**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician and notify the resident representative of a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #1) of 10 residents reviewed for notification of changes.The facility failed to notify Resident #1's physician when they did not administer his valproic acid, topiramate, levetiracetam, and lacosamide on 07/22/25-07/25/25 as ordered.The facility failed to notify Resident #1's physician after he had a seizure on 07/25/25.The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 07/22/2025 and ended on 07/26/2025. The facility had corrected the noncompliance before the survey began. Findings included: Record Review of Resident #1's face sheet dated 07/27/25 indicated the resident was a [AGE] year-old male with an original admission date of 07/10/2025 and readmission date of 07/22/2025. The resident had diagnoses including acute respiratory failure with hypoxia (a life threatening condition where the lungs cannot adequately oxygenate the blood, resulting in low blood oxygen levels), epilepsy with status epilepticus (a serious neurological condition where seizures are prolonged or occur frequently without recovery between them, posing a risk of brain damage), stroke, and high blood pressure.Record Review of Resident #1's readmission assessment note dated 07/22/2025 indicated there was no BIMS score due to resident's inability to answer questions. Resident #1 was alert but unable to speak due to the presence of a tracheostomy tube (a curved hollow tube inserted into a surgically created opening in the neck to create and airway into the windpipe), he had an indwelling urinary catheter and was incontinent of bowel, required extensive to total assistance for ADLs, he had a feeding tube inserted into his abdomen, and had a cough and abnormal lungs sounds of rhonchi (low-pitched, continuous, and rattling sounds heard during breathing, often described as resembling snoring or gurgling. Record Review of Resident #1's care plan with initiation date 0710/2025 and revised 07/26/2025 indicated the resident had a seizure disorder and interventions included for the facility staff to: administer seizure medication as ordered by the doctor, and seizure documentation should have included location of seizure activity, type of seizure activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after seizure activity. Review of Resident #1's Physician Orders last updated 07/26/25 included: Lacosamide Oral Solution 10 mg/ml Give 20 ml via G-tube two times a day for epilepsy, Levetiracetam 100 mg/ml Give 15 ml via G-tube twice a day for epilepsy, Topiramate 100 mg tablet Give one via G-tube two times a day for epilepsy, and Valproic Acid 250 mg/5 ml Give 10 ml via G-tube three times a day for epilepsy.Review of Resident #1's hospital after visit summary dated 07/23/2025 indicated the resident was to receive Lacosamide Oral Solution 10 mg/ml Give 20 ml via G-tube three times a day, Levetiracetam 100 mg/ml Give 15 ml via G-tube every 12 hours, Topiramate 100 mg tablet Give one via G-tube two times a day, and Valproic Acid 250 mg/5 ml Give 10 ml via G-tube every 8 hours.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Lacosamide Oral Solution 10 mg/ml Give 20 ml via G-tube two times a day for epilepsy was marked as unavailable for the PM dose on 07/22/2025,the AM dose on 07/23/2025 was blank and not marked as given, the PM dose for 07/23/2025, the AM dose for 07/24/2025 was marked as given, the PM dose for 07/24/2025 was marked as not given and the AM dose on 07/25/2025 was marked as given. There was no reason given for the blank and not given marks.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Levetiracetam 100 mg/ml Give 15 ml via G-tube twice a day. The 9:00 PM dose on 07/22/2025 was marked as unavailable, the 9:00AM on 07/23/2025 was blank and not marked as given, the 9:00 PM dose for 07/23/2025 was marked as given, the 9:00 AM dose for 07/24/2025 was marked as given, the 9:00 PM dose on 07/24/2025 was marked as not given, the 9:00 AM dose on 07/25/2025 was marked as unavailable. There was no reason given for the blank and not given marks. Review of Resident #1's electronic MAR dated July 2025 indicated the following:Topiramate 100 mg tablet Give one via G-tube two times a day the AM dose on 07/22/2025 was not marked as given and was blank. There was no reason given for the blank space.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Valproic Acid 250 mg/5 ml Give 10 ml via G-tube three times a day for epilepsy was marked as unavailable for the 9:00 PM dose on 07/22/2025, the 9:00 AM dose and 3:00 PM doses on 07/23/2025 were blank and not marked as given. The 9:00 AM, 3:00 PM and 9:00 PM doses on 07/24/2025 were marked as given. The 9:00 AM, 3:00 PM and 9:00 PM doses on 07/25/2025 were marked as given. There was no reason given for the blank and not given marks. During an interview on 07/27/2025 at 8:23 AM, Resident #1's family member said she was visiting Resident #1 around 1:00 PM-1:45 PM on 07/25/2025, when he had a seizure. Resident #1's family member said she called the nurse to the room for assistance, and LVN A assessed Resident #1 and told them he would probably be a little sleepy. Resident #1's family member said LVN A told her she would call the doctor to see if he wanted to do any labs. Resident #1's family member said later in the evening of 07/25/2025 she went to check on Resident #1 and was informed by LVN B that Resident #1's seizure medications had not been administered prior to 07/25/2025. Resident #1's family member said LVN B told her his seizure medications had just arrived (07/25/2025). Resident #1's family member said she had LVN B print her Resident #1's medication administration record and his seizure medications were marked as unavailable or administered. Resident #1's family member said the nurses falsified the documentation because the seizure medications were not in the facility. Resident #1's family member said she was very concerned about her family member because he had a history of seizures, and in the past had been hospitalized due to uncontrolled seizures that would not stop. Resident #1's family member said she had contacted the DON and ADON C and explained her concerns regarding Resident #1's seizure medications. Resident #1's family member said the DON told her the pharmacy did not provide the medications because they were out. Resident #1's family member said the DON told her they had ordered the medications on 7/25/2025. During an interview on 07/27/2025 at 11:00 AM, LVN A said the process for when patients admitted /re-admitted was that they verified the orders with the doctor, and then they carried the orders out. LVN A said when they put the orders in the electronic health record the pharmacy sent the medications the same night. LVN A said she re-admitted Resident #1 on 07/22/2025, and she verified his admission orders. LVN A said she normally tried to call the pharmacy to notify them of admission, but she did not have the time to call because she had two admissions back-to-back. LVN A said she was off the 2 days following Resident #1's admission (did not work on 07/23/2025 and 07/24/2025). LVN A said when she returned to work on 07/25/2025, the night nurse LVN D told her not all of Resident #1's medications had been delivered. LVN A said she contacted the pharmacy and gave them a list of the medications that were missing, and they had them delivered that night. LVN A said if a resident was missing medications, they are supposed to call the pharmacy to check on the medications and notify the doctor. LVN A said she did not notify the doctor the medications were not delivered, and Resident #1 missed doses of his seizure medications. LVN A said on Friday, 07/25/2025, Resident #1 had a small seizure. LVN A said she failed to notify the doctor Resident #1 had a seizure. LVN A said she should have notified the doctor, but she did not because she was busy and was sending out a different resident to the hospital when Resident #1 had his seizure. LVN A said it was important to notify the doctor of changes in condition because the doctor may want to order labs and adjust medications. LVN A said not notifying the doctor of changes in condition could result in seizures and hospitalizations. LVN A said not administering medications could result in seizures and high blood pressures that it depended on the medication what adverse effect resulted. During an interview on 07/27/2025 at 11:38 AM, LVN D said when a resident admitted /re-admitted to the facility the admitting nurse was responsible for putting in the orders in the electronic health record. LVN D said the orders should be sent to the pharmacy or they should call the pharmacy to notify them of the resident's admission so the medications could be sent. LVN D said if a resident's medication was not delivered from the pharmacy, they should indicate on the MAR the medication was unavailable and notify the pharmacy and management. LVN D said they should also notify the doctor the medication was not given. LVN D said she did not attempt to order Resident #1's medications until Thursday (07/24/2025) night. LVN D said she had not notified the doctor of Resident #1's missed doses because she thought she did not have to notify the doctor unless 3 doses were missed. LVN D said she tried to document unavailable or not administered for Resident #1's medications that she did not administer. LVN D said depending on the medication that was not administered the residents could have multiple adverse reactions such as high blood pressure and fluid buildup. LVN D said it was important to notify the doctor of missed medications to prevent hospitalizations. During an interview on 07/27/2025 at 12:44 PM, LVN B said all medication were delivered through the facility's pharmacy to the facility. LVN B said if medications were placed in the electronic health record before 3 PM, they would be delivered the same night. LVN B said Resident #1 admitted sometime on the day shift on 07/22/2025. LVN B said Resident #1's medications were not delivered on 07/22/2025. LVN B said she had no idea why Resident #1's medications were not delivered on 07/22/2025. LVN B said she did not work on 07/23/2025 and 07/24/2025. LVN B said on 07/25/2025, when she arrived for her shift, LVN A informed her some of Resident #1's medications had not been delivered, but they would be delivered that night (07/25/2025). LVN B said Resident #1's seizure medications were delivered 07/25/2025 during her night shift, and she was able to administer all of them. LVN B said the doctor should be notified when medications were not available for administration. LVN B said she did not notify the doctor Resident #1 had missed doses of his seizure medications. LVN B said the doctor should have been notified because they were medications that should not be missed, and it placed Resident #1 at risk for seizures and cardiac arrest and it affected the resident's overall health. LVN B said if a resident had a seizure, the doctor, DON, oncoming nurse, and the family should be notified. LVN B said not notifying the physician led to lack of care because the doctor would not know what was going on and it caused a gap in care that the residents needed. During an interview on 07/27/2025 at 1:01 PM, LVN E said the ADONs and DON put in the resident's physician orders into the electronic health record, and from her understanding they went to the pharmacy automatically. LVN E said if there was a new admission they should fax the orders to the pharmacy for the medications to be sent to the facility. LVN E said she worked on 07/23/2025 and 07/24/2025 on the day shift. LVN E said she did not administer any medications to Resident #1 on 07/23/2025 because she sent him to the hospital. LVN E said she was not able to remember if she had signed off the medications as administered in his MAR or as hospitalized . LVN E said she might have inaccurately documented some of Resident #1's medications as administered, when she did not administer them because she was in a rush and had a lot going on. LVN E said 07/24/2025, she contacted the pharmacy about Resident #1's medications, and the pharmacy told her his medications would be delivered Monday (07/28/2025). LVN E said she did not notify the doctor that Resident #1's medications were not delivered and were not administered. LVN E said at the time she was not aware she was supposed to notify the doctor. LVN E said it was important for the doctor to be notified of missed doses of medication to see if he wanted to order something different. LVN E said Resident #1 not receiving his seizure medications could result in him having seizure. During an interview on 07/27/2025 at 1:16 PM, the Pharmacist said the DON contacted them yesterday (07/26/2025) to ask about Resident #1's medications. The Pharmacist said when Resident #1 re-admitted to the facility for whatever reason they did not get the request to send his medications in their system. The Pharmacist said the facility possibly indicated the medications were on hand, which would result in the medications not being sent out to the facility. The Pharmacist said the request for Resident #1's medications was received on 07/25/2025. The Pharmacist said usually the electronic system used by the facility notified them when a resident admitted , and orders were put in because the facility's system was linked with the pharmacy. During an interview on 07/27/2025 at 1:22 PM, the DON said Resident #1 re-admitted on [DATE] or 07/23/2025. The DON said the nurses did not follow the facility's protocol and notify him Resident #1's medications were not delivered. The DON said the nurses should have notified him, so the doctor could be notified. The DON said late Friday evening (07/25/2025) Resident #1's family member notified him Resident #1 had not received his seizure medications, and he informed her the medications would be delivered to the facility that evening. The DON said they started in-services on abuse and neglect, medication errors, instructed the nurses to notify him of medications that were not available and notifying the doctor. The DON said LVN D and LVN E were suspended pending investigation due to them failing to notify the DON that Resident #1's medications were not available and documenting medications as administered when they were not available in the facility. The DON said when a resident admitted to the facility, orders were put into their electronic health system and the pharmacy was notified electronically to send the medications. The DON said LVN A did not notify the doctor of Resident #1's seizure. The DON said he reported it to the doctor when he was notified that