**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents are free from abuse, neglect, misappropriation of resident property, and exploitation for one (Resident #1) of four residents reviewed for abuse. The facility failed to ensure Resident #1 was in a safe environment when LVN A recorded instances of pouring water onto her face, verbally taunting her, and striking her with her knee and sitting on her arm. An immediate jeopardy existed from 03/05/24 - 03/06/24. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. This failure could affect residents by placing them at risk for abuse that could cause diminished quality of life and increased psychosocial harm as well as physical harm. Findings included: Review of Resident #1's undated face sheet revealed she was an [AGE] year-old female admitted to the facility 07/18/19 with diagnoses including: depression, history of stroke (bleeding in the brain), dementia, and kidney disease requiring dialysis (removal of blood by a machine to clean toxins then replacing cleaned blood). Review of Resident #1's quarterly MDS assessment dated [DATE] revealed she had moderate difficulty with her hearing. It further revealed she usually understood others and usually could be understood. The review also revealed Resident #1 had impaired vision that required corrective lenses. Resident #1's BIMS score was an 8, which correlated with moderately impaired cognition. Further review revealed that Resident #1 did not exhibit physical or verbal behavioral symptoms directed towards others nor behavioral symptoms not directed towards others. Review of Resident #1's latest care plan, dated 12/22/23, revealed Resident #1 was at risk for pressure related injury due to impaired mobility with intervention of administering medications as ordered and repositioning Resident #1 at least every 2 hours. Further review revealed Resident #1 was at risk for fluid deficit (dehydration) due to medications, dialysis and variable intake; the intervention for this concern was administer medication, encourage Resident #1 to drink fluids of choice, ensure fluids were within reach, and notify the nurse if Resident #1 refused to drink fluids. Further review revealed Resident #1 was at risk for discomfort/pain due to impaired mobility and recent hospitalization that led to dialysis; the intervention for Resident #1's potential discomfort/pain was anticipate her need for pain relief and respond immediately to any complaint of pain, evaluate the effectiveness of the pain intervention, and review for compliance. Further review revealed Resident #1 had a focus of being non-compliant with medication due to anxiety and interventions were to notify family and physician and notify supervisor. Review of the facility's self-report dated 03/06/24 revealed that LVN A used her cell phone camera to record herself verbally and physically abusing Resident #1. There was a total of 5 videos, with 2 being repeats, that were sent by LVN A to an undisclosed employee who then sent the videos to the corporate office of the facility. Review of the videos, sent to Corporate 03/05/24, revealed LVN A poured water on Resident #1 who was lying in bed. LVN A was heard taunting Resident #1 when Resident #1 became upset about the water poured on her face. Resident #1 swung her left arm out at LVN A each time LVN A approached her bed. LVN A was seen kneeing Resident #1, who was lying on a scoop mattress, and telling Resident #1 that she was going to take these pills. Resident #1 was heard calling LVN A a Black Bitch as she swung her arm at LVN A when LVN A approached Resident #1's bed. LVN A was heard asking Resident #1 if she is gay and throughout the video LVN A was laughing and taunting Resident #1. The next video revealed LVN A continued to taunt Resident #1 and she sat on Resident #1 while commenting that she was sitting on her. LVN A was seen sitting on Resident #1's left hip area, getting up and motioning to sit again as Resident #1 swung her arm at LVN A. LVN A was then seen grabbing Resident #1's blanket and trying to take it from Resident #1 while laughing and telling Resident #1 she was going to take these pills. The next video showed LVN A tugging at Resident #1's blanket and telling her that she would take the blanket if Resident #1 did not take these pills. Resident #1 stated to LVN A that it was her blanket and called LVN A a bitch. Resident #1 struck out with her right arm toward LVN A and LVN A responded by pouring more water on Resident #1's face, which was turned away from LVN A. Resident #1 called LVN A a bitch and LVN A laughed and held the water above Resident #1's head while Resident #1 lifted her right arm above her face to protect from further water being poured. LVN A slowly pretends to pour the water on Resident #1 while Resident #1's arm was over her face for protection but then withdrew the cup of water and laughed, then slowly moved closer to again threaten to pour water on Resident #1's face, held the cup for a few seconds and then poured the water when Resident #1 had lowered her arm. LVN A stated she was going to pour the water and Resident #1 said go ahead and pour it on me. LVN A poured a small amount on Resident #1 who then stated pour it all on me as she wiped the water away. LVN A was laughing and facing the camera. In the next clip, LVN A was kneeing Resident #1 3 times with Resident #1 swinging her left arm toward LVN A after the first kneeing incident. LVN A then grabbed Resident #1's left arm by the wrist and told her to open her mouth while grabbing Resident #1's mouth, and then poking her several times in the breast/chest area while calling Resident #1's name. LVN A then sat down on Resident #1's left arm and part of her abdomen while holding a cup of medication to Resident #1's mouth and looking back at the camera. LVN A then pulled on Resident #1's chin and Resident #1 opened her mouth and LVN A tilted the cup, so the medication ended up in Resident #1's mouth. LVN A then laughed and said ha ha gotcha; LVN A then grabbed the phone/camera. In all 5 video clips Resident #1 was wearing the same clothing and LVN A was wearing the same clothing in all 5 clips. During an interview on 03/13/24 at 11:00 am with the ADM she stated that LVN A sent the videos to an unknown employee who then sent the videos to the corporate office on 03/05/24; the corporate office immediately contacted the ADM, around 03/05/24 at 3:30 pm, and ADM began suspension and termination paperwork. LVN A was not at work at the time, so ADM stated she contacted LVN A to come to the building to sign the suspension paperwork and that she would be terminated for abuse. Corporate office reported LVN A to the board of nursing and included the video files. ADM contacted the family, the police department , the ombudsman and reported to SA . In addition, she notified the MD. The ADM, with support staff from the Corporate Office, began in-servicing all employees on Abuse/Neglect/Exploitation, use of photography/social media, and HIPAA privacy laws. All in-servicing was started 03/05/24 and completed 03/06/24. In addition, skin sweeps of all residents were started 03/05/24 and completed 03/06/24. Resident #1 was assessed by nursing immediately and Social Work met with the resident and continued meeting with her through 03/13/24 (exit ). Resident #1 was followed by Psychiatry, so a call for an immediate visit was made and a psychologist visited with Resident #1 on 03/11/24 (first available time). The psychologist had seen Resident #1 in the past and stated that she had not declined in her baseline from the last time he had seen her several months before and this visit. All residents were given safe resident surveys with no other issues identified. Staff were all given surveys related to LVN A and whether any staff had observed abusive behavior, but no witnessed or other issues were identified. An Ad Hoc QAPI was held with ADM, DON, and MD on 03/05/24. The dialysis clinic that Resident #1 visited 3 times per week were notified to be on alert. In addition, the facility notified every facility in a 60-mile radius that LVN A was terminated and not eligible for re-hire. ADM stated that the police detective informed the ADM that Resident #1's RP would have to press charges for LVN A to be charged with any criminal act. The ADM also stated that the facility would continue asking 5 alert and oriented residents about any abuse or neglect concerns and if the residents feel safe; these questions would be asked for the next 5 weeks (if no concerns are voiced in the future questioning). Record review of Resident #1's EHR assessments tab revealed a Weekly Skin Assessment was performed on 03/05/24 at 4:09 pm and revealed no bruising or skin tears, but noted bilateral non-pressure wounds to the heals which were not marked as new. Record review of the resident safe surveys revealed no other residents documented concerns about safety, nor did the residents feel abused and nor had they witnessed abuse at the facility. Record review of staff surveys revealed that no staff member documented witnessing abuse or neglect of any resident by LVN A nor by any other staff member. In addition, all staff were able to identify the ADM as the abuse coordinator to contact immediately should staff have any concerns about abuse or neglect. Record review of Resident #1's March 2024 Progress Notes revealed a progress note authored by the Social Worker (SW) on 03/05/24 at 6:02 pm and revealed the SW documented trying to interview Resident #1 about the abuse she endured from LVN A, but Resident #1 did not answer about abuse and asked for her breakfast. The SW documented that Resident #1 did not display signs of fear, distress or behavioral agitation. The next progress note authored by the SW on 03/06/24 at 12:24 revealed she contacted Resident #1's psychiatric provider who stated they would arrange for counseling services to contact the SW to setup an appointment. The SW authored a note on 03/06/24 at 5:01 pm that the counseling services contacted the SW, and a therapist would call the SW to discuss telehealth and in-person options. During an interview and observation on 03/13/24 at 3:00 pm with Resident #1 revealed her room was dark and she said to go away. Resident #1 appeared to be resting comfortably in bed; no concerns were visible. Police officer exited room moments before. During an interview with Police Detective on 03/13/24 at 3:10 pm he stated that he was gathering evidence still, as he had just attempted to interview Resident #1 but was unsuccessful. He further stated he still needed to interview Resident #1's RP and LVN A. He provided his contact information and stated he would provide an update and report when he was able. During an interview on 03/19/24 at 9:10 am with LVN A she stated that nobody liked Resident #1 because Resident #1 was physically abusive, used bad language and refused care. She stated that sometime in January of 2024, LVN A had a cup of water to give Resident #1 and Resident #1 swung her hand and caused a little bit of water to spill on Resident #1. She said Resident #1 would respond to requests from LVN A by calling her a bitch and Resident #1 said fuck you. She stated she was supposed to go to work on 03/06/24, and she picked up her paycheck on 03/05/24 and everything was fine but was contacted by the ADM on 03/05/24 around 5 or 6 pm and the ADM told her she was suspended pending an investigation. She said the ADM was not allowed to tell her the allegations. LVN A stated on 03/06/24 she was called and asked to come to the facility and was notified she would be terminated. She denied any further incidents of water being spilled on Resident #1, she denied raising her voice to Resident #1, putting her hands on Resident #1, or any other incidents that would be viewed as abusive. LVN A did state that she had documented when Resident #1 had aggressive behavior toward LVN A. Record review of Resident #1's January 2024 progress notes revealed that LVN A documented a behavior note on 01/30/24 at 7:22 am that further revealed that Resident #1 refused her medication and used foul language and told LVN A to leave her room. LVN A then offered Resident #1 her medication in the shower room and Resident #1 pulled LVN A's hair and knocked the medication cup out of LVN A's hand. LVN A then documented notifying Resident #1's RP of the encounter. Record review of Resident #1's February 2024 progress notes revealed that LVN A documented on 02/03/24 at 2:51 pm that she had contacted Resident #1's RP about a behavior incident earlier that morning (no description or note found specifying the incident) and that a new order for in-patient psychiatric services was placed and RP would be updated when new information was available. Further review revealed a progress note on 02/09/24 at 8:13 am authored by LVN A that stated LVN A called the Mental health and mental rehabilitation crisis hotline to report that Resident #1 was using explicit language and displaying inappropriate behavior (not described) towards LVN A and another staff; LVN A was waiting for a return phone call. Review of a note dated 02/09/24 at 11:22 am by LVN A that revealed the return call from the crisis hotline personnel recommended LVN A speak with RP and MD to obtain inpatient psychiatric services for Resident #1; LVN A spoke to the ADM who recommended LVN A speak to the SW. During an interview on 03/13/24 at 3:13 pm with LVN B, she stated the facility constantly trained on abuse and abuse prevention. She said, it starts your first day of work on the computer before you can work with residents. She stated at least once a month, but usually more, abuse was covered. LVN B stated the most recent abuse in-service was within the last week, she thought last Tuesday or Wednesday (03/05/24 or 03/06/24). She stated if she was concerned about abuse, she would have reported it to the abuse coordinator, the ADM and she felt the ADM would take it seriously. During an interview on 03/13/24 at 3:20 pm with LVN C, she stated that they were in-serviced at least every month on abuse and the most recent was within the last few days. If she suspected abuse, she would protect the resident and notify the abuse coordinator, the ADM. She stated the ADM was new, but seemed good, she said staff were told there was an incident of abuse and to watch Resident #1 for any signs of change from her baseline. LVN C said Resident #1 seemed to be having more good days this week than the last few weeks. During an interview on 03/13/24 at 3:26 pm with CNA D, she said she was trained on abuse at least every other month, but most recently last week. She said if she had witnessed abuse, she would have stopped it and notified the charge nurse immediately, then the DON, and the ADM who was the abuse coordinator. She gave the types of abuse and examples. During an interview on 03/13/24 at 3:37 pm with HK E she said abuse was mentioned in trainings and meetings at least 3 - 4 times a month, and the latest was within the last week. She stated Resident #1 had good and bad days, but Resident #1 had never been physical with her. She said sometimes Resident #1 would yell at her, but when HK E responded calmly to Resident #1 and told her what she was doing and kept talking to her that Resident #1 would calm down. She stated that usually staff stepped out and gave Resident #1 a moment to calm down and tried again later. Record review of in-services revealed all staff in-serviced on Abuse/neglect/exploitation, photography, social media usage, and HIPAA privacy laws which started on 03/05/24 and completed 03/06/24. Record review revealed an attendance sheet for an Ad Hoc QAPI meeting on 03/05/24 which included the ADM, the DON, and the MD. Record review of HR folder revealed termination paperwork that stated that LVN A was hired 11/17/23 and was suspended by the ADM on 03/05/24 with the ADM's stated intent to move straight to termination due to a substantiated allegation that LVN A abused a resident; the ADM also requested that LVN A be added to a list of people not to be rehired due to the abuse. Further review revealed a form titled Personnel Action Form and was marked Termination with LVN A's name and employee identification number. LVN A's final termination date was marked as 03/06/24, and her last day worked according to the form was 03/04/24. Further review of LVN A's HR folder revealed she was last in-serviced on Abuse/neglect/exploitation on the computer on 01/02/24. Further review revealed the facility documented all required background checks for LVN A, which included verification of her nursing license, criminal background check, check with the employee misconduct registry, and the state and federal office of the inspector general exclusion lists. Record review of March 2024 nursing schedule revealed LVN A was not scheduled after 03/05/24. Record review of facility's policy titled Abuse/Neglect dated 03/29/18 revealed abuse included . willful infliction of injury, intimidation, or punishment .verbal abuse included language that was disparaging or derogatory . Mental abuse included harassment, threats of punishment .physical abuse included . pinching, kicking, and hitting .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately consult and notify the resident's physician in an accident including the resident for one (Resident #1) of 7 Residents reviewed for quality of care. The facility nurses failed to immediately consult and notify the Physician when resident #1 sustained a fall with head injury on 09/04/2023 at 04:00 p.m. and the physician was not notified until 09/05/2023 at midnight, 8 hours later. Per the facility policy nurses should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention. An Immediate Jeopardy (IJ) situation was identified on 09/06/2023. While the IJ was removed on 09/07/2023, the facility remained out of compliance at a scope of isolated with actual harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving the highest practicable interventions, treatments and care through resident assessments by recognizing and addressing the physical, mental, and neurological dysfunctions such as altered state of consciousness, cognitive decline, confusion, memory loss, changes in behavior in an effective and timely manner to prevent residents from further harm, injury, or death. Findings include: Record review of Resident #1's face sheet, dated 09/06/2023, revealed a [AGE] year-old-female who was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke), metabolic encephalopathy (brain disruption), heart failure, obesity, and hypertension. Record review of Resident #1's MDS, dated [DATE], revealed a BIMS of 05, which indicated a severe cognitive impairment. Further review of Resident #1's MDS, Hearing, Speech, and Vision, revealed a Speech Clarity code of 0 revealed clear speech-distinct intelligible words, Makes Self Understood code of 1 revealed Usually understood-difficulty communicating some words or finished thoughts but able if prompted or given time. Further review of Resident #1's MDS, Health Conditions, revealed Fall history code of 0, which indicated Resident #1 did not have a fall in the last month, last 2 to 6 months, or fracture related to fall in the 6 months prior to admission. Further review of Resident #1's MDS, Functional status, revealed bed mobility at total dependence with two plus persons physical assist, transfer at activity did not occur, walk in room at activity did not occur, walk in corridor at activity did not occur, locomotion on unit at activity did not occur, dressing at total dependence with two plus persons physical assist, eating at limited assistance with one person physical assist, toilet use at total dependence with two plus persons physical assist, personal hygiene at total dependence with two plus persons physical assist, bathing at total dependence with two plus persons physical assist, balancing during transition and walking code of 8 which indicated activity did not occur, no impairment in upper and lower extremity, and that Resident #1 believes he or she is capable of increased independence code of 1 which indicated yes. Record review of Resident #1's care plan, undated, revealed a focus that resident (Resident #1) is risk for falls related to weakness, incontinent, a goal of resident (Resident #1) will be free of falls and will not sustain serious injury, and interventions/tasks to anticipate and meet resident (Resident #1) needs, be sure the resident's (Resident #1) call light is within reach and encourage the resident to use it for assistance as needed, educate resident/family/caregiver about safety reminders and what to do if a fall occurred, encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, keep furniture in locked position, keep needed items in reach, mechanical lift with staff x2 with transfers, physical therapy evaluate and treat as ordered or PRN, review information on past falls and attempt to determine cause of falls possible root causes, removed any potential causes, educate resident/family/caregivers/IDT (Interdisciplinary Team), provide a safe environment, and activities that minimize the potential for falls while providing diversion and distraction. Record review of the facility's incident report, dated 09/06/2023, revealed a fall incident with Resident #1 on 09/04/2023 at 4:00 p.m. Record review of Resident #1's, undated, progress notes in the EHR revealed a medical practitioner note effective date 09/05/2023 at 02:05 (2:00 a.m.), note text: yesterday 9/4/23 resident (Resident #1) was discovered on the floor, she was lying on her left side. Upon assessment on 10-6pm shift, it has been noted that, resident does not respond like she normally does. If someone asked her a question she responds with simple words. Now, if a questioned is asked she just shakes her head or she just stares at you with no response (this is new). Further review of progress notes revealed a transfer notification, 09/05/2023 05:09 (05:09 a.m.), note text: Resident #1 was transferred to a hospital on [DATE] at 04:43 AM related to neuro changes r/t (related) fall 9/4/23. Record review of Resident #1's assessment page in the, undated, EHR revealed the following assessments completed: 09/04/2023 Event Nurses-Note 8hr Fall 09/04/2023 Neuro Assessment 09/04/2023 Neuro Assessment 09/04/2023 Fall-Risk Assessment 09/05/2023 Neuro Assessment 09/05/2023 Fall Nurses Note 8 hr 09/05/2023 SBAR (situation, background, assessment, and recommendation) 