**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and Resident, Resident Responsible Party (RP), facility staff, Nurse Practitioner (NP), and Medical Director interviews the facility failed to notify the Medical Director of Resident #1's documented allergy to aspirin with a history of a gastrointestinal bleed, recent fall with fracture, and new immobility for further orders regarding anticoagulation. Resident #1's family had expressed concerns to the Director of Nursing (DON) on 12/11/2024 regarding Resident #1 not receiving an anticoagulant after falling at home and sustaining multiple fractures of her pelvis and lumbar spine. Resident #1 had a documented allergy to aspirin and the NP instructed the Assistant Director of Nursing (ADON) to reach out to the MD for further direction. The facility also failed to notify the NP that an ordered venous doppler study (an ultrasound used to diagnose blood clots) on 12/27/2024 could not be completed until the following week. On 12/28/2024, Resident #1 and the RP requested Resident #1 be transferred to the Emergency Department (ED). Upon arrival, Resident #1 was diagnosed with extensive deep vein thrombosis (DVT) of both lower extremities, was placed on a heparin infusion (blood thinning medication used to prevent or break up blood clots), and admitted . The deficient practice occurred for 1 of 3 residents (Resident #1) reviewed for change in condition. Immediate jeopardy began on 12/11/2024 when the facility failed to notify the Medical Director that Resident #1 had a documented allergy to Aspirin and the Resident's RP was concerned that she was not receiving an anticoagulant. Immediate jeopardy was removed on 1/7/2025 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The findings included: Hospital records from 11/25/2024 through 12/2/2024 revealed Resident #1 had experienced a fall and was found to have multiple fractures. Orthopedics was consulted while Resident #1 was in the ED. Orthopedics stated they felt none of Resident #1's fractures required surgical intervention and recommended admission for pain control and monitoring of functional status. Resident #1 received subcutaneous heparin injections while in the hospital, prior to her discharge to the facility on [DATE]. Resident #1 was discharged to the facility on [DATE] and was not prescribed an anticoagulant upon discharge. Resident #1 was admitted to the facility on [DATE] with diagnoses which included multiple pelvic fractures, fracture of the lumbosacral spine (lower back and tailbone), and a history of a gastrointestinal bleed (bleeding in the digestive tract). An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact. A nursing note dated 12/11/2024, authored by the Assistant Director of Nursing (ADON), revealed Resident #1's Responsible Party (RP) had requested for Resident #1 to be placed on anticoagulant therapy and the Nurse Practitioner (NP) was notified. An order was received for Aspirin. Resident #1 had an allergy to Aspirin. The order for Aspirin was discontinued. The RP requested anticoagulation due to enoxaparin being given at the hospital. Resident #1 and the RP explained that Resident #1 had a past medical history of gastrointestinal bleeding. Education was provided to Resident #1 and RP, that anticoagulation therapy would put Resident #1 at risk for developing a gastrointestinal bleed. A NP note dated 12/27/2024 revealed Resident #1 was noted to have increased pain and swelling in her left lower extremity. Resident #1 was documented to have 2+ edema, increased pain, and a positive Homan's sign (pain behind the knee when the persons toes are pointed towards their head in her left lower extremity, indicative of a deep vein thrombosis/blood clot). The NP recommended a venous doppler study and for Resident #1 to be non-weight bearing to her left lower extremity. A provider communication form dated 12/27/2024 revealed Resident #1 was ordered an in-house venous doppler study of the left lower extremity with a diagnosis of edema and pain as well as non-weight bearing on left lower extremity until the doppler studies were available. A nursing note dated 12/28/2024 at 10:25 am, authored by Nurse #2, revealed Resident #1 requested to go to the ED for left leg pain, swelling, and tenderness. Resident #1 stated she was hurting in the calf, behind the knee, and in her pelvic area. An ultrasound doppler was ordered but the company was not available on 12/27/2024 or over the weekend (12/28/2024-12/29/2024). Resident #1 and the RP were concerned about the pain and swelling, which is why they requested her to be sent to the ED. Nurse #2 spoke with the RP and the RP was going to meet Resident #1 at the hospital. The on-call provider was called prior to calling Emergency Medical Services (EMS) and a message was left for them to call back. Change of condition documentation dated 12/28/2024, authored by Nurse #2, revealed Resident #1 had requested to go to the ED. Resident #1's left leg was swollen (from hip to toes), painful, and tender to touch. The venous doppler study ordered 12/27/24 was unable to be performed before next week. Resident #1 was documented as having pain of a 4 on scale of 0-10 on the numerical pain scale (indicative of moderate pain) in the left knee, groin, and left lower leg. Nurse #2 attempted to notify the physician, but there was no answer, a message was left. An ED note dated 12/28/2024 revealed Resident #1 presented to the ED from the facility for evaluation of bilateral lower extremity swelling, which had worsened over the last 2 weeks. A bilateral venous doppler study was conducted in the ED which revealed extensive deep vein thrombosis in the left and right leg. A tibia/fibula (bones in the lower leg) x-ray revealed diffuse edema. Resident #1 was admitted to the hospital and placed on a heparin infusion with plans to later transition to Eliquis, an anticoagulant. An interview was conducted on 1/6/2025 at 11:34 am via telephone with Resident #1's RP. The RP stated she had gone to speak with the Director of Nursing (DON) on 12/11/2024 regarding her concern about Resident #1 not being on an anticoagulant due to her immobility/fractures, swelling in her legs, and a family history of blood clots. The RP stated Resident #1 had received blood thinner shots at the hospital prior to admission to the facility and was concerned that Resident #1 was not currently on an anticoagulant. An interview was conducted on 1/3/2025 at 4:00 pm with the NP. The NP stated she received notification from the ADON on 12/11/2024 that Resident #1's RP had requested Resident #1 to be placed on an anticoagulant. The NP stated she ordered aspirin to be administered daily and was later the same day contacted by the ADON about Resident #1 having an allergy to aspirin. The NP stated she instructed the ADON to refer to the Medical Director for further direction regarding anticoagulation. The NP verbalized she had not had any follow-up regarding anticoagulation after 12/11/2024. The NP stated the last time she saw Resident #1 was on 12/27/2024 for left leg pain at which time Resident #1 was having increased pain and swelling to her left lower extremity. The NP stated that she had ordered an in-house venous doppler study of the left lower extremity and recommended Resident #1 be non-weight bearing to the left leg. The NP stated Resident #1 had swelling and a positive Homan's sign at that time, but did not notice any redness or warmth. The NP stated she was not aware, and was not notified by the DON, the venous doppler study would not be performed until the following week. The NP stated she would have been okay with waiting until Monday for the venous doppler study to be completed but would have wanted to be notified if the venous doppler study could not have been performed until the first of the following week at which point she would have considered sending Resident #1 to the ED. An interview was conducted on 1/6/2025 at 12:59 pm with the DON. The DON stated she had first spoken to Resident #1's RP on 12/11/24 when the RP was concerned that Resident #1 was not on anticoagulation, was not ambulatory and had redness to her leg. The DON stated she had the NP evaluate Resident #1 on 12/27/2024 and a venous doppler study was ordered. The DON stated she had called the scheduler for the venous doppler study and was told the order would not be looked at until Monday (12/30/24). The DON stated she had told the NP about the delay in obtaining a venous doppler study and verbalized the NP was okay with it. An interview was conducted on 1/3/2025 at 5:22 pm with the ADON. The ADON stated she was in the DON's office on 12/11/2024 when Resident #1's RP voiced concerns about Resident #1 not being on an anticoagulant. The ADON stated she contacted the NP, at which time aspirin was ordered, and later discontinued after realizing Resident #1 had an allergy to aspirin. The ADON stated she did not recall the NP instructing her to reach out to the Medical Director for additional guidance regarding anticoagulation. The ADON stated she cared for Resident #1 on 12/25/2024 and noted swelling to Resident #1's left leg at that time, and stated she assumed it was normal because of the rash. The ADON stated Resident #1's left leg was not red warm to touch at that time. The ADON stated Resident #1 did not complain of pain when she applied the hydrocortisone cream. The ADON stated after she cared for Resident #1, she developed swelling from her hip to her toes on the left side and had pain and tenderness on 12/27/2024. The ADON stated the NP had ordered a venous doppler study on 12/27/24 which could not be conducted until the following week. The ADON stated the company had up to 7 days to complete venous doppler studies at the facility. An interview was conducted on 1/5/2025 at 4:17 pm with the Medical Director. The Medical Director stated he had seen Resident #1 shortly after admission to the facility but had not seen her since. The Medical Director stated the facility staff, nor the NP had reached out to him with concerns regarding Resident #1. The Medical Director stated if he had been contacted on 12/11/2024 regarding anticoagulation, he would have referred to orthopedics and evaluated whether Resident #1 was ambulatory to see if anticoagulation was needed. The Medical Director stated if Resident #1 had redness and swelling in her leg, he would have ordered a venous doppler study to have been performed on 12/27/2024. The Medical Director stated if he would have known there would have been a delay and Resident #1 had increased pain and swelling, he would have considered sending Resident #1 to the ED. The Medical Director did not specify if he wanted to be notified about the anticoagulant and events on 12/27/2024. An interview was conducted on 1/6/2025 at 5:31 pm with the Assistant Administrator. The Assistant Administrator stated if the NP had concerns that she felt like she could not handled she should consulted the Medical Director. The Administrator was notified of immediate jeopardy on 1/6/2025 at 6:08 pm. The facility provided the following credible allegation of immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance On 12/11/2024, facility failed to notify Medical Director of Resident #1's documented allergy to aspirin based on history of gastrointestinal bleeding, and family's concern and request for further orders for anticoagulation. The facility also failed to notify the medical provider that Resident #1's swelling and pain was not improving and was getting worse from 12/18/24 to 12/27/24 and that Resident #1 was not as mobile as she had been previously. On 12/27/2024, facility failed to notify Nurse Practitioner that an ordered venous doppler could not be completed before the next week. On 12/28/2024, Resident #1 and her family insisted on being transferred to the Emergency Department for evaluation and was transferred to hospital for this evaluation. All other residents with concerns regarding anticoagulation are at risk for this deficient practice. All other residents with complaints of leg pain and swelling (or signs and symptoms of a blood clot) are at risk for this deficient practice. On 12/28/2024, Resident #1 discharged from the facility. On 01/06/2025, an audit of all residents with significant changes between 11/27/2024 & 12/27/2024 was conducted by the Director of Nursing (DON) and Assistant Director of Nursing (ADON) with no additional failures to notify provider of delayed studies, treatment or transfer identified. On 01/06/2025, the medical director notified by DON of all residents with documented allergy or intolerance to aspirin due to a history of GI bleed and reviewed for any resident needing anticoagulation orders with no additional residents identified. No other residents identified with ordered diagnostic studies that were delayed; no other residents identified with unreported leg pain and swelling or concerns regarding a lack of anticoagulation. 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 0n 01/06/2025, all licensed nurses, medication aides, and certified nursing assistants were educated by the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on requirement to notify physician of all significant changes in condition to ensure timely treatment or transfers. Licensed nurses, medication aides and certified nursing assessments who are newly hired, including agency, will receive in-service prior to working their initial shift. Director of Nursing and/or Staff Development coordinator will be responsible to ensure education is received. Facility administrator communicated this responsibility on 01/06/2025. The education consisted of the following: -Ordered studies should be scheduled same day of order -If vendor is unable to perform study on same day of order, provider is to be notified by licensed nurse of expected date of study. -New orders from medical providers given to address changes in condition should be implemented on day of order, unless otherwise noted by provider. If orders are unable to be implemented timely, provider must be made aware immediately in order to ensure any new intervention or transfer is then implemented timely. -In this case, licensed nurse is to document notification and any new orders, to include transfer to hospital, deemed necessary by medical provider. -Physician or physician extender is to be made aware by licensed nurse of all residents with aspirin allergy to determine any needs for anticoagulation. This notification to occur upon admission or readmission with any newly identified aspirin allergy. -Certified nursing assistants and medication aides who identify changes in condition should notify licensed nurse. This removal of immediate jeopardy allegation was reviewed and approved by an ad hoc QAPI meeting on 01/06/2025. Facility administrator notified DON of responsibility for completion of this immediate jeopardy allegation removal on 01/06/2025. Alleged date of IJ removal: 01/07/2025. A validation of immediate jeopardy removal was conducted on 1/13/2025. Initial audits conducted revealed residents with an aspirin allergy were identified and their potential need for anticoagulation was addressed. Audits conducted regarding previous diagnostic studies from 11/27/2024 through 12/27/2024 revealed there were no other delays in obtaining ordered diagnostic testing. Interviews with facility nursing staff (Nurses, Medication Aides, and Nurse Aides) revealed staff had received education on having ordered studies performed on the same day the order was written, if the study is unable to be performed the day it was ordered staff is to notify the provider of the expected date of the study to see if the resident should have a different intervention or should be transferred to the hospital, and the Medical Director is to be made aware of residents with aspirin allergies on admission to determine if there should be any anticoagulation ordered. The immediate jeopardy removal date of 1/7/2025 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, Resident, Responsible Party (RP), Nurse Practitioner, and Medical Director interviews, the facility failed to protect a resident's right to be free from neglect when they failed to notify the Medical Director that Resident #1 had a documented allergy to aspirin with a history of gastrointestinal bleed, recent fall with fracture, and new immobility on 12/11/24 when Resident #1's family expressed concerns to the Director of Nursing (DON) that Resident #1 was not receiving anticoagulant. The Nurse Practitioner instructed the Assistant Director of Nursing to reach out the Medical Director for guidance an anticoagulation and failed to communicate or collaborate with the Medical Director herself. The facility further failed to recognize the seriousness of pain and leg swelling that started on 12/11/2024 and neglected to act on the severity of a potential blood clot when a resident (Resident #1) continued to experience increased pain and swelling to her left lower extremity. On 12/27/2024, Resident #1 was noted to have increased edema (swelling), a positive Homan's sign (pain behind the knee when the person's toes are pointed towards their head, indicative of a deep vein thrombosis/blood clot), and increased pain to her left lower extremity. The facility failed to seek emergent medical attention when they knew a venous doppler study could not be scheduled for at least three days after it was ordered on 12/27/24. On 12/28/2024, Resident #1 continued to have increased swelling, pain, and redness to her left lower extremity and at her (Resident #1) request, was transferred to the hospital at 10:45 am via Emergency Medical Services (EMS). Resident #1 was diagnosed with extensive deep vein thrombosis (DVT) of both lower extremities, was placed on a heparin infusion (blood thinning medication used to prevent or break up blood clots), and admitted . Resident #1 has remained in the hospital since she was transferred from the facility. Deep vein thrombosis (DVT) can be very dangerous because a blood clot formed in a deep vein can break loose and travel to the lungs, causing a pulmonary embolism which can be life-threatening. The deficient practice occurred for 1 of 3 residents (Resident #1) reviewed for neglect. Immediate jeopardy began on 12/11/24 when the facility failed to notify the Medical Director that Resident #1 had a documented allergy to aspirin and the RP was concerned about Resident #1 not receiving an anticoagulant, had increased edema and pain indicative of deep vein thrombosis. Immediate jeopardy was removed on 1/7/2025 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance with a lower scope and severity of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The findings included: This tag is cross-referenced to: F580: Based on record review, and Resident, Resident Responsible Party (RP), facility staff, Nurse Practitioner (NP), and Medical Director interviews the facility failed to notify the Medical Director of Resident #1's documented allergy to aspirin with a history of a gastrointestinal bleed, recent fall with fracture, and new immobility for further orders regarding anticoagulation. Resident #1's family had expressed concerns to the Director of Nursing (DON) on 12/11/2024 regarding Resident #1 not receiving an anticoagulant after falling at home and sustaining multiple fractures of her pelvis and lumbar spine. Resident #1 had a documented allergy to aspirin and the NP instructed the Assistant Director of Nursing (ADON) to reach out to the MD for further direction. The facility also failed to notify the NP that an ordered venous doppler study (an ultrasound used to diagnose blood clots) on 12/27/2024 could not be completed until the following week. On 12/28/2024, Resident #1 and the RP requested Resident #1 be transferred to the Emergency Department (ED). Upon arrival, Resident #1 was diagnosed with extensive deep vein thrombosis (DVT) of both lower extremities, was placed on a heparin infusion (blood thinning medication used to prevent or break up blood clots administer intravenously), and admitted . The deficient practice occurred for 1 of 3 residents (Resident #1) reviewed for change in condition. F684: Based on record review, and Resident, Resident Responsible Party (RP), facility staff, Nurse Practitioner (NP), and Medical Director interviews, the facility failed to seek emergent medical attention when Resident #1 who had a recent history of spine and pelvic fractures and anticoagulation therapy prior to admission, experienced increased leg swelling, pain and an ordered venous doppler study (a non-invasive diagnostic procedure that uses sound waves to examine the circulation in the body's veins and arteries) could not be scheduled for at least three days after it was