The Audit revealed that no other residents were noted to be affected. An audit was completed on 10/25/24 by the Director of Nursing of progress notes for the past 7 days to ensure that anyone reporting a change of condition had provider notification. The audit revealed that no one else was affected. As part of the staff education from 10/25/24-10/28/24, the Director of Nursing also questioned all of the licensed nurses regarding knowledge of any residents having had a change in condition that deviated from their baseline and did not have healthcare provider notification. Signatures accounted for both the education and the questionnaire. No residents were noted to be affected. From 10/31/24-11/1/24 the Director of Nursing or Staff Development Coordinator interviewed all nursing assistants regarding knowledge of any residents having change of conditions in the last 7 days that were not reported to the healthcare provider. No negative findings were noted. (2) Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: On 10/25/2024 the Director of Nursing initiated education to all licensed nurses to complete a clinical assessment of a minimum vital signs and pertinent body systems once notified of a change in condition to include accident or incident, injuries of unknown source, significant change in residents physical, emotional, or mental condition which can include elevated vital signs, altered mental status, blurred vision, headaches, numbness or tingling to body parts, uncontrolled pain, etc., to notify the healthcare provider immediately of findings once the assessment is complete. Education also included any changes reported by nursing assistants. Any licensed nurse that has not been educated by 10/28/2024 will be taken off the schedule until the educated has been received. All new hires will be educated by the Director of Nursing during orientation. The Director of Nursing will ensure all licensed nurses are in-serviced. On 11/1/2024, the Regional Director of Clinical Services educated the Administrator, The Director of Nursing, Staff Development Coordinator, and The Human Resource Director on the orientation process for nursing staff that will include education on recognizing change in condition, timely assessment and monitoring of change in condition, effective communication during a medical emergency, importance of notifying the healthcare provider, and effective communication during a medical emergency. On 11/1/2024, the Director of Nursing/Staff Development Coordinator re-educated all nursing assistants on change in condition of residents to include recognizing signs and symptoms of a stroke such as blurred vision, slurred speech, weakness to one side of the body, and facial drooping. Education also included the importance of reporting any change in condition or any of these symptoms to their nurse Any nursing assistant that has not received the education on 11/1/2024 will be taken off the schedule until the education has been received. The Director of Nursing will ensure all nursing assistant educated. The facility alleges removal of immediate jeopardy on 11/02/2024. An on-site validation of the facility's implementation of their credible allegation of immediate jeopardy removal was conducted on 11/4/24. Review of the completed facility audits included daily 24-hour resident report, resident clinical assessments to include neurological, pain and vital signs were documented in the record. Multiple interviews were conducted with nurse aides and licensed nurses to ensure the in-service/ education was provided prior to working their shift. The nurse aides and licensed nurses consistently reported they received in-service education, which included ensuring the medical team and Resident Representative was notified of the resident's change of condition assessment and verifying any new orders with a facility provider prior to initiating the orders. All nursing staff were educated on the reporting and documentation process of any signs of change of condition on the daily 24-hour report and in the resident record. An interview with the Director of Nursing and Staff Development Coordinator on 11/4/24 at 3:00 PM confirmed that re-education was done for all nurse aides and licensed nurses on the change of condition of residents including signs/symptoms of stroke, the importance of reporting any change of condition and documentation of notifying healthcare providers of a medical emergency. The Director of Nursing stated daily record reviews and monthly monitoring will be done to ensure the assessments and notification process was maintained. The immediate jeopardy removal date of 11/02/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #7 was admitted to the facility on [DATE], with diagnoses of history of right hemiparesis/hemiplegia (partial or complete paralysis of one side) with right side weakness related to a stroke, Type 1 diabetes mellitus. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #7 was cognitively intact and had functional impairment of the lower extremities bilaterally with use of a wheelchair, set up assistance for eating and oral hygiene/care, dependent care for toileting, showers, and lower extremity dressing including shoes, and maximum assistance for repositioning, sitting from lying, and transfers. The care plan dated 9/7/24 indicated that Resident #7 had a communication problem related to hearing loss (Right), hemiplegia/hemiparesis related to a stroke, needed assistance with transfers, mobility. A review of the medical record revealed there were no nursing progress notes entered on 10/21/24. The Medication Administration Record (MAR) indicated Resident #7 had his blood sugar checked at 10/21/24 at 5:00 PM by Nurse #5. Resident #7's blood sugar was 270 and he received 4 units of insulin lispro. Resident #7 was administered his evening oral medication at 9:00 PM by Nurse #5. An interview with Nurse # 5 on 10/29/24 at 6:06 PM revealed she worked the 3:00 PM to 11:00 PM shift on 10/21/24. Nurse #5 went to Resident #7's bedside to take his blood sugar at 5:00 PM. The Resident did not mention he was having any issues. Nurse #5 did not recall NA #5 telling her Resident #7 was having any change in condition. An interview with NA # 5 on 10/29/24 at 4:33 PM revealed she worked the 3:00 pm to 11:00 PM shift on 10/21/24 and did first rounds with Resident #7 at 6:30 PM and he did not have any concerns. When she did her second round at 9:00 PM, the resident told her he had pain and numbness in his left arm and leg. NA #5 indicated she went to tell Nurse #5 Resident #7 had numbness and pain, and Nurse #5 nodded to NA #5. NA #5 stated Nurse #5 did not go in to check on Resident #7, that she was aware of. An interview with NA #4 on 10/29/24 at 5:05 PM revealed she came in and started her rounds about 11:30 PM on 10/21/24. NA #4 stated she told Resident #7 she was coming in to change him. Resident #7 said, I'm moving slowly, I can't use my left arm. NA #4 stated Resident #7 didn't complain, just said he was moving slowly. She further indicated that Resident #7 was able to help himself using the bedrail prior to this. At 6:00 AM, Resident #7 said, I can't feel my left side. NA #4 went to tell Nurse #6 and Nurse #6 wrote something down but did not come with NA #4. NA #4 further stated she went back to the room and told Resident #7 she reported his symptoms to Nurse #6 and went on with her assignment. NA #4 did not take vital signs, as she was waiting on the nurse for further instructions. A follow up interview with NA #4 on 10/29/24 at 5:48 PM revealed she did not receive report from Nurse #6 when coming on to her shift. She did say that NA #5 told her that Resident #7 was not feeling his lower left side, and NA #5 had informed Nurse #5, and Nurse #5 just nodded her head. A review of Resident #7's medical administration record (MAR) indicated Nurse #6 gave an injection of 42 units Lantus insulin subcutaneously in the left arm on 10/21/24 at 10:41 PM. A review of the medical record indicated Nurse #6 did a fingerstick blood sugar at 6:30 AM on 10/22/24 and obtained a result of 112. There was no other documentation regarding Resident #7's condition. An interview with Nurse #6 on 10/30/24 at 12:47 PM revealed on 10/21/24 at around 6:00 AM NA #4 reported to her that Resident #7's left side wasn't feeling right. Nurse #6 stated that she did an assessment when she gave Resident #7 his medication and checked his blood sugar at around 6:00 AM. She stated she briefly spoke with him while doing the blood sugar and Resident #7 did not indicate anything was wrong at that time. Nurse #7 stated she had not been given any kind of report from the prior shift that anything was going on with Resident #7. An interview with NA #8 on 10/29/24 at 4:25 PM revealed she worked the 7:00 AM to 3:00 PM shift on 10/22/24 and had taken breakfast to the resident around 7:15 AM and asked Resident #7 how he was doing. He said, I am not well and I haven't felt well since last night and he couldn't feel his left side, and this had started after dinner. Resident #7 further