Resident #1 had a seizure. The DON said medications not being administered greatly increased the residents' chances of negative outcomes such as increased seizure activity and death. The DON said it was important to notify the doctor of changes in condition because it was the cornerstone of good patient care and so they could have documentation that something was done. During an interview on 07/27/2025 at 1:42 PM, ADON F said when a resident admitted to the facility the medications should be put into the electronic health record and the orders go to the pharmacy automatically. ADON F said when Resident #1 re-admitted to the facility nobody notified the pharmacy of his admission. ADON F said when Resident #1's medications were not delivered, they should have contacted the pharmacy. ADON F said she was not notified by the nurses that Resident #1's medications were not delivered. ADON F said the nurses should have notified the doctor of the medications that were not administered to Resident #1. ADON F said medications not administered as ordered could affect the residents' health, and they could end up dying or having a diminished quality of life. ADON F said when a resident had a change in condition the doctor should be notified. ADON F said it was important to notify the doctor to see if it was a one-time thing or to see if medications needed to be adjusted. During an interview on 07/27/2025 at 2:34 PM, the Regional Compliance Nurse said she had reviewed the admissions/re-admissions to make sure their orders and medications were in the facility on 07/26/2025. The Regional Compliance Nurse said she completed care plan audits to ensure residents receiving anti-convulsant medications had a care plan for them on 07/26/2025. The Regional Compliance Nurse said she reviewed the physician orders of residents who received anti-convulsant medications and verified their medications were in the facility. The Regional Compliance Nurse said the doctor was notified of Resident #1's medication error and he ordered loading doses on Resident #1's seizure medications and labs for Wednesday 07/30/2025. The Regional Compliance Nurse said in-services on change in condition, abuse and neglect, medication errors, following the physician orders, new/admission/readmission ordering medications, seizure management, medication reconciliation, medication administration, and following the doctor's orders and standing orders for labs upon admission were conducted. During an interview on 07/27/2025 2:41 PM, ADON C said when a resident was admitted to the facility the pharmacy received notification of the admission. ADON C said there was some kind of error in their system, and the pharmacy was not notified of Resident #1's admission. ADON C said when a resident had a change in condition the physician should be notified. ADON C said it was important for the physician to be notified of changes in condition for continuation of care and so they addressed the residents' changes in condition. ADON C said she spoke with Resident #1's family member regarding their concerns about Resident #1's seizure medications not being administered. ADON C said she talked to the nurses and started in-services with the nurses. ADON C said if a medication was unavailable the nurses needed to notify the doctor, DON, and pharmacy. ADON C said depending on the type of medication if a medication was not administered it could cause serious effects and the residents' labs could be affected. During an interview on 07/27/2025 at 5:21 PM, the Administrator said when a resident admitted to the facility she expected for the nurses to look at the doctor's orders, call the pharmacy, and let them know what medications the resident needed. The Administrator said if a medication was not available, the nurses should notify the physician and see what the physician wanted to order to replace the medication until the pharmacy filled the order. The Administrator said the nurse was responsible for ensuring the medications were in the facility and nurse management should provide oversight. The Administrator said it was important for the medications to be administered to prevent negative experiences. The Administrator said when Resident #1 returned on 07/22/2025 the nurses were supposed to contact the pharmacy to notify them of his return. The Administrator said the nurses failed to notify the pharmacy. The Administrator said she was notified yesterday morning (07/26/2025), that Resident #1 had not received his seizure medications. The Administrator said she was also notified Resident #1 had a seizure and the physician was not notified. The Administrator said she expected for all changes in condition to be reported to the physician. The Administrator said it was important for the physician to be notified of changes in condition to prevent things from happening such as a seizure. During an interview on 07/27/2025 at 7:45 PM, the Medical Director said he was not notified that Resident #1's seizure medications were not administered. The Medical Director said he was not notified Resident #1 had a seizure. The Medical Director said the facility typically reached out to his NP for orders, but he believed she had not been notified either. The Medical Director said Resident #1 not receiving his seizure medications for a couple days could absolutely cause him to have seizures. The Medical Director said he was surprised Resident #1 only had a small seizure because the missed doses could have resulted in more severe seizures. During an interview on 07/27/2025 at 7:56 PM, the NP said she was not notified Resident #1's seizure medications were not administered or that he had a seizure. The NP said she expected the nurses to notify her if this occurred. The NP said she was in the facility often and typically the nurses notified her Monday-Friday of anything that happened. The NP said Resident #1's seizure medications not being administered could result in him having seizures. Review of In-service documentation indicated the following: No staff will be allowed to take a shift until in-service education is completed. The following in-services were initiated on 07/26/2025 at 10:15 AM by the DON, ADON and regional nurse. Staff were sent the in-services via email to review prior to reporting for their shifts. The training was still ongoing at the time of the investigation. All Staff: Change in Condition and Abuse and NeglectNurses and Medication Aides: Medication Administration, Unavailable medications, Medication Error, Following physician orders, New/Admission/readmission ordering medications, Seizure Management, Medication Reconciliation During an interview on 07/28/2025 at 8:45 AM the Division Director of Clinical Services said Resident #1 originally admitted to the facility on [DATE] but returned to the hospital that same day. She said he did not re-admit until 07/22/2025. She said he went back to the hospital on [DATE] and returned to the facility later that same day. She said the emergency medication kit did not contain any liquid medications but the tablet medications were available. She said the pharmacy did not have one of the liquid medications. She said the physician and DON were not notified of the medications being unavailable for administration. During an interview on 07/28/2025 at 9:05 AM the administrator said the in-services were sent by email to staff to read and then the staff members were required to read and sign the in-service sheets when they physically returned to the facility for work. The signature sheets were verified by the administrator, DON, or ADONs for completion prior to working their shifts. During an interview on 07/28/2025 the Regional Compliance nurse said when it was discovered in the late afternoon on 07/25/2025 medications had not been administered and no one had informed the management of the absence of the medications for Resident #1 she said they immediately began to remedy the situation. She said the resident had multiple admissions/re-admissions to the facility in a short period of time. She said she thought the pharmacy was not sure if the resident was actually in the facility. She said the facility should have called the pharmacy to verify the resident's admission and that the medications could be filled and delivered. She said the pharmacy delivers medications twice a day and if an order can be placed by 6 PM it would be delivered that night around 11 PM. She said the pharmacy had been known to fill and deliver a medication stat (needed immediately). She said the error occurred due to poor communication and follow through. She said Resident #1 admitted on the afternoon of 07/22/2025 and medications had been reviewed and input into the electronic health record. She said apparently the order button was not pushed to send the request to the pharmacy but she was not sure exactly what happened. She said the night nurse (coming on at 6 PM) thought the medications had already been ordered and so she did not order them. She said the admitting nurse was off the next 2 days and would have caught the missed medications the next day, but did not catch the error until her return on 7/25/2025. She said the crushable medications were available from the emergency medication kit. She said they began by auditing physician orders for residents receiving anticonvulsants and for the presence of the medications in the facility. She said the MARs were checked for administration. She said the care plans were audited for seizure medication and updated as needed. She said in-servicing of staff began 07/26/2025. She said 2 nurses were suspended pending the investigation as they had signed the MAR indicating they gave Resident #1 the medications that were not present in the facility. She said other nurses indicated the medications were unavailable but did not notify the DON or physician.During an interview on 07/28/25 at 10:00 AM with RN G said he was provided additional training on many things. He noted Abuse and Neglect, Change of Condition, Medication Administration, Notification of the physician, DON and responsible parties of changes and/or missed medications, ordering of medications and unavailability of medications. He said if their pharmacy did not have a medication available they had 24 hour local pharmacy and they could get their pharmacy to send the prescription there. He indicated a new posting at the nurses' station that listed the 2 local pharmacies available to them. During an interview on 07/28/2025 at 10:05 AM with MDS/LVN H said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. During an interview on 07/28/2025 at 10:10 AM with LVN J indicated Resident #1 resided n her hall. She said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. She said Resident #1's medications were present in the facility and she administered them that morning. She verified all his seizure medications had been given. During an interview on 07/28/2025 at 10:15 AM with ADON C said she completed the audit on the medication carts and verified the presence of anticonvulsant medications with the corresponding physician orders on 07/26/2025. She said all medications were present except one medication that would have been needed that evening and was not in the emergency kit. She said she called the pharmacy and it was delivered as a high priority and was available at time of administration. During an interview on 07/28/2025 at 10:17 AM MA K said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. She said they had to make sure medications were available in house and not just mark the MAR as unavailable and go on to the next resident. She said she would report it to her charge nurse if something was not available and they could possibly get it for her out of the emergency kit. She said if she finished a medication card she checked her cart for an extra card and if not in her cart she would go immediately to let the charge nurse know about the medication. She said she was able to re-order medications on her computer. During an interview on 07/28/2025 at 10:20 AM MA L said she was shadowing MA K and had started work last week. She said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. During an interview on 07/28/2025 at 10:25 AM MA M said she received 5 or 6 in-services on Saturday and 2 more that morning and they included abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. She said they were told to report unavailable meds to the charge nurse, ADON or DON so they could re-order it or possibly get it from the emergency kit. During an interview on 07/28/2025 at 10:30 AM with LVN N said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. During an interview on 07/28/2025 at 10:35 AM MA O said she received in-services and they included abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. She said they were told to report unavailable meds to the charge nurse, ADON or DON so they could re-order it or possibly get it from the emergency kit. During multiple interviews on 07/28/2025 with general staff from the day shift (6AM-6PM) (Housekeeper P, Housekeeper Q, Housekeeper R, Dietary Manager T, Housekeeping Supervisor U, DA W, [NAME] X, DA FF) from 1:04 PM-1:47 PM indicated they said they had been trained on abuse and neglect and change of condition. They said they were given examples of how to identify a change of condition and report it to the charge nurse. They said the abuse coordinator was the administrator and was who they reported to. During multiple interviews on 07/28/2025 with nurses, CNAs, and Mas from both shifts (6AM-6PM and 6PM-6AM) (CNA S, CNA V, CNA Y, NA Z, HA AA, CNA BB, CNA DD, CNA EE, RN GG, MA HH, MA JJ, LVN KK, RN LL, LVN MM, MA NN, MA OO) from 1:08 PM-2:15 PM indicated they said they had been trained on abuse and neglect, change of condition, medication administration, notification of the physician, DON and responsible parties of changes and/or missed medications, ordering of medications and unavailability of medications.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Lacosamide Oral Solution 10 mg/ml Give 20 ml via G-tube two times a day for epilepsy was marked as given at 6:00 PM on 07/26/2025 and 12:00 AM and 6:00 AM on 07/27/2025.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Levetiracetam 100 mg/ml Give 15 ml via G-tube twice a day. The 9:00 PM dose on 07/25/2025 was marked as given and the 9:00 AM dose was marked as given on 07/26/2025. Review of Resident #1's electronic MAR dated July 2025 indicated the following:Topiramate 100 mg tablet Give one via G-tube two times a day was marked as given two times on 07/25/2025 and two times on 07/26/2025.