ordered. On 12/27/2024, Resident #1 was noted to have increased edema (swelling), a positive Homan's sign (pain behind the knee when the person's toes are pointed towards their head, indicative of a deep vein thrombosis/blood clot), and pain to her left lower extremity. The facility failed to seek emergent medical attention when they knew a venous doppler study could not be scheduled for at least three days after it was ordered. On 12/28/2024, Resident #1 continued to have increased swelling, pain, and redness to her left lower extremity and was transferred to the hospital at 10:45 am via Emergency Medical Services (EMS). Resident #1 was diagnosed with extensive deep vein thrombosis (DVT) of both lower extremities, was placed on a heparin infusion (blood thinning medication used to prevent or break up blood clots), and admitted . As of 1/6/2025, Resident #1 has remained in the hospital since she was transferred from the facility. Deep vein thrombosis (DVT) can be very dangerous because a blood clot formed in a deep vein can break loose and travel to the lungs, causing a pulmonary embolism which can be life-threatening. The deficient practice occurred for 1 of 3 residents (Resident #1) reviewed for change in condition. F714: Based on record review, staff, Resident, Resident Responsible Party (RP), Nurse Practitioner, and Medical Director interview the facility Nurse Practitioner (NP) failed to communicate and collaborate with the Medical Director after Resident #1's RP voiced concerns on 12/11/2024 that Resident #1 was not receiving an anticoagulant (blood thinning medication, used to prevent blood clots) after having a fall at home and sustaining multiple fractures of the pelvis and lumbar (lower back) spine, and was not as mobile as she had been prior to admission to the facility. The Assistant Director of Nursing (ADON) contacted the NP on 12/11/2024 at which time the NP ordered aspirin which was later discontinued due to a listed allergy due to a history of gastrointestinal bleeding. The NP instructed the ADON to consult the Medical Director for further guidance regarding anticoagulation for Resident #1 and failed to reach out to the MD herself. On 12/27/2024 Resident #1 was evaluated by the NP at which time Resident #1 had pain, increased swelling, and a positive Homan's sign (pain behind the knee when the person's toes are pointed towards their head, indicative of a deep vein thrombosis/blood clot) in her left lower extremity. Resident #1 was transferred to the hospital on [DATE] where she was diagnosed with the serious adverse outcome of deep vein thrombi to her bilateral lateral lower extremities, requiring anticoagulation, and hospitalization. The deficient practice was identified for 1 of 3 residents (Resident #1) reviewed for change in condition. An interview was conducted on 1/13/2025 at 2:07 pm with the DON. The DON stated examples of neglect would include staff letting someone lay in bed without changing them, not feeding a resident, and not treating pain when a resident reported it. The DON stated she had not felt like Resident #1 experienced neglect because the facility had provided interventions such as having the Nurse Practitioner evaluate Resident #1. The DON stated as soon as Resident #1 requested to go to the Emergency Department on 12/28/2024, she was sent. The Administrator was notified of immediate jeopardy on 1/6/2025 at 6:08 pm. The facility provided the following credible allegation of immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to recognize the seriousness of leg swelling and pain, manage Residents #1's pain, notify the medical director of a documented aspirin allergy with a history of a Gastrointestinal (GI) bleed for further anticoagulation orders. The Nurse practitioner neglected to communicate with the medical director and ensure the resident received necessary care and services, necessary medical evaluation and treatment. On 12/28/2024, Resident #1 discharged from the facility and was admitted to the hospital with blood clots to her bilateral lower extremities and was started on a heparin (used to break up clots) drip. On 01/06/2025, All residents had skin and pain user defined assessments conducted and documented in the medical record to include interview questions, for all interviewable residents, and observation by Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit manager (UM) or Wound Care Nurse for non-interviewable residents with additional findings addressed and provider notified. On 01/06/2025, an audit of all residents noted with significant change in condition (changes in status outside of residents baseline) assessments completed from 11/27/2024 to current was conducted by the Director of Nursing (DON) and Assistant Director of Nursing (ADON) to identify any unaddressed new or worsening pain or swelling. Audit of einteract Change in Condition user defined assessments (UDA) revealed no additional concerns noted. 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: 0n 01/06/2025, the DON, ADON, Staff Development (SDC) and Unit Managers began education for all licensed nurses, medication aides and certified nursing aides on Abuse and Neglect as it is related to not acting or following up on reported and assessed pain or changes in condition. Nursing staff newly hired, including agency, will receive in-service education prior to working their initial shift. Director of Nursing and/or Staff Development coordinator will be responsible to ensure education is received. Facility Administrator communicated this responsibility on 01/06/2025. On 1/6/25 Abuse and neglect policy was reviewed by Administrator prior to providing staff education, no changes to policy are required at this time. The education consisted of the following: - Identification of pain via verbal and non-verbal cues. - Pharmacological and non-pharmacological interventions for pain and swelling. - Failing to act on pain or change in condition is considered neglect. - Medical provider must be notified of any changes in condition to include acute pain. - Provider orders and interventions must be implemented timely. - Changes in condition to include pain should have timely follow up to ensure effectiveness of interventions. This credible allegation of immediate jeopardy removal plan was reviewed and approved by an ad hoc QAPI meeting on 01/06/2025. Facility administrator notified DON of responsibility for completion of this credible allegation of immediate jeopardy removal on 01/06/2025. Alleged IJ removal date is 01/07/2025. A validation of immediate jeopardy removal was conducted on 1/13/2025. Initial audits conducted on 1/6/2025 revealed residents were assessed for any concerns/new findings, if a provider had been notified of the concern/finding, if a resident was in pain, and if a resident had any new or worsening swelling. Concerns were identified and addressed. Interviews with facility staff revealed they had received education on neglect, examples of neglect, addressing pain (bother verbal and non-verbal indicators), administering pharmacological and nonpharmacological interventions for pain and/or swelling, acting on a change in condition, notifying a provider with concerns or a change in condition, and following through on intervention effectiveness. The immediate jeopardy removal date of 1/7/2025 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and Resident, Resident Responsible Party (RP), facility staff, Nurse Practitioner (NP), and Medical Director interviews, the facility failed to seek emergent medical attention when Resident #1 who had a recent history of spine and pelvic fractures and anticoagulation therapy prior to admission, experienced increased leg swelling, pain and an ordered venous doppler study (a non-invasive diagnostic procedure that uses sound waves to examine the circulation in the body's veins and arteries) could not be scheduled for at least three days after it was ordered. On 12/27/2024, Resident #1 was noted to have increased edema (swelling), a positive Homan's sign (pain behind the knee when the person's toes are pointed towards their head, indicative of a deep vein thrombosis/blood clot), and pain to her left lower extremity. The facility failed to seek emergent medical attention when they knew a venous doppler study could not be scheduled for at least three days after it was ordered. On 12/28/2024, Resident #1 continued to have increased swelling, pain, and redness to her left lower extremity and was transferred to the hospital at 10:45 am via Emergency Medical Services (EMS). Resident #1 was diagnosed with extensive deep vein thrombosis (DVT) of both lower extremities, was placed on a heparin infusion (blood thinning medication used to prevent or break up blood clots), and admitted . As of 1/6/2025, Resident #1 has remained in the hospital since she was transferred from the facility. Deep vein thrombosis (DVT) can be very dangerous because a blood clot formed in a deep vein can break loose and travel to the lungs, causing a pulmonary embolism which can be life-threatening. The deficient practice occurred for 1 of 3 residents (Resident #1) reviewed for change in condition. Immediate jeopardy began on Friday, 12/27/2024 when Resident #1 had increased edema, pain behind the knee indicative of deep vein thrombosis and the ordered venous doppler study could not be scheduled until Monday, 12/30/24. Immediate jeopardy was removed on 1/7/2025 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance with a lower scope and severity of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The findings included: Hospital records from 11/25/2024 through 12/2/2024 revealed Resident #1 had experienced a fall and was found to have multiple fractures. Orthopedics was consulted while Resident #1 was in the Emergency Department (ED). Orthopedics stated they felt none of Resident #1's fractures required surgical intervention and recommended admission for pain control and monitoring of functional status. Resident #1 received subcutaneous heparin injections (blood thinning shots given through the skin) while in the hospital, prior to her discharge to the facility on [DATE]. Resident #1 was admitted to the facility on [DATE] with diagnoses which included multiple pelvic fractures, fracture of the lumbosacral spine (lower back and tailbone), and a history of a gastrointestinal bleed (bleeding in the digestive tract). Resident #1's medical record revealed Resident #1 had an allergy to aspirin with unknown reactions and severity. A therapy note dated 12/6/2024 revealed nursing was to address Resident #1's pre-treatment pain. Resident #1 was educated on need for movement in decreasing pain from fracture. Resident #1 performed supine, head of bed elevated, to sitting at the edge of bed transfer with maximum assistance for lower extremity management. Resident #1 required significant increase in time for transfer due to pain. An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was cognitively intact, had impairment on both sides of her lower extremities, and utilized a wheelchair, received as needed pain medications, had pain frequently during the assessment period and rated pain at a 7 on a scaled of 0 -10. Pain assessments dated 12/11/2024 revealed Resident #1 had a pain level of 8 out of 10 on the numerical pain scale of 0 to 10 (indicative of severe pain) at 6:20 am and a pain level of 5 out of 10 on the numerical pain scale (indicative of moderate pain) at 3:33 pm. A nursing note dated 12/11/2024, authored by the Assistant Director of Nursing (ADON), revealed Resident #1's Responsible Party (RP) had requested anticoagulant therapy for Resident #1 and the Nurse Practitioner (NP) was notified. An order was received for Aspirin. Resident #1 had an allergy to Aspirin. The order for Aspirin was discontinued. The RP requested anticoagulation due to enoxaparin, an anticoagulant, being given at the hospital. Resident #1 and the RP explained that Resident #1 had a past medical history of gastrointestinal bleeding. The ADON provided education to Resident #1 and RP, that anticoagulation therapy would put Resident #1 at risk for developing a gastrointestinal bleed. An NP note dated 12/11/2024 revealed Resident #1 was evaluated per staff request due to chest congestion and was noted to have congestion and trace edema in bilateral lower extremities. The NP ordered a chest x-ray, guaifenesin (medication used to break up mucous), and breathing treatments. A care plan dated 12/13/2024 revealed Resident #1 acute pain related to multiple fractures with interventions which included administering analgesia as ordered and notifying the physician if interventions were unsuccessful or if current complaint is a significant change from residents past experience of pain. A NP note dated 12/13/2024 revealed Resident #1 was evaluated following an abnormal chest x-ray. Resident #1 was noted to have increased cough, congestion, and trace edema in bilateral lower extremities. Resident #1's chest x-ray revealed central pulmonary venous congestion (when blood pools instead of flowing properly). Resident was ordered furosemide (diuretic, used to treat edema and fluid retention) and staff were to monitor for a decrease in symptoms. A physician's order dated 12/13/2024 revealed Resident #1 was prescribed furosemide 40 milligrams (mg) by mouth once daily for venous congestion for 5 days. Change in condition documentation dated 12/18/2024, authored by the Director of Nursing (DON), revealed Resident #1 was noted to have a rash on her left lower extremity and was prescribed hydrocortisone cream. A pain assessment dated [DATE] revealed Resident #1 had a pain level of 7 out of 10 on the numerical pain scale at 9:59 pm. A provider communication form dated 12/18/2024 revealed Resident #1 had a rash to her left lower extremity and was ordered hydrocortisone cream to be administered twice daily for 5 days. An NP note dated 12/18/2024 revealed Resident #1 was evaluated for a rash to bilateral lower extremities and a dry, rough, red rash to the left lower extremity. Resident #1 complained of mild itching and was noted to have trace edema to bilateral lower extremities. The NP recommended hydrocortisone cream 1% to be applied to the left lower extremity twice daily for 5 days. An NP note dated 12/27/2024 revealed Resident #1 was noted to have increased pain and swelling in her left lower extremity. Resident #1 was documented to have 2+ edema, increased pain, and a positive Homan's sign in her left lower extremity. The NP recommended a venous doppler study and for Resident #1 to be non-weight bearing to her left lower extremity. A a provider communication form dated 12/27/2024 revealed Resident #1 was ordered an in-house venous doppler study of the left lower extremity with diagnoses of edema and pain as well as non-weight bearing on left lower extremity until the doppler studies were available. A nursing note dated Friday, 12/27/2024, authored by the DON, revealed Resident #1's RP was notified that a venous doppler study would not be available before Monday. The RP was fine with that knowledge and declined to send her to the Emergency Department (ED). Vital signs dated 12/28/2024 at 7:47 am revealed Resident #1's blood pressure was 128/70, heart rate was 75 beats per minute (normal is between 60 to 100 beats per minute), a respiration rate of 19 (normal is between 12 to 20 breaths per minute), a temperature of 97.4 degrees Fahrenheit, and an oxygen saturation level of 98%. A nursing note dated 12/28/2024 at 10:25 am, authored by Nurse #2, revealed Resident #1 requested to go to the Emergency Department (ED) for left leg pain, swelling, and tenderness. Resident #1 stated she was hurting in the calf, behind the knee, and in her pelvic area. An ultrasound doppler was ordered but the company was not available on 12/27/2024 or over the weekend (12/28/2024-12/29/2024). Resident #1 and the RP were concerned about the pain and swelling, which is why they requested her to be sent to the ED. Change of condition documentation dated 12/28/2024, authored by Nurse #2, revealed Resident #1 had requested to go to the Emergency Department (ED). Resident #1's left leg was swollen (from hip to toes), painful, and tender to touch. The venous doppler study ordered 12/27/24 was unable to be performed before next week. Resident #1 was documented as having pain of a 4 on scale of 0-10 on the numerical pain scale (indicative of moderate pain) in the left knee, groin, and left lower leg. Nurse #2 attempted to notify the physician, but there was no answer, a message was left. An EMS report dated 12/28/2024 revealed the facility had notified dispatch at 10:18 am regarding a sick person. EMS arrived at Resident #1's room at 10:31 am. Upon arrival to the facility, staff advised EMS that Resident #1 had broken her pelvis on both sides around 11/27/2024, starting 2 weeks ago Resident #1 had noticed her left lower leg was starting to swell, and a week ago began to feel pain in the leg. Facility informed EMS the MD was aware and had ordered a doppler study which would not be available until later the following week which is why they wanted to transfer Resident #1 to the hospital. EMS obtained vital signs at 10:41 am at which time Resident #1 had a blood pressure of 182/74 (normal is 120/80), a heart rate of 90 beats per minute (normal is 60 to 100 beats per minute), a respiration rate of 18 breaths per minute (normal is 12 to 20 breaths per minute), a temperature of 98.8 degrees, and a pain level of 8 out of 10 on the numerical pain scale (indicative of severe pain). Resident #1 was transferred to the hospital at 10:45 am. While enroute to the hospital, EMS administered 4 milligrams of morphine for pain intravenously (through a catheter inserted in a vein). An ED note dated 12/28/2024 revealed Resident #1 presented to the ED from the facility for evaluation of bilateral lower extremity swelling, which had worsened over the last 2 weeks. A bilateral venous doppler study was conducted in the ED which revealed extensive deep vein thrombosis in the left and right leg. A tibia/fibula (bones in the lower leg) x-ray revealed diffuse edema. Resident #1 was admitted to the hospital and placed on a heparin infusion with plans to later transition to Eliquis, an anticoagulant. An interview was conducted on 1/6/2025 at 11:41 am via telephone with Resident #1. Resident #1 stated while she was at the facility she had experienced left lower leg pain and swelling. Resident #1 stated she noticed increased leg swelling and pain that began on 12/18/2024. Resident #1 stated the swelling and pain continued to get worse, and recalled her leg being so swollen on Christmas (12/25/2024) that she tried to prop her leg up and stated her leg brace was much tighter than normal. Resident #1 stated on 12/27/2024, her left leg was really swollen. Resident #1 stated she experienced an achy pain and rated the pain as an 8-9 out of 10 on the numerical pain scale. Resident #1 stated the NP evaluated her on 12/27/2024 and ordered a test to be done at the facility. Resident #1 stated on 12/28/2024 she called the RP around 8:00 am and informed her that her left leg pain and swelling had gotten worse overnight and that she thought she needed to go to the hospital. Prior to Resident #1's conversation with the RP, Resident #1 recalled two nurse aides (NAs) commented on her leg and how swollen it was. An interview was conducted on 1/6/2025 at 11:34 am via telephone with Resident #1's RP. The RP stated she had gone to speak with the Director of Nursing (DON) on 12/11/2024 regarding her concern about Resident #1 not being on an anticoagulant due to her immobility/fractures, swelling in her legs, and a family history of blood clots. The RP stated Resident #1 had received blood thinner shots at the hospital prior to admission to the facility. The RP stated Resident #1 was seen by the NP on 12/18/2024 at which time she had discoloration to her left leg as well as swelling and was diagnosed with a rash. The RP stated the facility contacted her on 12/25/2024 about a planned discharge and insurance denial, at which time she expressed her concern over Resident #1's swollen left leg. The RP stated she spoke with the DON again on 12/27/2024, at which time she expressed concern about Resident #1 continuing to have swelling and pain in her left leg. The RP stated the DON had the NP evaluate Resident #1 at which time they ordered a venous doppler study. The RP stated neither the DON nor any facility staff offered to have Resident #1 sent to the hospital on [DATE] for further evaluation. The RP stated she received a call on 12/28/2024 at 8:08 am (per her cell phone call log) from Resident #1 stating that her leg was hurting/more swollen and thought she needed to