09/05/2023 Transfer Form Record review of Resident #1's Event Nurses-Note 8hr Fall, dated 09/04/2023 at 16:00 (4:00 p.m.), LVN A noted a nursing description of event, resident (Resident #1) was found by staff on the floor laying on her side on the side of her bed, in residents' room, un-witnessed fall discovered on floor, resident received a bruise from fall, located in face, redness noted, resident not in pain, NP notified on 09/04/2023 at 00:00 (12:00 a.m.), interventions prior to fall was low bed, interventions in response to fall was floor mat and low bed, cognition/behavior at time of event was oriented/no problem. Record review of Resident #1's Neuro Assessment, dated 09/04/2023 at 21:56 (9:56 p.m.), LVN A noted vitals: blood pressure at 117/58, pulse 58, and respirations 18, GCS (Glasgow Coma Scale): eyes opening spontaneously, oriented to person, place, and time, obeys commands, pupils reactive to light, and hand grips are equal. Record review of Resident #1's Neuro assessment dated [DATE] at 21:57 (9:57 p.m.), LVN A noted vitals: blood pressure at 108/58, pulse 60, and respirations 18, GCS (Glasgow Coma scale): eyes opening spontaneously, oriented to person, place, and time, obeys commands, pupils reactive to light, and hand grips are equal. Record review of Resident #1's Fall-Risk assessment dated [DATE] at 21:58 (9:58 p.m.), LVN A noted Resident #1 was alert and oriented. Record review of Resident #1's Neuro Assessment, dated 09/05/2023 at 02:02 (2:02 a.m.), revealed vitals: blood pressure at 116/73, pulse 56, and respirations n/a (not applicable), GCS (Glasgow Coma Scale): eyes opening spontaneously, words only intelligible single words, cannot have a conversation, considered as a new observation for Resident #1, obeys commands, pupil reactive to light, hand grips unable to assess due to paralysis, hemiplegia, injury, contractures, notification to NP/MD on 09/05/2023 02:10 (2:10 a.m.), physician/NP comments or orders listed as none at this time. Record review of Resident #1's Event Nurses-Note 8hr Fall, dated 09/05/2023 at 02:11 (2:11 a.m.), revealed left side of cheek was red, notification to NP/MD on 09/05/2023 02:10 (2:10 a.m.), physician/NP comments or orders listed as none at this time. Record review of Resident #1's SBAR (situation, background, assessment, and recommendation), 9/5/2023 04:51 (4:51 a.m.), situation neurological change, description of symptoms or signs revealed baseline as single words able to answer questions if asked, although currently no words just stares and difficult to arose, symptoms first appeared 9/5/2023. Record review of Resident #1's Transfer form, date 09/05/2023 05:09 (5:09 a.m.), LVN B's note reason for transfer was neuro changes r/t (related to) fall 09/04/2023. Record review of Resident #1's progress note, dated 09/05/2023 at 02:05 (02:05 a.m.), revealed LVN B's note text, Yesterday 9/4/23 resident was discovered on the floor, she was lying on her left side. Upon assessment on 10-6pmshift, it has been noted that resident does not respond like she normally does. If someone asked her a question she responds with simple words. Now, if a questioned is asked she just shakes her head or she just stares at you with no response (this is a new). Interview on 09/06/2023 at 10:29 a.m., the NP stated she needed to confirm if she was notified of the incident of Resident #1 on 9/4/2023, that would have been the on-call MD/NP. The NP stated she did not see a notification of the incident; The NP checked the call log used to record notifications and stated she could not confirm if the on-call MD/NP was notified. The NP stated after falls, when there was an injury to the head of any resident, the corporation had its own policy on neurological checks and monitoring that was evidenced based, nurses would monitor the set of criteria, and if there were any changes to the resident. When asked what the timeframes were for monitoring a resident with an unwitnessed fall or a injury to head, the NP could not recall the exact policy on time frames for neurological testing as it all depended on the evidence available, the NP stated with Resident #1's unwitnessed fall, she should have met the neurological monitoring criteria. The NP stated it was hard to speculate if the fall led to the Resident #1's change of condition. Interview on 09/06/2023 at 11:20 a.m., the ADM stated she had just received information Resident #1 is being transferred to another hospital. The ADM stated she did not know the detailed reason for a transfer, although she attempted to obtain hospital records where Resident #1 was first sent to and to call the family. Interview and observation on 09/06/2023 at 01:14 p.m., the Interim DON stated when a Resident fell, the facility did a standard check on residents ranging from obtaining vitals, assess resident for injuries, pain, skin assessment, and other recommended checks. The Interim DON stated if a resident could be placed back in his or her bed it was done, although after they contacted the MD or NP, and orders were obtained to send the resident to a hospital then they pursued those orders. The Interim DON stated if staff could place a resident back in his or her bed, they continued routine assessments and reported all changes to the MD or NP. The DON stated assessments were important as the process gave staff objective information on the resident, and to monitor a resident's condition. An observation was completed with the Interim DON to demonstrate how assessments were opened and completed to activate the facility's EHR systems UDA (User Defined Assessment) after resident involved incident. The Interim DON revealed the EHR systems risks management option, that documented related information for the resident, the incident, location, date, and time. The Interim DON revealed the EHR systems action plan for falls and UDA, which included the resident's fall nurses note, all details relevant information such as the location of injury, how the resident was found, pain, all pertinent information related to a resident's fall. The Interim DON demonstrated an option for an unwitnessed fall or head injury in the EHR systems automatically triggered a neurological assessment for the resident involved in an unwitnessed fall or a fall with a head injury. Interview during the demonstration, the Interim DON stated the nurses should call the MD or NP on duty and document any notes or additional interventions, and document what to do notes. The Interim DON stated per the facility policy it did not reveal specific timeframes for the completion of neurological checks, the Interim DON stated the facility EHR system would reveal timeframes for neurological assessments, and it would trigger the EHR's POC (point of care) systems to alert nursing for UDAs. The Interim DON stated and demonstrated, there was a timeframe for neurological checks for nursing practice and the EHR system, a neurological check should have been completed 15 minutes after opening the 8 hours fall note. The Interim DON stated at this time she was unable to provide documentation if LVN A documented the neurological assessments within the timeframes. The Interim DON stated if nursing did not properly open and document assessments it would create an inconsistency with timeframe assessments and accuracy on a resident's condition. The Interim DON stated nursing must do required assessments and document all findings, stating if it is not documented, it did not happen . Interview on 09/06/2023 at 02:13 p.m., the ADM stated she contacted Resident #1's family and obtained limited information on Resident #1, the resident had a suspected brain bleed, on the left side of the brain. The ADM revealed she reported the incident to HHSC after finding out about the serious injury. The ADM revealed the facility policy did not reveal specific timeframes for the completion of neurological checks, and the ADM was not able to confirm the process or timeframes of doing neurological checks for falls with head injuries or unwitnessed falls. The ADM stated staff were supposed to assess the residents for all incidents and call the MD or NP to inform them of the situation. The ADM stated assessments were needed to obtain current and accurate information on a resident's medical condition, such as pain, swelling, head injuries, and resident vitals. Interview on 09/06/2023 at 04:10 p.m., LVN A stated resident assessments were completed for all resident incidents, this included falls, unwitnessed falls, elopement, skin issues, or any new findings for a resident. LVN A stated after fall incidents with head injury or unwitnessed falls, staff used the EHR system to create an incident report, and neurological assessments would be triggered by the EHR system. LVN A stated neurological assessments were completed every 15 minutes for the first hour initially, and was not entirely clear on the next timeframes, LVN A stated she was aware of the first hour, having a quarterly or 15-minute neurological check. LVN A recalled the incident that involved Resident #1, the resident had an unwitnessed fall, on 9/4/2023, she could not recall the exact timeframe but stated it was during her shift which would be the early morning shift. LVN A stated Resident #1 was on the floor, in her room , laying on left side by the wall in room. LVN A stated Resident #1 had a bruise on the left side of face, LVN A proceeded to do a full body assessment, Resident #1 was not found to be in pain, and Resident #1 was able to state she fell. LVN A stated she completed the incident report a little later, LVN A stated she could not recall the exact time frame the resident was found on the floor, although gave an approximate timeframe between 4:00 p.m. and 5:00 p.m., LVN further stated she opened up the incident report but did not complete maybe around 8:00 p.m. or 9:00 p.m., as there were other duties performed that evening. LVN A stated she did not contact the NP on duty. LVN A stated she believes I did a neuro check; I was checking her already. LVN A stated she listed the neurological check information down on paper. When asked to provide that information, LVN A could not confirm the whereabouts of that information. LVN A stated, this was on me, I did not follow the procedure of documenting the neurological checks, there was a lot going on that day. LVN A stated if nurses did not properly perform neurological assessments, and all assessments, it could place the residents at risk as it is used for early detection. Record review of Resident #1's hospital records, dated 09/05/2023, revealed, encounter date 09/05/2023, history of present illness, patient (Resident #1) is not oriented and barely opens eyes to stimulation. On arrival in ER (emergency room) she (Resident #1) has a CT scan and chest x-ray which did not reveal significant acute abnormality. Hospital exam, general appearance ill appearing, cranial nerve intact, no focal deficits (There are no specific problems with nerve, spinal cord, or brain function). Record review of Resident #1's hospital records, dated 09/05/2023 and signed 05:49 a.m., revealed CAT scan report, preliminary report, Exam was CT head without intravenous contract. Findings: brain no masses, midline shift or intracranial hemorrhage, chronic atrophy, white matter disease, no hydrocephalus, orbits unremarkable, paranasal sinuses and mastoid air cells are clear, no significant facial or scalp tissue swelling evident, no radiopaque foreign body is seen, no acute skull fracture, impression no acute intracranial abnormality. Record review of Resident #1's hospital records, dated 9/6/2023 at 10:02 a.m., revealed CAT scan report, report status is a draft, preliminary report CAT angio head, findings included increased volume of left sylvian fissure subarachnoid hemorrhage. Impression increased left sylvian fissure subarachnoid hemorrhage now measuring up to 2.6 cm (centimeters) in AP dimension, with a width of up to 8 mm (millimeter) and a craniocaudal of 11 mm (millimeter), no high-grade mass effect. Large left frontal parietal scalp contusion and hemorrhage with contrast blush indicating active hemorrhage coronal. Record review of the facility policy for neurological checks, revised May 2016, revealed neurologic checks, they are a combination of objective observation and measurements done to evaluate neurologic status. The results of the checks assist to determine nervous system damage and/or deterioration. Goals are to identify changes indicating progressive improvement or deterioration in neurologic status, and the resident will be free from injury. Record review of the facility policy for notifying the Physician of Change in Status, revised March 11, 2013, revealed the nurse should not hesitate to contact the physician at any time when an assessment an their professional judgement deem it necessary for immediate medical attention. This facility utilizes the INERACT tool, Change in Condition-When to Notify the MD/NP/PA to review resident condition and guide the nurse when to notify the physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on Next Work day notification of the physician. 1. The nurse will notify the physician immediately with significant change in statis. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. 2. Before the physician is contacted, the nurse will gather and organize resident information. Applicable information will include current medications, vital signs, signs and symptoms initiating call, current laboratory information, and interventions that have currently been implemented. 3. The nurse may collect several non-emergent items and place one telephone call during the shift in order to avoid multiple calls to a physician with non-emergent questions. The nurse is responsible, however, for responding to a change of condition in a timely and effective manner. The nurse will document the time of the call to the physician in the clinical record. 4. If the physician does not return the call within a reasonable amount of time, the nurse will attempt to contact the physician a second time. If the situation is an emergency, and the physician does not call back within a reasonable amount of time, the nurse will contact the Medical Director or the nearest ambulance service for assistance. The nurse will document all attempts to contact the physician in the resident's clinical record. 5. The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident as specified otherwise. 6. The nurse will monitor and reassess the resident's status and response to intervention. Physicians should develop a working diagnosis and guide nursing staff in what to monitor, and when to notify the physician if the resident's condition does not improve. 7. The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician's response, the physician's orders and the resident's status and respond to interventions. 8. If the resident remains in the facility and a significant change has occurred, update the car plan accordingly. 9. Faxes should be following up by the end of the business day. 10. If a resident is transferred to the hospital, complete a transfer form. Send a copy of the most recent H & P, progress note, advance directives, MAR, diagnosis list, and pertinent lab and x-ray reports to the hospital. Document actions in the resident's clinical records. 11. Abnormal lab, x-ray and other diagnostic reports require physician notification. This was determined to be an Immediate Jeopardy (IJ) on 09/06/2023 at 05:28 p.m. The ADM was notified. The ADM was provided with the IJ template on 09/06/2023 at 05:57 p.m. The following plan of Removal submitted by the facility was accepted on 09/07/2023 at 06:00 p.m.: PLAN OF REMOVAL September,6, 2023 IJ Component: F684 Quality of Care Facility failed to initiate neurological checks on CR#1 after resident sustained a head injury. Seven residents with falls could have been affected by the deficient practice. Immediate Actions: As of 9/5/23 resident CR#1 was transferred to the hospital for evaluation. LVN-A was provided 1 on 1 education by Administrator on 9/6/23 and will be re-in serviced prior to next scheduled shift, regarding Event Notification; Abuse and Neglect; and Change of Condition, neuro checks and how to notify DON/Physician/RP and oncoming nurses. Facility Plan to ensure compliance: Inservices: Abuse & Neglect policy was reviewed by the Compliance Nurse, Administrator, DON, and ADON and in-serviced on 9/06/23. No changes were made to the policy. The Compliance Nurse in-serviced the DON and ADONs. The Compliance Nurse, DON, ADONs inserviced all staff including clinical, administrative, dietary, housekeeping, laundry, therapy, maintenance, and activities. to ensure compliance for this policy and procedure. All staff not present on 9/06/23 will be in-serviced prior to start of their next shift. Newly hired, PRN, and agency staff will be in-serviced by the DON or ADON prior to start of their scheduled shift. Compliance Nurse in-serviced Administrator, DON, and ADON's on Event note completion and Neuro check policy 9/06/23. The Compliance Nurse, DON, and the ADONs in-serviced Charge Nurses on neuro checks (neuro checks are to be initiated if a resident hits their head or had an un-witnessed fall) and Event note completion. Return demonstration with PCC was included in the in-services. In-services will be completed by the DON/Designee monthly for the next 3 months, then as needed thereafter. All staff not present on 9/06/23 will be in-serviced prior to start of their next shift. Newly hired, PRN, and agency staff will be in-serviced by the DON or ADON prior to start of their scheduled shift. Notifying Physician on change in status policy that includes falls with head injury or other serious injury was reviewed & in-serviced on 9/06/23, the Compliance Nurse in-serviced DON and ADONs. The Compliance Nurse, DON, and ADON in-serviced Charge Nurses to ensure compliance for this policy & procedure. Return demonstration with PCC was included in the in-services. In-services will be completed by the DON/Designee monthly for the next 3 months, then as needed thereafter. All staff not present on 9/06/23 will be in-serviced prior to start of their next shift. Newly hired, PRN, and agency staff will be in-serviced by the DON or ADON prior to start of their scheduled shift. The Regional Compliance Nurse visited the facility 9/06/23 to review resident falls in PCC. Inservicing was provided by the Compliance Nurse with the Administrator, DON, and ADON on Abuse & Neglect, Neuro checks, Notifying Physician on change in status, and process of reporting changes to oncoming shift nurses. The Administrator, Compliance Nurse, DON, and ADON provided all facility staff in-servicing on Abuse and Neglect. The Compliance Nurse, DON, and ADON inserviced the Charge Nurses on neuro checks and notifying the MD for a change in condition and reporting changes to the oncoming shifts. Inservicing began on 9/6/23. All staff not present on 9/6/23 will be in-serviced prior to start of their next shift. Newly hired, PRN, and agency staff will be in-serviced by the DON or ADON prior to start of their scheduled shift. Audits completed: Falls for the last 30 days were audited by the Regional Compliance Nurse and DON on 9/6/23. No additional issues were noted. Inservicing: Notifying oncoming Nurse in charge on any resident injury or change in condition that include falls during the change of shift report process. The Compliance Nurse in-serviced DON and ADON on 9/6/23. The DON/ADON in-service Charge Nurses to ensure compliance for this policy & procedure. The DON/Designee will continue in-servicing monthly for the next 3 months, then as needed thereafter. All staff were in-serviced by the compliance nurse, DON, and ADON on notifying the DON for any resident change in condition on 9/6/23. All staff not present on 9/6/23 will in-serviced prior to the start of the next shift. Newly hired, PRN, and agency staff will be in-serviced by the DON or ADON prior to start of their scheduled shift. The Medical Director was notified by the Administrator on 9/06/23 at 6:20pm on the immediate jeopardy citation. An AD HOC QAPI meeting was held on 9/06/23 by the Interdisciplinary Team to discuss the Immediate Jeopardies and review the Plan of Removal. Monitoring: The DON / designee will monitor Real Time clinical software and/or the PCC Dashboard for clinical alerts for any resident change of condition including falls, head injuries, other serious injuries, or changes of condition 7 days per week to ensure physician/NP were notified. All charge nurses will be responsible for notifying the MD on the weekends. DON/ADON/Designee will provide oversight. Monitoring began 9/06/23 and will continue x 4 weeks and weekly thereafter. The DON and/or designee will monitor fall events 7 days a week to ensure neuro checks and assessments were initiated for all falls. Monitoring began 9/06/23 and will continue x 4 weeks or until the administrator determines substantial compliance has been achieved and maintained. This plan will be reviewed monthly at QAPI for the next three months. The State Survey Team monitored the Plan of Removal on 09/07/2023 and included the following: Observation on 09/07/2023 at 10:39 a.m., reflected corporate staff in facility monitoring the POR process initiated by the facility. Interview on 09/07/2023 at 03:03 p.m., LVN A stated she was provided 1-on1 education by Administrator, LVN A stated she was in serviced regarding Event Notification; Abuse and Neglect; and Change of Condition, neuro checks and how to notify DON/Physician/RP and oncoming nurses. Interview on 09/07/2023, the Interim DON and ADON stated they were in-service and reviewed by corporate nurse, on 09/06/2023 on Abuse and Neglect, Event note completion and Neuro check policy, Notifying Physician on change in status policy that included falls with head injury or other serious injury. Interview on 09/07/2023 from 12:33 p.m. to 02:20 p.m., charge nurses from all shifts, stated they were in-serviced by Interim DON and ADON on 09/06/2023 and 09/07/2023 on Abuse and Neglect, Event note completion and Neuro check policy, Notifying Physician on change in status policy that included falls with head injury or other serious injury. Interview on 09/07/2023, the Interim DON stated continued monitoring on Real Time clinical software and fall events 7 days a week to ensure neuro checks and assessments were initiated for all falls. Interview on 09/07/2023 from 12:19 p.m. to 02:20 