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Valproic Acid 250 mg/5 ml Give 10 ml via G-tube three times a day for epilepsy was marked as given at 10:00 PM on 07/26/2025 and 9:00 AM, 3:00 PM on 07/27/2025 were marked as given. On 07/28/2025 at 12:54 PM, the Administrator was informed of the Immediate Jeopardy and provided the IJ template. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 07/22/2025 and ended on 07/26/2025. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident's drug regimen was free of significant medication errors for 1 (Resident #1) of 10 residents reviewed for pharmacy services. The facility failed to order Resident #1's valproic acid, topiramate, levetiracetam, and lacosamide after he re-admitted on [DATE]. Resident #1 had a seizure on 07/25/25. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 07/22/2025 and ended on 07/26/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, worsening or exacerbation of chronic medical conditions, and hospitalization.Findings included: Record Review of Resident #1's face sheet dated 07/27/25 indicated the resident was a [AGE] year-old male with an original admission date of 07/10/2025 and readmission date of 07/22/2025. The resident had diagnoses including acute respiratory failure with hypoxia (a life threatening condition where the lungs cannot adequately oxygenate the blood, resulting in low blood oxygen levels), epilepsy with status epilepticus (a serious neurological condition where seizures are prolonged or occur frequently without recovery between them, posing a risk of brain damage), stroke, and high blood pressure.Record Review of Resident #1's readmission assessment note dated 07/22/2025 indicated there was no BIMS score due to resident's inability to answer questions. Resident #1 was alert but unable to speak due to the presence of a tracheostomy tube (a curved hollow tube inserted into a surgically created opening in the neck to create and airway into the windpipe), he had an indwelling urinary catheter and was incontinent of bowel, required extensive to total assistance for ADLs, he had a feeding tube inserted into his abdomen, and had a cough and abnormal lungs sounds of rhonchi (low-pitched, continuous, and rattling sounds heard during breathing, often described as resembling snoring or gurgling.Record Review of Resident #1's care plan with initiation date 0710/2025 and revised 07/26/2025 indicated the resident had a seizure disorder and interventions included for the facility staff to: administer seizure medication as ordered by the doctor, and seizure documentation should have included location of seizure activity, type of seizure activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after seizure activity.Review of Resident #1's Physician Orders last updated 07/26/25 included: Lacosamide Oral Solution 10 mg/ml Give 20 ml via G-tube two times a day for epilepsy, Levetiracetam 100 mg/ml Give 15 ml via G-tube twice a day for epilepsy, Topiramate 100 mg tablet Give one via G-tube two times a day for epilepsy, and Valproic Acid 250 mg/5 ml Give 10 ml via G-tube three times a day for epilepsy.Review of Resident #1's hospital after visit summary dated 07/23/2025 indicated the resident was to receive Lacosamide Oral Solution 10 mg/ml Give 20 ml via G-tube three times a day, Levetiracetam 100 mg/ml Give 15 ml via G-tube every 12 hours, Topiramate 100 mg tablet Give one via G-tube two times a day, and Valproic Acid 250 mg/5 ml Give 10 ml via G-tube every 8 hours.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Lacosamide Oral Solution 10 mg/ml Give 20 ml via G-tube two times a day for epilepsy was marked as unavailable for the PM dose on 07/22/2025,the AM dose on 07/23/2025 was blank and not marked as given, the PM dose for 07/23/2025, the AM dose for 07/24/2025 was marked as given, the PM dose for 07/24/2025 was marked as not given and the AM dose on 07/25/2025 was marked as given. There was no reason given for the blank and not given marks.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Levetiracetam 100 mg/ml Give 15 ml via G-tube twice a day. The 9:00 PM dose on 07/22/2025 was marked as unavailable, the 9:00AM on 07/23/2025 was blank and not marked as given, the 9:00 PM dose for 07/23/2025 was marked as given, the 9:00 AM dose for 07/24/2025 was marked as given, the 9:00 PM dose on 07/24/2025 was marked as not given, the 9:00 AM dose on 07/25/2025 was marked as unavailable. There was no reason given for the blank and not given marks. Review of Resident #1's electronic MAR dated July 2025 indicated the following:Topiramate 100 mg tablet Give one via G-tube two times a day the AM dose on 07/22/2025 was not marked as given and was blank. There was no reason given for the blank space.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Valproic Acid 250 mg/5 ml Give 10 ml via G-tube three times a day for epilepsy was marked as unavailable for the 9:00 PM dose on 07/22/2025, the 9:00 AM dose and 3:00 PM doses on 07/23/2025 were blank and not marked as given. The 9:00 AM, 3:00 PM and 9:00 PM doses on 07/24/2025 were marked as given. The 9:00 AM, 3:00 PM and 9:00 PM doses on 07/25/2025 were marked as given. There was no reason given for the blank and not given marks.During an interview on 07/27/2025 at 8:23 AM, Resident #1's family member said she was visiting Resident #1 around 1:00 PM-1:45 PM on 07/25/2025, when he had a seizure. Resident #1's family member said she called the nurse to the room for assistance, and LVN A assessed Resident #1 and told them he would probably be a little sleepy. Resident #1's family member said LVN A told her she would call the doctor to see if he wanted to do any labs. Resident #1's family member said later in the evening of 07/25/2025 she went to check on Resident #1 and was informed by LVN B that Resident #1's seizure medications had not been administered prior to 07/25/2025. Resident #1's family member said LVN B told her his seizure medications had just arrived (07/25/2025). Resident #1's family member said she had LVN B print her Resident #1's medication administration record and his seizure medications were marked as unavailable or administered. Resident #1's family member said the nurses falsified the documentation because the seizure medications were not in the facility. Resident #1's family member said she was very concerned about her family member because he had a history of seizures, and in the past had been hospitalized due to uncontrolled seizures that would not stop. Resident #1's family member said she had contacted the DON and ADON C and explained her concerns regarding Resident #1's seizure medications. Resident #1's family member said the DON told her the pharmacy did not provide the medications because they were out. Resident #1's family member said the DON told her they had ordered the medications on 7/25/2025. During an observation of medication administration on 07/27/2025 starting at 9:08 AM, LVN A administered Resident #1's seizure medications: Lacosamide 10mg/ml give 20 ml 200 mg per g-tube twice daily, date received 7/25/25, 20 ml administered. Valproic Acid 250 mg/5 ml give 10 ml 500 mg via g-tube three times daily, date received 7/25/25, 10 ml administered. Levetiracetam 100 mg/ml give 15 ml 1500 mg per g-tube twice daily, date received 7/25/25, 15 ml administered. Topiramate 100 mg give 1 tab via g-tube two times a day, date received 7/25/25, 1 tab administered.During an interview on 07/27/2025 at 11:00 AM, LVN A said the process for when patients admitted /re-admitted was that they verified the orders with the doctor, and then they carried the orders out. LVN A said when they put the orders in the electronic health record the pharmacy sent the medications the same night. LVN A said she re-admitted Resident #1 on 07/22/2025, and she verified his admission orders. LVN A said she normally tried to call the pharmacy to notify them of admission, but she did not have the time to call because she had two admissions back-to-back. LVN A said she was off the 2 days following Resident #1's admission (did not work on 07/23/2025 and 07/24/2025). LVN A said when she returned to work on 07/25/2025, the night nurse LVN D told her not all of Resident #1's medications had been delivered. LVN A said she contacted the pharmacy and gave them a list of the medications that were missing, and they had them delivered that night. LVN A said if a resident was missing medications, they are supposed to call the pharmacy to check on the medications and notify the doctor. LVN A said she did not notify the doctor the medications were not delivered, and Resident #1 missed doses of his seizure medications. LVN A said on Friday, 07/25/2025, Resident #1 had a small seizure. LVN A said not administering medications could result in seizures and high blood pressures that it depended on the medication what adverse effect resulted. During an interview on 07/27/2025 at 11:38 AM, LVN D said when a resident admitted /re-admitted to the facility the admitting nurse was responsible for putting in the orders in the electronic health record. LVN D said the orders should be sent to the pharmacy or they should call the pharmacy to notify them of the resident's admission so the medications could be sent. LVN D said if a resident's medication was not delivered from the pharmacy, they should indicate on the MAR the medication was unavailable and notify the pharmacy and management. LVN D said they should also notify the doctor the medication was not given. LVN D said she did not attempt to order Resident #1's medications until Thursday (07/24/2025) night. LVN D said depending on the medication that was not administered the residents could have multiple adverse reactions such as high blood pressure and fluid buildup. During an interview on 07/27/2025 at 12:44 PM, LVN B said all medication were delivered through the facility's pharmacy to the facility. LVN B said if medications were placed in the electronic health record before 3 PM, they would be delivered the same night. LVN B said Resident #1 admitted sometime on the day shift on 07/22/2025. LVN B said Resident #1's medications were not delivered on 07/22/2025. LVN B said she had no idea why Resident #1's medications were not delivered on 07/22/2025. LVN B said she did not work on 07/23/2025 and 07/24/2025. LVN B said on 07/25/2025, when she arrived for her shift, LVN A informed her some of Resident #1's medications had not been delivered, but they would be delivered that night (07/25/2025). LVN B said Resident #1's seizure medications were delivered 07/25/2025 during her night shift, and she was able to administer all of them. During an interview on 07/27/2025 at 1:01 PM, LVN E said the ADONs and DON put in the resident's physician orders into the electronic health record, and from her understanding they went to the pharmacy automatically. LVN E said if there was a new admission they should fax the orders to the pharmacy for the medications to be sent to the facility. LVN E said she worked on 07/23/2025 and 07/24/2025 on the day shift. LVN E said she did not administer any medications to Resident #1 on 07/23/2025 because she sent him to the hospital. LVN E said she was not able to remember if she had signed off the medications as administered in his MAR or as hospitalized . LVN E said she might have inaccurately documented some of Resident #1's medications as administered, when she did not administer them because she was in a rush and had a lot going on. LVN E said 07/24/2025, she contacted the pharmacy about Resident #1's medications, and the pharmacy told her his medications would be delivered Monday (07/28/2025). During an interview on 07/27/2025 at 1:16 PM, the Pharmacist said the DON contacted them yesterday (07/26/2025) to ask about Resident #1's medications. The Pharmacist said when Resident #1 re-admitted to the facility for whatever reason they did not get the request to send his medications in their system. The Pharmacist said the facility possibly indicated the medications were on hand, which would result in the medications not being sent out to the facility. The Pharmacist said the request for Resident #1's medications was received on 07/25/2025. The Pharmacist said usually the electronic system used by the facility notified them when a resident admitted , and orders were put in because the facility's system was linked with the pharmacy. During an interview on 07/27/2025 at 1:22 PM, the DON said Resident #1 re-admitted on [DATE] or 07/23/2025. The DON said the nurses did not follow the facility's protocol and notify him Resident #1's medications were not delivered. The DON said the nurses should have notified him, so the doctor could be notified. The DON said late Friday evening (07/25/2025) Resident #1's family member notified him Resident #1 had not received his seizure medications, and he informed her the medications would be delivered to the facility that evening. The DON said they started in-services on abuse and neglect, medication errors, instructed the nurses to notify him of medications that were not available and notifying the doctor. The DON said LVN D and LVN E were suspended pending investigation due to them failing to notify the DON Resident #1's medications were not available and documenting medications as administered when they were not available in the facility. The DON said when a resident admitted to the facility, orders were put into their electronic health system and the pharmacy was notified electronically to send the medications. The DON said LVN A did not notify the doctor of Resident #1's seizure. The DON said he reported it to the doctor when he was notified that Resident #1 had a seizure. The DON said medications not being administered greatly increased the residents' chances of negative outcomes such as increased seizure activity and death. The DON said it was important to notify the doctor of changes in condition because it was the cornerstone of good patient care and so they could have documentation that something was done. During an interview on 07/27/2025 at 1:42 PM, ADON F said when a resident admitted to the facility the medications should be put into the electronic health record and the orders go to the pharmacy automatically. ADON F said when Resident #1 re-admitted to the facility nobody notified the pharmacy of his admission. ADON F said when Resident #1's medications were not delivered, they should have contacted the pharmacy. ADON F said she was not notified by the nurses that Resident #1's medications were not delivered. ADON F said the nurses should have notified the doctor of the medications that were not administered to Resident #1. ADON F said medications not administered as ordered could affect the residents' health, and they could end up dying or having a diminished quality of life. During