revealed that his vision was blurred on the left side, and he was numb and could not feel anything on the left side. NA #8 stated she noticed his speech was slurred too. She further stated that the resident told her he had reported to NA #4, Nurse #5 and NA #5 he was numb in his left arm and leg and could not move them. An interview with NA #6 on 10/29/24 at 3:31 PM revealed he had been called to Resident #7's room by NA #8 on 10/22/24 at about 7:15 AM to help NA #8 sit Resident #7 up. NA #6 stated that Resident #7 told NA #8 and him (NA #6) that he could not move his left side, and NA #8 went to get the nurse. Unit Manager #1 and NP #1 came in to assess Resident #7 and the Unit Manager asked NA #8 to call 911. The nursing progress note dated 10/22/24 at 8:25 AM by Unit Manager #1 indicated she was called to Resident #7's room by NA #8. Resident #7 was alert and oriented, and stated he could not move his left side, and could not raise his left arm; writer lifted the arm, and it was flaccid, falling back to the bed. Resident #7 was unable to move his left foot or toes. Resident#7 stated his vision was gone in his left eye. The Nurse Practitioner (NP) was called to the room, and an order was written to transfer Resident #7 to the Emergency Department. The note further indicated the family was made aware. EMS arrived and transported Resident #7 to the local hospital at 8:18 AM on 10/22/24. An interview with Unit Manager (UM) #1 on 10/29/24 at 11:40 AM revealed she was requested by NA #8 to come to Resident #7's room as soon as possible at 7:15 AM on 10/22/24. Upon arrival, she found Resident #7 with left-sided paralysis, including the left arm and left leg. UM #1 further revealed Resident #7 stated he had been unable to move his left side since last night after dinner. UM #1 stated she began her assessment and called for the Nurse Practitioner (NP). UM #1 stated Resident #7's left arm and leg were flaccid, dropping to the bed when she raised them up. The NP arrived, assessed Resident #7 and asked for EMS to be called because Resident #7 had had a stroke. An additional interview with UM #1 on 10/29/24 at 4:40 PM revealed Resident #7 was doing fine before she left on 10/21/24 after 1st shift. On the morning of 10/22/24 NA #8 and NA #6 were in with the resident to get him out of bed. NA #8 yelled out for her to come quickly to check the resident. UM #1 stated she did an assessment and Resident #7 was talking differently, his left arm and leg were flaccid, and his arm and leg were not reacting or feeling when she ran the curved side of a paper clip down his arm and leg. NP #1 came in immediately and said to send him to the ED for a stroke. UM #1 stated the family was informed. EMS came and took Resident #7 to the hospital. UM #1 further revealed that there had not been any documentation to support the change in condition of Resident #7 on 10/21/24. A phone interview with Resident #7 on 10/30/24 at 5:30 PM revealed after dinner on 10/21/24 he could not feel his left arm and left side when the nurse aide was trying to change him. He could not help due to the lack of movement. NA #5 and NA #9 (3:00 PM to 11:00 PM shift) helped him because one person couldn't do it. He further stated he usually could position himself on his side with the use of the bed rails and a push on his hip to the turning side. This was when he noticed he couldn't move his left side. Nurse #5 came in and he told her he couldn't move his left arm or left leg, and he did not know what was going on. Resident #7 further stated Nurse #5 did not respond. Resident #7 explained his condition stayed the same until NA #4 came in on third shift. He told NA #4 he could not feel his left side and she went and told Nurse #6. Nurse #6 came into his room around 6:00 am or so and gave him his medicine. Resident #7 indicated Nurse #6 did not assess him or ask if anything was wrong. When the first shift NA (NA #8) came in with breakfast at 7:15 AM, Resident #7 told her he was not himself and she asked what was going on. Resident #7 told her he could not move his left side, and NA #8 immediately called Unit Manager #1. NP #1 came in and assessed him then sent him to the local hospital. Attempts to interview NA #9 on 10/30/24 were not successful. A phone interview on 10/29/24 at 4:48 PM with the family member revealed she was called by NA #8 around 8:15 AM (on 10/22/24) and was told that Resident #7 had been sent to the hospital for a stroke. The DON told the family member that the NA reported the symptoms to the Nurse and the nurse (no name was given) then went in and asked if he was ok, and he replied yes. The family member indicated Resident #7 denied any assessment by a nurse or doctor until the next morning (10/22/24). The family member further stated if Resident #7 could tell the people at the hospital what had happened to him the day before (10/21/24), he certainly would have known if a nurse came to check on him. A review of NP #1's progress note dated 10/22/24 revealed that on physical assessment, Resident #7 exhibited 100% left arm drop. The Resident was alert and oriented, though his speech was slightly slurred. He was able to follow her finger with his eyes but reported blurred vision. Emergency Medical Services (EMS) were activated for stroke symptoms. The residents' vital signs were blood pressure 161/77, oxygen saturation 99% on room air, and blood sugar 192. The patient had a history of left-sided weakness and cerebrovascular accident (CVA), but according to both the patient and the nurse, he had been able to move and feel his left arm and leg previously. Now, he has completely lost mobility on his left side and reported numbness in his left arm and leg. The resident was transferred to the Emergency Department for evaluation of stroke symptoms. An interview with the NP on 10/29/24 at 4:40 PM revealed she was called by the Unit Manager #1 on 10/22/24 because Unit Manager #1 thought Resident #7 had a stroke, and that UM #1 called EMS. The NP stated she was told by Unit Manager #1 his symptoms started the night before. The NP indicated she spoke with Resident #7, and he stated he told the nurse after dinner, but she did not do anything. Resident #7 stated his numbness and ability to move his limbs had gotten worse through the night. NP #1 stated neuro-checks should have been done when his symptoms started on the evening of 10/21/24 and he should have been sent out to the ED on 10/21/24. She further indicated if he had been assessed when he first was having numbness and sent to the hospital his worsening condition could have been managed. NP #1 confirmed Resident #7 had been admitted to the local hospital with a left side stroke. The Emergency Department (ED) note dated 10/22/24 indicated Resident #7 had a medical history significant for congested heart failure, chronic renal insufficiency, coronary artery disease, and prior stroke with left-sided deficits. Resident #7 presented to the Emergency Department with new onset vision changes and inability to use his left upper and lower extremities. Stroke code was called upon arrival. A National Institute of Health Stroke Scale (NIH) was documented as an 8 which indicated a mild to moderately severe stroke. Resident #7 reported he was unable to move his arm or leg at 6:00 PM on 10/21/24, which was new for him. The computed tomography (CT) scan showed a right posterior frontal lobe hypodensity concerning edema which could be related to an acute/subacute infarct. It was noted Resident #7 was outside of the window for the administration of Alteplase (tPA) which is a medicine that dissolves blood clots used to treat ischemic strokes. Resident #7 was admitted to neurology stroke service. Resident #7's vitals were blood pressure 162/59, pulse rate 60, temperature 98.5, and oxygen saturation 90%. The clinical impression after evaluation findings were Cerebral vascular accident (CVA) with following cognitive deficits and dysphagia (oropharyngeal phase) post CVA. A review of the Emergency Department (ED) admission summary dated [DATE] indicated that Resident #7 presented the ED at 8:45 AM with left hemiplegia and stated that he was unable to move his left side. Resident #7 stated he had reported it to the facility staff last evening and nothing was done. Resident #7 reported it again this morning to the NA and 911 was called. He was transported to the local hospital. The physician assessment indicated Resident #7's left limb had no effort against gravity, and falls, left leg having no movement, and left facial weakness. Resident #7 was admitted to the hospital with a left side stroke. Resident #7 was admitted on [DATE] at 2:14 PM to the hospital Critical Care stroke unit, with a stroke on the posterior right frontal lobe. Neuro checks revealed no grip in the left hand, no left dorsiflexion or plantarflexion, motor response to the left upper and lower extremities are flaccid and without motor strength. The right side was normal with some weakness in the right lower extremity. Resident #7 was released to a skilled nursing facility on 10/29/24. An interview