**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 4 residents reviewed for quality of care. LVN A failed to read an abnormal x-ray result, resulting in Resident #1 experiencing pain with a hip fracture for 2 days before Resident #1 was hospitalized for evaluation. A past noncompliance Immediate Jeopardy was determined to have existed from 4/8/2025 to 4/10/2025. While the IJ was removed on 4/11/2025, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with the potential for more than minimal harm to resident health or safety due to the facility's need to implement corrective systems. The facility implemented actions that corrected the IJ on 4/11/2025 before the surveyor's entry. This failure could place residents at risk of delayed medical evaluation, treatment, and decrease in quality of care. Findings included: Review of Resident #1's face sheet, dated 4/23/2025, revealed resident was a [AGE] year-old female admitted on [DATE] with diagnoses of muscle weakness, dementia, and hypertension. Review of Resident #1's MDS assessment, dated 2/17/2025, revealed that resident's BIMS score was 4 out of 15 , indicating Resident #1 has low cognitive function. Review of Resident #1's Fall risk assessment, dated 4/5/2025, revealed that Resident #1 had balance problems while walking, decreased muscular coordination, and required use of assistive devices. Review of Resident #1's nursing note, dated 4/5/2025 at 9pm, LVN I documented that Resident #1 on 4/5/2025 during dinner time stood on the door way calling and asking if someone could help her .[Resident #1] said that she fell and was hurting on her left side of the torso. When she was asked how she fell and what she was doing at the time, the resident doesn't know and doesn't remember how it happened. Head to toe assessment was done. LVN I also indicated in this note that NP was notified and X-ray orders were obtained. Order for Tylenol extra strength 500mg tablets by mouth was also placed. Review of Resident #1's nursing note, dated 4/6/2025 at 8pm, LVN I reported and faxed negative X-ray result to NP. Review of Resident #1's nursing note, dated 4/8/2025 at 1:54pm, LVN B performed pain assessment which showed Resident #1 was in pain on her left hip and left waist. LVN B notified NP at 10:17am, LVN B notified Resident 1's family member]at 11:16am, stat X-ray was ordered. Review of nursing note, dated 4/8/2025 at 10:24pm, LVN A stated X-ray result faxed to NP for review no new orders. Review of Resident #1's nursing note, dated 4/10/2025 at 10:18am, LVN B noted [Resident #1] complains of pain to left side of body . Routine pain managements appear to be not effective as resident continues to complain of increased pain . Resident appears to be dragging left leg when attempting to make a step. All previous X-ray results to bilateral hips and waists and chest X-ray were negative. LVN B also noted that NP was consulted, EMS was called, and Resident #1's grandson was notified. Review of hospital record, dated 4/10/2025, revealed that x-ray done on 4/10/2025 at the hospital showed fracture to the left hip. Treatment in the hospital included pain management with Tylenol and Robaxin. Review of Resident #1's bilateral hips X-ray result, dated 4/8/2025, revealed that the impression of her left hip X-ray was stable acute appearing nondisplaced fracture noted of the superior and inferior of the left pubic rami (left pelvic fracture). In an observation and interview on 4/23/2025 at 12:30pm, Resident #1 was sitting in her wheelchair in the dining room. Resident #1 stated that she did not remember why she fell, but she remembered having a fracture. She stated that she was still having some discomfort from the fall, especially when she had to shift herself in the wheelchair. She stated that the pain had been interfering with her activities of daily living but she stated that pain was improving. In an interview on 4/23/2025 at 12:15pm, LVN B stated that on 4/8/2025, LVN B consulted the NP to order a stat X-ray because Resident #1 was still complaining of pain. When she left her shift on 4/8/2025, the result had not come back, so she relayed the message to LVN A to look out for the result. LVN A read the result on the evening of 4/8/2025, and reported to LVN B on morning of 4/9/2025 as negative via verbal reporting. LVN B did not look at the report and only took LVN A's verbal report. LVN B stated that when Resident #1 was sent to the hospital on 4/10/2025, she retrieved the X-ray report on 4/8/2025 from Resident #1's chart and realized that LVN A has misread the result. In an interview on 4/23/2025 at 1pm, the NP stated that she could not remember exactly what happened, but she remembered Resident #1 had 2 negative X-rays. She stated the fax of the second X-ray result on 4/8/2025, never got to her so LVN A called her to read the X-ray result verbally. On 4/23/2025 at 2:45pm, an attempt to interview LVN A via phone was unsuccessful. An Immediate Jeopardy (IJ) was determined to have existed from 4/8/2025 to 4/10/2025. The facility Administrator was provided the Immediate Jeopardy Template on 4/23/2025 at 3:39pm. Review of the facility's Provider Investigation Report, dated 04/11/25, revealed: The charge nurse will notify NP/MD of any changes of condition noted in a resident. If there is no response from either, the charge nurse will call again and if no answer they will send the resident to the ER . . Any fractures must be reported to DON/ADON as soon as the charge nurse becomes aware of them. Along with faxing X-ray results you must call the NP/MD and document notification. . Failure to review X-ray findings timely could delay care and be considered neglect. .ADON/DON will have all labs and X-ray results in the morning meeting to review daily. Labs and X-ray reports must be reviewed upon receipt. This involves reading the whole lab or x-ray report first page to however many pages follow. Once the report is read and there are abnormal findings the physician or NP must be called; this is not an option. After notifying them of the report the nurse is to document MD notification of x-ray report . In an interview on 4/23/2025 at 3:40pm, LVN C, who was a night shift nurse, stated that when he received an x-ray result, he would fax it to NP/MD, then call them to report the result, read every single page on the report, and report to ADON/DON. He stated that the risk of not reading the x-ray result correctly put the residents at risk for more pain and incorrect care. He was in-serviced about reading x-ray results and reporting to NP/MD 2 weeks ago. In an interview on 4/23/2025 at 3:48pm, LVN D, who was a day shift nurse, stated that the process of reporting x-ray result to NP/MD included: receiving the result, reviewing the result by reading all pages, calling NP/MD to report, and faxing the result to NP/MD, reporting to ADON/DON if any results came back abnormal. She stated the risk of reading incorrect results could lead to residents having increased pain, and risk of infection. She stated she was in-serviced a few weeks ago. In an interview on 4/23/2025 at 3:58pm, RN E who was a wound nurse, stated that she had not had to call NP/MD to report an imaging result. She stated she was in-serviced a couple of weeks ago. She stated that the process of report any abnormal labs or imaging results included: receiving the results, if abnormal, notify ADON/DON and NP immediately, read the result every single page, call NP/MD, fax the reports to NP/MD. She also stated that ADON/DON and Administrator met with all nurses to talk about the incident on 4/8/2025. She stated that the in-service included training all nurses to read all pages of reports and fax reports to the correct numbers. In an interview on 4/23/2025 at 4:17pm, LVN F, who usually worked weekend shifts, stated that once he received an anormal lab or abnormal imaging result, he reported to NP/MD and ADON/DON immediately. He also stated that ADON/DON also started going over 24-hour reports with all nurses every morning to look at any abnormal lab results or imaging findings. In an interview on 4/24/2025 at 11:30am, the DON stated that when Resident #1 was sent to the hospital on 4/10/2025, the DON, regional nurse, and all nurses reviewed Resident #1's clinical records to see what they missed and why the Resident #1 continued to have pain. DON stated they realized after looking at the X-ray on 4/8/2025 they had missed the fracture result. LVN A was in-serviced immediately. DON stated that LVN A told her she only saw 1 page of the report and that page stated no fracture, so she reported a negative result to the NP. The DON stated that all nurses were in-serviced immediately. The new process included: all nurses to let the DON know of any abnormal lab or imaging results, and report to NP/MD. ADON and DON would go over each resident's 24-hour report during every morning meeting to review all labs and imaging results. DON also stated that she printed out a sticker listing correct fax numbers for NP and MD at all nurse stations. DON stated that she expected nurses to do their own auditing after they report results to NP/MD and during morning meeting ADON/DON would do second layer of auditing. She stated that the risks to residents included life-threatening injuries, pain, fracture, infection. The facility provided the following in-service training topics: _Pain management, dated 4/10/2025 _Notification of changes, dated 4/10/2025 _Abuse and Neglect, dated 4/10/2025 _Resident Rights, dated 4/10/2025 _Incident reporting/fall assessment, dated 4/10/2025 _Lab and X-ray review and documentation, dated 4/11/2025 The facility also provided 1:1 in-service/coaching record between the DON and LVN A, with topic of X-ray not properly read by nurse and reported incorrect information. Signed and dated by DON & LVN A, dated 4/11/2025. Review of the