**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, ANA's [American Nurses Association] Principles for Nursing Documentation, review, job description review, medical record review, Neuro (Neurological) Check Assessment Form review, and interviews the facility failed to ensure treatment and care was provided in accordance with professional standards of practice, the comprehensive care plan and the resident's goals for care. The facility failed to promptly identify and intervene for an acute change in condition for 1 of 3 (Resident #1) sampled residents reviewed for quality of care. The facility's failure to ensure a resident received appropriate assessments and interventions resulted in Immediate Jeopardy when on [DATE] Resident #1 was noted to have a raised area on his left forehead. Nursing staff notified the contracted telehealth provider and failed to give complete, relevant, and accurate information resulting in Resident #1 remaining in the facility for 7 hours and 36 minutes before being transferred to the emergency room for evaluation of a life-threatening condition. Nursing staff also failed to notify a provider when Resident #1 had an acute change in condition from his baseline status resulting in the family requesting transfer to the hospital. Resident #1 was admitted to the hospital for a subdural hemorrhage on [DATE] and died on [DATE]. Immediate Jeopardy is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Administrator, the Director of Nursing (DON), the Regional Director of Operations (RDO), the Regional Director of Clinical Services (RDCS) and the Area Director of Clinical Services (ACDS) were notified of the Immediate Jeopardy (IJ) for F-684 during the complaint investigation on [DATE] at 7:39 PM, in the conference room. The facility was cited at F-684 at a scope and severity of J, which is Substandard Quality of Care. A partial extended survey was conducted from [DATE] through [DATE]. An acceptable Removal Plan, which removes the immediacy of the Jeopardy for F-684 was received on [DATE]. The Removal Plan was validated onsite by the surveyors on [DATE] through audit review, medical record review, observation, review of education records, and staff interviews. The IJ began on [DATE] and was removed on [DATE]. Noncompliance at F-684 continues at a scope and severity of D for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: Review of the facility policy titled, Neurological Assessment, with a facility review date of [DATE], revealed, .It is the policy of this facility to report potential head injuries to the physician and implement interventions to prevent further injury including Neurological Assessment.Guidelines.1. Neurological assessments are indicated.b. Following an unwitnessed fall.c. Following a fall or other accident/injury involving head trauma.d. When indicated by resident's condition.2. Any change in vital signs or/neurological status in a previously stable resident should be reported to the physician immediately.Compliance Guidelines.Resident Neurological Assessment.a. Vital signs.b. General condition and appearance.c. Neurological evaluation for changes in: i. Level of Consciousness.ii. Resident Response.iii. Movement.iv. Hand Grasp.v. Speech.vi. Pupil Reaction.vii. Pupil Size.d. Initial Evaluation of the head, eyes, ears, and nose for significant changes in vision, hearing, smell, or bleeding. e. Initial Assessment of any injuries to head.5. Notify family and document all assessments, actions, and notifications. Review of the facility policy titled, Notification of Changes, revised on 6/2025, revealed, .The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies.resident's representative when there is a change requiring notification.Life-Threatening Conditions Examples-Heart Attack or Stroke.Guidelines.Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status.Circumstances that require a need to alter treatment. Review of the undated Charge Nurse-Registered Nurse (RN)/Licensed Practical Nurse (LPN) job description revealed, .Complete accident/incident reports, as necessary.Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to care.Write nurses' notes to reflect that the care plan is being followed when administering nursing care or treatment.Deliver and maintain optimum resident care and comfort by demonstrating knowledge and skills of current nursing practices.Notify the resident's attending physician when the resident is involved in an accident or incident.Monitor seriously ill residents, as necessary. The facility was unable to provide a policy for Nursing Services. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses which included Heart Failure, Convulsion, Hypertension, Occlusion and stenosis of carotid artery, Difficulty in walking, Cognitive communication deficit, Anxiety disorder, and Insomnia. The facility provided Resident #1's hospital history and physical documentation which included a history of falls prior to his admission. Review of the Physician Order Report for Resident #1 revealed, XXX[DATE].carvedilol [medication given for high blood pressure] .12.5 mg [milligram].twice a day .Eliquis [anticoagulant- medication to prevent blood clots which increases the risk of bleeding] .5 mg .Twice A Day XXX[DATE] .levetiracetam [seizure medication] .750 mg .Twice A Day .Code Status: Full-Full Treatment . Review of the comprehensive care plan for Resident #1 dated [DATE], revealed .Problem .Anticoagulant .[Named Resident #1] has potential for injury/bleeding related to anticoagulant therapy .Approach .Observe for signs of active bleeding .Protect resident from injury/trauma . There was no care plan with interventions for Seizures/Anticonvulsant or Advance Directive of Full Code on Resident #1's care plan dated [DATE]. Review of the Risk Assessment Bundle for Resident #1 dated [DATE], revealed Resident #1 had a history of falls, altered gait (pattern in which a person walks) pattern and was high risk for falls. Review of the Physician Order Report for Resident #1 revealed, XXX[DATE] .aspirin [antiplatelet- medication to prevent blood clots, can increase risk of bleeding] .81 mg . Once A Day .amlodipine [blood pressure medication].10 mg.PRN [as needed] . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated severe cognitive impairment. Resident #1 required assistance with bed mobility, transfers, and walking 10 feet. Fall history on admission was marked unable to determine. Resident #1 received an anticoagulant, antiplatelet, and anticonvulsant over the 7-day look-back period for this assessment. Review of the meal intake documentation for Resident #1 dated [DATE]-[DATE], revealed meal intakes ranged between 51% to 76% except for [DATE]. On [DATE] Resident #1's meal intake was documented as none for breakfast and lunch. Review of the Progress Notes dated [DATE], [DATE], and [DATE], revealed Resident #1 was up walking around the memory care unit at various times. Review of the Medical Director's Progress Notes dated [DATE], revealed .[Resident #1].with past medical history significant for advanced dementia, hypertension, stroke and seizure disorder.[Resident #1] has history of dementia.continues with Melatonin for sleep. There are no current reported concerns of lethargy [lack of energy or excessive sleepiness] or mental status changes. There are no current reported concerns of decreased oral intake [meals and liquids].no current reported concerns of.elevated blood pressure readings.continues with Eliquis.High risk of fall.Hypercoagulable [High risk of forming blood clots] status.Continue to take.aspirin.Continue full code. Review of the Vital Signs Report dated 5/2025 revealed Resident #1's Blood Pressure (B/P-systolic top number represents pressure in your arteries when your heart beats/ diastolic bottom number the pressure inside the artery when your heart rests between beats) readings documented twice daily for 2 weeks prior to Resident #1's change in condition, averaged between 115-141 systolic and 70-90 diastolic. On [DATE], RN C documented Resident #1's BP reading of 168/97 taken at 8:58 AM. RN C did not document a follow up BP reading during her 6:00 AM-6:00 PM shift. Review of the Progress Note for Resident #1 dated [DATE] at 5:40 AM, revealed .Nurse [LPN B] was made aware by CNA [Certified Nursing Assistant A] .she noted a fluid filled raised area on LT [left] side of [Resident #1] forehead. No noted falls during the night and resident was in bed resting when CNA [CNA A] noticed area.BP 162/116.[Named Telehealth Provider] was contacted, and MD [Telehealth Provider - Medical Doctor (TMD) #1] stated to mark the area and monitor for increase in size and a cool compress could be applied. Review of TMD #1's Progress Note for Resident #1 dated [DATE] revealed, .5:40 [AM].Primary Chief Complaint.Facial Swelling.Defined area on the left side of the forehead noticed today patient denies, and there has been no recorded trauma no falls no hitting head. Patient has no tenderness and his mental status had remained at baseline area appears to look like a lipoma however, we will monitor the size. cold compress q [every] shift.Source of verification for all history: Per nurse and/or patient, Per scanned documents [scanned picture].BP Sys: [systolic]162 ./Dia: [diastolic] 116 .Exam findings per nurse and video observation.left forehead/temporal area with lipoma like mass nontender, no bruising skin intact.Diagnosis.Localized swelling, mass and lump.Please use skin marker to outline the area and evaluate for increase in size.use cool compress Q [every] shiftNotify [shift Notify] a clinician of any change in condition. Review of Resident #1's Medication Administration Record (MAR) dated [DATE], revealed there was no documented administration of amlodipine 10 mg which was ordered as needed for hypertension. There was no documented administration of Resident #1's scheduled medications which included carvedilol 12.5 mg given for hypertension (high blood pressure). Review of the Neuro Check Assessment Form dated [DATE], for Resident #1 revealed 9 neurological assessments were completed from 5:55 AM to 10:40 AM. All areas of the assessments were marked the same. Level of consciousness was marked 1 for fully conscious. Resident response was marked 1 for name. Movement was marked 1 for all 4 extremities. Hand grasp was marked 1 for equal and strong. Speech was marked 1 for clear. Pupil reaction was marked 1 for brisk (both eyes). Pupil size bilateral was marked 3 (choices were 1 for equal in size and 2 for not equal in size). There were no vital signs documented on the form. Review of the Vitals Report and the Progress Notes for Resident #1 revealed there were no vital signs documented on [DATE] after 5:40 AM (when LPN B noted the swollen area on Resident #1's forehead and a BP of 162/116) until Family Member (FM) E found Resident #1 unresponsive and requested RN C to transfer him to the hospital (approximately 7 hours later). The Neuro Check Assessment Form indicated Resident #1's neurological status findings were without change. RN C completed the assessments at 6:25 AM, 6:40 AM, and 7:10 AM. RN C confirmed Resident #1 did not wake up during the neuro check assessments and did not grasp her hand during the neuro check assessment which indicated Resident #1's change in condition. Review of the Daily Skilled Service Observation Details (Daily Skilled Note) for Resident #1 dated [DATE] at 10:07 AM, revealed .Cognition.Alert.Confused.Neurological Symptoms.None.Change in Cognitive Status.No Change.Pulmonary Status.Lungs Clear.Cardiovascular/Circulatory.N/a [Not Applicable].Integumentary Status.No new open Areas or skin issues. The daily Skilled Note was completed by RN S. Review of the Progress Note dated [DATE], revealed .12:46 [PM] .Resident [Resident #1] sent to [Named Hospital #1] ED [Emergency Department] for evaluation per family request. Review of the Discharge/Transfer with Bed Hold document for Resident #1 dated [DATE], revealed, .Blood Pressure 140/106 .Reason for Transfer .Resident or Family initiated transfer .Progress Note related to condition leading to transfer .Family requested resident be sent to ED for evaluation .Name of MD/Provider Notified . [Named NP] . Review of Resident #1's Emergency Medical Service (EMS) report dated [DATE] at 1:05 PM, revealed .dispatched and responded immediately with lights and sirens.to [Named Facility #1] for complaint of hematoma to forehead needing X-ray.Arrived to find [Named Resident #1] sitting limp in wheelchair unresponsive to verbal stimuli and sternal rub [Painful stimulus caused by firmly rubbing with knuckles across an unresponsive person's chest to cause a response]. Pt's [patient's/Resident #1] nurse [RN C] reports last known well to be approximately when she get [got] off her shift last night [[DATE] at approximately 6:30 PM] as he [Resident #1] was up and walking around. Pt's wife [FM E] had come to visit today [[DATE]] and noticed the hematoma on the forehead and requested nurse to send the patient out for evaluation. Nurse [RN C] reported that none of their staff had witnessed any fall or any other mechanism of injury over the night [[DATE]] and that the patient had been asleep all morning [[DATE]] in his wheelchair.Pt is on Eliquis blood thinner .PARAMEDIC ASSESSMENT - GCS [Glasgow Coma Scale- used to help assess acute brain injury and impaired consciousness] 7 [score] (1) eyes none, (2) verbal sounds (pt reacted to IV [catheter inserted into a vein] insertion by shouting), (4) normal flexion (when starting IVs, otherwise unresponsive to any other physical stimuli).hematoma to left forehead and right deviated gaze, pupils 4 mm [millimeter] bilaterally and sluggish reaction to light.extremities flaccid.Pt extremity lifted from wheelchair to stretcher by emt [Emergency Medical Technician] x 2 [two persons] .transported emergent with lights and sirens to [Hospital #2] ED due to neuro specialty. Pt condition remained unchanged throughout transport. Upon arrival.pt was triaged and immediately wheeled to CT [Computed Tomography imaging procedure that uses X-rays] .revealed large right subdural hemorrhage [a pool of blood between the brain and its outermost covering] . Review of Hospital #2's admission Record for Resident #1 dated [DATE], revealed .Chief Complaint Patient presents with Altered Mental Status.M [male] with a h/o [history of] afib [Atrial Fibrillation] on Eliquis, seizures.LKN [Last Known Normal] last night. Possible fall- nursing found pt [patient] this AM with a hematoma to his L [left] forehead.Vitals: BP 141/91.Neurological.Poorly responsive, R [right] gaze deviation - does not regard examiner [look at examiner] or track [follow objects with eyes], nonverbal, not withdrawing to painful stimulus at this time.ED Course.Spoke with radiology-large left sided SDH [Subdural Hematoma/Hemorrhage] 9mm midline shift [brain tissue is displaced across the brain's center line].Call out to neurosurgery, reversing Eliquis.Pt will now intermittently cross midline [moving arms or legs but not consistently], pulling at lines and clothes at times.Pt going to OR [Operating Room] with NSGY [Neurosurgery].CT evaluation of the nonvascular structures of the head and/or neck. Left hemispheric subdural hematoma again observed.There is an acute left cerebral convexity [outer surface of the brain] subdural hemorrhage with maximal thickness of 13 mm .Upon my evaluation, this pt had a high probability of clinically significant imminent or life-threatening deterioration due to subdural hemorrhage.Neuro Critical Care History and Physical.This.male.on Eliquis.seizure.presented with a change in mental status. The wife stated yesterday he was at baseline able to walk, feed himself, and talk some.NEUROSURGERY CONSULT NOTE.Presented to ER with hematoma on the left forehead above the eyebrow .Spoke with family at bedside. They wish for full neurosurgical intervention.PLAN.Unfortunately his exam continues to climb since arrival to ER. I think this is going to continue to get worse if we do not intervene.We will proceed to the OR for a [an] emergent left sided open craniotomy [surgical procedure that involves making an opening in the skull] for subdural hematoma evacuation [removal]. Review of Hospital #2's Patient Summary and Hospital Course dated [DATE], revealed Resident #1 was admitted for traumatic left acute subdural hematoma. Emergency craniotomy was performed to remove the hematoma. Resident #1's prognosis was complicated by postoperative seizures and Resident #1 required intubation (installed tube in the windpipe to maintain the airway) for respiratory failure. Further testing revealed concerns for anoxic/toxic encephalopathy (brain injury caused by a lack of oxygen and/or presence of toxins) with guarded prognosis. Discussion with family related to status resulted in the decision to switch Resident #1 to comfort care measures with Hospice. Resident #1 received Hospice care within the hospital setting and expired on [DATE]. During a telephone interview on [DATE] at 2:20 PM, FM E stated when she left Resident #1 around 6:30 PM on [DATE] he was walking, talking and smiling. FM E stated, .I was a little bit late getting to the facility that morning [[DATE]].about 10:30 [AM], [Resident #1] was not in the hallway like he often was before lunch.he was in the dining room sitting in a wheelchair with his head down.I called his name and he did not turn towards me, as he usually does.I touched him on the shoulder and he did not move or respond.the nurse [RN C] said he was like that when she got there around 6:30 [AM]. I [FM E] said he won't wake up, something is wrong, [RN C] told me he was probably just sleepy because [Resident #1] had been up during the night.[CNA D] told me he was up, dressed and in a chair when she got there.we took him to his room.[RN C] couldn't get him to wake up.I had to ask them to call an ambulance.the ambulance person called me from the ambulance and told me [Resident #1] symptoms were so severe he needed to go on to Memphis.[Facility #1] said he didn't have a fall, something happened, there was skin broke on his left arm. FM E stated the facility did not call her and tell her about the hematoma on Resident #1's forehead. FM E concluded she would have come in earlier and sent Resident #1 to the hospital. FM E then became emotional and ended the phone call. During a telephone interview on [DATE] at 4:38 PM, TMD #1 stated, .The nurse [LPN B] provided a picture.of a gentleman [Resident #1] with a raised area on his forehead.The nurse [LPN B] provided a detailed report of raised soft area and no complaint of pain or tenderness at site.the patient was at baseline cognitive level, and he did have an elevated BP.The nurse [LPN B] reported the patient had a history of hypertension and frequent episodes of elevated BP . TMD #1 confirmed LPN B did not report the patient's use of blood thinning medication, cognitive impairment, or status of fall risk. TMD #1 stated, .the nurse [LPN B] was very sure.clear the patient had not been involved in a fall or other trauma. TMD #1 acknowledged she gave the order to circle the area, monitor for increase in size, and follow up with changes. During a telephone interview on [DATE] at 11:39 PM, LPN B stated, .We [LPN B and CNA A] checked on [Resident #1] frequently all night [[DATE]-[DATE]].he was in bed asleep.a couple of times he was sitting on the side of the bed.