**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and interviews with staff and the Medical Director, the facility staff failed to utilize a blood glucose meter (glucometer) assigned to Resident #11 and used a glucometer that was assigned to another resident, Resident #141, to check Resident #11's blood glucose level. In addition, the staff member did not disinfect the glucometer before or after obtaining Resident #11's blood glucose level and would have had no way to know if another staff member had previously disinfected the glucometer assigned to another resident. Glucometers can become contaminated with blood and must be disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-registered disinfectant in accordance with the manufacturer of the glucometer has the high likelihood of exposing residents to the spread of bloodborne pathogens. There were no residents with documented blood borne pathogens in the facility at the time of the observation. The deficient practice occurred for 1 of 2 staff members observed for glucometer use (Nurse #1). Immediate Jeopardy began on 8/28/2025 when Nurse #1 was observed performing a blood glucose level check on Resident #11 using Resident #141's assigned glucometer without disinfecting the glucometer per the glucometer manufacturer's instructions and the disinfectant wipes manufacturer's recommendations before or after using the glucometer on Resident #11. Immediate Jeopardy was removed on 8/29/2025 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remained out of compliance at a lower scope and severity level of D (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems was in place and employee education was completed. The findings included: The facility's policy that was implemented on 12/1/2022 and reviewed on 1/1/2025 indicated glucometers would be disinfected with a wipe pre-saturated with an EPA registered healthcare disinfectant after each use and according to manufacturer's instructions regardless of whether they were intended for a single resident or multiple use. A review of the manufacturer's instructions for the glucometer used when Resident #11's blood glucose level was checked on 8/28/2025 at 9:42 am indicated the glucometer should be cleaned of any dirt, blood, or other bodily fluids from the exterior of the glucometer before performing the disinfecting procedure. The instructions further stated that the glucometer should be cleaned with two disposable, germicidal wipes after each use, one wipe to clean the glucometer and the second to disinfect the glucometer. The manufacturer's instructions for the disposable germicidal wipes used by the facility stated a glucometer should be wiped with a pre-moistened wipe on the surface of the glucometer remaining visibly wet for 2-minutes, additional wipes should be used to maintain wetness for the entire 2-minutes and then allow the surface to air dry after every blood glucose level check. Resident #11 was admitted to the facility on [DATE] with a cumulative list of diagnoses that included diabetes. Resident #141 was admitted to the facility on [DATE] with a cumulative list of diagnoses that included diabetes. Resident #141 did not have a diagnosis of a communicable disease. On 8/28/2025 at 9:42 am an observation and interview were conducted with Nurse #1 during a medication administration observation. During the observation Nurse #1 was observed to look through her medication cart and then removed a glucometer from the medication cart that was in a plastic bag and carried it into the resident's room without cleaning or disinfecting the glucometer. The name on the glucometer was not visible while Nurse #1 obtained Resident #11's blood glucose level. During the observation Nurse #1 checked Resident #11's blood glucose level and then placed the glucometer and storage bag on the table in front of the resident after sticking her finger and the name on the storage bag and glucometer were for another resident, Resident #141. Upon exiting Resident #11's room Nurse #1 stated she could not find Resident #11's glucometer in the medication cart and used Resident #141's glucometer which she stated was new and had not been used before, since the resident had just moved to unit from another unit. Review of the history for Resident #141's glucometer showed several previous blood glucose levels recorded. Nurse #1 placed Resident #141's glucometer on the medication cart and stated she would replace Resident #141's glucometer and obtain a new glucometer for Resident #11. Nurse #1 stated there were glucometers in the facility's supply room and she should have called down to get a replacement glucometer for Resident #11 but was anxious because of the observation. Nurse #1 stated she had been educated regarding how to clean the glucometer and stated they should be cleaned with disinfectant wipes after each time they were used. Nurse #1 opened the medication cart and identified the germicidal wipes used to clean the glucometer. She stated the glucometer should be cleaned with one wipe and then another wipe was to be used to disinfect the glucometer by wetting the surface for 2 minutes and then allowing the glucometer to air dry. Nurse #1 gave the Resident #141's glucometer to the Unit Manager and the Unit Manager stated she would dispose of the glucometer and obtain a new glucometer for Resident #141 and a new glucometer for Resident #11. An interview was conducted with the Administrator on 8/28/2025 at 10:39 am in the presence of the Chief of Nursing Operations (a corporate representative. The Director of Nursing was not available at the time. The Administrator and Chief of Nursing Operations were made aware Nurse #1 had used another resident's, Resident #141's, glucometer to check Resident #11's blood glucose level without cleaning and disinfecting the glucometer prior to use on Resident #11. The Administrator stated each resident in the facility had their own personal glucometer, and there were glucometers in the facility's central supply and the medication rooms on each floor to be assigned to any resident whose glucometer was not working or could not be found. The Administrator stated Nurse #1 should have notified the Unit Manager she was not able to find Resident #11's glucometer and a new glucometer should have been assigned to the resident. The Medical Director was interviewed by phone on 8/28/2025 at 1:41 pm and he stated he did not believe there was any harm, or risk, to Resident #11 when the staff used Resident #141's glucometer without cleaning it because there was no blood-to-blood contact. The Medical Director further stated Nurse #1 should have followed the facility's policy and cleaned the glucometer using the manufacturer's instructions for the disinfectant wipes. On 8/29/2025 at 8:37 am the Director of Nursing, who was certified as an Infection Preventionist, was interviewed, and she stated Nurse #1 should have immediately stopped what she was doing when she could not find Resident #11's glucometer in the medication cart and obtained a new glucometer from the Medication Room or the Supply Room. The Director of Nursing stated the facility felt it was best practice for residents who required a blood glucose level to have their own glucometer, and the glucometer should be labeled with the resident's name, room number, and the glucometer should be stored in a plastic bag in the medication cart. The Director of Nursing stated even though the facility had personal glucometers for each resident, Nurse #1 should have cleaned and disinfected the glucometer per the facility's protocol. The Director of Nursing stated Nurse #1 should have used one disinfectant wipe to clean the glucometer, another disinfectant wipe to disinfect the glucometer per the manufacturer's instructions and then allowed the glucometer to air dry before and after using the glucometer. The facility's Infection Preventionist was not available during the survey. The Administrator was made aware of the immediate jeopardy on 8/28/25 at 2:47 PM. The facility implemented the following plan for Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance; [NAME] 8/28/2025 at 11:00 a.m., Nurse #1 prepared to conduct a fingerstick blood glucose check on Resident #11. The Nurse was unable to locate a glucometer labeled for Resident #11. The Nurse removed a glucometer from the medication cart which had been designated and labeled for Resident #141. The Nurse did not cleanse or disinfect the glucometer designated for Resident #141, according to the glucometer's manufacturer's instructions and germicidal wipe manufacturer's instructions, prior to conducting the fingerstick blood glucose check on Resident #11. The nurse proceeded to conduct the fingerstick blood glucose check on Resident #11 utilizing the glucometer designated for Resident #141, which had not been cleaned or disinfected. Upon completion of the fingerstick blood glucose check on Resident #11 the nurse failed to cleanse and disinfect the glucometer designated for Resident #141 according to the glucometer's manufacturer's instructions and germicidal wipe manufacturer's instructions.All residents that required blood glucose monitoring through the use of a glucometer were identified as having suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance on the 8/28/2025. Through review of the census all residents who required blood glucose monitoring through the use of a glucometer were added to the potentially affected resident list. The facility had 61 residents who received blood glucose checks with a glucometer as of 8/28/2025. During the interview with Nurse #1 she denied using glucometer designated for a different resident on any resident other than when she used Resident #141's glucometer for Resident #11. The facility interviewed current nurses and current med aides and they denied using a glucometer labeled for another resident on a different resident. Residents that were alert and oriented, as determined by a Brief Interview for Mental Status (BIMS) score of 12 and higher, were interviewed and denied observing a glucometer used for checking their finger stick blood glucose with another resident's name.On 8/28/2025 at 11:48 a.m. the Assistant Director of Nursing (ADON) in-serviced Nurse #1 on the manufacturer's recommendations for the disinfectant wipes, and the glucometer's manufacturer's instructions for cleaning and disinfecting glucometers. The ADON then observed a return demonstration of cleaning and disinfecting the glucometer per manufacturer's instructions. Nurse #1 was educated by the ADON on potential consequences of not properly cleaning and disinfecting glucometers which included the potential to infect the resident with bloodborne pathogens. The education included the manufacturer's instructions for the glucometer and the germicidal wipe instructions to clean and then disinfect with two minutes of wet contact time as written in the germicidal wipe manufacturer's instructions.On 8/28/2025 the Unit Manager removed the glucometer of Resident #141 from the cart and discarded it. Resident #11's glucometer was not located. A new glucometer was placed and labeled in the resident's room for Resident #11 and Resident #141. Resident #11 was notified by the Unit Manager on 8/28/25 of the incident. Resident #11 had no questions or concerns. Resident #11 was her own responsible party and has a BIMS (Brief Interview for Mental Status) of 15 indicating no impairment in cognition. The BIMs was most recently assessed on 7/23/25. Labs for screening blood borne pathogens were offered to Resident #11 and she refused. 