with DON 10/29/24 4:07 PM revealed that when the NA tells the nurse that something was wrong with a Resident, the nurse goes in and does an assessment and notifies the Provider, she then notifies the party responsible. The nurse should document the findings. She further stated that documentation is done by exception. The DON indicated she interviewed Nurse #5 and Nurse #5 stated did not find any change in condition for Resident #7 on 10/21/24, and did not recall being notified of any change. The DON further stated Nurse #6 reported when she checked Resident # 7's blood sugar on 10/22/24 at 6:00 AM she did not see any change in his condition. She further revealed that she had not completed the investigation but had several notes on pieces of paper that she had not put into a report yet. The Administrator was notified of the immediate jeopardy on 10/29/24 at 2:00 PM. The facility provided the following credible allegation of immediate jeopardy removal: (1) Identify those recipients who have suffered, or are likely to suffer a serious adverse outcome as a result of the noncompliance: Resident #7, who has a history of a prior stroke with left sided weakness, reported to Nursing Assistant (NA) #7 on 10/21/24 at 9:00 PM he was experiencing pain and numbness to his left side. Nursing assistant #7 reported to the nurse who did not identify any acute changes, did not complete a neurological assessment or obtain vital signs, and did not initiate emergency medical services. On 10/21/24 at 11:30 PM the resident reported to NA #4 he was moving slowly and could not move his left arm. Nursing assistant #4 reported to the nurse who did not identify any acute changes, did not complete a neurological assessment or obtain vital signs, and did initiate emergency medical services. The resident reported further symptoms to NA #4 on 10/22/24 at 6:00 AM about being unable to move his left side who then reported to the nurse who did not identify any acute changes, did not complete a neurological assessment or obtain vital signs, and did not initiate emergency medical services. NA took Resident #7 his breakfast tray on 10/22/24 between 7 and 7:15 AM, the resident had slurred speech and was unable to move his left side. The CNA immediately reported the change in condition to Unit Manager #1. Unit Manager #1 assessed the resident and found his left side to be flaccid. The Resident was also complaining of blurry vision. Resident stated that he had been unable to move his left side since last night after dinner. The Nurse Practitioner then assessed the resident and directed the resident to be sent out to the hospital via Emergency Medical Services because he had had a stroke. The resident was admitted to the hospital with an acute stroke on 10/22/24. An audit to determine if any residents had reported any new change in condition that was not followed up on by a licensed nurse of residents with a brief interview for mental status (BIMS) score of 13 or higher was completed by the Administrator on 10/25/2024. The Audit revealed that no other residents were noted to be affected. An audit was completed on 10/25/2024 by the Director of Nursing of progress notes for the past 7 days to ensure that anyone reporting a change of condition had a prompt follow up and provider notification. The audit revealed that no one else was affected. As part of the staff education from 10/25-10/28, the Director of Nursing also questioned all of the licensed nurses regarding knowledge of any residents having had a change in condition that deviated from their baseline with no follow up. Signatures accounted for both the education and the questionnaire. No residents were noted to be affected. On 10/31-11/1/2024 the Director of Nursing or Staff Development Coordinator interviewed all nursing assistants regarding knowledge of any residents having change of conditions in the last 7 days that were not addressed. No negative findings were noted. (2) Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: On 10/25/2024 the Director of Nursing initiated education to all licensed nurses to complete a clinical assessment of a minimum vital signs and pertinent body systems once notified of a change in condition/medical emergency to include accident or incident, injuries of unknown source, significant change in residents physical, emotional, or mental condition which can include elevated vital signs, altered mental status, blurred vision, headaches, numbness or tingling to body parts, uncontrolled pain, etc., to call 911 and to notify the healthcare