[On [DATE]] about 5:30 [AM] [CNA A] was getting him up and she didn't see anything unusual.he [Resident #1] came down the hall and said good morning to me.he walked over to the door to answer because someone was knocking, that's when [CNA A] noticed the raised area on his forehead.his BP was 162/116, but that wasn't unusual for him, he has high blood pressure.I called [TMD #1], I sent a picture.the doctor knew his BP was high.I told her he had not fallen during the night, I told her there had not been any trauma.he was at baseline physically and cognitively.[Resident #1] didn't have any pain.[CNA A] had taken him outside for a while the evening before.I thought it [hematoma] could be an allergic reaction to a mosquito bite.area was soft and squishy.[TMD #1] told me to draw a line around the area to see if it gets bigger.I did not give her a list of medicines.don't recall telling her he was on a blood thinner, they can see his records and I assumed [TMD #1] looked at his meds. I didn't specifically tell [TMD #1] he was cognitively impaired or a high fall risk. Again, they [TMD #1] have access to the medical record, I assume they look at them.There wasn't any trauma that I know of.we watched him.we did not have him.1 on 1 every minute.I guess he could have fallen and got himself up.I know there wasn't an injury. The nurse confirmed she did not ask Resident #1 if he fell or what had happened due to his level of cognitive impairment. LPN B stated, .It is not likely [Resident #1] could tell me, he is on memory care for a reason.Dementia patients show pain in other ways, they don't always tell you. [Resident #1] wasn't scratching at the area, didn't look like bruising.on a blood thinner there would be a bruise, skin would be darker. LPN B was asked if she had opened an event/incident report in the EHR and replied, Yes. LPN B was asked if she performed neuro checks on Resident #1 and she responded, .Yes, I didn't document them [neuro check assessments] in the computer, I put them on the paper form. There is a place to put the neuro checks, it prompts you to add them for head injury.I'm not sure why I put them on paper, it's been a while since that [[DATE] the morning Resident #1 was observed with a hematoma on his left forehead] happened. During a telephone interview on [DATE] at 12:06 AM, CNA A stated, .I checked on him [Resident #1] frequently.he was either sleeping or sitting up on the side of the bed.the bed was in the lowest position, but he could get up.sometimes he did get up and wander around. CNA A confirmed she checked on Resident #1 during the night and was not always monitoring him because there were 15-16 other residents on the Memory Care Unit. CNA A stated the raised area was not present the night of [DATE] and she did not see it until the morning of [DATE]. CNA A stated, .I got him up and dressed him, the nurse [LPN B] took his vital signs and I walked with him to the common area. [Resident #1] was at baseline walking and talking.nothing unusual.didn't even notice the spot [hematoma] until he walked to the back door.it [hematoma] was small, soft, squishy.we [CNA A and LPN B] figured it was a reaction, like allergic to a mosquito bite.I had taken [Resident #1] outside for a little while the night [[DATE]] before.I don't remember asking [Resident #1] what happened to his head.[Resident #1] wasn't scratching at it [hematoma]. During an interview on [DATE] at 12:44 PM, the MD stated he would expect nursing staff to notify the provider to obtain an order for residents to be sent out for evaluation when any type of injury to the head was observed or suspected with use of anticoagulant therapy. The MD was asked about Resident #1's head injury on [DATE]. The MD replied, . [LPN B] called the [Named Telehealth Provider], and the resident was sent out for evaluation. The MD was unaware Resident #1 had remained in the facility for approximately 7 hours prior to being sent out per family request. The MD was asked to review the photo of Resident #1's raised area provided by LPN B to TMD #1. The MD responded, .[Resident #1] should have been sent to the hospital.high fall risk.anticoagulants.location of the area.not a lipoma.located on his forehead above the temple.not on his arm or leg.I am not here to judge another physician.on-call would depend on the nurse to report all risk and potential.should send out. The MD was asked if he would expect vital signs to be obtained and documented as part of the neurological assessments. The MD replied, Yes. The MD was asked if he expected nursing staff to obtain follow-up BP for abnormal readings and document the results. The MD replied, Yes. During a telephone interview on [DATE] at 3:05 PM, CNA D stated on [DATE] she received a report at 6:00 AM from CNA A related to Resident #1 having a raised area on his forehead. Resident #1 was sitting in a chair with a wheelchair beside him in the common area of the hall. CNA D described the raised area as .small, like a mosquito bite, like someone having an allergic reaction to a mosquito bite. CNA D stated at 7:00 AM Resident #1 got into the wheelchair and she pushed him to the dining room. Resident #1 went to sleep and did not eat breakfast. CNA D stated, .I woke him up and he just looked at it [breakfast].that wasn't unusual for him.[Resident #1] didn't eat lunch either, I woke him up and he looked over at the table, then went back to sleep.and like I said, that was not unusual for him.[FM E] came in and tried to wake him up.ask me to take him to his room.[Resident #1] woke up in the room when [FM E] shook him and patted his face.didn't talk, he just looked up and drifted back to sleep. CNA D concluded she had been around Resident #1 all morning in the dining room. CNA D was asked if she saw RN C do vital signs on Resident #1 in the dining room on [DATE]. CNA D replied, .not in the dining room, I saw her do vital signs one time and that was in the room.[FM E] told me to go get the nurse [RN C] because [Resident #1] would not wake up, [RN C] came in the room and did the BP at that time.[FM E] wanted [Resident #1] put in the bed.called [Named CNA R] to help me.