an interview on 07/27/2025 at 2:34 PM, the Regional Compliance Nurse said she had reviewed the admissions/re-admissions to make sure their orders and medications were in the facility on 07/26/2025. The Regional Compliance Nurse said she completed care plan audits to ensure residents receiving anti-convulsant medications had a care plan for them on 07/26/2025. The Regional Compliance Nurse said she reviewed the physician orders of residents who received anti-convulsant medications and verified their medications were in the facility. The Regional Compliance Nurse said the doctor was notified of Resident #1's medication error and he ordered loading doses on Resident #1's seizure medications and labs for Wednesday 07/30/2025. The Regional Compliance Nurse said in-services on change in condition, abuse and neglect, medication errors, following the physician orders, new/admission/readmission ordering medications, seizure management, medication reconciliation, medication administration, and following the doctor's orders and standing orders for labs upon admission were conducted. During an interview on 07/27/2025 2:41 PM, ADON C said when a resident was admitted to the facility the pharmacy received notification of the admission. ADON C said there was some kind of error in their system, and the pharmacy was not notified of Resident #1's admission. ADON C said she spoke with Resident #1's family member regarding their concerns about Resident #1's seizure medications not being administered. ADON C said she talked to the nurses and started in-services with the nurses. ADON C said if a medication was unavailable the nurses needed to notify the doctor, DON, and pharmacy. ADON C said depending on the type of medication if a medication was not administered it could cause serious effects and the residents' labs could be affected. During an interview on 07/27/2025 at 5:21 PM, the Administrator said when a resident admitted to the facility she expected for the nurses to look at the doctor's orders, call the pharmacy, and let them know what medications the resident needed. The Administrator said if a medication was not available, the nurses should notify the physician and see what the physician wanted to order to replace the medication until the pharmacy filled the order. The Administrator said the nurse was responsible for ensuring the medications were in the facility and nurse management should provide oversight. The Administrator said it was important for the medications to be administered to prevent negative experiences. The Administrator said when Resident #1 returned on 07/22/2025 the nurses were supposed to contact the pharmacy to notify them of his return. The Administrator said the nurses failed to notify the pharmacy. The Administrator said she was notified yesterday morning (07/26/2025), that Resident #1 had not received his seizure medications. The Administrator said she was also notified Resident #1 had a seizure and the physician was not notified. During an interview on 07/27/2025 at 7:45 PM, the Medical Director said he was not notified that Resident #1's seizure medications were not administered. The Medical Director said he was not notified Resident #1 had a seizure. The Medical Director said the facility typically reached out to his NP for orders, but he believed she had not been notified either. The Medical Director said Resident #1 not receiving his seizure medications for a couple days could absolutely cause him to have seizures. The Medical Director said he was surprised Resident #1 only had a small seizure because the missed doses could have resulted in more severe seizures. During an interview on 07/27/2025 at 7:56 PM, the NP said she was not notified Resident #1's seizure medications were not administered or that he had a seizure. The NP said she expected the nurses to notify her if this occurred. The NP said she was in the facility often and typically the nurses notified her Monday-Friday of anything that happened. The NP said Resident #1's seizure medications not being administered could result in him having seizures. Review of In-service documentation indicated the following: No staff will be allowed to take a shift until in-service education is completed. The following in-services were initiated on 07/26/2025 at 10:15 AM by the DON, ADON and regional nurse. Staff were sent the in-services via email to review prior to reporting for their shifts. The training was still ongoing at the time of the investigation. All Staff: Change in Condition and Abuse and NeglectNurses and Medication Aides: Medication Administration, Unavailable medications, Medication Error, Following physician orders, New/Admission/readmission ordering medications, Seizure Management, Medication Reconciliation During an interview on 07/28/2025 at 8:45 AM the Division Director of Clinical Services said Resident #1 originally admitted to the facility on [DATE] but returned to the hospital that same day. She said he did not re-admit until 07/22/2025. She said he went back to the hospital on [DATE] and returned to the facility later that same day. She said the emergency medication kit did not contain any liquid medications but the tablet medications were available. She said the pharmacy did not have one of the liquid medications. She said the physician and DON were not notified of the medications being unavailable for administration. During an interview on 07/28/2025 at 9:05 AM the administrator said the in-services were sent by email to staff to read and then the staff members were required to read and sign the in-service sheets when they physically returned to the facility for work. The signature sheets were verified by the administrator, DON, or ADONs for completion prior to working their shifts. During an interview on 07/28/2025 the Regional Compliance nurse said when it was discovered in the late afternoon on 07/25/2025 medications had not been administered and no one had informed the management of the absence of the medications for Resident #1 she said they immediately began to remedy the situation. She said the resident had multiple admissions/re-admissions to the facility in a short period of time. She said she thought the pharmacy was not sure if the resident was actually in the facility. She said the facility should have called the pharmacy to verify the resident's admission and that the medications could be filled and delivered. She said the pharmacy delivers medications twice a day and if an order can be placed by 6 PM it would be delivered that night around 11 PM. She said the pharmacy had been known to fill and deliver a medication stat (needed immediately). She said the error occurred due to poor communication and follow through. She said Resident #1 admitted on the afternoon of 07/22/2025 and medications had been reviewed and input into the electronic health record. She said apparently the order button was not pushed to send the request to the pharmacy but she was not sure exactly what happened. She said the night nurse (coming on at 6 PM) thought the medications had already been ordered and so she did not order them. She said the admitting nurse was off the next 2 days and would have caught the missed medications the next day, but did not catch the error until her return on 7/25/2025. She said the crushable medications were available from the emergency medication kit. She said they began by auditing physician orders for residents receiving anticonvulsants and for the presence of the medications in the facility. She said the MARs were checked for administration. She said the care plans were audited for seizure medication and updated as needed. She said in-servicing of staff began 07/26/2025. She said 2 nurses were suspended pending the investigation as they had signed the MAR indicating they gave Resident #1 the medications that were not present in the facility. She said other nurses indicated the medications were unavailable but did not notify the DON or physician. During an interview on 07/28/25 at 10:00 AM with RN G said he was provided additional training on many things. He noted Abuse and Neglect, Change of Condition, Medication Administration, Notification of the physician, DON and responsible parties of changes and/or missed medications, ordering of medications and unavailability of medications. He said if their pharmacy did not have a medication available they had 24 hour local pharmacy and they could get their pharmacy to send the prescription there. He indicated a new posting at the nurses' station that listed the 2 local pharmacies available to them. During an interview on 07/28/2025 at 10:05 AM with MDS/LVN H said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. During an interview on 07/28/2025 at 10:10 AM with LVN J indicated Resident #1 resided n her hall. She said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. She said Resident #1's medications were present in the facility and she administered them that morning. She verified all his seizure medications had been given. During an interview on 07/28/2025 at 10:15 AM with ADON C said she completed the audit on the medication carts and verified the presence of anticonvulsant medications with the corresponding physician orders on 07/26/2025. She said all medications were present except one medication that would have been needed that evening and was not in the emergency kit. She said she called the pharmacy and it was delivered as a high priority and was available at time of administration. During an interview on 07/28/2025 at 10:17 AM MA K said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. She said they had to make sure medications were available in house and not just mark the MAR as unavailable and go on to the next resident. She said she would report it to her charge nurse if something was not available and they could possibly get it for her out of the emergency kit. She said if she finished a medication card she checked her cart for an extra card and if not in her cart she would go immediately to let the charge nurse know about the medication. She said she was able to re-order medications on her computer. During an interview on 07/28/2025 at 10:20 AM MA L said she was shadowing MA K and had started work last week. She said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. During an interview on 07/28/2025 at 10:25 AM MA M said she received 5 or 6 in-services on Saturday and 2 more that morning and they included abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. She said they were told to report unavailable meds to the charge nurse, ADON or DON so they could re-order it or possibly get it from the emergency kit. During an interview on 07/28/2025 at 10:30 AM with LVN N said she received in-services on abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. During an interview on 07/28/2025 at 10:35 AM MA O said she received in-services and they included abuse, neglect, change of condition, missing medications, reporting to the DON, notifying the physician regarding changes and medications not being available. She said they were told to report unavailable meds to the charge nurse, ADON or DON so they could re-order it or possibly get it from the emergency kit. During multiple interviews on 07/28/2025 with general staff from the day shift (6AM-6PM) (Housekeeper P, Housekeeper Q, Housekeeper R, Dietary Manager T, Housekeeping Supervisor U, DA W, [NAME] X, DA FF) from 1:04 PM-1:47 PM indicated they said they had been trained on abuse and neglect and change of condition. They said they were given examples of how to identify a change of condition and report it to the charge nurse. They said the abuse coordinator was the administrator and was who they reported to. During multiple interviews on 07/28/2025 with nurses, CNAs, and Mas from both shifts (6AM-6PM and 6PM-6AM) (CNA S, CNA V, CNA Y, NA Z, HA AA, CNA BB, CNA DD, CNA EE, RN GG, MA HH, MA JJ, LVN KK, RN LL, LVN MM, MA NN, MA OO) from 1:08 PM-2:15 PM indicated they said they had been trained on abuse and neglect, change of condition, medication administration, notification of the physician, DON and responsible parties of changes and/or missed medications, ordering of medications and unavailability of medications. Review of Resident #1's electronic MAR dated July 2025 indicated the following:Lacosamide Oral Solution 10 mg/ml Give 20 ml via G-tube two times a day for epilepsy was marked as given at 6:00 PM on 07/26/2025 and 12:00 AM and 6:00 AM on 07/27/2025.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Levetiracetam 100 mg/ml Give 15 ml via G-tube twice a day. The 9:00 PM dose on 07/25/2025 was marked as given and the 9:00 AM dose was marked as given on 07/26/2025. Review of Resident #1's electronic MAR dated July 2025 indicated the following:Topiramate 100 mg tablet Give one via G-tube two times a day was marked as given two times on 07/25/2025 and two times on 07/26/2025.Review of Resident #1's electronic MAR dated July 2025 indicated the following:Valproic Acid 250 mg/5 ml Give 10 ml via G-tube three times a day for epilepsy was marked as given at 10:00 PM on 07/26/2025 and 9:00 AM, 3:00 PM on 07/27/2025 were marked as given. On 07/28/2025 at 12:54 PM, the Administrator was informed of the Immediate Jeopardy and provided the IJ template. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 07/22/2025 and ended on 07/26/2025. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to ensure a resident environment remained as free of accident hazards as is possible for 1 of 3 residents reviewed for accidents (Resident #1) Resident #1 asked for hot water, MA A heated the water in the microware and did not place a lid on the cup. Resident #1 spilled the water and received a burn on her leg. The facility failed to have measures in place to prevent residents from burns. The noncompliance was identified as Immediate Jeopardy PNC (past non-compliance). The IJ (Immediate Jeopardy) began on 9/1/24 and ended on 9/10/24. The facility had corrected the noncompliance before the survey began. This failure could place resident at risk of suffering, injuries, and hospitalization. Findings included: Record review of Resident #1's face sheet dated 7/11/25 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses were Cervical disc disorder with myelopathy (compressed cervical spine with a potential for problems with fine motor skills, balance, and walking). Record review of Resident #1's quarterly MDS dated [DATE] indicated a BIMS score of 12 (moderate cognitive impairment). Resident #1 had functional limited range of motion on one side of the upper extremity. The assessment indicated that for eating, Resident #1 required substantial to maximal assist, with the helper providing more than half the effort. Record review of Resident #1's care plan dated 9/1/24 indicated she was at risk for burns due to hot liquids. Some of the interventions were coffee and other hot liquids should not be served if over 140-degree, the resident was to use a cup with a lid, and use dominate hand for drinking. Record review of Resident #1's nursing notes dated 9/1/24 indicated the following:*at 10:40 a.m. indicated the resident notified staff of spilling chicken broth in her lap. The skin assessment completed at that time had findings of a scald marks measuring 15 cm long and 1 cm wide at the widest point. Vaseline was applied to the area, and the resident denied pain at this time. The responsible party and the physician were notified. *At 11:41 a.m. indicated the physician gave an order for Silvadene cream to be applied two times daily to the right medial thig until resolved. *At 1:25 p.m. indicated reassessed burn to the right medial thigh *At 1:00 p.m. indicated A blister was noted to be forming to the superior portion of the original scald mark measuring 1.5 cm x 0.9cm. Record review of Resident #1's first hot liquid assessment dated [DATE] indicated she had a loss of mobility /reduced movement to the upper extremities. Resident #1 could not consume hot liquids without interventions. She required lids on cups to reduce the potential for burns with coffee or hot liquids. Record Review of a facility Provider Investigation Report indicated on 9/1/24 around 10:50 a.m. Resident #1 asked MA A for some hot water for some chicken broth. The aide provided the hot water, and the resident spilled her chicken broth in her lap. Record review of a written statement from MA A indicated on 9/1/24 Resident #1 requested hot water. The MA said she heated the water in the microwave and took it back to Resident #1's room. She said the resident put a cube of stock in the cup and stirred it up and took a sip. The MA said she exited the room, and a short time later Resident #1 came to the nurse's station with and empty cup stating she had spilled the hot liquid on her thighs. MA A said at that time Resident #1 said she usually had a lid on her cups to prevent spills. The MA said she had not known Resident #1 used lids for her cups. Record review of a written statement from RN B indicated on 9/1/24 at about 10:50 a.m. Resident #1 wheeled herself to the nursing station. Resident #1 said she spilled chicken broth in her lap. A skin assessment was done at that time and the burn was found to the right medial thigh measuring 15 cm x 1 cm. The resident stated when she picked up the mug with the broth in it the mug slipped from her fingers and spilled on her lap and on the floor. The resident stated she did not have a lid for her mug. The physician was notified and ordered Silvadene ointment twice a day until resolved. At 1:00 p.m. the resident was reassessed and had a blister measuring 1.5 cm x 0.9 cm noted to the superior portion of the burn. Aides and CNAs were instructed this resident needed a lid on all cups of hot liquids. During an interview on 6/30/25 at 10:30 a.m. Resident #1 said a long time ago, she spilled hot water on her lap, and it burned her leg. She said the cup just slipped and the cup of hot water spilled onto her lap. She said she could not feel it at the time but told the nurse. She said she asked the MA to bring her some hot water to make her broth. She said the MA heated the water in the microwave and brought it to her. She said since then, the facility had removed the microwaves, and they cannot use them anymore. During an interview on 7/10/25 at 12:22 p.m. the Regional Compliance Nurse said their company took over the facility 7/01/24. She said when they first took over the building there were microwaves available throughout the building. She said after the incident with Resident #1 they removed all the microwaves from nutrition rooms. They placed only one microwave in the medication room for the nurses to provide hot food and liquids to the residents. She said there as a thermometer in the medication room and all staff were educated on the temperature being at 140 or below. She said the nurses were the only ones that could heat up liquids or food for residents. The Regional Compliance Nurse said on 9/1/24 they had conducted audits of all residents at risk for hot liquids, completed hot liquid assessments, and care plan updates for at risk residents. Record review of an in- service dated 9/1/24 indicated MA A had a one-on-one in service and all staff including dietary staff on hot liquids. The in service indicated hot liquids should not be served if above 140 degrees. Lids are to be placed to prevent hot liquid from spilling. Record review of the facility Self-Reporting Protocol /Ad Hoc QAPI- Hot Liquid Burn dated 9/1/24 indicated the following:* Reported intake into the state agency. * Notified the physician to determine if any new orders were need. *The facility competed hot liquid assessments in PCC for all residents who drink coffee, or hot liquids. * Care planned any resident at risk for hot liquid burns. *The facility indicated they ensured any special dietary interventions were on the tray cards of applicable residents. * In- serviced nursing staff, and dietary staff to follow any interventions for residents requiring hot liquid interventions. * In- serviced all staff that a charge nurse or dietary staff member are the only employee that can heat up liquid in the microwave for residents. All liquid temperature at 140 degrees or below before serving. *The facility initiated a monitoring system to ensure interventions for those at risk was care planned and interventions were in place, for four weeks. Record review of hot liquid temperature monitoring indicated the Dietary Manager at least 5 times a week will ensure any dietary initiated interventions for those at risk for hot liquids are in place and care planned. Monitoring indicated The Dietary Manager and the DON would ask at least 10 staff per week how liquids should be warmed up if requested by a resident and what temperatures hot liquids should be prior to making accessible or serving residents. The monitoring sheets included dates from 9/4/24 through 9/10/24. During an interview on 7/11/25 at 11:15 a.m. the Regional Compliance Nurse said the monitoring was completed for the four weeks. She said the missing sheets had likely been misplaced due to a significant staff turnover they had changed Administrators at least two times since then and the DON is also relatively new. Therefore, the sheet could have been lost during transitions. Record review of care plans and hot liquid assessments for Resident #1, sampled Residents #4, #5 and #6 indicated they were completed with interventions in place. Interviews were conducted with facility employees as follows: 7/10/25*at 8:50 a.m. CNA E worked 6a to 6p*at 9:00 a.m. MA F worked 7a to 7p*at 9:03 a.m. LVN G worked form 5:45 a.m. to 6p*at 9:20 a.m. CNA H worked from 6a to 6p*at 9:24 a.m. ADON/LVN I- said she worked various hours and shifts*at 9:30 a.m. MA J worked 7 a to 7p*at 9:35 a.m. RN K worked 6a to 6p*at 9:45 a.m. CNA L worked 6a to 6 p*at 10:17 a.m. LVN M worked 6a to 6 p*at 10:30 a.m. ADON/LVN O said she worked various hours and shifts7/11/25* at 4:17 a.m. RN P worked from 6p to 6a* at 4:29 a.m. LVN Q worked from 6p to 6a* at 4:36 a.m. CNA R worked from 6p to 6a* at 9:55 a.m. RN T worked 6a to 6p CNAs and MAs said they were aware that only nurses or dietary staff could heat up liquids. They said anytime a resident asked for hot water or food the nurse was informed. They were also aware the liquids were to be at 140 degrees or less. Nurses said there was only one microwave, and it was in the medication room. They were responsible for heating resident liquids. They said there was a thermometer in the medication room next to the microwave. They were to check the temperatures to make sure it was 140 degrees or less. They said the residents that needed lids with their hot liquids were identified and had those lids were in place. They had extra lids if needed. Observation of the facility on 7/11/15 at 11:15 a.m. showed there was a microware in the employee break room that had a keypad entry. The only other microware noted in the facility was in the medication room. There was a thermometer noted next to it. The noncompliance was identified as Immediate Jeopardy PNC (past non-compliance). The IJ (Immediate Jeopardy) began on 9/1/24 and ended on 9/2/24. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure residents were free from significant medication errors for 1 of 3 residents reviewed for medications (Resident #2). The facility failed to follow their policy on medication administration resulting in a significant medication error. *Resident #2 was readmitted [DATE] and had an order on 12/22/24 for Eliquis to be held until 12/27/24- the order did not have a restart date. *Resident #2 had an order on 12/23/24 to hold Eliquis for 4 days and restart the medication on 12/27/24. *The facility did not resume Resident #2's Eliquis medication and he was sent to the hospital on 1/26/25 with DVT and pulmonary embolism. The noncompliance was identified as Immediate Jeopardy PNC (past non-compliance). The IJ (Immediate Jeopardy) began on 1/26/25 and ended on 2/28/25. The facility had corrected the noncompliance before the survey began. This failure could jeopardized resident heath and could have been terminal. Findings Included: Record review of Resident#2's face sheet dated 1/28/25 indicated he was an [AGE] year-old male admitted to the facility 2/13/23. He had diagnoses of Hemorrhage of anus and rectum, history of pulmonary embolism, and chronic embolism and thrombosis of deep veins of left lower extremity. Record review of Resident #2's quarterly MDS dated [DATE] indicated a BIMS score of 13(cognitively intact). His functional limitation in range of motion indicated he had impairment on both sides of his lower extremities and used a wheelchair for mobility. Record review of Resident #2's care plan dated 7/2/24 indicted a focus area of anticoagulant(Eliquis-mediation used to prevent and treat blood clots in the blood vessels and the heart) therapy. An intervention was to monitor, document and report to the physician, signs and symptoms of anticoagulant complications. Record review of Resident #2's computerized physician an order dated 6/28/24 indicated an order for Eliquis 5mg to give one tablet by mouth two times a day related to personal history of pulmonary embolism. Record review of Resident #2's nursing notes dated 12/20/24 at 3:21 a.m. indicated he was transferred to the hospital. Record review of Resident #2's nursing notes dated 12/21/24 indicated the following: *at 4:32 a.m. indicated Resident #2 returned to the facility. *At 4:54 p.m. the report from the hospital nurse indicated Resident #2 was schedule for a polyp removal and to hold Eliquis for 6 days. *At 8:00 p.m. indicated to hold the Eliquis until 12/27/24. Record review of Resident #2's physician orders indicated an order dated 12/22/24 indicated to place the medication on hold on 12/27/24 with no duration or start date. Record review of Resident #2's physician order dated 12/23/24 indicated place the Eliquis on hold from 12/23/24 with a duration of 4 days and restart on 12/27/24. Record review of Resident #2's December 2024 MAR revealed Eliquis oral table 5mg by mouth two times a day. The MAR indicated on 12/20/24 the resident was hospitalized and from 12/21/24 the medication was on hold through 12/31/24. Record review of Resident #2's MAR for January 2025 revealed Eliquis oral table 5mg by mouth two times daily was not administered and was on hold until 1/29/25. During an interview on 7/11/25 at 9:15 a.m. the Regional Compliance Nurse said the two orders for Resident #2's Eliquis canceled each other out. She said the facility computer system would automatically rerestart medications that were on hold. However, the order written on 12/23/24 said to restart the medications on 12/27/24 and that order ended on 12/27/24 at 12:00 a.m. She said the 12/22/24 order placed the Eliquis on hold starting 12/27/24 and began on 12/27/24 at 12:00 a.m. That was why the medication were placed on hold indefinitely. The Regional Compliance Nurse said the 12/22/24 order did not indicate a duration or a restart date. Record review of Resident #2's hospital records dated 1/26/25 indicated he was admitted with diagnosis of noncompliant with Eliquis. Resident #2 presented to the hospital with syncope, he was found to have symptomatic acute pulmonary embolism with right ventricular strain and right DVT requiring mechanical thrombectomy (surgical intervention to remove blood clots) and transition to Eliquis. Record review of the facility Self-Reporting Protocol /Ad Hoc QAPI- Neglect- Medication Error Resulting in Harm. indicated the following:* conducted an audit to determine if any other residents were affected. *An abuse and neglect in-service for all staff to include failure to administer medications as ordered by the physician can be considered neglect. *Staff were in serviced on notification of a change in condition to include reporting change of condition to the nurse. *An in-service was conducted on following MD orders for all nurses to include how to place a medication on hold and add stop/start dates to the physician orders. *An in-service was conducted on Medication Administration policy to include the ensure medications were given correctly. *A medication error policy in-service was conducted with Mas and all nurses to include notification of the physician. *An in service was conducted on medication reconciliation for all nurses to include medication review upon admission and readmission to reduce the incidence of medication errors. *The facility initiated a monitoring system to monitor orders to ensure they were transcribed correctly, physician orders were followed, for at least 4 weeks. The medical director signed the protocol. Record review of an in service dated 1/26/25 indicated nurses and MAs were in serviced on medication administrator to verify the medication and liable to the MAR, always follow the 5 rights of medication administration, right drug, dose, resident, time and route. If the medication is showing that is in on hold, investigate and verify why the medication was being held. The Medication Administration policy was attached. The staff were also in serviced on the facility Medication Error Policy. Record review of an in service dated 1/26/25 indicated staff were in serviced on abuse and neglect. The in service indicated failure to administer medications as order by the physician can be considered neglect. Record review of an in service dated 