facility's policy on Notifying Physician of Change in Status , dated 3/11/2023, revealed that The nurse will notify the physician immediately with significant change in status . Abnormal lab, x-ray and other diagnostic reports require physician notification. The IJ was removed on 4/11/2025 because the facility implemented actions that corrected the the IJ prior to 4/23/2025 entry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for 1 (Resident #1) of 4 residents reviewed for quality of care. LVN A failed to read an abnormal x-ray result, resulting in Resident #1 experiencing pain with a hip fracture for 2 days before Resident #1 was hospitalized for evaluation. A past noncompliance Immediate Jeopardy was determined to have existed from 4/8/2025 to 4/10/2025. While the IJ was removed on 4/11/2025, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with the potential for more than minimal harm to resident health or safety due to the facility's need to implement corrective systems. The facility implemented actions that corrected the IJ on 4/11/2025 before the surveyor's entry. This failure could place residents at risk of delayed medical evaluation, treatment, and decrease in quality of care. Findings included: Review of Resident #1's face sheet, dated 4/23/2025, revealed resident was a [AGE] year-old female admitted on [DATE] with diagnoses of muscle weakness, dementia, and hypertension. Review of Resident #1's MDS assessment, dated 2/17/2025, revealed that resident's BIMS score was 4 out of 15 , indicating Resident #1 has low cognitive function. Review of Resident #1's nursing note, dated 4/8/2025 at 1:54pm, LVN B performed pain assessment which showed Resident #1 was in pain on her left hip and left waist. LVN B notified NP at 10:17am, LVN B notified Resident 1's family member]at 11:16am, stat X-ray was ordered. Review of nursing note, dated 4/8/2025 at 10:24pm, LVN A stated X-ray result faxed to NP for review no new orders. Review of Resident #1's nursing note, dated 4/10/2025 at 10:18am, LVN B noted [Resident #1] complains of pain to left side of body . Routine pain managements appear to be not effective as resident continues to complain of increased pain . Resident appears to be dragging left leg when attempting to make a step. All previous X-ray results to bilateral hips and waists and chest X-ray were negative. LVN B also noted that NP was consulted, EMS was called, and Resident #1's grandson was notified. Review of hospital record, dated 4/10/2025, revealed that x-ray done on 4/10/2025 at the hospital showed fracture to the left hip. Treatment in the hospital included pain management with Tylenol and Robaxin. Review of Resident #1's bilateral hips X-ray result, dated 4/8/2025, revealed that the impression of her left hip X-ray was stable acute appearing nondisplaced fracture noted of the superior and inferior of the left pubic rami (left pelvic fracture). In an observation and interview on 4/23/2025 at 12:30pm, Resident #1 was sitting in her wheelchair in the dining room. Resident #1 stated that she did not remember why she fell, but she remembered having a fracture. She stated that she was still having some discomfort from the fall, especially when she had to shift herself in the wheelchair. She stated that the pain had been interfering with her activities of daily living but she stated that pain was improving. In an interview on 4/23/2025 at 12:15pm, LVN B stated that on 4/8/2025, LVN B consulted the NP to order a stat X-ray because Resident #1 was still complaining of pain. When she left her shift on 4/8/2025, the result had not come back, so she relayed the message to LVN A to look out for the result. LVN A read the result on the evening of 4/8/2025, and reported to LVN B on morning of 4/9/2025 as negative via verbal reporting. LVN B did not look at the report and only took LVN A's verbal report. LVN B stated that when Resident #1 was sent to the hospital on 4/10/2025, she retrieved the X-ray report on 4/8/2025 from Resident #1's chart and realized that LVN A has misread the result. In an interview on 4/23/2025 at 1pm, the NP stated that she could not remember exactly what happened, but she remembered Resident #1 had 2 negative X-rays. She stated the fax of the second X-ray result on 4/8/2025, never got to her so LVN A called her to read the X-ray result verbally. On 4/23/2025 at 2:45pm, an attempt to interview LVN A via phone was unsuccessful. An Immediate Jeopardy (IJ) was determined to have existed from 4/8/2025 to 4/10/2025. The facility Administrator was provided the Immediate Jeopardy Template on 4/23/2025 at 3:39pm. Review of the facility's Provider Investigation Report, dated 04/11/25, revealed: The charge nurse will notify NP/MD of any changes of condition noted in a resident. If there is no response from either, the charge nurse will call again and if no answer they will send the resident to the ER . . Any fractures must be reported to DON/ADON as soon as the charge nurse becomes aware of them. Along with faxing X-ray results you must call the NP/MD and document notification. . Failure to review X-ray findings timely could delay care and be considered neglect. .ADON/DON will have all labs and X-ray results in the morning meeting to review daily. Labs and X-ray reports must be reviewed upon receipt. This involves reading the whole lab or x-ray report first page to however many pages follow. Once the report is read and there are abnormal findings the physician or NP must be called; this is not an option. After notifying them of the report the nurse is to document MD notification of x-ray report . In an interview on 4/23/2025 at 3:40pm, LVN C, who was a night shift nurse, stated that when he received an x-ray result, he would fax it to NP/MD, then call them to report the result, read every single page on the report, and report to ADON/DON. He stated that the risk of not reading the x-ray result correctly put the residents at risk for more pain and incorrect care. He was in-serviced about reading x-ray results and reporting to NP/MD 2 weeks ago. In an interview on 4/23/2025 at 3:48pm, LVN D, who was a day shift nurse, stated that the process of reporting x-ray result to NP/MD included: receiving the result, reviewing the result by reading all pages, calling NP/MD to report, and faxing the result to NP/MD, reporting to ADON/DON if any results came back abnormal. She stated the risk of reading incorrect results could lead to residents having increased pain, and risk of infection. She stated she was in-serviced a few weeks ago. In an interview on 4/23/2025 at 3:58pm, RN E who was a wound nurse, stated that she had not had to call NP/MD to report an imaging result. She stated she was in-serviced a couple of weeks ago. She stated that the process of report any abnormal labs or imaging results included: receiving the results, if abnormal, notify ADON/DON and NP immediately, read the result every single page, call NP/MD, fax the reports to NP/MD. She also stated that ADON/DON and Administrator met with all nurses to talk about the incident on 4/8/2025. She stated that the in-service included training all nurses to read all pages of reports and fax reports to the correct numbers. In an interview on 4/23/2025 at 4:17pm, LVN F, who usually worked weekend shifts, stated that once he received an anormal lab or abnormal imaging result, he reported to NP/MD and ADON/DON immediately. He also stated that ADON/DON also started going over 24-hour reports with all nurses every morning to look at any abnormal lab results or imaging findings. In an interview on 4/24/2025 at 11:30am, the DON stated that when Resident #1 was sent to the hospital on 4/10/2025, the DON, regional nurse, and all nurses reviewed Resident #1's clinical records to see what they missed and why the Resident #1 continued to have pain. DON stated they realized after looking at the X-ray on 4/8/2025 they had missed the fracture result. LVN A was in-serviced immediately. DON stated that LVN A told her she only saw 1 page of the report and that page stated no fracture, so she reported a negative result to the NP. The DON stated that all nurses were in-serviced immediately. The new process included: all nurses to let the DON know of any abnormal lab or imaging results, and report to NP/MD. ADON and DON would go over each resident's 24-hour report during every morning meeting to review all labs and imaging results. DON also stated that she printed out a sticker listing correct fax numbers for NP and MD at all nurse stations. DON stated that she expected nurses to do their own auditing after they report results to NP/MD and during morning meeting ADON/DON would do second layer of auditing. She stated that the risks to residents included life-threatening injuries, pain, fracture, infection. The facility provided the following in-service training topics: _Pain management, dated 4/10/2025 _Notification of changes, dated 4/10/2025 _Abuse and Neglect, dated 4/10/2025 _Resident Rights, dated 4/10/2025 _Incident reporting/fall assessment, dated 4/10/2025 _Lab and X-ray review and documentation, dated 4/11/2025 The facility also provided 1:1 in-service/coaching record between the DON and LVN A, with topic of X-ray not properly read by nurse and reported incorrect information. Signed and dated by DON & LVN A, dated 4/11/2025. Review of the facility's policy on Notifying Physician of Change in Status , dated 3/11/2023, revealed that The nurse will notify the physician immediately with significant change in status . Abnormal lab, x-ray and other diagnostic reports require physician notification. The IJ was removed on 4/11/2025 because the facility implemented actions that corrected the the IJ prior to 4/23/2025 entry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician; and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status that was, a deterioration in health, mental, or psychosocial status in either life threatening conditions or clinical complications, for one of three residents (Resident #1) reviewed for notification of changes. 