**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure the resident's environment remained as free of accident hazards as is possible and received adequate supervision and assistance for one (Resident #1) of five residents reviewed for Incident and accidents. 1.The facility failed to provide adequate supervision for Resident #1 to prevent her from having injuries and falls from 02/02/25 to 02/08/25; subsequently Resident #1 sustained a left wrist fracture of unknown origin on 02/02/25, fell on [DATE] sustained a lip bleed, found on the floor next to her bed on 02/07/25 and on 02/08/25 she had left sided facial bruising, a swollen chin, and dark reddish gums. She was later diagnosed at the hospital on [DATE] with a hematoma of her jaw and previously diagnosed left wrist fracture. 2. The facility failed to provide supervision in the B Hall Memory Care unit when 2 CNA's were discovered asleep in the unit at the nurses station with the light off on 03/05/25. 3. The facility failed to ensure the staff worked their complete 8-hour shifts (not including 30-minute lunch breaks), did not clocked in to work late or clocked out early and there was no evidence to show who worked in their places if staff called out, which resulted in a lack of supervision of the residents as evidenced by: a. Employees either clocked in late or clocked out early during their shifts for halls A and halls B (Memory Care Unit) on 01/31/25, 02/01/25, 02/02/25, 02/03/25, 02/04/25, 02/05/25, 02/06/25, 02/07/25 and 02/08/25. b. There was no second staff scheduled to work Sunday 02/02/25 from 6:00 am to 2:00 pm that cared for the Memory Care residents where Resident #1 resided. And after the DON reviewed it she said MA P worked from 9:33 am to 2:00 pm, but MA P said she only cleaned the resident's rooms in the Memory Care unit. c. The facility failed to ensure the nursing department employees worked their 8 hours shift (minus 30 minutes for lunch) for dates: 03/02/25, 03/03/25, 03/04/25, 03/05/25, 03/06/25. An IJ (Immediate Jeopardy) was identified on 03/05/25. The IJ template was provided to the facility on [DATE] at 2:34 pm. While the IJ was removed on 03/07/25 at 5:43 pm, the facility remained out of compliance at a scope of no actual harm and a severity level of pattern because all staff had not been trained on their plan to prevent re-occurrences and due to the facility's continued monitoring the implementation and effectiveness of their plan of removal. These failures could place fall risk residents in the memory care unit, at risk of continued falls or possible abuse, which could result in more injuries and pain and cause the residents to experience a health decline and decreased psycho-social well-being. The findings included: A) Record review or Resident #1's admission MDS Assessment completed by MDS Coordinator R on 02/06/25 revealed, a [AGE] year-old female who admitted on [DATE] with a BIMS score of 02 (Severe cognitive impairment). She was admitted to the 100 hall (memory care unit). She had disorganized thinking and inattention that fluctuated and no assistance for mobility needed and did not have any mood or behaviors. She needed partial to moderate assistance with toileting, bathing, upper and lower body dressing, personal hygiene and partial to moderate assistance with transfers. She was always continent with urine and bowel and she had other neurological conditions. She had diagnoses of hypertension (high blood pressure), viral hepatitis (liver infection and damage), hyperlipidemia (high level of fat particles), thyroid disorder (gland dysfunction), non -Alzheimer's - Dementia (cognitive loss), malnutrition (nutritional deficit), encephalopathy (brain disease) , insomnia (poor sleep habit), muscle weakness (weak muscles), difficulty walking, other lack of coordination, cognitive communication deficit. She had a history of falling with no injury and for the past seven days took antipsychotic and antidepressant medications. (The MDS did not address her combative behaviors) Record review of Resident #1's Care Plan dated 01/30/25 revealed, the resident had impaired cognitive function/dementia or impaired thought processes related to dementia. On 01/23/25 she was at risk for elopement related to elopement evaluation risk score and required a secured unit environment for safety and at risk for falls related to decreased safety awareness, impaired cognition, wandering and will often lay on the floor. With interventions: Anticipate and meet the resident's needs and to be sure the resident's call light was within reach and encouraged the resident to use it for assistance as needed. Educated the resident/family/caregivers about safety reminders and what to do if a fall occurred. Encouraged the resident to participate in activities that promoted exercise, physical activity for strengthening and improved mobility. Ensured that the resident was wearing appropriate footwear examples included nonskid socks, closed footed shoes and other safe footed coverings when ambulating or mobilizing in w/c. On 01/25/25 she was dependent on staff for activities, cognitive stimulation, social interaction related to cognitive deficits. Interventions: Introduced the resident to residents with similar background, interests, and encourage/facilitate interaction. Invited the resident to scheduled activities and provided the resident with materials for individual activities as desired the resident liked the following independent activities and to Provide with activities calendar. Notify resident of any changes to the calendar of activities. The resident needed 1 to 1 bedside/in-room visits and activities if unable to attend out of room events On 02/04/25 had an actual fall with major injury (wrist fracture) with Interventions: For no apparent acute injury, determine and address causative factors of the fall. And to monitor/document /report PRN x 72 hours to Medical Doctor for signs/symptoms: Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. Provided activities that promoted exercise and strength building where possible. And to Provide 1:1 activities if bedbound On 02/05/25 alteration in musculoskeletal status related to fracture of the left wrist. (The Care plans did not address her combative behaviors). Record review of all of Resident #1's Incidents by incident type printed 02/14/24 revealed: Falls with no injury incidents: 02/02/25 at 8:23 pm, 02/06/25 at 10:22 pm, 02/07/25 at 11:30 pm. Skin tear incidents: 02/02/25 at 8:23 pm and 8:36 pm. Other incidents (observed swelling to left wrist): 02/02/25 at 8:58 pm. Record review of Resident #1's Fall Assessments since she admitted revealed: 01/23/25 score was 2 Low risk 02/03/25 score was 7 Moderate risk 02/06/25 score was 13 High risk 02/08/25 score was 26 High risk Record review of Resident #1's Progress Note dated 01/26/2025 at 4:57 pm Type: Skilled Evaluation by RN Q revealed, .Teaching and Training;, assessed behavior, assess for pain, assess for anxiety , provided redirection, Neurological: Resident is Alert: Oriented to Person; Oriented to Place; Resident has Impaired decision making ability; Resident is Confused; Resident has Delusions: Difficulty understanding others, Skin/Skin Conditions: No changes in skin integrity, Cardiovascular .Muscular: Resident has an unsteady gait requiring supervision; Resident has had a change in ADL functional ability, Resident is Ambulatory, Walks Independently, Mood/Behavior: Changes noted in behavior, Resident intentionally lay herself to the floor; uncooperative to be provided assistance to her safety, or to be redirected, and combative to the staff. Record review of Resident #1's Progress Note dated 01/27/2025 at 11:33 a.m., by ADON F revealed, Type: Skilled Evaluation LATE ENTRY Teaching and Training; assessed behavior, assess for pain, assess for anxiety , provided redirection, Neurological: Resident is Alert; Oriented to Person; Oriented to Place; Resident has Impaired decision-making ability; Resident is Confused; Resident has Delusions. Difficulty understanding others; Skin/Skin Conditions: No changes in skin integrity, Gastrointestinal: ,Continent of Bowel, Bowel Sounds: Present; Gastro-urinary: Continent of Bladder, Urine Color: Amber, Urine Clarity Clear, No foul odor noted . Muscular: Resident has an unsteady gait requiring supervision; Resident has had a change in ADL functional ability, Resident is Ambulatory, Walks Independently; Mood/Behavior: Changes noted in behavior, Resident intentionally lay herself to the floor; uncooperative to be provided assistance to her safety, or to be redirected, and combative to the staff. Record review of Resident #1's Progress note: Skilled Nursing documentation dated 01/31/25 at 11:35 am by ADON F revealed, Receiving both Skilled Nursing and Skilled Therapy Services with skilled diagnosis: ENCEPHALOPATHY (brain disease), Mood/Behavior: Changes noted in behavior, Res continues to refuse medications, this nurse explained to Res that it is important to adhere to medication regimen as prescribed by her MD, nurse attempted reproach, Res refused. Res has no s/s of distress. Record review of Resident #1's Progress note: Alert note dated 02/01/25 at 5:30 pm, Resident c/o hip pain while the FM was present. requests the nurse to ask NP G to increase the Tylenol 500 to the Tylenol Arthritis 650mg. NP G approve the request. Record review of Resident #1's Progress note: Change of condition dated 02/02/25 at 7:57 pm by LVN A revealed, Observed resident L wrist/hand swollen. Resident stated it hurts during assessment. Ice pack applied. The FM was present during the assessment. NP G notified. STAT X-ray ordered for the L wrist/hand. Record review of Resident #1's Incident Report by LVN A dated 02/02/25 at 4:41 pm revealed, Incident Description Nursing Description: observed swelling to left wrist. Incident was unwitnessed. Resident Description: Resident was unable to specify. Was this incident witnessed: No. Immediate Action Taken: Description: Attempted to do ROM exercises. Resident stated it is too painful. Picture taken and sent to NP G. STAT X-RAY was ordered. Ice applied to the Left wrist/hand. PRN Tylenol given for the pain. Resident Taken to Hospital? No. Mental status: oriented to person, lack of safety awareness, forgetful, Predisposing physiological factors: confused, gait imbalanced, Administrator, [Weekend Supervisor E] and the [FM] notified. Record review of Resident #1's left wrist and hand 2 D (dimensional) X-ray results, dated 02/03/25, revealed, Final Reason for Study: R22.32 LOCALIZED SWELLING, MASS, AND LUMP, LEFT UPPER LIMB - WRIST 2V (view), LEFT See Note FINDINGS: There is a dorsal impaction fracture (wrist bone break)involving the distal radius (broken wrist) with modest callus (bone cartilage) and mild displacement. There is associated soft tissue swelling. Diffuse osseous demineralization (decreased bone density) is noted. Moderate degenerative changes are seen. See Note CONCLUSION: Impacted wrist fracture (wrist bone driven into another bone, compression damage) as described. Correlation is needed with history, symptomatology, and physical exam to determine precise acuity. CT or MRI examination follow-up is advised if clinical ambiguity remains. Record review on Resident #1's Nurses note dated 02/03/25 by LVN B revealed, [NP G] n/o to send resident to ER for evaluation, the FM requests that resident be sent to Hospital ER. Record review of Resident #1's Hospital Discharge Record dated 02/03/25 revealed, Diagnosis: wrist Mildly displaced intra-articular fracture of the distal radius (break in wrist bone) with mild apex volar angulation (small degree tilt or bending of fracture point). Surrounding soft tissue swelling. The carpal arcs are preserved (wrist bones were intact). Orders: Fracture non-mobile under fluoro (medical imaging technique), placed in volar (palm side of hand) resting splint, weight bearing status: NWB LUE, Ortho clinic 2 weeks, pain control per ER Record review of Resident #1's Nurses Note dated 02/03/25 by RN H revealed, Returned from the ER Hospital. Was sent there for left wrist fx. Returned with dx closed fx of distal end of left radius (broken bone at the wrist), unspecified fx morphology(shape/form) . A splint immobilizer was applied, wrapped with ace wrap. Plan is for surgical procedure - closed reduction (realign of fracture without surgery) for the wrist at surgical center. The center will call for further information. The [FM] aware. Assessed for pain continuing. Denied pain on arrival to reassess. Record review of Resident #1's Provider Investigation Report incident dated 02/08/25 at 2:30 pm, revealed the [FM] alleged that the nurse supervisor (Weekend Supervisor E) had hit Resident #1 in her mouth. There was a bruise on the right side of her chin and redness inside her mouth on the bottom gums. The resident denied any pain or discomfort. Treatment was provided and the resident was taken to the hospital. Statements, interviews, and resident safe surveys were completed and determined the facial bruising and swelling was from her fall 02/07/25. Findings: Unfounded. Record review of Resident #1's Hospital Report dated 02/18/25 revealed, She admitted [DATE]: Review of systems: Jaw bruising and pain, Physical exam: Bruising on chin and swelling of left side of cheek, Bruising gums, patient has negative popsicle test (fractured jaw test). Assessment plan: Recurrent falls: 1:1 sitter in place, follow-up x-ray neck, head, perimandibulbar hematoma: supportive care and outpatient dental, Left distal radius fracture, osteoarthritis, vascular dementia, debility. Pertinent Items Requiring Follow-up Post-Discharge 1. Adjust psychiatric medications PRN, 2. Monitor thyroid function, 3. Follow up w/ hand clinic, 4. Follow up w/ dentist. Record review of the facility's Daily Staffing sheet dated 01/31/25 for the 10:00 pm - 6:00 am shift for five halls revealed, they had 1 RN, 2 LVN's, 0 MA and 5 CNA's total at the facility. (The census section was blank). Record review of the facility's Daily Staffing sheet dated 02/01/25 for the 10:00 pm - 6:00 am shift for five halls revealed, they had 1 RN, 2 LVN's, 0 MA and 5 CNA's total at the facility. (The census section was blank). Record review of the facility's Daily Staffing sheet dated 02/02/25 for the 6:00 am - 2:00 pm shift for five halls revealed, they had 1 RN, 4 LVN's, 3 MA and 4 CNA's. (The census section was blank) Record review of the facility's schedule sheet dated Friday 01/31/25 revealed CNA J was the only staff scheduled to work in the Memory care Unit Hall B during the 10:00 pm - 6:00 am shift. Record review of CNA J's Timesheet dated Friday 01/31/25 revealed she clocked in at 10:25 pm and clocked out at 5:52 am - 7.45 total hours. Record review of the facility's schedule sheet dated 01/31/25 revealed RN H was scheduled to work the A Hall from 10:00 pm - 6:00 am. Record review of the RN H's Timesheet dated 01/31/25 revealed RN H clocked in at 10:35 pm and clocked out at 7:29 am - 8.91 hours. Record review of the facility's schedule sheet dated Friday 01/31/25 on the 10:00 pm - 6:00 am shift, revealed LVN O was scheduled to work the E Hall (2nd floor). Record review of LVN O's Time sheet dated Friday 01/31/25 revealed she clocked in at 10:14 pm and clocked out at 6:25 am - 7.69 total hours. Record review of the schedule sheet dated 02/01/25 revealed CNA T was scheduled to work the B Hall Memory care from 2:00 pm - 10:00 pm. Record review of CNA T's Timesheet sheet dated 02/01/25 revealed she clocked in at 3:31 pm and clocked out at 10:08 pm - 6.61 hours. Record review of the facility's schedule sheet dated 02/01/25 revealed CNA J was scheduled to work the B Hall Memory Care unit from 10:00 pm - 6:00 am. Record review of CNA J's Timesheet dated 02/01/25 revealed she clocked in at 10:30 pm and clocked out at 6:11 am - 7.68 hours. Record review of the facility's schedule sheet dated Saturday 02/01/25 revealed CNA K was scheduled to work the A Hall from 2:00 pm - 10:00 pm and Hall B Memory care unit from 10:00 pm - 6:00 am. Record Review of CNA K's Timesheet dated 02/01/25 revealed she clocked in at 2:21 pm and clocked out at 6:36 am - 15.38 hours. Record review of the Facility's schedule sheet dated Saturday 02/01/25 revealed LVN N was scheduled to work the A Hall unit on the 10:00 pm - 6:00 am. Record review of the Facility's Timesheet sheet dated Saturday 02/01/25 for LVN N was requested but not provided by the facility. Record review of the facility's Schedule sheet dated Saturday 02/01/25 for the 10:00 pm - 6:00 am shift revealed, LVN O was schedule to work the D Hall (2nd floor). LVN O's Timesheet was requested for Saturday 02/01/25 but the DON gave the HHSC surveyor LVN's 01/31/25 timesheet. Record review of the facility's schedule sheet dated Saturday 02/01/24 revealed LVN A was scheduled to work 02/01/25 from 6:00 am to 2:00 pm. Record review of LVN A's Timesheet dated 02/01/25 revealed she clocked in at 6:17 am and clocked out at 2:08 pm, clocked in at 2:40 pm, clocked out 9:18 pm, clocked in at 9:50 pm and clocked out at 10:06 pm - 14.75 hours. Record review of the facility's schedule sheet dated Sunday 02/02/25 revealed LVN A was