[FM E] changed her mind, asked [RN C] to call an ambulance.left him in the chair. During a telephone interview on [DATE] at 12:24 PM, the Paramedic stated Resident #1 was sitting in a wheelchair, limp and slumped over when EMS arrived at the room. Resident #1 was not responsive to physical or verbal stimuli. RN C reported Resident #1's last known well time at the end of her shift (approximately 6:30 PM) on [DATE]. RN C reported Resident #1 was up and walking around when she left on [DATE] and sitting in wheelchair limp and nonresponsive when she arrived the morning (6:00 AM) of [DATE]. RN C reported staff had not witnessed any falls or any injury mechanism overnight. FM E came in to visit and requested to send Resident #1 out. Resident #1 had been sleeping all morning in his wheelchair. The Paramedic stated, .[Resident #1]'s feet were edematous [swollen with fluid].Resident #1] did make a sound when I started the IV.had flexion in his arm when we started the IV.never opened his eyes.GCS of 7. 1 for eyes [no eye opening], 2 for verbal sound [incomprehensible sounds], 4 for flexion [arm-withdrawal from pain].remained unresponsive for duration of care.We took him to [Named Hospital #2].because of his responses and the time he had been sitting with the head injury.being unresponsive gave me a high index of suspicion of traumatic brain injury or brain bleed or stroke.[Resident #1] had a right deviated gaze.gives suspicion of intercranial pressure.indicates brain bleed.Very large hematoma, about the size of a golf ball. The Paramedic confirmed Resident #1 did not wake or walk to the stretcher, his extremities were limp requiring two person lift to the stretcher, and he was never alert during transport. During an interview on [DATE] at 12:38 PM, CNA R stated on [DATE] CNA D asked her to assist with putting Resident #1 in bed. CNA R stated when she arrived at Resident #1's room, she observed Resident #1 sitting in his wheelchair with his head down and eyes closed. CNA R stated, .[Resident #1]'s wife [FM E] told me she didn't want him in the bed, she wanted an ambulance to come and get him.I tried to wake [Resident #1] up.I shook him and called his name, and he never responded.[RN C] came in the room as I was leaving. During an interview on [DATE] at 3:20 PM, RN M stated, .On [DATE] [Named RN C] called and asked what [Named Resident #1]'s baseline was because the wife said he wasn't at his baseline.[Resident #1] was normally alert, oriented to self and recognizes his wife. usually up and walking around, hard to get him to stay in one spot, anxious.I never actually went back to memory care and looked at [Resident #1].helped by documenting [Named Resident #1]'s vital signs, a progress note and printing off transfer paperwork. with a head injury and use of anticoagulants, even if the doctor did not order a transfer out, I would press on to get the order to send out.at times you have to press a little harder with the on-call doctors. During an interview on [DATE] at 3:56 PM, RN S stated she documented Resident #1's Skilled Observation Note on [DATE]. RN S acknowledged she had not actually observed Resident #1 on [DATE] and documented the information provided by RN C. RN S confirmed a resident with a head injury or possible head injury and on blood thinning medications would need to be sent out for evaluation for a brain bleed. RN S stated, .if the telehealth physician did not order the transfer, I would request the order due to the risk of brain bleed.getting evaluation and treatment could prevent death to the resident.I would complete neuro checks in the computer under the event note.if you are performing neuro checks there was a reason to open an event note.wouldn't document in progress note only. During an interview on [DATE] at 4:49 PM, LPN U confirmed residents who present with a raised area or swelling on the forehead need to be evaluated for head injury and if they are taking anticoagulants, they should be sent to the emergency room for evaluation. LPN U concluded she would call the on-call and request the transfer order due to risk of brain bleed. During an interview on [DATE] at 4:55 PM, LPN P was asked what steps she would take for a resident who presented with a raised area to their head, and she was unaware of how the injury occurred. LPN P stated, .the resident could have had a fall or accident.risk of blood clot or brain bleed.need to call someone and get him sent out even if the resident appeared fine, I would be more concerned if the resident was taking Eliquis.could be something more serious.neuro checks are done in the computer system, and they include a blood pressure check. During an interview on [DATE] at 5:16 PM, RN N stated when

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure Cardiopulmonary Resuscitation (CPR) was performed for 1 of 10 residents (Resident #1) reviewed for advance directives. The facility's failure resulted in Immediate Jeopardy (IJ) when Resident #1 was found unresponsive without respirations and staff failed to perform CPR with chest compressions and artificial respirations per the choice of Resident #1. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator, Director of Nursing, Regional Director of Clinical Services, Registered Nurse (RN) #1, Area Director Clinical Services (ADCS), Regional Director of Operation (RDO), and Licensed Practical Nurse (LPN) #2 were notified of the Immediate Jeopardy (IJ) for F-678 on [DATE] at 4:47 PM, in the Conference Room. The facility was cited F-678 at a scope and severity of J, which is substandard quality of care. A partial-extended survey was completed on [DATE]. The IJ began on [DATE] through [DATE]. The surveyor validated the facility's IJ Removal Plan on [DATE], through medical record review, audit reviews, drill observation, review of education, sign in sheets, interviews with staff and administration. The last day of Immediate Jeopardy was [DATE]. The findings include: 1. Review of the facility's policy titled Emergency Code/ CPR Procedure, Revised 2/2023, revealed .It is the policy of this facility to respond to medical emergencies for residents staff and visitors .The employee who first witnesses or is first on the site of a medical emergency, that are trained will initiate immediate action, including CPR as appropriate, will initiate basic first aid and summon for assistance. CPR will not be initiated if a DNR [Do Not Resituate] order is in place .A nurse will .Assess the situation and determine the severity of the emergency .Stay with the resident .Designate a staff member to announce a Code Blue if necessary, notify the physician and call 911 as needed .A Code Blue will be announced over the intercom system, in necessary .If the resident experiences cardiac arrest, the facility must provide basic life support, including CPR, prior to the arrival of emergency medical services .In accordance with the resident's advance directives, or .In absence of advance directives or a Do Not Resuscitate order . 