p.m., AIT (administrator in training), rehabilitation director, and two CNAs stated in-service, knowledge and reporting on Abuse and Neglect. Record review on 09/07/2023, revealed in-service initiated on 09/06/2023 on training of notification of change of conditions to DON, Fall prevention, Abuse & Neglect, Neuro checks, Shift change=nurse provides oncoming shift nurse with information to provide care to residents, and Event note completion. Record review on 09/07/2023, revealed Neuro Checks-Relias course, when a resident hits their head during a fall or the fall is unwitnessed, neuro checks will need to be completed at the time of the fall then according to the schedule below: every 15 minutes x 4, then every 30 minutes x2, then every 1 hour x2, then every 2 hours x 2, then every 8 hours x 8 Record review on 09/07/2023, revealed QAPI meeting held 9/7/23. The ADM was informed the Immediate Jeopardy was removed on 09/07/2023 at 08:00 p.m. The facility remained out of compliance at a severity level of actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of 7 Residents reviewed for quality of care. The facility nurses failed to ensure nurses conducted neurological exams after Resident #1 sustained a fall with head injury on 09/04/2023 at 4:00 p.m., 10 of 12 neuro checks were not conducted. The first documented neuro exam was not until approximately 6 hours after the incident, 09/04/2023 at 9:56 pm. The next neuro exam was not until 09/05/2023 at 2:05 am at which time a change in condition was identified. The resident was not sent to the hospital until 09/05/2023 at 4:43 am. The 04:00 am Neuro check was not done. Resident #1 was subsequently diagnosed with a left sylvian fissure subarachnoid hemorrhage (bleeding). An Immediate Jeopardy (IJ) situation was identified on 09/06/2023. While the IJ was removed on 09/07/2023, the facility remained out of compliance at a scope of isolated with actual harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving the highest practicable care through resident assessments by recognizing and addressing the physical, mental, and neurological dysfunctions such as altered state of consciousness, cognitive decline, confusion, memory loss, changes in behavior in an effective and timely manner to prevent residents from further harm, injury, or death. Findings include: Record review of Resident #1's face sheet, dated 09/06/2023, revealed a [AGE] year-old-female who was admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke), metabolic encephalopathy (brain disruption), heart failure, obesity, and hypertension. Record review of Resident #1's MDS, dated [DATE], revealed a BIMS of 05, which indicated a severe cognitive impairment. Further review of Resident #1's MDS, Hearing, Speech, and Vision, revealed a Speech Clarity code of 0 revealed clear speech-distinct intelligible words, Makes Self Understood code of 1 revealed Usually understood-difficulty communicating some words or finished thoughts but able if prompted or given time. Further review of Resident #1's MDS, Health Conditions, revealed Fall history code of 0, which indicated Resident #1 did not have a fall in the last month, last 2 to 6 months, or fracture related to fall in the 6 months prior to admission. Further review of Resident #1's MDS, Functional status, revealed bed mobility at total dependence with two plus persons physical assist, transfer at activity did not occur, walk in room at activity did not occur, walk in corridor at activity did not occur, locomotion on unit at activity did not occur, dressing at total dependence with two plus persons physical assist, eating at limited assistance with one person physical assist, toilet use at total dependence with two plus persons physical assist, personal hygiene at total dependence with two plus persons physical assist, bathing at total dependence with two plus persons physical assist, balancing during transition and walking code of 8 which indicated activity did not occur, no impairment in upper and lower extremity, and that Resident #1 believes he or she is capable of increased independence code of 1 which indicated yes. Record review of Resident #1's care plan, undated, revealed a focus that resident (Resident #1) is risk for falls related to weakness, incontinent, a goal of resident (Resident #1) will be free of falls and will not sustain serious injury, and interventions/tasks to anticipate and meet resident (Resident #1) needs, be sure the resident's (Resident #1) call light is within reach and encourage the resident to use it for assistance as needed, educate resident/family/caregiver about safety reminders and what to do if a fall occurred, encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, keep furniture in locked position, keep needed items in reach, mechanical lift with staff x2 with transfers, physical therapy evaluate and treat as ordered or PRN, review information on past falls and attempt to determine cause of falls possible root causes, removed any potential causes, educate resident/family/caregivers/IDT (Interdisciplinary Team), provide a safe environment, and activities that minimize the potential for falls while providing diversion and distraction. Record review of the facility's incident report, dated 09/06/2023, revealed a fall incident with Resident #1 on 09/04/2023 at 4:00 p.m. Record review of Resident #1's, undated, progress notes in the EHR revealed a medical practitioner note effective date 09/05/2023 at 02:05 (2:00 a.m.), note text: yesterday 9/4/23 resident (Resident #1) was discovered on the floor, she was lying on her left side. Upon assessment on 10-6pm shift, it has been noted that, resident does not respond like she normally does. If someone asked her a question she responds with simple words. Now, if a questioned is asked she just shakes her head or she just stares at you with no response (this is new). Further review of progress notes revealed a transfer notification, 09/05/2023 05:09 (05:09 a.m.), note text: Resident #1 was transferred to a hospital on [DATE] at 04:43 AM related to neuro changes r/t (related) fall 9/4/23. Record review of Resident #1's assessment page in the, undated, EHR revealed the following assessments completed: 09/04/2023 Event Nurses-Note 8hr Fall 09/04/2023 Neuro Assessment 09/04/2023 Neuro Assessment 09/04/2023 Fall-Risk Assessment 09/05/2023 Neuro Assessment 09/05/2023 Fall Nurses Note 8 hr 09/05/2023 SBAR (situation, background, assessment, and recommendation) 09/05/2023 Transfer Form Record review of Resident #1's Event Nurses-Note 8hr Fall, dated 09/04/2023 at 16:00 (4:00 p.m.), LVN A noted a nursing description of event, resident (Resident #1) was found by staff on the floor laying on her side on the side of her bed, in residents' room, un-witnessed fall discovered on floor, resident received a bruise from fall, located in face, redness noted, resident not in pain, NP notified on 09/04/2023 at 00:00 (12:00 a.m.), interventions prior to fall was low bed, interventions in response to fall was floor mat and low bed, cognition/behavior at time of event was oriented/no problem. Record review of Resident #1's Neuro Assessment, dated 09/04/2023 at 21:56 (9:56 p.m.), LVN A noted vitals: blood pressure at 117/58, pulse 58, and respirations 18, GCS (Glasgow Coma Scale): eyes opening spontaneously, oriented to person, place, and time, obeys commands, pupils reactive to light, and hand grips are equal. Record review of Resident #1's Neuro assessment dated [DATE] at 21:57 (9:57 p.m.), LVN A noted vitals: blood pressure at 108/58, pulse 60, and respirations 18, GCS (Glasgow Coma scale): eyes opening spontaneously, oriented to person, place, and time, obeys commands, pupils reactive to light, and hand grips are equal. Record review of Resident #1's Fall-Risk assessment dated [DATE] at 21:58 (9:58 p.m.), LVN A noted Resident #1 was alert and oriented. Record review of Resident #1's Neuro Assessment, dated 09/05/2023 at 02:02 (2:02 a.m.), revealed vitals: blood pressure at 116/73, pulse 56, and respirations n/a (not applicable), GCS (Glasgow Coma Scale): eyes opening spontaneously, words only intelligible single words, cannot have a conversation, considered as a new observation for Resident #1, obeys commands, pupil reactive to light, hand grips unable to assess due to paralysis, hemiplegia, injury, contractures, notification to NP/MD on 09/05/2023 02:10 (2:10 a.m.), physician/NP comments or orders listed as none at this time. Record review of Resident #1's Event Nurses-Note 8hr Fall, dated 09/05/2023 at 02:11 (2:11 a.m.), revealed left side of cheek was red, notification to NP/MD on 09/05/2023 02:10 (2:10 a.m.), physician/NP comments or orders listed as none at this time. Record review of Resident #1's SBAR (situation, background, assessment, and recommendation), 9/5/2023 04:51 (4:51 a.m.), situation neurological change, description of symptoms or signs revealed baseline as single words able to answer questions if asked, although currently no words just stares and difficult to arose, symptoms first appeared 9/5/2023. Record review of Resident #1's Transfer form, date 09/05/2023 05:09 (5:09 a.m.), LVN B's note reason for transfer was neuro changes r/t (related to) fall 09/04/2023. Record review of Resident #1's progress note, dated 09/05/2023 at 02:05 (02:05 a.m.), revealed LVN B's note text, Yesterday 9/4/23 resident was discovered on the floor, she was lying on her left side. Upon assessment on 10-6pmshift, it has been noted that resident does not respond like she normally does. If someone asked her a question she responds with simple words. Now, if a questioned is asked she just shakes her head or she just stares at you with no response (this is a new). Interview on 09/06/2023 at 10:29 a.m., the NP stated she needed to confirm if she was notified of the incident of Resident #1 on 9/4/2023, that would have been the on-call MD/NP. The NP stated she did not see a notification of the incident; The NP checked the call log used to record notifications and stated she could not confirm if the on-call MD/NP was notified. The NP stated after falls, when there was an injury to the head of any resident, the corporation had its own policy on neurological checks and monitoring that was evidenced based, nurses would monitor the set of criteria, and if there were any changes to the resident. When asked what the timeframes were for monitoring a resident with an unwitnessed fall or a injury to head, the NP could not recall the exact policy on time frames for neurological testing as it all depended on the evidence available, the NP stated with Resident #1's unwitnessed fall, she should have met the neurological monitoring criteria. The NP stated it was hard to speculate if the fall led to the Resident #1's change of condition. Interview on 09/06/2023 at 11:20 a.m., the ADM stated she had just received information Resident #1 is being transferred to another hospital. The ADM stated she did not know the detailed reason for a transfer, although she attempted to obtain hospital records where Resident #1 was first sent to and to call the family. Interview and observation on 09/06/2023 at 01:14 p.m., the Interim DON stated when a Resident fell, the facility did a standard check on residents ranging from obtaining vitals, assess resident for injuries, pain, skin assessment, and other recommended checks. The Interim DON stated if a resident could be placed back in his or her bed it was done, although after they contacted the MD or NP, and orders were obtained to send the resident to a hospital then they pursued those orders. The Interim DON stated if staff could place a resident back in his or her bed, they continued routine assessments and reported all changes to the MD or NP. The DON stated assessments were important as the process gave staff objective information on the resident, and to monitor a resident's condition. An observation was completed with the Interim DON to demonstrate how assessments were opened and completed to activate the facility's EHR systems UDA (User Defined Assessment) after resident involved incident. The Interim DON revealed the EHR systems risks management option, that documented related information for the resident, the incident, location, date, and time. The Interim DON revealed the EHR systems action plan for falls and UDA, which included the resident's fall nurses note, all details relevant information such as the location of injury, how the resident was found, pain, all pertinent information related to a resident's fall. The Interim DON demonstrated an option for an unwitnessed fall or head injury in the EHR systems automatically triggered a neurological assessment for the resident involved in an unwitnessed fall or a fall with a head injury. Interview during the demonstration, the Interim DON stated the nurses should call the MD or NP on duty and document any notes or additional interventions, and document what to do notes. The Interim DON stated per the facility policy it did not reveal specific timeframes for the completion of neurological checks, the Interim DON stated the facility EHR system would reveal timeframes for neurological assessments, and it would trigger the EHR's POC (point of care) systems to alert nursing for UDAs. The Interim DON stated and demonstrated, there was a timeframe for neurological checks for nursing practice and the EHR system, a neurological check should have been completed 15 minutes after opening the 8 hours fall note. The Interim DON stated at this time she was unable to provide documentation if LVN A documented the neurological assessments within the timeframes. The Interim DON stated if nursing did not properly open and document assessments it would create an inconsistency with timeframe assessments and accuracy on a resident's condition. The Interim DON stated nursing must do required assessments and document all findings, stating if it is not documented, it did not happen . Interview on 09/06/2023 at 02:13 p.m., the ADM stated she contacted Resident #1's family and obtained limited information on Resident #1, the resident had a suspected brain bleed, on the left side of the brain. The ADM revealed she reported the incident to HHSC after finding out about the serious injury. The ADM revealed the facility policy did not reveal specific timeframes for the completion of neurological checks, and the ADM was not able to confirm the process or timeframes of doing neurological checks for falls with head injuries or unwitnessed falls. The ADM stated staff were supposed to assess the residents for all incidents and call the MD or NP to inform them of the situation. The ADM stated assessments were needed to obtain current and accurate information on a resident's medical condition, such as pain, swelling, head injuries, and resident vitals. Interview on 09/06/2023 at 04:10 p.m., LVN A stated resident assessments were completed for all resident incidents, this included falls, unwitnessed falls, elopement, skin issues, or any new findings for a resident. LVN A stated after fall incidents with head injury or unwitnessed falls, staff used the EHR system to create an incident report, and neurological assessments would be triggered by the EHR system. LVN A stated neurological assessments were completed every 15 minutes for the first hour initially, and was not entirely clear on the next timeframes, LVN A stated she was aware of the first hour, having a quarterly or 15-minute neurological check. LVN A recalled the incident that involved Resident #1, the resident had an unwitnessed fall, on 9/4/2023, she could not recall the exact timeframe but stated it was during her shift which would be the early morning shift. LVN A stated Resident #1 was on the floor, in her room , laying on left side by the wall in room. LVN A stated Resident #1 had a bruise on the left side of face, LVN A proceeded to do a full body assessment, Resident #1 was not found to be in pain, and Resident #1 was able to state she fell. LVN A stated she completed the incident report a little later, LVN A stated she could not recall the exact time frame the resident was found on the floor, although gave an approximate timeframe between 4:00 p.m. and 5:00 p.m., LVN further stated she opened up the incident report but did not complete maybe around 8:00 p.m. or 9:00 p.m., as there were other duties performed that evening. LVN A stated she did not contact the NP on duty. LVN A stated she believes I did a neuro check; I was checking her already. LVN A stated she listed the neurological check information down on paper. When asked to provide that information, LVN A could not confirm the whereabouts of that information. LVN A stated, this was on me, I did not follow the procedure of documenting the neurological checks, there was a lot going on that day. LVN A stated if nurses did not properly perform neurological assessments, and all assessments, it could place the residents at risk as it is used for early detection. Record review of Resident #1's hospital records, dated 09/05/2023, revealed, encounter date 09/05/2023, history of present illness, patient (Resident #1) is not oriented and barely opens eyes to stimulation. On arrival in ER (emergency room) she (Resident #1) has a CT scan and chest x-ray which did not reveal significant acute abnormality. Hospital exam, general appearance ill appearing, cranial nerve intact, no focal deficits (There are no specific problems with nerve, spinal cord, or brain function). Record review of Resident #1's hospital records, dated 09/05/2023 and signed 05:49 a.m., revealed CAT scan report, preliminary report, Exam was CT head without intravenous contract. Findings: brain no masses, midline shift or intracranial hemorrhage, chronic atrophy, white matter disease, no hydrocephalus, orbits unremarkable, paranasal sinuses and mastoid air cells are clear, no significant facial or scalp tissue swelling evident, no radiopaque foreign body is seen, no acute skull fracture, impression no acute intracranial abnormality. Record review of Resident #1's hospital records, dated 9/6/2023 at 10:02 a.m., revealed CAT scan report, report status is a draft, preliminary report CAT angio head, findings included increased volume of left sylvian fissure subarachnoid hemorrhage. Impression increased left sylvian fissure subarachnoid hemorrhage now measuring up to 2.6 cm (centimeters) in AP dimension, with a width of up to 8 mm (millimeter) and a craniocaudal of 11 mm (millimeter), no high-grade mass effect. Large left frontal parietal scalp contusion and hemorrhage with contrast blush indicating active hemorrhage coronal. Record review of the facility policy for neurological checks, revised May 2016, revealed neurologic checks, they are a combination of objective observation and measurements done to evaluate neurologic status. The results of the checks assist to determine nervous system damage and/or deterioration. Goals are to identify changes indicating progressive improvement or deterioration in neurologic status, and the resident will be free from injury. Record review of the facility policy for notifying the Physician of Change in Status, revised March 11, 2013, revealed the nurse should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention. This facility utilizes the INERACT tool, Change in Condition-When to Notify the MD/NP/PA to review resident condition and guide the nurse when to notify the physician. This tool informs the nurse if the resident condition requires immediate notification of the physician or non-immediate/Report on Next Work day notification of the physician. 1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. 2. Before the physician is contacted, the nurse will gather and organize resident information. Applicable information will include current medications, vital signs, signs and symptoms initiating call, current laboratory information, and interventions that have currently been implemented. 3. The nurse may collect several non-emergent items and place one telephone call during the shift in order to avoid multiple calls to a physician with non-emergent questions. The nurse is responsible, however, for responding to a change of condition in a timely and effective manner. The nurse will document the time of the call to the physician in the clinical record. 4. If the physician does not return the call within a reasonable amount of time, the nurse will attempt to contact the physician a second time. If the situation is an emergency, and the physician does not call back within a reasonable amount of time, the nurse will contact the Medical Director or the nearest ambulance service for assistance. The nurse will document all attempts to contact the physician in the resident's clinical record. 5. The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident as specified otherwise. 6. The nurse will monitor and reassess the resident's status and response to intervention. Physicians should develop a working diagnosis and guide nursing staff in what to monitor, and when to notify the physician if the resident's condition does not improve. 7. The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician's response, the physician's orders and the resident's status and respond to interventions. 8. If the resident remains in the facility and a significant change has occurred, update the car plan accordingly. 9. Faxes should be following up by the end of the business day. 10. If a resident is transferred to the hospital, complete a transfer form. Send a copy of the most recent H & P, progress note, advance directives, MAR, diagnosis list, and pertinent lab and x-ray reports to the hospital. Document actions in the resident's clinical records. 