the only staff scheduled to work in the Memory care unit Hall B during the 6:00 am - 2:00 pm shift. Record review of LVN A's Timesheet revealed on Sunday 02/02/25 she clocked in at 6:20 am and clocked out at 10:09 pm - 23.81 total hours. Record review of the facility's schedule sheet dated Sunday 02/02/25 revealed MA P was scheduled to work A Hall from 6:00 am - 2:00 pm and 2:00 pm to 10:00 pm. Record review of MA P's Time sheet dated Sunday 02/02/25 revealed she clocked in at 9:33 am and clocked out at 12:27 pm for lunch and clocked back in at 1:02 pm and clocked out at 10:11 pm - 12.06 total hours. Interview and observation of Resident #1 on 02/13/25 at 7:10 pm at the hospital revealed, she had 1:1 monitoring (constant observation of the resident). A hospital sitter was in the room with her and she was watching TV and she had a beige bandage wrapped around her left wrist and forearm and cotton was underneath the bandage. She stated she had not fallen that she knew of and that her arm was broken because she was always picking up something too heavily. Her lower left chin and face was not swollen, discolored, or bruised. She stated she had no pain of her mouth or left wrist and said she could not remember where she lived prior to coming to this hospital. She stated she could not remember if anyone had been abusive to her and the people should know if they were abusive because she did not have time for that. She stated the IV port and hospital ID band on her right arm got on her nerves more so than the bandage around her left wrist. Record review of Resident #1's Incident report dated 02/06/25 at 10:22 p.m., by LVN D revealed, Resident was seen walking slumped over when she tripped over her socks, this nurse and on shift CNA attempted to assist Resident to floor when she became combative and physically aggressive with staff, hitting herself in the mouth with her splinted left wrist. Resident was eased to the floor by staff and allowed to rest before being helped back to her feet and assisted to her room. Full head to toe assessment was completed resulting vital signs within normal limits, no apparent bruising, no s/s of respiratory distress. Resident had a complaint of pain in her lip where she hit her mouth with wrist. PRN pain medication administered, and pain has since subsided upon recheck. Resident seen lying in bed resting. Hydration and call light are within reach, bed is in lowest position possible. Care continues. Resident Description: She lost her footing because her socks were too slippery and did not need help getting up. Resident was eased to the floor by staff and allowed to rest before being helped back to her feet and assisted to her room. Full head to toe assessment was completed resulting vital signs within normal limits, no apparent bruising, no s/s of respiratory distress. Res had a complaint of pain in her lip where she hit her mouth with wrist. PRN pain medication administered, and pain has since subsided upon recheck. MD notified, DON/ADON notified. RP notified. Resident seen lying in bed resting. Hydration and call light are within reach, bed is in lowest position possible. Care continues. Resident taken to hospital: No. Injury location: face. Pain level 5 (moderate pain level), Alert, ambulatory with assistance. Mental status: Oriented to person, impulsiveness, lack of safety awareness, forgetful. Res the inside of her lip, Resident taken to rest room to rinse her mouth, given PRN pain med which was effective at recheck. Res resting in bed with eyes closed at this time. Confused, impaired memory, sundowning. Interview on 02/13/25 at 4:39 pm, CNA C stated Resident #1 was a new admit and walked without assistance and needed assistance to the toilet. She stated on Saturday 02/01/25 or Sunday 02/02/25, the dinner trays came out and as she helped Resident #1 lean up in her chair, she noticed her left wrist was swollen. She stated she told LVN B, and LVN B went to assess Resident #1 and later on she heard it was fractured and she was sent to the hospital. She stated she was not sure what happened to her wrist and the previous CNA (CNA I) said she did not know what happened or noticed any swelling or bruising of Resident #1's wrist. She stated LVN A said she did not know what happened to Resident #1's wrist either. She stated on Thursday 02/06/25 during the 2 pm - 10 pm shift, Resident #1 was walking down the hall, leaned backwards, and she and LVN D ran and guided Resident #1 down to the floor. She stated during that process Resident #1 got agitated and started swinging her arms and hit herself in her mouth with the soft cast. She stated Resident #1's mouth bled a little on the right side of her lip; it was a little swollen. She stated she did not hit her head on the wall or rail, and at that time, she had no bruising to her face. She stated she worked Saturday 02/08/25 and asked LVN A to help reposition Resident #1 but Resident #1 said she did not want to be bothered. She stated Resident #1 was sleeping sideways in the bed and she asked could she reposition her better in bed and Resident #1 said to leave her alone. She stated around 10:00 am, Weekend Supervisor E and LVN A went in Resident #1's room and she heard Resident #1 hit Weekend Supervisor E. She stated after the incident, she did not see any bruising on Resident #1's face all the way up to the end of her shift at 10:00 pm. She stated she had not seen anyone being abusive to Resident #1. She stated when she returned to work, she heard Resident #1 was taken to the hospital. She stated the facility had enough staff working in the dementia care unit Resident #1 was in. She stated their dementia care unit currently had 21 residents with one CNA and one LVN working per shift. She stated most of the residents walked without assistance. She stated Resident #1 was not good with expressing her needs. Interview on 02/13/25 at 5:30 pm, LVN D stated Resident #1 admitted [DATE] and she discharged last weekend 02/08/25. She stated Resident #1 was ambulatory without assistance and used to work at a hospital because she always said she had to go to work. She stated Resident #1 had the typical dementia behavior and she was verbally and physically abusive to the staff. She stated Resident #1's mindset was that she was always at work and she required a lot of redirecting. She stated she heard Resident #1 went the hospital on [DATE] after her x-ray results showed she had a fractured wrist. She stated they were not sure how her wrist got fractured. She stated Resident #1 had a splint with an ace bandage around it to keep it in place. She stated Thursday 02/06/25, Resident #1 was walking around 10:00 pm or 11:00 pm down the hallway, by the dining room and she appeared to be unsteady. She stated she and CNA C tried to keep her from falling but Resident #1 said she did not want any help. She stated Resident #1 kept leaning backwards and they lowered Resident #1 to the floor and in the process Resident #1 hit the right side of her mouth with her soft cast. She stated Resident #1 never hit the floor, and she and CNA C turned Resident #1 around and eased her down to the floor. She stated she had one arm under Resident #1's arm and CNA C was on the other side under Resident #1's other arm. She stated she had minimum bleeding and her lip had a skin tear for which she gave her PRN Tylenol. She stated she called Resident #1's doctor and got a doctor's order for a skull series x-ray as a precaution. She stated she went to check on Resident #1 later and she was fine and with no bleeding or bruising. She stated she spoke to the FM about Resident #1 stumbling like she was about to fall and they tried to catch her before she fell. She stated on Friday 02/07/25, the x-ray tech came to do the x-rays but the FM told the x-ray tech to come back another time. She stated the last time she saw Resident #1 was Friday 02/07/25 around 10:30 pm and she was fine and had no signs or symptoms of distress, pain, or bleeding. She stated Resident #1 was her normal self, walking around with her juice saying she was getting her people together. She stated she informed the FM about seeing Resident #1 hit her mouth with her soft cast by mistake. She stated measures to prevent Resident #1 from falling was to continue with a lot of redirection and anticipating her needs. She stated after 5:00 pm, they did showers and got the residents ready for bed. She stated she reported Resident #1's fall on 02/07/25 to ADON F and added guided falls were considered falls that was why she did an incident report and contacted Resident #1's doctor, the FM, and the ADON. She stated she was not aware of Resident #1 having any other falls. Interview on 02/14/25 at 10:13 am, LVN B stated she worked Monday 02/03/25 and she sent Resident #1 to the hospital. She stated LVN A said they noticed Resident #1's arm was slightly swollen with no change in bone structure. She stated Resident #1 did not want her wrist touched and she explained to Resident #1 she needed to check to see how she was doing. She stated she kept Resident #1's wrist elevated with ice on it while she waited for the x-ray results. She stated Resident #1 had no signs of pain and slept most of the night. She stated Resident #1 got up once to use bathroom with the CNA's assistance while they were waiting for the x-ray results. She stated around 7:00 am, the doctor said to send Resident #1 to the ER, and she passed the information to the Administrator, DON, the FM, and the next nurse. She stated Resident #1's x-ray result showed she had an impacted wrist fracture and LVN A and no one else knew what caused her fractured wrist. She stated she informed the FM about the need to transfer her to the hospital and when she was being transferred, she had no bruises on her face or bleeding or swollen lip. She stated Resident #1 was laughing and said It sucks getting old when being transported to the hospital. She stated she contacted management for injuries of unknown origin because it was their protocol. She stated she notified the Administrator, DON, and ADON about Resident #1's x-ray results and the Administrator responded to call her (the FM). She stated she called and spoke to the Administrator about Resident #1's wrist fracture x-ray result. Interview on 02/14/25 at 10:39 am, LVN A stated she worked double weekends. She stated Resident #1 admitted about three weeks ago, and she was very familiar with Resident #1. She stated Resident #1 normally walked but had an unsteady gait and they always made sure her bed was in the lowest position. She stated they also increased monitoring of Resident #1 and anticipated her needs and that she was A/O x1 (person). She stated Resident #1 was doing well walking without assist, but once or twice she was sent to the hospital (for the swollen wrist and bruised and swollen face). She stated she worked Saturday 02/01/25, and Resident #1 did not have any falls, unusual occurrences ,or wrist swelling, but she did have generalized and hip pain. She stated she called Resident #1's doctor and her Tylenol 300 mg was increased to 650 mg which was effective. She stated the FM said she did not want Resident #1 on narcotics and the hip pain was probably due to a fall she had at home. She stated she did not remember Resident #1 having a fall the weekend of Saturday 02/01/25 or Sunday 02/02/25. She stated on Sunday 02/02/25, Resident #1 was not a morning person and they would let her sleep in. She stated Resident #1 woke up around 9:00 am or 10:00 am on 02/02/25 and she had no swelling of her left wrist, but later that afternoon the FM visited and reported Resident #1's left wrist was swollen. She stated when she assessed Resident #1, she saw the swelling of her left wrist, but the FM said her left wrist was not swollen the previous day. She stated she took a picture of Resident #1's left wrist to show the DON and ADON F and to her doctor. She stated she asked Resident #1 to flex her arm, Resident #1 said it hurt, and her doctor ordered a STAT x-ray. She stated she was confused as to how Resident #1's left wrist got swollen even though Resident #1 said she fell a couple of days of ago. She stated the FM said Resident #1 could be saying she fell, but she could have fallen the night prior 02/01/25 or that day 02/02/25. She stated Resident #1 was fine on 02/02/25 and few hours later her left wrist was swollen then she did Resident #1's full body assessment. She stated Resident #1's left kneecap and left elbow had STs and Resident #1 said she fell but could not say how. She stated if she had a fall who could have helped her off the floor, because she did not have a lot of strength. She stated they could not say if Resident #1 was able to get up without assist after falling, and they did not know what caused Resident #1's swollen broken left wrist. She stated on 02/02/25, Resident #1's left wrist x-ray was done, and LVN B sent her to the hospital on [DATE]. She stated when she returned to work Saturday 02/08/25, she noticed Resident #1 had a soft wrap bandage across Resident #1's left middle fingers up to her middle arm. On Saturday 02/08/25, Resident #1 was lying horizontally off the bed. She said she asked Weekend Supervisor E to help reposition the resident. She stated Resident #1 swung at and hit Weekend Supervisor E's head and they both stepped back and stopped trying to reposition Resident #1. She stated Resident #1 did not have any bruises or swelling to her face. She stated she called the FM about the incident regarding trying to turn her and noticed she was taking the cast wrapping around her arm apart. She stated the FM came to the facility around 1:00 pm and said,[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for one (Resident #1) of eight residents reviewed for change in condition. LVN A failed to contact Resident #1's Dr. on 06/08/24, for his drastically decreased BP and he was not transferred to the hospital until 06/09/24. Subsequently, Resident #1 was currently at the hospital diagnosed with septic shock and on a ventilator machine (mechanical life support). An Immediate Jeopardy (IJ) was identified on 06/13/24. An IJ Template was provided to the facility on [DATE] at 10:00 am. While the Immediate Jeopardy was removed on 06/14/24 at 5:00 pm, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that was not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. This failure could place all residents at risk of not being assessed and treated in a timely manner and appropriately, with PA/MD interventions, which could result in a decline in their health and psycho-social well-being or death. Findings included: Record review of the facility's census revealed they had 114 residents. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a male who admitted to this facility 08/03/23 with a BIMS Score of 10 (moderate cognitive impairment). He had 1 sided upper extremity impairment and 2 sided lower extremity impairment and substantial maximal assist with ADL's. He was frequently incontinent to bladder and always incontinent to bowel. He had medically complex conditions with diagnoses anemia (low red blood cells and hemoglobin), hypertension (high blood pressure), peripheral vascular disease (circulatory condition/reduced blood flow). And he had diagnoses renal insufficiency (kidney failure), diabetes mellitus (high blood sugar), hyperlipidemia (high level fat particles), malnutrition (lack of nutrients), depression (lowered mood), and generalized muscle weakness (muscle weakness). Record review of Resident #1's Order Summary Report dated 06/12/24 revealed orders for: regular diet with thin liquids, 2.0 supplement 120cc 3xd, Amlodipine besylate oral tab 10 mg, 1-tab 1xd for HTN, hold SBP <110, DBP <60, HR 60, and Ondansetron HCI (hydrochloride) Oral tab 4 mg 1 tab by mouth every 6 hours a needed for nausea and vomiting, etc. Record review of Resident #1's Care Plan printed 06/12/24 revealed, date initiated: 08/08/23: dialysis due to chronic kidney disease, altered respiratory status/difficulty breathing related to history of respiratory failure, impaired cognitive function or thought processes. And had bladder incontinence, communication problem and dialysis and diabetes. Date initiated: 01/25/24: potential for fluid overload related to kidney failure: will remain free of signs/symptoms of fluid overload through review date, as evidenced by . changes in mood or behavior, nausea/vomiting . Monitor/document/report to MD PRN signs/symptoms of fluid overload. Hypertension related to Norvasc - Oral. Date Initiated: 08/09/2023, Revision on: 08/09/2023: will maintain a blood pressure within the following parameters: (110/60) through review date. Revision on: 03/03/2024, Target Date: 07/21/2024. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow Record review of Resident #1's Progress note by LVN A dated 06/08/24 at 9:13 am revealed, Resident noted with abnormal vital signs: BP 93/44, O2:88% room air . Weakness, vomiting, poor eating. Resident offered 120 ml of orange juice, elevated head of bed, and more fluid. (There was not any documentation showing LVN A checked Resident #1's BP on 06/08/24 from 12:09 pm to 10:00 pm. And there was no documentation LVN A notified Resident #1's PA/MD on 06/08/24 about Resident #1's change in condition). Record review of Resident #1's Progress note by LVN A dated 06/09/24 at 9:15 am revealed, Resident noted with abnormal vital signs: BP 83/44, O2:88% RA . Resident very weak, nausea, vomiting, poor eating. Resident is alert. PA notified and ordered resident to be sent to hospital using 911. 