1/26/25 indicated all staff were in serviced on notification of change in condition. The in service indicated a nurse is to be notified anytime a change in condition is notice. The charge nurse will then be responsible for assessing the resident and notifying the physician and responsible party. This will be documented on the SBAR. Record review of an in service dated 1/26/25 indicated nurses were in serviced on the Medication Reconciliation Process which involved reconciling and comparing medication orders at each stage of the resident stay in the facility to resolve any discrepancies. Medication reviews should occur upon admission or readmission to reduce the incidence of medication errors. The in service indicated that was to be documented in the drug regimen review. Record review of an in service dated 1/26/25 indicated nurses were in serviced on following physician orders to verify the order that was received was correct and to contact the physician for any clarification. When orders were received a progress note or SBAR should be completed along with the notification of the responsible party. Review of the attached policy on Physician's Orders indicted the purpose was to monitor and ensure the accuracy and completeness of the medication orders, treatments orders, and ADL order for each resident. The orders were to be reviewed for accuracy if written orders, telephone orders, or verbal orders. Record review indicated the facility had audited orders on hold and anticoagulants and all medications completed on 1/28/25. Record review of the facility medication error monitoring indicated it began on 1/27/25 ended 2/28/25. The medication administration error monitoring indicated at least 5 times a week all new admissions and readmission from previous days to ensue all orders are transcribed in the system and that all ordered medications were available. The DON or designee would interview a least 4 nurses and medication aides each week and ask them what they would do if medication were not available or what to do regarding medications for any residents returning to the facility. Interviews conducted with facility employees as follows:7/10/25 * at 8:50 a.m. CNA E worked 6a to 6p* at 9:00 a.m. MA F worked 7a to 7p* at 9:03 a.m. LVN G worked form 5:45 a.m. to 6p* at 9:20 a.m. CNA H worked from 6a to 6p* at 9:24 a.m. ADON/LVN I- said she worked various hours and shifts* at 9:30 a.m. MA J worked 7 a to 7p* at 9:35 a.m. RN K worked 6a to 6p* at 9:45 a.m. CNA L worked 6a to 6 p* at 10:17 a.m. LVN M worked 6a to 6 p* at 10:30 a.m. ADON/LVN O said she worked various hours and shifts7/11/25* at 4:17 a.m. RN P worked from 6p to 6a* at 4:29 a.m. LVN Q worked from 6p to 6a* at 4:36 a.m. CNA R worked from 6p to 6a* at 9:55 a.m. RN T worked 6a to 6p Interviews with staff revealed they were knowledgeable about the in services that were provided. Interviews with nurses revealed they were familiar on how to put medications on hold, with durations, and restart dates for residents with appointments or readmissions. They said if they had admissions or readmissions they would reconcile the medications with the physician orders, contact the facility physician for clarification on medications. The nurses said if they noted a change in condition or were informed of a change in condition of a resident they would assess. The CNAs said if they noted a change in the condition of a resident, they would notify the nurse and document on the required form. The MAs said if they had any medication questions they would notify the nurse for clarification. If they noted a medication on hold for longer than the usual 3 to 5 days, they would ask questions for clarification. The noncompliance was identified as Immediate Jeopardy PNC (past non-compliance). The IJ (Immediate Jeopardy) began on 1/26/25 and ended on 1/28/25. The facility had corrected the noncompliance before the survey began.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 7 (Resident #1) residents reviewed for quality of care. The facility failed to perform neurological assessments following an incident report dated 1/9/25 indicating Resident #1 had a fall and hit her head resulting in her being hospitalized with a subdural hematoma. The facility failed to recognize a change in Resident #1's level of consciousness resulting in the family requesting for Resident #1 to be sent to the hospital and Resident #1 being admitted to the hospital with a diagnosis of a subdural hematoma. The failures resulted in an identification of an Immediate Jeopardy (IJ) at 11:00 a.m. on 1/23/25. While the IJ was removed on 1/24/25, the facility remained out of compliance with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could result in residents with falls not being monitored appropriately or residents a change in condition not being recognized leading to further resident decline, residents not receiving timely treatment, and death. Findings Included: 1. Record review of the face sheet dated 1/22/25 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including dementia, anxiety, hemiplegia (muscle weakness or partial paralysis on one side of the body), cerebral infarction (ischemic stroke), and chronic kidney disease (longstanding disease of the kidneys leading to renal failure). Record review of the MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS of 11 and was moderately cognitively intact. The MDS indicated Resident #1 required substantial/maximum assistance with toileting, bathing, and transfers. Record review of the care plan revised 12/15/24 indicated Resident #1 was at risk for falls related to actual continuous falls with a goal of the resident will not sustain serious injury through the review date. Record review of the incident report for Resident #1 date 1/9/25 indicated, This RN found resident on the floor laying on her right her right side and head against the wall. Resident stated, I was trying to walk to the bathroom and fell. vital signs and neuro assessment done due to resident stating she hit her head on the wall, range of motion intact without pain . Record review of the nursing progress note for Resident #1 dated 1/12/25 written by LVN A indicated, family is requesting resident go to ER due to change in [level of consciousness . Record review of the hospital records dated 1/14/25 indicated Resident #1 was admitted to the hospital on [DATE] with diagnoses including subacute subdural hematoma (brain bleed), metabolic encephalopathy (brain disorder that occurs when there is an imbalance of chemicals in the blood), probably secondary to subacute subdural hematoma vs urinary tract infection, and urinary tract infection. During an interview on 1/22/25 at 1:39 p.m. the Regional Compliance Nurse said the facility did not have neuro assessments for Resident #1's fall on 1/9/25. The Regional Compliance Nurse said the nurse who entered the incident report did so incorrectly and the EMR system did not generate for neuro assessments to be completed. The Regional Compliance Nurse said RN B no longer was employed at the facility. The Regional Compliance Nurse said RN B quit after they were questioning her regarding Resident #1's fall on 1/9/25. The Regional Compliance Nurse said RN B was confused about the process of entering the incident report, at first claimed Resident #1 fell, then said it was another resident, and then corrected herself again stating Resident #1 was the resident who had fell. The Regional Compliance Nurse said CNA C was working with RN B on 1/9/25 and was questioned regarding the fall. The Regional Compliance Nurse said CNA C said Resident #1 had a fall and she assisted RN B in getting Resident #1 off the floor. During an interview on 1/22/25 at 2:06 p.m. RN B said she had not been employed at the facility since 1/17/25. RN B said she had resigned from the facility. RN B said she had worked on 1/9/25. RN B said she had a resident fall on 1/9/25. RN B said she thought it was Resident #1. RN B said Resident #1 was in the doorway lying on her right side and Resident #1 stuck out in her mind because she was not aware Resident #1 could move. During an interview on 1/22/25 at 2:12 p.m. the DON said the incident on 1/9/25 was confusing. The DON said she had called RN B regarding the fall. The DON said RN B at first said Resident #1 fell, then said it was the resident across the hall from Resident #1, and then said no, it was Resident #1. During an interview attempt on 1/22/25 at 2:53 p.m. CNA C did not answer the phone and a voicemail was left for her. During an interview on 1/23/25 at 10:10 am the DON said she expected nurses to perform neurological assessments after any head injury, any fall where the resident hit their head or may have hit their head, when a resident had a change in condition not related to their diagnosis that would indicated a neurological issue such as change in behavior or speech. The DON said neurological checks were performed every 15 minutes for an hour, every 30 minutes for an hour, every hour for two hours, every 2 hours for four hours, and then every shift for 48 hours to total 72 hours. During an interview on 1/23/25 at 5:04 p.m. LVN D said she had worked on 1/11/25 and 1/12/25. LVN D said she had assisted in taking care of Resident #1 on 1/11/25. LVN D said she was being trained by LVN A on 1/12/25. LVN D said she had noticed Resident #1 was not responding to her on 1/12/25 the same way she had been on 1/11/25. LVN D said she told LVN A she believed Resident #1 had a change in condition as she was not responding the same way or talking as much. LVN D said LVN A told her Resident #1 did that sometimes and they did not worry about it. LVN D said later in the day on 1/12/25 Resident #1's family came in and were concerned about her change in condition and not happy it had not been addressed. LVN D said Resident #1's family requested she be sent to the hospital. LVN D said at that time Resident #1 was sent to the hospital for evaluation. During an interview attempt on 1/24/25 at 12:05 pm LVN A did not answer the phone and the surveyor was unable to leave a message. Record review of the facility's Neurologic Checks policy last revised May 2016 indicated, Neurologic checks are a combination of objective observations and measurements done to evaluate neurologic status. The results of the checks assist to determine nervous system damage and/or deterioration. The caregiver will identify changes indicating progressive improvement or deterioration in neurologic status. The resident will be free from energy. Procedure 1. Perform handwashing 2. Explain the procedure to the resident based on the ability of the resident to understand the procedure. 3. Become familiar with general physical assessment and history of neurological disorders and conditions affecting mental status. 4. Assess vital signs .5. Asses best eye response .6. Assess best verbal response .7. Assess best motor response .8. Use penlight to check response of pupils to light .9. Check grip of the hand and ability to squeeze hand. Compare grip strength in both hands. 10. Frequency of checks after initial neuro check: every 15 minutes times four, every 30 minutes times two, one-hour times two, every two hours times two, then every shift times 48 hours. 11. All deterioration in neurologic status will be immediately reported to the physician. The nurse will document assessment and the time of physician notification in the clinical record. The Administrator was notified on 1/23/25 at 11:22 a.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on 1/23/25 at 11:27 a.m. The facility's Plan of Removal was accepted on 1/23/25 at 2:41 p.m. and included: Plan of Removal On 1/23/25 Resident #1 had a head to toe and neurological assessment completed by the charge nurse. No change in condition noted. Completed 1/23/25. As of 1/23/25 Resident #1's nurse from 1/9/25 is no longer employed with the facility. As of 1/23/25 a neurological assessment was completed on all residents that had an unwitnessed fall or hit their heads within the last 30 days. No changes in condition were identified. This was completed on 1/23/25. The Administrator, DON, ADON, or designee will review all falls during the morning clinical meeting to ensure that all neuro assessments have been completed for all unwitnessed falls or residents who hit their heads. This will start 1/23/25 and continue indefinitely. The Medical Director was notified of the immediate jeopardy on 1/23/25. An ADHOC QAPI was completed on 1/23/25 with medical director and interdisciplinary team to discuss the immediate jeopardy and plan of removal. The Compliance Nurse in-serviced the Administrator, DON, and ADON 1:1 on the following topics below. This was completed on 1/23/25. o Abuse and Neglect Policy- failure to complete neurological assessment on residents that suffer an unwitnessed fall or hit their head could be considered neglect. o Fall Prevention Policy- to include neurological assessment for unwitnessed falls or resident who it their head. o Neurological Assessment Policy. o Incident reporting - how and when to complete an incident report with the post assessments to include fall notes and neuro assessments. o Notification of Change in Condition Policy to physician and responsible part for any change in condition. o Documentation - to include User Defined Assessments (UDA), progress notes, 24-hour report, etc. and follow-up for incidents and post incident assessments. The following in-services were initiated by the Regional Compliance nurse, Administrator, DON, and ADON on 1/23/25. Any staff member not present or in-serviced on 1/23/25 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN staff will in-serviced prior to start of their next shift. All agency staff will in-serviced prior to their assignment. All Staff o Abuse and Neglect- failure to complete neurological on residents that suffer an unwitnessed fall could be considered neglect. o Notification of Change in Condition Policy report to a charge nurse for any resident that suffers a fall or change in condition immediately. Licensed Nurses: o Abuse and Neglect Policy- failure to complete neurological on residents that suffer an unwitnessed fall could be considered neglect o Fall Prevention Policy- to include neurological assessment for unwitnessed falls or resident who it their head. o Incident reporting - how and when to complete an incident report with the post assessments to include fall notes and neuro assessments. o Neuros Assessment Policy o Notification of Change in Condition Policy to physician and responsible part for any change in condition. o Documentation - to include UDAs, progress notes, 24-hour report, incident reports, and post incident assessments. On 1/24/25 