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 8/28/2025 at 11:14 a.m., The Medical Director was notified of the incident by the Director of Nursing. The clinical team discussed education and systems to put into place to prevent future staff competency issues related to infection control of blood glucose monitoring. These systems included education provided by the Director of Nursing and Assistant Director of Nursing started on 8/28/25 to nurses, and medication aides in the facility. Education provided included the manufacturer's recommendations for the disinfectant wipes, and the glucometer's manufacturer's instructions for cleaning, disinfecting glucometers, and system to keep resident glucometer in resident's room labeled. The Director of Nursing, Assistant Director of Nursing, and Unit Managers audited residents that require glucometers and placed them in the resident room labeled with the resident's name. For staff not in the facility the Director of Nursing and Assistant Director of Nursing began making calls to provide education. The education will be monitored by the Assistant Director of Nursing and Director of Nursing and will be included in orientation to newly hired nurses and medication aides. Training will be completed with oncoming staff prior to starting their assignments. On 8/28/2025 at 11:48 a.m. the Assistant Director of Nursing (ADON) in-serviced Nurse #1 on the manufacturer's recommendations for the disinfectant wipes, and the glucometer's manufacturer's instructions for cleaning and disinfecting glucometers. The ADON then observed a return demonstration of cleaning and disinfecting the glucometer per manufacturer's instructions. Nurse #1 was educated by the ADON on potential consequences of not properly cleaning and disinfecting glucometers. The education included the manufacturer's instructions for the glucometer and the germicidal wipe instructions to clean and then disinfect with two minutes of wet contact time as written in the germicidal wipe manufacturer's instructions.On 8/28/2025 at 2:10 p.m. the clinical team reviewed the manufacturer's recommendations for glucose cleansing and disinfecting. The manual under section B read; Testing confirmed the following wipes will not damage the functionality or performance of the meter, this included suggested manufacturer germicidal disposable wipes. The germicidal disposable wipes directions for use read: To disinfect nonporous surfaces use a wipe to remove visible soil prior to disinfecting. Unfold a clean wipe and thoroughly wet surface of the glucometer. Allow the surface of the glucometer to remain wet for two minutes. Let the glucometer air dry. The Assistant Director of Nursing then began in-servicing nurses and medication aides working on 8/28/2025. The Assistant Director of Nursing then began in-servicing nurses and medication aides not currently working at the facility via the telephone. Nursing staff and medication aides were instructed to see the Director of Nursing (DON) and/or Assistant Director of Nursing before their next shift for a return demonstration of blood glucose monitoring cleansing and disinfection process. The Assistant Director of Nursing will educate newly hired nurses and medication aides regarding cleaning and disinfection of glucometers per manufacturer's instructions during orientation and before receiving an assignment. On 8/28/2024, the Assistant Director of Nursing was notified by Nurse Consultant #1 of his responsibility to conduct education with nurses and medications aides regarding each resident's personal glucometer for individual use, the proper steps to clean and disinfect a glucometer, storage of a glucometer, and where to locate a glucometer when needed. The Assistant Director of Nursing will be responsible for keeping up with the newly hired staff. In the event a nurse or med aide cannot locate a resident's glucometer, education was provided to retrieve a new glucometer from Central Supply. The glucometer will be labeled using a permanent marker with first initial and last name. The Unit Manager will be made aware the glucometer was placed/replaced. On 8/28/2025 the Director of Nursing, Assistant Director of Nursing and Unit Manager, assessed, cleansed, and disinfected all glucometers according to the manufacturer recommendations for glucometer disinfection and per the directions for the germicidal disposable wipes. On 8/28/2025, an audit was conducted by the Unit Managers to verify each resident who required fingerstick blood glucose monitoring had a designated glucometer on the medication carts, and that the designated glucometer was bagged and labeled. The audit revealed 100% of residents who required glucose monitoring had individualized glucometers available including Resident #11 and Resident #141, The Administrator notified [NAME] County Department of Health of the incident on 8/28/2025. The Health Department staff member was not available, but a message was left requesting a return call. The glucometer policy was placed on every medication cart by the Assistant Director of Nursing on 8/28/25 and read: 1. Obtain needed equipment and supplies: Gloves, glucometer, alcohol pads, gauze pads, single-use lancet, blood glucose testing strips, germicidal disposable wipe (bactericidal, tuberculocidal, and virucidal). 3. Perform Hand Hygiene. 3. Explain the procedure to the resident. 4. Provide privacy. 5. [NAME] gloves. 6. Obtain capillary blood glucose sampling. 7. Remove and discard gloves, perform hand hygiene prior to exiting the room. 8. Retrieve (2) wipes from germicidal (bactericidal, tuberculocidal, and virucidal) disposable wipe container. 9. Using the first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. 10. After cleaning, use the second wipe to disinfect the glucometer thoroughly with the germicidal (bactericidal, tuberculocidal, and virucidal) wipe, according to the glucometer manufacturer's instructions. Follow the germicidal wipe directions for the dry time. Allow the glucometer to air dry. 11. Discard germicidal (bactericidal/tuberculocidal/virucidal) wipes in waste receptacle.12. Perform hand hygiene. On 8/28/2025 the Director of Nursing, Assistant Director of Nursing, Unit Managers, Administrator and Nurse Consultant made the decision to move the glucometers off the medication carts and into each resident's room and will be stored in a pencil box/pouch. Education was provided by the Unit Managers to the nurses and the Medication Aides (MA) working on 8/28/2025 regarding the location of the glucometers in the rooms and this education will be provided to nursing and MA staff prior to working the next shift, by the Unit Managers. Any nurse or medication aide found to be sharing glucometers will be subject to disciplinary action. IJ removal date 8/29/2025Date of Removal of Immediate Jeopardy: 8/29/2025The facility's credible allegation of immediate jeopardy removal was validated on 8/29/2025. A review was conducted of the facility's education for glucometer disinfection with the nursing staff and the education was completed on 8/29/2025. The nursing staff were able to verbalize the education and training provided regarding disinfection of glucometers assigned to the residents before and after use. An observation was conducted on 8/29/2025 when a nurse performed a blood glucose check and there were no issues observed, the assigned glucometer was used on the correct resident, and the assigned nurse disinfected the glucometer before and after use. During the observation, disinfectant wipes were observed in the medication cart. A sample of residents were observed of the residents' personal glucometers in their room and stored in a container with each resident's name and room number on the glucometer and the container. An observation was also made to ensure the facility had replacement glucometers in stock. The immediate jeopardy removal date of 8/29/2025 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and Nurse Practitioner (NP) interviews the facility failed to immediately notify the physician of Resident #250's unwitnessed fall that occurred on [DATE] at 1:00 p.m. The on-call physician was not notified of the fall until [DATE] at 6:50 p.m. when it was discovered the resident had an altered mental status. The facility also failed to immediately notify the physician when the ordered intervention of STAT (immediate) laboratory work and normal saline (mixture of sodium chloride and water used to treat dehydration) were not able to be completed STAT. Additionally, the facility failed to notify the physician of Resident #250's tube feeding that was found leaking on the floor and in the bed. These failures resulted in a delay in the physician's initial assessment and initiation of treatment. Resident #250 was discovered unresponsive in her bed on [DATE] at 9:50 p.m. and pronounced as deceased at 10:09 p.m. This occurred in 1 of 2 residents reviewed for notification of change. Immediate Jeopardy began on [DATE] when Resident #250 had an unwitnessed fall from the bed that occurred at 1:00 p.m. and Charge Nurse #1 failed to immediately notify the physician. Immediate jeopardy was removed on [DATE] 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 (actual harm that is not immediate jeopardy) to ensure the monitoring of the systems put into place and to complete facility employee training. The findings included: Resident #250 was admitted to the facility on [DATE]. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #250 had severe cognitive impairment and had not had a fall since the prior assessment. The Resident had a feeding tube and received greater than 51% of meals and greater than 501 cubic centimeters (cc) of fluids by this route. A review was conducted of an incident report for Resident #250, completed by Nurse # 6, dated [DATE], and revealed the Resident had an unwitnessed fall from the bed. She was discovered on the floor by staff. She was free of injury. The physician was notified. An interview was conducted with Charge Nurse #1 on [DATE] at 3:37 p.m. and revealed on [DATE] Resident #250 had a second unwitnessed fall and was discovered lying on the floor at 1:00 p.m. She assessed the Resident and she had no injuries. She then conducted a neurological assessment, and the Resident was verbally responsive. She then assisted the Resident back to the bed. She did not notify a physician of the fall at that time, and she was unsure why because a provider was available in the facility on that Friday at 1:00 p.m. Later in the shift, a nursing assistant, name unknown, informed her that the Resident was not responding like usual. Charge Nurse #1 was not able to specify an approximate time. She went to assess the Resident and discovered she had an altered mental status. The Resident was responding to questions with a yes or no reply only and was lethargic (drowsy, sluggish, and difficult to arouse). Charge Nurse #1 notified the on-call physician of the change in mental status and the fall that occurred at 1:00 p.m. She was not able to specify an approximate time for the on-call physician notification. This was the first time a physician was notified of the fall. The On-call Physician conducted a visit via video conference at 6:50 PM and felt the Resident might be dehydrated. He ordered STAT (immediate) intravenous (IV) fluids of Normal Saline (NS) at 100 milliliters/hour (ml/hr.) for 72 hours, STAT laboratory work that included a complete blood count (CBC), complete metabolic panel (CMP), and a urinalysis (UA) with a culture and sensitivity (C&S). She then stated she had been unsuccessful at starting an IV for the Resident and called the on-call Physician back to request the fluids be delivered by hypodermoclysis (a method of administering fluids subcutaneously under the skin). The physician agreed and adjusted the administration route as requested and the dosage was changed to 60 ml/hr. She added she had been unable to start the hypodermoclysis fluids because she needed to order the supplies from the pharmacy, and they did not arrive on her shift. She revealed she had not notified the on-call physician that the supplies for the fluids were unavailable and would be delayed. She added she had thought the on-call physician would know the facility did not have the supplies. She conducted an in an out urine catheterization and did not receive enough urine to complete the urine lab orders. She added she had not notified the on-call physician that she was unable to collect the urine. She stated she reported to the following shift nurse to try to collect more urine. A review of the On-Call Physician video visit summary, dated [DATE] at 6:50 p.m., documented the resident had a fall out of the bed earlier in the day, and the staff were requesting the Resident be evaluated due to an altered mental status. The Resident presented with lethargy, increased confusion, nonverbal, and not engaging. The Resident had tenting skin (a sign of poor skin turgor that can be dehydration), was in mild distress, and had occasional moans. The assessment plan noted recent repeated falls and altered mental status (a change from a resident's base line alertness and cognition). Recommendations included to continue the facility post fall protocol, conduct a STAT CBC, CMP, UA with C&S, and NS at 100 ml/hr. x 72 hours. A review of the On-Call Physician summary dated [DATE] at 8:35 p.m., documented Charge Nurse #1 requested to administer the IV fluids via hypodermoclysis. The order was adjusted to 60 ml/hr. NS via hypodermoclysis. Nurse reported the UA C&S and laboratory work was pending and an additional video conference was not needed. An interview was conducted with Nurse Aide #1 (NA) on [DATE] at 5:25 p.m. and she revealed she had been assigned as the care giver to Resident #250 frequently. About a month prior to [DATE]/5/2023 and [DATE]/6/2023, she had reported to the Unit Manager (UM) the Resident's gastrostomy (G-tube) was leaking. She stated the leaking and the flap to close the tube had not closed. She was informed by the UM a piece of tape had been placed over the closure area. She stated the concerns with the leaking tube feeding continued for the month and she had tried to inform the previous administrator by going to his office and requesting to speak with him regarding Resident #250 but he shooed her away without listening and was ignored. She continued to provide reports regarding the leaking tube feeding to the UM. She added the Resident could move a little but did not usually fall out of the bed from movement. The two falls ([DATE] and [DATE]), close together, were new for the Resident. A review of the facility progress notes for Charge Nurse #2, the 11:00 p.m. - 7:00 a.m. hall nurse for Resident #250, documented: 1) [DATE] at 3:48 a.m. she attempted to collect a UA C&S from Resident #250 and a small amount returned from the in and out urine catheterization. 2) [DATE] at 4:09 a.m. Resident #250 was started on NS via hypodermoclysis running at 60 ml/hr. Attempted the UA C&S earlier with no results due to a small amount of urine. This nurse will continue to monitor. An interview was conducted with Charge Nurse #2 on [DATE] at 9:31 a.m. and she revealed the Pharmacy delivery sometimes comes as late as 2:00 a.m. She added on the night of [DATE] through [DATE] Resident #250 looked dehydrated during her assessment and did not respond to her name. She had not reported to the physician about the time of the pharmacy delivery because she was not aware it had not been previously reported. A review of the electronic medical record revealed Resident #250 was discovered unresponsive in her bed on [DATE] at 9:50 p.m. and pronounced as deceased at 10:09 p.m. A review of the death certificate for Resident #250 listed the cause of death as a Cerebral Vascular Accident. An interview was conducted with the Medical Director on [DATE] at 12:25 p.m. and he revealed he was not allowed to list some conditions as the cause of death on a death certificate but if he was able, he would have listed fluid volume depletion disorder as the cause of death for Resident #250. An interview was conducted with Nurse Practitioner (NP) #1 on [DATE] at 10:17 a.m. and she revealed she had a routine visit with Resident #250 on the morning of [DATE] prior to 1:00 p.m. The Resident had responded to questions during the visit. The NP stated this was routine visit. The On-Call physician for the medical group, had been notified on [DATE] at 6:50 p.m. that the Resident had an unwitnessed fall from the bed at 1:00 p.m. When she arrived at the facility on [DATE] she read the On-Call physician documentation from the 6:50 p.m. video visit and went to visit the Resident. Upon arrival in the room, the Resident had NS 60 ml/hr running via hypodermoclysis. The STAT laboratory work was not available in the electronic medical record. She called the laboratory provider and requested the results. She was informed there was pending laboratory blood work for Resident #250, but they had not been informed it was a STAT lab. The NP added she had not been notified of an error in the ordering of the STAT laboratory blood work. She revealed the failure to notify a Physician of the fall on [DATE] at 1:00 p.m. and the STAT laboratory work delayed the treatment and workup. She added, if she had received the critical laboratory results, at the expected time, around noon on [DATE], she would have recommended treatment at a higher level of care. The Administrator and Corporate Consultant were notified of the immediate jeopardy on [DATE] at 6:15 p.m. The facility provided the following plan for IJ removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On [DATE] resident #250 had a second unwitnessed fall from the bed at 1:00 p.m. that would have required medical attention. The charge nurse did not notify the medical provider regarding this fall from the bed. Approximately 6:40pm resident #250 had a change of condition. The charge nurse sent the medical director a message and called the on-call provider. The on-call provider called back and did a tele-health visit with the resident at 6:50 p.m. The nurse practitioner asked the charge nurse to perform a skin turgor on the resident and he then stated the resident seemed to be mildly dehydrated. The nurse practitioner provided stat orders on [DATE] for intravenous fluids normal saline at 100 milliliters per hour and urine for culture and sensitivity. The charge nurse attempted to gain IV access and failed twice. The charge nurse called the on-call provided approximately 8:15 p.m. The nurse practitioner gave a new order to change the IV fluids to be administered through a hypodermoclysis and change the rate to 60 milliliters per hour. Charge nurse #1 noted there were no hypodermoclysis kits in the facility. She called the pharmacy and requested the kits to be delivered on the next delivery. The kits were delivered on [DATE] at 3:05 a.m. and the IV fluids were started immediately by a different charge nurse. The charge nurse obtained the urine and she stated that she was unable to obtain enough urine to for the lab to be able to run the culture and sensitivity test. Charge nurse #1 failed to notify the physician of the second unwitnessed fall, the unavailability of the hypodermoclysis, and that she was unable to obtain enough urine for the culture and sensitivity. The charge nurse #1 also failed to notify the medical provider she failed to obtain stat labs. The nurses failed to notify the medical provider regarding the tube feeding that was found leaking on the floor and in the bed. Resident #250 was discovered unresponsive on [DATE] at approximately 8:45 p.m. and was pronounced deceased at 10:09 p.m. On [DATE] the Director of Nursing, unit managers, and MDS nurses reviewed current residents who have fallen during [DATE] through [DATE] to validate that a medical physician had been notified of the fall. Any opportunities identified during this audit will be corrected by the Nurse Managers by [DATE]. On [DATE] the Director of Nursing, unit managers, and MDS nurses reviewed notes during [DATE] through [DATE] for any change in conditions and new orders for stat labs of the current residents and validate that a medical physician was notified of the change in condition and that the stat labs were drawn. Any opportunities identified during this audit will be corrected by the Nurse Managers by [DATE]. On [DATE] the Registered Dietitian reviewed residents' medication administration record to ensure residents were receiving the correct amount of tube feeding. Any opportunities identified during this audit will be corrected by the Nurse Managers by [DATE]. On [DATE] the Director of Nursing, unit managers, and MDS nurses assessed the current residents for a change in condition. The assessment included a change in mental status, abnormal pain, a decrease in range of motion, and dehydration and will notify a medical physician immediately if a change in condition is 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: On [DATE] the Director of Nursing and Unit Managers educated Licensed Nurses regarding the requirement of notifying the medical provider following an incident, such as a fall, or change of condition and when they are unable to obtain a stat lab. The Director of Nursing and unit managers educated nurse aides and medication aides on when a change in condition is noted in the resident, they are to notify the Charge nurse immediately. The Director of Nursing and the Administrator will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift via phone or in person. Education will be completed by [DATE]. On [DATE] the Director of Nursing and unit managers educated licensed nurses when a resident is found to not receive the required amount of tube feeding the licensed nurses will inform medical provided immediately. The Director of Nursing and the Administrator will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift via phone or in person. Education will be completed by [DATE]. On [DATE], the Director of Nursing and unit managers educated the nurse aides on if a resident has fallen or if a change in condition is noted they are to notify the licensed nurses immediately. If the nurse aides assume the licensed nurses have not assessed the resident or made an attempt to call the medical physician, they will call the Director of Nursing and Administrator. The nurse aides were informed where the Administrator and the Director of Nursing numbers are posted, which is behind each nurse's station. On [DATE], the Director of Nursing called the staff that were scheduled in the facility on [DATE] for the hours of 7:00 a.m. until 3:00 p.m. to ensure education was received and understood. The Director of Nursing and the Administrator will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift via phone or in person. The education will include a pretest and posttest. Education will be completed by [DATE]. On [DATE] the Regional Nurse Consultant educated the Director of Nursing and unit managers on informing the Registered Dietitian when a resident is noted to have not received the required amount of tube feeding. Education completed on [DATE]. On [DATE] the Regional Director of Clinical Services educated the Director of Nursing, all unit managers, MDS nurse, and the Administrator regarding the clinical morning meeting process to include a review of residents with falls, stat labs, and change of condition, to validate completion and documentation notification of the MD and responsible party by reviewing progress notes, incident reports, medical provider notes, and orders. This education was completed on [DATE]. Effective [DATE] the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Date of alleged immediate jeopardy removal is [DATE]. On [DATE] the facility's credible allegation for Immediate Jeopardy removal was validated. The validation was evidenced by record review of in-services given to staff and audits completed by staff management. Validation was also evidenced by interview of staff members from various departments. The facility's education was reviewed and included documentation of completion, per the facility's immediate jeopardy removal plan. The facility's audits were also reviewed. There was documentation that audits had been completed. Staff members from various departments were interviewed and reported that they had attended in-service training on notification of changes. The staff attendance was verified on the attendance logs. Staff members were able to report specific details of the training they had received that included notifying the medical providers following an incident, such as a fall, and if they were unable to complete a STAT order/lab. The Administrative team reported the education provided regarding notification of the medical team when a change of condition occurred. The immediate jeopardy was removed on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff, Nurse Practitioner (NP) and Medical Director interviews the facility failed to ensure a resident had on-going comprehensive assessments completed after a resident with functional quadriplegia experienced a second unwitnessed fall on [DATE] at 1:00 p.m. and then later that same day had altered mental status due to suspected dehydration. A Physician video visit was conducted on [DATE] at 6:50 p.m. to evaluate the resident due to altered mental status. At that time the physician noted the resident had tenting skin (a sign of poor skin turgor that can be dehydration), was in mild distress, and had occasional moans. The physician ordered STAT (immediately) laboratory blood work and intravenous (IV) normal saline (mixture of sodium chloride and water used to treat dehydration). The STAT blood work was not collected until the morning of [DATE]. The staff's failure to communicate pertinent information about the resident to each other and lack of comprehensive assessments caused a delay in medical evaluation and medical services which resulted in a serious adverse outcome. The Resident was discovered unresponsive in bed on [DATE] at 9:50 p.m. and pronounced as deceased at 10:09 p.m. This occurred for 1 of 1 resident reviewed for quality of care (Resident #250). Immediate Jeopardy began on [DATE] when Resident #250 had an acute change in condition and did not receive necessary care and services. Immediate Jeopardy was removed on [DATE] 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 (actual harm that is not immediate jeopardy) to ensure the monitoring of the systems put into place and to complete facility employee training. The findings include: Resident #250 was admitted to the facility on [DATE] with diagnoses that included functional quadriplegia, gastrostomy, and a cerebrovascular disease. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #250 had severe cognitive impairment and had not had a fall since the prior assessment. She required extensive assistance of two staff members with bed mobility and personal hygiene and total assistance of one staff member for bathing. The Resident had a feeding tube and received greater than 51% of meals and greater than 501 cubic centimeters (cc) of fluids by this route. A review of the Care Plan dated [DATE], for Resident #250, had an identified focused area that read; The Resident had an activities of daily living self-care performance deficit related to confusion, dementia, and limited mobility. The interventions included, provide extensive assistance of staff to turn and reposition in bed, required extensive assistance with personal hygiene, and monitor/document declines in function. An incident report dated [DATE] and completed by Charge Nurse #7, revealed the Resident #250 had an unwitnessed fall from the bed. She was discovered on the floor by staff. She was free of injury. A mental status assessment documented Resident #250 was oriented to person, place, and time. The physician was notified. The Administrator and Corporate Nurse Consultant were requested to provide any neurological exams conducted on [DATE] after the fall and the fall incident report was the only documentation from Resident #250's medical record provided. An interview was conducted with the Corporate Nurse Consultant on [DATE] at 11:09 a.m. and she provided a fall incident report for Resident #250 dated [DATE]. She confirmed this was all the documents from the medical record she had regarding the fall on [DATE]. An interview was conducted with Charge Nurse #7 on [DATE] at 2:39 p.m. and revealed she had been assigned to Resident #250 on [DATE] and [DATE]. When asked if she conducted assessments and provided tube feedings as ordered, she stated she documents what she had completed in the electronic medical record and tube feeding documentation would be on the Medication Administration record (MAR). An interview was conducted with Nurse Practitioner (NP) #1 on [DATE] at 10:17 a.m. and she revealed she had a routine visit with Resident #250 on the morning of [DATE] prior to 1:00 p.m. The Resident had responded to questions during the visit. She had not been informed on [DATE] the family had concerns with leaking from the gastrostomy tube site and had not been informed the family had concerns for dehydration. A review of a grievance report, dated [DATE], filed by the Guardian for Resident #250, revealed the family had concerns the Resident was dehydrated and her diet had been changed. It stated the family had discussed the concern with the Administrator the previous Thursday, [DATE]. The findings of the investigation included a note from the Administrator, that read; I spoke with the family on Tuesday, [DATE], and not on Thursday. Resident showed no signs of dehydration at that time. Her skin turgor (the elasticity or firmness of skin) was good. Her mucous membranes were moist. Family were concerned regarding resident being wet and it not being urine but leakage from her tube feeding. Area being treated by the nurse. The nurse was not identified in the grievance report. An interview was conducted with the Administrator on [DATE] at 10:00 a.m. The grievance report, dated [DATE] for the date of [DATE], was reviewed and indicated the family had requested to meet with her. She met with the family in the Resident's room [DATE]. The family had expressed concerns that the Resident's tube feeding was leaking and causing dehydration. The Administrator stated assessed good skin turgor and moist mucous membranes. She did not assess the gastrostomy tube site. The Resident was wet as evidenced by dampness on her sheet. The Administrator indicated did not lift the sheet to assess if the wetness was from the tube site or urine. She requested the assigned nurse to arrange for the Resident to be provided dry sheets. She was unable to provide the name of the nurse because this was the Administrator's second day at the facility. A review of the nursing progress notes for [DATE] written by Charge Nurse #1 included the following late entries: - 9:04 p.m. A situation, background, assessment, recommendation (SBAR) report was completed for a fall. The report stated: At the time of the evaluation the resident's vital signs were: Blood Pressure: 132/68 taken on [DATE] at 2:40 p.m. Pulse: 63 taken on [DATE] at 2:40 p.m. Respiratory rate: 16 taken on [DATE] at 2:40 p.m. Temperature: 97.5 taken [DATE] at 2:40 p.m. Pulse oximetry: 96% taken [DATE] at 2:40 p.m. The recommendations provided by the provider were documented to follow the facility fall protocol. The SBAR did not include vital signs for the time of the fall. A post fall blood sugar was not included. - 9:17 p.m. An SBAR was conducted for altered mental status. The vital signs were: Blood Pressure: 109/67 taken on [DATE] at 8:11 p.m. Pulse: 86 taken on [DATE] at 8:12 p.m. Respiratory Rate: 20 taken on [DATE] at 8:12 p.m. Temperature: 97.7 taken [DATE] at 8:12 p.m. Pulse Oximetry: 90% taken [DATE] at 8:12 p.m. on room air. Findings reported on resident for this change in condition were altered level of consciousness. The Provider recommendations included a Complete Blood Count (CBC) with no differential, Comprehensive Metabolic Panel (CMP) with glomerular filtration rate (GFR), a Urine Analysis (UA) culture and sensitivity (C&S). A late entry progress note written at 9:17 p.m. on [DATE] by Charge Nurse #1 read: Resident rolled out of the bed onto floor, bed was in lowest position. No complaints of pain or discomfort. No injury to note. Vital signs within normal range. Resident alert and able to respond appropriately to staff. On-call made aware of incident. No new orders concerning fall to note. There were no details regarding, 1) what happened to the reported assessments, 2) the specific values for the vital signs, and 3) if the fall was witnessed or if neuro checks were initiated. There was not a fall incident report completed on [DATE] by Charge Nurse #1 for Resident #250's fall. In addition, there were no documented neurological checks located in the medical record. A late entry progress note written at 9:20 p.m. on [DATE], by Charge Nurse #1 read: Resident slightly lethargic, vital signs taken, and resident denies pain. Responding appropriately to staff, telehealth contacted. Video conference call made by on call physician. Determined altered mental status with tenting of skin the Resident had some dehydration. Labs were ordered and telephone order to begin resident on Intravenous (IV) normal saline at 100ml (milliliters)/hour x 72 hours. An attempt to start the IV was unsuccessful. Contacted telehealth on call to start hypodermoclysis (a method of administering fluids or medication under the skin). On call gave a telephone order to start the Normal saline at 60 ml/hour by hypodermoclysis until an IV could be started. There were no details regarding the specific values for the vital signs or if neurological checks were initiated or continued. A review of the On-Call Physician video visit summary, dated [DATE] at 6:50 p.m., documented the resident had a fall out of the bed earlier in the day, and the staff were requesting the Resident be evaluated due to an altered mental status. The Resident presented with lethargy, increased confusion, nonverbal, and not engaging. The Resident had tenting skin (a sign of poor skin turgor that can be dehydration), was in mild distress, and had occasional moans. The assessment plan noted recent repeated falls and altered mental status (a change from a resident's base line alertness and cognition). Recommendations included to continue the facility post fall protocol, conduct a STAT CBC, CMP, UA with C&S, and Normal Saline (NS) at 100 ml/hr. x 72 hours. A review of the On-Call Physician summary dated [DATE] at 8:35 p.m., documented Charge Nurse #1 requested to administer the IV fluids via hypodermoclysis. The order was adjusted to 60 ml/hr. NS via hypodermoclysis. The Nurse reported the UA C&S and laboratory work was pending and an additional video conference was not needed. The Corporate Nurse Consultant and Administrator provided a copy of the SBAR notes and the telehealth visit for the date of [DATE]. No other neurological assessments and no fall incident report for [DATE], were provided. An interview was conducted with Charge Nurse #1 on [DATE] at 3:37 p.m. and revealed on [DATE] she was the assigned nurse on the 7:00 a.m. - 11:00 p.m. shift. Resident #250 had a second unwitnessed fall and was discovered lying flat on the floor, on the window side of the bed, at 1:00 p.m. She was unable to provide the name of the staff member that discovered the Resident on the floor. She assessed the Resident, and she had no injuries. She was unsure if the Resident had hit her head, so she completed a neurological assessment, and the Resident was verbally responsive then she and another staff member (she did not recall) assisted the Resident back to the bed. She stated she had completed the neurological assessments and documented them on a piece of paper but did not conduct them at the recommended intervals required for an unwitnessed fall, that included every 15 minutes x 4, every 30 minutes x 4, every hour x 4, then every 4 hours x 4. When asked how many assessments she had completed, she stated, a few. She added she did not document an assessment (neurological assessment or vital signs), at the time of the fall, in the electronic medical record because she accidentally shredded the paper and was unable to obtain access to the shred storage box. Charge Nurse #1 added she did not write a progress note to summarize what she had assessed and did not notify a physician of the fall at that time. She was unsure why because a provider was available in the facility on that Friday at 1:00 p.m. Later in the shift, a nursing assistant, name unknown, informed her that the Resident was not responding like usual. Charge Nurse #1 was not able to specify an approximate time. She went to assess the Resident and discovered she had an altered mental status. The Resident was responding to questions with a yes or no reply only and was lethargic (drowsy, sluggish, and difficult to arouse). Charge Nurse #1 notified the on-call physician of the change in mental status and the fall that occurred at 1:00 p.m. She was not able to specify an approximate time for the on-call physician notification. This was the first time a physician was notified of the fall. She stated she created an SBAR that included the information reported to the physician and included the vital signs and neurological assessment conducted. The