1. The facility failed to immediately notified the physician of a change in condition or decline when Resident #1 experienced shortness of breath and required as needed breathing treatments and oxygen therapy on [DATE] and [DATE]. There was no documented evidence that the facility attempted to notify the physician on [DATE] on 2P - 10P and 10P - 6A shifts or during any shift (6A - 2P, 2P - 10P, 10P - 6A) on [DATE] there was a need to alter treatment significantly, decide to transfer, or discharge Resident #1 to the hospital. On [DATE], Resident #1 was transferred to the ER. Resident #1 was intubated and passed away at the hospital. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems . These failures could place residents at risk of serious injury, harm, impairment, or death . Findings included: Record review of Resident #1's MDS significant change in status assessment, dated [DATE], reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had active diagnoses which included COPD (a common lung disease that makes it difficult to breathe) and Other Secondary Pulmonary Hypertension (a chronic condition that occurs when pulmonary hypertension is caused by a known risk factor or underlying disease. [symptoms include Shortness of breath, at first while exercising and eventually while at rest; Blue or gray skin color due to low oxygen levels; Chest pressure or pain; Dizziness or fainting spells; Fast pulse or pounding heartbeat; Fatigue]). Resident #1's most recent re-entry to the facility was [DATE] with a diagnosis which included Displaced Commuted Fracture of Shaft of Right Femur. The MDS assessment reflected no known shortness of breath or trouble breathing with exertion, when sitting at rest, or when lying flat. Record review of Resident #1's Order Summary Report reflected: - Physician written Order date - [DATE]: Administer oxygen at 2 LPM via NC continuously every night for SOB (D/C : [DATE]) - Physician written Order date - [DATE]: Tylenol Oral Tablet 325 Mg (Acetaminophen). Give 2 tablets by mouth every 4 hours as needed for pain. (D/C: [DATE]) - Physician written Order date - [DATE]: Oxygen 2 LPM as needed for SOB - Physician written Order date - [DATE]: Ipratropium-Albuterol Solution 0.5-2.5, 3mg/3mL. 3mL inhale orally via nebulizer every 8 hours as needed for SOB or Wheezing. - Verbal Order date - [DATE]: Acetaminophen-Codeine Oral Tablet 300-60 mg (Acetaminophen with Codeine) Give 1 tablet by mouth every 6 hours as needed for pain (pain level 7 - 10) for 30 days. Do not exceed >4,000 mg/24 hrs - Verbal Order date - [DATE]: Tramadol Oral Tablet 50 mg. Give 1 tablet by mouth every 8 hours for pain for mild to moderate pain (pain level 1 - 5) - Phone Order date - [DATE]: Send patient to the hospital for SOB for further evaluation and treatment as indicated. Record review of Resident #1's [DATE] TAR reflected he was administered Ipratropium-Albuterol Solution 0.5-2.5, 3mg/3mL. 3mL inhale orally via nebulizer for SOB or Wheezing on [DATE] at 9:09 AM (O2 Sat = 94%) by LVN A; [DATE] at 5:13 PM (O2 Sat = 93%) by LVN B. Both breathing treatments were documented as effective. Record review of Resident #1's care plan, last reviewed [DATE], reflected, [Resident #1] has oxygen therapy PRN (Date initiated: [DATE]). Goal: [Resident #1] will have no s/sx of poor oxygen absorption through the review date (Date initiated: [DATE]; Target Date: [DATE]). Interventions included: Monitor for s/sx of respiratory distress and report to MD PRN; Respirations, pulse oximetry, increased heart rate . lethargy, confusion . accessory muscle usage, skin color (Initiated: [DATE]) Record review of Resident #1's vital signs summary reflected the following. There were not a full set of vitals (Temperature, Pulse, Respirations, Blood Pressure, Oxygen Saturation, and Pain) on [DATE] - [DATE] in the Vitals Summary: Temperature values: [DATE] at 2:34 PM (98.0 F via Forehead [non-contact]) - entered by LVN A Pulse value: [DATE] at 9:44 AM (60 bpm) - entered by LVN A; [DATE] at 7:48 PM (64 bpm) - entered by MA E; [DATE] at 10:21 AM (68 bpm ) - entered by LVN A; [DATE] at 8:19 PM (69 bpm) - entered by MA D; [DATE] at 10:25 AM (90 bpm) - entered by LVN C. Respiration values: [DATE] at 2:34 PM (18 breaths/min ) - entered by LVN A O2 Sats values [Range 96% - 97% on RA]: [DATE] at 9:09 AM (94%; with Oxygen via NC) - entered by LVN A; [DATE] at 5:13 PM (93%; with Oxygen via NC) - entered by LVN B. The amount of oxygen received was not documented. Record review of Resident #1's progress notes reflected: - Nursing Progress Note Effective Date: [DATE] at 2:55 PM, LVN A entered, Resident noted with SOB after coming from therapy, O2 Sat checked 88%, oxygen 2 Liters via nasal canula and breathing treatment administered. O2 Sat rechecked later and was 90 - 91%. NP called and left a message, [RP] also notified. Remain on oxygen therapy and coming nurse notified to continue to monitor. - Nursing Progress Note Effective Date: [DATE] at 10:25 PM, LVN B did not reflect an attempt to contact the MD/NP about Resident #1's O2 Sat at 91% -92% while he received oxygen 3 LPM via NC or when O2 Sat was 90% - 92% during bedtime and that [Resident #1] would not leave the oxygen in place . - Nursing Progress Note Effective Date: [DATE] at 3:10 PM, LVN A did not reflect an attempt to contact the MD/NP that [Resident #1] Continued to monitor resident for SOB, O2 Sat 94 - 96%. Breathing treatment administered and tolerated well. - Nursing Progress Note Effective Date: [DATE] at 9:17 PM, LVN B did not reflect an attempt to contact the MD/NP that [Resident #1] was administered pain meds and breathing treatment. Well tolerated. After therapy and oxygen remains 92% - 93% - Nursing Progress Note Effective Date: [DATE] at 1:30 PM, LVN C entered, [Resident #1] with increased SOB even though he is on 2LPM via NC, BP - 130/80, P-120, R-22, T-103.1 F. Breathing treatment was administered. Tylenol 500 mg 1 tablet was given for fever at this time. NP was notified via phone and gave order for patient to be sent to [hospital] for further evaluation and treatment as indicated. 911 call was initiated at this time. At 2PM the ambulance left . At 2:05 PM the RP was notified about the change of condition of patient . The ADON was called and updated via voicemail. The 10P - 6A nurse(s) did not enter progress notes that reflected an attempt to contact the MD/NP on [DATE] or [DATE]. Record review of Resident #1's [DATE] MAR/TARs did not reflect administration of pain medications at any time on [DATE] - [DATE]. The MAR/TARs did not reflect a breathing treatment administered on [DATE] or [DATE]. Record review of a SBAR note, dated [DATE], written by LVN C, reflected the primary provider was contacted at 1:50 PM about [Resident #1] with a Respiratory Change-Suspected Infection. BP - 130/80; P - 120; R - 22; T - 103.1 F; O2 Sat - 90%; received oxygen at 2lpm via NC. Suspected respiratory infection r/t fever > 102 F, abnormal lung sounds (bilateral lower lobes [sound heard not listed]), and shortness of breath .This started on and/or symptoms first appeared: [DATE] .[breathing treatment(s)] attempted to help resolve . This condition, symptom, or sign has occurred before with antibiotics. Record review of Resident #1's chart did not reflect other SBARs were documented between [DATE] - [DATE] or indicated MD/NP notification. A record review of the 24 Hour Report for [DATE] reflected dated reports [DATE] - [DATE]. The next 24-hour report was undated and reflected remarks related to [Resident #1] Day shift - monitor for SOB; Evening shift - SOB at 9:30 PM, 92%, pain management. There were no remarks for the Night shift. The next 24-hour report was dated [DATE] and reflected remarks related to Resident #1. Day shift - continue to monitor for SOB, O2 94%. There was no remark for the Evening shift. Night shift - monitor SOB. The 24-hour report dated [DATE] reflected Resident #1 was sent out to [hospital] for SOB, elevated temperature, and elevated heart rate. The Night shift entered Monitor SOB. Resident #1 did not return to the facility. Resident #1 passed away at the hospital. Record review of an Occupational Therapy Treatment Encounter Note, dated [DATE], entered by COTA D, reflected, [Resident #1] participated in task presented, but demonstrated increased fatigue and weakness. [Resident #1] continues to demonstrate decline in health and fear of falling while seated in wheelchair. [Resident #1] also demonstrated labored breathing when he is given his utensils to participate in feeding A record review of Resident #1's hospital medical records, dated [DATE], reflected [Resident #1] arrived at the ED on [DATE] at 2:51 PM. The reason for visit reflected Fever and high heart rate for 3 days. The visit diagnoses included Acute hypoxic respiratory failure. The ED provider notes reflected EMS states [facility] staff reported [Resident #1] with worsened confusion from baseline for the past 2 days. EMS states [Resident #1] was noted to be SOB and in mild respiratory distress on arrival and was given an albuterol/Atrovent treatment, 125 mg solumedrol, and 1 Liter bolus fluids enroute. Facility denied any falls or trauma, however history otherwise limited. Initial assessment reflected a temperature of 105 degrees Fahrenheit, heart rate of 170 bpm, lung sounds crackle bilaterally, and was started on BiPAP (a device that helps you breathe) on arrival due to respiratory distress. Resident #1 was intubated [[DATE]] at 5:20 PM. The lowest O2 saturation during intubation was 92%. CPR was initiated on [DATE] at 5:31 PM. Resident #1 ultimately expired. Time of death was called at 6:27 PM. The final