go to the hospital. The RP stated she called the facility at 10:08 am and insisted that the facility call EMS to have Resident #1 transferred to the hospital for further evaluation. The RP stated she received a phone call from a facility staff member at 10:21 am, at which time they reported EMS had been called. The RP stated when Resident #1 arrived at the hospital, a doppler study was performed in the ED, and Resident #1 was diagnosed with blood clots in her bilateral lower extremities and started on heparin. An interview was conducted on 1/5/2025 at 12:55 pm with Nurse Aide (NA) #1. NA #1 stated she worked on night shift (7:00 pm to 7:00 am) at the facility and stated the last night that she worked with Resident #1 was on 12/26/2024 at which time she noticed Resident #1's left leg was a little red and swollen, nothing too serious. NA #1 stated Resident #1 expressed she was in pain at which time she notified Nurse #1. Nurse #1 was unavailable for interview. An interview was conducted on 1/5/2025 at 1:24 pm with NA #3. NA #3 stated she worked dayshift (7:00 am to 7:00 pm) on 12/27/2024 and was assigned Resident #1. NA #3 stated Resident #1's left leg was more swollen than the other leg and stated Nurse #3 was aware of the swelling and Resident #1 was evaluated by the NP on 12/27/2024. An interview was conducted on 1/3/2025 at 4:09 pm with Nurse #3. Nurse #3 stated she worked dayshift (7:00 am to 7:00 pm) and had been assigned Resident #1 on multiple occasions, including 12/27/2024. Nurse #3 stated Resident #1's legs started swelling before Christmas, 12/25/2024. Nurse #3 stated she the NP had evaluated her (unsure of date) and ordered cream to be administered. Nurse #3 stated the swelling in Resident #1's left leg had worsened and when she was assigned Resident #1 on 12/27/2024 and had the DON come assess Resident #1's leg with her. Nurse #3 was unable to recall if Resident #1 was in pain. An interview was conducted on 1/5/2025 at 1:51 pm with Nurse #4. Nurse #4 stated she worked nightshift and had been assigned Resident #1 on 12/25/2024. Nurse #4 stated Resident #1 was not able to ambulate, required full assist, and was bedbound mostly. Nurse #4 stated Resident #1 had been admitted to the facility with an injury to her hip and always had a lot of pain. Nurse #4 was unable to recall Resident #1 having any swelling to her left or right leg. An interview was conducted on 1/6/2025 at 10:30 am with NA #2. NA #2 stated she worked dayshift and was assigned Resident #1 on 12/28/2024. NA #2 stated when she rounded on Resident #1 between 7:30 am and 8:00 am, she noticed Resident #1 she had noticeable swelling of her left leg, redness near the ankle, and warmness to the touch. NA #2 stated Resident #1 had also expressed pain in her left leg. NA #2 stated she immediately notified Nurse #2 and stated Resident #1 was transferred to the hospital later that morning on 12/28/2024. An interview was conducted on 1/5/2025 at 4:48 pm with NA #4. NA #4 stated she worked dayshift and assisted with caring for Resident #1 on 12/28/2024. NA #4 stated when she went in Resident #1's room at the beginning of the shift (between 7:00 am and 8:00 am) Resident #1 was complaining about her left leg being swollen. NA #4 stated Resident #1 had swelling from her left hip down to her toes. NA #4 stated there was redness towards the bottom of Resident #1's left lower leg, and stated Resident #1 was in a lot of pain. NA #4 stated she reported the concerns to Nurse #2. An interview was conducted on 1/5/2025 at 12:48 pm with Nurse #2. Nurse #2 stated she worked dayshift and 12/28/2024 she was assigned Resident #1 for the first time. Nurse #2 stated Medication Aide (MA) #1 was also assigned Resident #1. Nurse #2 stated she was approached by a staff member (unable to remember who) about Resident #1's left leg being swollen. Nurse #2 stated she assessed Resident #1's left leg was significantly more swollen than the right leg, had redness from the knee to the ankle, was warm to the touch, and painful (from behind the knee, the calve, and the pelvic area). Nurse #2 stated Resident #1's RP called her and asked to have Resident #1 sent to the hospital for evaluation. Nurse #2 stated she tried to call the on-call provider and there was no answer, so she left a message for a return call. Nurse #2 stated she then decided to call EMS. An interview was conducted on 1/5/2025 at 3:16 pm with the Rehabilitation Director. The Rehabilitation Director stated Resident #1 was seen by both Occupational Therapy (OT) and Physical Therapy (PT). The Rehabilitation Director stated Resident #1 was originally assessed by OT on 12/4/2024 at which time she required moderate assistance and was unable to stand. The Rehabilitation Director stated Resident #1 was initially assessed by PT on 12/6/2024 at which time she was unable to do much due to pain and required maximum assistance with transfers and bed mobility. The Rehabilitation Director stated Resident #1 had left foot drop and required a brace from a previous injury. The Rehabilitation Director stated he worked with Resident #1 on 12/24/2024, at which time he was able to apply the brace to the left leg. The Rehabilitation Director stated he noticed minor signs of swelling, but no discoloration. The Rehabilitation Director stated he reported the minor swelling to nursing staff. The Rehabilitation Director stated the RP reached out to him on 12/27/2024 over concerns regarding Resident #1 having leg swelling and overall concern about Resident #1 not being ready for discharge. The Rehabilitation Director stated he reported the RP's concerns to nursing staff (unable to recall who). An interview was conducted on 1/3/2025 at 4:00 pm with the NP. The NP stated she received notification from the ADON on 12/11/2024 that Resident #1's RP had requested Resident #1 to be placed on an anticoagulant. The NP stated she ordered aspirin to be administered daily and was later contacted by the ADON about Resident #1 having an allergy to aspirin. The NP stated she instructed the ADON to refer to the MD for further direction regarding anticoagulation. The NP stated she had evaluated Resident #1 on 12/11/2024 per staff request for chest congestion at which time Resident #1 had trace edema to bilateral lower extremities and a congested cough and stated she ordered a chest x-ray, guaifenesin, and breathing treatments. The NP stated she evaluated Resident #1 on 12/13/14 following an abnormal chest x-ray which revealed central pulmonary venous congestion and stated she ordered furosemide, a diuretic, to be administered daily for 5 days. The NP stated she evaluated Resident #1 on 12/18/2024 due to a rash to her left lower extremity, trace edema in bilateral lower extremities, and stated she ordered hydrocortisone cream 1% to be administered to the left lower extremity twice a day for 5 days. The NP stated the last time she saw Resident #1 was on 12/27/2024 for left leg pain at which time Resident #1 was having increased pain and swelling to her left lower extremity. The NP stated that she had ordered an in-house venous doppler study of the left lower extremity and recommended Resident #1 be non-weight bearing to the left leg. The NP stated Resident #1 had swelling and a positive Homan's sign at that time, but did not notice any redness or warmth. The NP stated she was not aware the venous doppler study would not be performed until the following week. The NP stated she would have been okay with waiting until Monday for the venous doppler study to be completed but would have considered sending Resident #1 to the ED if it could not have been obtained until after Monday. The NP stated she had seen Resident #1 on multiple occasions since she was admitted to the facility and was familiar with Resident #1's history. An interview was conducted on 1/3/2025 at 5:22 pm with the ADON. The ADON stated she was in the DON's office on 12/11/2024 when Resident #1's RP voiced concerns about Resident #1 not being on an anticoagulant. The ADON stated she contacted the NP, at which time aspirin was ordered, and later discontinued after realizing Resident #1 had an allergy to aspirin. The ADON stated she did not recall the NP instructing her to reach out to the MD for additional guidance regarding anticoagulation. The ADON stated Resident #1 was seen by the NP on 12/18/2024 due to a rash on her left lower leg at which time hydrocortisone cream was ordered. The ADON stated she cared for Resident #1 on 12/25/2024 and noted swelling to Resident #1's left leg at that time, and stated she assumed it was normal because of the rash. The ADON stated Resident #1's left leg was not red or warm to touch at that time. The ADON stated Resident #1 did not complain of pain when she applied the hydrocortisone cream. The ADON stated after she cared for Resident #1, she developed swelling from her hip to her toes on the left side and had pain and tenderness. The ADON stated the NP had ordered a venous doppler study which could not be conducted until the following week. The ADON stated that per documentation the RP had declined to send Resident #1 to the ED on 12/27/2024. The ADON stated Resident #1 was sent to the ED on 12/28/2024 and did not return to the facility. An interview was conducted on 1/6/2025 at 12:59 pm with the DON. The DON stated she had first spoken to Resident #1's RP after Resident #1 had been prescribed hydrocortisone cream for a rash when she was concerned it had not been applied. The DON stated she received a call from the RP on 12/27/2024 at which time the RP was upset about an insurance denial, Resident #1 not being able to ambulate, and about Resident #1's left leg being red. The DON stated she had the NP evaluate Resident #1 on 12/27/2024 and a venous doppler study was ordered. The DON stated she had called the scheduler for the venous doppler study and was told the order would not be looked at until Monday. The DON stated she had told the NP about the delay in obtaining a venous doppler study and verbalized the NP was okay with it. The DON stated she told the RP about the delay of the venous doppler study and offered to send Resident #1 to the hospital at which time the RP declined. An interview was conducted on 1/5/2025 at 4:17 pm with the Medical Director. The Medical Director stated he had seen Resident #1 shortly after admission to the facility but had not seen her since. The Medical Director stated the facility staff, nor the NP had reached out to him with concerns regarding Resident #1. The Medical Director stated if he had been contacted on 12/11/2024 regarding anticoagulation, he would have referred to orthopedics and evaluated whether Resident #1 was ambulatory to see if anticoagulation was needed. The Medical Director stated if Resident #1 had redness and swelling in her leg, he would have ordered a venous doppler study to have been performed on 12/27/2024. The Medical Director stated if he would have known there would have been a delay and Resident #1 had increased pain and swelling, he would have considered sending Resident #1 to the ED. The Administrator was notified of immediate jeopardy on 1/6/2025 at 6:08 pm. The facility provided the following credible allegation of immediate jeopardy removal: Identify those recipients who have suffered and those who are likely to suffer a serious adverse outcome as result of the noncompliance: The facility failed to recognize the severity or seriousness of bilateral leg swelling and pain for resident #1. Resident #1 had a recent history of fall with fractures in her lumbar spine and pelvis and was not as mobile as she had been previously and was not on an anticoagulant (to prevent blood clot) medication. The facility failed to seek necessary medical attention. On 12/28/24 resident#1 was discharged to the hospital where she was admitted with bilateral blood clots and placed on a heparin (used to break up blood clots) drip. On 1/6/25 the Director of Nursing (DON) and Nursing Leadership team which includes the Assistant Director of Nursing (ADON) and Unit Managers, assessed all current facility residents via a head-to-toe body audit and pain assessment to ensure that no other resident was experiencing pain, leg swelling or redness with no additional residents identified. 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 1/6/25 the DON, ADON, Staff Development (SDC) and Unit Managers began education for licensed nurses, medication aides and certified nursing assistants on assessing and responding to pain and signs/symptoms of blood clots. Licensed nurses, medication aides, and certified nursing assistants newly hired, including agency, will receive in-service prior to working their initial shift. Director of Nursing and/or Staff Development coordinator will be responsible to ensure education is received. Facility administrator communicated this responsibility on 01/06/2025. Education included: -How to recognize deep vein thrombosis (DVT) is a blood clot -Symptoms: Pain, Swelling, Discoloration, Warmth, Positive Homan's sign -Explaining the seriousness of DVT and how they can be life threatening to Responsible Party's or families so they can make informed decisions. As of 01/06 /2025, 24-hour report will be reviewed at least five days weekly by the DON, ADON or a unit manager to identify any residents with leg swelling or pain requiring follow-up from provider. The Administrator communicated the responsibility of reviewing 24-hour reports to the DON, ADON and Unit Managers on 01/06/2025. This credible allegation of immediate jeopardy removal plan was reviewed and approved by an ad hoc QAPI meeting on 01/06/2025. Facility administrator notified DON of responsibility for completion of this credible allegation of immediate jeopardy removal plan on 01/06/2025. Alleged date of IJ removal: 01/07/2025. A validation of immediate jeopardy removal was conducted on 1/13/2025. Initial audits conducted revealed residents were evaluated for the presense of pain, if a provider had been notified, and for new/worsening leg swelling. Interviews with facility nursing staff (Nurses, Medication Aides, Nurse Aides) revealed staff had received education regarding pain assessment, change in condition, and how to report changes in condition to a medical provider without delay. Facility nursing staff were also educated about recognizing the signs and symptoms of a deep vein thrombosis and recognizing the seriousness of the development of a deep vein thrombosis. Facility nursing staff verbalized they were to explain the seriousness of a deep vein thrombosis to the resident and/or responsible party so they could make informed decisions involving care and treatment. The immediate jeopardy removal date of 1/7/2025 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff, Resident, Resident Responsible Party (RP), Nurse Practitioner, and Medical Director interview the facility Nurse Practitioner (NP) failed to communicate and collaborate with the Medical Director after Resident #1's RP voiced concerns on 12/11/2024 that Resident #1 was not receiving an anticoagulant (blood thinning medication, used to prevent blood clots) after having a fall at home and sustaining multiple fractures of the pelvis and lumbar (lower back) spine, and was not as mobile as she had been prior to admission to the facility. The Assistant Director of Nursing (ADON) contacted the NP on 12/11/2024 at which time the NP ordered aspirin which was later discontinued due to a listed allergy due to a history of gastrointestinal bleeding. The NP instructed the ADON to consult the Medical Director for further guidance regarding anticoagulation for Resident #1 and failed to reach out to the MD herself. On 12/27/2024 Resident #1 was evaluated by the NP at which time Resident #1 had pain, increased swelling, and a positive Homan's sign (pain behind the knee when the person's toes are pointed towards their head, indicative of a deep vein thrombosis/blood clot) in her left lower extremity. Resident #1 was transferred to the hospital on [DATE] where she was diagnosed with the serious adverse outcome of deep vein thrombosis to her bilateral lateral lower extremities, requiring anticoagulation, and hospitalization. The deficient practice was identified for 1 of 3 residents (Resident #1) reviewed for change in condition. Immediate jeopardy began on 12/11/2024 when the NP failed to collaborate with the Medical Director for guidance about anticoagulation concerns raised by Resident #1's RP. Immediate jeopardy was removed on 1/8/2025 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance with a lower scope and severity of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The findings included: A Collaborative Practice Agreement (Nurse Practitioner) revealed the undersigned Nurse Practitioner (NP) and the undersigned physician (Physician) agree that NP shall practice in collaborative practice with Physician in accordance with terms of this Collaborative Practice Agreement (this Agreement). The Physician shall be continuously available for communication, consultation, collaboration, referral, and evaluation of care provided by NP. Consultation, which may include telecommunication, with Physician shall occur, at a minimum, (i) in any circumstance where NP feels uncertain regarding management of any patient problem or concern; (ii) when medical management is beyond NP's scope of practice; and (iii) when a patient requests the involved Physician. The Collaborate Practice Agreement was signed by the NP on 11/23/2024 and the Medical Director on 11/24/2024. Resident #1 was admitted to the facility on [DATE] with diagnoses which included multiple pelvic fractures, fracture of the lumbosacral spine (lower back and tailbone), and a history of a gastrointestinal bleed (bleeding in the digestive tract). Resident #1's medical record revealed Resident #1 had an allergy to aspirin with unknown reactions and severity. A nursing note dated 12/11/2024, authored by the Assistant Director of Nursing (ADON), revealed Resident #1's Responsible Party (RP) had requested to be placed on anticoagulant therapy and the Nurse Practitioner (NP) was notified. An order was received for Aspirin. Resident #1 had an allergy to Aspirin. The order for Aspirin was discontinued. The RP requested anticoagulation (blood thinning medication, used to prevent blood clots) due to enoxaparin (an anticoagulant injection used to prevent blood clots) being given at the hospital. Resident #1 and the RP explained that Resident #1 had a past medical history of gastrointestinal bleeding. The ADON provided education to Resident #1 and RP, that anticoagulation therapy would put Resident #1 at risk for developing a gastrointestinal bleed. An interview was conducted on 1/3/2025 at 4:00 pm with the NP. The NP stated she received notification from the ADON on 12/11/2024 that Resident #1's RP had requested Resident #1 to be placed on an anticoagulant. The NP stated she ordered aspirin to be administered daily and was later contacted by the ADON about Resident #1 having an allergy to aspirin. The NP stated she instructed the ADON to refer to the MD for further direction regarding anticoagulation. The NP stated she did not reach out or collaborate with the MD because she had instructed the ADON to do so. An NP note dated 12/18/2024 revealed Resident #1 was evaluated for a rash to bilateral lower extremities and a dry, rough, red rash to the left lower extremity. Resident #1 complained of mild itching and was noted to have trace edema to bilateral lower extremities. The NP recommended hydrocortisone cream 1% to be applied to the left lower extremity twice daily for 5 days. An NP note dated 12/27/2024 revealed Resident #1 was noted to have increased pain and swelling in her left lower extremity. Resident #1 was documented to have 2+ edema, increased pain, and a positive Homan's sign. The NP recommended a venous doppler study and for Resident #1 to be non-weight bearing to her left lower extremity. A provider communication form dated 12/27/2024 revealed Resident #1 was ordered an in-house venous doppler study of the left lower extremity with a diagnosis of edema and pain as well as non-weight bearing on left lower extremity until the doppler studies were available. Review of a nursing note dated 12/27/2024, authored by the DON, revealed Resident #1's RP was notified that a venous doppler study would not be available before Monday. The RP was fine with that knowledge and declined to send her to the Emergency Department (ED). An interview was conducted on 1/6/2025 at 11:34 am via telephone with Resident #1's RP. The RP stated she had gone to speak with the Director of Nursing (DON) on 12/11/2024 regarding her concern about Resident #1 not being on an anticoagulant due to her immobility/fractures, swelling in