2. Review of the facility's policy titled Residents' Right Regarding Treatment and Advance Directives, Revised [DATE], revealed .It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive .Advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law .relating to the provision of health care when the individual is incapacitated .On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive .Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care . 3. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses of Diabetes Mellitus, Atrial Fibrillation, Cellulitis of Abdominal Wall, and Chronic Kidney Disease. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #1 was assessed with a Brief Interview for Mental Status score (BIMs) of 15, indicating she was cognitively intact. Review of the Care Plan dated [DATE], revealed .Advance Directive .My code status is Full .Administer CPR in the event that the resident is found without pulse or respirations . Review of the Progress Notes dated [DATE], revealed .06:10 (AM) Upon making shift change rounds Resident was observed laying on right side in floor between bed and night stand table. Resident was assessed and resident was noted unresponsive to verbal or painful stimuli .No rise and fal [fall] of chest observed .911 called at 0610 . Review of the Ambulance Report dated [DATE], revealed, .ON ARRIVAL FOUND A 77 YR [year] .LYING ON RIGHT SIDE OF FLOOR BETWEEN BED, NIGHT STAND AND WALL. NO NURSE WAS AROUND AND HAD TO GET CNA [Certified Nursing Assistant] TO GET ONE. TO COME TO ROOM. WHEN NURSE CAME TO ROOM SHE TOLD ME THAT SHE WAS TRYING TO FIND OUT IF SHE [Resident #1] WAS A FULL CODE. I EXPLAINED THAT IT DID NOT MATTER DUE TO PT. [patient - Resident #1] BEING DOWN FOR SEVERAL HOURS .NURSE TOLD ME .THEY LAST CHECKED ON HER AT 6:00AM THEN THEY CHANGED THAT TIME TO 5:30 THEN AGAIN TO 4:00AM. UNKNOWN HOW LONG PT. HAD BEEN DOWN ON FLOOR. NURSE INFORMED ME THAT THEY FOUND HER WHEN THE DAY SHIFT CAME IN AND FOUND THE PT. IN BED ONE ON FLOOR WHILE TRYING TO PICK HER UP THEY FOUND THE OTHER PT [Resident #1]. AT 0616 .I PLACED MONITOR ON PT. ASYSTOLE IN 3 LEADS AT 6:20 AM. PT WAS PRONOUNCED DOA [dead on arrival] .I HAD TO GO BACK TO NURSING STATION DUE TO NURSE NOT STAYING IN ROOM WITH US . During an interview on [DATE] at 10:17 AM, Nursing Assistant (NA) #1 stated, .I peep around the curtain to check on the other lady .[Named Resident #1] and she was in the floor .she was wedged between the bed and night stand with her .her face was lying down on the floor .I told [Named Licensed Practical Nurse #1 (LPN) #1] this lady [Resident #1] was on the floor too .she [LPN #1] looked at her [Resident #1] from the foot board and said yea she [Resident #1] is gone .didn't touch her [Resident #1] or nothing .she [LPN #1] went to walk out of the room .I have never been in a situation like this and my nurse did not know what to do .I asked her [LPN #1] what are we going to do and asked if we are going to call 911 and she said go ahead and call them .I was in shock .I didn't know at that time .[if Resident #1 had died yet] .on our charting it will say full code or DNR .she [Resident #1] didn't have one .it's automatic a code .she [Resident #1] just came in a week or two and hadn't got all her stuff in the system .they [the nurses] found out after they had done some reading .that she was a full code .I walk out of the room .I call 911 .the lady [911 dispatcher] asked me was she [Resident #1] DNR .I had to go to the nurses station .and [LPN #1] was sitting down at the nurses station .I think she [LPN #1] was trying to figure out if she was a DNR .I asked her [LPN #1] .was she [Resident #1] DNR .full code .and she [LPN #1] said I don't know I'm trying to find it .she [LPN #1] tells the other nurse to take the crash cart down there [to Resident #1's room] .they [the nurses] didn't even open it .EMS [emergency medical services] was down there [in Resident #1's room] .pronounced her [Resident #1] dead at 6:20 . NA #1 confirmed an emergency procedure to perform CPR was never initiated. During an interview on [DATE] at 1:01 PM, Certified Nursing Assistant (CNA) #1 stated, .probably 6:05 [6:05 AM] .[Named NA #1] walked in there first .[Named Resident #7] was in the floor .and she [NA #1] hollered at me to come in there .I see [Named Resident #7] siting up by the door .didn't look like she [Resident #7] was hurt .she [Resident #7] was talking .she wasn't on her oxygen when we found her .[Named NA #1] went to go get the nurse .[Named LPN #1] .she came down the room and asked [Named Resident #7] how did you get in the floor .[Named NA#1] had pulled the curtain back and was saying that [Named Resident #1] .was in the floor .and bleeding .I was going to try to help get her up .she [Resident #1] wasn't moving or answering .and her arm was still in the bed .she [Resident #1] was between the night stand and the bed .I was asking are you ok .she [Named LPN #1] came in between both beds and just looked at her [Resident #1] and said she is probably gone .I couldn't see her back to see if she was breathing .I couldn't see her face .her hair was covering her face .we hadn't had her [Resident #1] long .after [LPN #1] went to the desk and sit down .she [LPN #1] didn't call a code blue [an emergency procedure to initiate CPR] .[NA#1] is on the phone with 911 .and asking if they were a code .she [referring to LPN #1] wouldn't talk to the lady on the phone .she [LPN #1] said she couldn't find what she [Resident #1] was .you are supposed to start CPR . During an interview on [DATE] at 11:16 AM, the Medical Director was asked what Resident #1's code status was. The Medical Director stated, I asked her [Resident #1] that day [day of admission] of code status .I asked her [Resident #1] specially if something was to happen what she wanted done and she said to do everything . The Medical Director was asked would you expect CPR to be initiated. The Medical Director stated, Yes .it's full code .