diagnosis was Acute hypoxic respiratory failure that led to Cardiac arrest. During an interview on [DATE] at 2:21 PM, the ADON stated she was informed about Resident #1's episodes of shortness of breath on [DATE]. The ADON said interventions were implemented as ordered - supplemental oxygen and breathing treatments as needed. The ADON said no significant concerns were reported to her. The ADON said she expected for nurses to initiate nursing interventions, notify the MD/NP, and notify the RP; as well as notify the ADON and DON . The ADON said vital signs should be monitored daily as ordered and as needed. The ADON said any changes in vital signs, behavior, level of functioning from a resident baseline should be documented and reported. The ADON stated therapy staff would monitor a resident oxygen level of concerned and always communicated with nursing staff. During an interview on [DATE] at 1:56 PM, CNA F stated she worked Friday, [DATE] and Saturday, [DATE], 6A - 2P shifts. CNA F said she notified LVN A on Friday morning that Resident #1 appeared to have difficulty breathing, even with oxygen. CNA F demonstrated shallow breathing and other than normal rise and fall of the chest. CNA F said Resident #1 felt warm to touch. CNA F said LVN A assessed Resident #1 and told [CNA F] he did not have an elevated temperature. During an interview on [DATE] at 2:44 PM, LVN B stated she worked Thursday, [DATE] and Friday, [DATE], 2P - 10P shifts. LVN B stated she received verbal handoff shift report from LVN A on Thursday, [DATE] at 2:00 PM. LVN B said [LVN A] reported Resident #1 had shortness of breath when he returned from therapy, received a breathing treatment, and was on oxygen therapy. [LVN A] said to monitor for shortness of breath. LVN B said she did not notify the MD/NP because she figured LVN A called during the day shift (6A - 2P). LVN B said she checked Resident # 1's vital signs and O2 Sat after occupational therapy and applied oxygen, but there were no other concerns. LVN B said Resident #1's RP visited on [DATE] and requested Resident #1 get up out of bed. LVN B said she tried to explain to the RP that Resident #1 was in bed to be monitored for shortness of breath. LVN B said Resident #1 was assisted up to his wheelchair and went to occupational therapy. LVN B said she had to administer a breathing treatment when Resident #1 returned from therapy after dinner. LVN B denied inspection for abnormal findings such as blue or pale discoloration, labored breathing, or listening to lung sounds. LVN B said unexpected respiratory findings should be reported to the MD/NP immediately included a decreased oxygen saturation of less than 92%, restlessness, and increased difficulty breathing. During an interview on [DATE] at 4:13 PM, LVN C stated she worked Saturday, [DATE], 6A - 10P shift. LVN C stated she received verbal handoff shift report from the overnight nurse to monitor Resident #1 for shortness of breath. LVN C said she inquired if Resident #1 had pneumonia and the nurse stated to monitor for shortness of breath. LVN C said she observed Resident #1 in his room during change of shift walking rounds and he received oxygen via NC. LVN C said she worked weekend doubles and Resident #1 did not receive oxygen continuously the previous weekends. LVN C said she asked the CNA to come get her when ADLs were provided to Resident #1 so she could monitor breathing when repositioned. LVN C said when she assisted with Resident #1's ADLs, she noticed Resident #1 had difficulty breathing. LVN C said she raised the head of the bed when they finished to help Resident #1 breathe a little easier. LVN C said when she checked Resident #1's vital signs after breakfast, and he was breathing fast and had an elevated temperature. LVN C said she administered a breathing treatment, administered Tylenol for the fever, and when Resident #1 did not appear to improve, notified the NP ([DATE] at 1:30 PM), called 911, and transferred Resident #1 to the hospital An attempt to interview the PCP on [DATE] at 1:34 PM was routed to an automated voicemail. A message identified caller, explained purpose of call, and a callback number was left on the voicemail. No callback was received. Interview on [DATE] at 2:23 PM, LVN A stated she worked Thursday, [DATE] and Friday, [DATE], 6A - 2P shifts. LVN A said therapy staff reported on [DATE] Resident #1 had shortness of breath. LVN A said she checked Resident #1's O2 Sats. LVN A said [Resident #1] oxygen level was low (less than 90%) and administered a breathing treatment and applied oxygen via nasal cannula. LVN A said the breathing treatment was effective. LVN A said she left a message for the NP and did not receive a callback before her end of shift at 2 PM. LVN A said she reported to the oncoming nurse (LVN B) to monitor Resident #1 for shortness of breath. LVN A said to monitor meant to watch for signs of shortness of breath, like a low oxygen level. LVN A said the next nurse would be responsible to call the MD/NP if they had concerns to report. LVN A said she checked Resident #1's vital signs and he did not have a temperature. LVN A said she listened to Resident #1's lungs but could not describe what she heard. LVN A said Resident #1's lungs were clear. LVN A said a breathing treatment was administered on [DATE] and it was effective. During an interview on [DATE] at 1:27 PM, the NP indicated it was not unusual not to call back if she received a page from the facility nurse. The NP stated if the nurse did not hear back [from the NP] within 15 minutes, she should have tried to call again. The NP stated Resident #1 had a diagnosis of cardiomegaly (an enlarged heart), COPD (a group of diseases that cause airflow blockage and breathing-related problems), and a medical history of pneumonia that she would have suggested a PRN diuretic and a chest x-ray had she received a call about the change in condition before Saturday, [DATE]. The NP said the suggested treatments would have been ineffective by Saturday ([DATE]) and sending Resident #1 to the hospital for a higher level of care was the best treatment option at the time. The NP stated she may have requested a COVID test if demonstrated temperature and/or cough. A record review of the facility's policy titled, Significant Change in Condition, Response, revised [DATE], reflected 1. If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware 4. The nurse will communicate the change to other departments as appropriate and updated communications will be available during morning report Record review of the facility's Notifying the Physician of Change in Status policy, revised [DATE], reflected: The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgment deem it necessary for immediate medical attention. This facility utilizes the INTERACT tool, Change in Condition - When to Notify the MD/NP/PA to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on Next Work day notification of the physician. This was determined to be an Immediate Jeopardy (IF) on [DATE] at 5:50 PM. The NFA was notified and was provided with the IJ template on [DATE] at 5:50 PM . The following Plan of Removal submitted by the facility was accepted on [DATE] at 3:17 PM: All residents have the potential to be affected by this deficient practice. Interventions: All residents in the facility were assessed for any change of condition by the DON, ADON and Charge Nurses as of [DATE]. No additional issues were found. DON, ADON will audit all resident nursing notes for a change of condition to ensure notification of changes to the attending physician/nurse partitioner. Completed [DATE]. Going forward the DON/ADON/designee will monitor progress notes for a change in condition and notification to the attending physician/nurse practitioner daily during the morning clinical meeting. All residents with orders for oxygen continuous and as needed had oxygen saturation levels obtained as of [DATE] by the DON/ADON. No additional issues were found. LVN A and LVN B were immediately suspended pending investigation on [DATE]. LVN A and LVN B will not be permitted to return to work or provide care to residents until the following 1:1 in-services have been completed by the DON or Compliance Nurse. Completed [DATE]. Abuse and Neglect-failure to perform and assessment and notify a NP/MD for a resident change in condition could be considered neglect. Performing an assessment and providing care to residents who are experiencing a change in condition or respiratory distress. Notification of change of condition to the physician immediately. If any staff members notice a resident in respiratory distress, they will notify a charge nurse or DON immediately. All charge nurses will notify the NP or the Attending MD after an assessment is performed. If the NP cannot be reached, the Attending or Medical Director will be notified. The medical director was notified by the administrator of this plan on [DATE]. An Ad Hoc QAPI meeting to include the Director and IDT team was held [DATE]. In-services: All charge nurses will be in-serviced by [DATE] by the DON/ ADON regarding the following and all nurses not in-serviced by [DATE] will not be allowed to work their assigned position until completion of these in-services. All PRN staff, new hires, and agency staff will be in-serviced prior to start of their shift. The Administrator, DON and ADON were in-serviced 1: 1 by Compliance Nurse. Abuse and Neglect- failure to perform and assessment and notify a NP/MD for a resident change in condition could be considered neglect. Performing an assessment and providing care to residents who are experiencing a change in condition or respiratory distress including not limited to: 02 saturation on room air or with oxygen and how much oxygen if applicable, skin color, any use of accessory muscle, lung sounds, any purses lip breathing, is