11. Abnormal lab, x-ray and other diagnostic reports require physician notification. This was determined to be an Immediate Jeopardy (IJ) on 09/06/2023 at 05:28 p.m. The ADM was notified. The ADM was provided with the IJ template on 09/06/2023 at 05:57 p.m. The following plan of Removal submitted by the facility was accepted on 09/07/2023 at 06:00 p.m.: PLAN OF REMOVAL September,6, 2023 IJ Component: F684 Quality of Care Facility failed to initiate neurological checks on CR#1 after resident sustained a head injury. Seven residents with falls could have been affected by the deficient practice. Immediate Actions: As of 9/5/23 resident CR#1 was transferred to the hospital for evaluation. LVN-A was provided 1 on 1 education by Administrator on 9/6/23 and will be re-in serviced prior to next scheduled shift, regarding Event Notification; Abuse and Neglect; and Change of Condition, neuro checks and how to notify DON/Physician/RP and oncoming nurses. Facility Plan to ensure compliance: Inservices: Abuse & Neglect policy was reviewed by the Compliance Nurse, Administrator, DON, and ADON and in-serviced on 9/06/23. No changes were made to the policy. The Compliance Nurse in-serviced the DON and ADONs. The Compliance Nurse, DON, ADONs inserviced all staff including clinical, administrative, dietary, housekeeping, laundry, therapy, maintenance, and activities. to ensure compliance for this policy and procedure. All staff not present on 9/06/23 will be in-serviced prior to start of their next shift. Newly hired, PRN, and agency staff will be in-serviced by the DON or ADON prior to start of their scheduled shift. Compliance Nurse in-serviced Administrator, DON, and ADON's on Event note completion and Neuro check policy 9/06/23. The Compliance Nurse, DON, and the ADONs in-serviced Charge Nurses on neuro checks (neuro checks are to be initiated if a resident hits their head or had an un-witnessed fall) and Event note completion. Return demonstration with PCC was included in the in-services. In-services will be completed by the DON/Designee monthly for the next 3 months, then as needed thereafter. All staff not present on 9/06/23 will be in-serviced prior to start of their next shift. Newly hired, PRN, and agency staff will be in-serviced by the DON or ADON prior to start of their scheduled shift. Notifying Physician on change in status policy that includes falls with head injury or other serious injury was reviewed & in-serviced on 9/06/23, the Compliance Nurse in-serviced DON and ADONs. The Compliance Nurse, DON, and ADON in-serviced Charge Nurses to ensure compliance for this policy & procedure. Return demonstration with PCC was included in the in-services. In-services will be completed by the DON/Designee monthly for the next 3 months, then as needed thereafter. All staff not present on 9/06/23 will be in-serviced prior to start of their next shift. Newly hired, PRN, and agency staff will be in-serviced by the DON or ADON prior to start of their scheduled shift. The Regional Compliance Nurse visited the facility 9/06/23 to review resident falls in PCC. Inservicing was provided by the Compliance Nurse with the Administrator, DON, and ADON on Abuse & Neglect, Neuro checks, Notifying Physician on change in status, and process of reporting changes to oncoming shift nurses. The Administrator, Compliance Nurse, DON, and ADON provided all facility staff in-servicing on Abuse and Neglect. The Compliance Nurse, DON, and ADON inserviced the Charge Nurses on neuro checks and notifying the MD for a change in condition and reporting changes to the oncoming shifts. Inservicing began on 9/6/23. All staff not present on 9/6/23 will be in-serviced prior to start of their next shift. Newly hired, PRN, and agency staff will be in-serviced by the DON or ADON prior to start of their scheduled shift. Audits completed: Falls for the last 30 days were audited by the Regional Compliance Nurse and DON on 9/6/23. No additional issues were noted. Inservicing: Notifying oncoming Nurse in charge on any resident injury or change in condition that include falls during the change of shift report process. The Compliance Nurse in-serviced DON and ADON on 9/6/23. The DON/ADON in-service Charge Nurses to ensure compliance for this policy & procedure. The DON/Designee will continue in-servicing monthly for the next 3 months, then as needed thereafter. All staff were in-serviced by the compliance nurse, DON, and ADON on notifying the DON for any resident change in condition on 9/6/23. All staff not present on 9/6/23 will in-serviced prior to the start of the next shift. Newly hired, PRN, and agency staff will be in-serviced by the DON or ADON prior to start of their scheduled shift. The Medical Director was notified by the Administrator on 9/06/23 at 6:20pm on the immediate jeopardy citation. An AD HOC QAPI meeting was held on 9/06/23 by the Interdisciplinary Team to discuss the Immediate Jeopardies and review the Plan of Removal. Monitoring: The DON / designee will monitor Real Time clinical software and/or the PCC Dashboard for clinical alerts for any resident change of condition including falls, head injuries, other serious injuries, or changes of condition 7 days per week to ensure physician/NP were notified. All charge nurses will be responsible for notifying the MD on the weekends. DON/ADON/Designee will provide oversight. Monitoring began 9/06/23 and will continue x 4 weeks and weekly thereafter. The DON and/or designee will monitor fall events 7 days a week to ensure neuro checks and assessments were initiated for all falls. Monitoring began 9/06/23 and will continue x 4 weeks or until the administrator determines substantial compliance has been achieved and maintained. This plan will be reviewed monthly at QAPI for the next three months. The State Survey Team monitored the Plan of Removal on 09/07/2023 and included the following: Observation on 09/07/2023 at 10:39 a.m., reflected corporate staff in facility monitoring the POR process initiated by the facility. Interview on 09/07/2023 at 03:03 p.m., LVN A stated she was provided 1-on1 education by Administrator, LVN A stated she was in serviced regarding Event Notification; Abuse and Neglect; and Change of Condition, neuro checks and how to notify DON/Physician/RP and oncoming nurses. Interview on 09/07/2023, the Interim DON and ADON stated they were in-service and reviewed by corporate nurse, on 09/06/2023 on Abuse and Neglect, Event note completion and Neuro check policy, Notifying Physician on change in status policy that included falls with head injury or other serious injury. Interview on 09/07/2023 from 12:33 p.m. to 02:20 p.m., charge nurses from all shifts, stated they were in-serviced by Interim DON and ADON on 09/06/2023 and 09/07/2023 on Abuse and Neglect, Event note completion and Neuro check policy, Notifying Physician on change in status policy that included falls with head injury or other serious injury. Interview on 09/07/2023, the Interim DON stated continued monitoring on Real Time clinical software and fall events 7 days a week to ensure neuro checks and assessments were initiated for all falls. Interview on 09/07/2023 from 12:19 p.m. to 02:20 p.m., AIT (administrator in training), rehabilitation director, and two CNAs stated in-service, knowledge and reporting on Abuse and Neglect. Record review on 09/07/2023, revealed in-service initiated on 09/06/2023 on training of notification of change of conditions to DON, Fall prevention, Abuse & Neglect, Neuro checks, Shift change=nurse provides oncoming shift nurse with information to provide care to residents, and Event note completion. Record review on 09/07/2023, revealed Neuro Checks-Relias course, when a resident hits their head during a fall or the fall is unwitnessed, neuro checks will need to be completed at the time of the fall then according to the schedule below: every 15 minutes x 4, then every 30 minutes x2, then every 1 hour x2, then every 2 hours x 2, then every 8 hours x 8 Record review on 09/07/2023, revealed QAPI meeting held 9/7/23. The ADM was informed the Immediate Jeopardy was removed on 09/07/2023 at 08:00 p.m. The facility remained out of compliance at a severity level of actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to ensure each resident received adequate supervisions and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and hazards, in that:supervision. The facility failed to conduct two-hour checks and Resident #1 eloped from the facility without facility knowledge and Resident #1 was found on a busy roadway a mile from the facility by a passer-by. An IJ was identified on 06/28/2023. The IJ began on 06/18/2023 and was removed on 06/20/2023. The facility took action to remove the IJ before the survey began. While the IJ was removed on 06/20/2023, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with a potential for more than minimal harm that is not immediate due to the facility's need to monitor interventions. This failure could place residents at risk of elopement, accidents and, heat exhaustion due to lack of supervision. Findings included: Record review of Resident #1's face sheet, dated 06/28/2023, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had with diagnoses which included Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), cognitive communication deficit (difficulty with thinking and how someone uses language), muscle weakness (a lack of strength in the muscles), unspecified osteoarthritis (a progressive, degenerative joint disease, the most common form of arthritis, especially in older persons), and essential hypertension (when you have abnormally high blood pressure that is not the result of a medical condition). Record review of Resident #1's Quarterly MDS, dated [DATE], reflected a BIMS score of a 3, indicating which indicated the resident's cognition was severely impaired. Resident #1 did not wander or have any type of behavioral symptoms. Resident #1 required supervision with bed mobility, transfers, walk in room/corridor, eating, and toileting. Resident #1 required limited one person assistance with dressing and personal hygiene. He was total dependent on staff for bathing. Resident #1 did not require and any devices when ambulating. Record review of Resident #1's Comprehensive Care Plan, revised on 06/18/2023 , reflected the resident was confused and wandered outside the facility unattended. Interventions: supervise closely and make regular compliance rounds whenever resident is was in room. Frequent monitoring of resident. Apply alarm system, such as wander-guard, to reduce risk of elopement. If resident is was exit seeking, stay with the resident, and notify the charge nurse by calling out, sending another staff member, call system etc . Record review of Resident #1's Elopement Risk Assessment, dated 06/18/2023, reflected Resident #1 was not a risk for elopement. Resident did not have a history of attempts to leave the facility. He understood and verbalized acceptance of need for nursing home care. Resident #1 recognized stop lights and signs. He knew precautions when crossing streets. He could state name and knew location of current residence. He recognized physical needs and there were not any changes in his status such as: medication, illness, pain, infection, frustration, or personal tragedy. Signed by LVN C. Record review of Resident #1's event nurses' note, dated 06/18/2023 at 12:20 PM, reflected LVN B was notified at 12:00 PM by a Policeman, Resident #1 was found on a busy roadway and had been taken to the ER for observation and evaluation of physical condition. LVN B last saw Resident #1 approximately 7:00 AM in the dining room after obtaining his blood sugar. LVN B notified the Administrator, DON, ADON and family. LVN B called the hospital and checked on Resident #1's condition. The ED Nurse stated the resident was fine and routine labs were being completed and the ER nurse would call and if they needed anything. It was unknown the door exited and, how long resident was missing. There were not any injuries related to the elopement. Resident #1 was unable to give statement (Resident was at the hospital). Record review of Resident #1's Elopement Nurses Note, dated 6/18/2023 at 08:20 PM, reflected Resident #1 had not attempted to leave the facility. Resident #1 was on one-on-one monitoring. Resident #1 did not have any changes that required physician notification. Resident #1 was calm. Signed by the DON. Record review of Resident #1's Skin Assessment, dated 06/18/2023 , reflected the resident's skin color was normal. Resident #1 did not have any bruises, skin tears, abrasions, or lacerations. Resident #1 had a rash to the upper chest area. There was not any moisture associated skin damage. He did not have any pressure, venous, arterial, or diabetic ulcer. He had some redness to face. The assessment also reflected there was not any new areas that had not been communicated to the physician/NP or family. Signed by RN B. Record review of Resident #1's Emergency Record, dated 06/18/2023, reflected the following: Cardiovascular- Heart sounds normal- no murmur rubs of [NAME], normal sinus rhythm Respiratory chest- lungs clear to auscultation Abdomen: abdomen soft, non-tender, no guarding, rebound or rigidity Upper and lower extremities: Pulses equal in all extremities and moves all extremities Neuro: alert and oriented x 1, cranial nerves intact, no visual field deficits. Skin: no rash, warm, dry, and normal color Head: no hemotympanum, no battle sign, no raccoon eyes Back: no midline spinal tenderness Labs and imaging reviewed. All results normal. CT head was negative. Resident #1's vital signs were the following: B/P- 113/75, Pulse- 75, Pain -0, and O2 96. Reviewed studies with nursing home and plan for Resident #1 to be discharge to the facility. Record review of Resident #1's Physician Orders, dated 6/19/2023, there was a verbal order for the resident to wear wander guard . Record review of Resident #1's Elopement Nurses Note, dated 06/19/2023 at 8:20 PM, reflected Resident #1 was calm and there were no elopement attempts. Resident #1 received one - one monitoring and was wearing wander alarm bracelet. Signed by RN E. Record review of Psychiatric Services note, dated 06/19/2023, reflected Resident #1 reported he was good. The Medical Doctor had a meeting with nursing staff. The nursing staff reported to the Medical Doctor, Resident #1 had normal appetite. Resident #1 did not exhibit any anxiety or hostility toward other residents or staff. Resident #1 did not have any depression and no sleep complaints. His energy level was normal. Resident #1 did not have any paranoid ideations and he was not resisting assistance with ADLs. Resident #1 was not isolating himself and did not have any emotional behaviors such as crying. During the Medical Doctor assessment of Resident #1 it was determined he did not have any acute distress. Resident #1 was smiling and interactive. No suicide ideations or mood disturbance. Resident was screened for future fall risk: no documentation of two or more falls in the past year and no documentation of any fall with injury in past year. Signed by Medical Doctor Record review of the Social Workers documentation dated 06/19/2023, in the electronic medical records reflected Resident #1's Responsible Party was contacted concerning Resident #1 being transferred to a facility with a secure unit. Resident #1's Responsible Party was pleased with the decision for resident's safety . Record review of plan to monitor dated 06/19/2023 the front door reflected the nursing supervisor would sit at the nurse's desk facing the front door. When the nurse supervisor needed to visit residents for wound care she would have another staff sit at the nurse's desk facing the front door to ensure residents does not leave the facility when families exited the facility. The facility had increased changing their door codes from monthly to weekly. Observation on 6/28/2023 between 9:30 AM - 5:30 PM revealed a nurse was sitting at the nurses station facing the front door. Observation on 6/28/2023 at 8:30 AM - 10:15 AM revealed the front door was locked and all the exit doors on all the halls were locked. The alarm did sound when the doors were opened. There was a sign on the doors which reflected Visitors: Please check with nurses' station before allowing residents outside. This sign was posted on the front door when entering and exiting the facility. In an interview with the Administrator on 06/28/2023 at 8:55 AM, the Administrator stated Resident #1 was last seen by Med-Aide A at 9:45 AM. She stated Resident #1 never wandered or exit seek prior to 6/18/2023. She stated he was usually in his room or sitting in the common area watching TV . She also stated an elopement risk assessment was completed on the resident on 06/16/2023 and reflected he was not at risk for elopement. She also stated the facility had more than usual number of visitors all day on 06/18/2023 due to being Father's Day. She also stated there were no reports of the doors or alarms not working in the facility on 06/18/2023. She stated there were some family members who knew the code to exit from the front door. She stated these were the families frequently visited their loved ones visit during the week and on weekends . She stated during the investigation of Resident #1's elopement no one in the facility heard sounds of any door alarms. She stated on 6/18/2023 the police officer arrived at the facility approximately 12:00 PM. Nurse Supervisor B informed the police officer Resident #1 did reside at the facility. She stated the police officer explained to Nurse Supervisor B a lady was in her car was driving on [NAME] the street on a busy roadway and observed Resident #1 on the sidewalk (approximately 1 mile from the facility). The lady contacted the police. The police arrived where Resident #1 was located and transported him to the ER. Once at the ER the police saw Resident #1's name in his shoes and determined Resident #1 was probably a resident at a nearby nursing home. She stated Resident #1 was evaluated at the ER and was later transferred to the facility at approximately 4:15 PM on 06/18/2023. She stated Resident #1 did not have any injuries or any health concerns when discharged from the ER. She stated a skin assessment was completed on the resident when he returned from the hospital, and he had a small area of a rash on his chest and this area was not exposed to the sun. She stated the shirt he was wearing was a button-down shirt and it covered the chest area. The Administrator also stated his vital signs were normal and there were not any changes in his mood or behavior. She stated a wander guard was placed on the resident. She stated he was placed on 1:1 monitoring until he was discharged to a secured unit at a sister facility with agreement of the resident and the resident's R/P. He was discharged on 06/20/2023. She also stated she had spoken with the Administrator at the sister facility and was informed Resident #1 was adjusting satisfactory to his new environment and had developed a friendship with his roommate and was more social . She stated the facility was informed by the Police Officer of Resident #1 was missing from the facility. She also stated resident was out of snuff on 06/18/2023. She stated in conclusion of the facilities investigation it was determined he exited the facility behind the families and probably was going to get snuff. She stated it was very seldom he was without snuff and the facility had called the family to remind the R/P to bring resident snuff , mail check to facility for his patient trust fund or to bring money to facility for the facility staff to purchase him some snuff. Record review of Resident #1's Monitoring Records reflected Resident #1 was monitored one-on-one upon returned from ER on [DATE] until he was discharged to sister facility on 06/20/2023. Record review of Elopement Drill records reflected the facility had elopement drills on 04/05/2023, 05/02/2023, 05/08/2023, and 6/20/2023. Record review of Elopement Inservice was conducted on 06/19/2023. Record review of Abuse/Neglect and elopement Inservice was conducted on 06/18/2023. Record review of Doors, Locks and Alarms tests reflected all doors, and all alarms were tested and checked on 05/30/2023, 06/06/2023, 06/13/2023,06/18/2023, 06/20/2023 and 06/27/2023. Record review of nursing staff record for 06/18/2023 on the day shift reflected 6- CNAs, 2- Med-Aides, 1- Restorative Aide, and 4- Nurses. In an interview with the Administrator on 06/28/2023 at 8:55 AM, The Administrator stated Resident #1 was last seen by Med-Aide A at 9:45 AM. She stated Resident #1 never wandered or exit seek prior to 6/18/2023. She stated he was usually in his room or sitting in the common area watching tv. She also stated an elopement risk assessment was completed on resident 06/16/2023 and reflected he was not at risk for elopement. She also stated the facility had more than usual number of visitors all day on 06/18/2023 due to being Father's Day. She also stated there were no reports of the doors or alarms not working in the facility on 06/18/2023. She stated there were some family members knew the code to exit from the front door. She stated these were the families frequently visited their loved ones visit during the week and on weekends. She stated during the investigation of Resident #1's elopement no one in the facility heard sounds of any door alarms. She stated on 6/18/2023 the police officer arrived at the facility approximately 12:00 PM. Nurse Supervisor B informed the police officer Resident #1 did reside at the facility. She stated the police officers explained to Nurse Supervisor B a lady was in her car was driving on [NAME] Street and observed Resident #1 on the sidewalk (approximately 1 mile from the facility). The lady contacted the police. The police arrived where Resident #1 was located and transported him to the ER. Once at the ER the police saw Resident #1's name in his shoes and determined Resident #1 was probably a resident at a nearby nursing home. She stated Resident #1 was evaluated at the ER and was later transferred to the facility approximately 4:15 PM on 06/18/2023. She stated Resident #1 did not have any injuries or any health concerns when discharged from the ER. She stated a skin assessment was completed on the resident when he returned from the hospital, and he had a small area of a rash on his chest and this area was not exposed to the sun. She stated the shirt he was wearing was a button-down shirt and it covered the chest area. The Administrator also stated his vital signs were normal and there were not any changes in his mood or behavior. She stated a wander guard was placed on resident. She stated he was placed on 1:1 monitoring until he was discharged to a secured unit at a sister facility with agreement of Resident and Resident's R/P. He was discharged on 06/20/2023. She also stated she had spoken with the Administrator at the sister facility and was informed Resident #1 was adjusting satisfactory to his new environment and had developed a friendship with his roommate and was more social. The staff did not ask the Police officer name or receive a card from the police officer or inquire of the name of the lady saw Resident #1 