provider of findings once the assessment is complete and the assessment is documented in the medical record. Education also included any changes reported by nursing assistants. Any licensed nurse that has not been educated by 10/28/2024 will be taken off the schedule until the educated has been received. All new hires will be educated by the Director of Nursing during orientation. The Director of Nursing will ensure all licensed nurses are in-serviced. On 11/1/2024, the Regional Director of Clinical Services educated the Administrator, The Director of Nursing, Staff Development Coordinator, and The Human Resource Director on the orientation process for nursing staff that will include education on recognizing change in condition, timely assessment and monitoring of change in conditions, recognizing a medical emergency, effective communication during a medical emergency, and calling 911. On 11/1/2024, the Director of Nursing and Staff Development Coordinator re-educated all nursing assistants on change in condition of residents to include recognizing signs and symptoms of a stroke such as blurred vision, slurred speech, weakness to one side of the body, and facial drooping. Education also included the importance of residents receiving immediate medical attention should any of these signs be identified. Any nursing assistant that has not received the education on 11/1/2024 will be taken off the schedule until the education has been received. The Director of Nursing will ensure all nursing assistants are educated. Alleged date of immediate jeopardy removal: 11/2/2024 An on-site validation of the facility's implementation of their credible allegation of immediate jeopardy removal was conducted on 11/4/24. Review of the completed facility audits included daily 24-hour resident report, resident clinical assessments to include neurological, pain and vital signs were documented in the record. The nursing notes reflected a narrative of the clinical assessment, and the change of condition reported to the medical team. Multiple interviews were conducted with nurse aides and licensed nurses to ensure the in-service/ education was provided prior to working their shift. The nurse aides and licensed nurses consistently reported they received in-service education, which included the change of condition assessment process, completion of facility neurological and pain assessment, signs/symptoms of stroke, vital signs, verifying any new orders with a facility provider prior to initiating the orders. All nursing staff were educated on the reporting and documentation process of any signs of change of condition on the daily 24-hour report and in the resident record. An interview with the Director of Nursing and Staff Development Coordinator on 11/4/24 at 3:00 PM confirmed that re-education was done for all nurse aides and licensed nurses on the change of condition of residents including signs/symptoms of stroke, the importance of reporting any change of condition and documentation of notifying healthcare providers of a medical emergency. The Director of Nursing stated daily record reviews and monthly monitoring will be done to ensure the assessments process was maintained. The IJ removal date of 11/02/24 was validated. Based on observation, record review, resident, family member, staff, Emergency Medical Technician (EMT), Physician, and Nurse Practitioner (NP) interviews, the facility failed to comprehensively assess a resident (Resident #1) who had untreated obstructive sleep apnea (a condition that causes the upper airway to become blocked during sleep, reducing or stopping airflow) to determine the root cause of periodic abdominal pain, change in mental status, and migraines that occurred intermittently over the last 6 months in conjunction with Carbon Dioxide (CO2) levels near the upper limit of the reference range (a set of numbers that are the high and low ends of the range of results that's considered to be normal) in August 2024 and October 2024. When breathing is reduced due to sleep apnea it can lead to a decrease in oxygen and an increase in CO2 in the blood. The facility also failed to implement Physician's orders for Resident #1 for a Continuous positive Airway Pressure (CPAP) machine (used to treat sleep apnea by keeping the airways open while sleeping) ordered on 4/13/24, pulmonary consultation (insurance requirement for obtaining the CPAP) ordered on 5/10/24, neurology consultation (ordered for constant migraines) ordered on 8/24/24, and an x-ray (ordered for abdominal