the head of the bed flat or elevated. What interventions have you provided to the resident non pharmacological or pharmacological . Notification of the MD and RP. Notification of change of condition to the physician immediately. If any staff members notice a resident in respiratory distress, they will notify a charge nurse or DON immediately. All charge nurses will notify the NP or the Attending MD after an assessment is performed. If the NP cannot be reached, the Attending or Medical Director will be notified. The medical director was notified by the administrator of this plan on [DATE]. An Ad Hoc QAPI meeting to include the Director and IDT team was held [DATE]. Monitoring: The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 times per week, indefinitely to ensure than an assessment was completed for any new or worsened shortness of breath and is communicated to the NP, Attending MD, or Medical Director immediately. Monitoring began [DATE] and will continue x 4 weeks. Monitoring of the POR included the following: During an interview and record review on [DATE] at 2:49 PM, the DON stated she initiated an audit of nurse progress notes to identify actions taken related to shortness of breath, nurse assessment and interventions, provider, and RP notification, and if new orders were received and acted on . Record review revealed recent assessments. Interviews conducted with nurses and CNAs scheduled on the 6A - 2P shift (RN D, LVN J, CNA I and CNA K), on the 2P - 10P shift (LVN H, CNA G, LVN L, CNA N, LVN Q and RN C [recently transitioned from 10P - 6A shift]), and 10P - 6A shift (LVN O, LVN M and CNA P) stated they participated in various in-service trainings. The staff stated topics of discussion included how to recognize a resident's change in condition, physician notification, and documentation. Each nurse stated in their own words the procedure to notify physicians immediately about resident change in condition. Each nurse demonstrated how to perform a respiratory assessment and verbalized abnormal findings. CNAs stated in their own words' signs and symptoms of acute respiratory distress, what must be reported to the charge nurse, and how to ensure oxygen therapy equipment functioned and applied appropriately on the resident. Record review of a QAPI ad hoc meeting minutes, dated [DATE], reflected the QAPI team met to discuss the facility's failure to conduct a respiratory assessment, to notify the physician about a resident's change in condition and steps the facility must take to address the concern. Record review of an in-service conducted by the RCN , dated [DATE] with the NFA, DON and ADON. Objectives of the in-service included Abuse and Neglect; Performing an assessment and providing care to residents who are experiencing a change in condition or respiratory distress; and Notification of change of condition to the physician immediately. Follow-up activities included one-on-one in-service. The NFA was informed the Immediate Jeopardy was removed on [DATE] at 4:30 PM . The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that residents who needed respiratory care, including tracheostomy care and tracheal suctioning, provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 3 residents (Resident #1) reviewed for respiratory care . On [DATE] - [DATE], the facility failed to conduct a respiratory assessment for a potential change in condition or decline when Resident #1 experienced shortness of breath and required as needed breathing treatments and oxygen therapy. On [DATE], Resident #1 was transferred to the ER. Resident #1 was intubated and passed away at the hospital. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems . This failure could place residents at risk of not receiving timely medical interventions as needed, which could result in a delay in medical intervention and decline in health or possible worsening of symptoms, including death. Findings included: Record review of Resident #1's MDS significant change in status assessment, dated [DATE], reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had active diagnoses which included COPD (a common lung disease that makes it difficult to breathe) and Other Secondary Pulmonary Hypertension (a chronic condition that occurs when pulmonary hypertension is caused by a known risk factor or underlying disease. [symptoms include Shortness of breath, at first while exercising and eventually while at rest; Blue or gray skin color due to low oxygen levels; Chest pressure or pain; Dizziness or fainting spells; Fast pulse or pounding heartbeat; Fatigue]). Resident #1's most recent re-entry to the facility was [DATE] with a diagnosis which included Displaced Commuted Fracture of Shaft of Right Femur. The MDS assessment reflected no known shortness of breath or trouble breathing with exertion, when sitting at rest, or when lying flat. Record review of Resident #1's Order Summary Report reflected: - Physician written Order date - [DATE]: Administer oxygen at 2 LPM via NC continuously every night for SOB (D/C: [DATE]) - Physician written Order date - [DATE]: Tylenol Oral Tablet 325 Mg (Acetaminophen). Give 2 tablets by mouth every 4 hours as needed for pain. (D/C: [DATE]) - Physician written Order date - [DATE]: Oxygen 2 LPM as needed for SOB - Physician written Order date - [DATE]: Ipratropium-Albuterol Solution 0.5-2.5, 3mg/3mL. 3mL inhale orally via nebulizer every 8 hours as needed for SOB or Wheezing. - Verbal Order date - [DATE]: Acetaminophen-Codeine Oral Tablet 300-60 mg (Acetaminophen w/Codeine) Give 1 tablet by mouth every 6 hours as needed for pain (pain level 7 - 10) for 30 days. Do not exceed >4,000 mg/24 hrs - Verbal Order date - [DATE]: Tramadol Oral Tablet 50 mg. Give 1 tablet by mouth every 8 hours for pain for mild to moderate pain (pain level 1 - 5) - Phone Order date - [DATE]: Send patient to the hospital for SOB for further evaluation and treatment as indicated. Record review of Resident #1's [DATE] TAR reflected he was administered Ipratropium-Albuterol Solution 0.5-2.5, 3mg/3mL. 3mL inhale orally via nebulizer for SOB or Wheezing on [DATE] at 9:09 AM (O2 Sat = 94%) by LVN A; [DATE] at 5:13 PM (O2 Sat = 93%) by LVN B. Both breathing treatments were documented as effective. Record review of Resident #1's care plan, last reviewed [DATE], reflected, [Resident #1] has oxygen therapy PRN (Date initiated: [DATE]). Goal: [Resident #1] will have no s/sx of poor oxygen absorption through the review date (Date initiated: [DATE]; Target Date: [DATE]). Interventions included: Monitor for s/sx of respiratory distress and report to MD PRN; Respirations, pulse oximetry, increased heart rate . lethargy, confusion . accessory muscle usage, skin color (Initiated: [DATE]) Record review of Resident #1's vital signs summary reflected the following. There were not a full set of vitals (Temperature, Pulse, Respirations, Blood Pressure, Oxygen Saturation, and Pain) on [DATE] - [DATE] in the Vitals Summary: Temperature values: [DATE] at 2:34 PM (98.0 F via Forehead [non-contact]) - entered by LVN A Pulse value: [DATE] at 9:44 AM (60 bpm) - entered by LVN A; [DATE] at 7:48 PM (64 bpm) - entered by MA E; [DATE] at 10:21 AM (68 bpm) - entered by LVN A; [DATE] at 8:19 PM (69 bpm) - entered by MA D; [DATE] at 10:25 AM (90 bpm) - entered by LVN C. Respiration values: [DATE] at 2:34 PM (18 breaths/min) - entered by LVN A O2 Sats values [Range 96% - 97% on RA]: [DATE] at 9:09 AM (94%; with Oxygen via NC) - entered by LVN A; [DATE] at 5:13 PM (93%; with Oxygen via NC) - entered by LVN B. The amount of oxygen received was not documented. Record review of Resident #1's progress notes indicated: - Nursing Progress Note Effective Date: [DATE] at 2:55 PM, LVN A entered, Resident noted with SOB after coming from therapy, O2 Sat checked 88%, oxygen 2L via nasal canula and breathing treatment administered. O2 Sat rechecked later and was 90 - 91%. NP called and left a message, [RP] also notified. Remain on oxygen therapy and coming nurse notified to continue to monitor. Nursing Progress Note Effective Date: [DATE] at 10:25 PM, LVN B did not reflect respiratory assessments, vital signs, or an attempt to contact the MD/NP about Resident #1's O2 Sat at 91% -92% while he received oxygen 3 LPM via NC or when O2 Sat was 90% - 92% during bedtime and that [Resident #1] would not leave the oxygen in place . - Nursing Progress Note Effective Date: [DATE] at 3:10 PM, LVN A did not reflect a respiratory assessments, vital signs, or an attempt to contact the MD/NP that [Resident #1] Continued to monitor resident for SOB, O2 Sat 94 - 96%. Breathing treatment administered and tolerated well. - Nursing Progress Note Effective Date: [DATE] at 9:17 PM, LVN B did not reflect respiratory assessments, vital signs, or an attempt to contact the MD/NP that [Resident #1] was administered pain meds and breathing treatment. Well tolerated. After therapy and oxygen remains 92% - 93% - Nursing Progress Note Effective Date: [DATE] at 1:30 PM, LVN C entered, [Resident #1] with increased SOB even though he is on 2LPM via NC, BP - 130/80, P-120, R-22, T-103.1 F. Breathing treatment was administered. Tylenol 500 mg 1 tablet was given for fever at this time. NP was notified via phone and gave order for patient to be sent to [hospital] for further evaluation and treatment as indicated. 