911 called and took resident to hospital. Family member informed that resident is sent to hospital. DON notified. Record review of Resident #1's SBAR Communication Form dated 06/09/24 by LVN A revealed, Before calling MD/NP/PA evaluate the resident, check vital signs, review record, review an INTERACT (Interventions to Reduce Acute Care Transfers) care path or acute change in condition file card. Have relevant information when reporting. Situation: This started on 06/08/24, since this started it has gotten worse, BP 83/44, altered level of consciousness, weakness, Full Code review and notify: Primary Care Clinician notified yes 06/09/24 8:15 am. Record review of Resident #1's Hospital H&P (history & physical) dated 06/09/24 revealed, Upon arrival to the ED (emergency department), the patient was noted to be minimally responsive with poor oral care .he was hypotensive (low blood pressure) and tachycardiac (fast irregular heartrate), which was only transiently responsive to 1 L fluid bolus (single large dose medicine) .admitted to MICU. Vitals: BP 108/60, pulse 100, SP O2 92%. Labs: WBC (white blood cell) 13.64 (high), Assessment: admitted to MICU for shock of likely mixed etiology, requiring pressors (life support). Problem list: presumed septic shock (widespread infection causing organ failure), AMS (altered mental status), SOB (shortness of breath), Left calcareous wound (ulcer infection), history of osteomyelitis (bone inflammation), hyperbilirubinemia (liver disfunction) and abdominal pain, hypoglycemia (low blood sugar), ESRD (End Stage Renal Disease), hyponatremia (low sodium level), hypothyroidism (underactive thyroid) and HTN (high blood pressure). Addendum at 06/09/2024: Following arrival to the ICU, the patient was noted to have large volume emesis (vomit) that progressed to possible coffee ground emesis. Due to concern for inability to protect airway, the patient was intubated as per procedure note. Record review of Resident #1's Hospital follow-up note dated 06/11/24 revealed, BP 116/66, SP O2 100%, labs: WBC 13.43 (high), IV antibiotic for ESBL and VRE for sacral wound, placed on CRRT (continuous renal replacement therapy) and palliative care consult. Note: Assumed respiratory care of patient with ventilator settings. Interview on 06/11/24 at 3:06 pm with Hospital Representative stated Resident #1 admitted with AMS (altered mental status) and septic shock (widespread infection causing organ failure) and was currently on a ventilator in MICU. He stated Resident #1's prognosis was poor and he was still the same since he admitted . Observation on 06/11/24 at 5:05 pm, Resident #1 was at the hospital's MICU, he was nonresponsive and using a ventilator machine. Interview by phone on 06/12/24 at 12:28 pm, LVN A stated he worked double shift weekends and on 06/08/24 Resident #1 had a change in condition. LVN A said he was good and talking, but then around 7:00 am or 7:30 am he noticed his vitals were low 93/something. He stated he checked Resident #1's vitals again and it was 101/something and kept monitoring the resident and at 9:00 pm he forgot to document those vital signs in the EMR. He stated he checked his vitals several times throughout the day and was not sure why he did not document those readings and not call Resident #1's PA/MD. He stated he left on 06/08/24 around 10:00 pm and gave a report to LVN B to continue monitoring Resident #1 for his low BP. Then stated he did not contact the Dr. because he was able to get Resident #1's vitals up. He stated at the end of his shift he succeeded in getting Resident #1's vitals increased and he was stable. He stated he returned to work on 06/09/24 and checked Resident #1's BP and his vital signs were getting worse and his O2 sats were going down. He stated he called PA D and she told him to send Resident #1 to the hospital because he was having nausea/vomiting, poor eating, low blood sugar and low BP. He stated Resident #1 was able to respond but he was not drinking fluids like he was the day before. He stated he was doing everything he could for Resident #1. He stated he spoke to the corporate nurse and the DON this morning (06/12/24) from 8:00 am - 10:00 am about what he did when Resident #1's BP dropped. He stated they told him he was suspended because of his actions of not calling PA/MD. He stated in hindsight Resident #1 was stable and there was no need for him to go to the hospital until the next day 06/09/24. Interview on 06/12/24 at 2:20 pm, LVN B stated she was Resident #1's night shift nurse on 06/08/24 from 10:00 pm to 06/09/24 at 6:00 am and she usually did her rounds between 4:00 am to 6:00 am. She stated the previous nurse LVN A did not say Resident #1 had a change in condition. She stated if he did, she would have called his Dr. and did another BP check to see what the Dr. wanted to do. She stated she would not play around with someone's life and did what she needed to do to take care of the residents properly. She stated if Resident #1's BP was too low she would have rechecked it and checked his orders to see if anything could have been given by talking to his Dr. She stated if a resident's BP were 93/44, she replied Oh yes she would have called the Dr. about that. She stated she would not play around with the resident's BP because she was there to help the residents. She stated if a resident's BP dropped, they could shut down and go into respiratory distress especially if their BP was low. She stated a resident might end up dying and pass away. Interview on 06/12/24 at 2:44 pm, CNA C stated on 06/09/24 she was doing her rounds and around 6:30 am - 6:45 am Resident #1's speech was slurred like he was tired. She stated she spoke to LVN A and he said he was aware and was making arrangements to send him to the hospital then he was sent to the hospital. She stated the previous time she saw him was 06/06/24 and he appeared to be fine. Interview on 06/12/24 at 4:15 pm, the Administrator stated they had an AD HOC meeting because Resident #1's BP dropped and it was not reported timely to the physician. He stated LVN A got focused on one thing, the vital signs and missed documenting the BP checks. He stated they had a meeting with their Medical Director and they were taking this matter seriously. He stated he had suspended some staff and currently doing countless in-service trainings with the other staff. Interview on 06/12/24 at 5:52 pm, PA D stated she was temporarily filling in working for the regular PA for this facility. She stated she received a call from a nurse that Resident #1's vitals were off on 06/09/24 and she told the LVN to send the resident to the hospital. She stated she had not received any calls from anyone about Resident #1 abnormal vitals on 06/08/24. She stated she expected the nurse to call her or the Dr. when the resident's BPs were low. She stated with Resident #1 being a dialysis patient, she would have ordered him Midodrine to bring his BP back up depending on his pulse and fluid buildup. She stated the treatment depended on the person because everybody was different. She stated if a resident's BP dropped, sepsis or dehydration could occur. She stated she had not spoken to the Administrator about any issues with Resident #1. Interview 06/12/24 at 6:10 pm, the DON stated LVN A said Resident #1 went to the hospital for his irregular vital signs on 06/09/24. She stated the first time she heard about his irregular vitals was 06/09/24 and since finding out LVN A did not call Resident #1's Dr. they started staff trainings. She stated the staff were trained on change of condition and for the on-call person to start reviewing change of condition on the weekends. She stated after review of Resident #1's records he did not complete his dialysis treatment 06/07/24. She stated she saw on Saturday 06/08/24 Resident #1 had a low BP of 93/something then LVN A did another BP check again and it was 101/something. She stated LVN A said he felt like Resident #1's BP was fine so he did not call the Dr. and just gave him fluids and Zofran (prevents nausea). She stated she tried to call LVN A Monday 06/10/24 and spoke to him this morning 06/12/24 and educated him on reporting change of condition, reviewing the 24-hour report on EMR dashboard (EMR overview of all resident information), completing audits on vital signs and went over doing his documentation. She stated he told her he rechecked Resident #1's vital signs but did not document the results. She stated she wrote him up because he failed to follow their change of condition protocol and they reviewed what was a change of condition and abnormal vs. all vital sign types. She stated she spoke to LVN B who also did not do any BP checks and monitoring of Resident #1, because she said, She was not told Resident #1 had abnormal vitals. She stated LVN B said, She did not follow-up with Resident #1's vitals or contacted the Doctor because LVN A did not notify her of his abnormal vitals. She stated LVN B said, had she known she would have asked the PA/MD to get further direction. She stated had LVN A called the Doctor maybe the Doctor would have put Resident #1 on supplemental O2, to get his O2 sats greater than 90% or offer a 120-cc supplemental shake. She stated Resident #1's BP being 93/44 was not his baseline and the Doctor should have definitely been notified after LVN A received that BP reading on 06/08/24. She stated Resident #1 was currently at the hospital intubated with and elevated white blood cell count. She stated they started Inservice trainings with the nurses, CNAs, and MAs on change of condition, knowing when to contact the PA/MD and they had a QAPI meeting today (06/12/24) with the Medical Director. She stated he went over what should be done to prevent this from happening again. She stated she was not sure why every two-hour checks of Resident #1 had not been done because they should have been done on 06/08/24 and 06/09/24. She stated they needed to make sure the nurses looked at the vital audits screen, to review the EMR dashboard. Interview on 06/12/24 at 6:58 pm, the Administrator stated since finding out about Resident #1's condition they had an AD HOC meeting today (06/12/24) about the immediate interventions to put in place. He stated they started re-educating all nursing staff on physician notification, change in condition, and vital signs. He stated they suspended LVN A and gave him a corrective action memo. He stated they put in audit tools right now and the whole team was reviewing the residents' records to ensure vital sign abnormalities were done properly. He stated Resident #1 was currently at the hospital and the marketing director said he was intubated and that was the extent of what he was privy to. He stated the two ADONs and DON was responsible for ensuring change in conditions were being communicated to the PA/MD. In a group interview on 06/13/24 at 10:00 am, the RNC stated they were aware of the issues involving LVN A not notifying the PA/MD when Resident #1 had a change in condition. The RDO stated they were aware of what happened to Resident #1, prior to the HHSC investigator arriving on 06/11/24, but he was not able to say how many employees they had and how many had the in-service trainings. He stated he would follow up with HHSC investigator and provide their internal investigation later. Interview on 06/13/24 at 10:32 am, RN E stated if a resident's BP were to get too low, it could cause the resident to have a significant declination and become lethargic, confused and beyond their baseline. Interview on 06/13/24 at 12:08 pm, the RDO stated all the nurses who worked Monday 06/10/24 were trained on change in condition, before their shifts started. He stated he was not sure who else had been trained and would have to check. He stated as of this day (06/13/24) the Monday-Friday staff were trained on change in condition but the weekend staff had not been yet. He stated LVN A was suspended on Monday 06/10/24 and they had their AD HOC meeting on Monday with the Medical Director. He stated the DON and ADON's did audits and said he was not sure if any other residents were negatively affected. He stated they implemented the Change in condition and using the interact tool stop and watch and notified the physician. He stated the PA/MD had to answer and nursing had to fully assess the residents. He stated they dropped the ball and wanted to ensure the staff were highly trained, to understand how to care for the residents. He stated he would provide the facility's Incident report and Internal investigation. Interview on 06/13/24 at 1:39 pm, the DON stated they spoke to LVN A about what occurred with Resident #1 on 06/08/24 and he was written up this morning 06/13/24 with a warning due to failure to not contact Resident #1's PA/MD when his BP dropped. Interview on 06/13/24 at 3:20 pm, the DON stated she was not sure how many staff had the change in condition training. She stated all staff who worked Monday 06/10/24 had the training but the PRN and weekend staff had not been trained yet. Interview on 06/13/24 at 4:52 pm, the DON stated she received Resident #1's updated hospital report today (06/13/24) and his condition was still the same with a sepsis diagnosis. Record review of the facility's Change in condition policy dated 06/2020 - revealed, Purpose: To ensure residents, family, legal representative, and physicians are informed of changes in the resident's condition in a timely manner. Procedure: The licensed nurse will notify the resident's attending physician, Reporting information to the attending physician, family notification and documentation. An Immediate Jeopardy (IJ) was identified on 06/13/24. An IJ Template was provided to the facility on [DATE] at 10:00 am. While the Immediate Jeopardy was removed on 06/14/24 at 5:00 pm, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. Record review of the facility's Plan of Removal provided to the HHSC investigator on 06/14/24 at 10:45 am and approved at 11:00 am revealed, PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it may concern, Summary of Details which lead [sic] to outcomes: On 6/11/2024, a complaint was initiated at [This facility]. On 6/13/2024 a surveyor provided an IJ Template notification that the Survey Agency has determined that a condition at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F580 Change of Condition LVN A failed to contact Resident #1's Dr. after his BP decreased to 93/44 on 06/08/24 at 10:23 am. LVN A checked Resident #1's BP again 06/08/24 at 12:08 pm and it was 101/54 and did not do any further BP checks during the remainder of his shift. On 06/08/24 between 10p - 6 a there was no evidence LVN B checked on Resident #1 during her shift. Interviews with LVN A and LVN B revealed they had not notified the DON or Dr. about Resident #1's condition. Resident #1's NP C and the DON stated they had not received any calls about Resident #1's decreased BP until 06/09/24 when he went to the hospital. Identify residents who could be affected: All residents have the potential to be affected. Identify responsible staff/ what action taken: 1. Licensed Nurses, RNs and LVNs received a re-education by the DON on the facility policy and procedure regarding documentation, notification on following parameters for abnormal BPs. Initiated on 6/10/24 with a completion of 6/14/24. 2. LVN received a 1:1 re-education and disciplinary action including suspension by the DON on the facility policy and procedure notification of changes of condition to the charge nurse promptly. Completed on 6/12/24. 3. Training for licensed Nurses, RNs and LVNs and Medication aides on notification changes of condition to physician and nurse management with proper documentation was initiated on 6/10/2024 by the Director of Nursing with a completion date of 6/14/24. 4. Medication aides and Licensed nurses, LVNs and RNs were also re-educated to follow up on abnormal vital signs by the Director of Nursing on 6 /10/2024 with a completion date of 6/14/24. 5. An audit of all BP medications with parameters was initiated on 6/10/24 by the DON and ADON with a completion date of 6/14/24. 6. Audit of all vitals including BPs to identify any abnormalities from baseline was initiated on 6/10/24 by the DON and ADON. With a completion date of 6/14/24. 7. Post test given to all licensed nurses RN/LVN on change of condition, vitals, notification, and documentation. Initiated 6/10/24 with a completion date of 6/14/24. In-Services conducted: 1. Change in condition. 