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review on 1/23/24 of Resident #1's neurologic assessment. Record review of 14 out of 18 residents with unwitnessed falls or that hit their heads in the past 30 days neurologic assessments indicated all neurological exams did not indicate any change in the residents' current condition. Record review of the sign-in sheet for the ADHOC QAPI meeting dated 1/23/25 indicated the facility had a QAPI meeting regarding the above failure. Record review of an undated Payroll Input/Personnel Action Form indicated RN B's last date worked at the facility was 1/15/25. The Payroll Input/Personnel Action Form indicated RN B quit/walked of the job on 1/16/25. During interviews with licensed nurse (the Treatment Nurse, ADON E, LVN F, LVN G, LVN H, RN J, RN K, and LVN D) on 1/23/25 and 1/24/25 between 7:15 a.m. and 4:04 p.m. staff were able to name all types of abuse including physical, verbal, sexual, misappropriation of property, and neglect. Staff interviewed said in the case of reported abuse they would notify the abuse coordinator immediately. Staff interviewed said the abuse coordinator was the Administrator. Staff interviewed said if a resident had a change in condition including a fall the physician should be notified immediately. Staff interviewed said in the event of an unwitnessed fall the resident should be assessed and neuro checks initiated, the physician should be notified, and an incident report should be accessed through the risk management tab in the electronic medical records and completed. Staff interviewed said accessing the incident report through the risk management tab resulted in all necessary UDAs including neuro checks being automatically populated. Staff interviewed said all assessments should be documented in the electronic medical record and all changes in condition, medication, etc. should be documented on the 24-hour report. Staff interviewed said neurological assessments consisted of assessing vital signs, assessing best eye response, assessing best verbal response, assessing best motor response, using a penlight to check response of pupils to light, and checking grip of the hand and ability to squeeze hand including comparing grip strength in both hands. Staff interviewed said frequency of neurologic assessment should be as follows: after initial neuro check: every 15 minutes times four, every 30 minutes times two, one-hour times two, every two hours times two, then every shift times 48 hours. During interviews with staff (CNA M, CNA N, CNA P, CNA R, CNA S, CNA T, CNA V, the Admissions Director, Housekeeper W, and the Social Worker) on 1/24/25 between 10:21 a.m. and 10:45 a.m. staff were able to name all types of abuse including physical, verbal, sexual, misappropriation of property, and neglect. Staff interviewed said in the case of reported abuse they would notify the abuse coordinator immediately. Staff interviewed said the abuse coordinator was the Administrator. Staff said if they noticed a change in condition in a resident, they would report it to the nurse immediately and fill out a Stop and Watch Form (a form used by the facility uses to determine what type of change in condition was observed, who the resident was, who reported the change in condition, and who the change of condition was reported to. On 1/24/25 at 10:45 a.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance the facility remained out of compliance with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical and mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 6 (Resident #1) residents reviewed for notification of change. 1. The facility failed to consult with the physician when Resident #1 who was taking Eliquis (blood thinner) and Aspirin (blood thinner) fell and sustained a hematoma to the back of her head. 2. The facility failed to follow their policy on physician notification when the resident had a change of conditions including decreased blood pressure of 80/48 (normal blood pressure is 120/80), increased restlessness, confusion, and hallucinations following her fall on [DATE] at 3:01 a.m. resulting in the Resident #1 being sent to the emergency room on [DATE] at 4:42 p.m. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 4:30 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for not receiving care and services to meet resident needs. Findings Include: 1. Record review of the face sheet dated [DATE] indicated Resident #1 was admitted to the facility on [DATE] with diagnoses including dementia, peripheral vascular disease (narrowing of the blood vessels situated away from the heart or brain), unsteadiness on feet, abnormalities of gait and mobility, long term use of anticoagulants (blood thinners), and hypertension. Record review of the physician orders dated [DATE] indicated Resident #1 had an order for Aspirin 81mg daily starting [DATE] for occlusion of unspecified carotid artery (major blood vessel that supplies blood to the brain). The physician orders indicated Resident #1 had an order for Eliquis 2.5mg twice a day starting [DATE] for atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow). Record review of the MDS dated [DATE] indicated Resident #1 sometimes understood others and was sometimes understood by others. The MDS indicated Resident #1 had a BIMS of 00 and was severely cognitively impaired. The MDS indicated Resident #1 required extensive assistance with bed mobility, transferring, toileting, locomotion on and off the unit, and walking. The MDS indicated Resident #1 used a wheelchair for mobility. Record review of the baseline care plan dated [DATE] indicated Resident #1 was non-ambulatory with interventions including provide assistance with transfers, encourage/remind use of assistive devices with ambulation, bed in low position, and keep call light in reach. The care plan indicated Resident #1 was on anticoagulants with interventions including observe for signs and symptoms of bleeding. Record review of the fall risk assessment dated [DATE] indicated Resident #1 had no risk for falls. Record review of nursing progress noted dated [DATE] at 3:01 a.m. indicated Resident #1 was found lying on the floor on right lateral side in close proximity to the bed. The progress note indicated Resident #1 had a closed, raised area to the back of her head. The progress noted indicated an ice pack was applied to the back of Resident #1's head. The progress note indicated neurological checks were initiated, education was provided on call light use, and bed was in lowest position. The progress note indicated there was an addendum in [DATE] a 1:06 a.m. indicating Resident #1 family, physician, and the ADON had been notified of the fall. Record review of the Neurological Assessment Flow sheet dated [DATE] between 6:00 a.m.- 6:00 p.m. indicated Resident #1 had a blood pressure of 80/48 (normal range for an adult is 120/80). Record review of the nursing notes for Resident #1 dated [DATE] between 6:00 a.m. and 6:00 p.m. indicated there was no documentation to indicate Resident #1's physician was notified when Resident #1 had a blood pressure of 80/48, was restless, confused, and hallucinating, or was consulted when the physician inquired if the resident was anticoagulants. Record review of a nursing progress noted dated [DATE] at 1:33 p.m. indicated Resident #1 was restless, confused, and hallucinating. Record review of a nursing progress note dated [DATE] at 4:42 p.m. indicated Resident #1 was transferred to the emergency room due to fall from [DATE], the hematoma to the back of her head, and changes in level of consciousness. Record review of a nursing progress note dated [DATE] at 5:39 p.m. written by the DON indicated the physician and nurse practitioner were updated on Resident #1's change in neurologic status post fall. The progress note indicated the physician and nurse practitioner agreed with Resident #1's transfer to the emergency room. Record review of the intake revealed the complaint was called into the state agency on [DATE] by the complainant indicated the Resident #1 a fall on [DATE] and was not notified until [DATE] at 8:00 a.m. The complaint indicated Resident #1 was more confused than usual on [DATE] when the complainant visited and requested Resident #1 be sent to the emergency room for evaluation. The complaint indicated Resident #1 had a fractured rib as well as the injury to the back of her head. Record review of Resident #1's inpatient hospice medical records dated [DATE] indicated she was admitted to the hospice facility from the hospital with diagnoses including senile degeneration of the brain and dementia. The hospice medical record indicated Resident #1 was comatose on admission. The hospice medical record indicated Resident #1 had rib fractures. Record review of Resident #1's inpatient hospice medical records dated [DATE] indicated Resident #1 expired on [DATE] at 7:18 p.m. During an interview on [DATE] at 2:09 p.m. the Nurse Practitioner said she had not been notified of Resident #1's fall on [DATE]. The Nurse Practitioner said if she had been notified of Resident #1's fall she would have given orders to transfer to the emergency room for evaluation. The Nurse Practitioner said she would recommend all residents that have a fall with head injury, especially those taking anticoagulants, should be sent to the emergency room for evaluation. During an interview on [DATE] at 3:10 p.m. the Physician said anyone over [AGE] years old and taking blood thinners who had a fall with head injury would require a cat scan. The Physician said he had received a message on [DATE] notifying him of Resident #1's fall. The physician was not able to provide the time he received the message. The Physician said he had sent a message back asking if Resident #1 was on any blood thinners. The Physician said he never received a response regarding Resident #1's medication orders. The Physician was unaware of the times of the messages. The Physician said he was later informed of Resident #1 being sent to the emergency room. During an interview on [DATE] at 3:48 p.m. the DON said the nurse on duty at the time of Resident #1's fall was no longer an employee at the facility due to taking a job in another city. During an interview on [DATE] at 3:49 p.m. the ADON said he did not remember the incident with Resident #1. The ADON said he did not remember being notified of Resident #1's fall. The ADON said if a fall was reported to him with a resident having a raised area to their head he would advise the nursing staff to send them to the emergency room. The ADON said if a resident had a fall with head injury and was taking anticoagulants he would expect them to be sent to the emergency room immediately, and then notifications be made. Record review of the facility's Fall-Clinical Protocol policy revised [DATE] indicated, The physician will help identify individuals with a history of falls and risk factor for falling .In addition, the nurse shall assess and document/report the following .Recent injury, especially fracture or head injury .All current medication .The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved . Record review of the facility's Change in a Resident's Condition or Status policy revised [DATE] indicated, .The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): accident or incident involving the resident .significant change in the resident's physical/emotional/mental condition .Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider . The Administrator was notified on [DATE] at 4:45 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on [DATE] at 4:52 p.m. The facility's Plan of Removal was accepted on [DATE] at 11:05 a.m. and included: Notified Medical Directors of Immediate Jeopardy by the DON. The Administrator and DON initiated in-services for all licensed nurses that educated on Policy of Change in Resident's Condition or Status; Provider notification - notifying provider of anticoagulant medication, dose, and frequency in the setting of unwitnessed falls or falls with head involvement. [DATE] Added in-servicing for all staff to include Interact 4.0 Stop and Watch Early Warning Tool. In addition, for licensed staff added on [DATE] In-servicing Interact 4.0 Change in Condition - When to Report to the MD/NP/PA forms that include Vital Signs, Lab Tests and Diagnostic Procedures, Signs and Symptoms A's, Sign and Symptoms B's, Signs and Symptoms C's, Signs and Symptoms D's, Signs and Symptoms E, F, G's, Signs and Symptoms H, I's, Signs and Symptoms L, M, N's, Signs and Symptoms P, R's, Signs and Symptoms S's, Signs and Symptoms T, U, V's, Signs and Symptoms W's. Added in-servicing for all licensed staff to utilize the Interact 4.0 SBAR Communication form as a reference to guide their assessments of residents and communication to providers. Also added in-services for licensed staff regarding Interact 4.0 Care Path for Acute Mental Status Change, interact 4.0 Care Path for Fall and Interact 4.0 Care Path for Change in Behavior. Initiated review for provider notification if unwitnessed fall or fall involving head in the setting of anticoagulant use in past 30 days. In-services will be completed by [DATE] and any clinical staff who have not been present by this time for in-servicing will be in-serviced before they care for residents. The Director of Nursing, the Assistant Director of Nursing and the treatment nurse-initiated chart reviews for appropriate assessment and notification if unwitnessed fall or fall involving head in the setting of anticoagulant use in past 30 days. These chart reviews are occurring by the Director of Nursing, if a resident is identified who has experienced an unwitnessed fall or fall involving their head and are on anticoagulant(s) in the absence of appropriate assessment and notifications the resident will be assessed for any changes in level of consciousness or significant variation in vital signs or resident's condition the provider will be updated with this information for further recommendations. This task will be completed by [DATE]. The Director of Nursing, the Assistant Director of Nursing and the treatment nurse Initiated assessments of any residents who have had an unwitnessed fall or fall involving head in past 30 days who are still in the facility for change of level of consciousness and will discuss with Provider team for any changes in treatment plan. This task will be completed [DATE]. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Verifying the Medical Director and Nurse Practitioner had been informed of the Immediate Jeopardy. Interviews of Licensed Nurses (LVN A, LVN B, LVN C, LVN D, LVN E, LVN F, LVN G, LVN H, ADON, RN J) were performed. During the interviews all licensed nurses were able to correctly identify when to notify the physician of a resident's change in condition including falls with head injuries and informing the physician of all medication the residents were taking when notifying changes in condition. Interviews of Staff (LVN A, LVN B, LVN C, LVN D, LVN E, LVN F, LVN G, LVN H, ADON, RN J, Front Door Receptionist K, Housekeeper L, CNA M, CNA N, CNA P, DOR, Dietary Aide R, Dietary Aide S, CNA T, Dietary Aide U, Housekeeper V, OT W, CNA X, CNA Y, CNA Z) were performed. During the interviews all staff were able to correctly identify changes in condition of a resident and who to report the changes to. Record review of audits performed by the Administrator, DON and Treatment Nurse of resident fall assessment, falls witnessed and unwitnessed over the past 30 days, and physician notification were completed. On [DATE] at 4:08 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 6 (Resident #1) residents reviewed for quality of care. 1. The facility failed to intervene when Resident #1, who was on anticoagulants fell, hit her head resulting in a raise area on her head. The resident experienced a change in condition which include low blood pressure and hallucinating. The resident was not sent to the hospital until 3 hours after the change when the family had her sent out. 2. The facility failed to consult with the physician of the resident orders for Eliquis (blood thinner) and Aspirin (blood thinner) when reporting the fall. This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 4:30 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk of harm or death related to not receiving proper care or death following a fall with head injury while taking anticoagulation medication (blood thinners). Findings Include: 1. Record review of the face sheet dated [DATE] indicated Resident #1 was admitted to the facility on [DATE] with diagnoses including dementia, peripheral vascular disease (narrowing of the blood vessels situated away from the heart or brain), unsteadiness on feet, abnormalities of gait and mobility, long term use of anticoagulants (blood thinners), and hypertension. Record review of the physician orders dated [DATE] indicated Resident #1 had an order for Aspirin 81mg daily starting [DATE] for occlusion of unspecified carotid artery (major blood vessel that supplies blood to the brain). The physician orders indicated Resident #1 had an order for Eliquis 2.5mg twice a day starting [DATE] for atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow). Record review of the MDS dated [DATE] indicated Resident #1 sometimes understood others and was sometimes understood by others. The MDS indicated Resident #1 had a BIMS of 00 and was severely cognitively impaired. The MDS indicated Resident #1 required extensive assistance with bed mobility, transferring, toileting, locomotion on and off the unit, and walking. The MDS indicated Resident #1 used a wheelchair for mobility. Record review of the baseline care plan dated [DATE] indicated Resident #1 was non-ambulatory with interventions including provide assistance with transfers, encourage/remind use of assistive devices with ambulation, bed in low position, and keep call light in reach. The care plan indicated Resident #1 was on anticoagulants with interventions including observe for signs and symptoms of bleeding. Record review of the fall risk assessment dated [DATE] indicated Resident #1 had no risk for falls. Record review of nursing progress noted dated [DATE] at 3:01 a.m. indicated Resident #1 was found lying on the floor on right lateral side in close proximity to the bed. The progress note indicated Resident #1 had a closed, raised area to the back of her head. The progress noted indicated an ice pack was applied to the back of Resident #1's head. The progress note indicated neurological checks were initiated, education was provided on call light use, and bed was in lowest position. The progress note indicated there was an addendum in [DATE] a 1:06 a.m. indicating Resident #1 family, physician, and the ADON had been notified of the fall. Record review of the Neurological Assessment Flow sheet dated [DATE] between 6:00 a.m.-6:00 p.m. indicated Resident #1 had a blood pressure of 80/48 (normal range for an adult is 120/80). Record review of the nursing notes for Resident #1 dated [DATE] between 6:00 a.m. and 6:00 p.m. indicated there was no documentation to indicate Resident #1's physician was notified when Resident #1 had a blood pressure of 80/48, was restless, confused, and hallucinating, or was consulted when the physician inquired if the resident was anticoagulants. Record review of a nursing progress noted dated [DATE] at 1:33 p.m. indicated Resident #1 was restless, confused, and hallucinating. Record review of a nursing progress note dated [DATE] at 4:42 p.m. indicated Resident #1 was transferred to the emergency room due to fall from [DATE], the hematoma to the back of her head, and changes in level of consciousness. Record review of a nursing progress note dated [DATE] at 5:39 p.m. written by the DON indicated the physician and nurse practitioner were updated on Resident #1's change in neurologic status post fall. The progress note indicated the physician and nurse practitioner agreed with Resident #1's transfer to the emergency room. Record review of the intake revealed the complaint was called into the state agency on [DATE] by the complainant indicated the Resident #1 a fall on [DATE] and was not notified until [DATE] at 8:00 a.m. The complaint indicated Resident #1 was more confused than usual on [DATE] when the complainant visited and requested Resident #1 be sent to the emergency room for evaluation. The complaint indicated Resident #1 had a fractured rib as well as the injury to the back of her head. Record review of Resident #1's inpatient hospice medical records dated [DATE] indicated she was admitted to the hospice facility from the hospital with diagnoses including senile degeneration of the brain and dementia. The hospice medical record indicated Resident #1 was comatose on admission. The hospice medical record indicated Resident #1 had rib fractures. Record review of Resident #1's inpatient hospice medical records dated [DATE] indicated Resident #1 expired on [DATE] at 7:18 p.m. During an interview on [DATE] at 2:09 p.m. the Nurse Practitioner said she had not been notified of Resident #1's fall on [DATE]. The Nurse Practitioner said if she had been notified of Resident #1's fall she would have given orders to transfer to the emergency room for evaluation. The Nurse Practitioner said she would recommend all residents that have a fall with head injury, especially those taking anticoagulants, should be sent to the emergency room for evaluation. During an interview on [DATE] at 3:10 p.m. the Physician said anyone over [AGE] years old and taking blood thinners who had a fall with head injury would require a cat scan. The Physician said he had received a message on [DATE] notifying him of Resident #1's fall. The physician was not able to provide the time he received the message. The Physician said he had sent a message back asking if Resident #1 was on any blood thinners. The Physician said he never received a response regarding Resident #1's medication orders. The Physician was unaware of the times of the messages. The Physician said he was later informed of Resident #1 being sent to the emergency room. During an interview on [DATE] at 3:48 p.m. the DON said the nurse on duty at the time of Resident #1's fall was no longer an employee at the facility due to taking a job in another city. During an interview on [DATE] at 3:49 p.m. the ADON said he did not remember the incident with Resident #1. The ADON said he did not remember being notified of Resident #1's fall. The ADON said if a fall was reported to him with a resident having a raised area to their head he would advise the nursing staff to send them to the emergency room. The ADON said if a resident had a fall with head injury and was taking anticoagulants he would expect them to be sent to the emergency room immediately, and then notifications be made. Record review of the facility's Fall-Clinical Protocol policy revised [DATE] indicated, The physician will help identify individuals with a history of falls and risk factor for falling .In addition, the nurse shall assess and document/report the following .Recent injury, especially fracture or head injury .All current medication .The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved . Record review of the facility's Change in a Resident's Condition or Status policy revised [DATE] indicated, .The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): accident or incident involving the resident .significant change in the resident's physical/emotional/mental condition .Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider . Record review of https://premierneurologycenter.com/blog/blood-thinners-head-injuries-what-you-need-to-know/#:~:text=%3D%3EIf%20you%20are%20taking%20a,seek%20medical%20attention%20right%20away which specifically says in the conclusion If you are taking a blood thinner, it is important to be aware of the risk associated with head injuries. If you experience a bump, blow, or jolt to the head, it is important to seek medical attention right away. Even if you do not feel any symptoms after the injury, it is still important to be evaluated by a doctor. If you are taking an older blood thinner such as .aspirin in addition to a blood thinner, it is especially important to seek medical attention right away if you experience a head injury since the risk of delayed hemorrhage is higher in patients taking these medications. The Administrator was notified on [DATE] at 4:45 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on [DATE] at 4:52 p.m. The facility's Plan of Removal was accepted on [DATE] at 11:20 a.m. and included: Notified Medical Directors of the Immediate Jeopardy in writing on [DATE] at 10:42 p.m Administrator and Director of Nursing initiated in-services for all licensed nurses that educated on Policy of Change in Resident's Condition or Status; Provider notification - notifying provider of anticoagulant medication, dose, and frequency in the setting of unwitnessed falls or falls with head involvement. [DATE] Added in-servicing for all staff to include Interact 4.0 Stop and Watch Early Warning Tool. In addition, for licensed staff added on [DATE] In-servicing Interact 4.0 Change in Condition - When to Report to the MD/NP/PA forms that include Vital Signs, Lab Tests and Diagnostic Procedures, Signs and Symptoms A's, Sign and Symptoms B's, Signs and Symptoms C's, Signs and Symptoms D's, Signs and Symptoms E, F, G's, Signs and Symptoms H, I's, Signs and Symptoms L, M, N's, Signs and Symptoms P, R's, Signs and Symptoms S's, Signs and Symptoms T, U, V's, Signs and Symptoms W's. Added in-servicing for all licensed staff to utilize the Interact 4.0 SBAR Communication form as a reference to guide their assessments of residents and communication to providers. Also added in-services for licensed staff regarding Interact 4.0 Care Path for Acute Mental Status Change, interact 4.0 Care Path for Fall and Interact 4.0 Care Path for Change in Behavior. In-services will be completed by [DATE] and any clinical staff who have not been present by this time for in-servicing will be in-serviced before they care for residents. The Director of Nursing, the Assistant Director of Nursing and the treatment nurse-initiated chart reviews for appropriate assessment and notification if unwitnessed fall or fall involving head in the setting of anticoagulant use in past 30 days. These chart reviews are occurring by the Director of Nursing, if a resident is identified who has experienced an unwitnessed fall or fall involving their head and are on anticoagulant(s) in the absence of appropriate assessment and notifications the resident will be assessed for any changes in level of consciousness or significant variation in vital signs or resident's condition the provider will be updated with this information for further recommendations. This task will be completed by [DATE]. Reviewed policy for Falls - Clinical Protocol for any necessary changes. It was determined to move 2g., i., j., #3. Physician was changed to Provider team to include NPs and PAs, reviewed inserted for collaboration sections of the policy and stand and go portions of the document changed to orthostatic vitals of blood pressures and pulse in the setting of residents who may not be able to stand. Director of Nursing, Assistant Director of Nursing and treatment nurse-initiated assessments of any residents who have had an unwitnessed fall or fall involving head in past 30 days who are still in the facility for change of level of consciousness. Any concerns to be discussed with Provider team for further instruction. This task to be completed [DATE] In daily clinical meetings IDT will discuss and review incidents to monitor for appropriate identification of risk for serious adverse outcome. Although this has been a process, greater focus on falls with risk for serious adverse outcome is a focal point starting [DATE]. The Director of Nursing (or designee Nursing Manager if Director of Nursing is not available) will report this to the Administrator during daily Leadership meeting. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Verifying the Medical Director and Nurse Practitioner had been informed of the Immediate Jeopardy. Interviews of Licensed Nurses (LVN A, LVN B, LVN C, LVN D, LVN E, LVN F, LVN G, LVN H, ADON, RN J) were performed. During the interviews all licensed nurses were able to correctly identify when to notify the physician of a resident's change in condition including falls with head injuries and informing the physician of all medication the residents were taking when notifying changes in condition. Interviews of Staff (LVN A, LVN B, LVN C, LVN D, LVN E, LVN F, LVN G, LVN H, ADON, RN J, Front Door Receptionist K, Housekeeper L, CNA M, CNA N, CNA P, DOR, Dietary Aide R, Dietary Aide S, CNA T, Dietary Aide U, Housekeeper V, OT W, CNA X, CNA Y, CNA Z) were performed. During the interviews all staff were able to correctly identify changes in condition of a resident and who to report the changes to. Record review of audits performed by the Administrator, DON and Treatment Nurse of resident fall assessment, falls witnessed and unwitnessed over the past 30 days, and physician notification were completed. Record review of the facility's Change in Condition and Falls-Clinical Protocol policies confirmed the updated language from Physician to Provider Team. On [DATE] at 4:08 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.