911 call was initiated at this time. At 2PM the ambulance left . At 2:05 PM the RP was notified about the change of condition of patient . The ADON was called and updated via voicemail. The 10P - 6A nurse(s) did not enter progress notes that reflected respiratory assessments, vital signs, or an attempt to contact the MD/NP on [DATE] or [DATE]. Review of Resident #1's [DATE] MAR/TARs did not reflect administration of pain medications at any time on [DATE] - [DATE]. The MAR/TARs did not reflect a breathing treatment administered on [DATE] or [DATE]. Record review of a SBAR note dated [DATE], written by LVN C, revealed the primary provider was contacted at 1:50 PM about [Resident #1] with a Respiratory Change-Suspected Infection. BP - 130/80; P - 120; R - 22; T - 103.1 F; O2 Sat - 90%; received oxygen at 2lpm via NC. Suspected respiratory infection r/t fever > 102 F, abnormal lung sounds (bilateral lower lobes [sound heard not listed]), and shortness of breath. This started on and/or symptoms first appeared: [DATE] [breathing treatment(s)] attempted to help resolve This condition, symptom, or sign has occurred before with antibiotics. Record review of Resident #1's chart did not reflect other SBARs were documented between [DATE] - [DATE] or indicated MD/NP notification. A review of the 24 Hour Report for [DATE] revealed dated reports [DATE] - [DATE]. The next 24-hour report was undated and revealed remarks related to [Resident #1] Day shift - monitor for SOB; Evening shift - SOB at 9:30 PM, 92%, pain management. There were no remarks for the Night shift. The next 24-hour report was dated [DATE] and revealed remarks related to Resident #1. Day shift - continue to monitor for SOB, O2 94%. There was no remark for the Evening shift. Night shift - monitor SOB. The 24-hour report dated [DATE] indicated Resident #1 was sent out to [hospital] for SOB, elevated temperature, and elevated heart rate. The Night shift entered Monitor SOB. Resident #1 did not return to the facility. Resident #1 passed away at the hospital. Record review of an Occupational Therapy Treatment Encounter Note, dated [DATE], entered by COTA D, reflected, [Resident #1] participated in task presented, but demonstrated increased fatigue and weakness. [Resident #1] continues to demonstrate decline in health and fear of falling while seated in wheelchair. [Resident #1] also demonstrated labored breathing when he is given his utensils to participate in feeding . A record review of Resident #1's hospital medical records, dated [DATE], reflected [Resident #1] arrived at the ED on [DATE] at 2:51 PM. The reason for visit reflected Fever and high heart rate for 3 days. The visit diagnoses included Acute hypoxic respiratory failure. The ED provider notes reflected EMS states [facility] staff reported [Resident #1] with worsened confusion from baseline for the past 2 days. EMS states [Resident #1] was noted to be SOB and in mild respiratory distress on arrival and was given an albuterol/Atrovent treatment, 125 mg solumedrol, and 1 Liter bolus fluids enroute. Facility denied any falls or trauma, however history otherwise limited. Initial assessment reflected a temperature of 105 degrees Fahrenheit, heart rate of 170 bpm, lung sounds crackle bilaterally, and was started on BiPAP (a device that helps you breathe) on arrival due to respiratory distress. Resident #1 was intubated [[DATE]] at 5:20 PM. The lowest O2 saturation during intubation was 92%. CPR was initiated on [DATE] at 5:31 PM. Resident #1 ultimately expired. Time of death was called at 6:27 PM. The final diagnosis was Acute hypoxic respiratory failure that led to Cardiac arrest. During an interview on [DATE] at 2:21 PM, the ADON stated that she was informed about Resident #1's episodes of shortness of breath on [DATE]. The ADON said that interventions were implemented as ordered - supplemental oxygen and breathing treatments as needed. The ADON said that no significant concerns were reported to her. The ADON said that she expected for nurses to initiate nursing interventions, notify the MD/NP, and notify the RP; as well as notify the ADON and DON. The ADON said that vital signs should be monitored daily as ordered and as needed. The ADON said that any changes in vital signs, behavior, level of functioning from a resident baseline should be documented and reported. The ADON stated that therapy staff would monitor a resident oxygen level of concerned and always communicated with nursing staff. During an interview on [DATE] at 1:56 PM, CNA F stated she worked Friday, [DATE] and Saturday, [DATE], 6A - 2P shifts. CNA F said that she notified LVN A on Friday morning that Resident #1 appeared to have difficulty breathing, even with oxygen. CNA F demonstrated shallow breathing and other than normal rise and fall of the chest. CNA F said that Resident #1 felt warm to touch. CNA F said that LVN A assessed Resident #1 and told [CNA F] that he did not have an elevated temperature. During an interview on [DATE] at 2:44 PM, LVN B stated she worked Thursday, [DATE] and Friday, [DATE], 2P - 10P shifts. LVN B stated that she received verbal handoff shift report from LVN A on Thursday, [DATE] at 2:00 PM. LVN B said that [LVN A] reported that Resident #1 had shortness of breath when he returned from therapy, received a breathing treatment, and was on oxygen therapy. [LVN A] said to monitor for shortness of breath. LVN B said that she did not notify the MD/NP because she figured LVN A called during the day shift (6A - 2P). LVN B said that she checked Resident # 1's vital signs and O2 Sat after occupational therapy and applied oxygen, but there were no other concerns. LVN B said that Resident #1's RP visited on [DATE] and requested Resident #1 get up out of bed. LVN B said that she tried to explain to the RP that Resident #1 was in bed to be monitored for shortness of breath. LVN B said that Resident #1 was assisted up to his wheelchair and went to occupational therapy. LVN B said that she had to administer a breathing treatment when Resident #1 returned from therapy after dinner. LVN B denied inspection for abnormal findings such as blue or pale discoloration, labored breathing, or listening to lung sounds. LVN B said that unexpected respiratory findings that should be reported to the MD/NP immediately included a decreased oxygen saturation of less than 92%, restlessness, and increased difficulty breathing. During an interview on [DATE] at 4:13 PM, LVN C stated she worked Saturday, [DATE], 6A - 10P shift. LVN C stated she received verbal handoff shift report from the overnight nurse to monitor Resident #1 for shortness of breath. LVN C said she inquired if Resident #1 had pneumonia and the nurse stated to monitor for shortness of breath. LVN C said she observed Resident #1 in his room during change of shift walking rounds and he received oxygen via NC. LVN C said she worked weekend doubles and Resident #1 did not receive oxygen continuously the previous weekends. LVN C said she asked the CNA to come get her when ADLs were provided to Resident #1 so she could monitor breathing when repositioned. LVN C said when she assisted with Resident #1's ADLs, she noticed Resident #1 had difficulty breathing. LVN C said she raised the head of the bed when they finished to help Resident #1 breathe a little easier. LVN C said when she checked Resident #1's vital signs after breakfast, and he was breathing fast and had an elevated temperature. LVN C said she administered a breathing treatment, administered Tylenol for the fever, and when Resident #1 did not appear to improve, notified the NP ([DATE] at 1:30 PM), called 911, and transferred Resident #1 to the hospital An attempt to interview the PCP on [DATE] at 1:34 PM was routed to an automated voicemail. A message identified caller, explained purpose of call, and a callback number was left on the voicemail. No callback was received. On [DATE] at 2:23 PM, a return phone call was accepted by LVN A. During a phone interview, LVN A stated she worked Thursday, [DATE] and Friday, [DATE], 6A - 2P shifts. LVN A said that therapy staff reported on [DATE] that Resident #1 had shortness of breath. LVN A said that she checked Resident #1's O2 Sats. LVN A said that [Resident #1] oxygen level was low (less than 90%) and administered a breathing treatment and applied oxygen via nasal cannula. LVN A said that the breathing treatment was effective. LVN A said that she left a message for the NP and did not receive a callback before her end of shift at 2 PM. LVN A said that she reported to the oncoming nurse (LVN B) to monitor Resident #1 for shortness of breath. LVN A said to monitor means to watch for signs of shortness of breath, like a low oxygen level. LVN A said that the next nurse would be responsible to call the MD/NP if they had concerns to report. LVN A said that she checked Resident #1's vital signs and he did not have a temperature. LVN A said that she listened to Resident #1's lungs but could not describe what she heard. LVN A said that Resident #1's lungs were clear. LVN A said that a breathing treatment was administered on [DATE] and it was effective. During an interview on [DATE] at 1:27 PM, the NP indicated it was not unusual not to call back if she received a page from the facility nurse. The NP stated if the nurse did not hear back [from the NP] within 15 minutes, she should have tried to call again. The NP stated Resident #1 had a diagnosis of cardiomegaly (an enlarged heart), COPD (a group of diseases that cause airflow blockage and breathing-related problems), and a medical history of pneumonia that she would have suggested a PRN diuretic and a chest x-ray had she received a call about the change in condition before Saturday, [DATE]. The NP said the suggested treatments would have been ineffective by Saturday ([DATE]) and sending Resident #1 to the hospital for a higher level of care was the best treatment option at the time. The NP stated she may have requested a COVID test if demonstrated temperature and/or cough. A record review of the facility's policy titled, Significant Change in Condition, Response, revised [DATE], reflected Policy: It is the policy of this facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. Procedure: 1. If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to) . new complaints of pain or worsening of pain . 