2. Documentation 3. Notification 4. Vitals The in-service was attended by licensed caregivers which include Registered Nurse, Licensed Vocational Nurse, and Certified Medication Aid [sic], Certified Nurse Aide, and staff from all other departments. Understanding of the in service was verbalized and confirmed by written/ verbal post test. This in-service was initiated on 6/10/24 with a completion date of 6/14/24 and all staff must be in-service before they are allowed to work. New staff will be educated about resident change in condition, documentation, notification and vitals before their floor orientation. Implementation of changes: The changes which include monitoring of vitals (BP) and change in condition of residents through 24 reports [sic] were started by the Director of Nursing. The changes were implemented effective on 6/10/24 with a completion date of 6/14/24 and will be ongoing until all staff are re-educated. The Director of Nursing will ensure competency through verbalization of understanding by staff and in servicing. Monitoring The Administrator/Director of Nursing/Assistant Director of Nursing will be responsible for monitoring the implementation and effectiveness of in-service on 6/10/24. o The Administrator/Director of Nursing/Designee will monitor/review vitals daily and review 24-hour report for change in condition x4 weeks, then weekly x2 weeks, then monthly and report any adverse finding during QAPI o Director of Nursing/Designee will conduct a daily audit of vitals and change in condition daily x4 weeks, then weekly x 2 weeks, then monthly and report any adverse findings during QAPI o Director of Nursing/Designee will conduct a daily audit of vitals daily x4 weeks, then weekly x 2 weeks, then monthly and report any adverse findings during QAPI Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 6/10/24 and conducted an Ad HOC QAPI regarding physician notification, documentation, change in condition, and vitals. The Medical Director was notified about the immediate Jeopardy on 6/13/24, the Plan of removal was reviewed and accepted by Doctor. Involvement of QA An Ad Hoc QAPI meeting was held with the Medical Director, Facility Administrator, Director of Nursing and Assistant Director of Nursing to review plan of removal on 6/10/24 [sic] Who is responsible for the implementation of process? The Director of Nursing will be responsible for the implementation of the new process. The New Process/system was started on 6/10/2024. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy verbally issued on 6/13/2024. [END] In a group meeting on 06/14/24 at 11:00 am, The Administrator, DON, RDO and RNC was notified that the POR was accepted and this facility was in the monitoring phase to ensure their POR was implemented. Interview on 06/14/24 at 11:10 am, RNC stated they were still working on their investigation summary. Interview on 06/14/24 at 2:55 pm, the DON stated they would start having the on-call weekend nurse review the 24-hour EMR dashboard for any changes of the resident's vital signs. She stated she was responsible for ensuring the staff followed their change in condition policy. She stated her expectations were for the staff to monitor the residents and if anything was different from their baseline, they needed to notify the PA/MD and RP. She stated not monitoring the residents and notifying the PA/MD could cause the staff to miss something that could delay care. She stated it could further delay getting the resident evaluated resulting in a number of things such as a worsening condition or death. Interview on 06/14/24 at 4:00 pm, the Administrator stated based on what occurred with Resident #1, they planned on terminating LVN A, and complete the Inservice trainings with everyone. He stated the DON and two ADON's would continue reviewing the residents' vital signs daily with his oversight over the nurse management team. He stated the weekend nurse supervisor would be doing the monitoring of the vitals on the weekends to ensure the nurses were notifying the PA/MD. He stated all staff had to do their change in condition trainings with the post tests before they were able to work on the floor. He stated they had 117 employees total and was not sure how many more staff needed to be trained then said maybe one or two staff. He stated in the QA (Quality Assurance) Meeting they reviewed with the medical director Resident #1's change in condition and what could be done to prevent this from happening again. He stated if residents had a change in condition and the PA/MD was not notified, could result in the deterioration of the resident and exacerbation of the resident's symptoms. He stated his expectation for resident care was for PA/MD notifications and documentation were done. Record review of the Facility's Investigation undated provided by the Administrator on 06/14/24 at 1:24 pm revealed, Internal Investigation Re: Resident #1 Patient Information: Resident is a [AGE] year-old male who admitted to facility on xx/xx/xxxx under the care of Dr. XXX. Resident is cognitively intact as evidenced by a BIMS score of 15. Primary diagnosis: osteomyelitis, left ankle and foot. Additional diagnosis: PVD, major depressive disorder, type 2 diabetes, acute and subacute infective endocarditis (heart infection), anemia (low iron), and hypertension. Incident: On 6/8/2024 LVN A documented Resident #1 to have the following vital signs: BP 93/44, O2:88% room air, P106, FSBS 67 mg/dl. Weakness, vomiting, poor eating. LVN A did not document notification of these abnormal vital signs to Physician. On 6/9/2024 LVN A documented Resident #1 to have the following vital signs: BP83/44, P111, O2:88% RA, R21/min, T97.8, FSBS 85mg/dl LVN A called physician's PA and resident was sent to acute care hospital via EMS. Investigation: Interview with LVN A revealed the following: LVN A said he was concerned about the blood sugar level and that is why he gave the patient 120 mL of orange juice. He said that he repositioned the patient in the bed to address the other abnormal vital signs. He says that he had remeasured his BP and that it had started going up into the normal ranges. Review of the Medication Aides charting she had recorded a BP high enough that BP reducing medication according to parameters was administered. The medication aide said that the patient seemed stable and normal with no signs of distress during medication administration, and he received medications well. LVN A admits that he did not notify the physician of the abnormal vitals on Saturday. He also admits that he did not document the later vital signs that he had taken in the medical record. Actions to Address: LVN A was given one on one in-service by DON on expectations for physician notification for any abnormal vital signs and medication administration. Employee suspended pending investigation. [END] Interviews on 06/13/24 between 10:32 am - 11:40 am with RN E, RN F, LVN G, MA H, CNA I revealed they were trained between 06/10/24 and 06/13/24 on change in condition, notifying PA/MD of drops in resident's BPs., Interviews on 06/14/24 between 11:44 am - 3:34 pm revealed, LVN K, Medical Record L, MA M, Housekeeper/Laundry aide N, Housekeeper O, Dietary aide P, Dietary cook Q, Laundry aide R, Laundry aide S, RN T, ADON U, OT (Occupational Therapy) V, PTA (Physical Therapy Assistant) W, CNA X, MA Y, RN Z stated they were trained between 06/10/24 and 06/14/24 on change in condition, notifying the PA/MD, stop and watch and notifying the nurses, the DON and ADONs when a resident had a change in condition. Record review on 06/13/24 of the facility's Supporting documents emailed by the Administrator on 06/12/24 at 9:10 pm revealed, Inservice trainings on 06/10/24 with mostly administrative/department head staff and some floor staff. And on 06/11/24 and 06/12/24 more floor staff were trained on change in condition and stop and watch reporting. Record review on 06/13/24 of the facility's Supporting documents emailed by the Administrator on 06/13/24 at 2:22 pm, revealed three duplicate in service signature sheets dated 06/10/24. There was signed training sheets from the 8:00 am to 5:00 pm staff on 06/10/24 on topics change in condition and. And signature sheets on 06/12/24, posttests from 06/10/24 - 06/13/24 and resident chart audits from 06/10/24 to 06/13/24 revealed staff were proficient in change in condition procedures. Record review of signage posting currently being put at all nurses stations: NOTIFY MD/NP OF LOW BLOOD PRESSURES . SYSTOLIC LESS THAN 95 DIASTOLIC LESS T:HAN . SYSTOLIC GREATER THAN 170 AND DIASTIC GREATER THAN 90 . ASSESS YOUR PATIENT AND DOCUMENT. Record review of LVN A's Corrective Action Memo dated 06/12/24 by DON revealed, Violation of policy and procedure, carelessness, Employer Statement: Acute change in condition is a sudden, clinically important deviation from the patient's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death. Alert charting is documentation done to track a medical event for a period of 72 hours or longer. Events may include but not necessarily limited to suspected or actual change in condition. Action being taken Suspension Objective/Solution: Employee will understand the importance of communicating change of condition with MD, NP, DON, ADON, on call phone. Employee will review abnormal vital signs and verbalize values in EMR Failure to document indicates task was not completed. Employee will be suspended pending investigation. Employee statement: blank. Signed by LVN A and DON. Record review of LVN B's Corrective Action memo dated 06/13/24 by DON revealed, Violation of policy and procedure Em[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews and interviews the facility failed to ensure that based on the comprehensive assessment of a resident, residents receive 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 eight residents reviewed for quality of care. 1. LVN A failed to provide appropriate treatment and care on 06/08/24 as indicated: a. Did not monitor and check Resident#1's BP after 12:08 pm. b. Did not notify the DON and LVN B, about Resident #1's change in condition and need for continued BP monitoring. c. Did not follow Resident #1's Nephrologist's Doctor order and this facility's Care Plan to ensure the resident did not experience possible fluid overload. 2. LVN B failed to check on Resident #1 throughout her shift and she said she did a BP check on Resident #1 at 5:00 am on 06/09/24 but failed to document it. An Immediate Jeopardy (IJ) was identified on 06/13/24. An IJ Template was provided to the facility on [DATE] at 10:00 am. While the Immediate Jeopardy was removed on 06/14/24 at 5:00 pm, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. These failures could place residents at risk of harm which could cause a decline in their health and psycho-social well-being and lead to need for hospital intervention or death. Findings included: Observation on 06/11/24 at 5:05 pm, Resident #1 was at the hospital's MICU, he was nonresponsive and using a ventilator machine (life support). Record review of the facility's census revealed they had 114 residents. Record review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a male who admitted to this facility 08/03/23 with a BIMS Score of 10 (moderate cognitive impairment). He had 1 sided upper extremity impairment and 2 sided lower extremity impairment and substantial maximal assist with ADL's. He was frequently incontinent to bladder and always incontinent to bowel. He had medically complex conditions with diagnoses anemia (low red blood cells and hemoglobin), hypertension (high blood pressure), peripheral vascular disease (circulatory condition/reduced blood flow). And diagnosed with renal insufficiency (kidney failure), diabetes mellitus (high blood sugar), hyperlipidemia (high level fat particles), malnutrition (lack of nutrients), depression (lowered mood), and generalized muscle weakness (muscle weakness). Record review of Resident #1's Order Summary Report dated 06/12/24 revealed orders for: regular diet with thin liquids, 2.0 supplement 120cc 3xd, Amlodipine besylate oral tab 10 mg, 1-tab 1xd for HTN, hold SBP <110, DBP <60, HR 60, and Ondansetron HCI (hydrochloride) Oral tab 4 mg 1 tab by mouth every 6 hours a needed for nausea and vomiting. And there was not any standing orders for renal diet wirh fluid restrictions. Record review of Resident #1's Care Plan printed 06/12/24 revealed, date initiated: 08/08/23: dialysis due to chronic kidney disease, altered respiratory status/difficulty breathing related to history of respiratory failure, impaired cognitive function or thought processes. And had bladder incontinence, communication problem and dialysis and diabetes. Date initiated: 01/25/24: potential for fluid overload related to kidney failure: will remain free of signs/symptoms of fluid overload through review date, as evidenced by . changes in mood or behavior, nausea/vomiting . Date Initiated: 01/25/2024: Monitor/document/report to MD PRN signs/symptoms of fluid overload Hypertension related to Norvasc - Oral. Date Initiated: 08/09/2023, Revision on: 08/09/2023: will maintain a blood pressure within the following parameters: (110/60) through review date. Revision on: 03/03/2024, Target Date: 07/21/2024. Record review of Resident #1's Progress note by LVN A dated 06/08/24 at 9:13 am revealed, Resident noted with abnormal vital signs: BP 93/44, O2:88% room air . Weakness, vomiting, poor eating. Resident offered 120 ml of orange juice, elevated head of bed, and more fluid. (There was not any documentation showing LVN A monitored or checked Resident #1's BP on 06/08/24 from 12:09 pm to 10:00 pm. And there was no documentation LVN A notified the DON and LVN B on 06/08/24 about Resident #1's change in condition and fluid amounts given). Record review of Resident #1's Progress note by LVN A dated 06/09/24 at 9:15 am revealed, Resident noted with abnormal vital signs: BP 83/44, O2:88% RA . Resident very weak, nausea, vomiting, poor eating. Resident is alert. PA notified and ordered resident to be sent to hospital using 911. 911 called and took resident to hospital. Family member informed that resident is sent to hospital. DON notified. Record review on Resident #1's Progress note from 06/08/24 from 10:00 pm to 06/09/24 at 6:00 am, revealed LVN B did not document she checked on Resident #1 every two hours or at all during her shift. Record review of Resident #1's SBAR Communication Form dated 06/09/24 by LVN A revealed, Before calling MD/NP/PA evaluate the resident, check vital signs, review record, review an INTERACT(Interventions to Reduce Acute Care Transfers) care path or acute change in condition file card. Have relevant information when reporting. Situation: This started on 06/08/24, since this started it has gotten worse, BP 83/44, altered level of consciousness, weakness, Full Code review and notify: Primary Care Clinician notified yes 06/09/24 8:15 am. Record review of Resident #1's Hospital H&P (history & physical) dated 06/09/24 revealed, Upon arrival to the ED (emergency department), the patient was noted to be minimally responsive with poor oral care .he was hypotensive (low blood pressure) and tachycardiac (fast irregular heartrate), which was only transiently responsive to 1 L fluid bolus (single large dose medicine) .admitted to MICU. Vitals: BP 108/60, pulse 100, SP O2 92%. Labs: WBC (white blood cell) 13.64 (high), Assessment: admitted to MICU for shock of likely mixed etiology, requiring pressors (life support). Problem list: presumed septic shock (widespread infection causing organ failure), AMS (altered mental status), SOB (shortness of breath), Left calcareous wound (ulcer infection), history of osteomyelitis (bone inflammation), hyperbilirubinemia (liver disfunction) and abdominal pain, hypoglycemia (low blood sugar), ESRD (End Stage Renal Disease), hyponatremia (low sodium level), hypothyroidism (underactive thyroid) and HTN (high blood pressure). Addendum at 06/09/2024: Following arrival to the ICU, the patient was noted to have large volume emesis (vomit) that progressed to possible coffee ground emesis. Due to concern for inability to protect airway, the patient was intubated as per procedure note. Record review of Resident #1's Hospital follow-up note dated 06/11/24 revealed, BP 116/66, SP O2 100%, labs: WBC 13.43 (high), IV antibiotic for ESBL and VRE for sacral wound, placed on CRRT (continuous renal replacement therapy) and palliative care consult. Note: Assumed respiratory care of patient with ventilator settings. Interview on 06/11/24 at 3:06 pm with Hospital Representative stated Resident #1 admitted with AMS and septic shock and was currently on a ventilator in MICU. He stated Resident #1's prognosis was poor and he was still the same since he admitted . Interview by phone on 06/12/24 at 12:28 pm, LVN A stated he worked double shift weekends and stated on 06/08/24 Resident #1 had a change in condition. LVN A said he was good and talking, but then around 7:00 am or 7:30 am he noticed his vitals were low 93/something. He stated Resident #1 was alert/orient and drank his Orange Juice then he vomited and then gave him Zofran (prevent nausea/vomiting) He stated he checked Resident #1's vitals again and it was 101/something and kept monitoring the resident and at 9:00 pm he forgot to document those vital signs in the EMR. He stated he checked his vitals several times throughout the day and was