on the sidewalk. In an interview on 06/28/2023 at 10:50 AM, LVN Charge Nurse F stated on 06/18/2023 she was in the dining room at approximately 7:30 AM until 9:00 AM and assisted with delivering meal trays to residents and making observations of residents during meals. She stated she was sat at the same table with Resident #1. She stated she was feedingfed another resident. She stated Resident #1 was exited the dining room at approximately 9:00 AM. She also stated she was not assigned to the hall where Resident #1 resided. She stated she did not see Resident #1 after 9:00 AM on 06/28/2023. She also stated Resident #1 did not have a history of attempting to exit seek or elope from the facility. She stated she had beenwas assigned to the hall where he resided. She stated she was walking from 300 hall toward the nurses' desk and saw a police officer at the desk. She stated she stopped at the nurses' desk and heard the Policeman speaking with RN B. She stated she heard the police officer ask if the facility had a resident named - [stated Resident #1 last name]. RN B stated the facility did have a resident with the same last name. She stated the police officer stated he identified the resident by the name in his shoes. She stated she called the DON and was instructed to check every resident to ensure all residents were in the facility. She stated the staff was divided and they verified all residents was in the facility except for Resident #1. She also stated she checked the doors, and all the doors were locked. She stated she opened the doors, and the alarms were soundingsounded, and she assisted all residents to the doors with wander guards and the system was working when the residents with wander guards was were near all the doors. She stated this was very unusual for Resident #1 to elope or even attempt to elope from the facility. She also stated he had the same routine every day. He would go to the dining room for meals, go to his room after eating and he would sit in the common area and watch tv. She stated she did not hear any alarms sound on 06/18/2023 and no one reported to her any of the exit doors was not locking. LVN Charge Nurse stated she did visited with Resident #1 on 06/19/2023 during breakfast and he did not have any signs or symptoms of being in any physical or mental distress. She stated he was calm, smiling and was acting normal. She stated the resident was on one-one monitoring as soon as he returned from the hospital and a wander guard was placed on Resident #1. She also stated there were a lot of visitors in the morning and afternoon on 06/18/2023. She stated the frequent visitors knows knew the code to exit the facility, however, the visitors did not visit very often will and would ask staff to assist them with the code. In an interview on 06/28/2023 at 11:25 AM, CNA G stated she was assigned to Resident #1 on 06/18/2023. She stated before 7:20 AM on 6/18/2023 she assisted Resident #1 with dressing for breakfast. She stated he exited his room and was ambulating toward the dining room. She stated the next time she observed Resident #1 he was in dining room for breakfast at approximately 7:20 AM -8:00 AM. She stated she did not see Resident #1 after 8:00 AM on 06/18/2023. She also stated Resident #1 had his own schedule he liked to do things such as: after he ate he would go to his room and then go to the tv area and watch tv. She stated when she finished in the dining room she exited and assisted another resident with a shower. She stated after the shower it was time for her break at 8:30 AM and she returned from her break at approximately 8:45 AM. She stated she did not make her rounds on Resident #1 . She stated she was busy with shower and checking residents remains in bed she didn't think about the time. She stated she was required to do every 2-hour rounds on all the residents she was assigned to, and she did not make rounds on Resident #1 . She stated he had his daily routine where he went to his room after breakfast and then to the common area. She stated she mostly did rounds on bedfast residents she was assigned to, but she was required to make rounds on every resident on her assignment sheet. She also stated she did not know why she did not check on Resident #1 during her rounds at 10:00 AM. She stated she expected him to be in the common area where he usually was around that time every day. She also stated she took her lunch break at 11:00 AM and returned from her lunch break at 11:30 AM. She stated when she returned from her lunch break, she entered the dining room to assist with the lunch meal service. She stated CNA H entered the dining room and asked her if there were any residents missing on the 400 hall. She stated she explained to CNA H she was not aware of any resident missing. She stated Resident #1 had not returned from the hospital when she clocked out for the day. She stated she had been in serviced on making rounds every 2 hours, and she participated in elopement drills several times. She also stated she was in serviced on elopement. She also stated she had been assigned to Resident #1 several times per week. She stated Resident #1 never attempted to ambulate to the doors and attempt to leave the facility. She stated He did not wander into other resident's room. She also stated The resident did not always interact with other residents. She stated when she heard Resident #1 eloped from the facility, she was shocked due to Resident #1 did not have a history of trying to leave the facility or wander. She stated she did not hear any door alarm sounds on 06/18/2023. She stated No one reported to her of any ofthat the alarms were not working or any of the doors having had problems of not locking. She stated there were more than usual visitors in the morning and the afternoon on 06/18/2023 for Father's Day. She stated she did not know when staff observed Resident #1 during the morning of 06/18/2023 and if she did know other staff observed Resident #1, she was expected to make rounds every 2 hours. She stated she was in serviced on abuse/ neglect, elopement, and making rounds on residents every two hours in June and few months ago. In an interview on 06/28/2023 at 11:50 AM, LVN D stated she was workingworked on 06/18/2023 when Resident #1 eloped from the facility. She stated at approximately 7:00 AM she checked Resident #1's blood sugar, and this was the first time she observed Resident #1. She also stated she did not observe the resident after 7:00 AM on 06/18/2023. She stated the CNAs and nurses were expected to make rounds on the residents they were assigned to every 2 hours. She stated Resident #1 did not have a history of exit seeking or attempting to leave the facility. She stated He did not wander inside the facility. He usually had a routine of going to his room after breakfast and would go to the common area and watch TV. She stated he did not interact very often with other residents. She stated There were a lot of visitors in the facility all day on 06/18/2023 due to it being Father's Day. She also stated The nurses or med-aides did not report to the CNAs if they have observed a resident unless there was unusual behavior or circumstances with the resident. She stated the only time a med-aide would report to a CNA they observed a resident was if the med-aide gave a resident a certain medication such as a laxative. She stated the families visited numerous times per week knew the code to enter and exit the front door of the facility. She stated only the families very seldom visited did not know the code to exit the front door of the facility. She stated she had been in serviced on making rounds every 2 hours on 06/18/2023 and few months ago. She stated this was expected of nurses and CNAs to make rounds every 2 hours by the administration. In an interview on 06/28/2023 at 2:45 PM, RN E stated she was workingworked the 2-10 PM shift on 06/18/2023. She stated she observed Resident #1 when he returned from the hospital at approximately 5:30 PM. She stated she did not observe any changes in his cognition or his mood . She stated he did eat supper in the dining room. She stated she completed a skin assessment on resident, and she did see a small rash on his chest area. She stated resident was always calm unless he had an urinary tract infection and he would sometimes become agitated. She also stated he would a quiet person and he very seldom interacted with other residents. She also stated he would usually go to his room after meals and go to watch tv in the area where all the residents could watch tv together. She stated he had is daily routine. She stated she did not observe him every wandering into other resident's room. She stated this was a surprise to her that he left the facility it was not his usual behavior. She stated Resident #1 did not require any type of treatment. She stated he was calm and relaxed during her interaction with him. She also stated he was immediately placed on one-on-one monitoring when he returned from hospital. She stated A staff was sitting outside his door and when he exited his room the staff would walk with him to wherever he wanted to go, and it was usually the common area. She stated Resident #1 did not have any sunburn or blisters on his skin. She stated his cognition or mood had not changed. She also stated there were not changes in his physical, mood, or mental condition. She stated Resident #1 did not exhibit any signs or symptoms of pain such as moaning, grimacing, furrowed brow, flinching, yelling, crying, complain of headache, and or rapid or unusual breathing. She also stated nurses and CNAs were expected to make rounds every 2 hours of their assigned residents. She stated she had beenwas in serviced on elopement, abuse/neglect and making rounds every 2 hours in June 2023 and within the last 2 or 3 months. In an interview on 06/28/2023 at 3:45 PM, CNA I stated he worked on 06/18/2023 from 6:00 AM - 6:00 PM. He stated he observed the Resident #1 in the common area at approximately 8:30 AM. He stated Resident #1 was calm and he did not observe any changes in his mood or behavior. He stated he did not observe him after 8:30 AM until he returned from the hospital later that day. CNA I stated he did observed the resident in the dining room at approximately 5:45 PM on 06/18/2023 and Resident #1 was calm and did not appear to have any changes in his mood or mental status. He stated resident went to his room and then he went to watch tv with other residents. He stated this what he usually did every day. He stated he had not observed Resident #1 wander in the facility or even attempt to leave the facility for any reason. He stated CNA I stated there were more visitors in the morning and afternoon than usual for a weekend. He stated Resident #1 was out of snuff. He stated he usually does did the smoke breaks and noticed Resident #1 did not have any snuff over the weekend and he was informed by Nurse Supervisor that the family had been contacted. He stated this did not occur very often to his knowledge. He also stated the families who visits visited the facility frequently throughout the week knows knew the code to the door to exit the facility and the families who only visited very few times usually did not know the code to the front door and would require assistance to exit the facility. CNA I stated all the staff in the facility was were in serviced on elopement and participated in elopement drills the week of 06/18/2023. She also stated the staff was were in serviced at the same time of on abuse/ neglect and making rounds every two hours. She stated the staff was were in serviced approximately 2 months ago about making rounds every 2 hours and abuse /neglect. The staff also participated in elopement drills in April and May of 2023. In an interview on 06/28/2023 at 4:30 PM, the Maintenance Supervisor stated he received a form generated by the corporate office of the steps he is was to complete when checking all exit doors, and alarms on the doors. He stated the doors, and door alarms are were checked monthly. Since the elopement, he stated the doors and alary alarm systems on the doors were being checked daily. He stated he was not at work on 06/18/2023, however, he received a phone call about the elopement and immediately came in the facility to check the exit doors and the alarms. He stated he checked all the doors and door alarms in the facility. He stated all were in working order. He also stated he did not find any alarm or door not working properly. He also stated the wander guards were also checked and all were working properly. He stated if there was anything not working properly in the facility the staff filled out a maintenance request and there was not any request filled out concerning which concerned the doors but he stated if the doors or door alarms was were not working the staff would notify him immediately. He stated the codes are were not given to the families, however, when there are were families visits who visited numerous times a week they will would watch staff enter the code and will would know the code and use it when they visited their family families in the facility. He stated a company came to the facility on [DATE] and checked all the doors and alarms and they did not find any alarm or doors not in working order. In an interview on 06/28/2023 at 5:45 PM, the Administrator stated upon her investigation of Resident #1's elopement there were more than the usual number of visitors in the facility on 06/18/2023. She stated the families visits who visited frequently throughout the week knows knew the code to exit the facility. She stated she interviewed the employees who worked on 06/18/2023 and no one observed Resident #1 exit seeking or any changes in his mood /behavior. She stated Resident #1 did not have a history of exit seeking or wandering. She stated the staff did not hear any door alarms sounding. She also stated it was determined the only door the resident may have exited when he eloped was the front door and may have followed visitors out the front door. The Administrator stated Resident #1 was out of snuff over the weekend and it was a possibility he may have been trying to leave the facility to get snuff. She stated the activity director or social worker usually will would go shopping for residents. She also stated Resident #1's family had been contacted to bring money for his snuff and they had not visited the resident to bring snuff or bring money for staff to purchase the snuff. She stated it was determined all the exit doors and alarms were in working order and no one heard any door alarms in the AM morning, on 06/18/202. She stated in the area where the front door is was located there is was approximately 100 feet from the only nurses' desk to the front door. She stated during the week she was in her office and the business office manager was in her office. She stated our office doors was were within 5-10 feet of the front door. She stated there were staff entering and exiting their offices throughout the day and more people could make more observations of the front door than on the weekends. She stated they had begun a stricter monitoring system for weekends and holidays . She stated the nurse supervisor was always at the nurse's desk except when she was doing wound care. She stated the nurse supervisor was to sit at the nurse's desk facing the front door. When she left the nurses desk for any reason she was to assign another staff to sit at the nurse's desk facing the front door . She also stated she placed a sign on the outside and inside of the front door which stated and there is was staff by the front door continuously during the week entering and exiting the offices. The nursing staff and administrative staff had increased making rounds on the residents and observing the front door. She stated the systems breakdown was the nursing staff was were not making rounds every two hours to ensure residents were not going outside without assistance from staff. The Administrator stated she also expected the nurses to make rounds every 2 hours and monitor to ensure the CNAs were completing their tasks. She stated if a resident eloped the resident had a potential of a heat stroke or acquire any type of injury and possibly need to be hospitalized . She stated it was the DON and ADON's responsibility to in-service and train nursing staff. She stated the nurses speaking who spoke with the police officer did not ask for his name and they did not know the policeman's name. She stated the interdisciplinary team had a meeting and discussed the elopement and to ensure resident safety they thought it would be in his best interest to be on a secure unit. The Social Worker contacted Resident #1's responsible party and discussed the option. Resident #1's family agreed they thought he needed to be in a secure unit and agreed with the transfer. The transfer was also [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately inform a resident's physician when there was a significant change in a resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #15) reviewed for notification of changes in that: The facility failed to fully notify Resident #15's primary care physician of all of Resident #15's status including ongoing elevated blood pressures and increased edema. These failures resulted in an Immediate Jeopardy (IJ) situation on 06/22/2022. While the IJ was removed on 06/24/2022, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of not having their primary care physician notified of changes, resulting in a delay in medical intervention and decline in health. Findings included: Review of Resident #15 face sheet revealed Resident #15 was a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses of history of a stroke, Type 2 Diabetes Mellitus, high cholesterol and high blood pressure. Review of Resident #15 quarterly MDS assessment dated [DATE] revealed Resident #15 had a BIMS score of 14 to indicate intact cognition. Resident #15 required extensive assistance by two or more staff members for bed mobility, transfers and toilet use. Review of Resident #15 Care plan dated 03/24/2022 revealed Resident #15 was on diuretic therapy (Hydrochlorothiazide) with interventions including administer medication as ordered, monitor vital signs as ordered and report to physician if abnormal for this resident, report any increased swelling of legs, arms or face to the charge nurse, report ordered labs to the physician, and resident could experience dizziness, postural hypertension, fatigue and increased risk for falls. Observed for possible side effects. In an observation on 06/21/2022 at 9:28 AM, Resident #15 was observed to have swelling in his right arm, right lower leg and in his neck and back of head. In an interview on 06/21/2022 at 9:30 AM, Resident #15 stated he felt like he had a lot of fluid on him, and his right arm and leg were swollen. He stated he had pneumonia recently and was not seen by a doctor and he wanted to see a doctor. He said the lady down the hall had pneumonia too and was seen by a doctor. He said the facility told him the swelling was normal for him and not to worry about it. He said his auntie had recently been hospitalized for fluid in her lungs and he was worried he had the same problem. He said at the end of May (2022) he felt like he could not breathe, and his chest was hurting and when he reported it to the first nurse, she told him he was fine and did nothing. He said he was on the phone with his brother and sister, who were telling him to go to the hospital. He said the nurse told him if he wanted to go to the hospital, he would have to call 911 himself. He said his sister called up to the facility and the nurse coming on shift assessed him and started him on oxygen and breathing treatments which made him feel better. He said he had a chest x-ray the next day and was started on antibiotics for pneumonia. He did not see a doctor since that happened and requested multiple times to see a doctor. He said the facility told him last week he gained a lot of weight and needed to stop eating so many snacks from the vending machine. Review of Resident #15 EMR for Physician Progress Notes dated 03/22/2022 - 06/21/2022 revealed a physician progress noted completed by PHYS ASST on 03/29/2022. There were no other physician progress notes in Resident #15's EMR. Review of Resident #15 Weight Records dated 03/22/2022 -06/21/2022 revealed: 03/24/2022 - 310.6 pounds on the wheelchair scale 04/01/2022 - 314.6 pounds (scale unknown) 05/10/2022 - 314.8 pounds (scale unknown) 06/16/2022 - 356.7 pounds (scale unknown) In an interview on 06/21/2022 at 4:00 PM, the DON said PHYS K was notified of Resident #15's weight gain but was not sure if he was notified regarding Resident #15's elevated blood pressures. In an interview on 06/21/2022 at 5:29 PM, LVN D said Resident #15 had issues with intermittent high blood pressures and edema since May 2022. She tried to contact Resident #15's attending physician, PHYS K, about two weeks ago regarding the issues but had not received a response. When asked where the documentation of the notification of the high blood pressures and edema to PHYS K was, she said she was not sure she documented it and then confirmed it was not in the EMR. She stated she will notify a resident's doctor depending on the parameters set by the doctor. She stated she did not know the parameters for Resident #15 but did call and leave a message for PHYS K when Resident #15's blood pressure was 190/94 and received no response. She stated Resident #15 had a chest x-ray at the end of May (2022) and was diagnosed with pneumonia. She stated she notified PHYS K at that time (05/31/2022) and received a verbal order for antibiotics for the pneumonia. She stated she did not report increased edema and elevated blood pressures to PHYS K at that time. She stated she was not aware of a physician examining Resident #15 following the pneumonia diagnosis. She stated she was not aware of Resident #15's increased weight from May to June 2022. In an interview on 06/21/2022 at 5:52 PM, PHYS K stated he was notified by the facility about the excessive weight gain from May to June 2022. He stated he was told by the facility that Resident #15 ate a lot and was likely to blame for the 41.9-pound weight gain because diet non-compliance. He stated he was told Resident #15 had increased swelling on his right arm and leg, but the facility attributed that to the stroke causing a change in blood flow. He stated he did not remember being contacted about intermittent high blood pressures. He did not remember being contacted about increased edema overall. Review of Resident #15 Blood Pressures 05/25/2022-06/22/2022 out of range in the EMR or greater than 145/90: 05/25/2022 - 9:26 AM - 176/84 mmHg 05/25/2022 - 8:38 PM - 157/99 mmHg 05/26/2022 - 9:53 AM - 158/72 mmHG **no other BP readings documented for this day.