two SBAR progress notes were created at the end of her shift. Charge Nurse #1 explained the On-call Physician conducted a visit via video conference at 6:50 PM and felt the Resident might be dehydrated. He ordered STAT (immediate) intravenous (IV) fluids of Normal Saline (NS) at 100 milliliters/hour (ml/hr.) for 72 hours, STAT laboratory work that included a complete blood count (CBC), complete metabolic panel (CMP), and a urinalysis (UA) with a culture and sensitivity (C&S). She entered the STAT laboratory order into the computer and wrote the laboratory order on the lab book. She did not call the Laboratory provider to inform them she had STAT blood work ordered. She then stated she had been unsuccessful at starting an IV for the Resident and called the on-call Physician back to request the fluids be delivered by hypodermoclysis (a method of administering fluids subcutaneously under the skin). She added she did not request a second nurse to attempt to start the IV. The physician agreed and adjusted the administration route as requested and the dosage was changed to 60 ml/hr. She added she had been unable to start the hypodermoclysis fluids because she needed to order the supplies from the pharmacy, and they did not arrive on her shift. She revealed she had not notified the on-call physician that the supplies for the fluids were unavailable and would be delayed. Charge Nurse #1 added she had thought the on-call physician would know the facility did not have the supplies. She conducted an in and out urine catheterization and did not receive enough urine to complete the urine lab orders and she had not notified the on-call physician that she was unable to collect the urine. She stated she reported to the following shift, Charge nurse #2, to try to collect more urine and did not report to the nurse another attempt to start the IV was requested by the on-call physician. An interview was conducted with Nurse Aide (NA) #1 on [DATE] at 5:25 p.m. and she revealed she had been assigned as the care giver to Resident #250 frequently. She added the Resident could move a little but did not usually fall out of the bed from movement. She was assigned to Resident #250 on [DATE] and [DATE], day shift. She was assigned to Resident #250 on [DATE], 7:00 a.m. - 11:00 p.m. On [DATE] she was assigned to Resident #250 from 7:00 a.m. - 3:00 p.m. At 3:00 she was pulled to conduct showers. She was unsure what NA took over the assignment. During her shifts, she added the Resident was squirming around more like she was uncomfortable. She stated the Resident was not her normal self on [DATE] and this was reported this to the nurse. She did was not sure of the Nurses name. About a month prior to [DATE] and [DATE], she had reported to the Unit Manager (UM) the Resident's gastrostomy (G-tube) was leaking. She stated the leaking and the flap (the feeding port cover) to close the tube had not closed. She was informed by the UM a piece of tape had been placed over the closure area. She stated the concerns with the leaking tube feeding continued for the month and she had tried to inform the previous Administrator by going to his office and requesting to speak with him regarding Resident #250 but he shooed her away without listening and was ignored. She continued to provide reports regarding the leaking tube feeding to the UM. A review of the facility progress notes for Charge Nurse #2, the 11:00 p.m. - 7:00 a.m. shift hall nurse for Resident #250, documented: 1) [DATE] at 3:48 a.m. she attempted to collect a UA C&S from Resident #250 and a small amount returned from the in and out urine catheterization. 2) [DATE] at 4:09 a.m. Resident #250 was started on NS via hypodermoclysis running at 60 ml/hr. Attempted the UA C&S earlier with no results due to a small amount of urine. This nurse will continue to monitor. An interview was conducted with Charge Nurse #2 on [DATE] at 9:31 a.m. and she revealed she was assigned to Resident #250 on the [DATE] at 11:00 p.m. - [DATE] at 7:00 a.m. shift. She received a report from Charge Nurse #1 that the Resident required Hypodermoclysis at 60 ml/hour to be started when the supplies arrived from Pharmacy. She did not receive a report that the on-call Physician requested the hypodermoclysis be conducted until an IV could be obtained on the Resident. At 3:48 a.m. she received the supplies and started the ordered fluids. She attempted to collect urine and was unable. She reported the Resident appeared to be dehydrated and had labored breathing. Charge Nurse #2 did not notify the on-call physician that she was unable to collect the UA C&S or that the Resident appeared dehydrated, because she had not been told she needed to. She did not conduct scheduled neurological assessments and document them in the electronic medical record. A review of the [DATE] NP #1 progress note documented an unwitnessed fall without injury was reported. The Resident had a new onset of tachycardia and hypotension. Fluids from hypodermoclysis was observed initiated. Orders for a CBC, CMP, UA with C&S were ordered. The laboratory results were not completed at the time of the evaluation. Vital Signs: Blood pressure 83/46, Pulse 112, temperature 97.9, oxygen saturation 95% on room air. Level of consciousness: Nonverbal, lethargic, makes eye contact when spoken to. Information regarding this encounter were shared with the Unit Manager and Director of Nursing in person. An interview was conducted with Nurse Practitioner (NP) #1 on [DATE] at 10:17 a.m. and she revealed the On-Call physician for the medical group, had been notified on [DATE] at 6:50 p.m. that the Resident had an unwitnessed fall from the bed at 1:00 p.m. When she arrived at the facility on [DATE] she read the On-Call physician documentation from the 6:50 p.m. video visit on [DATE] and went to visit the Resident. Upon arrival in the room, the Resident had NS 60 ml/hr. running via hypodermoclysis. The Resident had vital signs, taken by NP #1, that included a blood pressure of 83/46 and a pulse of 112. The low blood pressure and the tachycardia could represent dehydration or an infection, therefore she needed to evaluate the laboratory results. The STAT laboratory work was not available in the electronic medical record. She called the laboratory provider and requested the results. She was informed there was pending laboratory blood work for Resident #250, but they had not been informed it was a STAT lab. The NP added she had not been notified of an error in the ordering of the STAT laboratory blood work. She revealed the failure to notify a Physician of the fall on [DATE] until 1:00 p.m. and the laboratory work not being drawn STAT delayed the treatment and workup. She added, if she had received the critical laboratory results, at the expected time, around noon on [DATE], she would have recommended treatment at a higher level of care. She did not receive the laboratory results prior to leaving for the day. The NP provided the following instructions and orders prior to leaving the facility on [DATE]: 1) Midline IV to be placed and once started, begin 0.45% normal saline at 100 ml/hr. x 2 liters. 2) Discontinue the hypodermoclysis once the Midline is obtained. 3) Obtain a chest x-ray. 4) If the chest x-ray or UA results were abnormal or if the [NAME] Blood cells were elevated, please initiate 1-gram Rocephin intramuscular every day for 7 days. 5) If the Oxygen saturation drops below 90% give supplemental oxygen via nasal cannula as needed to keep oxygen saturation above 90%. A progress note was written by Charge Nurse #3 for the date of [DATE] at 12:47 a.m. that read; Resident was alert and oriented x 1. Nurse Practitioner ordered a Midline to be placed for fluids. Laboratory blood work was ordered and blood drawn. Will continue to monitor. A progress note was written by the Unit Manager on [DATE] at 6:39 p.m. that read; This writer notified on-call Nurse Practitioner #2 about the Resident's critical lab values reported from the laboratory provider. The Blood urea nitrogen (BUN) was 157.4 (normal range 6-20 mg/dl) , Sodium 156 (normal range 135 - 145 mEq/l). The X-rays were ordered per the earlier orders and an IV access provider was contacted to start the midline. Attempts were made to interview NP #2 without success. Review of the critical lab results revealed: BUN at 157.4 mg/dL (normal range 6-20 mg/dL) Na at 156 mmol/L (normal range of 136-145) Creatinine at 6.01 mg/dL (normal range 0.5-1.2 mg/dL) BUN/Creatinine ratio at 26.2 (range of 6-25). A progress note was written by Nurse #3 at 10:44 p.m. written by Charge Nurse #3, that read; Resident #250 was discovered unresponsive in her bed on [DATE] at 9:50 p.m. and pronounced as deceased at 10:09 p.m. An interview was conducted with Charge Nurse #3 on [DATE] at 11:02 a.m. She revealed she had an assignment change on [DATE] at 3:00 p.m. and was then assigned to Resident #250. This was the first time she was assigned to this resident. She stated she did not get all the information she was supposed to get in report. The Director of Nursing was present during the report. She thought the Resident had transitioned to Hospice services based on her report and that the Resident was experiencing an expected decline. She was not informed of the pending laboratory values and when the critical laboratory value results were received, the Unit Manager had received them and failed to inform her of the status and the family had been in to visit the Resident. She reported she was informed by a staff member and did not recall the name, that the Resident was unresponsive at 8:50- 9:00 p.m. (the progress note stated 9:50) and she went to the telephone to contact the physician and the Guardian. That was when she discovered the Resident was a full code and she began cardiopulmonary resuscitation (CPR). The team contacted 911 and emergency medical services (EMS) arrived around 10:00 p.m. and pronounced the Resident as deceased at 10:09 p.m. The Midline was never placed. An interview was conducted with the Corporate Nurse Consultant on [DATE] at 12:48 p.m. and she reviewed the Laboratory provider results for Resident #250, dated [DATE]. She stated the results should have indicated the term, STAT somewhere on the results. She investigated and discovered the Laboratory order should have been entered into the electronic medical record and then the Nurse was expected to call the laboratory provider to inform them the order was STAT. She was informed this step did not occur because the nurse forgot to call. The death certificate signed by the Physician on [DATE] revealed the immediate cause of death were Cerebrovascular Accident (CVA), Vascular dementia, Lupus, and Dysphagia as late effect of CVA. An interview was conducted with the Medical Director on [DATE] at 12:25 p.m. and he revealed he was not allowed to list some conditions as the cause of death on a death certificate but if he was able, he would have listed fluid volume depletion disorder as the cause of death for Resident #250. He added it was his expectation that neurological assessments be conducted following an unwitnessed fall and documented in the electronic medical record. He stated it was his expectation that STAT laboratory work be conducted as ordered. The Administrator and Corporate consultant were notified of the immediate jeopardy (IJ) on [DATE] at 6:12 p.m. The facility provided the following plan for IJ removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On [DATE] resident #250 had an unwitnessed fall approximately 11:07 a.m. The charge nurse stated in her interview that a nurse aide informed her the resident had slid out of the bed. Upon entering the residents' room, the charge nurse noted the resident sitting on the floor with her back up against the nightstand. She asked the resident if she slid out of the bed and the resident shook her head yes. The charge nurse assessed the resident for pain, abnormal range of motion, and obtained her vitals. She stated that this was all within normal limits. The charge nurse assessed the resident for mental status, cognition, strength, coordination, range of motion, pain, gait and mobility, and level of consciousness because she was under the impression the fall was witnessed by the nurse aide. The charge nurse stated