her legs, and a family history of blood clots. The RP stated Resident #1 had received blood thinner shots at the hospital prior to admission to the facility. The RP stated Resident #1 was seen by the NP on 12/18/2024 at which time she had discoloration to her left leg as well as swelling and was diagnosed with a rash. The RP stated the facility contacted her on 12/25/2024 about a planned discharge and insurance denial, at which time she expressed her concern over Resident #1's swollen left leg. The RP stated she spoke with the DON again on 12/27/2024, at which time she expressed concern about Resident #1 continuing to have swelling and pain in her left leg. The RP stated the DON had the NP evaluate Resident #1 at which time they ordered a venous doppler study. The RP stated neither the DON nor any facility staff offered to have Resident #1 sent to the hospital on [DATE] for further evaluation. The RP stated she received a call on 12/28/2024 at 8:08 am (per her cell phone call log) from Resident #1 stating that her leg was hurting/more swollen and thought she needed to go to the hospital. The RP stated she called the facility at 10:08 am and insisted that the facility call EMS to have Resident #1 transferred to the hospital for further evaluation. The RP stated she received a phone call from a facility staff member at 10:21 am, at which time they reported EMS had been called. The RP stated when Resident #1 arrived at the hospital, a doppler study was performed in the ED, and Resident #1 was diagnosed with blood clots in her bilateral lower extremities and started on heparin. A nursing note dated 12/28/2024 at 10:25 am, authored by Nurse #2, revealed Resident #1 requested to go to the Emergency Department (ED) for left leg pain, swelling, and tenderness. Resident #1 stated she was hurting in the calf, behind the knee, and in her pelvic area. An ultrasound doppler was ordered but the company was not available on 12/27/2024 or over the weekend (12/28/2024-12/29/2024). Resident #1 and the RP were concerned about the pain and swelling, which is why they requested her to be sent to the ED. Change of condition documentation dated 12/28/2024, authored by Nurse #2, revealed Resident #1 had requested to go to the Emergency Department (ED). Resident #1's left leg was swollen (from hip to toes), painful, and tender to touch. The venous doppler study ordered 12/27/24 was unable to be performed before next week. Resident #1 was documented as having pain of a 4 on scale of 0-10 on the numerical pain scale (indicative of moderate pain) in the left knee, groin, and left lower leg. Nurse #2 attempted to notify the physician, but there was no answer, a message was left. An interview was conducted on 1/6/2025 at 11:41 am via telephone with Resident #1. Resident #1 stated while she was at the facility she had experienced left lower leg pain and swelling. Resident #1 stated she noticed increased leg swelling and pain that began on 12/18/2024. Resident #1 stated the swelling and pain continued to get worse, and recalled her leg being so swollen on Christmas (12/25/2024) that she tried to prop her leg up and stated her leg brace was much tighter than normal. Resident #1 stated on 12/27/2024, her left leg was really swollen. Resident #1 stated she experienced an achy pain and rated the pain as an 8-9 out of 10 on the numerical pain scale. Resident #1 stated the NP evaluated her on 12/27/2024 and ordered a test to be done at the facility. Resident #1 stated on 12/28/2024 she called the RP around 8:00 am and informed her that her left leg pain and swelling had gotten worse overnight and that she thought she needed to go to the hospital. Prior to Resident #1's conversation with the RP, Resident #1 stated there were two Nurse Aides (NAs) commented on her leg and how swollen it was. An EMS report dated 12/28/2024 revealed the facility had notified dispatch at 10:18 am regarding a sick person. EMS arrived at Resident #1's room at 10:31 am. Upon arrival to the facility, staff advised EMS that Resident #1 had broken her pelvis on both sides around 11/27/2024. Documentation revealed Resident #1 had noticed her left lower leg was starting to swell two weeks prior, and a week ago began to feel pain in the leg. Facility informed EMS the MD was aware and had ordered a doppler study which would not be available until later the following week which is why they wanted to transfer Resident #1 to the hospital. EMS obtained vital signs at 10:41 am at which time Resident #1 had a blood pressure of 182/74 (normal is 120/80), a heart rate of 90 beats per minute (normal is 60 to 100 beats per minute), a respiration rate of 18 breaths per minute (normal is 12 to 20 breaths per minute), a temperature of 98.8 degrees, and a pain level of 8 out of 10 on the numerical pain scale (indicative of severe pain). Resident #1 was transferred to the hospital at 10:45 am. EMS administered 4 milligrams (mg) of morphine for pain intravenously (through a catheter inserted in a vein). An Emergency Department (ED) note dated 12/28/2024 revealed Resident #1 presented to the ED from the facility for evaluation of bilateral lower extremity swelling, which had worsened over the last 2 weeks. A bilateral venous doppler study was conducted in the ED which revealed extensive deep vein thrombi in the left and right leg. A tibia/fibula (bones in the lower leg) x-ray revealed diffuse edema. Resident #1 was admitted to the hospital and placed on a heparin infusion with plans to later transition to Eliquis, an anticoagulant. Resident #1 remained in the hospital and did not return to the facility. As of date, she was still in the hospital was unsure of her actual discharge date from the hospital to another Skilled Nursing Facility. An interview was conducted on 1/6/2025 at 5:31 pm with the Assistant Administrator. The Assistant Administrator verbalized there was an agreement between the NP and the Medical Director regarding caring for residents. The Assistant Administrator stated if the NP needed guidance she was to reach out to the Medical Director. An interview was conducted on 1/7/2025 at 9:32 am with the Medical Director. The Medical Director stated that he collaborated with the NP by reading her notes. The Medical Director stated that he was never notified by the NP or any of the facility staff regarding Resident #1. The Medical Director stated he would have only expected the NP to reach out if there was a situation that she did not feel comfortable handling. The Medical Director stated if he had been notified about the increase in pain and swelling to Resident #1's left leg, he would have ordered a venous doppler study to be done within a day. The Medical Director stated if the venous doppler study would have been positive, indicating a blood clot, he would have started Resident #1 on an anticoagulant. The Medical Director stated if he would have been made aware the venous doppler study could not have been completed until the following week after it was ordered, he would have considered sending Resident #1 to the ED if she had experienced an increase in pain and swelling. The Administrator was notified of immediate jeopardy on 1/7/2025 at 11:10 am. The facility provided the following credible allegation of immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility Nurse Practitioner (NP) failed to communicate and collaborate with the Medical Director (MD) after Resident #1's family voiced concerns regarding anticoagulation therapy. The NP ordered Aspirin and later discontinued due to a documented allergy and because of history of gastrointestinal bleeding. The NP failed to collaborate with the MD for guidance of how to proceed. The NP did not consult with nor collaborate with the physician regarding the resident's symptoms. Resident had risk factors for Deep Vein Thrombosis (DVT), should have had coagulation therapy and sent out to the hospital for Doppler (diagnostic test to diagnose a blood clot or DVT). The NP delegated the collaboration to the Assistant Director of Nursing (ADON) instead of collaborating with the MD herself. Resident #1 was transferred to the hospital on [DATE] where she was diagnosed with blood clots to her bilateral lower extremities. Resident #1 required anticoagulation and hospital admission. All residents are at risk related to deficient practice On 1/7/25 the MD audited residents seen within the last thirty days by the NP to ensure if further collaboration was required. No residents identified at risk. 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 completed: On 1/7/25 the Administrator met with the Medical Director and NP and reviewed the expectations of the MD and NP communicating and collaborating with each other. NP should consult with MD in any circumstance regarding medical management needing a higher level of care or beyond his/her scope of practice. The agreement between the providers was reviewed, no changes were made to the provider agreement. The NP was educated on when she should consult with the MD based on review of scope of practice and collaborative provider agreement. On 1/7/25 the Medical Director/Senior partner of provider group educated the MD and all attending Physicians and on call that the NP should consult with MD in any circumstance regarding medical management needing a higher level of care or beyond his/her scope of practice defined by the North Carolina Medical Board and North Carolina Board of Nursing. On 1/7/25 The Medical Director informed the Administrator and DON that the MD and NP will have weekly meetings to ensure ongoing collaboration, and the MD will report any results of the meetings to Administrator and DON. This credible allegation of immediate jeopardy removal reviewed and approved by an AD Hoc QAPI meeting on 1/7/25. Facility administrator notified MD of responsibility for credible allegation of immediate jeopardy removal on 01/07/25. Alleged IJ removal date is 1/8/2025 A validation of immediate jeopardy removal was conducted on 1/13/2025. Initial audits conducted revealed the Medical Director had reviewed all resident visits for the last thirty days with no further issues present. Interviews with facility staff revealed the Nurse Practitioner was to collaborate with the Medical Director regarding any issues/concerns regarding the care of a resident. Facility nursing staff verbalized they were also to alert nursing management regarding issues/concerns so that nursing management could ensure follow-through. Interviews with the Nurse Practitioner and the Medical Director revealed they had received education regarding collaborating about resident care. The Nurse Practitioner verbalized understanding that she was supposed to reach out to the Medical Director if there was an issue in question or if something out of her scope needed to be addressed. The immediate jeopardy removal date of 1/8/2025 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, crash cart checklist, and staff, Respiratory Therapist, and Medical Director (MD) interviews the facility failed to immediately initiate Cardiopulmonary Resuscitation (CPR) when Resident #103, who was a full code had agonal breathing (a state of breathing of gasping for air due to the brain receiving insufficient oxygen) and went pulseless, failed to immediately utilize the overhead paging system to call staff to Resident #103's room (code blue), and failed to immediately active Emergency Medical [NAME] (EMS). Once the Respiratory Therapy recognized the need for CPR, they failed to implement the use of the Automated External Defibrillator (AED), failed to have available or use an oral airway, and the regulator on the emergency oxygen tank on the crash cart only went to 10 liters. Resident #103 was pronounced deceased and resuscitative efforts were stopped. This affected 1 of 1 resident reviewed for CPR. Immediate jeopardy began on 7/18/2024 when the staff failed to immediately initiate CPR for Resident #103 who was a full code. Immediate jeopardy was removed on 09/20/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The findings included: A review of the facility's Emergency Procedure - Cardiopulmonary Resuscitation policy dated 2022 revealed the facility's procedure for administering CPR shall incorporate the steps covered in the American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care of facility Basic Life Support (BLS) training material. The policy stated the facility should maintain equipment and supplies necessary for CPR/BLS in the facility at all times and if an individual is found unresponsive, briefly assess for abnormal or absence of breathing. If sudden cardiac arrest is likely, begin CPR: instruct a staff member to activate the emergency response system. Review of the American Heart Association Guidelines for Adult Basic Life Support for Healthcare providers dated 2020 read in part, verify scene, check for responsiveness, shout for help, activate emergency response, get AED and emergency equipment. Start CPR, perform cycles of 30 compressions and 2 breaths, and use AED as soon as it is available. A review of the standard Crash Cart checklist located on top of the crash cart, not dated, revealed a full tank of oxygen with a 15-liter regulator, oxygen wrench, sharps container, backboard, suction machine with tubing, bag-valve mask, and clipboard with paper should be kept outside of the cart. Gauze, a flashlight, a roll of tape, alcohol pads, safety needs, CPR kit, Narcan, 3-milliliter (ml) syringe, 10 ml syringe, pulse oximetry device, lubricant, tongue blades, saline bullets, and needles should be kept in the top drawer of the crash cart. A non-rebreather face mask, simple face mask, oxygen tubing, suction catheter kits, nasal cannula, oral airway (a devise used to keep the tongue from covering the airway), suction, and sterile water should be kept in the second drawer of the crash cart. A saline flush, intravenous (IV, needle or catheter placed in the vein to deliver medications/fluids) kits, IV cap, IV connector, Huber needle (used to access ports), Normal Saline, central line dressing change kit, and IV tubing should be kept in the third drawer of the crash cart. Various sizes of gloves, a stethoscope, blood pressure cuff, spill kit, and AED with 2 sets of pads should be kept in the bottom drawer of the code cart. Resident #103 was admitted to the facility on [DATE] with a diagnosis of a fracture (break) of the right femur (long bone located at the top of the leg) and post right periprosthetic hip fracture (a broken bone that occurs around the implant of a total hip replacement). Review of an admission Minimum Data Set (MDS) dated [DATE] revealed Resident #103 was moderately cognitively impaired. Review of a physician's order dated 7/5/2024 revealed Resident #103 was a full code and wanted to receive cardiopulmonary resuscitation (CPR). A review of the July 2024 Medication Administration Record (MAR) revealed Resident #103 was documented as having received ondansetron (medication used to treat nausea and vomiting) 4 milligrams (mg) by mouth on 7/18/2024 at 5:21 pm. A review of a nursing note dated 7/18/2024 and the time of entry was 8:43 PM, authored by Nurse #3, revealed Resident #103's family requested ondansetron for nausea for Resident #103. The dose was given at 5:21 pm. Resident #103 had returned from a doctor's appointment vomiting green fluid with no food particles per Resident #103's family. Resident #103 refused supper and ondansetron was effective. The family later came to the nurses' station and stated Resident #103 was not responding. A sternal rub was performed by Nurse #3 with minimal response from Resident #103. Vital signs were taken, and the resident had a blood pressure of 49/33 (normal range is 90/60 to 120/80), heart rate of 90 beats per minute (normal range is 60 to 100 beats per minute), respiration rate of 18 breaths per minute (normal range is 12 to 20 breaths per minute), and a temperature of 96.7 degrees (normal is 98.6 degrees Fahrenheit). Resident #103's oxygen saturation level dropped into the 70's (normal range is greater than or equal to 92%) and Resident #103 was placed on oxygen (unspecified amount). 911 was called and CPR was started on Resident #103. Resident #103 was pronounced deceased at 7:50 pm. Nurse #3 was unavailable for an interview. Review of a telephone statement dated 7/19/2024, taken by the former Director of Nursing (DON), who was the Assistant Director of Nursing at the time) on behalf of Nurse #3, revealed at approximately 4:00 pm on 7/18/2024, Resident #103 returned to the facility from a doctor's (orthopedic) appointment with green bile on him that he had vomited in the car with his family. Resident #103's family had assumed Resident #103 had gotten car sick. The family came to the nurses' station around 5:15 pm and requested ondansetron (medication used to treat nausea and vomiting) for Resident #103. Ondansetron was administered at 5:21 pm. The family came and got Nurse #3 around 6:30 pm and Nurse #3 went into Resident #103's room and assessed him. Nurse #3 checked Resident #103's vital signs, and his blood pressure was low, pulse and respirations were good, and he did not have a fever. Nurse #3 performed a sternal rub on Resident #103, and he opened his eyes. The family thought Resident #103 was sleepy. Nurse #3 reported she was going to send Resident #103 to the hospital but did not know where the on-call provider number was and then the second shift (7:00 pm to 7:00 am) nurse came in. Nurse #3 stated she informed Nurse #8 that Resident #103 was not doing well and they proceeded to go to Resident #103's room. Nurse #3 reported she called 911 and told EMS it was emergent, and someone had paged a Code Blue. Nurse #3 reported Nurse #8 performed CPR until EMS got there and took over. Nurse #3 reported Resident #103 was pronounced dead at 7:50 pm. An interview was conducted on 9/19/2024 at 9:32 am with Nurse Aide (NA) #2. NA #2 stated she worked on 7/18/2024 during second shift (3:00 pm to 11:00 pm) and was assigned Resident #103. NA #2 stated she was in the process of taking her lunch break, around 7:00 pm, and was approached by Nurse #3 in the hall. NA #2 stated that Nurse #3 panicked and did not know what to do and stated that Resident #103 had coded. NA #2 stated she showed her where the crash cart was at the nurses' station and instructed Nurse #3 to call 911. NA #2 stated Nurse #3 did not initiate CPR and had someone use the overhead paging system to call a Code Blue. NA #2 stated several minutes passed by when she was assisting Nurse #3 locate the crash cart and directing her to call 911 for EMS. NA #2 stated she stood at Resident #103's door with the family until the nurses and Respiratory Therapist entered the room, CPR was then initiated several minutes later. NA #2 stated she stayed out in the hall with Resident #103's family. A review of a typed statement dated 7/19/2024, authored by Nurse #9, revealed the staff told her a resident was gone (had expired). Nurse #9 ran down to the 600 hall and told staff to call a Code Blue over the intercom. Nurse #9 arrived at the room around 7:00 pm after she received report from the 200-hall nurse. Nurse #3 was sitting at the nurses' station on the phone with Emergency Medical Services (EMS). Nurse #9 documented the crash cart was in the room and Nurse #8 was monitoring the situation. Nurse #9 documented Resident #103 had a pulse, but did not look good, and noticed his fingers were blue. Nurse #9 checked on the family member in the hallway and informed her Resident #103 was still alive, at which time staff called out of the room that they had started chest compressions. Nurse #9 documented Nurse #14 started compressions, and the RT began bagging (ventilating) Resident #103. Nurse #3 remained on the phone with EMS. EMS arrived in the room and placed a CPR vest (mechanical chest compression device that goes around the resident's chest) on Resident #103. An interview was conducted on 9/18/2024 at 3:46 pm with Nurse #9. Nurse #9 stated she worked second shift (3:00 pm to 11:00 pm) on 7/18/2024 and was not assigned Resident #103. Nurse #9 stated an NA (name unknown) came to her and told her to go to Resident #103's room because they needed help. Nurse #9 stated when she arrived at Resident #103's room, Nurse #3 was calling EMS from the nurse's station and the family was in the hall. Nurse #9 stated she spoke with Nurse #8 and was told by Nurse #8 Resident #103 was not breathing well. Nurse #9 stated she went into the room and yelled for someone to get the crash cart and call a Code Blue. Nurse #9 stated she did not perform CPR and comforted the family member in the hall. A review of a Report on a Code Blue event dated 7/18/2024, authored by the agency RT and submitted to her supervisor, revealed