** 05/28/2022 - 10:04 AM - 164/79 mmHG 05/28/2022 - 7:50 PM - 157/70 mmHG 05/29/2022 - 6:28 PM - 167/94 mmHG 05/30/2022 - 10:12 AM - 178/90 mmHG 05/30/2022 - 8:41 PM - 155/80 mmHG 05/31/2022 - 10:29 AM - 165/100 mmHG 05/31/2022 - 7:57 PM - 151/99 mmHG 06/01/2022 - 10:05 AM - 166/99 mmHG 06/01/2022 - 7:43 PM - 170/83 mmHG 06/02/2022 - 4:47 AM - 153/100 mmHG 06/02/2022 - 9:51 AM - 159/95 mmHG 06/02/2022 - 7:02 PM - 150/98 mmHG 06/03/2022 - 2:32 AM - 155/80 mmHG 06/03/2022 - 10:38 AM - 164/86 mmHG 06/04/2022 - 10:28 AM - 166/82 mmHG 06/04/2022 - 8:44 PM - 176/84 mmHG 06/05/2022 - 1:09 AM - 163/96 mmHG 06/05/2022 - 10:33 AM - 175/97 mmHG 06/05/2022 - 5:43 PM - 186/94 mmHG 06/05/2022 - 6:02 PM - 190/100 mmHG 06/06/2022 - 9:45 AM - 158/78 mmHG 06/06/2022 - 7:44 PM - 176/73 mmHG 06/07/2022 - 2:09 AM - 174/80 mmHG 06/08/2022 - 1:25 AM - 174/88 mmHG 06/08/2022 - 11:28 AM - 179/91 mmHG 06/08/2022 - 8:22 PM - 183/84 mmHG 06/09/2022 - 2:02 AM - 149/80 mmHG 06/09/2022 - 1:38 PM - 189/100 mmHG 06/09/2022 - 6:50 PM - 167/87 mmHG 06/10/2022 - 9:45 AM - 169/84 mmHG 06/10/2022 - 7:11 PM - 186/53 mmHG 06/11/2022 - 6:29 AM - 156/76 mmHG 06/11/2022 - 10:23 AM - 193/91 mmHG 06/11/2022 - 7:45 PM - 145/76 mmHG 06/12/2022 - 8:57 AM - 160/100 mmHG 06/13/2022 - 7:38 PM - 153/96 mmHG 06/14/2022 - 10:30 AM - 154/68 mmHG 06/14/2022 - 6:50 PM - 150/74 mmHG 06/15/2022 - 9:44 AM - 181/89 mmHG 06/15/2022 - 6:49 PM - 190/94 mmHG 06/16/2022 - 9:49 AM - 163/71 mmHG 06/16/2022 - 6:51 PM - 189/85 mmHG 06/17/2022 - 10:21 AM - 160/81 mmHG 06/18/2022 - 10:08 AM - 175/91 mmHG 06/18/2022 - 6:20 PM - 165/86 mmHG 06/19/2022 - 10:09 AM - 155/86 mmHG 06/19/2022 - 7:36 PM - 152/88 mmHG 06/22/2022 - 10:21 AM - 160/101 mmHG Review of Resident #15 Nursing Progress Notes dated 05/25/2022 - 06/20/2022 revealed no progress notes regarding Resident #15's elevated blood pressures or any interventions regarding resolution of the elevated blood pressures. Review of Resident #15 Nursing Progress note dated 05/30/2022 at 11:55 PM written by LVN J revealed Resident #15 is alert and oriented. Skin is warm and dry to touch. At 2325, resident had complained of wheezing, SOB and chest pain rated 4/10., not radiating to the shoulders or other areas. Lung's sound cleared on both sides; no apparent wheezing noticed at this time. V/S Temp 98.2 Pulse 90, Resp 26, BP 169/96 LT arm lying, 02 sat between 88% to 96% on room air. Doctor on call informed to the situation, nurse practitioner ordered for duo nebulizer treatment (aerosol breathing treatment), chest x-ray, 02 therapy. Staff to call back if resident condition is not improving. Please see TAR/orders. Duo nebulizer and 02 therapy initiated. Resident denies chest pains before treatment initiated. Call light put within reach. Will continue to monitor. Review of Resident #15 Nursing progress note dated 05/31/2022 at 5:32 AM written by LVN J revealed At 1150 V/S Temp 97.5, Pulse 90, Resp 22 02 95% N/C, BP 157/94 At 0108 V/S Temp 96.3, Pulse 85, 02 99% N/C At 0135 Pulse 87, 02 97% At 0210 V/S Temp 96.4, Pulse 84, Resp 22, 02 97% with O2 via nasal cannula At 0255 V/S Temp 96.3, Pulse 82, Resp 24, 02 99% with O2 via nasal cannula At O320 V/S Temp 96.2, Pulse 81, Resp 22, 02 96% with O2 via nasal cannula At 0455 V/S Temp 96.3, Pulse 78, 02 99% with O2 via nasal cannula At 0545 V/S Temp 97.5, Pulse 82, 02 97% with O2 via nasal cannula, BP 155/100 [FAMILY MEMBER] called this morning about the change in condition and the treatment initiated. Would like update from of us. Review of Resident #15 Respiratory Infection Nurses Note dated 06/01/2022 at 8:00 AM, revealed Resident #15 was being treated for pneumonia with Oxygen at 2 LPM (liters per minute), duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 170/83 taken 06/01/2022 at 7:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/01/2022 at 4:00 PM, revealed Resident #15 was being treated for pneumonia with Oxygen at 2 LPM (liters per minute), duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 170/83 taken 06/01/2022 at 7:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/02/2022 at 12:00 AM, revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 153/100 taken 06/02/2022 at 4:47 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/03/2022 at 12:00 AM, revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 155/80 taken 06/03/2022 at 2:32 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Resident #15 was noted to have an additional symptom of fatigue. Review of Resident #15 Respiratory Infection Nurses Note dated 06/03/2022 at 8:00 AM, revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 164/86 taken 06/03/2022 at 10:38 AM and to nasal congestion with fatigue. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/04/2022 at 7:00 PM, revealed Resident #15 was being treated for pneumonia with oxygen at 2 LPM (liters per minute), duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 166/82 taken 06/04/2022 at 10:28 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/04/2022 at 11:00 PM, revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 163/96 taken 06/05/2022 at 1:09 AM and had fatigue. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/05/2022 at 10:00 AM, revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 175/97 taken 06/05/2022 at 10:33 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/05/2022 at 5:00 PM, revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 183/94 taken 06/05/2022 at 5:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/06/2022 at 1:00 AM, revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 130/97 taken 06/05/2022 at 1:09 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Nursing Progress Note dated 06/16/2022 at 10:27 AM written by ADON revealed Significant weight gain noted. Resident receives large portions at mealtimes and request a to go plate as well of lunch and dinner meals. Resident is non-compliant with diet orders and frequents the vending machine often and eats outside food that friends bring into him. 2+ edema noted to right lower leg. Provider and dietitian notified. There were no follow-up notes completed or additional interventions provided to Resident #15 after 06/16/2022. Review of Notifying the Physician of Change in Status dated 03/11/2013 revealed the nurse should notify the physician immediately with significant change in status. If the physician does not return the call and if the nurse does not receive a response after trying twice, the nurse will contact the medical director for assistance. The nurse will document all attempts to contact the physician in the resident's clinical record. The Administrator, DON and the Regional Compliance Nurse were notified of on 06/22/2022 at 2:35 PM an IJ situation was identified due to the above failures and the IJ template was provided. The Plan of Removal was accepted on 06/24/2022 at 3:38 PM and included the following: Problem: Notify of Changes All residents have the potential to be affected by this deficient practice. Interventions: o Physician was notified by the Compliance Nurse and DON of identified resident's weight gain, increased edema, elevated B/P and blood sugar readings on 6/22/2022 and completed an evaluation of identified resident on 6/22/2022. o The DON, ADON and/or compliance nurse obtained blood pressure notification parameters from the Physician / NP which have been entered as an order in PCC. As ordered by the Physician, treatment for intermittent elevated blood pressure was entered into PCC. This was completed in PCC on 6/22/22. o The DON/ADON will ensure all new admissions are followed by a Physician. This was completed on 6/22/22 and will be ongoing. o All charge nurses were in-serviced beginning 6/22/2022 by the Compliance Nurse / DON and/or ADON regarding the following and all nurses not in-serviced by 6/22/2022 will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-serviced by Compliance Nurse. o Immediate reporting changes of condition to the physician including Elevated B/P, Blood sugar (according to parameters as determined by the Physician), increased edema and significant weight gain. o Ensuring appropriate size blood pressure cuffs are utilized to ensure accurate readings. o Assessing for increased edema and/or swelling. o Signs and symptoms of hyperglycemia and notification of Physician. o The DON, ADON, and or compliance nurse reviewed last weeks documented blood pressures to ensure physician/NP were notified for blood pressures out of parameters. This was completed on 6/22/22 for all residents. DON/ADON/Compliance Nurse will review EMR clinical alert reports/Real Time Clinical software at least 5 times per week indefinitely. o The DON, ADON, and or compliance nurse reviewed the last weeks documented blood sugars for applicable residents to ensure physician/NP were notified for blood sugars out of parameters. This was completed on 6/22/22. There were no additional finding that required physician notification. DON/ADON/Compliance Nurse will review EMR clinical alert reports/Real Time Clinical software at least 5 times per week indefinitely for any abnormal blood sugars. o The DON, ADON, compliance nurse, and/or designated licensed nurses assessed all residents to determine if the resident has new or increased edema, and there were no additional findings requiring physician notification. This was completed on 6/22/22. Weekly skin assessments on all residents will be performed ongoing by the Treatment Nurse/designee for any skin changes including edema. This will be monitored by DON/ADON weekly, ongoing. o The medical director was notified by the administrator of this plan on 6/22/2022. An Ad Hoc QAPI meeting was held 6/23/2022. Monitoring: o Monitoring of this plan began on 6/22/2022 and will continue weekly x 4. o The DON and/or designee will monitor the vitals summary report from EMR at least 5 times per week to determine if blood pressures or blood sugars were out of parameters and/or significant weight gains and if so, the physician/NP will be notified. Monitoring began 6/22/2022 and will continue x 4 weeks. o The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 times per week, indefinitely to ensure any new or worsened edema is communicated to the physician/NP and follow up as needed. o The DON and/or designee will ensure that the proper blood pressure cuffs are available for use at least 5 times per week x 4 weeks. DON/ADON provided in-servicing on the use of manual blood pressure cuffs on 6/22/22. Training is ongoing. Staff will not report to their assigned shifts prior to in-servicing. New hires will be trained during orientation. The Survey team monitored the plan of removal as follows: Monitoring done from 06/23/2022 - 06/25/2022. Observation on 06/25/2022 at 11:40 AM Resident #15 was weighed using the mechanical lift and his weight was 346.6 which was a 6.5 pound decreased since Resident #15 received three doses of Lasix on 06/23/2022, 06/24/2022 and 06/25/2022. Resident #15 was noted to have decreased swelling in his leg, arm and area behind his head and neck. In an interview on 06/25/2022 at 11:35 AM, Resident #15 stated he had been using the bathroom a lot and could tell his arm and leg was less swollen. He stated he felt better now that someone was monitoring his swelling and having fluid on. Review of Resident #15 Physician Orders dated 06/22/2022 revealed Resident #15's blood pressure medications were changed and will be monitored by PHYS ASST weekly for effectiveness. In an interview on 06/24/2022 at 3:07 PM CMA R stated she was educated regarding the use of the appropriate blood pressure cuff and that Resident #15's blood pressure should be taken using the arm cuff and not the wrist cuff. She was educated regarding the parameters of what to report to a nurse for follow-up when Resident #15's blood pressure was high. She said they were also in serviced regarding high blood sugars for Resident #15. In an interview on 06/24/2022 at 3:15 PM, LVN P stated she was educated regarding blood pressure parameters, notifying a doctor regarding a change in condition and using the right sized blood pressure cuff. Review of facility Inservice education completed as part of Plan of Removal: 06/22/2022 Reporting Change in Condition to include high BP, increased edema and significant weight gain. All nurses completed the education. 06/22/2022 Notifying Charge Nurse of Abnormal Vital Signs. Medication Aides and nurses were educated. 06/22/2022 Bariatric BP cuff can be found on the crash cart as well as in the med room. These are to be cleaned and returned after each use. The appropriate sized cuff has to be used for accurate readings. All nurses and medication aides were educated. 06/22/2022 Signs and Symptoms of Hyperglycemia and physician notification. All nurses completed the education. 06/22/2022 Edema Causes and signs. All nurses completed the education. While the IJ was removed on 06/24/2022, the facility remained out of compliance at a severity level of actual harm and a scope of 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 observation, interview, and record review the facility failed to, ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices for one (Resident #15) of five residents reviewed for quality of care. -The facility failed to provide treatment and care to Resident #15 who had a 41.9-pound weight gain with a diagnosis of chronic kidney disease who reported increased swelling in his limbs and had not been examined by a physician or physician assistant since 03/29/2022 following his admission to the facility on [DATE]. -The facility failed to notify Resident #15's physician when he experienced high blood pressures up to 190/110 and increased edema. -The facility failed to have parameters in place for notification to physician for nursing staff regarding high blood pressure and failed to have standing orders for treatment of intermittent high blood pressure. -The facility failed to ensure they had the proper size blood pressure cuff to ensure accurate blood pressure readings in Resident #15 following a high result from a wrist cuff. -The facility failed to properly address Resident #15's health complications from 05/30/2022 to 06/20/2022 and subsequently retaliated against Resident #15 by having him sign a Negotiated Risk Agreement effectively blaming him for his health problems related to his non-compliance with his diet. These failures resulted in an Immediate Jeopardy (IJ) situation on 06/22/2022. While the IJ was removed on 06/24/2022, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures placed residents at risk for heart failure, kidney disease, increased disease complications, hospitalization, and death. Findings included: Review of Resident #15 face sheet revealed Resident #15 was a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses of history of a stroke, Type 2 Diabetes Mellitus, high cholesterol and high blood pressure. Review of Resident #15 quarterly MDS assessment dated [DATE] revealed Resident #15 had a BIMS score of 14 to indicate intact cognition. Resident #15 required extensive assistance by two or more staff members for bed mobility, transfers and toilet use. Resident #15 was not noted to have gained or lost weight in the last month or six months. Review of Resident #15 Care plan dated 03/24/2022 revealed Resident #15 was on diuretic therapy (Hydrochlorothiazide) with interventions including administer medication as ordered, monitor vital signs as ordered and report to physician if abnormal for this resident, report any increased swelling of legs, arms or face to the charge nurse, report ordered labs to the physician, and resident could experience dizziness, postural hypertension, fatigue and increased risk for falls. Observed for possible side effects. Review of Resident #15 Physician Orders dated 04/06/2022 revealed Resident #15 to be ordered Regular Consistency/Texture, low concentrated sweets diet with larger portions. Review of Resident #15 Physician Order dated 03/22/2022 revealed Resident #15 to be ordered the following blood pressure medications and instructions: -Carvedilol 25 MG - Give 1 tablet by mouth times per day related to high blood pressure. Hold for SBP less than 90, DBP less than 50, pulse less than 50 and notify charge nurse. -Hydrochlorothiazide Capsule 12.5 MG - Give one capsule by mouth one time a day as related to high blood pressure. -Lisinopril Tablet 20 MG - Give one table by mouth one time a day as related to high blood pressure. Hold for SBP less than 90, DBP less than 50, pulse less than 50 and notify charge nurse. -Nifedipine ER Tablet 60 MG - Give one table by mouth one time a day related to high blood pressure. Hold for SBP less than 90, DBP less than 50, pulse less than 50 and notify charge nurse. There were no high blood pressure parameters defined in the physician orders for Resident #15. Review of Resident #15 EMR for Physician Progress Notes dated 03/22/2022 through 06/21/2022 revealed a physician progress noted completed by PHYS ASST on 03/29/2022. There were no other physician progress notes in Resident #15's EMR.Review of Physician Progress note dated 03/29/2022 written by PHYS ASST revealed Resident #15 was admitted to the facility after a tornado damaged his previous facility. Resident #15 noted to have prior diagnoses of stroke with right sided hemiplegia (partial paralysis), Type 2 Diabetes Mellitus, high blood pressure and chronic kidney disease. His weight was noted at 310.6 pounds and he was noted to have mild peripheral edema and right lower extremity edema. There was no note that the right upper extremity had edema. In an interview on 06/21/2022 at 3:31 PM, the medical records assistant stated she uploaded all physician progress notes into the EMR for all residents. She stated Resident #15's EMR should be current with no missing physician progress notes. She stated she would double check that there were no pending notes that needed to be uploaded. She said she typically received the notes within two days of the doctor or physician assistant rounding and uploaded them to the EMR within a day. Review of Resident #15 Weight Records dated 03/22/2022 -06/21/2022 revealed: 03/24/2022 - 310.6 pounds on the wheelchair scale 04/01/2022 - 314.6 pounds (scale unknown) 05/10/2022 - 314.8 pounds (scale unknown) 06/16/2022 - 356.7 pounds (scale unknown) Review of Resident #15 Nursing Progress note dated 06/16/2022 at 10:27 AM, written by ADON revealed Significant weight gain noted. Resident receives large portions at mealtimes and request a to go plate as well of lunch and dinner meals. Resident is non-compliant with diet orders and frequents the vending machine often and eats outside food that friends bring into him. 2+ edema noted to right lower leg. Provider and dietitian notified. In an observation on 06/21/2022 at 9:28 AM, Resident #15 was observed to have swelling in his right arm, right lower leg and in his neck and back of head. In an interview on 06/21/2022 at 9:30 AM, Resident #15 stated he felt like he had a lot of fluid on him, and his right arm and leg were swollen. He stated he had pneumonia recently and was not seen by a doctor and he wanted to see a doctor. He said the lady down the hall had pneumonia too and was seen by a doctor. He said the facility told him the swelling was normal for him and not to worry about it. He said his auntie had recently been hospitalized for fluid in her lungs and he was worried he had the same problem. He said at the end of May (2022) he felt like he could not breathe, and his chest was hurting and when he reported it to the first nurse, she told him he was fine and did nothing. He said he was on the phone with family members, who were telling him to go to the hospital. He said the nurse told him if he wanted to go to the hospital, he would have to call 911 himself. He said his family member called up to the facility and the nurse coming on shift assessed him and started him on oxygen and breathing treatments which made him feel better. He said he had a chest x-ray the next day and was started on antibiotics for pneumonia. He did not see a doctor since that happened and requested multiple times to see a doctor. He said the facility told him last week he gained a lot of weight and needed to stop eating so many snacks from the vending machine. In an interview on 06/23/2022 at 2:45 PM, RP T stated she was the family member of Resident #15 and was on the phone with him when he was short of breath, coughing and having chest pain at the end of May (2022). She said Resident #15 said he had fluid on and did not feel good and felt like he could not breathe. She said she called to the nurse's station because no one was answering his call light. The nurse said she would go check on Resident #15. She said she was back on the phone with Resident #15 when the nurse checked on him and heard Resident #15 tell her the same symptoms. She said Resident #15 asked to see a doctor or go to the hospital and the nurse responded that if if he wanted to go to the hospital he would have to call 911 himself. She said the nurse then left the room. She said it was shift change and she called back to speak with new nurse, and she checked on Resident #15 and found his oxygen levels to be low and started him on oxygen. She said she was grateful the nurse did something for the resident and the other nurse refused to help. She said she could not remember that nurse's name. She said she checked on Resident #15 the next day and was told he had pneumonia. She said they called yesterday and told her Resident #15 had a large weight gain in one month and said it was because of large meals and too many snacks from the vending machine. She said they told her the PHYS ASST started him on fluid pills. She said she asked, if the weight gain was from snacks why would fluid pills help? and they had no answer. In an interview on 06/21/2022 at 04:25 PM, CMA G stated she weighed Resident #15 on 06/16/2022 using the wheelchair scale in the therapy room. She stated she did not re-weigh him to confirm the weight. She stated she gave the ADON the