pain) ordered on 8/24/24. On 10/6/24 Resident #1 was excessively sleeping, difficult to rouse, and had no oral intake. On 10/7/24 Emergency Medical Service (EMS) were contacted for altered mental status changes and upon EMS assessment Resident #1 was confused and hypoxic (low oxygen saturation) with an oxygen (O2) saturation of 60% (normal 90-100%) and a CO2 level in the 90's (normal 22-31). The resident's Glasgow Coma Scale (scale used to measure a person's level of consciousness) showed she was in a comatose state, and she was assessed at the hospital with hypercapnia (CO2 retention with elevated CO2 levels), prolonged systemic hypoxemia/severe respiratory failure, acute kidney injury, and transaminitis (high level of liver enzymes in the blood) suspected due to the prolonged systemic hypoxemia/severe respiratory failure. The contributing factors included untreated obstructive sleep apnea. Resident #1 was admitted to the Intensive Care Unit (ICU) on 10/7/24 and spent 10 days in the hospital. In addition, the facility failed to identify the seriousness of a change in condition, complete ongoing comprehensive assessments and identify the urgent need for medical attention for a resident with a history of a stroke. Resident #7 had intact cognition and on 10/21/24 at approximately 9:00 PM he reported to a nurse aide (NA) he had pain and numbness in his left arm and leg. The NA aide reported this to the nurse. On the next shift at approximately 6:00 AM Resident #7 informed another NA he could not feel his left side. The NA reported this to the nurse. There were no documented comprehensive assessments for Resident #7 by either nurse. On 10/22/24 between 7:00 and 7:15 AM a NA took Resident #7 his breakfast and Resident #7 stated he was not well, couldn't feel his left side, and his vision was blurred on the left side, and this had all started after dinner (on 10/21/24). Unit Manager #1 was called to the room and assessed Resident #7 and found his speech was slurred, his left arm and leg did not have any feeling, and they did not have any muscle tone. The Nurse Practitioner was in the facility and assessed Resident #7 and had him transferred to the Emergency Department (ED) for evaluation of stroke symptoms. Resident #7 presented to the ED with new onset vision changes and inability to use his left upper and lower extremities. Diagnoses included cerebral vascular accident (CVA- ischemic stroke) with following cognitive deficits and dysphagia (difficulty swallowing) post CVA. It was noted Resident #7 was outside of the window for the administration of Alteplase (tPA) which is a medicine that dissolves blood clots used to treat ischemic strokes. Resident #7 was admitted to the critical care stroke unit and was discharged on 10/29/24. This deficient practice occurred for 2 of 3 residents reviewed for professional standards of care. Immediate jeopardy for Resident #1 began on 10/7/24 when Resident #1 had a significant change in condition and was assessed by EMS with an O2 saturation of 60% and a CO2 level in the 90s and immediate jeopardy ended on 10/25/24. Immediate jeopardy began on 10/21/24 for Resident #7 when he reported his left arm and leg were numb and a comprehensive assessment was not completed to determine if medical interventions were necessary. Immediate jeopardy ended for Resident #7 on 11/02/24. Immediate jeopardy was removed on 11/02/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity of D (no actual harm with potential for more than minimal harm that is immediate jeopardy) to ensure education is completed and monitoring systems are in place and are effective. The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included tachycardia (increased heart rate), asthma, and obstructive sleep apnea. The resident did not have a diagnosis of migraines on admission. A Physician order dated 3/28/23 revealed Resident #1 was to receive Fioricet 50-300-40 milligrams (mg) every 6 hours as needed for headache. A Physician order for Resident #1 dated 7/11/23 indicated Protonix (acid reflux medication) 40 milligrams (mg) twice a day. A Physician order for Resident #1 dated 11/8/23 indicated Propranolol (beta blocker) 20mg three times a day for headaches and migraines. A Physician order for Resident #1 dated 1/6/24 indicated Topamax 25mg daily for migraine headache. A Physician order dated 4/13/24 revealed an order for Resident #1 to receive a CPAP machine for obstructive sleep apnea. Another Physician order dated 5/10/24 revealed Resident #1 was to receive a pulmonology consult for her