that at approximately 7:15 pm, an overhead announcement for a Code Blue was called for Resident #103. The RT responded to Resident #103's room at which time she observed Resident #103 was unresponsive, with an oxygen saturation level at 76% and dropping, CPR had not been initiated. The RT instructed staff to begin CPR and requested a bag-valve mask (mask used to give breaths during CPR using positive pressure, squeezing bag). Resident #103 was observed with a simple mask on with insufficient oxygen flow, which she documented as likely causing carbon dioxide retention. The bag-valve mask did not inflate properly which indicated inadequate oxygenation. Challenges faced were documented as a delay in CPR initiation: initial hesitation and lack of coordinated effort from the team delayed effective CPR. The resident's pupils were fixed and dilated, indicating a critical need for timely intervention. Equipment and flow issues: the bag-valve mask did not inflate properly, raising concerns about oxygen delivery. The outcome was documented as despite multiple efforts, including epinephrine administration and advanced airway management attempts, the patient remained unresponsive. After approximately 25 minutes of high-performance CPR, the resident was pronounced dead at 7:50 pm. Post-event reflection documentation revealed the RT had spoken with Nurse #3 at which time Nurse #3 reported she was called to check on Resident #103, who had agonal breathing, however, CPR was not started promptly. The RT emphasized the importance of initiating CPR immediately upon finding a resident without a pulse and ensuing continuous efforts are made until help arrives, as per the American Heart Association (AHA) guidelines. The conclusion documentation stated This event highlights the critical need for prompt and coordinated response during Code Blue situations. Immediate initiation of CPR and effective team communication are essential to improve resident outcomes. Further training and drills are recommended to ensure all staff are prepared to respond effectively to similar emergencies in the future. The report was electronically signed by the RT. An interview was conducted on 9/18/2024 at 10:24 am with the agency Respiratory Therapist (RT). The RT stated she worked as an RT on night shift 7:00 pm to 7:00 am and responded to the Code Blue called on 7/18/2024 for Resident #103. The RT stated she was in the RT office when she heard a Code Blue paged overhead on the intercom for Resident #103's room around 7:15 pm and immediately responded (The RT's office was approximately 400 feet from the resident's room). The RT stated upon entering the room, there was a nurse and an NA standing beside the resident's bed, Resident #103 was hooked up to a vital sign machine, was on oxygen via face mask, and had an oxygen saturation of 76% (normal oxygen saturation range is >92%). The RT stated that she immediately assessed Resident #103 at which time he had no carotid pulse (pulse in the neck), fixed/dilated pupils, and agonal breathing, but was warm to touch. The RT stated other nurses had arrived in the room behind her and she instructed them to initiate CPR. The RT stated during the code the oxygen tank on the crash cart would only go up to 10 liters of oxygen per minute (instead of 15 liters per minute) and that the pressure that came out of the oxygen tank was not enough to inflate the bag on the bag-valve-mask, there was no oral airway in the cart, and she was unsure if there was an AED in the crash cart. The RT stated chest compression and ventilation were performed by a nurse (name unknown) until EMS arrived on scene. The RT stated CPR continued until EMS called a time of death. After the Code Blue the RT approached Nurse #3 and asked her why she had not initiated CPR and was told by Nurse #3 it was because she was alone and did not have any shoes on. An interview was conducted on 9/18/2024 at 1:35 pm with Nurse #8. Nurse #8 stated she was an agency nurse, and was scheduled to work from 7:00 pm to 7:00 am on 7/18/2024. Nurse #8 stated on 7/18/2024 she arrived at work late around 7:15 PM and was met in the hall by staff and was told Resident #103 did not look well. Nurse #8 stated she asked Nurse #3 about Resident #103 and urgently grabbed the vital sign equipment and ran into the room. Nurse #8 stated when she arrived in Resident #103's room the resident had difficulty breathing and he was unable to get a pulse oximetry reading. Nurse #8 stated the RT entered the room; she could not feel a pulse and began CPR. Nurse #8 stated the RT ran the code and instructed staff. Nurse #8 stated 2 other nurses arrived at the room and they rotated chest compressions every two minutes and one nurse called 911. Nurse #8 stated 2 to 3 rounds of CPR were performed and the RT remained at the head of the bed prior to EMS arrival, ventilating (supplying breaths) the resident, Nurse #8 stated when EMS arrived, they placed a defibrillator (an electrical shock across the chest used to treat life-threatening arrhythmias such as ventricular tachycardia and ventricular fibrillation) on Resident #103 and the chest compression device. Nurse #8 recalled EMS defibrillating (shocking) Resident #103 after he was placed on the cardiac monitor. Nurse #8 stated EMS spoke with the family, and the family wanted to stop chest compressions, and the time of death was called. Nurse #8 stated the AED was not on the crash cart which is why it was not placed on Resident #103 prior to EMS arrival. An observation of the crash cart on 09/18/24 at 10:43 AM along with the Unit Manager revealed there was an Automated External Defibrillator (AED) in the bottom drawer of the cart. A review of an EMS report dated 7/18/2024 revealed EMS call was received at 7:22 PM, the call was reported as emergent with lights and sirens for cardiac arrest. EMS arrived on scene at 7:28 PM, and arrived at Resident #103 at 7:36 PM at which time CPR was being performed by facility staff on Resident #103. CPR had been performed for approximately 10 minutes prior to EMS arrival. Resident #103 had a shockable rhythm and was manually defibrillated at 7:41 pm and again at 7:43 pm. Time of death was documented at 7:50 pm. An interview was conducted on 9/19/2024 at 9:37 am with DON. The DON stated on 7/18/2024 she was in the position of Assistant Director of Nursing (ADON). The DON stated after the Code Blue on 7/18/2024 which involved Resident #103, she was asked by the Former DON, to gather written statements from Nurse #3 and Nurse #8. The DON stated she was told by Nurse #3 that Resident #103 had gone to a doctor's appointment and when he returned to the facility, he stated having nausea. The DON stated the family had later approached Nurse #3 and said that something was not right. DON was told by Nurse #3 that Nurse #3 and Nurse #8 had gone to the room to assess Resident #103 at which time they called a Code Blue and initiated CPR. The DON stated Nurse #3 was terminated following the Code Blue incident on 7/18/2024. A telephone interview was conducted on 9/19/2024 at 10:31 am with the Former DON. The Former DON stated she was not able to recall much about the Code Blue event which involved Resident #103. An interview was conducted on 9/24/2024 at 10:04 am with the Medical Director (MD). The MD stated Resident #103 had been admitted to the facility following a hip fracture. The MD was made aware of Resident #103 requiring CPR and later deceased . The MD stated he was not aware that the AED had not been applied prior to EMS arrival at the facility and was not aware that EMS had defibrillated Resident #103 two times after their arrival on scene. The MD stated the application would have not hurt his chance of survival had it been applied by facility staff and said that it was hard to say if it would have changed the outcome of the situation. The MD stated he suspected Resident #103 may have died of a pulmonary embolism (a blood clot that stops the flow of blood to an artery in the lungs). The MD stated that if a resident was a full code and in distress, he would expect them to initiate EMS and CPR if indicated. An interview was conducted on 9/19/2024 with the Administrator. The Administrator stated she was familiar with Resident #103 and recalled that on 7/18/2024 Resident #103 had gone out of the facility to a doctor's appointment and passed away later that night. The Administrator stated she was informed about the Code Blue during the morning meeting on 07/19/24. The Administrator stated she had read some statements from facility staff regarding the Code Blue. She had not been made aware the RT's written statement had been emailed to the Respiratory Therapy Supervisor who was an administrative staff member at the facility. Had she been made aware that the email which outlined a delay in response and initiation of CPR and equipment failure she would have immediately addressed the issues. The Administration was notified of Immediate Jeopardy on 9/19/2024 at 3:33 pm. The facility provided the following credible allegation of Immediate Jeopardy Removal: Identify those recipients who have suffered and those who are likely to suffer a serious adverse outcome as result of the noncompliance: Beginning on 7/18/24 on the 3-11 shift, Resident #103 had a change in condition which led to resident becoming unresponsive and went into Cardiopulmonary arrest. The staff failed to respond timely to initiate CPR and delayed in calling 911. The facility staff failed to implement the use of the AED. The center failed to have available or use an oral airway during event and the emergency tank on crash cart had a regulator which only went to 10 liters. On 9/19/2024 at approximately 4:00 p.m. the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) completed an audit of the centers three Crash Carts to ensure that they were adequately supplied, all carts noted to be supplied with all required supplies/equipment in working order (Full O2 tank with 15-LPM Regulator, Suction machine and tubing, Oxygen wrench, sharps container, backboard, clipboard with paper, ambu bag, gauze 4x4, flashlight, tape, alcohol pads, Huber needle, 3cc syringe, 10cc syringe, safety needles, Surgi lube, tongue blades, saline, pulse oximeter, IV start kits, IV cap, IV tubing, IV connector, 20, 22 & 24G Jelco catheters, non-rebreather face mask, face mask, oxygen tubing, suction cath kit, nasal cannula, oral airway, Yankaur, gloves, stethoscope, BP cuff, Spill kit). 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. The center has a policy that has been reviewed by the IDT and medical director, the policy indicates that the center will perform BLS level CPR. Policy states a licensed staff member is responsible for providing BLS CPR. Policy review dated 9/19/24. On 9/19/24 the Director of Nursing validated that all three crash carts have emergency oxygen tanks that go to 15 liters. On 9/19/24 the Administrator and Medical Director decided to remove the AED's from the center. A note was place on each crash cart indicating that the AEDs are no longer in use at the center. On 9/19/24 center HR Director reviewed all current staff and agency staff cpr certification and they were current. The center HR Director and /or the Assistant Administrator verifies agency staff are cpr certified upon their assignment to the center. On 9/19/24 the center Administrator notified the Director of Nursing of immediate implementation of Mock Code Drills increasing from Quarterly to Monthly. Mock Code Drills are conducted by the DON or ADON. On 9/19/2024 at approximately 5:00 p.m. the Director of Nursing and Nursing Leadership Team which includes ADON, Unit Managers, Wound Nurse, initiated education for all licensed nurses and Respiratory Therapy on Assessing and Responding to Changes in Condition to include abnormal vital signs. Education also included review of the center CPR policy and how and when to call a Code Blue and when to call 911, immediate initiation of CPR in cardiopulmonary arrest and the Location of Crash Carts/Emergency Supplies. During education staff have been informed that the AEDs have been removed from the center. On 9/19/2024 at approximately 5:00 pm the Regional Nurse initiated education with all staff to include, Administrative Staff, Maintenance, Dietary, Laundry, Housekeeping, Licensed staff, Nurse Aides, and Therapy Staff on the Location of the Crash Carts/Emergency Supplies, how to call Code Blue and to notify a nurse with any noted change in a resident condition. This education included the Nurse's Aides responsibility in alerting licensed staff immediately of abnormal vital signs and/or unresponsive residents. Education includes per policy that the licensed staff will call 911 for Cardiorespiratory events. This education includes Full-Time, Part Time, PRN and Agency Staff. No staff shall work until they receive this education. Director of Nursing is responsible for making sure all receive the above education. Director of Nursing informed the Staff Development Coordinator on 9/19/2024 that she would be responsible for new hire and new agency education on the above, to include assigning supervisory staff members to provide the education in her absence. Education will be included in new hire orientation and new agency orientation via in person review or a written education packet by a member of the Nurse Management Team (DON, ADON, SDC, Unit Managers, Shift Supervisors). Training to occur prior to the beginning of an unsupervised shift. Night shift charge nurses are responsible for checking the crash carts nightly to ensure appropriately stocked, licensed nurses re-educated to this process as of 09/19/2024 by director of nursing or other member of nurse leadership team. Beginning 9/19/24 ADON or DON will check the crash carts weekly to ensure that they are appropriately stocked and in working order. Alleged date of IJ removal: 9/20/24. A validation of IJ removal was conducted on 09/24/24. All three facility crash carts were observed to have the needed emergency supplies and were in working order. Each cart contained a sign alerting the staff that the AED machines had been removed and contained a checklist that had been initialed nightly by the night shift nurse. The facility's CPR policy was reviewed as was the center's list of CPR certified staff. Nursing staff interviews revealed that they had received the education on CPR, responding to emergencies, location of crash carts, calling EMS services and the overhead page of Code Blue when an emergency was identified. Interviews with non-nursing departments revealed that they were aware of their role during an emergency and were able to verbalize tasks that they could do in the event of a Cod Blue. The facility conducted a mock Code Blue drill on 09/24/24 which was also observed without concerns. The nursing staff secured the crash cart, notified emergency personnel, and all staff including the RT responded and began performing CPR on the victim. The IJ removal date of 09/20/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident, staff, Nurse Practitioner (NP), Medical Director (MD), and Pharmacist interviews the facility failed to assess a resident and initiate the sepsis protocol when Resident #96, who was continuously ventilator dependent, was found by Nurse #1 between 8:00 and 9:00 pm on 9/16/2024 to have a fever of 100.4 degrees Fahrenheit (F) (normal is 98.6 degrees), a heart rate of 116 beats per minute (normal is 60-100 beats per minute), and a respiratory rate of 24 breaths per minute (normal is 12-20 breaths per minute). Nurse #1 did not initiate the sepsis protocol when Resident #96 met two criteria on the Ventilator Unit Sepsis Protocol (a heart rate greater than 90 beats per minute and a respiration rate of greater than or equal to 20 breaths per minute), failed to re-check Resident #96's temperature for the remainder of the shift, and did not administer fever reducing medication. Then on 09/17/24 at approximately 6:30 AM to 7:00 AM Nurse Aide (NA) #1 obtained another set of vital signs that revealed a temperature of a 103 degrees Fahrenheit, a heart of rate of 121, and respiratory rate of 22 breaths per minute and reported the vital signs to Nurse #1 (who was the night shift nurse) that was reporting off to Nurse #2. Resident #96 was given Acetaminophen (medication used to reduce fever) 650 milligrams (mg) and Ibuprofen (medication used to reduce fever) 400 mg between 9:00 am and 11:00 am by Nurse #2. Nurse #2 failed to recheck Resident #96's temperature until approximately 3:00 pm at which time it was 102.3 degrees Fahrenheit after being prompted by the Unit Manager. The Unit Manager reported a temperature should have been obtained between 30 minutes to an hour after the administration of fever-reducing medication. At 3:00 pm, the Unit Manager contacted the NP and initiated the Sepsis Protocol (set of orders to follow when a resident has signs/symptoms of infection). Resident #96 was sent to the Emergency Department at approximately 4:15 pm and was later admitted to the Intensive Care Unit (ICU) with sepsis (life-threatening infection), urinary tract infection (UTI), an infected sacral (buttocks) wound, and dehydration. The deficient practice occurred for 1 of 3 residents (Resident #96) reviewed for change in condition. Immediate jeopardy began on 9/16/2024 when Resident #96 was found by Nurse #1 to have a change in condition and did not reassess Resident #96 after he was found to have a temperature of 100.4 degrees F, a heart rate of 116 beats per minute, and a respiration rate of 24 breaths per minute, which met the facility's sepsis criteria. Immediate jeopardy was removed on 09/19/24 when the facility implemented a credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a lower scope and severity of D (no actual harm with a potential for minimal harm that is not immediate jeopardy) to ensure education is completed and monitoring systems put into place are effective. The findings included: The Ventilator Unit Sepsis Protocol revealed it was to be initiated if a patient exhibits two or more of the following Systemic Inflammatory Response Syndrome (SIRS, exaggerated defense response) criteria: temperature greater than 100.4 degrees or less than 96.8 degrees, heart rate greater than 90 beats per minute, respiratory rate greater than or equal to 20 breaths per minute, or a white blood count greater than or equal to 12,000 cubic millimeters (mm3) or less than or equal to 4,000 (mm3) and suspected or proven infection. Protocol interventions included staff were to obtain immediate labs, a chest x-ray, and begin cefepime 2 grams intravenously (IV) every 12 hours for 7 days or doxycycline 100 mg IV every 12 hours for 7 days. If the systolic blood pressure (top number on a blood pressure reading) was less than 100, staff should administer normal saline IV at 100 milliliters (ml) per hour for 48 hours. Staff should monitor intake and output for 48 hours for residents with a catheter. Staff should notify the MD or NP during their next visit to the facility. The protocol had an area for the nurse who initiated the protocol to sign. Resident #96 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure (lungs are unable to exchange oxygen and carbon dioxide), ventilator associated pneumonia (a lung infection that develops when a person is on a ventilator), quadriplegia (inability to move all four extremities), unstageable pressure wound of the sacral region, gastrostomy tube (tube inserted through the stomach used to provide nutrition and medications), and dependence on a respiratory ventilator (machine used for breathing). A review of a care plan dated 8/2/2024 revealed Resident #96 was at risk for respiratory complications related to ventilator (a machine used to help breathe) and tracheostomy (an opening in the neck to facilitate breathing). Staff were to monitor for signs and symptoms of pneumonia (an infection of the lungs), bronchitis (inflammation of the linings of the lungs), etc. and advise the medical provider of any abnormal findings. A review of an annual Minimum Data Set (MDS) dated [DATE] revealed Resident #96 was severely cognitively impaired, required extensive assistance for mobility and was coded for a tracheostomy mechanical ventilator, suctioning (used to remove secretions from the respiratory tract), oxygen, and intravenous (IV, given through the veins) medications. A physician's order dated 9/9/2024 revealed Resident #96 was ordered ceftazidime (an antibiotic used to treat bacterial infections) injection 1 gram intravenously (IV, infused through the vein) every 8 hours for 10 days for a urinary tract infection and ciprofloxacin (an antibiotic used to treat infections) 500 milligrams (mg) via gastrostomy tube twice a day for 10 days for