the lack of documentation was due to her becoming busy and it was a lapse in judgement. There is no supporting documentation regarding the on-going assessments being performed on the resident on [DATE]. On [DATE] resident #250 had an unwitnessed fall approximately 1:00 p.m. The charge nurse stated in her interview that the maintenance assistant discovered the resident on the floor approximately 1:00 p.m. He asked the resident if she was okay, and she gave him a smile. The charge nurse was informed immediately and assessed the residents' range of motion, pain level, and vital signs. The charge nurse stated that the resident was not in pain and the range of motion and vital signs were within normal limits. During the duration of the day the charge nurse increased her rounds on the resident to ensure she did not have a change in condition. During the rounds the charge nurse stated she assessed the residents mental status, cognition, strength, coordination, range of motion, pain, gait and mobility, and level of consciousness. The mental status, cognition, strength, coordination, range of motion, pain, gait and mobility, and level of consciousness were within normal limits. The charge nurse stated the lack of documentation about the findings of her assessment were due to her throwing the sheet she had documented on in the shredder box and no one had a key to open the box. The charged nurse was asked why there was a lack of documentation in the residents' medical record from the fall and she stated that the day was extremely busy, and time got away from her. On [DATE] approximately 6:40 p.m. resident #250 was found to have a change in her mental status and the charge nurse informed the medical provider immediately. The medical provider called through tele-health and gave the charge nurse stat orders to obtain blood work, and urine for a culture and sensitivity and administer fluids via IV at 100mls per hour. The nurse attempted to start the IV twice and was unsuccessful. The nurse stated that she attempted to locate another nurse on a different unit and was unable to locate the nurse she was looking for. She called the on-call medical provider and received an order to run the fluids via hypodermoclysis and change the rate to 60mls per hour. The charge nurse could not locate a hypodermoclysis kit in the facility. She then called the pharmacy to send some kits on the next run. She stated she failed to call the provider back because she assumed the kits would be delivered before she left the facility. There is supporting documentation on [DATE] at the following times 9:04 p.m., 9:11p.m., 9:17 p.m., and 9:50 p.m. On [DATE] the kits arrived at the facility at approximately 3:00 a.m. The charge nurse that was on duty applied the cylsis kit and started the IV fluids approximately 3:20 a.m. The charge nurse #1 entered the orders for the blood work to be drawn stat in the resident's medical record, however she failed to enter the orders into the lab computer system and failed to call the lab company for the labs to be drawn. She stated the reason is due to her forgetting that she needed to call the lab company to have the labs drawn stat. The blood work was drawn as a routine lab on [DATE] due to the 11:00 p.m. to 7:00 a.m. nurse writing a requisition form at 6:00 a.m. and resulted at 5:28 p.m. per the lab results in the resident's medical record. The nurse practitioner viewed the resident medical recorded and noted the stat labs that were ordered had not resulted. She placed another order in the residents' medical record to obtain stat labs, however the NP was unaware of the labs being drawn that morning. The charge nurses and unit managers failed to call the lab company to follow-up on lab results. The NP called the lab company approximately 3:00 p.m. to follow up on the results and she was informed the labs were not drawn stat. She then asked the lab company to have the labs run stat. The lab work resulted at 5:28 p.m., and the critical labs were called to the facility at 6:28 p.m. to the unit manager. The unit manager attempted to reach out to the provider on-call immediately. The provider called the unit manager back approximately 9:23 p.m. with no new orders. The charge nurse stated the resident was last seen at 8:45 p.m. and the resident was resting. The resident was found to be unresponsive on [DATE] approximately at 8:45 p.m. and resident was pronounced deceased at 10:09 p.m. On [DATE], the Regional Nurse Consultant spoke with the Director of Client Services for the pharmacy regarding the cylsis kits. He stated that the kits are normally not sent to the facility unless it is requested. The Director of Client Services stated that 12 clysis kits will be sent to the facility on [DATE]. On [DATE], the Regional Nurse Consultant educated Central Supply on the ordering process for the cylsis kits, such as filling out the ordering form and faxing the sheet to pharmacy or calling the pharmacy to request to amount that is needed, to ensure 10 kits are in the facility for licensed nurses to access in the medication rooms. On [DATE] the Director of Nursing, unit managers, and MDS nurse reviewed current residents that had fallen on [DATE] through [DATE] to ensure nurse assessed residents for a change in condition by reviewing the progress notes in the residents' medical record. The assessments included range of motion to ensure within normal limits, pain to ensure resident has no abnormal pain, mental status, cognition, strength, coordination, gait and mobility, and level of consciousness to ensure there were no changes to the residents. There were no abnormal findings. On [DATE] the Director of Nursing, unit managers, and MDS nurse reviewed current residents progress notes from the medical providers from [DATE] through [DATE] to ensure orders that were ordered stat were implemented immediately. There were no stat orders that were not implemented immediately. 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 Director of Nursing and Unit Managers educated Licensed Nurses regarding the requirements to complete fall documentation after the resident is assessed. The requirements for the documentation will be when a resident falls the licensed nurse will assess the resident immediately for pain, decrease in range of motion, and vital signs. If the resident has an unwitnessed fall the licensed nurse will assess for mental status, cognition, str[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff, Registered Dietician (RD), Speech Therapy (SLP), Nurse Practitioner (NP) and Physician interviews, the facility failed to maintain the hydration status for 1 of 2 residents reviewed for tube feedings (Resident # 250). When it was determined the resident was dehydrated, the facility failed to administer ordered fluids immediately, and failed to complete STAT (immediate) laboratory orders to assess the resident and provide information to the physician for needed treatment. The resident had critical laboratory values of Blood Urea Nitrogen (BUN) - 157.4 milligrams per deciliter (mg/dL) (normal range 6 - 20 mg/dL) (test measures the amount of urea nitrogen found in blood), Creatinine at 6.01 mg/dL (normal range 0.5-1.2 mg/dL), and Sodium level (Na) -156 millimoles per liter (mmol/L) (normal range 135 - 145 mEq)(measures the amount of sodium in your blood) (elevated BUN, Creatinine and Sodium can be indicators of dehydration; dangerously high BUN levels indicates kidney damage that should be addressed immediately) on 7/6/23 at 5:30 pm. The resident was pronounced dead on 7/6/23 at 10:09 pm. This was for 1 of 2 residents (Resident #250) reviewed for tube feeding. Immediate Jeopardy began on 7/5/23 when Resident #250 was observed to have signs and symptoms of dehydration and the facility failed to ensure the resident received immediate interventions. Immediate Jeopardy was removed on 8/4/23 when the facility implemented a credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with potential of more than harm that is not immediate jeopardy) to complete education and to immediately implement effective systems for residents with tube feedings to ensure adequate hydration. Findings included: Resident #250 was readmitted to the facility on [DATE] with diagnoses that included Cerebral Vascular Accident (CVA), lupus, dysphagia, and gastrostomy tube placement. Review of Medical Orders for Scope of Treatment (MOST) form with an effective date of 3/9/2021 revealed checked mark on Attempt Resuscitation with full scope of treatment including antibiotic use and feeding tube for long term if indicated. A lab report for CMP on 1/26/23 at 10:19 am revealed the results were BUN - 13.2 mg/dL, Na - 141 mmol/L, Creatinine - 0.57 mg/dL (check for normal function of kidney) (normal range 0.5 - 1.20 mg/dL), and BUN/Creatinine ratio - 23.2 (normal range 6 -25). Interview with RD on 8/2/23 at 8:28 am revealed Resident #250 had been receiving Gastrostomy Tube (GT) feedings since her admission to the facility in 2020. She stated that in October 2021, the resident had order for therapeutic nutrition formula 1.2 continuous tube feeding at 60ml/hr. A physician order on 3/23/23 revealed pleasure food with aspiration precautions was initiated. The pleasure food tray consisted of a pureed diet and thin liquids. The quarterly Minimum Data Set (MDS) on 5/1/23 coded Resident #250 with severely impaired cognition. Resident #250 could communicate her needs to staff. She was coded to require extensive assistance with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. She was coded to have a feeding tube for nutrition. A physician order for tube feeding on 5/4/23 revealed Resident #250 would receive a GT feed of therapeutic nutrition formula 1.2 Cal at 60 ml per hour continuous feeding and 125 ml of water flush every 4 hours. The order also included an instruction to allow tube feeding to be turned off for 2 hours per day to prevent the feeling of fullness for the resident. A care plan dated 5/31/23 revealed a goal to remain free of side effects or complications related to tube feeding, to maintain adequate nutritional and hydration status, and no signs and symptoms of malnutrition or dehydration. The intervention included to monitor aspiration, shortness of breath, tube dysfunction/malfunction, abnormal lab values, and dehydration. Interview with the RD on 8/2/23 at 9:10 am revealed the resident weighed 131 pounds (lbs.) on 6/12/23 and needed at least 1,800 ml of fluids per day to maintain her hydration. A telephone interview with SLP on 8/2/23 at 11:41 am revealed she evaluated Resident #250 on 6/27/23 for her swallowing and meal consumption. She stated the facility wanted to advance the resident to bolus tube feeding due to clogging issues with her GT. She stated the resident needed one person assistance to eat. She stated during her assessment, the resident ate 100% with her help. She said the resident demonstrated good rehabilitation potential as she followed direction and was an active participant. She further stated that the resident could drink thin liquids. A progress note written by RD on 6/28/23 revealed that Resident #250 was referred by Director of Nursing (DON) due to recently being seen by SLP with good oral intake of pureed diet with thin liquids. The height of 68 inches with Current Body Weight (CBW) of 131.30 (6/12/2023) with a normal Body Mass Index (BMI) of 20.0. Weight history of 1.00% change for 30 days and -0.45% for 90 days. There were no significant weight changes and/or trends present during her assessment. A weekly weight order was to monitor the resident. Resident #250 receives a pleasure tray of a pureed diet with thin liquids consuming about 51-100% of some meals. Resident previously reported that she normally doesn't eat anything by mouth. The resident on red tray status related to aspiration precautions. Resident #250 also receives therapeutic nutrition formula 1.2 at 60cc/hr. with 125cc H2O flushes q4hrs. Tube Feed (TF) may be turned off for 2 hours per day to prevent a feeling of fullness. The current TF regimen provides: 1320 mL, 1584 kcals (kilo calorie), 73-gram protein, and 1082 mL free water plus 750 mL from flushes equals to 1832 mL fluid total. The GT is also flushed with 30 ml of water before/after meds, before