obstructive sleep apnea and CPAP machine. The Physician order dated 4/12/24 revealed an order for Acetaminophen 325mg give 2 tablets 3 times a day for pain. A phone interview occurred with Physician #1 on 10/22/24 at 3:52pm. Physician #1 verified he had written the order for Resident #1 to receive a CPAP machine and a Pulmonology consultation. He stated he had ordered the CPAP machine in April 2024 first because he understood Resident #1 already had a CPAP machine. Physician #1 stated Resident #1 required a CPAP machine for her obstructive sleep apnea. The Physician stated about a month later he learned (could not remember from who) that Resident #1 did not have a CPAP machine and needed a Pulmonology appointment to obtain a CPAP machine, so he wrote an order for a Pulmonology consultation in May 2024. He stated he did not know if Resident #1 ever attended the Pulmonology consultation but said he knew Resident #1 never had a CPAP machine. During a telephone interview with Physician #2 on 10/22/24 at 3:36pm, the Physician stated Resident #1 was required by insurance to receive a Pulmonary consultation prior to receiving a CPAP machine. He explained that the insurance company needed proof and severity of Resident #1's obstructive sleep apnea before they would approve Resident #1 for a CPAP machine. The Physician stated Resident #1 required a CPAP machine due to her obstructive sleep apnea. Physician #2 stated Resident #1 was never able to receive the consultation due to transportation difficulties. An interview with Transport Staff occurred on 10/22/24 at 4:54pm. Transport Staff confirmed she was responsible for making residents' appointments. She also discussed being responsible for securing alternate transportation if a resident did not fit in the facility's van. Transport Staff discussed Resident #1 being too large to transport in a wheelchair van and would need non-emergency stretcher transport. She stated the facility had a contract with a non-emergency transport company but said they are always booked up. Transport Staff discussed not receiving the consultation request for Pulmonology until 7/30/24. She stated since 7/30/24 she had been periodically trying to schedule the appointment with Pulmonology that would also meet the non-emergency transportation schedule. She stated she had been unsuccessful in getting Resident #1 to the Pulmonologist. A review of a Physicians note dated 6/19/24 written by Physician #1 revealed Resident #1 had episodic altered awareness, ongoing chronic headaches that were being treated with Topamax (migraine medication) daily and Fioricet (migraine medication) as needed, and insomnia with tiredness during the day which was documented as being treated with a CPAP machine and follow up with a Pulmonologist. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact, no rejection of care, and no shortness of breath. The MDS also documented Resident #1 did not have a CPAP machine. Resident #1 was documented as having a weight of 430 pounds. The MDS documented the resident also had pain that occasionally interfered with her daily routine and that she received pain medication. The physician order dated 8/18/24 revealed an order for lab work that included a complete blood count (CBC), comprehensive metabolic panel (CMP), lipid panel (for cholesterol), and an A1C (for diabetes). Resident #1's lab work dated 8/20/24 revealed her CO2 level was 30. On 8/24/24 there was a physician order for Resident #1 to receive a neurology consultation for constant migraines. There was an order on 8/24/24 for Resident #1 to receive an x-ray for abdominal pain. A nurses note dated 8/25/24 written by Nurse #3 revealed the x-ray technician told her the x-ray was unable to be performed because Resident #1 weighed more than the machine can hold. The care plan dated 8/26/24 for Resident #1 revealed no goals or interventions related to her diagnosis of sleep apnea. The resident's care plan also did not include information on migraines, abdominal pain, or refusals of care. A Physician's order revealed Resident #1's Fioricet 50-300-40 milligrams (mg) every 6 hours as needed for headache was discontinued on 9/8/24. Nursing documentation on 9/11/24 written by Unit Manager #1 revealed Resident #1 did not want to get out of bed due to not feeling well and having a headache. A Physician order for Resident #1 dated 9/14/24 indicated Fioricet 50-300-40 milligrams (mg) every 6 hours as needed for headache. On 9/14/24 a nursing note written by the Director of Nursing (DON) revealed Resident