pseudomonas (an infection that can affect your skin, blood, lungs, and gastrointestinal tract) in the sputum. The Medication Administration Record (MAR) revealed documentation that Resident #96 had received ceftazidime on 9/9/2024 (2:00 pm and 10:00 pm) , 9/10/2024 (6:00 am, 2:00 pm, and 10:00 pm), 9/11/2024 (6:00 am, 2:00 pm, and 10:00 pm), 9/12/2024 (6:00 am, 2:00 pm, and 10:00 pm), 9/13/2024 (6:00 am, 2:00 pm, and 10:00 pm), 9/14/2024 (6:00 am, 2:00 pm, and 10:00 pm), 9/15/2024 (6:00 am, 2:00 pm, and 10:00 pm), 9/16/2024 (6:00 am, 2:00 pm, and 10:00 pm), and 9/17/2024 (6:00 am) and ciprofloxacin on 9/9/2024 (9:00 am), 9/10/2024 (9:00 am and 6:00 pm), 9/11/2024 (9:00 am and 6:00 pm), 9/12/2024 (9:00 am and 6:00 pm), 9/13/2024 (9:00 am and 6:00 pm), 9/14/2024 (9:00 am and 6:00 pm), 9/15/2024 (9:00 am and 6:00 pm), 9/16/2024 (9:00 am and 6:00 pm), and 9/17/2024 (9:00 am). An observation was conducted on 9/16/2024 at 10:43 am of Resident #96. Resident #96 was observed lying in bed. Resident #96 had a tracheostomy and was on the ventilator. Ventilator settings were the following: oxygen at 5 liters per minute, respiration rate of 18 breaths per minute, Resident #96 was able to open his eyes and mouthed that he was hot. The Surveyor notified Nurse Aide (NA) #3. Resident #96's ventilator was set on Assist Control/Volume Control (AC/VC, the ventilator produces a fixed tidal volume, the amount of air that moves in and out of the lungs with each breath, that is delivered at set time intervals or when the individual initiates a breath). A review of vital signs on 9/16/2024 at 11:18 pm revealed Resident #96 had a temperature of 100.4 degrees (normal temperature is 98.6 degrees), heart rate of 116 beats per minute (normal heart rate is 60-100 beats per minute, respiration rate of 24 breaths per minute (normal respiration rate is 12-20 breaths per minute), a blood pressure of 113/62, and an oxygen saturation of 96% (normal is greater than 92%). The vital signs were documented by Nurse #1 and were not reported to the physician. An interview was conducted on 9/18/2024 at 4:49 pm with Nurse #1. Nurse #1 stated she had worked on the ventilator unit on 9/16/24 from 7:00 pm until 9/17/2024 at 7:00 am and was assigned Resident #96. Nurse #1 stated Resident #96 had a low-grade fever of 100.4 degrees Fahrenheit when she checked his vital signs close to the start of her shift somewhere between 8:00 pm and 9:00 pm. Nurse #1 stated she had not thought to re-check it until she had been informed around 7:00 am while giving report to Nurse #2, that Resident #96 had a temperature of 103 degrees. Nurse #1 stated Resident #96 met criteria for the Sepsis Protocol during her shift but stated she usually did not initiate the protocol if a resident was already on antibiotics. Nurse #1 stated Resident #96 met sepsis criteria because he had high heart rate of 116 beats per minute and an elevated respiratory rate of 24 breaths per minute. Nurse #1 stated the nurse could implement the Sepsis Protocol if a resident met two or more criteria, however, she was not sure how that worked since Resident #96 was on antibiotics. Nurse #1 stated staff typically only checked vital signs once a shift. Nurse #1 stated did not notify the provider because Resident #96 was already on antibiotics. A review of vital signs on 9/17/2024 at 6:30 am revealed Resident #96 had a temperature of 103 degrees F, heart rate of 121 beats per minute, respiratory rate of 22 breaths per minute, and a blood pressure of 106/63. The vital signs were documented on a vital sign report sheet completed by NA #1. An interview was conducted on 9/17/2024 at 10:35 am with Nurse Aide (NA) #1. NA #1 stated she was assigned Resident #96 and had arrived on shift at 6:00 am on 9/17/2024. NA #1 stated shortly after she arrived, she obtained Resident #96's vital signs and recalled Resident #96 having an elevated temperature. NA #1 stated she wrote down Resident #96's vital signs and gave them to Nurse #1. NA #1 documented Resident #96's vital signs on a vital sign report sheet. An interview was conducted on 9/17/2024 at 10:45 am with Nurse #2. Nurse #2 stated she was assigned Resident #96 and arrived on shift at 7:00 am. Nurse #2 stated she was told in report that Resident #96 had a temperature of 103 degrees Fahrenheit, heart rate of 121 beats per minute, respiration rate of 22, and a blood pressure of 106/63. Nurse #2 stated she had just received orders for Acetaminophen and Ibuprofen but had not given them yet. Nurse #2 had no response for why Acetaminophen and Ibuprofen had not been administered earlier. Nurse #2 stated she was not sure if the facility had a Sepsis Protocol and was unsure where the standing orders were. A physician's order dated 9/17/2024 at 8:45 am revealed Resident #96 was ordered ibuprofen 400 mg via gastrostomy tube one time only for hyperthermia (increased body temperature). A physician's order dated 9/17/2024 at 9:00 am revealed Resident #96 was ordered prednisone (steroid used to decrease inflammation) 60 mg via gastrostomy tube once a day for seven days for ventilator associated pneumonia. An observation was conducted on 9/17/2024 at 9:07 am of Resident #96. Resident #96 would not make eye contact or mouth any words. Resident #96's lips were dry and cracked. Ventilator settings were the following: oxygen at 10 liters per minute, respiration rate of 18 breaths per minute. An interview was conducted on 9/17/2024 at 10:45 am with Nurse #2. Nurse #2 stated she was assigned Resident #96 and arrived on shift at 7:00 am. Nurse #2 stated she was told in report that Resident #96 had a temperature of 103 degrees Fahrenheit, heart rate of 121 beats per minute, respiration rate of 22, and a blood pressure of 106/63. Nurse #2 stated she had just received orders for Acetaminophen and Ibuprofen but had not given them yet. Nurse #2 had no response for why Acetaminophen and Ibuprofen had not been administered earlier. Nurse #2 stated she was not sure if the facility had a Sepsis Protocol and was unsure where the standing orders were. An interview was conducted on 9/18/2024 at 5:19 pm with Wound Care Nurse #2. Wound Care Nurse #2 stated she had changed Resident #96's dressing around lunch time on 9/17/2024. Wound Care Nurse #2 stated at that time Resident #96's skin felt warm, and she told Nurse #2, and was told by Nurse #2 she was going to give him acetaminophen. An interview was conducted on 9/18/2024 at 5:01 pm with the Wound Care Nurse #1. Wound Care Nurse #1 stated she had been told by Wound Care Nurse #2 that Resident #96 had a fever, because he felt warm, when she had changed his dressings on 9/17/2024 around lunchtime. Wound Care Nurse #1 stated she had walked to Resident #96's room to check on him around 3:30 pm at which time he appeared terrible and grayish blue in color. Wound Care Nurse #1 stated RT #1 was in the room with Resident #96 at that time giving him a nebulizer treatment and she left the room to inform the DON. An interview was conducted on 9/17/2024 at 2:47 pm with Respiratory Therapist (RT) #1. RT #1 stated Resident #96 had been on antibiotics for pneumonia and was ventilator dependent. RT #1 stated Resident #96 had his oxygen level desaturate (get lower) on 9/16/2024 and had to have his oxygen requirements increased from 5 liters to 10 liters. RT #1 stated that was not uncommon for Resident #96. RT #1 stated nursing staff had not made him aware that Resident #96 had an elevated temperature and heart rate and stated that could be an indication of sepsis. A physician's order dated 9/17/2024 at 3:20 pm revealed Resident #96 was ordered a sputum culture one time only for a fever, a urinalysis with culture and sensitivity one time only for a fever, and blood cultures/comprehensive blood count (CBC, used to evaluate for infection)/platelets (help blood to clot). A sputum sample was documented as collected on 9/17/2024 at 3:29 pm. A physician's order dated 9/17/2024 at 3:37 pm revealed Resident #96 was ordered Ibuprofen 400 mg via gastrostomy tube one time only for hyperthermia (fever). A physician's order dated 9/17/2024 at 3:45 pm revealed Resident #96 was ordered tobramycin nebulizer treatments 300 mg via tracheostomy two times a day for pneumonia for 13 administrations to be nebulized with oxygen and 150 mg via tracheostomy one time for hyperthermia for one day. A physician's order dated 9/17/2024 at 4:00 pm revealed Resident #96 was ordered meropenem (antibiotic) 1 gram/100 milliliters (ml) every 8 hours for hyperthermia for 7 days. An interview was conducted on 9/17/2024 at 3:41 pm with the Unit Manager. The Unit Manager stated the ventilator unit utilized a Sepsis Protocol. The Unit Manager stated that the sepsis protocol typically applied to residents that were not currently on antibiotics and had experienced brand new sepsis symptoms. The Unit Manager stated she had not initiated the Sepsis Protocol for Resident #96 earlier in the shift because he was already on two different antibiotics. The Unit Manager stated she had contacted the NP earlier in the shift around 8:30 am and received orders to administer acetaminophen and ibuprofen at the same time. The Unit Manager stated she had to go to the store to get ibuprofen and when she returned, she gave it to Nurse #2 and told her to administer it with the acetaminophen. The Unit Manager stated she asked Nurse #2 around 3:00 pm what Resident #96's temperature was, at which time she had not checked it. Resident #96's temperature was 102.3 degrees Fahrenheit at that time. The Unit Manager stated that a temperature was typically rechecked between 30 minutes and 1 hour after the administration of medication for a fever. The Unit Manager stated she was unsure why Nurse #2 had not rechecked Resident #96's temperature sooner stated she contacted the NP at 3:20 pm and was told to alternate Acetaminophen and Ibuprofen and initiate the Sepsis Protocol. A review of a physician's order dated 9/17/2024 at 4:05 pm revealed Resident #96 was to be transferred to the hospital for evaluation and treatment for respiratory distress and fever. Review of an Emergency Medical Services (EMS) report dated 9/17/2024 at 4:04 pm revealed that EMS had been dispatched to the facility in reference to Resident #96 having a fever. Upon arrival documentation revealed Resident #96 presented with septic shock. Facility staff had stated Resident #96's mental status was abnormal. Resident #96's skin was warm and diaphoretic. Resident #96's initial vital signs were a blood pressure of 94/60, heart rate of 118 beats per minute, and an oxygen saturation level of 100% on the ventilator. Resident #96 was given a normal saline fluid bolus (fluid administered through the vein to increase blood pressure) of 500 ml enroute to the hospital. Review of an emergency room note dated 9/17/2024 at 5:48 pm revealed Resident #96 presented to the ER with a concern for sepsis (life-threatening infection). Resident #96's initial blood pressure was 83/58, heart rate of 101 beats per minute, respiration rate of 18, an oxygen saturation level of 97%, and a temperature of 98.4 degrees Fahrenheit. Resident #96 had extremely dry mucous membranes and a large, stage 3 sacral wound that was foul-smelling. Resident #96 went into ventricular tachycardia (irregular heart rate that can be life-threatening) and required an amiodarone (medication used to treat ventricular tachycardia) drip and continued to have worsening blood pressures which required a dose of epinephrine and initiation of a norepinephrine (medication used to increase blood pressure) drip. Resident #96 was admitted to the Critical Care Unit and remained in the hospital. An interview was conducted on 9/17/2024 at 12:05 pm with the Pharmacist. The Pharmacist stated Resident #96 was on ciprofloxacin for a gram-negative bacterium, pseudomonas, and was also on ceftazidime, a third-generation cephalosporin, that was broader spectrum. The Pharmacist stated Resident #96 had been on antibiotics for several days and stated if Resident #96 had a fever of 103 degrees the facility should reinitiate the Sepsis Protocol to determine which bacteria was causing the elevation and adjust antibiotics as necessary. An interview was conducted on 9/18/2024 at 2:16 pm with the Medical Director (MD). The MD stated the Sepsis Protocol was developed by the NP. The MD stated the Sepsis Protocol had to be initiated by himself, the Pulmonologist, or the NP, not the nursing staff. The MD stated the nursing staff at the facility should call the MD when a resident experienced signs or symptoms of sepsis before initiating the Sepsis Protocol. The MD stated Resident #96 had pneumonia in the past and had been on a couple of broad-spectrum antibiotics. The MD stated Resident #96 was on antibiotics which would typically start working within 3 to 5 days. The MD stated he would not be concerned about a fever of 103 degrees Fahrenheit not being treated unless the resident experienced symptoms of discomfort. The MD stated a fever was only dangerous when it reached 105 degrees, which could cause seizures. An interview was conducted on 9/18/2024 at 4:11 pm with the Director of Nursing (DON). The DON stated on 9/17/2024 around 3:30 pm that she was approached by the Wound Care Nurse that Resident #96 did not look good, at which time she and the ADON started to the ventilator unit. The DON stated she stopped by the Unit Manager's office and asked how Resident #96 had been doing and was told he had been running a fever and orders had been obtained from the NP to initiate the Sepsis Protocol. The DON stated when she entered the room Resident #96 looked malaise, was warm to the touch, had a bounding heart rate, and looked like he needed to be transferred. The DON stated acetaminophen should have been administered by Nurse #2 per standing order when Resident #96 had a fever of 103 degrees, and stated she was unsure why there was a long delay in the administration of acetaminophen and ibuprofen. The DON was unsure why the Sepsis Protocol was also not initiated when Resident #96 had an elevated temperature and heart rate at the beginning of shift and agreed it should have been. The DON also reported Nurse #1 should not have waited multiple hours to recheck a temperature after the administration of antipyretics (fever-reducing medications). An interview was conducted on 9/19/2024 at 10:04 am with the NP. The NP stated that she had created the Ventilator Unit Sepsis Protocol specifically for residents in the ventilator unit to prevent frequent hospitalizations. The NP stated that any nurse in the facility could initiate the Sepsis Protocol, and the nursing staff would inform her when she was in the building the next day. An interview was conducted on 9/18/2024 at 5:37 pm with the Administrator. The Administrator stated that she had been informed that Resident #96 had a fever of 103 degrees and that the Unit Manager had went to the store to get ibuprofen. The Administrator stated she was under the impression that Nurse #2 had given Resident #96 ibuprofen and acetaminophen. The Administrator stated the Sepsis Protocol could be initiated by any hall nurse and that the nurse did not have to call the MD or NP prior to initiating it. The Administrator reported Nurse #2 should have performed continuous assessments, including vital sign checks, until the resident had stabilized or was transferred to a higher level of care. The Administrator was notified of Immediate Jeopardy on 9/18/2024 at 6:06 pm. The facility provided the following credible allegation of Immediate Jeopardy Removal: Identify those recipients who have suffered and those who are likely to suffer a serious adverse outcome as result of the noncompliance: Beginning on 9/16/24 on 3-11 shift, resident # 96 met criteria to implement the center's sepsis protocol. Facility failed to implement the sepsis protocol and failed to reassess resident timely after administration of acetaminophen and ibuprofen on 9/17/24. On 9/18/2024 at approximately 7:00 p.m. the Director of Nursing (DON) and Nursing Leadership team which includes the Assistant Director of Nursing (ADON), Unit Managers, and Wound Nurse obtained vital signs, to include temperature, respirations, pulse, oxygen saturations and blood pressure, of all current residents in the center to ensure that no other resident was experiencing an acute change in condition. No other residents were identified as having abnormal vital signs. 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 9/18/2024 at approximately 7:00 p.m. the Staff Development Coordinator (SDC) initiated education for all licensed nurses and Respiratory Therapists on the Facility Sepsis Protocol (Sepsis Protocol to be initiated when the patient exhibits two or more symptoms), Assessing and Responding to Changes in Condition to include abnormal vital signs, notifying the provider and re-assessment for efficacy after initial intervention (residents should be reassessed one hour after intervention). Licensed nurses also educated at this time to new process for monitoring vital sign exception report at end of every shift and that nurses are to enter their vital signs every shift as ordered (The Vital Signs Exception Report is a report that is ran from the electronic health record that shows any vital signs that are abnormal) The Nurses' Aides were educated on Vital Signs and reporting abnormal results immediately to the charge nurse. This education includes Full-Time, Part Time, PRN and Agency Staff. No licensed staff shall work until they have received this education. Director of Nursing is responsible for making sure all receive the above education. Director of Nursing informed the Staff Development Coordinator on 9/18/2024 that she would be responsible for new hire and new agency education on the above. Education will be included in new hire orientation and new agency orientation via in person review or a written education packet by a member of the Nurse Management Team (DON, ADON, SDC, Unit Managers, Shift Supervisors). No Licensed Nurses, Respiratory Therapists or Nurses Aides shall work until they have received the above education. On 9/18/24 at 7:00 p.m. a new process implemented by the Director of Nursing that begins having the Director of Nursing, Assistant Director of Nursing, Unit Manager, or charge nurse monitor resident vital signs exception report at end of shift daily to ensure that abnormal vital signs were addressed timely. The Unit Managers will round on their residents daily to ensure that there is no evidence of change in condition, to include abnormal vital signs, for any resident. If Unit Manager is not present the ADON, DON or Shift Supervisor will complete the rounds on that unit. Alleged date of IJ removal: 9/19/24. A validation of IJ removal was conducted on 09/24/24. A review of the initial audit completed on 09/18/24 revealed all resident vital signs were obtained to ensure no other change in condition was identified. Staff interviews revealed that they had received the education on identifying a change in condition, abnormal vital signs, and initiating the Sepsis protocol. The nursing staff were also able to verbalize the new process of running a vital sign exception report at the end of their shift to ensure that all abnormal vital signs had been acted upon appropriately and nothing had been missed. Interviews with the Unit Manager/Charge Nurse revealed that they rounded daily on their units to look for any change in condition and ensuring that none were missed or overlooked including reviewing vital signs for the shift. The IJ removal date of 09/19/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews the facility failed to ensure that a nurse was competent in responding to medical emergencies and activating emergency procedures with emergency medical services (EMS). Resident #103 was a Full Code and experienced sudden cardiac arrest on [DATE]. Nurse #3 was unable to locate the crash cart, the automated external defibrillator and did not immediately call 911. Resident #103 was pronounced deceased by EMS on [DATE] at 7:50 pm. The deficient practice was identified for 1 of 5 nurses (Nurse #3) reviewed for competency and had the high likelihood for causing serious harm to other residents. Immediate jeopardy began on [DATE] when Nurse #3 did not demonstrate competency in responding to a medical emergency. Immediate jeopardy was removed on [DATE] when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level D (no actual harm with the potential for more than minimal harm that is not immediate jeopardy) to complete employee education and ensure monitoring systems put into place are effective. The findings included: This tag is cross referred to: F678: Based on record review, observation, crash cart checklist, staff, Respiratory