2. The nurse will perform and document an assessment of the resident and identify need for additional interventions, considering implementation of exiting orders or nursing interventions or through communication with the resident's provider using SBAR or similar process to obtain new orders or interventions. 3 . Nursing will provide no less than three (3) days of observation, documentation, and response to any interventions. An attempt to identify the cause for decline, when it occurs . 4. The nurse will communicate the change to other departments as appropriate and updated communications will be available during morning report . 6. Each department notified will perform their own evaluation and assessment to determine if the change requires further intervention and implement actions accordingly This was determined to be an Immediate Jeopardy (IF) on [DATE] at 5:50 PM. The NFA was notified and provided with the IJ template on [DATE] at 5:50 PM . The following Plan of Removal submitted by the facility was accepted on [DATE] at 3:17 PM: All residents have the potential to be affected by this deficient practice. Interventions: All residents in the facility were assessed for any change of condition by the DON, ADON and Charge Nurses as of [DATE]. No additional issues were found. DON, ADON will audit all resident nursing notes for a change of condition to ensure notification of changes to the attending physician/nurse partitioner. Completed [DATE]. Going forward the DON/ADON/designee will monitor progress notes for a change in condition and notification to the attending physician/nurse practitioner daily during the morning clinical meeting. All residents with orders for oxygen continuous and as needed had oxygen saturation levels obtained as of[DATE] by the DON/ADON. No additional issues were found. LVN A and LVN B were immediately suspended pending investigation on [DATE]. LVN A and LVN B will not be permitted to return to work or provide care to residents until the following 1:1 in-services have been completed by the DON or Compliance Nurse. Completed [DATE]. Abuse and Neglect-failure to perform and assessment and notify a NP/MD for a resident change in condition could be considered neglect. Performing an assessment and providing care to residents who are experiencing a change in condition or respiratory distress including not limited to: 02 saturation on room air or with oxygen and how much oxygen if applicable, skin color, any use of accessory muscle, lung sounds, any purses lip breathing, is the head of the bed flat or elevated. What interventions have you provided to the resident nonpharmacological or pharmacological. Notification of the MD and RP. Notifications of changes of conditions test, to include components of a focused respiratory assessment. Notification of change of condition to the physician immediately. If any staff members notice a resident in respiratory distress, they will notify a charge nurse or DON immediately. All charge nurses will notify the NP or the Attending MD after an assessment is performed. If the NP cannot be reached, the Attending or Medical Director will be notified. The medical director was notified by the administrator of this plan on [DATE]. An Ad Hoc QAPI meeting to include the Director and IDT team was held [DATE]. In-services: All charge nurses will be in-serviced by [DATE] by the DON/ ADON regarding the following and all nurses not in-serviced by [DATE] will not be allowed to work their assigned position until completion of these in-services. All PRN staff, new hires, and agency staff will be in-serviced prior to start of their shift. The Administrator, DON and ADON were in-serviced 1: 1 by Compliance Nurse. Abuse and Neglect- failure to perform and assessment and notify a NP/MD for a resident change in condition could be considered neglect. Performing an assessment and providing care to residents who are experiencing a change in condition or respiratory distress including not limited to: 02 saturation on room air or with oxygen and how much oxygen if applicable, skin color, any use of accessory muscle, lung sounds, any purses lip breathing, is the head of the bed flat or elevated. What interventions have you provided to the resident nonpharmacological or pharmacological. Notification of the MD and RP. Notifications of changes of conditions test, to include components of a focused respiratory assessment. Notification of change of condition to the physician immediately. If any staff members notice a resident in respiratory distress, they will notify a charge nurse or DON immediately. All charge nurses will notify the NP or the Attending MD after an assessment is performed. If the NP cannot be reached, the Attending or Medical Director will be notified. The medical director was notified by the administrator of this plan on [DATE]. An Ad Hoc QAPI meeting to include the Director and IDT team was held [DATE]. Monitoring: The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 times per week, indefinitely to ensure than an assessment was completed for any new or worsened shortness of breath and is communicated to the NP, Attending MD, or Medical Director immediately. Monitoring began [DATE] and will continue x 4 weeks. On [DATE] the investigator began monitoring if the facility implemented their plan of removal sufficiently to remove the IJ by: During an interview and record review on [DATE] at 2:49 PM, the DON indicated that she initiated an audit of nurse progress notes to identify actions taken related to shortness of breath, nurse assessment and interventions, provider, and RP notification, and if new orders were received and acted on. Record review revealed recent assessments. Interviews conducted with nurses and CNAs scheduled on the 6A - 2P shift [RN D, LVN J, CNA I and CNA K], on the 2P - 10P shift [LVN H, CNA G, LVN L, CNA N, LVN Q and RN C (recently transitioned from 10P - 6A shift)], and 10P - 6A shift [LVN O, LVN M and CNA P] indicated they participated in various in-service trainings. The staff stated topics of discussion included how to recognize a resident's change in condition, physician notification, and documentation. Each nurse stated in their own words the procedure to notify physicians immediately about resident change in condition. Each nurse demonstrated how to perform a respiratory assessment and verbalized abnormal findings. CNAs stated in their own words' signs and symptoms of acute respiratory distress, what must be reported to the charge nurse, and how to ensure oxygen therapy equipment functioned and applied appropriately on the resident. Record review of a QAPI ad hoc meeting minutes dated [DATE] revealed the QAPI team met to discuss the facility's failure to conduct a respiratory assessment, to notify the physician about a resident's change in condition and steps the facility must take to address the concern. Record review of an in-service conducted by the RCN dated [DATE] with the NFA, DON and ADON. Objectives of the in-service included Abuse and Neglect; Performing an assessment and providing care to residents who are experiencing a change in condition or respiratory distress; and Notification of change of condition to the physician immediately. Follow-up activities included one-on-one in-service. The NFA was informed the Immediate Jeopardy was removed on [DATE] at 4:30 PM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to ensure the resident environment was free of accident hazards and failed to ensure each resident received adequate supervision and assistance to prevent accidents for 1 of 4 (Resident #9) residents reviewed for accidents and hazards. The facility failed to implement new and effective interventions for Resident #9 who had an unwitnessed fall on 04/28/23 that resulted in the resident having a large subdural hematoma. Resident #9 required admission to the ICU for monitoring of intercranial pressure and had large amount of bleeding. The resident had a history of falls with injury. Resident #9 was currently taking blood thinner . An Immediate Jeopardy (IJ) was identified on 05/17/23. While the IJ was removed on 05/18/23, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. These failures placed residents at risk of incidents such as falls which could result in physical harm, injury, emotional distress, or even death. Findings included: A review of Resident #9's face sheet dated 04/12/23, revealed a [AGE] year-old female. She was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #9's diagnoses included Dementia, Muscle weakness, and cognitive communication deficit. A review of Resident #9's active physician orders for April 2023 revealed Resident #9 may wear a helmet for safety while awake. Monitor/assess skin for breakdown with the start date of 04/04/23 every shift. Observation on 05/10/23 at 10:04 am revealed Resident #9 located in the secure unit with a blue padded helmet, ambulating throughout the unit. Review of Resident #9's care plan last revised on 11/18/22 revealed Resident #9 was at risk of falls. The care plan included interventions . A review of the care plan revealed no evidence of Resident #9 utilizing a helmet to prevent further injury from a fall. The interventions reflected, anticipate and meet the resident needs. Ensure the resident is provided a safe environment, with even floors, free from spills and or clutter. A review of an Event Report dated 04/10/23 for Resident #9 revealed she was found laying on the floor bleeding from the back of her head and had a big hematoma. There was no evidence the helmet was worn by Resident #9's before the injury. The Report was completed by LVN B. Review of the hospital records dated 04/10/23 for Resident #9 revealed she was admitted to the hospital following a fall. The resident was diagnoses with a minor head injury, with a laceration of occipital scalp. Resident #9's head was treated with