weights for the residents and she manually entered them into the EMR. She stated she did not realize there was a significant difference in the previous weight because she did not have his record in front of her when weighing him and the other residents. She stated he did tell her about the increase swelling his right arm, but she thought that was his baseline due to his stroke that affected his right arm. An observation 06/21/2022 at 4:28 PM, Resident #15 was weighed using the mechanical lift scale. His weight was 353.0 pounds, an increase of 38.2 pounds since 05/10/2022. In an interview on 06/21/2022 at 3:25 PM, the ADMIN stated the medical director, or his physician assistant sees all of their residents weekly. She stated Resident #15 was followed by an attending physician from Resident #15's previous facility that was evacuated in March 2022 due to tornado damage. She stated PHYS K was Resident #15 attending physician and he rounded on his own patients. She stated she was not sure of when he rounded on Resident #15 since admission. When asked for physician progress notes for Resident #15 (because there was only one uploaded into Resident #15's EMR), she stated she would check with their medical records assistant for additional physician progress notes. She stated Resident #15 was seen by the physician assistant when he was first admitted . She stated she was aware of the large weight gain in Resident #15 from May to June, but he was non-compliant with his diet and ate snacks from the vending machines, larger portions at meals and his family brought food from the outside in large portions. She stated his diet was the cause of the weight gain and the dietitian was notified to conduct an assessment. In an interview on 06/21/2022 at 4:00 PM, the DON stated the weight for Resident #15 may have been an error because his weight in April and May were done using the mechanical lift scale and the weight on 06/16/2022 was done using the wheelchair scale. She said she would have him re-weighed using the mechanical lift scale. She said Resident #15 was non-compliant with his diet and ate all meals with larger portions and snacks from the vending machine all day. She said she had not spoken to him regarding the edema in his arm and leg. She said the swelling was normal for him on his right side because he had a stroke on his right side that caused paralysis and affected blood flow which resulted in the swelling. She said the swelling was normal for him and there had not been a change that she knew of in his right arm and leg from baseline. She said Resident #15 was seen by PHYS K's nurse practitioner via tele-health. When asked if anyone had performed a physical exam on Resident #15 since 03/29/2022, she said no. In an interview on 06/21/2022 at 4:35 PM, the DON stated Resident #15 decided to switch to the medical director as his physician and the PHYS ASST would see him the next morning to assess and evaluate the weight gain. In a follow-up interview on 06/23/2022 at 2:16 PM, Resident #15 said the DON made him sign a document that he would not eat so much. He said he told them he had fluid on his body, and they told him that maybe if you did not eat so many snacks you wouldn't have so much fluid. He said he did not understand why they kept blaming snacks for his swelling when the PHYS ASST told him the swelling was due to fluid related to him either having congestive heart failure or decreased kidney function. He said he did not understand why they did not want to help him see a doctor when he first began complaining about the fluid when he was short of breath and told him he would have to call 911 himself. Review of Resident #15 Negotiated Risk Agreement signed 06/22/2022 at 3:20 PM by Resident #15 and the facility. The summary of Resident's Current Health and Potential Risk were 36 pound weight gain in one month, edema, hypertensive crisis, diabetic crisis, repeated stroke death. The resident's desire or preference was noted as to eat, drink and smoke cigarettes as he desires without diet restrictions - resident eats double portions, seconds, and take away trays from kitchen as well as outside foods and vending machine. The final agreement with Resident #15 was he agreed to to try eating only double portions but not seconds or take away trays. Agrees to try to smoke less. Agrees to try to stay away from junk foods. In an interview on 06/23/2022 at 2:03 PM, RNC A stated they had Resident #15 sign the NRA because he was not following his diet and subsequently gained 36 pounds. She said they asked him to limit his portions to stop the weight gain. When asked if the weight could be due to edema from complications of his health conditions, she responded the resident needed to control his portions to reduce his weight gain. When asked if his diagnosis of chronic kidney disease, and a possible decline in kidney function could have caused fluid retention and edema, she replied she was not aware of Resident #15 having chronic kidney disease as it was not on his diagnosis list in the EMR. When asked why it was not on his diagnosis list in the EMR when it was on his physician progress notes and history and physical, she did not know. In an interview on 06/23/2022 at 2:10 PM, the ADMIN stated she wanted the doctor to stop the larger portions for Resident #15 because he was eating too much and that caused the weight gain. She said he ate two snacks at activities and would have two ice creams at ice cream socials which likely caused the weight gain. When asked if she thought he was eating greater than 14,000 calories per day consistently to be able to gain that much weight so fast, she said she did not know and was not a doctor, nurse or dietitian. In an interview on 06/23/2022 at 1:36 PM, the RD stated she was notified of Resident #15's weight gain and planned to complete an assessment when she returned to the facility next week. She stated the ADON said he gained 40 pounds. She asked the ADON if Resident #15 had fluid on legs and arms and the ADON said he ate a lot at meals, ate snacks from the vending machine, and had food brought in from the outside that caused the weight gain. She said she saw Resident #15 was on a mild diuretic. She said had she known about the edema she would have recommended they re-weigh Resident #15 and assess for edema. She said the doctor would have been consulted for further orders regarding edema and the need for a stronger diuretic. She said she did not know why Resident #15 was not assessed for edema and his doctor notified of his weight gain and edema. She said it was not likely that Resident #15 gained 40 pounds in a month and all of it be related to excess calories causing increased fat stores. She said it was more likely he had fluid on and needed a diuretic. She stated she was not aware that Resident #15 had chronic kidney as it was not on his list of diagnoses and did not know why it was not on his diagnoses list. Review of Resident #15 Nursing Progress note dated 05/30/2022 at 11:55 PM written by LVN J revealed Resident #15 is alert and oriented. Skin is warm and dry to touch. At 2325, resident had complained of wheezing, SOB and chest pain rated 4/10., not radiating to the shoulders or other areas. Lung's sound cleared on both sides; no apparent wheezing noticed at this time. V/S Temp 98.2 Pulse 90, Resp 26, BP 169/96 LT arm lying, 02 sat between 88% to 96% on room air. Doctor on call informed to the situation, nurse practitioner ordered for duo nebulizer treatment (aerosol breathing treatment), chest x-ray, 02 therapy. Staff to call back if resident condition is not improving. Please see TAR/orders. Duo nebulizer and 02 therapy initiated. Resident denies chest pains before treatment initiated. Call light put within reach. Will continue to monitor. In an interview on 06/24/2022 at 3:14 PM, LVN J stated in late May she was called by Resident #15's responsible party and they reported Resident #15 was having respiratory problems. She said she assessed Resident #15 and found him to be breathing heavy and his oxygen levels were low. She said started oxygen on him and paged the on-call doctor. She said she received orders for Resident #14 for nebulizer treatments and with the oxygen and nebulizer treatment his symptoms improved. She said he required oxygen for several days all day and then only at night. She said she was not sure if any physician or anyone followed up on his symptoms or resolution of pneumonia. She said Resident #15 did report increased swelling or edema but was not sure if anyone was addressing it with his attending physician. She stated she was unaware of Resident #15 having a large weight gain from May to June. She said that would likely fit with his elevated blood pressures, respiratory issues and edema. Review of Resident #15 Imaging Report dated 05/31/2022 revealed Resident #15 had a chest x-ray (single frontal projection of the chest) related to chest pain. The impression was a slight right basilar infiltrate in the right lung. A note written by LVN D on 05/31/2022 on the x-ray report revealed verbal order from PHYS K start doxycycline 100 MG BID (twice per day) for seven days. Review of Resident #15 Nursing progress note dated 05/31/2022 at 5:32 AM written by LVN J revealed At 1150 V/S Temp 97.5, Pulse 90, Resp 22 02 95% N/C, BP 157/94 At 0108 [1:08 AM]V/S Temp 96.3, Pulse 85, 02 99% N/C At 0135 [1:35 AM]Pulse 87, 02 97% At 0210 [2:10 AM] V/S Temp 96.4, Pulse 84, Resp 22, 02 97% N/C At 0255 [2:55 AM] V/S Temp 96.3, Pulse 82, Resp 24, 02 99% N/C, At 0320 [3:20 AM] V/S Temp 96.2, Pulse 81, Resp 22, 02 96% N/C At 0455 [4:55 AM]V/S Temp 96.3, Pulse 78, 02 99% N/C At 0545 [5:45 AM] V/S Temp 97.5, Pulse 82, 02 97% N/C, BP 155/100. [family member] called this morning about the change in condition and the treatment initiated. Would like update from of us. Review of Resident #15 Respiratory Infection Nurses Note dated 06/01/2022 at 8:00 AM, written by LVN H revealed Resident #15 was being treated for pneumonia with Oxygen at 2 LPM (liters per minute), duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 170/83 taken 06/01/2022 at 7:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/01/2022 at 4:00 PM, written by LVN H revealed Resident #15 was being treated for pneumonia with Oxygen at 2 LPM (liters per minute), duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 170/83 taken 06/01/2022 at 7:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/02/2022 at 12:00 AM, written by LVN J revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 153/100 taken 06/02/2022 at 4:47 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/03/2022 at 12:00 AM, written by LVN H revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 155/80 taken 06/03/2022 at 2:32 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Resident #15 was noted to have an additional symptom of fatigue. Review of Resident #15 Respiratory Infection Nurses Note dated 06/03/2022 at 8:00 AM, written by LVN D revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 164/86 taken 06/03/2022 at 10:38 AM and to nasal congestion with fatigue. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/04/2022 at 7:00 PM, written by LVN D revealed Resident #15 was being treated for pneumonia with oxygen at 2 LPM (liters per minute), duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 166/82 taken 06/04/2022 at 10:28 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/04/2022 at 11:00 PM, written by LVN J revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 163/96 taken 06/05/2022 at 1:09 AM and had fatigue. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/05/2022 at 10:00 AM, written by LVN H revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 175/97 taken 06/05/2022 at 10:33 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/05/2022 at 5:00 PM, written by LVN Q revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 183/94 taken 06/05/2022 at 5:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/06/2022 at 1:00 AM, written LVN J revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 130/97 taken 06/05/2022 at 1:09 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. There were no follow-up notes completed or additional interventions provided to Resident #15 after 06/16/2022. In an interview on 06/21/2022 at 5:52 PM, PHYS K stated he was notified by the facility about the excessive weight gain from May to June 2022. He stated he was told by the facility that Resident #15 ate a lot and was likely to blame for the 41.9-pound weight gain. He stated he was told Resident #15 had increased swelling on his right arm and leg but attributed that to the stroke causing a change in blood flow. He stated he did not remember being contacted about intermittent high blood pressures but did not consider them a hypertensive emergency since they resolved when his BP medications were administered . He did not remember being contacted about increased edema overall. Without seeing Resident #15, he stated could not say whether Resident #15 needed an intervention for the edema, weight gain and elevated blood pressures. He could not say whether the shortness of breath and decreased O2 saturation levels Resident #15 experienced at the end of May were caused by congestive heart failure or a complication of Resident #15 having chronic kidney disease. He stated he had not physically examined Resident #15 since he was admitted to the facility. Review of Resident #15 Physician Progress note dated 06/21/2022 revealed the MED DIR wrote a progress note after Resident #15 caught him in the hallway. The note referred to labs drawn 10 days prior to the date of the note. There wereno labs drawn in the previous 10 days for Resident #15. It noted Resident #15 to have edema on his right arm and right leg likely due to lack of movement as Resident #15 was partially paralyzed due to a stroke two years prior. This is a stable, chronic issue. Resident #15's high blood pressure was noted as stable, continue present prescriptions and monitor. In an interview on 06/23/2022 at 3:10 PM, RNC B was asked to provide a copy of the labs MED DIR referred to in his note on 06/21/2022. RNC B stated those labs did not exist as Resident #15 had not had labs since 03/25/2022. He said he did not know what MED DIR was referring to in his note. When asked why MED DIR wrote the progress note and did not address the 36 pound weight gain, he did not know. In an interview on 06/23/2022 at 3:21 PM, MED DIR stated he saw Resident #15 briefly on 06/21/2022 because Resident #15 had a question regarding the swelling in his right arm and leg. He said the swelling was likely due to Resident #15 not being able to move his right arm and leg because of a stroke that caused partial paralysis. When asked if the swelling in Resident #15's arm and leg accounted for a 36 pound weight gain in one month, he responded that is the same resident that has the swollen arm and leg? I thought they were two different residents. He said the 36 pound weight was fluid retention related to an underlying health condition either decreased kidney function or congestive heart failure. He said Resident #15 needed to be seen by a cardiologist to rule out congestive heart failure. He said 10 pounds of the weight gain may be due to excessive calories, but not 36 pounds. He said the respiratory distress Resident #15 experienced at the end of May was possibly related diastolic heart failure and Resident #15 should have been evaluated by a physician. He stated an echocardiogram was needed to look at Resident #15's heart. He stated he and his physician assistant would be following Resident #15 moving forward and refer him to a cardiologist. In an interview on 06/24/2022 at 4:00 PM, the DON stated Resident #15 was not seen by a physician due to PHYS K wanting to continue to follow Resident #15. She stated staff contacted PHYS K multiple times regarding Resident #15's elevated blood pressures and received no response. When asked why they did not follow their facility policy regarding a lack of response from an attending physician, she said she they did when Resident #15 experienced respiratory distress at the end of May. She said they should have had the MED DIR or PHYS ASST follow-up with Resident #15 after the respiratory issues and the discovery of the large weight gain. She said they did not have anyone follow-up with Resident #15 after the discovery of the large weight gain because she and the ADON felt the weight gain was from excess calories because Resident #15 eats a lot of food. She said she was not aware that when Resident #15 first complained of respiratory distress in May that he was told he would have to call 911 himself. She said a physician should have examined and assessed Resident #15 sooner. When asked why the facility had Resident #15 sign the negotiated risk agreement within an hour of the IJ being called, she said yeah she could see now that the timing could have been better and could be seen as punitive towards Resident #15. When asked why they did not have him sign it when they saw him eating all the snacks, she said she did not realize until the weight gain and the complications that they were a problem. When asked why another non-compliant resident with CHF who was sent out to the hospital for high fluid gains was not asked to sign an NRA, she said she did not know, and they should probably have her sign an NRA as well. She said she knew the facility had the extra-large cuffs in the past and was not sure when or how they went missing. She said they had one in the crash cart and should have used it until the new cuff was bought to take Resident #15's blood pressure. She stated she did not know why Resident #15 did not have upper parameters for his blood pressure except it was chaotic when they evacuated the sister facility that was damaged by a tornado and some areas were dropped. She said they have since added parameters and PRN medications for high blood pressures for Resident #15. She said the nurses should have been documenting for blood pressures > 160/110 an intervention or a re-check. She said they likely re-took the blood pressure with a manual cuff and it wasn't as high, or they administered his morning medications and re-checked his blood pressure, and it was normal. She said they should have been documenting any out of parameter blood pressure and noted the intervention. In an interview on 06/24/2022 at 4:15 PM, the ADMIN stated she was not a nurse and did not know much about Resident #15's disease process, edema and weight gains. She said they attributed to high meal and snack intake. She said they signed the NRA with him so he would know his daily choices have an effect on his health. She said she was not aware of him experiencing swelling and fluid gains. She said she was not aware of his CKD diagnosis and was not sure how that affected his weight gain. She said she did not think the NRA was punitive, it was done to educate the resident. She said they had not previously had him sign it because RNC A recommended after the IJ was called. She said a physician should have seen Resident #15 following the respiratory issues and excessive weight gain. She said they did not follow their facility policy to have the medical director see the resident if they did not receive a response from an attending physician. In an observation and interview on 06/22/2022 at 10:19 AM, the PHYS ASST completed a physical exam and assessment of Resident #15. Resident #15 stated to the PHYS ASST he had not seen a PHYS K since admitted to the facility. The PHYS ASST said she saw the swelling in Resident #15's right arm and right leg. Resident #15 stated he felt like he had swelling in his abdomen. He reported the shortness of breath in late May of 2022 to the PHYS ASST and she stated she ordered the chest x-ray which showed pneumonia. She stated she was not told Resident #15 was also complaining of having fluid on and swelling. Resident #15 reported to the PHYS ASST he needed oxygen at night and in the past at his previous facility he did not need oxygen routinely. He said he has not been able to wear a shoe on his right foot because of the swelling in at least 2 months. He stated he had a family history of having fluid on their heart and lungs. The PHYS ASST asked Resident #15 was on fluid pills in the past, and he said yes at his previous facility but not since being admitted here. He said he was told his kidneys were not working all the way, but they were just going to watch it. She said she would have lab work done to check his kidneys and start him on a fluid pill. Resident #15 did not know why they stopped the fluid pills. The PHYS ASST stat[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medical care of each resident was supervised by a physician for one (Resident #15) of five residents reviewed for supervision of medical care by a physician. The facility did not ensure Resident #15's physician examined and assessed Resident #15 upon a significant change in condition following Resident #15 having intermittent high blood pressures, shortness of breath, chest pain, and a 41.9-pound weight gain in 36 days. These failures resulted in an Immediate Jeopardy (IJ) situation on 06/22/2022. While the IJ was removed on 06/24/2022, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could affect residents who had a change in condition by not ensuring that residents' care was provided by a physician who was knowledgeable of their current health status changes. Findings included: Review of Resident #15 face sheet revealed Resident #15 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of history of a stroke, Type 2 Diabetes Mellitus, high cholesterol and high blood pressure. Review of Resident #15 quarterly MDS dated [DATE] revealed Resident #15 had a BIMS score of 14 to indicate he had intact cognition. Resident #15 required extensive assistance by two or more staff members for bed mobility, transfers and toilet use. Review of Resident #15 Care plan dated 03/24/2022 revealed Resident #15 was on diuretic therapy (Hydrochlorothiazide) with interventions including administer medication as ordered, monitor vital signs as ordered and report to physician if abnormal for this resident, report any increased swelling of legs, arms or face to the charge nurse, report ordered labs to the physician, and resident could experience dizziness, postural hypertension, fatigue and increased risk for falls. Observed for possible side effects. Review of Resident #15 Physician or Non-Physician Provider (Nurse Practitioner or Physician Assistant) Visits dated from 03/22/2022 through 06/20/2022 revealed Resident #15 was seen these following dates: -03/29/2022 by PHYS ASST upon admission -05/05/2022 by nurse practitioner via tele-health Review of Physician Progress note dated 03/29/2022 written by PHYS ASST revealed Resident #15 was admitted to the facility after a tornado damaged his previous facility. Resident #15 noted to have prior diagnoses of stroke with right sided hemiplegia (partial paralysis), Type 2 Diabetes Mellitus, high blood pressure and chronic kidney disease. His weight was noted at 310.6 pounds and he was noted to have mild peripheral edema and right lower extremity edema. There was no note that the right upper extremity had edema. Review of Resident #15 Blood Pressures from 05/25/2022-06/22/2022, that were out of range in the EMR or greater than 145/90 were as follows : -05/25/2022 - 9:26 AM - 176/84 mmHg -05/25/2022 - 8:38 PM - 157/99 mmHg -05/26/2022 - 9:53 AM - 158/72 mmHG **no other BP readings document for this day.