Therapist, and Medical Director (MD) interviews the facility failed to immediately initiate Cardiopulmonary Resuscitation (CPR) when Resident #103, who was a full code had agonal breathing (a state of breathing of gasping for air due to the brain receiving insufficient oxygen) and went pulseless, failed to immediately utilize the overhead paging system to call staff to Resident #103's room (code blue), and failed to immediately active Emergency Medical [NAME] (EMS). Once the Respiratory Therapy recognized the need for CPR, they failed to implement the use of the Automated External Defibrillator (AED), failed to have available or use an oral airway, and the regulator on the emergency oxygen tank on the crash cart only went to 10 liters. Resident #103 was pronounced deceased and resuscitative efforts were stopped. This affected 1 of 1 resident reviewed for CPR. A review of Nurse #3's Nurse Orientation Checklist dated [DATE] revealed Nurse #3 had knowledge of the location of the crash cart and emergency procedures. The Checklist was signed as completed by Nurse #3 and the Staff Development Coordinator (SDC). The Checklist ensured that staff members knew where the crash cart and emergency procedures were located. A review of a Termination/Discipline Notice dated [DATE] revealed Nurse #3 was terminated for not adequately responding to a resident with a change in condition. The notice was signed by the Administrator and Human Resources (HR) Director. Nurse #3 was not available for an interview. An interview was conducted on [DATE] at 4:39 pm with the Staff Development Coordinator (SDC). The SDC stated all staff were required to attend in-person orientation which lasts several hours. The SDC stated during orientation all staff were given a facility tour and shown the location of the crash carts. The SDC stated there were three crash carts in the facility, and each crash cart contained an AED. The SDC stated she did not open crash carts to go over the components and location of supplies and stated that there was a list on top of the cart that explained where to find needed items because the cart was locked with a plastic tag. The SDC stated all nursing staff in the facility were required to be CPR certified and should have received training on the usage of an AED during their certification course. The SDC stated Nurse #3 received a facility tour, was shown the location of the crash cart, and where to find the on-call provider contact information at the nurse's station. The SDC stated she was unsure why Nurse #3 could not locate the crash cart, find information to notify the on-call provider, or what to do when Resident #103 experienced sudden cardiac arrest on [DATE]. An interview was conducted on [DATE] at 9:37 am with the Director of Nursing (DON). The DON stated there were concerns after the Code Blue on [DATE] that involved Resident #103 and Nurse #3 not acting sooner and recognizing things. The DON stated [DATE] was the last shift that Nurse #3 worked at the facility and stated staff received education on [DATE] regarding notification and to respond when a change in condition occurred to prevent a Code Blue situation. An interview was conducted on [DATE] at 2:21 pm with the Administrator. The Administrator stated she had not been previously made aware of Nurse #3 not knowing where the crash cart was, when to initiate CPR, or when to activate 911 during the Code Blue event involving Resident #103. The Administrator stated she would have expected Nurse #3 to remain with Resident #103, perform ongoing assessments/vital signs, call 911, and initiate CPR if the resident did not have a pulse. The Administration was notified of Immediate Jeopardy on [DATE] at 3:33 pm. The facility provided the following credible allegation of Immediate Jeopardy Removal: Identify those recipients who have suffered and those who are likely to suffer a serious adverse outcome as result of the noncompliance: Nurse # 3 was hired as a full time RN to the center on [DATE]. She completed the center's orientation process on [DATE], which included location of crash cart. Nurse # 3 did not have training on emergency process. Nurse # 3 failed to follow process and stated she did not know where crash cart was located on [DATE]. Nurse # 3 failed to respond appropriately in an emergency for resident # 103. Nurse # 3 failed to locate the emergency equipment and did not know how/when to respond in an emergency. On [DATE] the Regional Nurse reviewed new hire and new agency staff orientation from [DATE] to current for validation of training and location on emergency equipment, procedures, and how to respond in case of emergency with attestation provided on [DATE] by staff development coordinator that all new and agency hires were trained on emergency equipment, crash cart location, emergency procedures and how to respond to emergencies at the time of orientation. 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 [DATE] the center Administrator notified the Director of Nursing of immediate implementation of Mock Code Drills increasing from Quarterly to Monthly. Mock Code Drills are conducted by the DON or ADON. Agency staff receive an abbreviated orientation that includes location of crash carts and emergency process. The center orientation process includes emergency equipment location and emergency process. On [DATE] the Director of Nursing informed the Staff Development Coordinator that it is her responsibility to orient new hires and new agency staff. On [DATE] at approximately 5:00 p.m. the Director of Nursing and Nursing Leadership Team which includes ADON, Unit Managers, Wound Nurse, initiated education for all licensed nurses and Respiratory Therapy on Assessing and Responding to Changes in Condition to include abnormal vital signs. Education was completed for all staff on how and when to call a Code Blue, Calling 911, and the Location of Crash Carts/Emergency Supplies. This education includes Full-Time, Part Time, PRN and Agency Staff. On [DATE] at approximately 5:00 pm the Regional Nurse initiated education with all staff to include Administrative Staff, Maintenance, Dietary, Laundry, Housekeeping, Nurses' Aides and Therapy Staff on the Location of the Crash Carts/Emergency Supplies, how to call Code Blue. No staff shall work until they have received this education. The Director of Nursing is responsible for making sure all receive the above education. Director of Nursing informed the Staff Development Coordinator on [DATE] that she would be responsible for new hire and new agency education on the above, as well as responsible for verifying competencies and understanding of training. Education will be included in new hire orientation and new agency orientation via in person review by a member of the Nurse Management Team (DON, ADON, SDC, Unit Managers, Shift Supervisors). No Licensed Nurses, Respiratory Therapists shall work until they have received the above education. SDC will verify the competency and understanding of emergency procedures and emergency procedures and their role in an emergency. On [DATE] at 6:00 p.m. a new process was implemented by the Director of Nursing that will include validation of new hire and new agency staff orientation to emergency procedures, crash cart locations, and procedures for calling Code Blue and 911 via a post test administered following orientation. Alleged date of IJ removal: [DATE]. A validation of IJ removal was conducted on [DATE]. The initial audit of staff hired since [DATE] was reviewed to ensure that they had received the necessary orientation including location of emergency supplies and crash carts, how to activate EMS, when to initiate CPR and how to respond in a Code Blue situation. The facility conducted a mock Code Blue drill on [DATE] which was also observed without concerns. The nursing staff secured the crash cart, notified emergency personnel, and all staff including the RT responded and began emulating CPR on the victim. Nursing staff interviews revealed that they had received the education on CPR, responding to emergencies, location of crash carts, calling EMS services and the overhead page of Code Blue when an emergency was identified. Interviews with non-nursing departments revealed that they were aware of their role during an emergency and were able to verbalize tasks that they could do in the event of a Code Blue. The IJ removal date of [DATE] was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to have a nurse assess Resident #19 after the resident fell from the bed to the floor. Resident #19 was on life support and connected to a ventilator. Before reporting the fall to a nurse, staff transferred Resident #19 from the floor to the bed, then from the bed to a shower stretcher, provided a shower and then transferred the resident from the shower stretcher to her bed. Nurse #1 was made aware of the fall after Resident #19 had been transferred three times and showered. Nurse #1 performed a head-to-toe assessment and determined that Resident #19 had abrasions to her abdomen and right arm. Resident #19 was sent to the emergency room and was determined to have acute right tibia and fibula fractures. This deficient practice affected 1 of 1 resident reviewed for falls (Resident #19). The immediate jeopardy began on 10/31/21 when Resident #19 who was on a ventilator for life support and received an anticoagulant fell from her bed and was transferred three times before a nurse was notified and assessed the resident. The immediate jeopardy was removed on 02/17/22 when the facility provided and implemented a credible allegation of immediate jeopardy removal. The facility remained out of compliance at a lower scope and severity of a D (an isolated situation with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education was in place and monitoring systems put into place were effective. Findings included: Resident #19 was admitted to the facility on [DATE] with diagnoses that included a persistent vegetative state with chronic ventilator usage and severe osteoporosis. A physician's order dated 8/1/19 indicated Resident #1 was to receive Xarelto (an anticoagulant- blood thinner) 20mg (milligram) daily at bedtime. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #19 had a urinary catheter, special respiratory treatments including oxygen therapy, suctioning, tracheostomy care and ventilator and received an anticoagulant. A review of a document written by Nurse Aide (NA) #1 dated 10/31/21 read, in part, while I was changing [Resident #19], she started coughing and bouncing. I couldn't catch her before she rolled off the bed. [Respiratory Therapist (RT)/NA #2] and I put a bed pad under her and lifted her back into bed. We then took her to the bath. This document did not provide any details after Resident #19 was taken to the shower. Three attempts were made to contact NA #1 were unsuccessful. A review of a document written by RT/NA #2 dated 10/31/21 read, in part, walking past resident's room. C.N.A (NA#1) asked for assistance getting resident in bed. Assisted C.N.A. in getting into bed. Resident covered in BM (bowel movement). C.N.A took resident to shower. An additional typed witness statement signed by RT/NA #2 on 10/31/21 read, in part, Resident #19 was sitting on the floor/leaned up against bed in between the bed and the wall air conditioner. Resident #19 was covered in BM; BM was all over the floor and Resident #19's fully inflated catheter was lying on the floor under Resident #19. NA #1 stated he just needed help getting Resident #19 back in the bed. RT/NA #2 believed NA #1 had already reported to the nurse and NA #1 just needed help to transfer Resident #19 back to bed. After Resident #19 returned from the shower, NA #1 commented to RT/NA #2 and NA #3 that the catheter needed to be replaced. RT/NA #2 wrote after this conversation, he alerted the nurse about what he had observed and notified her that the catheter needed to be replaced. At that time, he learned she was unaware of the fall. An interview with RT/NA #2 on 02/15/22 at 3:53 PM revealed he did not notify the nurse that Resident #19 was on the floor prior to assisting NA #1 to move her from the floor to bed. RT/NA #2 stated that he assumed NA #1 had already reported the fall to Nurse #1 but stated he told her about it on his way back to his unit. He stated it was five to ten minutes after he had assisted NA #1 to transfer Resident #19 back to the bed. There were no written statements written by NA #3 provided by the facility. An interview with NA #3 on 02/16/22 at 7:15 PM revealed she was familiar with Resident #19 and was working on the 500 Hall on the night of 10/31/21. NA #3 indicated she was approached and asked for assistance by NA #1 when he was enroute to retrieve a shower stretcher for Resident #19 after she had a large BM and needed to be bathed. NA #3 said RT/NA #2 performed tracheostomy care and ensured Resident #19 was properly attached to the ventilator before he left the room to alert the nurse and let her know the catheter needed to be replaced. NA #3 stated she did not know that Nurse #1 was not made aware of the fall immediately by NA #1 and did not alert Nurse #1 herself. An incident report dated 10/31/21 at 5:50 AM written by Nurse #1 read, in part, I assessed resident for injuries and noted abrasions on right forearm and left lower abdomen. Also, right lower leg swelling just below the knee and some discoloration noted. I was not informed of fall until after she was back in bed and taken to shower and put in bed again. C.N.A. (NA#1) said he was changing her, and she rolled off bed into floor. A nurses' note written by Nurse #1 on 10/31/21 at 7:00 AM indicated Resident #19 had noted swelling to her right lower extremity. An interview with Nurse #1 on 2/15/21 at 1:42PM revealed she cared for Resident #19 on the night of 10/30/21 (7:00 PM to 7:00 AM). Nurse #1 indicated she was made aware that Resident #19 had fallen earlier in her shift while Resident #19 was being provided incontinence care by NA #1. Nurse #1 recalled RT/NA #2 making her aware Resident #19's catheter needed to be replaced, but as she recalled she thought NA #1 told her about the fall when she went to the room about the catheter. Nurse #1 explained NA #1 reported that Resident #19 began coughing and jerking after she was rolled on her side during incontinence care. Resident #19 came out of bed because NA #1 was unable to catch her before she came off the bed and landed on the floor. Nurse #1 found Resident #19 bathed and back in bed when she arrived at the room to assess her. She had abrasions to her abdomen and right forearm as well as swelling in her right lower extremity. Nurse #1 described Resident #19's right lower extremity to be more flexible and different. Nurse #1 stated she did not notify the provider at the time of her assessment but passed the abnormalities along to the oncoming day shift nurse (Nurse #2). Nurse #1 indicated she was busy finishing her shift duties and planned to notify the provider at the end of her shift because she did not assess Resident #19 to have sustained major injuries. A physician's order written by Nurse #2 and dated 10/31/21 at 6:59 AM indicated Resident #19 was to have an anterior/posterior (AP) and lateral x-ray of the right lower extremity. An interview with Nurse #2 on 2/15/21 at 4:45 PM revealed he arrived to work on 10/31/21 at approximately 6:45 AM. He stated Nurse #1 reported to him that Resident #19 had fallen out of the bed earlier on the shift and the staff had not reported the fall to her until after she was placed back in the bed. Nurse #2 explained that he and Nurse #1 went to Resident #19's room to assess her. He stated that her right leg was positioned differently and was very flexible at the top, near her knee, which was abnormal for Resident #19. Nurse #2 stated that during the assessment and thereafter Resident #19 remained at her baseline with no visible facial grimacing or nonverbal signs of pain that he could recall. He stated that he returned to the nurse's station and notified the physician and obtained new orders. He said later in the shift the portable x-rays were obtained and resulted in fractures to her tibia and fibula on her right side. A review of x-ray reports from both the contracted in -house company and the hospital dated 10/31/21 confirmed acute fractures to the right tibia and fibula. According to an emergency room (ER) report dated 10/31/21, Resident #19 was transported to the ER after a traumatic injury of the right lower leg. Per the report, it was unable to determine if Resident #19 fell during incontinence care or if she was dropped during a transfer from the bed to the shower stretcher. Resident #19 was splinted because she was not a surgical candidate and ordered to be non-weight bearing and subsequently discharged back to the facility on [DATE]. During an interview with the Director of Nursing (DON) on 2/15/22 at 5:00 PM, additional documentation titled Fall Investigation-Resident #19-10/31/21 5:50 AM signed by the DON on 11/2/21 was provided which indicated in an abundance of caution and concern for our resident safety, all facility nurses and NAs were reeducated on positioning a resident in lateral position. The DON reported that following any fall in the facility, when a resident was found to be on the floor, a staff member should immediately notify a nurse prior to moving a resident. She also explained she determined Resident #19 had received a shower before assessed for injury by Nurse #1. The DON stated she did not think NA #1 did anything wrong related to the fall but was an accident. An interview with the DON, Assistant Administrator, and Administrator on 2/16/22 at 12:00 PM revealed each expected all staff to notify the nurse if a resident had a fall and a nurse should assess the resident for injury before the resident is moved to ensure safety. An interview with the Physician on 2/17/22 at 2:01 PM revealed he expected to be contacted with all changes in conditions to include a fall. The Physician stated he thought this occurrence was an accident. The Administrator was notified of the Immediate Jeopardy on 2/16/22 at 12:11 PM. The facility provided the following IJ removal plan. o Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the noncompliance. Resident # 19 slid off the bed to the floor during incontinent care at approximately 5:50a. Nurse Aide (NA) #1 requested help from Respiratory Therapist/Nurse Aide #2 and they placed a pad under the resident's buttocks, lifted and transferred her back to the bed. Respiratory Therapist/NA#2 ensured that the resident's airway was patent, ventilator circuit and tracheostomy tube were connected, and patient was being ventilated appropriately before leaving the room. Nurse Aide #1 and Nurse Aide #3 then transferred Resident #19 to the shower stretcher and took her to the shower room and Nurse Aide #1 completed a shower because she had a large amount of bowel on her. Respiratory Therapist/NA#2 notified Nurse # 1 after resident #19 had been transferred back to the bed. Nurse #1 performed a head-to-toe assessment of Resident #19 after she was made aware of the fall. Nurse #1 noticed that the resident had an abrasion to her abdomen and her right forearm and that her right leg was positioned differently and was very flexible at the top near her knee. Then at approximately 6:45am Nurse #2 came on shift and he and Nurse #1 assessed the resident together. The Physician on call was notified at 6:59am and gave new orders for an X-ray of right leg. Nurse #2 stated that during the assessment and thereafter, Resident #19 remained at her baseline, no facial grimacing, or nonverbal signs of pain were observed. Nurse #2 immobilized the resident's leg while awaiting the x-ray report. X-ray report received indicating fractures of right tibia and fibula. Nurse #2 reported the X-ray results to the Physician and the order was received for Resident #19 to be sent to the CVMC Emergency Room. EMS arrived at approximately 6:00pm on 10/31/2021 to transport. Resident returned to this facility at 00:15 on 11/1/21. The facility Nurse Practitioner assessed and evaluated this resident on the morning of 11/1/21. On 11/1/2021 the DON suspended NA#1 while an incident investigation was conducted. NA#1 was subsequently terminated from employment on 11/3/2021 due to not immediately notifying the nurse of the fall and for moving the resident prior to her being assessed by the Nurse. To identify any other resident who may have been affected; beginning on 11/21/2021, the DON began reviewing and monitoring all fall incidents. All fall incidents are monitored to ensure immediate nurse notification and assessment before the resident was moved. As of 2/16/22 all falls incidents have been in compliance