not sure why he did not document those readings. He stated he left on 06/08/24 around 10:00 pm and gave a report to LVN B to continue monitoring Resident #1 for his low BP. He stated at the end of his shift he succeeded in getting Resident #1's vitals increased and he was stable. He stated he forgot to document checking Resident #1's BP throughout the duration of his shift on 06/08/24, because it was the end of the shift but knew he should have documented that. He stated not documenting resident's vitals could make it very hard to follow up and compare previous conditions and limit communication because the documentation was missing. He stated he spoke to the corporate nurse and the DON this morning (06/12/24) from 8:00 am - 10:00 am about what he did when Resident #1's BP dropped. He stated they told him he was suspended because of his actions of not calling the DON. Interview on 06/12/24 at 2:20 pm, LVN B stated she was Resident #1's night shift nurse on 06/08/24 from 10:00 pm to 06/09/24 at 6:00 am and she usually did her rounds between 4:00 am to 6:00 am. She stated on 06/09/24 she saw Resident #1 at 5:00 am and took his BP and it was normal and he had no fever, he was stable. She stated she put his vital signs on his dialysis paper and not the EMR. She stated he said good morning to her and was talking and she gave him some water. She stated there was only two nurses that worked upstairs on her shift and she had a lot to do and wrote Resident #1's BP reading on her pad. She stated the previous nurse LVN A did not say Resident #1 had a change in condition. She stated if he did, she would have called his Dr. and did another BP check to see what the Dr. wanted to do. She stated she would not play around with someone's life because she would ensure the residents were properly cared for. She stated if Resident #1's BP was too low she would have rechecked it and checked his orders to see if anything could have been given and by talking to his Dr. She stated if a resident's BP were 93/44, she replied Oh yes she would have called the Dr. about that. She stated she would not play around with the resident's BP and would check it more often because it could drop. She stated upstairs they only had two nurses on the night shift and she and other nurse had to split one of the halls (Hall E) for which Resident #1 was on. She stated she was not able to complete all her documentation at night, because they really needed a third night nurse upstairs to cover Hall E. She stated she asked about getting another nurse and the administrator said they would once they were full upstairs. She stated if a resident's BP dropped, they could shut down and go into respiratory distress especially if their BP was low. She stated a resident might end up dying and pass away. Interview on 06/12/24 at 4:15 pm, the Administrator stated LVN A got focused on one thing, the vital signs and missed documenting the BP checks. He stated they had a meeting with their Medical Director and they were taking this matter seriously. He stated he suspended some staff and currently doing countless in-service trainings with the other staff. Interview on 06/12/24 at 5:52 pm, PA D stated if a resident's BP dropped, sepsis or dehydration could occur. Interview on 06/12/24 at 6:10 pm, the DON stated LVN A said Resident #1 went to the hospital for his irregular vital signs on 06/09/24. She stated the first time she heard about Resident #1's irregular vitals was 06/09/24. She stated on 06/08/24 they started staff trainings on change of condition and for the on-call person to start reviewing change of condition on the weekends. She stated she saw on Saturday 06/08/24 Resident #1 had a low BP of 93/something then LVN A did another BP check again and it was 101/something. She stated LVN A said, He felt like Resident #1's BP was fine and just gave him fluids and Zofran. She stated she tried to call LVN A Monday 06/10/24 and spoke to him this morning 06/12/24 and educated him on reporting change of condition, reviewing the 24-hour report on EMR dashboard, completing audits on vital signs, and went over doing his documentation. She stated she wrote him up because he failed to follow their change of condition protocol and they reviewed what was a change of condition and abnormal vs. all vital sign types. She stated LVN B said she did not follow-up with Resident #1's vitals because LVN A did not notify her of his abnormal BP. She stated LVN B said had she known she would have asked the MD/NP to get further direction. She stated Resident #1 was currently at the hospital intubated (tube place down throat to assist with breathing) and elevated white blood cell count. She stated they started Inservice trainings with the nurses, CNAs, and MAs on change of condition and they had a QAPI meeting today (06/12/24) with the Medical Director. She stated the Medical Director went over what should be done to prevent this from happening again. She stated they had enough nurses working upstairs, because they had roughly 80 residents on the 2nd floor and from 10:00 pm - 6:00 am there was two nurses because only PRN medications were given. She stated she was not sure why every two-hour checks of Resident #1 had not been done because they should have been done on 06/08/24 and 06/09/24. She stated they needed to make sure the nurses looked at the vital audits screens by reviewing the EMR dashboard for any abnormal vital readings. Resident #1 did not have any fluid restriction standing orders but could see LVN A gave Resident #1 120 cc of orange juice. She stated she was not aware the documentation showed LVN A gave the resident 'more fluids'. Interview on 06/12/24 at 6:58 pm, the Administrator stated since finding out about Resident #1's condition they had an AD HOC meeting today (06/12/24) about the immediate interventions to put in place. He stated they started re-educating all nursing staff on change of condition, and vital signs. He stated they suspended LVN A and gave him a corrective action memo. He stated they put in audit tools right now and the whole team was reviewing the residents' records to ensure vital sign abnormalities were done properly. He stated Resident #1 was currently at the hospital and the marketing director said he was intubated and that was the extent of what he was privy to. In a group interview on 06/13/24 at 10:00 am, the RNC stated they were aware of the issues involving LVN A not notifying the PA/MD when Resident #1 had a change in condition. The RDO stated they were aware of what happened to Resident #1, prior to the HHSC investigator arriving on 06/11/24, but he was not able to say how many employees they had and how many had the in-service trainings. He stated he would follow up with HHSC investigator and provide their internal investigation later. Interview on 06/13/24 at 10:32 am, RN E stated if a resident's BP were to get too low, it could cause the resident to have a significant declination and become lethargic, confused and beyond their baseline. Interview on 06/13/24 at 10:50 am, RN F stated if a resident who was on dialysis had a drop in their BP, she would never give them fluids because they could retain the fluids and could get fluid overload. She stated especially if the Doctor did not order additional fluids. She stated if a resident's BP were too low or high, she would give them the PRN medication and check their BP within 30 minutes to an hour. She stated all of her focus would be on that resident. She stated she would get more BP readings to ensure the resident was stable. Interview on 06/13/24 at 11:16 am, LVN G stated if a resident's BP dropped, they could pass out and said she would not just give a resident fluids because she was just a nurse who worked based off of Dr. orders. She stated if a dialysis resident who was on dialysis had a 93/44 BP, she would never give them fluids without a Dr. order. Interview on 06/13/24 at 12:08 pm, the RDO stated all the nurses who worked Monday 06/10/24 were trained on change in condition and stop and watch reporting, before their shifts started. He stated he was not sure who else had been trained and would have to check. He stated as of this day (06/13/24) the Monday - Friday staff were trained on change in condition but the weekend staff had not been yet. He stated LVN A was suspended on Monday and they had their AD HOC meeting on Monday (06/10/24) with the Medical Director. He stated the DON and ADONs did audits and said he was not sure if any other residents were negatively affected. He stated they implemented the Change in condition interact tool stop and watch. He stated they dropped the ball and wanted to ensure the staff were highly trained, to understand how to care for the residents. Interview on 06/13/24 at 1:39 pm, the DON stated they were going to audit every resident getting BP medications. She stated they spoke to LVN A about what occurred with Resident #1 on 06/08/24. And LVN B was written up this morning (06/13/24) due to failure to not document Resident #1's vital signs. Interview on 06/13/24 at 3:20 pm, the DON stated she was not sure how many staff had the change in condition training. She stated all staff who worked Monday 06/10/24 had the training but the PRN and weekend staff had not been trained yet. Interview on 06/13/24 at 4:52 pm, the DON stated she received Resident #1's updated hospital report today (06/13/24) and his condition was still the same with a sepsis diagnosis. Record review of the facility's Care and Services Policy dated 06/2020 revealed, To ensure through an interdisciplinary team (IDT) process, that all residents receive the necessary care and services based on an individualized comprehensive assessment process. Policy: Residents are provided with the necessary care and services to maintain the highest practicable. physical, mental, and social well-being level of in an environment that enhances quality of life in the scope of a long-term care facility. Care and services are provided in a manner that consistently enhances self-esteem and self-worth. Procedure: I. The Facility will have sufficient staff to provides services to residents with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being as determined by individualized resident assessments and plans of care. An Immediate Jeopardy (IJ) was identified on 06/13/24. An IJ Template was provided to the facility on [DATE] at 10:00 am. While the Immediate Jeopardy was removed on 06/14/24 at 5:00 pm, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy due to the facility continuing to monitor the implementation and effectiveness of their plan of removal. Record review of the facility's Plan of Removal provided to the HHSC investigator on 06/14/24 at 10:45 am and approved at 11:00 am revealed, PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it may concern, Summary of Details which lead to outcomes: On 6/11/2024, a complaint was initiated at [This facility]. On 6/13/2024 a surveyor provided an IJ Template notification that the Survey Agency has determined that a condition at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F 684 Quality of Care - Based on observation, interviews, and record reviews LVN A failed to contact the resident's Doctor after Resident #1's BP decreased to 93/44 on 06/08/24 at 10:23 am. LVN A checked Resident #1's BP again 06/08/24 at 12:08 pm and it was 101/54 and did not do any further BP checks during the remainder of his shift. There's no documentation of the 10p - 6 a LVN B checking Resident #1 or doing vitals. Then on 06/09/24 at 8:37 am LVN A returned to work and checked Resident #1's BP was 83/44 then Resident #1 was sent to the hospital. Identify residents who could be affected: All residents have the potential to be affected. Identify responsible staff/ what action taken: 1. Director of Nurses were re-educated by the Regional Nurse Consultant on the facility policy on monitoring, documenting, and reporting abnormal signs or symptoms on 6/10/2024. Understanding was verified by a written posttest. 2. Licensed Nurses received a re-education by the DON on the facility policy and procedure on physician notification and documentation initiated on 6/10/2024. Knowledge of education was verified by written signatures and verbalization of understanding completed on 6/14/2024. 3. Training for licensed nurses and medication aides on notification of changes in condition to physician and nurse management with proper documentation was initiated on 6/10/2024 by the Director of Nursing. Knowledge of education was verified by written signatures and verbalization of understanding completed on 6/14/2024. 4. Training for non-clinical staff on notification of changes in condition to the charge nurse or nurse manager 6/10/2024 by the Director of Nursing. Knowledge of education was verified by written signatures and verbalization of understanding completed on 6/14/2024. 5. Training for licensed nurses on Physician notification on critical lab results and abnormal vital signs with proper documentation was initiated on 6/10/2024 by the Director of Nursing. Knowledge of education was verified by written signatures and verbalization of understanding completed on 6/14/2024. 6. An audit of all resident vital signs was initiated on 6/10/2024 by DON and ADON. To verify that physician was notified of any abnormal reading. Audit was completed on 6/10/2024. In-Services conducted: 1. Change in condition. 2. Medication administration 3. Physician notification 4. Labs and Vitals 5. Documentation of care provided The in-services were attended by licensed caregivers which include Registered Nurse, Licensed Vocational Nurse, Certified Medication Aide, Certified Nurse Aides and staff from all other departments. Understanding of in-services was verified with a written/and or verbal posttest. This in-service was initiated on 6/10/2024 and completed on 06/14/2024. All staff must be in-serviced before they are allowed to work. New staff will be educated about resident change in condition, medication administration, physician notification before their floor orientation and monitoring will be continued ongoing by the DON/Designee. Implementation of changes (Monitoring all or any medication not given and change in condition of residents through 24-hour report). The changes which include daily monitoring of lab results, vital sign readings, change in condition and physician notification of residents through 24-hour reports were started by the Director of Nursing. The changes of monitoring of all residents with a change in condition and abnormal vital signs or labs /imaging results over 24hr were implemented effective on 6/10/2024 and completed on 06/14/2024. No staff will be allowed to work before completion of these in-services. The Director of Nursing will ensure competency through verbalization of understanding by staff and in servicing. Monitoring The Administrator/Director of Nursing/Assistant Director of Nursing will be responsible for monitoring the implementation and effectiveness of in-service on 6/10/2024. o The Director of Nursing/Designee will monitor/review vital signs daily and review 24-hour reports for change in condition and physician notification x4 weeks, then weekly x2 weeks, then monthly and report any adverse finding during QAPI. o Director of Nursing/Designee will conduct a daily audit of resident vital signs and change in condition daily x4 weeks, then weekly x 2 weeks, then monthly and report any adverse findings during QAPI. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 6/10/2024 and conducted an Ad HOC QAPI regarding physician notification and change in condition. The Medical Director, Doctor was notified about the immediate Jeopardy on 6/13/2024, the Plan of removal was reviewed and accepted by Doctor. Involvement of QA An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, and social services director to review plan of removal on 6/13/2024. Who is responsible for the implementation of the process? The Director of Nursing will be responsible for the implementation of the new process. The New Process/system was started on 6/10/2024. The Administrator will ensure DON implements the new process. Regional Nurse Consultant will audit the implementation of the new process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy verbally issued on 6/13/2024. [END] In a group interview on 06/14/24 at 11:00 am, The Administrator, DON, RDO and RNC was notified that the POR was accepted and this facility was in the monitoring phase to ensure their POR had been implemented. Interview on 06/14/24 at 11:10 am, RNC stated they were still working on their investigation summary. She stated LVN A gave Resident #1 120 cc of orange juice from his meal tray and was not aware more fluids was given as reported in the progress notes, she said Resident #1 was not on a fluid restriction or renal diet and they just recently scheduled a meeting with Resident #1's dialysis staff to get fluid restriction and renal diet and go over other dialysis orders to ensure their accurate. Interview on 06/14/24 at 2:33 pm, RN Z stated the nurses needed to give treatments to the residents that were PA/MD ordered and he would ensure checking the resident's BP for the remainder of the shift if they had a change in condition. Interview on 06/14/24 at 2:55 pm, the DON stated they would start having the on-call weekend nurse review the 24-hour EMR dashboard for any changes of the resident's vital signs and nurses' documentation. She stated she was responsible for ensuring the staff followed their change in condition policy. She stated her expectations was for the staff to monitor the residents and if anything was different from their baseline, . She stated not monitoring the residents and could cause the staff to miss something that could delay care. She stated it could further delay in getting the resident evaluated resulting in a number of things such as a worsening condition or death. Interview on 06/14/24 at 4:00 pm, the Administrator stated based on what occurred with Resident #1, they planned on terminating LVN A and completed Inservice trainings with almost everyone. He stated the DON and two ADONs would continue reviewing the residents' vital signs daily with his oversight over the nurse management team. He stated the weekend nurse supervisor would be doing the monitoring of the vitals on the weekends to ensure the nurses were He stated all staff had to do their change in condition trainings with the post tests before they were able to work on the floor. He stated they had 117 employees total and was not sure how many more staff needed to be trained. He stated in the QA (Quality Assurance) Meeting they reviewed with the medical director about Resident #1's change in condition and what could be done to prevent this from happening again. He stated if residents had a change in condition and not documented timely, could result in the deterioration and exacerbation of the resident's symptoms. He stated his expectation for resident care was for documentation of the residents were done. He stated they have a care meeting scheduled with the resident's dialysis center next week to ensure the Doctor order were correct. He stated the Medical Doctor agreed the meeting with dialysis was a good idea. Interviews on 06/13/24 between 10:32 am - 11:40 am with RN E, RN F, LVN G, MA H, CNA I revealed they were trained between 06/10/24 and 06/13/24 on change in condition, of drops in resident's BP and documentation residents vital signs. Interviews on 06/14/24 between 11:44 am - 3:34 pm revealed, LVN K, Medical Record L, MA M, Housekeeper/Laundry aide N, Housekeeper O, Dietary aide P, Dietary cook Q, Laundry aide R, Laundry aide S, RN T, ADON U, , CNA X, MA Y, RN Z stated they were trained between 06/10/24 and 06/14/24 on change in condition, documentation, stop and watch and notifying the nurses, the DON and ADONs when a resident had a change in condition. Record review on 06/13/24 of the facility's Supporting documents emailed by the Administrator on 06/12/24 at 9:10 pm revealed, Inservice trainings on 06/10/24 with mostly administrative/department head staff and some floor staff. And on 06/11/24 and 06/12/24 more floor staff were trained on change in condition and stop and watch reporting. Record review on 06/13/24 of the facility's Supporting documents emailed by the Administrator on 06/13/24 at 2:22 pm, revealed three duplicate in service signature sheets dated 06/10/24. There was signed training sheets from the 8:00 am to 5:00 pm staff on 06/10/24 on topics change in condition and documentation. And signature sheets on 06/12/24, posttests from 06/10/24 - 06/13/24 and resident chart audits from 06/10/24 to 06/13/24 revealed staff were proficient in change in condition and documentation procedures. Record review of signage posting currently being put at all nurses stations: NOTIFY MD/NP OF LOW BLOOD PRESSURES . SYSTOLIC LESS THAN 95 DIASTOLIC LESS T:HAN . SYSTOLIC GREATER THAN 170 AND DIASTIC GREATER THAN 90 . ASSESS YOUR PATIENT AND DOCUMENT. Record review of LVN A's Corrective Action Memo dated 06/12/24 by DON revealed, Violation of policy and procedure, carelessness, Employer Statement: Acute change in condition is a sudden, clinically important deviation from the patient's baseline in physical, cognitive, behavioral, or functional domains. Clinically important means a deviation that, without intervention, may result in complications or death. Alert charting is documentation done to track a medical event for a period of 72 hours or longer. Events may include but not necessarily limited to suspected or actual change in condition. Action being taken Suspension Objective/Solution: Employee will understand the importance of communicating change of condition with DON, ADON, on call phone. Employee will review abnormal vital signs and verbalize values in EMR Failure to document indicates task was not completed. Employee will be suspended pending investigation. Employee statement: blank. Signed by LVN A and DON. Record review of LVN B's Corrective Action memo dated 06/13/24 by DON revealed, Violation of policy and procedure Employer Statement: Treatments completed and documented as per physician's order. Documentation will be completed by the end of the assigned shift. Failure to document

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately consult with the physician of a significant change in the resident's health status; or a need to alter treatment significantly for 1 (Resident #1) of 3 residents reviewed for parameters to notify Physician of critical blood pressure levels. 1. The facility failed to notify Resident #'1's physician and administer PRN Clonidine, when Resident #1's systolic blood pressure was over 170, as ordered, on at least four days; on 10/17/23 when the systolic blood pressure was 200, 10/27/23 when the systolic blood pressure was 196, 11/08/23 when the systolic blood pressure was 185, and 11/09/23 when the systolic blood pressure was 181, all when Resident#1's systolic blood pressure was over 170. Resident #1 was sent to the hospital on [DATE] after a change of condition, Resident #1's initial blood pressure was documented as 214/117, Resident #1 did not eat breakfast, could not swallow, and jaws shifted to the left. Resident #1's hospital admission diagnoses was a hemorrhagic stroke. Resident #1 passed away at the hospital on [DATE]. An immediate Jeopardy was identified on 12/29/23. While the Immediate Jeopardy was removed on 01/02/24, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuation of in-servicing and monitoring the Plan of Removal. This deficient practice placed residents at high risk of, or the likelihood of, serious injury, harm, impairment, or death by not receiving treatment, developing complications, and a negative outcome to a resident's physical, mental, or psychosocial health or well-being. Findings included: Record review of Resident #1' face sheet, dated 01/02/24, revealed a [AGE] year-old female, who admitted to the facility on [DATE], with a readmission date of 12/22/20. Her diagnoses included Seizures, Cerebral Infarction (stroke), Vitamin D deficiency, Long-term use of anticoagulants (blood thinners), Dysphagia (difficulty swallowing), Difficulty in walking, Cognitive Communication Deficit (difficulty thinking and how someone uses language), Conversion Disorder with Seizures or convulsions (physical and sensory problems), Hyperlipidemia (high cholesterol), and Essential Hypertension (high blood pressure). Record review of the active physician's order dated 10/30/22, revealed the following: Clonidine HCI tablet 0.1 MG. Give 1 tablet by mouth every 12 hours as needed for elevated B/P related to essential (primary) hypertension. Give clonidine 0.1 MG if the systolic blood pressure is > 170. Record review of Resident #1's Care Plan, dated 11/09/23, revealed the following, [Resident Name] will remain free from s/sx of hypertension through the next review date. Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (blood pressure issues when standing up or sitting down) and increased heart rate and effectiveness. Monitor for and document any edema. Notify MD. Monitor/Document/Report to MD PRN any s/sx of malignant hypertension: Headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, seizure activity, difficulty breathing. Obtain blood pressure readings per order. Take blood pressure readings under same condition each time. Record review of Resident #1's Medication Administration Record dated, October 2023, revealed a blood pressure reading on 10/17/23 of 200/108 and another blood pressure reading on 10/27/23 of 196/113. There was no documentation of the blood pressure rechecked after these readings. There was no evidence documented that the PRN clonidine was administered to Resident #1 on either of these dates. Record review of Resident #1's Medication Administration Record, dated, November 2023, revealed a blood pressure reading on 11/08/23 of 185/30 and another blood pressure reading on 11/09/23 of 181/111. There was no documentation of the blood pressure rechecked after these readings. There was no evidence documented that the PRN clonidine was administered to Resident #1 on either of these dates. Record review of Resident #1's Progress Notes/Nurses Notes on the electronic record, revealed no documentation on 10/17/23, 10/27/23, 11/08/23, or 11/09/23. There was no documentation on Resident #1' electronic record regarding, rechecked blood pressure, administration of clonidine, or a consultation with the physician. There was no documentation that Resident #1's physician was contacted on either of these days. Record review of the progress note on 11/16/23, revealed the resident's physician was contacted regarding the change in condition. Record review of Resident #1's Progress Notes/Nurse Notes on the electronic record, revealed on 11/16/23, resident was checked on at 6:02 AM by Nurse G, she appeared stable, then 8:30 AM, Nurse G noticed she was not eating her breakfast, did not respond when her name was called, but just looked at the nurse. It was noted Nurse G noticed resident could not swallow, vitals were taken, and Resident #1's blood pressure was 214/117. The PRN Clonidine was noted as given, Nurse G rechecked vital signs at 10:03 AM and Resident #1's blood pressure was 161/89. It was noted that Nurse G noticed resident's jaws shifting to one side. Per the progress/nurse notes, the doctor and family were notified, and Resident #1 was sent to the hospital via ambulance at 10:25 AM. Record review of Resident #1's hospital record dated 12/28/23, revealed an admission date of 11/16/23 with an admission diagnosis of hemorrhagic stroke. Resident #1's blood pressure was documented as 240/158 at admission, after intubation. The hospital record noted, She was hypertensive to the 240s systolic upon arrival and was minimally responsive. The death pronounced at 12:31 PM on 11/18/23. The preliminary cause of death was intraventricular hemorrhage. In an interview on 12/28/23 at 4:59 PM, Corporate Nurse stated Med Aide A was the person that noted the high systolic blood pressures. She stated Med Aide A informed a nurse about the high blood pressure. Corporate Nurse stated typically, a med aide would tell a nurse about a resident with high blood pressure. The staff would give a resident their scheduled blood pressure medication to see if that would help lower the resident's blood pressure. She stated in Resident #1's situation, if the scheduled high blood pressure medication was given and her blood pressure was checked later and the blood pressure was still elevated, then a nurse would give the PRN Clonidine medication. Corporate Nurse stated it should have been documented on the resident's electronic record if the blood pressure was elevated and needed to be rechecked. She stated sometimes the nurses did not document when the blood pressure had to be rechecked, but that should have been noted as well as if the PRN blood pressure medication had to be given. In an interview on 12/29/23 at 10:12 AM, Med Aide B stated she was the med aide who gave Resident #1 her medication on 10/17/23 and 10/27/23. Med Aide B stated she verbally notified Nurse C of Resident #1's high blood pressure. She stated Nurse C said okay, and she would handle it. Med Aide B stated most med aides don't document in the progress notes in the electronic record. She stated that most nurses would complete the documentation. Med Aide B stated she was told last night by DON, Administrator, and Corporate Nurse that she should have documented the high blood pressure and her verbal notification to Nurse C. She stated she was trained to document the blood pressures when she took them and to notify the nurse if there were any concerns. In an interview on 12/29/23 at 10:37 AM, Nurse Practitioner stated he was not informed of Resident #1's high blood pressure on 10/17/23, 10/27/23, 11/08/23, or 11/09/23. He stated he also was not notified that she did not receive the PRN Clonidine on those dates for the elevated systolic blood pressure. In an interview on 12/29/23 at 10:54 AM, Med Aide A stated she was one of the med aides that gave medications to Resident #1. She stated when Resident #1's blood pressure was high she gave Resident #1 her scheduled medications and let Nurse C know about the blood pressure. Med Aide A stated the nurses handled PRN medications and documentation regarding PRN medications given. Med Aide A stated the med aides would tell the nurses about the high blood pressure and the nurses would document in PCC and contact the doctor if needed. In an interview on 12/29/23 at 11:00 AM, Resident #1's physician stated the facility should have given the scheduled blood pressure medications to Resident #1, rechecked the blood pressure if it was high, then should have given the PRN blood pressure mediation if needed. On 12/29/23 at 11:15 AM, an attempt was made to contact Nurse G via telephone, but there was no answer or returned call. In an interview on 12/29/23 at 11:28 AM, Nurse C stated she was not told by any med aide that Resident #1 had high blood pressure on 10/17/23, 10/27/23, or 11/09/23. Nurse C stated Med Aide D told her Resident #1 had high blood pressure on 11/08/23. Nurse C stated she called Resident #1's physician on 11/08/23 and did not get an answer. Nurse C stated she also called and texted Resident #1's nurse practitioner but did not receive an answer regarding the high blood pressure. Nurse C stated she failed to document the blood pressure after she rechecked it, and did not remember what the last blood pressure reading was specifically. She stated she remembered the blood pressure went down, so she did not administer the PRN Clonidine. She stated she failed to note the PRN medication was not given due to Resident #1's blood pressure decreasing. Nurse C stated the risk of not notifying the doctor of any changes would be the doctor not having the option to make changes to the resident's care. In an interview on 12/29/23 at 2:47 PM, DON stated the med aides were supposed to verbally tell the nurses or write down on any piece of paper any issues or concerns with a resident. She stated there was no specific way, but the med aides knew to notify a nurse of any concerns. DON stated the nurse should recheck the blood pressure levels after the med aide voiced any concern. She stated if there were no concerns after rechecking, then the nurses do not have to document anything regarding rechecking and if any PRN medications were given. DON stated if the nurse rechecked and the blood pressure was abnormal, the nurse would either contact the doctor, or if there were orders for PRN medication, then the nurse would just follow those orders. DON stated the nurses should document if there were further issues or concerns after rechecking the blood pressure. DON stated she considered it a problem if a nurse rechecked a resident's blood pressure and it was still high. She stated if a med aide stated she told a nurse about an issue with a resident and did not document it, or if a nurse stated a med aide did not inform them, then it was no way to really know if a med aide told a nurse about an issue with a resident. DON stated the nurses are responsible for contacting the doctor if there are any concerns with the resident. DON stated Nurse C should have contacted her or an ADON if she was not able to get in contact with the doctor. DON stated since Nurse C did not document on the days in questions, she could only take the word of Nurse C when she told her Resident #1's blood pressure was rechecked and went down on the day she was informed by the med aides of any concerns. DON stated Resident #1's blood pressure would have generally been taken around 8 AM and 5 PM, give or take an hour from the scheduled medication time. DON stated Nurse G was the one that cared for Resident #1 on 11/16/23, but Nurse G's last day working at the facility was on 12/26/23. She stated Nurse G resigned. Record review of the facility's policy titled, Preventing and Detecting Adverse Consequences and Medication Errors, dated 08/2020, revealed the following: Policy The facility employs a system to ensure that medication usage is evaluated on an ongoing basis. When a resident has a change in condition, medication-related problems are considered. Significant medication-related problems are assessed, documented and reported as appropriate to the resident's attending physician, the Quality Assessment and Assurance Committee, the pharmacy, the consultant pharmacist, and the Food and Drug Administration MedWatch or Medication Error Reporting Program when applicable. An Immediate Jeopardy was identified on 12/29/23. Corporate Nurse, Administrator, DON, Regional Director of Operations, and Director of Clinical Education were notified of the Immediate Jeopardy on 12/29/23 at 4:18 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was accepted on 01/02/23 at 10:35 AM and reflected the following: PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it may concern, Summary of Details which lead to outcomes On 12/29/23, a complaint was initiated at (Facility Name and Address). A surveyor provided an IJ Template notification that the Survey Agency has determined that a condition at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F580 Notify Physician of Changes The facility failed to notify the resident's physician when there was significant change in the resident's physical status and a need to alter treatment significantly. . Identify residents who could be affected All residents have the potential to be affected. Identify responsible staff/ what action taken 1. Director of Nurses were re-educated by the Regional Nurse Consultant on the facility policy on physician notification on 12/29/23. Understanding was verified by a written post test. 2. Licensed Nurses received a re-education by the DON on the facility policy and procedure regarding documentation and following parameters for elevated blood pressures. Knowledge of education was verified by written signatures and verbalization of understanding. 