[unless] you prove the opposite . During a telephone interview on [DATE] at 3:32 PM, LPN #1 was asked what Resident #1's code status was. LPN #1 stated, I couldn't find her code status in the system didn't know what it was at the time .might have been one in place but I couldn't find it .I think where I went wrong I left the room to check her code status .I told the graduate nurse to go get the crash cart .and [Named NA #1] asked me do I need to call 911 and I said yes . LPN #1 was asked what you did when you first walked in Resident #1's room. LPN #1 stated, .what original happened when they come in at 6:03 they were asking me to get Bed A [Resident #7] out of the floor .[Named NA #1] walked over to the side of the bed and seen she [Resident #1] was in the floor .said .she [Resident #1] is in the floor too .I immediately walked over there .I touched her .and shook her .felt for a pulse .I just looked at her for a second and it shocked me .the way her arm was up .I told [GPN #1] to get the crash cart .she was on her right side .but her right arm was up behind her .don't know how it happened . LPN #1 was asked did you call a code. LPN #1 stated, No ma'am it happened so fast .I was headed in that direction .I did tell [Named GPN #1] to call up front and tell them to come back here .I should have said page code blue .when I went to go check for code status the paramedic and police was already there .[Named Graduate Practical Nurse (GPN) #1] went back down there with the crash cart .and she couldn't get in there with the crash cart .because [Named Resident #7] was still in the floor .CNAs hadn't got her up .I don't usually get shook up .but finding her [Resident #1] like that shook me up the way her [Resident #1] arm was .it was horrible .the way it was .she [Resident #1] might have been hanging on and maybe her arm went up behind her . LPN #1 was asked how staff know if residents are a code or DNR. LPN #1 stated, It's always put in the computer .I couldn't find it that morning .I went to check her [Resident #1] code status .it just happened so fast .I told them we needed to get her [Resident #1] on her back .not trying to point fingers .the CNAs wasn't helping .not at all .I know they aren't nurses .could have got [Resident #7] out of the floor .I should have told her [GPN #1] to page up front all code blue .for some reason .I just don't know .that morning wasn't my morning threw me all the way off . LPN #1 was asked the process for code. LPN #1 stated, .to check for life .and call code blue right away .I don't know what happened .it wasn't done intentionally .I remember [Named NA #1] talking to 911 in the hallway outside of the room and I got up from the room and went to go check code status .she was on her right side .the bed was in the way .[Resident #7] would have to get up .everything was in the way . LPN #1 was asked what you should have done. LPN #1 stated, I should have stayed in that room .told the aides to call code blue and help me get [Named Resident #7] out of the floor and help me get [Named Resident #1] on her back and initiated CPR .I have been a nurse long enough to know .nothing is wrong with me .it just threw me off .I have done codes before .nurse for 13 years . During an interview on [DATE] at 10:34 AM, Paramedic #1 stated, .no one tried to do anything with her [Resident #1] .had not moved or anything .I'm not seeing how she fell out of bed .small side rail was up .the side she [Resident #1] was on .she was so large .she was on the right side .right arm .was behind her .wasn't touching anything .we had to flip her over .nobody had touched her .I could not put my monitor on her [Resident #1] till we moved the bed .no one could answer any questions .I don't know how long she had been down .it had been longer than 30 minutes .they [facility staff] should have cleared it [the room] out .it was the fire department that moved the bed and the body .so they could turn her [Resident #1] over so I could actually get to the front part of her .she was wedged . Paramedic #1 was asked what were you told the Resident #1's code status was. Paramedic #1 stated, .nobody told us anything .except the aides let us in and told us first room .didn't even tell us the patient [Resident's name] .I thought it was bed 1 [Resident #7] .the fire department walked in and found her [Resident #1] .I demanded a nurse to come down there .they told me she [LPN #1] was down there [at the nurse's station] looking for her [Resident #1] status .the actual aide that was supposed to be taking care of the patient [Resident #1] had actually left, it was the day shift aide that had found her [Resident #1] .but no one was in the room .even with me telling them you have got to get me a nurse now .I still didn't get anybody .to tell me something about the patient [Resident #1] .how long had she [Resident #1] been down .in the floor .when the last time someone checked on her . During a telephone interview on [DATE] at 2:19 PM, Graduate Practical Nurse (GPN) #1 was asked if she had taken the crash cart to Resident #1's room. GPN #1 stated, .nurse did asked me to bring it to her [Resident #1] room .I believe she [LPN #1] was at the desk .she [LPN #1] was looking for her [Resident #1] post status .and the other lady [Resident #7] was still in floor .we couldn't get in the room or anything .she [Resident #7] was right in front of A bed .at the end of her bed .she [LPN #1] was trying to figure out if she [Resident #1] was a full code or anything .we found her [Resident #1] right after shift change .you could tell she [LPN #1] went blank .I remember she [LPN #1] was asking for help .she [LPN #1] was saying get the other lady [Resident #7] off the floor .nobody came together to help out .I went back to the desk .was asked was anybody in the room and helping [Named Resident #7] and [Named Resident #1] .stated no . GPN #1 was asked did you see Resident #1. GPN #1 stated, .she was beside her bed by the window .she was like on her right side .kinda face down .her right arm was behind her back .her bed was kinda high .grab bar by her was up .she had on .shirt or gown .I was looking to see if her chest was raising .nobody was doing anything .I just looked at her .it didn't look like she was .she was kinda slumped over and you couldn't tell if she was . GPN #1 confirmed no code was initiated and stated, .now we know if you don't see their code status .go ahead and administered CPR . During an interview on [DATE] at 3:52 PM, the DON was asked what Resident #1 code status was. The DON stated Full Code . The DON confirmed Resident #1 didn't have an advance directive or a POST form and was asked what the protocol was if a resident is not listed to have a post form or advance