with nurse notification and assessment. -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 11/01/21 the DON provided in-service training for all Certified Nursing Assistants on immediately notifying a Nurse upon observation of any resident experiencing a fall and that the nurse is to assess the resident before the resident is moved. On 11/1/21 the DON began reviewing all falls that occur to determine if a nurse was notified immediately of the fall and the nurse performed an assessment prior to the resident being moved. All fall incidents have been in compliance with requirement of immediate nurse notification and nurse assessment of the resident. On 2/16/22, the DON implemented facility wide in-service training for all staff (dietary, housekeeping, activities, maintenance, Social Workers, Therapy staff, office staff, Licensed nursing staff and Certified Nursing Assistance including all agency staff on the Fall Protocol that includes: Notifying a Licensed Nurse immediately before moving the resident. Before the resident is moved, the Licensed Nurse shall perform an assessment of the resident to determine if any injury has occurred. If no obvious injury is present, the resident should be assisted back to the bed, chair, or wheelchair using the appropriate transfer device. The Director of Nursing informed Nursing Supervisors of their responsibility to continue this education / re-education on all shifts for all staff. The Director of Nursing and / or her designee will track which staff has been educated by comparing educational roster to the employee work schedule. Any Staff not working on 2/16/22 are required to receive this education on their next scheduled workday. Staff will not be allowed to work until this education is completed. New educational material has been added to the New Hire Orientation packet, new CNA clinical check off list, and the facility information that is provided to Nursing Agency staff. Alleged IJ removal date: 2/17/22 A credible allegation validation for quality of care was conducted in the facility on 02/17/22. Record review included Resident #19's [NAME] and care plan. Notable revisions were as follows: Resident #19's transfer status has been updated to 2- person draw sheet on both the [NAME] and care plan which are available to all nursing staff. The in-service training records reflected all staff to include nursing, housekeeping, maintenance, dietary, activities, and administrative staff were in serviced on notification of a nurse with any changes in a resident's condition to include a fall and staff were not to move a resident without a nurses' assessment and direction to do so. The facility's IJ removal date of 2/17/22 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide incontinence care according to an established plan to Resident #19 who was on a ventilator and in a persistent vegetative state. Nurse Aide #1 (NA #1) lost control of Resident #19 when he was in the process of providing incontinent care to Resident #19 who began to cough and bounce on the air mattress. NA #1 was unable to prevent Resident #19 from falling out of bed. NA#1 did not immediately report to a nurse. Prior to a nursing assessment to check for injury, nurse aides transferred Resident #19 three times, from the floor to the bed, from the bed to the shower stretcher and then from the shower stretcher to her bed. These transfers were performed by two staff without the use of the mechanical lift. This deficient practice affected 1 of 1 resident reviewed for falls (Resident #19). Resident #19 was sent to the emergency room and diagnosed with acute right tibia and fibula fractures. The immediate jeopardy began on 10/31/21 when Resident #19 fell from her bed during incontinence care and sustained acute fractures. The immediate jeopardy was removed on 02/17/22 when the facility provided and implemented a credible allegation of immediate jeopardy removal. The facility remained out of compliance at a lower scope and severity of a D (an isolated situation with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure education was in place and monitoring systems put into place were effective. Findings included: Resident #19 was admitted to the facility on [DATE] with diagnoses that included a persistent vegetative state with chronic ventilator usage and severe osteoporosis. A physician's order dated 8/1/19 indicated Resident #1 was to receive Xarelto (an anticoagulant- blood thinner) 20mg (milligram) daily at bedtime. A quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #19 required physical assistance from two or more persons with bed mobility, transfers, and toileting. She had a urinary catheter and was always incontinent of bowel. She received special respiratory treatments including oxygen, suctioning, tracheostomy care and was on a ventilator. She also received tube feeding for nutrition and anticoagulant medication. A self-care deficit care plan revised on 1/24/22 indicated Resident #19 was dependent for transfers and incontinence care with rounds and as needed. The care plan did not indicate how many staff should provide incontinence care or how to transfer the resident. According to the DON, on 2/15/22 at 5:00 PM, most ventilator residents in a vegetative state are transferred using a mechanical lift which required the assistance of 2 staff members. NA #1's statement read, while I was changing Resident #19, she started coughing and bouncing. I couldn't catch her before she rolled off the bed. RT/NA #2 and I put a bed pad under her and lifted her back into bed. We then took her to the bath. Multiple attempts to contact NA #1 were made without success. A review of a document written by RT/NA #2 dated 10/31/21 read, in part, walking past resident's room. C.N.A (NA #1) asked for assistance getting resident in bed. Assisted C.N.A. in getting into bed. Resident covered in BM (bowel movement). C.N.A took resident to shower. An additional typed witness statement signed by RT/NA #2 on 10/31/21 read, in part, Resident #1 was sitting on the floor/leaned up against bed in between the bed and the wall air conditioner. Resident #19 was covered in BM. Resident #19's fully inflated catheter was lying on the floor under Resident #19. NA #1 stated he just needed help getting Resident #19 back in the bed. RT/NA #2 indicated NA #1 had already conversed with the nurse and NA #1 just needed help to transfer Resident #19 back to bed. NA #3 ' s assistance was requested to help clean Resident #19 and she was taken to the shower room for bathing. RT/NA #2 wrote after this conversation, he alerted the nurse, shared what he had observed and notified her that the catheter needed to be replaced. At this time, he learned she was unaware of the fall. An interview with RT/NA #2 on 02/15/22 at 3:53 PM revealed he recalled the events surrounding the fall sustained by Resident #19 on 10/31/21. RT/NA #2 stated he was walking by Resident #19's room and NA #1 was in the hallway and asked for help to transfer Resident #19 from the floor to the bed. He noticed Resident #19 lying on the floor on her right side with her catheter no longer intact. RT/NA #2 explained that he and NA #1 placed a cloth incontinence pad under Resident #19 then lifted her up to the bed. RT/NA #2 indicated before NA #1 left the room to retrieve the shower stretcher, NA #1 stated he would need to reinsert Resident #19's catheter because it had come out during the fall. When NA #1 returned to the room with the shower stretcher, NA#3 entered the room and she assisted NA #1 to slide Resident #19 from the bed to the shower stretcher using the cloth bed pad used to lift her from the floor. RT/NA #2 stated he left the room to go back to the unit and he stopped and told Nurse #1 about the incident because he knew the catheter was no longer intact. RT/NA #2 stated normally Resident #19 was transferred using a mechanical lift and two-person physical assistance. He stated for some reason they were just in a hurry and did not use the lift. RT/NA #2 stated that he assumed NA #1 had already reported the fall to Nurse #1 but stated he told her about it on his way back to his unit which he stated was five to ten minutes after he had assisted NA #1 to transfer Resident #19 back to the bed. There were no written statements written by NA #3 provided by the facility. An interview with NA #3 on 02/16/22 at 7:15 PM revealed she was familiar with Resident #19 and was working on the 500 Hall on the night of 10/31/21. NA #3 indicated she was approached and asked for assistance by NA #1 when he was enroute to retrieve a shower stretcher for Resident #19 after she had a large BM and needed to be bathed. NA #3 reported she followed NA #3 back to Resident #19's room where she found Resident #19 lying in the bed with her catheter lying on the floor near the bed. NA #3 indicated she and NA #1 transferred Resident #19 from the resident ' s bed to the shower stretcher using a cloth incontinence pad and NA #1 took Resident #19 to the shower room independently. Approximately 20-30 minutes later, when NA #1 returned with Resident #19 from the shower room, she assisted NA #1 to transfer Resident #19 from shower stretcher to the resident ' s bed via a clean cloth incontinence pad. NA #3 vocalized she was aware Resident #19's transfer status was a mechanical lift with 2-person physical assistance, but stated staff never transferred Resident #19 using a mechanical lift and always used a cloth incontinence pad for transfers. An interview with NA #4 on 2/17/22 at 11:00 AM revealed she was familiar with Resident #19 and cared for her often. NA #4 indicated she tried to have 2-person assist for incontinence care, bed mobility, but there were times when they must provide incontinence care and bed mobility with only one person if other staff were busy helping other residents. An interview with Nurse #3 on 2/17/22 at 11:00 AM indicated staff were required to provide 2-person physical assistance for transfers of Resident #19 and make attempts to provide 2-person physical assistance for bed mobility and toileting. An incident report dated 10/31/21 at 5:50 AM written by Nurse #1 read, in part, I assessed resident for injuries and noted abrasions on right forearm and left lower abdomen. Also, right lower leg swelling just below the knee and some discoloration noted. I was not informed of fall until after she was back in bed and taken to shower and put in bed again. C.N.A. said he was changing her, and she rolled off bed into floor. A nurses' note written by Nurse #1 on 10/31/21 at 7:00 AM indicated Resident #19 had noted swelling to her right lower extremity. An interview with Nurse #1 on 2/15/21 at 1:42PM revealed she cared for Resident #1 on the night of 10/30/21 (7:00 PM to 7:00 AM). Nurse #1 indicated she was made aware that Resident #19 had fallen earlier in her shift while Resident #19 was being provided incontinence care by NA #1. Nurse #1 explained NA #1 reported Resident #19 began coughing and jerking after she was rolled on her side during incontinence care. She subsequently fell out of bed because NA #1 was unable to catch her before she came off the bed and landed on the floor. According to Nurse #1, Resident was found bathed and back in bed when she assessed Resident #19. She found her to have abrasions to her abdomen and right forearm as well as swelling in her right lower extremity. Nurse #1 described Resident #19's right lower extremity appeared to be more flexible and different. Nurse #1 indicated Resident #19 was dependent for transfers using the mechanical lift. Nurse #1 did not feel Resident #19 was injured and did not feel contacting the physician before the end of her shift which was approximately 1 hour later was warranted. A physician's order written by Nurse #2 and dated 10/31/21 at 6:59 AM indicated Resident #19 was to have an anterior/posterior (AP) and lateral x-ray of the right lower extremity. An interview with Nurse #2 on 2/15/22 at 4:45 PM revealed he arrived to work on 10/31/21 at approximately 6:45 AM. Nurse #2 explained that he and Nurse #1 went to Resident #19's room to assess her. He stated that her right leg was positioned differently and was very flexible at the top, near her knee, which was abnormal for Resident #19. Nurse #2 stated that during the assessment and thereafter Resident #19 remained at her baseline with no visible facial grimacing or nonverbal signs of pain that he could recall. Nurse #2 stated Resident #19 was dependent for transfers using a total body mechanical lift and 2 staff physical assistance for safety. He elaborated Resident #19 should not have been lifted using an incontinence pad after she fell from her bed. A review of x-ray reports from both the contracted in -house company and the hospital dated 10/31/21 confirmed acute fractures to the right tibia and fibula. According to an emergency room (ER) report dated 10/31/21, Resident #19 was transported to the ER after a traumatic injury of the right lower leg. Per the report, it was unable to determine if Resident #19 fell during incontinence care or if she was dropped during a transfer from the bed to the shower stretcher. Resident #19 was splinted and ordered to be non-weight bearing and subsequently discharged back to the facility on [DATE]. During an interview with the Director of Nursing (DON) on 2/15/22 at 5:00 PM, additional documentation titled, Fall Investigation- [Resident #19] 10/31/21 5:50 AM, signed by the DON on 11/2/21, was provided which indicated the DON investigated and determined that the NAs involved in the incident surrounding Resident #19's fall did no wrong and the root cause of the fall was due to the air mattress' slick surface and the resident's coughing. The document further indicated in an abundance of caution and concern for our resident safety, all facility nurses and NAs were reeducated on positioning a resident in lateral position. The DON reported that following any fall in the facility, when a resident was found to be on the floor, a staff member should immediately notify a nurse prior to moving a resident. Once the resident was assessed not to have an injury, the resident may be transferred based on their current transfer method Once the resident is transferred and safety established, the physician, responsible party, and the DON should be notified immediately for further orders and investigation. The DON verbalized she discovered during her investigation Resident #19 was transferred incorrectly using the incorrect transfer method. An interview with the DON, Assistant Administrator, and Administrator on 2/16/22 at 12:00 PM revealed each expected all staff to notify the nurse if a resident had a fall. They stated they did not believe the mechanical lift wouldn't fit on that side of the bed where Resident #19 fell, but later acknowledged the bed was able to have been moved to allow for transfer using the mechanical lift. The Administrator was notified of the Immediate Jeopardy on 2/16/22 at 12:11 PM. The facility provided the following IJ removal plan. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance Resident #19 was provided incontinence care by a Certified Nursing Assistant (CNA) on 10/31/21. During the care the resident had a coughing spell and began bouncing around on the bed. Before the Certified Nursing Assistant #1 could reach the resident, she rolled from the bed. MDS indicated resident required 2 assist to provide incontinence care 1 time in the 7 day look back period. Information the resident required 2 assists when providing incontinence care was not available on the [NAME] file. It is unknown if the side rail on the opposite side was up or down. Per CNA Resident #19 was rolled away from him. Resident #19 requires 2 person assist for incontinence care. [NAME] and Care Plan was updated to 2 person assist for incontinence care on 2/16/2022. Transfer status for Resident #19 was evaluated by the Physical Therapist Doctor of Physical Therapy for patient safety and mobility 2/17/2022. Therapist determined resident is dependent on functional mobility and would benefit utilizing a draw sheet for lateral transfers with total assistance from 2+ staff. This deficient practice has the potential to affect all residents residing within the facility who are incontinent and require assistance with care. On November 1, 2021 Director of Nursing implemented in-service training for all Nursing staff on Safe Positioning of Resident when Turning and Providing Incontinence Care Independently. In service covered positioning a resident in lateral position, using proper body mechanics, assure residents face is not obstructed. Use supporting devices. This education is covered in orientation and was used as a refresher to remind the nursing staff to be cognizant of residents position on the bed during incontinent care and required no additional steps for implementation. On February 16, 2022, Director of Nursing, MDS RNS and Nursing Supervisors reviewed all other resident's residing in the facility to determine those who needed two person assistance with incontinence care and those residents who required a mechanical lift for transfers. The MDS nurses then reviewed each Resident's [NAME] (tool used in the electronic health record to inform staff of care requirements) and made changes where necessary to provide information to staff on amount of assistance needed for safe transfer of resident, the mobility status of a resident and the required number of staff to provide safe toileting/incontinence care to a resident while in bed. This was completed on 2/16/2022. · Transfer Status · Mobility Status · Toileting Status 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. All resident falls are reviewed in Morning Standup meetings. The Director of Nursing presents the review of falls to the clinical team. Clinical team consists of DON, MDS Nurse, Wound Care Nurse, Nursing Supervisors, Administration, Director of Rehab, Social Worker, Director of Respiratory Therapy, Root cause of why the fall occurred is investigated by the DON and shared with all disciplines participating in the review. Interventions are put in place to keep the resident from having a recurring fall. MDS Nurse adds interventions to the care plan which populates the [NAME]. Nursing Supervisors inform hall staff of any updates in plan of care. Previous implemented interventions are reviewed at our monthly At Risk meetings to determine effectiveness. If the intervention does not work and a resident has a repeat fall, root cause is evaluated again and additional interventions put in place or previous interventions removed. Interventions are updated in the care plan immediately after the meeting and staff notified by Nursing Supervisors. CNA's have access to both the care plan and the [NAME]. On February 16, 2022 the Director of Nursing implemented in-services for all Nursing Staff including Agency on Locating Required Staff Assistance for Toileting and Incontinence Care. Any nursing staff or agency nursing staff reporting to work after this date will receive this in-service prior to working. · Locating information in electronic [NAME] which indicates residents need for number of staff required to provide safe toileting/incontinence care . · Use the correct number of staff when providing care. · Informing supervisor if additional staff is needed to provide incontinence care to resident safely. · Use correct equipment/assistance devices for lifting and/or transfers according to the assessment and care plan of the resident. · Reviewed location of Care Plan and [NAME] within the Electronic Records. New educational material has been added to the New Hire Orientation packet for Nursing and Nurse Aide staff as well as the Clinical version . · [NAME] Information · Care Plan Information Alleged IJ removal date: Requested for February 17, 2022 A credible allegation validation for supervision to prevent accidents was conducted in the facility on 02/17/22. Record review included Resident #19's [NAME] and care plan. Notable revisions were as follows: Resident #19's transfer status has been updated to 2- person draw sheet on both the [NAME] and care plan which are available to all nursing staff. The in-service training records reflected all staff to include nursing, housekeeping, maintenance, dietary, activities, and administrative staff were in-serviced on notification of a nurse with any changes in a resident's condition to include a fall and staff were not to move a resident without a nurses' assessment and direction to do so. Staff were observed to perform incontinence care using the appropriate turning education provided as well as residents were transferred using 2 person physical assistance when using the mechanical lift. The facility's IJ removal date of 2/17/22 was validated.