3. Training for licensed nurses and Medication aides on notification changes of condition to physician and nurse management with proper documentation was initiated on 12/29/2023 by the Director of Nursing. Knowledge of education was verified by post test ad verbal signatures. 4. Medication aides and nurses were also re-educated to follow physician orders regarding interventions to maintain the resident's medication regime by the Director of Nursing on 12/29/23. Understanding of education was verified by written signatures and verbalization of understanding. 5. An audit of all blood pressure medications with parameters was initiated on 12/29/2023 by the DON and ADON. Resulting in parameters being adjusted by physician and orders updated. 6. Audit of all PRN blood pressure medication with parameters was initiated on 12/29/2023 by the DON and ADON. In-Services conducted: 1. Change in condition 2. Medication administration 3. Physician notification The in-services were attended by licensed caregivers which include Registered Nurse, Licensed Vocational Nurse, and Certified Medication Aide. Understanding of in-services will be verified with a written/and or verbal post test. This in-service was initiated on 12/29/23 and all staff must be in-service before they are allowed to work. New staff will be educated about resident change in condition, medication administration before their floor orientation and monitored will be continued ongoing by the DON/Designee. Implementation of changes: The changes which include monitoring of medications not given and change in condition of residents through 24 reports were started by the Director of Nursing. The changes were implemented effective on 12/29/23 and will be ongoing until all staff are re-educated. The Director of Nursing will ensure competency through verbalization of understanding by staff and in servicing. Monitoring The Administrator/Director of Nursing/Assistant Director of Nursing will be responsible for monitoring the implementation and effectiveness of in-service on 12/29/23. Director of Nursing/Designee will monitor/review vital signs on the 24-hour report and SBAR for change in condition and physician notification x4 weeks, then weekly x2 weeks, then monthly and report any adverse finding during QAPI Director of Nursing/Designee will conduct a daily audit of scheduled and PRN blood pressure medications with parameters daily x4 weeks, then weekly x 2 weeks, then monthly and report any adverse findings during QAPI. The Regional Nurse Consultant will audit the implementation process 3x per week x4weeks, then weekly x4weeks, then monthly ongoing and report any adverse findings during QAPI Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 12/29/23 and conducted an Ad HOC QAPI regarding physician notification and change in condition. The Medical Director, (Doctor's Name) was notified about the immediate Jeopardy on 12/29/23, the Plan of removal was reviewed and accepted by (Doctor's Name). Involvement of QA An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, and social services director to review plan of removal on 12/29/23. Who is responsible for implementation of process? The Director of Nursing will be responsible for the implementation of the new process. The New Process/system was started on 12/29/23. The Administrator will ensure DON implements the new process. Regional Nurse Consultant will audit the implementation of the new process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy verbally issued on 12/29/23. Monitoring: In an interview on 01/02/24 at 12:01 PM, Social Worker stated she had received some in-services since 12/29/23. She stated she received an in-service on change of condition, protocols related to changes in residents, and how those changes should be reported. In an interview on 01/02/24 at 12:22 PM, Med Aide B stated she received in-services since Friday, 12/29/23. She stated she received an in-service on resident blood pressures, what and when to check and when it needs to be reported to a nurse. Med Aide B stated the in-services covered documenting the blood pressure and any changes and documenting that nurse was notified. She stated she also received an in-service on change of condition. In an interview on 01/02/24 at 12:35 PM, Charge Nurse stated she received in-services last Thursday that covered medication administration, documentation of meds administered and when vitals are rechecked, change of condition, taking blood pressure, physician's orders, what nurses should do if med aides report any changes of conditions, how to document change of condition in residents, blood pressure medications, care plans, vital signs, what to do when there is irregular vitals, and PRN blood pressure medications, if it's ordered to go ahead and give the medication according to the doctor's orders. In an interview on 01/02/24 at 1:05 PM, Med Aide D stated she was in-serviced yesterday, 01/01/24, that covered medications and residents changes of condition. She stated during the in-service she was told to notify the nurse with any changes of any resident. Med Aide D stated the in-service also covered how to take blood pressures and when to know there were issues with a resident's blood pressure. In an interview on 01/02/24 at 1:14 PM, ADON stated she received in-services last Thursday (12/28/23), and it covered medication administration, elevated blood pressures, change of condition in residents, notifying the resident's physician and family, following the care plan, and proper documentation. She stated she was in-serviced by DON. In an interview on 01/02/24 at 1:20 PM, DON stated she in-serviced all of the staff in the facility that reported to her, and Corporate Nurse in-serviced her. She stated she was in-serviced on change of condition, medication administration, when and how to notify the doctor and family, how to review the 24-hour reports to monitor for a change in condition, and how to ensure nurses are documenting and reporting changes in blood pressure. She stated the housekeeping and laundry department was in-serviced as well. In a telephone interview on 01/02/24 at 1:30 PM, Med Aide E stated he was in-serviced on change of condition, PRN medications, notifying the nurse when there are concerns, and blood pressures. In an interview on 01/02/24 at 1:36 PM, Nurse C stated she was in-serviced since last Thursday on PRN medications, vitals, change of conditions, and notifying the physician of any changes. In an interview on 01/02/24 at 1:48 PM, Housekeeper stated she received an in-service on change of condition in residents. She stated she was trained to notify the nurse if they see something different about the resident, like breathing differently, looks differently, or if they appear to not be their normal self. Housekeeper stated she was told to contact the DON or ADON if the nurse did not do anything about her concerns. In a telephone interview, on 01/02/24 at 1:52 PM, Nurse F stated he received additional training last week, around 12/28/23, that covered notification on changes, how the med aide should notify a nurse of any issues, how a nurse should contact the physician, or the DON/ADON if there are concerns of if the nurses are not able to reach the doctor. He stated the in-service also covered PRN medications, and checking vitals, including blood pressure. In an interview on 01/02/24 at 1:58 PM, Administrator stated he was in-serviced by Corporate Nurse. He stated he was in-serviced on change of condition, medication errors, physician notification, blood pressure, who needs to notify who of a change in condition with a resident, what the nurses should do once they are notified of a change in condition, and what the med aides are required to do in the process. A record review of the following was completed on 01/02/24: Blood Pressure medication audit of all residents, including all revisions since 12/28/23. There were no concerns. An in-service for Medication Administration, Documentation of rechecked Vitals, Documentation when all medications are given, Documentation of notifications to nurse and doctor, Change of Condition, and Following Physician's Orders, dated 12/29/23, instructor noted as DON, and instructor for DON was Corporate Nurse All post tests for all in-services completed Sign-off Verification that all vitals were checked on all residents and audits were completed on calendar for 12/28/23, 12/29/23, 12/30/23, 12/31/23, 01/01/24, and 01/02/24, and signed-off by Administrator, DON, and Corporate Nurse. An untitled, undated, facility document with review of all vitals for residents on 12/28/23, 12/29/23, 12/30/23, 12/31/23, 01/01/24, and 01/02/24, which included weight, respiration, blood pressure, temperature, pulse, blood sugar, height, O2 saturation, and pain levels for each resident. Document of verification of all active orders reviewed and updated if needed. Administrator was notified on 01/02/24, the Immediate Jeopardy was removed. While the immediacy was removed on 01/02/24, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy due to the facility continuing in-servicing and monitoring of the Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one resident (Resident #1) of three residents reviewed for change in physical, mental, or psychosocial status. The facility failed to give Resident #1 her PRN anti-hypertensive medication as ordered and noted on the care plan. The facility failed monitor and document signs and symptoms of malignant hypertension as noted on the care plan for Resident #1. Resident #1 was sent to the hospital on [DATE] after a change of condition, when Resident #1's initial blood pressure was documented as 214/117, Resident #1 did not eat breakfast, could not swallow, and jaws shifted to the left. Resident #1's hospital admission diagnoses was a hemorrhagic stroke. Resident #1 passed away at the hospital on [DATE]. An immediate Jeopardy was identified on 12/29/23. While the Immediate Jeopardy was removed on 01/02/24, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuation of in-servicing and monitoring the Plan of Removal. This failure could affect residents by placing them at risk for a delay in medical treatment and worsening in condition, hospitalization, and/or death. Findings included: Record review of Resident #1' face sheet, dated 01/02/24, revealed a [AGE] year-old female, who admitted to the facility on [DATE], with a readmission date of 12/22/20. Her diagnoses included Seizures, Cerebral Infarction (stroke), Vitamin D deficiency, Long-term use of anticoagulants (blood thinners), Dysphagia (difficulty swallowing), Difficulty in walking, Cognitive Communication Deficit (difficulty thinking and how someone uses language), Conversion Disorder with Seizures or convulsions (physical and sensory problems), Hyperlipidemia (high cholesterol), and Essential Hypertension (high blood pressure). Record review of the active physician's order dated 10/30/22, revealed the following: Clonidine HCI tablet 0.1 MG. Give 1 tablet by mouth every 12 hours as needed for elevated B/P related to essential (primary) hypertension. Give clonidine 0.1 MG if the systolic blood pressure is > 170. Record review of Resident #1's Care Plan, dated 11/09/23, revealed the following, [Resident Name] will remain free from s/sx of hypertension through the next review date. Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (blood pressure issues when standing up or sitting down) and increased heart rate and effectiveness. Monitor for and document any edema. Notify MD. Monitor/Document/Report to MD PRN any s/sx of malignant hypertension: Headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, seizure activity, difficulty breathing. Obtain blood pressure readings per order. Take blood pressure readings under same condition each time. Record review of Resident #1's Medication Administration Record dated, October 2023, revealed a blood pressure reading on 10/17/23 of 200/108 and another blood pressure reading on 10/27/23 of 196/113. There was no documentation of the blood pressure rechecked after these readings. There was no evidence documented that the PRN clonidine was administered to Resident #1 on either of these dates. Record review of Resident #1's Medication Administration Record, dated, November 2023, revealed a blood pressure reading on 11/08/23 of 185/30 and another blood pressure reading on 11/09/23 of 181/111. There was no documentation of the blood pressure rechecked after these readings. There was no evidence documented that the PRN clonidine was administered to Resident #1 on either of these dates. Record review of Resident #1's Progress Notes/Nurses Notes on the electronic record, revealed no documentation on 10/17/23, 10/27/23, 11/08/23, or 11/09/23. There was no documentation on Resident #1' electronic record regarding, rechecked blood pressure, administration of clonidine, or a consultation with the physician. There was no documentation that Resident #1's physician was contacted on either of these days. Record review of the progress note on 11/16/23, revealed the resident's physician was contacted regarding the change in condition. Record review of Resident #1's Progress Notes/Nurse Notes on the electronic record, revealed on 11/16/23, resident was checked on at 6:02 AM by Nurse G, she appeared stable, then 8:30 AM, Nurse G noticed she was not eating her breakfast, did not respond when her name was called, but just looked at the nurse. It was noted Nurse G noticed resident could not swallow, vitals were taken, and Resident #1's blood pressure was 214/117. The PRN Clonidine was noted as given, Nurse G rechecked vital signs at 10:03 AM and Resident #1's blood pressure was 161/89. It was noted that Nurse G noticed resident's jaws shifting to one side. Per the progress/nurse notes, the doctor and family were notified, and Resident #1 was sent to the hospital via ambulance at 10:25 AM. Record review of Resident #1's hospital record dated 12/28/23, revealed an admission date of 11/16/23 with an admission diagnosis of hemorrhagic stroke. Resident #1's blood pressure was documented as 240/158 at admission, after intubation. The hospital record noted, She was hypertensive to the 240s systolic upon arrival and was minimally responsive. The death pronounced at 12:31 PM on 11/18/23. The preliminary cause of death was intraventricular hemorrhage. In an interview on 12/28/23 at 4:59 PM, Corporate Nurse stated typically, the staff, typically the med aide, would give a resident their scheduled blood pressure medication to see if that would help lower the resident's blood pressure. She stated in Resident #1's situation, if the scheduled high blood pressure medication was given, and her blood pressure was checked later, the blood pressure was still elevated, then a nurse should have given the PRN Clonidine medication. Corporate Nurse stated someone should have documented on the resident's electronic record if the blood pressure was elevated, needed to be rechecked, and if the PRN medication was given or not. In a telephone interview on 12/29/23 at 10:37 AM, Nurse Practitioner stated the blood pressure being high and not addressed could have contributed to Resident #1 going to the hospital, but he stated he could not say because he did not know all the specifics. He stated the PRN clonidine should have been given to Resident #1 as ordered. He stated the facility staff should have given