initiating feeding, or when there is an interruption of feeding to maintain tube patency. Resident tolerated the TF. RD Recommended to add to promote oral intake, to change TF regimen to 8 oz bolus feedings of therapeutic nutrition formula 1.5 TID 1 hour after each meal if consumes less than 50% of corresponding meal to promote oral intake/nutrition support. Always give 8 oz bolus of therapeutic nutrition formula 1.5 every day at 9 pm for additional nutrition support. Interview with RD on 8/2/23 at 8:29 am revealed that she visited Resident #250 twice a month since 2020 for her dietary evaluation. She stated Resident #250 was stable and had an order for pleasure trays with thin liquids. She stated that the Director of Nursing (DON) spoke to her on changing the continuous tube feeding to bolus for the resident was eating more than 75% of her food. The RD then recommended on 6/28/23 to give the resident pureed diet meal with thin liquids and changed the tube feeding to bolus of therapeutic nutrition formula 1.5 Cal 8oz 4 times a day with 30 ml of water flushes before and after the bolus. An additional instruction was that bolus will only be given if the resident ate less than 50% of her meal. A physician order that was initiated on 6/28/23 revealed Resident #250's GT feeding was changed to a bolus of therapeutic nutrition formula 1.5 Cal 8oz 4 times a day with 30 ml of water flush before and after the bolus. An instruction to give bolus 1 hour after every meal if the resident ate less than 50%. A 30 ml of water flushes before and after medication was also included. Interview with Medication Aide #1 (Med Aide) on 8/2/23 at 2:59 pm revealed she worked with Resident #250 for 2 to 3 weeks before she passed. She stated that the NA's would report how much the resident ate for her meals and if it was less than 50%, they should give the bolus feeding. She stated that the GT leaked feeding several times and she stated that NA #1 also reported the leaking to the Charge Nurse in the hall several times. Review of the staff schedule provided by the Director of Nursing (DON) on 8/2/23 revealed that NA #1 was scheduled to work with Resident #250 on 7/1/23, 7/2/23, 7/3/23, 7/4/23, 7/5/23, and 7/6/23 in the morning and part of the evening shift. Interview with NA #1 on 8/1/23 at 5:25 pm revealed she took care of Resident #250 most of the time when she was working on the third floor. She stated that the tube feeding was leaking and draining in the bed that started on June 16, 2023. She stated that when she checked the resident, the bed sheets would be wet with the tube feeding solution. She stated that the tube leaked due to the top of the GT not closing well and the nurses put tape around the top but would dislodge all the time. She also stated the GT would be clogged and it will keep the feeding pump beeping for hours before a nurse would come and stop the pump from beeping. She stated she told the Charge Nurse #1 of resident's poor meal intake which was less than 50% on 7/1/23, 7/2/23, 7/3/23, 7/4/23, 7/5/23, and 7/6/23. She stated she reported it to the Unit Manager and even reported it to the previous Administrator about the resident not eating and the GT was leaking. Interview with RD on 8/2/23 at 8:29 am stated that therapeutic nutrition formula 1.5 Cal 8oz 4 times a day amounted to 724 ml of free water. She stated after looking at the electronic record filled by the NA's, the resident received all tube feeding boluses from June 28 - 30, 2023 and from July 1 - 6, 2023. Review of the Medication Administration Record (MAR) and per mouth (PO) Intake form provided by the facility revealed Resident #250 was documented of receiving fluid on the following dates: 6/28/23 with 2,314 ml of fluid intake 6/29/23 with 2,264 ml of fluid intake 6/30/23 with 1.964 ml of fluid intake 7/1/23 with 1,894 ml of fluid intake 7/2/23 with 1,964 ml of fluid intake 7/3/23 with 2,014 ml of fluid intake 7/3/23 with 1,964 ml of fluid intake 7/4/23 with 1,964 ml of fluid intake 7/5/23 with 1,664 ml of fluid intake 7/6/23 with 2,384 ml of fluid intake. Interview with NA #2 on 8/3/23 at 11:51 am revealed she had seen the tube feed leaking from the Resident #250's tube. She saw the G-tube removed from resident's stomach one time and was hanging out, and she reported it to the Charge Nurse on the hall. She did not remember what day it happened or who the charge nurse was at that time. Interview with the Housekeeper #1 on 8/1/23 at 2:56 pm revealed she worked on the short hall on the third floor where Resident #250 resided. She stated that the tube feeding machine pump kept beeping and it could take an hour before nursing staff would come and look. Housekeeper #1 stated she reported the beeping to the Charge Nurse. She stated that the tube feeding leaked brown milky drips on the floor next to Resident #250's bed. She would mop them every day when she worked in the hall. She described the spill on the floor as big as a basketball ball and needed a scraper to remove the dried tube feeding on the floor. She reported the tube feeding leakage to her supervisor and the Charge Nurse on the hall. Interview with the Unit Manager on 8/2/23 at 2:02 pm revealed a Charge Nurse on the floor once reported Resident #250's feeding tube was leaking a little and she didn't remember when and who reported to her. She stated it was never leaked or clogged when she was working as a charge nurse on the hall. Interview with the Power of Attorney (POA) on 8/3/23 at 12:40 pm stated the family was visiting the resident twice a week. She stated the family told her they were worried about Resident #250's report from staff that Resident #250 was not eating well and her changed condition. She said the resident used to be alert and communicated her needs to family. She said the family reported the GT leaking to the Charge Nurse. She stated she didn't understand why the resident went downhill from the time they changed the tube feeding order. Interview with the Administrator on 8/2/23 at 10:13 am revealed the grievance report for 7/6/23 was received after the death of the resident. She documented on the bottom of the form that she had assessed Resident #250 on 7/4/23. The Administrator wrote that Resident #250 showed no signs of dehydration at that time. She wrote the skin turgor was good, observed her with moist mucous membranes. She stated the family was concerned of dehydration and the GT leaking. Record review of printed cellphone text messages provided by the facility on 7/5/23 at 6:40 pm revealed Charge Nurse #1 contacted the Physician via text messaging. She informed the Physician of Resident #250 was refusing meals, slightly lethargic and thought the resident may be dehydrated. The Physician answered that he was not the primary physician for Resident #250. Record of telehealth document dated 7/5/23 at 6:50 pm provided by NP#1 revealed that Charge Nurse #1 contacted the on-call Physician via telehealth, and she wanted Resident #250 to get checked out for altered mental status with lethargy and increased confusion. Resident #250 was seen by the on-call Physician through video call with the Charge Nurse and skin tenting (test that can indicate severe dehydration) was seen by the on-call Physician. It was also noted that the resident had multiple falls including earlier that day on 7/5/23. The on-call Physician ordered STAT Complete Blood Count (CBC) no differential (the total number of white blood cells), Comprehensive Metabolic Panel (CMP), Serum Osmolality (the concentration of chemicals in your blood for fluid imbalance), Urinalysis with Culture and Sensitivity (UA C&S) (culture looks for bacteria that cause UTI's and sensitivity test can pinpoint the bacteria), and IV of Normal Saline (NS) at 100 ml/hr. for 72 hours. The telehealth video was not recorded according to the facility Administrator when asked for a copy of the encounter. A Situation Background Assessment Recommendation (SBAR) note dated 7/5/23 at 8:17 pm completed by the Charge Nurse #1 revealed Resident #250 had altered mental status. The Nurse contacted the On-call Physician via telehealth, and she got the order for Intravenous (IV) fluids for Normal Saline (NS) to run for 100ml per hour (ml/hr.) for 72 hours, stat CBC, CMP, and UA C&S. Record review of the telehealth document dated 7/5/23 at 8:35 pm provided by NP #1 revealed Charge Nurse #1 contacted the on-call Physician asking if they can do hypodermoclysis since she could not get an IV started and on-call Physician advised her to do hypodermoclysis at 60 ml/hr. and to continue all previous orders. Interview with Charge Nurse #1 on 8/1/23 at 2:40 pm revealed she received an order from the on-call Physician after the Telehealth call 7/5/23 at 9:17 pm. She stated that Resident #250 was not as responsive as she was before the past two weeks. She stated she was on vacation a week before and came back the week of 7/5/23. She stated that the on-call Physician asked her to do skin tenting on the resident's skin and the on-call Physician determined that the resident was dehydrated and ordered the IV of NS for 100ml/hr. Charge Nurse #1 stated she was unsuccessful in her attempts to start an IV and there was no available nurse when she tried to seek help for the IV insertion. She called the on-call Physician again and asked for an order for hypodermoclysis (a method of administering fluids under the skin) instead of IV. She got the order to infuse NS 60ml per hour via hypodermoclysis until the IV could be placed. Charge Nurse #1 revealed that there was no hypodermoclysis kit available in the facility and she called the pharmacy to deliver hypodermoclysis kit in their next delivery. Charge Nurse #1 did not mention the order for urine C&S. A telephone interview with Charge Nurse #2 on 8/3/23 at 9:31 am revealed she started the hypodermoclysis on 7/6/23 at 3:57 am. She stated the pharmacy delivered the hypodermoclysis kit around 3 am. She stated that Resident #250 looked dehydrated with very dry lips. She also stated that Resident #250 had labored breathing. She stated that her attempt to collect the urine sample was unsuccessful with an in-and-out catheter because there was small amount urine output, and it was not enough to send to lab. She stated she didn't think of reporting anything to the Physician at that time. Record review of the progress note written on 7/6/23 at 3:57 am revealed the hypodermoclysis was started by Charge Nurse #2. A note included that the attempt to collect urine sample was unsuccessful due to the small amount of urine. The note also read to continue to monitor the resident. Interview with the NP #1 on 8/2/23 at 10:17 am revealed she visited Resident #250 in the morning of 7/6/23 around 10 am. She followed up on the stat laboratory results that were ordered by the on-call Physician and discovered they were not drawn or completed. No one from the facility staff could answer her about the labs. She said if they were ordered stat, they should already have the lab result. NP#1 stated she reordered the stat labs, chest x-ray, and reordered the IV. NP #1 spoke to the lab technician around 11 am -12 pm and stated the lab result should be out around 1 pm. She kept checking the electronic medical record around 1 pm and there was no lab result. NP #1 called the lab again to follow up and learned the lab requisition did not indicate stat. She stated the Lab Tech tracked the blood specimen to complete the testing. NP #1 stated she requested the RD to change the water flushes to 240ml of water for 24 hours for dehydration. Record review of the progress note on 7/6/23 at 12:47 pm written by Charge Nurse #3 revealed the NP ordered Mid-line catheter (an 8-12 centimeters catheter inserted in the upper arm with the tip located just below the axilla) for IV fluids. The blood sample was drawn at noon and was sent to the lab for testing. An encounter note dated 7/6/23 at 2:47 pm by the NP #1 revealed the resident was nonverbal and lethargic. The vital signs taken by the NP #1 revealed the Blood Pressure (BP) - 83/46-millimeter mercury (normal range above 90/60 and less than 120/80), and Heart Rate (HR) - 112 beats per minute (normal range 60 -100). The progress notes further revealed that Resident #250 became tachycardic (high HR) and hypotensive (low BP). NP #1 ordered Mid-line IV and to continue hypodermoclysis of Sodium chloride (NaCl) at 60 ml/hr. until IV was placed. Then begin 0.45% NaCl at 100 ml/hr. She added an order for stat chest x-ray and UA with C&S. NP #1 also ordered an increase in water flushes to 240 ml every four hours. NP #1 wrote that she was waiting for the stat CBC and CMP and would change fluids if needed. And then she wrote that for positive results, or elevated WBC, she will initiate treatment with 1gm Ceftriaxone (antibiotic) intramuscularly (IM) daily for 7 days. She added on her instruction that if SpO2 (oxygen saturation level) is less than 90% (normal range is 95% - 100%) to give supplemental oxygen via nasal cannula as needed to keep SpO2 less than 90%. Interview with NP #1 on 8/2/23 at 11:51 am revealed she didn't know about issues of GT leaking or clogging of Resident #250's GT. Interview with NP #1 at 8/2/23 on 10:17 am revealed the delay in drawing the labs and obtaining the results delayed the treatment and work up for the resident. NP #1 stated she would have sent the resident to a higher level of care for evaluation which would have provided the best possible outcome. The progress notes on 7/6/23 at 6:39 pm written by the Unit Manager revealed she notified NP for Resident #250's critical laboratory results with a BUN at 157.4 mg/dL (normal range 6-20 mg/dL), and Na at 156 mmol/L (normal range of 136-145). The other laboratory high results were Creatinine at 6.01 mg/dL (normal range 0.5-1.2 mg/dL), and BUN/Creatinine ratio at 26.2 (range of 6-25). There were orders for chest x-ray and Mid-line IV access to be started. The progress note revealed the Unit Manager contacted IV access (a third-party company that inserts Mid-line catheter) to place Mid-line catheter. Progress note written by Charge Nurse #3 on 7/6/223 at 10:44 pm revealed Resident #250 was found unresponsive at 9:50 pm. The emergency response was initiated immediately and 911 was called to help. Cardio-Pulmonary Resuscitation (CPR) was started. The NP #1 was notified about the resident's status. At 10:09 pm the Emergency Medical Services (EMS) team pronounced Resident #250 deceased and the Power of Attorney (POA) was notified. Interview with Charge Nurse #3 on 8/3/23 at 11:02 am revealed that she was working with Resident #250 on 7/6/23 at 7:30 pm and that there was an order from the NP #1 for Mid-line catheter placement. She stated that the Mid-line catheter was never inserted, and she did not know who was supposed to insert the Mid-line catheter. She stated Resident #250 didn't look too good and the family members were in the room with the resident. She stated that the resident was able to shake her head to answer when the family was talking to her. She stated there was so much confusion at that time and it was her first-time taking care of the resident. She said she was not told by the Unit Manager what was happening with the resident. Interview with the Physician on 8/2/23 at 12:25 pm revealed that the cause of death on the death certificate he signed for Resident #250 was chosen based on the most recent diagnoses. He stated that the state won't allow him to write fall or dehydration. He added he would have chosen Fluid Depletion Disorder based on the electronic medical record information that included critical lab values. The death certificate signed by the Physician on 7/20/23 revealed the immediate cause of death were Cerebrovascular Accident (CVA), Vascular dementia, Lupus, and Dysphagia as late effect of CVA. The Administrator and the Regional Nurse Consultant were notified of the immediate jeopardy on 8/2/23 at 6:12 pm. The Administrator provided and implemented the following credible allegation of compliance on 8/4/23. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On 6/28/2023 resident #250 had an order to receive bolus tube feeding of 8 ounces of Osmolite 1.5 for nutrition support one time a day. She also had an order to receive 8 ounces of Osmolite 1.5 for nutrition support after corresponding meal if consumed <50% three times a day. The order includes flushing with 30 cc of water before and after bolus. The resident received the new orders due to her ability to eat a puree diet and drink thin liquids per the speech therapist. The resident received a new order on 7/6/2023 to receive 240ml of water flushes every 4 hours. In interviewing the staff that worked on the unit resident resided on the residents feeding from the tube were found to be leaking on the floor from the tube hanging on the pole or leaking in the bed due to the tube becoming disconnected from the peg. On 7/5/2023 approximately 6:40 p.m. resident #250 was found to have a change in her mental status and the charge nurse informed the medical provider immediately. On 7/5/2023 the medical provider called through tele-health at 6:50 p.m. and gave the charge nurse stat orders to obtain blood work, urine culture and sensitivity, and administer fluids via IV at 100mls per hour. The nurse attempted to start the IV twice and was unsuccessful. She called the on-call medical provider and received an order to run the fluids via hypodermoclysis and change the rate to 60mls per hour. The charge nurse could not locate a hypodermoclysis kit in the facility. She then called the pharmacy to send some kits on the next run. She stated she failed to call the provider back because she assumed the kits would be delivered before she left the facility. On 7/6/2023 the kits arrived at the facility at approximately 3:00 a.m. The charge nurse that was on duty applied the cylsis kit and started the IV fluids approximately 3:20 a.m. On 7/5/2023 charge nurse #1 entered the orders for the blood work to be drawn stat. The charge nurse failed to enter the orders into the lab computer system and failed to call the lab company for the labs to be drawn. She stated the reason is due to a lapse in memory to call the lab company. The charge nurse attempted to obtain urine on the resident. She stated she was unable to obtain enough for the lab company to run the lab. The blood work was drawn on 7/6/2023 at 6:00 a.m. and resulted at 5:28 p.m. The critical lab values of BUN 157.4 mg/dl and sodium level 156mEq/L were called to the unit manager at 6:28 p.m. By this evidence, the resident did not receive an adequate amount of fluid. Upon reviewing the residents' medical record there was a lack of evidence that assessments for dehydration were completed. On 8/2/2023 Registered Dietitian reviewed and assessed current residents that are receiving tube feeding to ensure residents are receiving adequate hydration. The RD assessed the following, estimated energy needs verses what the tube feeding regimes are providing and for any complications or intolerances. The RD reviewed the residents that are receiving continuous feeding via pump to ensure the correct feeding was being administered, rate of the feeding, flushes were entered correctly on the tube feeding pump, and to verify the amount that was administered correlated to the time it was started. The RD verified the residents that are receiving their tube feeding via bolus have the correct tube feeding on each unit. The RD confirmed there are no further residents residing in the facility receiving food intake and supplement tube feeding. There are no residents that reside in the facility that are receiving meals and supplement tube feeding. There was no area of concern. On 7/13/2023, the Director of Nursing was reviewing the medical recorded of resident #250. Upon reviewing the critical labs, the Director of Nursing called the medical director to receive new orders to obtain lab work on current residents that were receiving tube feeding. There were no areas of concern. On 7/13/2023, the Director of Nursing assessed current residents on tube feeding for nutrition and hydration for signs and symptoms of dehydration due to resident #250 not assessed appropriately for dehydration. This is to ensure residents that are receiving tube feeding are being properly hydrated. There were no areas of concern. 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 8/2/2023, the Director of Nursing and unit managers educated license nurses to ensure residents are receiving the amount of tube feeding, this is also to include water flushes as ordered by the medical physician. Education includes when orders for fluids are received to give stat this is to be done without lapse of time, without delay. The Director of Nursing called the staff that were scheduled in the facility on 8/2/2023 for the hours of 7:00 a.m. until 3:00 p.m. to ensure education was received and understood. The Director of Nursing and the Administrator will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift via phone or in person. Education will be completed by 8/3/2023. On 8/2/2023, the Director of Nursing and unit managers educated current staff, to include housekeeping, dietary, maintenance, social workers, and nursing, if they notice the tube feeding leaking feeding pump alarming, or removal of tube, they are to notify the nurse immediately. The Director of Nursing called the following staff, housekeeping, dietary, and nursing, that were scheduled in the facility on 8/2/2023 to ensure education was received and understood. The Director of Nursing and the Administrator will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift via phone or in person. Education will be completed by 8/3/2023. On 8/3/2023, the Director of Nursing and unit manages educated the license nurses, medication aides, and nurse aides on the signs and symptoms of dehydration, which are fatigue, dark colored urine and low urine output, dry skin, decrease in skin elasticity, and cracked lips, headaches, light-headedness and dizziness, and low blood pressure. The Director of Nursing called the license nurses, medication aides, and nurse aides that were scheduled in the facility on 8/2/2023 on all shifts throughout the day to ensure education was received and understood. The Director of Nursing and the Administrator will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift via phone or in person. Education will be completed by 8/3/2023. On 8/3/2023, the Director of Nursing and unit managers educated the license nurses on dehydration is a serious risk for the long-term tube-fed resident who is not allowed oral intake, has an altered mental status, is unable to communicate, is elderly or fluid-restricted, or has thirst impairment. The Director of Nursing called the staff that were scheduled in the facility on 8/2/2023 on all shifts to ensure education was received and understood. The Director of Nursing and the Administrator will ensure no staff will work without receiving this education. Any new hires, including agency staff, will receive education prior to the start of their shift via phone or in person. Education will be completed by 8/3/2023. Effective 8/3/2023 the Administrator will be ultimately responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of IJ Removal: 8/4/2023 On 8/7/23, the facility's credible allegation for immediate jeopardy was validated. The survey team confirmed the education and training included information on calling the Physician, NP, and On-Call NP immediately after assessing a change of mental status for any residents. Education on implementing orders that are given stat to be done immediately without lapse, to report the inability to follow a physician order (that includes not being able to get stat orders carried out) to be reported to the physician immediately. Education on assessing and documenting residents with change of mental status. Education on signs and symptoms of dehydration. Education of any staff who notices a gastrostomy tube leaking, feeding pump alarming or removal of tube, will notify the nurse immediately. Interview with several facility staff about getting the educations were validated. The team observed a resident on tube feeding and there were no concerns. The facility provided the logs and audits for tube feedings. The facility also implemented the monitoring process for reviewing weekly assessments for each resident with tube feedings and to assess for clinical signs of dehydration weekly. The facility's corrective action plan was validated on 8/7/23.