sutures. A review of the Incident/Accident report dated 04/28/23 revealed Resident #9 had an unwitnessed fall in the dining room. Resident #9 had a large hematoma to the back of the head, with a large amount of bleeding. There was no evidence Resident #9 wore a helmet during the fall . The Incident/Accident report was completed by LVN A. An interview with LVN A on 05/17/23 at 11:31 am revealed Resident #9 did not have on a helmet during the fall on 04/28/23. Review of the Incident report log dated 05/17/23 for Resident #9 revealed she suffered falls on 03/17/23, 03/28/23, 04/10/23 and 04/28/23. Review of Resident #9 hospital record dated 04/28/23 revealed she was admitted to the hospital with the diagnoses of subdural hematoma. CT scan of Resident #9's head revealed acute left parietal subdural hematoma measuring up to 7 mm in thickness with mass effect causing 2 mm of left to right midline shift an no herniation. Resident #9 was prescribed a blood thinner (Eliquis) for Atrial Fibrillation. An interview with LVN B on 05/10/23 at 10:47 am revealed she had worked with Resident #9 since being in the secure unit. LVN B stated Resident #9 often wandered throughout the secure unit. Resident #9 had suffered several falls in which she had hit her head causing bleeding. LVN B revealed she completed the Event Report dated 04/10/23. When Resident #9 was located on the floor, the helmet was not on the resident. LVN B revealed Resident #9 would often remove the helmet, and staff had been instructed to place the helmet back on Resident #9 once it had been removed. LVN B stated because of Resident'#9's diagnosis, it was difficult to ensure Resident #9 kept the helmet on . She was not aware Resident #9's care plan did not address the helmet and that the resident removed the helmet. She had not been informed of any new interventions to prevent Resident #9 from falling. An interview with CNA C on 05/10/23 at 11:04 am revealed Resident #9 would wander throughout the secure unit. Resident #9 had suffered several falls. The redirection of Resident #9 was unsuccessful because of her diagnosis of Dementia. She was not aware Resident #9's care plan was not being updated to reflect the helmet should be worn. She revealed all the staff knew the helmet must be worn by Resident #9 when she was out of bed. An interview with the DON on 05/10/23 at 12:57 pm revealed she was responsible for updating the resident's care plans when there had been a change in condition or new orders. The DON revealed Resident #9's care plan had not been updated to include the utilization of the helmet. Resident #9's care plan had not been updated with new interventions after the 04/28/23 fall. Following the fall on 04/10/23 the facility updated the care plan to reflect moving Resident #9 closer to the nurses' station, but no new interventions had been added. An additional interview with the DON on 05/17/23 at 11:21 am revealed the facility had not evaluated the effectiveness of the fall prevention methods. The DON revealed she had not included any new interventions after the fall on 04/28/23, in which Resident #9 had a fall and suffered a hematoma to the back of the head with bleeding. The DON instructed the staff to continue the same interventions. Resident #9 had been ordered to wear a helmet, and the start date of the order was 04/04/23. The DON revealed that after Resident #9 took off the helmet, the facility staff were not documenting and notifying her of the helmet being off. A review of Resident #9's Fall Risk assessment dated [DATE] revealed she was at high risk of falls. Resident #9 had a history of falls. Resident #9 had 3 or more falls in the past 3 months. No previous fall assessments were provided. Review of the facility's Preventive Strategies to Reduce Fall Risk policy dated 10/05/16 revealed After risk is assessed, individualized nursing care plan will be implemented to prevent falls. The resident and family members will be educated on methods to prevent falls. Interventions will focus on manipulating the environment, educating the resident/family, implementing rehab programs to improve functional ability, and careful monitoring of medication side effects. The facility Administrator and DON were notified on 05/17/23 at 11:19 am that an IJ situation had been identified due to the above failures. A Plan of Removal was submitted by the Administrator on 05/17/23. After several revisions, the final Plan of Removal was accepted on 05/17/23 at 4:07 pm. The plan of removal included the following: Plan to remove Immediate Jeopardy Resident #9 continues to reside in the facility in the secured unit Resident #9 was screened by the Rehab Director on 5/17/23 for proper fitting of the helmet Resident #9 is to wear the helmet while awake, monitor/assess skin for breakdown every shift If Resident #9 removes the helmet, staff will re-direct and re-apply the helmet On 4/10/23, resident #9 had an unwitnessed fall with a hematoma to the back of her head. The resident was sent out to the emergency room. The resident returned to the facility the same day with staples to the back of the head On 4/28/23, resident #9 had an unwitnessed fall with a hematoma to the back of her head. The resident returned to the facility on 5/1/23 and signed up for hospice services Resident 9's fall care plan was reviewed for fall interventions on 5/17/2023 by the DON. Resident 9# fall risk assessment was updated on 5/17/2023 by the Director of Nursing DON/ADON / Designee began updating all resident fall risk assessments on 5/17. Any resident identified at risk for falls with injuries will have new and effective interventions in place DON/ADON/ Designee began reviewing and updating all resident fall care plans for interventions on 5/17/23. The following in-services were initiated by the Regional Compliance nurse and DON on 5/17/2023. Any staff member not present or in-serviced on 5/17/2023 will not be allowed to assume their duties until in-serviced. o Licensed Nurses: 1. Implementing interventions to minimize the risk of falls. 2. Fall Prevention Policy The DON or designee will in-service nursing staff on 5/17/23 regarding when resident #9 uses the helmet and what to do when resident #9 removes the helmet. Any staff member not present or in-serviced will not be allowed to assume their duties until in-serviced A Fall risk assessment will be completed on all new admissions or re-admissions after a fall has occurred. The MD was notified of the immediate jeopardy situation on 5/17/2023 at 12:19 pm. Ad Hoc QAPI meeting will be held on 5/17/23 to discuss the IJ and review the plan of removal Monitoring: DON and Administrator will review all fall during the morning meeting to ensure appropriate interventions have been implemented. Monitoring will occur 5 days per week for a minimum of 6 weeks. DON and Administrator will review all fall during the weekly Standard of Care Meeting to ensure appropriate interventions have been implemented. Monitoring will occur weekly for a minimum of 6 weeks. Above will be reviewed during the facility's monthly QA meeting for no less than 60 days, or until the Administrator determines substantial compliance has been achieved and maintained. Monitoring of the Plan to lower the Immediately Jeopardy: Observation on 05/17/23 and 05/18/23 of Resident #9 revealed the resident had a helmet on her head. Resident #9 was located near the nurses station. Record review of In-services education regarding Resident #9's use of Helmet, started on 05/17/23. Record review of Inservice education regarding Implementing interventions to minimize the risk of falls started on 05/17/23. A review of Resident #9's care plan revealed the plan had been updated with interventions to include the resident must wear a helmet when not in bed. Resident would be involved in activities more. The staff must redirect and placed the helmet back on the resident is the helmet is taken off. Interviews on 05/17/23 and 05/18/23 with LVN A, LVN B, LVN D, CNA C, CNA D, CNA F, LVN J, CNA K, CNA M, LVN H, and CNA T that worked on each of the facility's shifts, revealed the facility staff had been educated regarding identifying residents with falls. Implementation of fall interventions, Resident #9 fall interventions, Resident #9 fused of the helmet, and notification of Resident #9 's helmet being taken off. The Nurses were informed following the falls the care plans must be updated with interventions after each fall. The interventions will be communicated to the aides. An interview with the DON on 05/18/23 at 11:09 am revealed the care plans with interventions will be updated following each resident's falls. The staff was educated that Resident #9 must wear a helmet while out of bed. The DON will be notified if Resident #9 took off the helmet. Resident #9 and other residents with falls will have interventions added after each fall. An interview with the Administrator on 05/18/23 at 11:41 am revealed all residents of the facility were assessed for falls. The resident's care plans were updated with interventions. Resident #9's care plan was updated to include interventions. The Administrator will review all falls during the morning meeting to ensure appropriate interventions have been implemented. The administrator will monitor any falls to ensure fall prevention interventions were added. The Administrator will review all falls during the weekly Standard of Care Meeting to ensure appropriate interventions have been implemented. Monitoring will occur weekly for a minimum of 6 weeks. The Administrator and DON were notified the IJ was removed on 05/18/23 at 11:52 am. However, the facility remained out of compliance at the severity of the level of actual harm that is not immediate jeopardy and a scope of isolation due to the facility needing more time to monitor the plan of correction effectiveness.