** -05/28/2022 - 10:04 AM - 164/79 mmHG -05/28/2022 - 7:50 PM - 157/70 mmHG -05/29/2022 - 6:28 PM - 167/94 mmHG -05/30/2022 - 10:12 AM - 178/90 mmHG -05/30/2022 - 8:41 PM - 155/80 mmHG -05/31/2022 - 10:29 AM - 165/100 mmHG -05/31/2022 - 7:57 PM - 151/99 mmHG -06/01/2022 - 10:05 AM - 166/99 mmHG -06/01/2022 - 7:43 PM - 170/83 mmHG -06/02/2022 - 4:47 AM - 153/100 mmHG -06/02/2022 - 9:51 AM - 159/95 mmHG -06/02/2022 - 7:02 PM - 150/98 mmHG -06/03/2022 - 2:32 AM - 155/80 mmHG -06/03/2022 - 10:38 AM - 164/86 mmHG -06/04/2022 - 10:28 AM - 166/82 mmHG -06/04/2022 - 8:44 PM - 176/84 mmHG -06/05/2022 - 1:09 AM - 163/96 mmHG -06/05/2022 - 10:33 AM - 175/97 mmHG -06/05/2022 - 5:43 PM - 186/94 mmHG -06/05/2022 - 6:02 PM - 190/100 mmHG -06/06/2022 - 9:45 AM - 158/78 mmHG -06/06/2022 - 7:44 PM - 176/73 mmHG -06/07/2022 - 2:09 AM - 174/80 mmHG -06/08/2022 - 1:25 AM - 174/88 mmHG -06/08/2022 - 11:28 AM - 179/91 mmHG -06/08/2022 - 8:22 PM - 183/84 mmHG -06/09/2022 - 2:02 AM - 149/80 mmHG -06/09/2022 - 1:38 PM - 189/100 mmHG -06/09/2022 - 6:50 PM - 167/87 mmHG -06/10/2022 - 9:45 AM - 169/84 mmHG -06/10/2022 - 7:11 PM - 186/53 mmHG -06/11/2022 - 6:29 AM - 156/76 mmHG -06/11/2022 - 10:23 AM - 193/91 mmHG -06/11/2022 - 7:45 PM - 145/76 mmHG -06/12/2022 - 8:57 AM - 160/100 mmHG -06/13/2022 - 7:38 PM - 153/96 mmHG -06/14/2022 - 10:30 AM - 154/68 mmHG -06/14/2022 - 6:50 PM - 150/74 mmHG -06/15/2022 - 9:44 AM - 181/89 mmHG -06/15/2022 - 6:49 PM - 190/94 mmHG -06/16/2022 - 9:49 AM - 163/71 mmHG -06/16/2022 - 6:51 PM - 189/85 mmHG -06/17/2022 - 10:21 AM - 160/81 mmHG -06/18/2022 - 10:08 AM - 175/91 mmHG -06/18/2022 - 6:20 PM - 165/86 mmHG -06/19/2022 - 10:09 AM - 155/86 mmHG -06/19/2022 - 7:36 PM - 152/88 mmHG -06/22/2022 - 10:21 AM - 160/101 mmHG Review of Resident #15 Nursing Progress Notes dated 05/25/2022 to 06/20/2022 revealed no progress notes regarding Resident #15's elevated blood pressures or any interventions regarding resolution of the elevated blood pressures. Review of Resident #15 Imaging Report dated 05/31/2022 revealed Resident #15 had a chest x-ray (single frontal projection of the chest) related to chest pain. The impression was a slight right basilar infiltrate in the right lung. A note written by LVN D on 05/31/2022 on the x-ray report revealed verbal order from PHYS K start doxycycline 100 MG BID (twice per day) for seven days. Review of Resident #15 Nursing Progress note dated 05/30/2022 at 11:55 PM written by LVN J revealed Resident #15 is alert and oriented. Skin is warm and dry to touch. At 2325[11:35pm] , resident had complained of wheezing, SOB and chest pain rated 4/10., not radiating to the shoulders or other areas. Lung's sound cleared on both sides; no apparent wheezing noticed at this time. V/S Temp 98.2 Pulse 90, Resp 26, BP 169/96 LT arm lying, 02 sat between 88% to 96% on room air. Doctor on call informed to the situation, nurse practitioner ordered for duo nebulizer treatment (aerosol breathing treatment), chest x-ray, 02 therapy. Staff to call back if resident condition is not improving. Please see TAR/orders. Duo nebulizer and 02 therapy initiated. Resident denies chest pains before treatment initiated. Call light put within reach. Will continue to monitor. Review of Resident #15 Nursing progress note dated 05/31/2022 at 5:32 AM written by LVN J revealed At 1150 V/S Temp 97.5, Pulse 90, Resp 22 02 95% N/C, BP 157/94 At 0108 [1:08 AM]V/S Temp 96.3, Pulse 85, 02 99% N/C At 0135 [1:35 AM]Pulse 87, 02 97% At 0210 [2:10 AM] V/S Temp 96.4, Pulse 84, Resp 22, 02 97% N/C At 0255 [2:55 AM] V/S Temp 96.3, Pulse 82, Resp 24, 02 99% N/C, At 0320 [3:20 AM] V/S Temp 96.2, Pulse 81, Resp 22, 02 96% N/C At 0455 [4:55 AM]V/S Temp 96.3, Pulse 78, 02 99% N/C At 0545 [5:45 AM] V/S Temp 97.5, Pulse 82, 02 97% N/C, BP 155/100. [family member] called this morning about the change in condition and the treatment initiated. Would like update from of us. Review of Resident #15 Respiratory Infection Nurses Note dated 06/01/2022 at 8:00 AM, written by LVN H revealed Resident #15 was being treated for pneumonia with Oxygen at 2 LPM (liters per minute), duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 170/83 taken 06/01/2022 at 7:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/01/2022 at 4:00 PM, written by LVN H revealed Resident #15 was being treated for pneumonia with Oxygen at 2 LPM (liters per minute), duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 170/83 taken 06/01/2022 at 7:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/02/2022 at 12:00 AM, written by LVN J revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 153/100 taken 06/02/2022 at 4:47 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/03/2022 at 12:00 AM, written by LVN H revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 155/80 taken 06/03/2022 at 2:32 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Resident #15 was noted to have an additional symptom of fatigue. Review of Resident #15 Respiratory Infection Nurses Note dated 06/03/2022 at 8:00 AM, written by LVN Drevealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 164/86 taken 06/03/2022 at 10:38 AM and to nasal congestion with fatigue. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/04/2022 at 7:00 PM, written by LVN D revealed Resident #15 was being treated for pneumonia with oxygen at 2 LPM (liters per minute), duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 166/82 taken 06/04/2022 at 10:28 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/04/2022 at 11:00 PM, written by LVN J revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 163/96 taken 06/05/2022 at 1:09 AM and had fatigue. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/05/2022 at 10:00 AM, written by LVN H revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 175/97 taken 06/05/2022 at 10:33 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/05/2022 at 5:00 PM, written by LVN Q revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 183/94 taken 06/05/2022 at 5:43 PM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Resident #15 Respiratory Infection Nurses Note dated 06/06/2022 at 1:00 AM, written LVN J revealed Resident #15 was being treated for pneumonia with duo nebulizer treatments and antibiotics. Resident #15 blood pressure noted at 130/97 taken 06/05/2022 at 1:09 AM. Under question #16 Notification were there any negative changes that required physician notification the answer was no. Review of Nursing Progress Note dated 06/16/2022 at 10:27 AM written by ADON revealed Significant weight gain noted. Resident receives large portions at mealtimes and request a to go plate as well of lunch and dinner meals. Resident is non-compliant with diet orders and frequents the vending machine often and eats outside food that friends bring into him. 2+ edema noted to right lower leg. Provider and dietitian notified. Review of Nursing Progress Note dated 06/16/2022 at 10:27 AM written by ADON revealed Significant weight gain noted. Resident receives large portions at mealtimes and request a to go plate as well of lunch and dinner meals. Resident is non-compliant with diet orders and frequents the vending machine often and eats outside food that friends bring into him. 2+ edema noted to right lower leg. Provider and dietitian notified. There were no follow-up notes completed or additional interventions provided to Resident #15 after 06/16/2022. In an observation on 06/21/2022 at 9:28 AM, Resident #15 was observed to have swelling in his right arm, right lower leg, in his neck and back of head. In an interview on 06/21/2022 at 9:30 AM, Resident #15 stated he felt like he had a lot of fluid on him, and his right arm and leg were swollen. He stated he had pneumonia recently and was not seen by a doctor and he wanted to see a doctor. He said the lady down the hall had pneumonia too and was seen by a doctor. He said the facility told him the swelling was normal for him and not to worry about it. He said his family member had recently been hospitalized for fluid in her lungs and he was worried he had the same problem. He said at the end of May (2022) he felt like he could not breathe, and his chest was hurting and when he reported it to the first nurse , she told him he was fine and did nothing. He said he was on the phone with his family members, who told him to go to the hospital. He said the nurse told him if he wanted to go to the hospital, he would have to call 911 himself. He said his family member called up to the facility and the nurse coming on shift assessed him and started him on oxygen and breathing treatments which made him feel better. He said he had a chest x-ray the next day and was started on antibiotics for pneumonia. He did not see a doctor since that happened and requested to the nurses multiple times to see a doctor. He said the facility told him last week he gained a lot of weight and needed to stop eating so many snacks from the vending machine. In an interview on 06/21/2022 at 3:25 PM, the ADMIN stated the medical director, or his physician assistant saw all their residents weekly. She stated Resident #15 was followed by an attending physician from Resident #15's previous facility that was evacuated in March 2022 due to tornado damage. She stated PHYS K was Resident #15 attending physician and he rounded on his own patients. She was not sure of when the doctor rounded on Resident #15 since Resident #15 was admitted to the facility. When asked for physician progress notes for Resident #15, she stated she would check with their medical records assistant for additional physician progress notes. She stated Resident #15 was seen by the physician assistant when he was first admitted . In an interview on 06/21/2022 at 3:31 PM, the medical records assistant stated she uploaded all physician progress notes into the EMR for all residents. She stated Resident #15's EMR should be current with no missing physician progress notes. She stated she would double check that there were no pending notes that needed to be uploaded. She said she typically received the notes within two days of the doctor or physician assistant rounding and uploaded them to the EMR within a day. In an interview on 06/21/2022 at 4:00 PM, the DON said Resident #15 was seen by PHYS K's nurse practitioner via tele-health on 05/05/2022. When asked if anyone had performed a physical exam on Resident #15 since 03/29/2022, she said no. In an interview on 06/21/2022 at 5:29 PM, LVN D said Resident #15 had been having issues with intermittent high blood pressures and edema. She tried to contact Resident #15's attending physician, PHYS K, about two weeks ago regarding the issues but had not received a response. She stated the CMAs would notify the nurse of high blood pressure if it was over 145/90. She stated she will notify a resident's doctor depending on the parameters set by the doctor. She stated she did not know the parameters for Resident #15 but did call and leave a message for PHYS K when Resident #15's blood pressure was 190/94 and received no response. She stated Resident #15 had a chest x-ray at the end of May (2022) and was diagnosed with pneumonia. She stated she notified PHYS K at that time and received a verbal order for antibiotics for the pneumonia. She stated she was not aware of a physician examining Resident #15 following the pneumonia diagnosis. She stated she was not aware of Resident #15's increase weight from May to June 2022 . When asked where the documentation of the notification of the high blood pressures and edema to PHYS K was, she said she was not sure she documented it and then stated it was not in the EMR. In an interview on 06/21/2022 at 5:52 PM, PHYS K stated he was notified by the facility about the excessive weight gain from May to June 2022. He stated he was told by the facility that Resident #15 ate a lot and was likely to blame for the 41.9-pound weight gain. He stated he was told Resident #15 had increased swelling on his right arm and leg but attributed that to the stroke causing a change in blood flow. He stated he did not remember being contacted about intermittent high blood pressures but did not consider them a hypertensive emergency since they resolved when his BP medications were administered. He did not remember being contacted about increased edema overall. Without seeing Resident #15, he stated could not say whether Resident #15 needed an intervention for the edema, weight gain, and elevated blood pressures. He could not say whether the shortness of breath and decreased O2 saturation levels Resident #15 experienced at the end of May were caused by congestive heart failure or a complication of Resident #15 having chronic kidney disease. He stated he had not physically examined Resident #15 since he was admitted to the facility. In a follow-up interview on 06/24/2022 at 4:00 PM, the DON stated Resident #15 was not seen by a physician due to PHYS K wanting to continue to follow Resident #15. She stated staff contacted PHYS K multiple times regarding Resident #15's elevated blood pressures and received no response. When asked why they did not follow their facility policy regarding a lack of response from an attending physician, she said she they did when Resident #15 experienced respiratory distress at the end of May. She said they should have had the MED DIR or the PHYS ASST follow-up with Resident #15 after the respiratory issues and the discovery of the large weight gain. She said they did not have anyone follow-up with Resident #15 after the discovery of the large weight gain because she and the ADON felt the weight gain was from excess calories because Resident #15 eats a lot of food . She said a physician should have examined and assessed Resident #15 sooner. In an interview on 06/24/2022 at 4:15 PM, the ADMIN said they did not follow their facility policy to have the medical director see the resident if they did not receive a response from an attending physician. The ADMIN could not say why Resident #15 was not seen sooner by a doctor. In an interview on 06/25/2022 at 11:30 AM, RNC B stated, it would have been ideal to have Resident #15 seen by a physician following his respiratory distress, elevated blood pressures and excessive weight gain. He said he was not sure why the facility did not follow the policy to have the medical director see Resident #15 when they facility was not receiving a response from the attending physician. Facility did not have a policy for physician services or supervision of a resident by a physician. Review of the facility's policy, Notifying the Physician of Change in Status dated 03/11/2013 revealed the nurse should notify the physician immediately with significant change in status. If the physician does not return the call and if the nurse does not receive a response after trying twice, the nurse will contact the medical director for assistance. The nurse will document all attempts to contact the physician in the resident's clinical record. The Administrator, DON and the Regional Compliance Nurse were notified of on 06/22/2022 at 2:35 PM an IJ situation was identified due to the above failures and the IJ template was provided. The Plan of Removal was accepted on 06/24/2022 at 3:38 PM and included the following: Problem: Physician Visits All residents have the potential to be affected by this deficient practice. Interventions: o Physician was notified by the Compliance Nurse and DON of identified resident's weight gain, increased edema, elevated B/P and blood sugar readings on 6/22/2022 and completed an evaluation of identified resident on 6/22/2022. o The DON, ADON and/or compliance nurse obtained blood pressure notification parameters from the Physician / NP which have been entered as an order in PCC. As ordered by the Physician, treatment for intermittent elevated blood pressure was entered into PCC. This was completed in PCC on 6/22/22. o The DON/ADON will ensure all new admissions are followed by a Physician. This was completed on 6/22/22 and will be ongoing. o All charge nurses were in-serviced beginning 6/22/2022 by the Compliance Nurse / DON and/or ADON regarding the following and all nurses not in-serviced by 6/22/2022 will not be allowed to work their assigned position until completion of these in-services: This will be ongoing. DON and ADON were in-serviced by Compliance Nurse. o Immediate reporting changes of condition to the physician including Elevated B/P, Blood sugar (according to parameters as determined by the Physician), increased edema and significant weight gain. o Ensuring appropriate size blood pressure cuffs are utilized to ensure accurate readings. o Assessing for increased edema and/or swelling. o Signs and symptoms of hyperglycemia and notification of Physician. o The DON, ADON, and or compliance nurse reviewed last weeks documented blood pressures to ensure physician/NP were notified for blood pressures out of parameters. This was completed on 6/22/22 for all residents. DON/ADON/Compliance Nurse will review EMR clinical alert reports/Real Time Clinical software at least 5 times per week indefinitely. o The DON, ADON, and or compliance nurse reviewed the last weeks documented blood sugars for applicable residents to ensure physician/NP were notified for blood sugars out of parameters. This was completed on 6/22/22. There were no additional finding that required physician notification. DON/ADON/Compliance Nurse will review EMR clinical alert reports/Real Time Clinical software at least 5 times per week indefinitely for any abnormal blood sugars. o The DON, ADON, compliance nurse, and/or designated licensed nurses assessed all residents to determine if the resident has new or increased edema, and there were no additional findings requiring physician notification. This was completed on 6/22/22. Weekly skin assessments on all residents will be performed ongoing by the Treatment Nurse/designee for any skin changes including edema. This will be monitored by DON/ADON weekly, ongoing. o The medical director was notified by the administrator of this plan on 6/22/2022. An Ad Hoc QAPI meeting was held 6/23/2022. Monitoring: o Monitoring of this plan began on 6/22/2022 and will continue weekly x 4. o The DON and/or designee will monitor the vitals summary report from EMR at least 5 times per week to determine if blood pressures or blood sugars were out of parameters and/or significant weight gains and if so, the physician/NP will be notified. Monitoring began 6/22/2022 and will continue x 4 weeks. o The DON and/or designee will monitor Real Time clinical software and the PCC dashboard at least 5 times per week, indefinitely to ensure any new or worsened edema is communicated to the physician/NP and follow up as needed. o The DON and/or designee will ensure that the proper blood pressure cuffs are available for use at least 5 times per week x 4 weeks. DON/ADON provided in-servicing on the use of manual blood pressure cuffs on 6/22/22. Training is ongoing. Staff will not report to their assigned shifts prior to in-servicing. New hires will be trained during orientation. The Survey team monitored the plan of removal as follows: Monitoring done from 06/23/2022 - 06/25/2022. Observation on 06/25/2022 at 11:40 AM Resident #15 was weighed using the mechanical lift and his weight was 346.6 which was a 6.5 pound decreased since Resident #15 received three doses of Lasix on 06/23/2022, 06/24/2022 and 06/25/2022. Resident #15 was noted to have decreased swelling in his leg, arm and area behind his head and neck. In an interview on 06/25/2022 at 11:35 AM, Resident #15 stated he had been using the bathroom a lot and could tell his arm and leg was less swollen. He stated he felt better now that someone was monitoring his swelling and having fluid on. Review of Resident #15 Physician Orders dated 06/22/2022 revealed Resident #15's blood pressure medications were changed and will be monitored by PHYS ASST weekly for effectiveness. In an interview on 06/24/2022 at 3:07 PM CMA R stated she was educated regarding the use of the appropriate blood pressure cuff and that Resident #15's blood pressure should be taken using the arm cuff and not the wrist cuff. She was educated regarding the parameters of what to report to a nurse for follow-up when Resident #15's blood pressure was high. She said they were also in serviced regarding high blood sugars for Resident #15. In an interview on 06/24/2022 at 3:15 PM, LVN P stated she was educated regarding blood pressure parameters, notifying a doctor regarding a change in condition and using the right sized blood pressure cuff. Review of facility Inservice education completed as part of Plan of Removal: 06/22/2022 Reporting Change in Condition to include high BP, increased edema and significant weight gain. All nurses completed the education. 06/22/2022 Notifying Charge Nurse of Abnormal Vital Signs. Medication Aides and nurses were educated. 06/22/2022 Bariatric BP cuff can be found on the crash cart as well as in the med room. These are to be cleaned and returned after each use. The appropriate sized cuff has to be used for accurate readings. All nurses and medication aides were educated. 06/22/2022 Signs and Symptoms of Hyperglycemia and physician notification. All nurses completed the education. 06/22/2022 Edema Causes and signs. All nurses completed the education. While the IJ was removed on 06/24/2022, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.