direction. The DON stated, A full code . The DON was asked what the nurse or staff should do if they find a resident unresponsive and not breathing. The DON stated, .I think the nurse should be competent enough to start CPR .or the event of irreversible death .they should assess the patient and initiate CPR . The DON was asked what should have happened that morning when staff found Resident #1. The DON stated, .she should have assessed the patient and check for pulse .what she [LPN #1] told me was vital signs was unattainable .should have called code blue . The DON was asked should LPN #1 have left the room. The DON stated, No .you could understand it better if she was a new nurse .and maybe panic .but she has been a nurse for years . The DON confirmed LPN #1 did not call a code blue and CPR was not initiated. The DON was asked what the root cause of the incident was. The DON stated, .we don't know if she fell first or expired first .don't know if she had blood clot that had dislodge and was trying to get up and fell .we are waiting to see what the autopsy shows . The DON was asked if LPN #1 had initiated CPR would it have changed the outcome. The DON stated, .only God knows . During an interview on [DATE] at 4:53 PM, the Administrator was asked what a nurse or staff should do if they find a resident unresponsive and not breathing. The Administrator stated, .first make sure resident is position and do a quick assessment .get in touch 911 .do best practice . The Administrator was asked what Resident #1 code status was. The Administrator stated, .to my knowledge .full code .get in touch with 911 and start the CPR process .based on what I'm hearing she didn't start it . The Administrator was asked if you find a resident that is unresponsive and no pulse what should have been done. The Administrator stated, .CPR . During an interview on [DATE] at 7:55 AM, Regional Director of Clinical Reimbursement (RDCR) confirmed she had done Resident #1's care plan and stated, .she didn't have an advance directive .if you don't have an advance directive and a copy of the POST you have to treat them as a full code . The facility's acceptable IJ Removal Plan was validated onsite by the surveyor on [DATE] through policy review, medical record review, observation, review of education, sign in sheets and staff interviews conducted on all shifts. The Removal Plan was as follows: On [DATE] the Facility notified the Medical Director of the incident. This was verified by the surveyor though medical record review and interview with the Medical Director. On [DATE] The DON or designee completed a chart audit on every resident and compared the advance directives to the physician order for accuracy. This was verified by the surveyor though medical record review and interviews with the DON. On [DATE] The licensed nurse who did not perform CPR on the full code status resident was suspended pending investigation. This was verified by the surveyor though medical record review and interview with the licensed nurse. On [DATE] disciplinary action was taken with licensed nurse who did not initiate CPR on the full code resident and was suspended pending investigation. On [DATE] the nurse was terminated by the administrator and was reported to the Board of Nursing by the Director of Nursing. This was verified by the surveyor though medical record review and interviews with administration. Beginning on [DATE] the DON or designee Staff Development Coordinator (SDC) educated all licensed nurses on the facility's policy and procedure for initiating CPR and the exact steps to take when a resident is found non-responsive. Nurses on leave will receive education prior to their next scheduled shift. After [DATE] no licensed nurse will be permitted to work after without receiving the education. This was verified by the surveyor through review of the education, sign in sheets, interviews with nursing staff, DON and SDC. On [DATE] the SDC added to the orientation outline for all new employee's education regarding Code Status and how to respond to a full code resident and will assure that this education is complete and that return demonstration is performed during orientation. This was verified by the surveyor though interview with the SDC. On [DATE] a Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) by the DON. The DON to monitor for code status compliance by interviewing licensed nurses about facility CPR policy and procedure, as well as requesting return demonstration of CPR process including exactly how to respond in a code situation. Compliance checks will be conducted 2 times weekly for three months on alternating shifts. Findings will be reported at monthly QAA Committee meeting for 3 months. This was verified by the surveyor though interviews with administration. The DON or designee (SDC, Unit Manager) will audit new admissions to compare the resident's advance directives to the physician orders for accuracy. This audit will continue daily and will be ongoing. The findings will be reviewed at the monthly QAA Committee meeting for 3 months. This was verified by the surveyor though audit review and interviews with staff and the DON. The Unit managers and SDC initiated a Code Blue drill on all shifts for 48 hours with licensed nursing staff. Drills will continue to be held 2 times a month for 3 months. The findings will be reviewed at the monthly QAA Committee meeting for 3 months. This was verified by the surveyor though drill observation, sign in sheets and interviews with the SDC and staff. Upon admission, change of status and quarterly code status will be reviewed with resident and/or responsible party, during resident's care plan meeting (in attendance for care plan meetings are: Social services director, MDS coordinator, Dietary manager, Activities, and Unit Manager). Clinical representative (Unit Manager or DON) will review code status and POST form with resident and/or responsible party. Any changes will be discussed with the MD (by the DON or Unit Manager) and an updated order will be obtained. Residents care plan and face sheet will be updated at that time. Residents face sheet banner in EMR will notify nursing personnel of change. A full code residents banner is GREEN and a DNR residents banner is RED. This was verified by the surveyor though medical record review and interviews with staff and DON. The facility's noncompliance of F-678 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.