the scheduled blood pressure medications, if the systolic was high, the staff should have rechecked the blood pressure, and if it was still high, the facility staff should have given Resident #1 the PRN medication. He stated if the blood pressure was still high after that, or if resident had any change in condition, he or the resident's physician should have been notified. Nurse Practitioner stated he did not recall being contacted on 10/17/23, 10/27/23, 11/08/23, or 11/09/23. In a telephone interview on 12/29/23 at 11:00 AM, Resident #1's Physician stated Resident #1's high blood pressure on 11/16/23, could have contributed to her having to go to the hospital. He stated he could not say if the high blood pressure on the other dates could have contributed to her going to the hospital on [DATE]. He stated he did not recall being contacted by any facility staff regarding Resident #1's change in condition on 10/17/23, 10/27/23, 11/08/23, or 11/09/23. He stated he may have made changes to Resident #1's orders, but he stated he could not say for certain, because he did not know the specifics of what occurred. On 12/29/23 at 11:15 AM, an attempt was made to contact Nurse G via telephone, but there was no answer or returned call. In an interview on 12/29/23 at 11:28 AM, Nurse C stated she was not told by any med aide that Resident #1 had a systolic reading over 170 on 10/17/23, 10/27/23, or 11/09/23, so she was not aware that the resident might have needed the PRN medication. Nurse C stated Med Aide A told her about Resident #1's systolic blood pressure being over 170 on 11/08/23. She stated they rechecked Resident #1's blood pressure, it was lower, but she failed to document it on Resident #1's electronic record. She stated she did not give the PRN blood pressure medication on that day either. Nurse C stated she contacted the doctor and nurse practitioner, but did not receive a response. She stated she failed to document her attempt to reach the doctor or nurse practitioner. Nurse C stated at the time there was no risk of not giving the PRN medication to Resident #1 on 11/08/23, because the resident's blood pressure went down. Nurse C stated that the staff should follow the care plan of a resident, and that care plan can be located on the resident's electronic record. Nurse C stated she failed to document the blood pressure after she rechecked it, and did not remember what the last blood pressure reading was specifically. She stated she remembered the blood pressure went down, so she did not administer the PRN Clonidine. She stated she failed to note the PRN medication was not given due to Resident #1's blood pressure decreasing. She stated a risk of not following the plan could be issues with the resident. In an interview on 12/29/23 at 2:47 PM, DON stated the nurse should recheck the blood pressure levels after the med aide voiced any concern. She stated if there were no concerns after rechecking, then the nurses do not have to document anything regarding rechecking and if any PRN medications were given. DON stated Nurse C should have followed the physician's orders for PRN medications, if the systolic blood pressure was over 170. DON stated she considered it a problem if a nurse rechecked a resident's blood pressure and it was still high, and the PRN medication was not given. DON stated the nurses were responsible for giving PRN medication. DON stated since Nurse C did not document on the days in question, she could only take the word of Nurse C when she told her Resident #1's blood pressure was rechecked and went down on the day she was informed by the medication aides of any concerns. DON stated all staff should follow the care plan and all orders. DON stated Nurse G was the one that cared for Resident #1 on 11/16/23, but Nurse G's last day working at the facility was on 12/26/23. She stated Nurse G resigned. She stated the risk of not following the care plan or orders is possible changes with the resident. Record review of The American Heart Association's article titled, The Facts About High Blood Pressure, dated 05/25/23, revealed the following: Most of the time there are no obvious symptoms. Blood pressure cannot be cured. But it can be managed effectively through life style changed and, when needed, medication. When left untreated, the damage that high blood pressure does to your circulatory system is a significant contributing factor to heart attack, stroke and other health threats. Review of the facility's policy titled, Care Planning, revised on 06/20, and titled Care Planning stated the following: IX. Each resident's Comprehensive Care Plan will describe the following: A. Services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychological well-being . An Immediate Jeopardy was identified on 12/29/23. Corporate Nurse, Administrator, DON, Regional Director of Operations, and Director of Clinical Education were notified of the Immediate Jeopardy on 12/29/23 at 4:18 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was accepted on 01/02/23 at 10:35 AM and reflected the following: Date: 12/29/23 PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it may concern, Summary of Details which lead to outcomes: On 12/29/23, a complaint was initiated at (Facility name and address). A surveyor provided an IJ Template notification that the Survey Agency has determined that a condition at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F684 Quality of Care The facility failed to follow Resident #1's care plan regarding hypertension. The plan stated to monitor, document, and report signs or symptoms of malignant hypertension, and it was not documented as monitored on all days, the doctor was not notified of all signs or symptoms. Identify residents who could be affected: All residents have the potential to be affected. Identify responsible staff/ what action taken: 13. Director of Nurses were re-educated by the Regional Nurse Consultant on the facility policy on monitoring, documenting, and reporting abnormal signs or symptoms on 12/29/23. Understanding was verified by a written post test. 14. Licensed Nurses received a re-education by the DON on the facility policy and procedure regarding documentation and following parameters for elevated blood pressures initiated on 12/29/23. Knowledge of education was verified by written signatures and verbalization of understanding. 15. Training for licensed nurses and medication aides on notification of changes in condition to physician and nurse management with proper documentation was initiated on 12/29/2023 by the Director of Nursing. Knowledge of education was verified by written signatures and verbalization of understanding. 16. Medication aides and nurses were also re-educated to follow the resident plan of care regarding interventions to maintain the resident's medication regime by the Director of Nursing on 12/29/23. Knowledge of education was verified by written signatures and verbalization of understanding. 17. An audit of all blood pressure medications with parameters was initiated on 12/29/2023 by the DON and ADON. Resulting in parameters being adjusted by physician and orders updated. 18. Audit of all PRN blood pressure medication with parameters was initiated on 12/29/2023 by the DON and ADON. In-Services conducted: 7. Change in condition. 8. Medication administration 9. Following plan of care The in-services were attended by licensed caregivers which include Registered Nurse, Licensed Vocational Nurse, and Certified Medication Aide. Understanding of in-services will be verified with a written/and or verbal post test. This in-service was initiated on 12/29/23 and all staff must be in-service before they are allowed to work. New staff will be educated about resident change in condition, medication administration before their floor orientation and monitored will be continued ongoing by the DON/Designee. Implementation of changes (Monitoring all or any medication not given and change in condition of residents through 24 hour report). The changes which include monitoring of all or any medications not given and change in condition of residents through 24 hr. reports were started by the Director of Nursing. The changes of monitoring of all or any medications not given and change in condition of residents through 24hr were implemented effective on 12/29/23 and will be ongoing until all staff are re-educated. The Director of Nursing will ensure competency through verbalization of understanding by staff and in servicing. Monitoring The Administrator/Director of Nursing/Assistant Director of Nursing will be responsible for monitoring the implementation and effectiveness of in-service on 12/29/23. The Director of Nursing/Designee will monitor/review vital signs daily and review 24-hour report for change in condition x4 weeks, then weekly x2 weeks, then monthly and report any adverse finding during QAPI. Director of Nursing/Designee will conduct a daily audit of missing medications and change in condition daily x4 weeks, then weekly x 2 weeks, then monthly and report any adverse findings during QAPI. Director of Nursing/Designee will conduct a daily audit of scheduled and PRN blood pressure medications with parameters daily x4 weeks, then weekly x 2 weeks, then monthly and report any adverse findings during QAPI. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 12/29/23 and conducted an Ad HOC QAPI regarding physician notification and change in condition. The Medical Director, (Doctor's Name) was notified about the immediate Jeopardy on 12/29/23, the Plan of removal was reviewed and accepted by (Doctor's Name). Involvement of QA An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, and social services director to review plan of removal on 12/29/23. Who is responsible for the implementation of the process? The Director of Nursing will be responsible for the implementation of the new process. The New Process/system was started on 12/29/23. The Administrator will ensure DON implements the new process. Regional Nurse Consultant will audit the implementation of the new process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy verbally issued on 12/29/23. Monitoring: In an interview on 01/02/24 at 12:01 PM, Social Worker stated she had received some in-services since 12/29/23. She stated she received an in-service on change of condition, protocols related to changes in residents, and how those changes should be reported. In an interview on 01/02/24 at 12:22 PM, Med Aide B stated she received in-services since Friday, 12/29/23. She stated she received an in-service on resident blood pressures, what and when to check and when it needs to be reported to a nurse. Med Aide B stated the in-services covered documenting the blood pressure and any changes and documenting that nurse was notified. She stated she also received an in-service on change of condition. In an interview on 01/02/24 at 12:35 PM, Charge Nurse stated she received in-services last Thursday that covered medication administration, documentation of meds administered and when vitals are rechecked, change of condition, taking blood pressure, physician's orders, what nurses should do if med aides report any changes of conditions, how to document change of condition in residents, blood pressure medications, care plans, vital signs, what to do when there is irregular vitals, and PRN blood pressure medications, if it's ordered to go ahead and give the medication according to the doctor's orders. In an interview on 01/02/24 at 1:05 PM, Med Aide D stated she was in-serviced yesterday, 01/01/24, that covered medications and residents changes of condition. She stated during the in-service she was told to notify the nurse with any changes of any resident. Med Aide D stated the in-service also covered how to take blood pressures and when to know there were issues with a resident's blood pressure. In an interview on 01/02/24 at 1:14 PM, ADON stated she received in-services last Thursday (12/28/23), and it covered medication administration, elevated blood pressures, change of condition in residents, notifying the resident's physician and family, following the care plan, and proper documentation. She stated she was in-serviced by DON. In an interview on 01/02/24 at 1:20 PM, DON stated she in-serviced all of the staff in the facility that reported to her, and Corporate Nurse in-serviced her. She stated she was in-serviced on change of condition, medication administration, when and how to notify the doctor and family, how to review the 24-hour reports to monitor for a change in condition, and how to ensure nurses are documenting and reporting changes in blood pressure. She stated the housekeeping and laundry department was in-serviced as well. In a telephone interview on 01/02/24 at 1:30 PM, Med Aide E stated he was in-serviced on change of condition, PRN medications, notifying the nurse when there are concerns, and blood pressures. In an interview on 01/02/24 at 1:36 PM, Nurse C stated she was in-serviced since last Thursday on PRN medications, vitals, change of conditions, and notifying the physician of any changes. In a telephone interview, on 01/02/24 at 1:52 PM, Nurse F stated he received additional training last week, around 12/28/23, that covered notification on changes, how the med aide should notify a nurse of any issues, how a nurse should contact the physician, or the DON/ADON if there are concerns of if the nurses are not able to reach the doctor. He stated the in-service also covered PRN medications, and checking vitals, including blood pressure. In an interview on 01/02/24 at 1:58 PM, Administrator stated he was in-serviced by Corporate Nurse. He stated he was in-serviced on change of condition, medication errors, physician notification, blood pressure, who needs to notify who of a change in condition with a resident, what the nurses should do once they are notified of a change in condition, and what the med aides are required to do in the process. A record review of the following was completed on 01/02/24: Blood Pressure medication audit of all residents, including all revisions since 12/28/23. There were no concerns. An in-service for Medication Administration, Documentation of rechecked Vitals, Documentation when all medications are given, Documentation of notifications to nurse and doctor, Change of Condition, and Following Physician's Orders, dated 12/29/23, instructor noted as DON, and instructor for DON was Corporate Nurse All post tests for all in-services completed Sign-off Verification that all vitals were checked on all residents and audits were completed on calendar for 12/28/23, 12/29/23, 12/30/23, 12/31/23, 01/01/24, and 01/02/24, and signed-off by Administrator, DON, and Corporate Nurse. An untitled, undated, facility document with review of all vitals for residents on 12/28/23, 12/29/23, 12/30/23, 12/31/23, 01/01/24, and 01/02/24, which included weight, respiration, blood pressure, temperature, pulse, blood sugar, height, O2 saturation, and pain levels for each resident. Document of verification of all active orders reviewed and updated if needed. Administrator was notified on 01/02/24, the Immediate Jeopardy was removed. While the immediacy was removed on 01/02/24, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy due to the facility continuing in-servicing and monitoring of the Plan of Removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed ensure residents were free of any significant medication errors for one (Residents #1) of three residents reviewed for medications. Nurse C failed to give the PRN Clonidine as ordered by the physician for Resident #1 on 10/17/23, 10/27/23, 11/08/23, and 11/09/23, when Resident #'s systolic blood pressure was over 170. Resident #1 was sent to the hospital on [DATE] after a change of condition, when Resident #1's initial blood pressure was documented as 214/117, Resident #1 did not eat breakfast, could not swallow, and jaws shifted to the left. Resident #1's hospital admission diagnoses was a hemorrhagic stroke. Resident #1 passed away at the hospital on [DATE]. An immediate Jeopardy was identified on 12/29/23. While the Immediate Jeopardy was removed on 01/02/24, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuation of in-servicing and monitoring the Plan of Removal. This failure could affect residents by placing them at risk for a delay in medical treatment, worsening in condition, or possible death. Findings included: Record review of Resident #1' face sheet, dated 01/02/24, revealed a [AGE] year-old female, who admitted to the facility on [DATE], with a readmission date of 12/22/20. Her diagnoses included Seizures, Cerebral Infarction (stroke), Vitamin D deficiency, Long-term use of anticoagulants (blood thinners), Dysphagia (difficulty swallowing), Difficulty in walking, Cognitive Communication Deficit (difficulty thinking and how someone uses language), Conversion Disorder with Seizures or convulsions (physical and sensory problems), Hyperlipidemia (high cholesterol), and Essential Hypertension (high blood pressure). Record review of the active physician's order dated 10/30/22, revealed the following: Clonidine HCI tablet 0.1 MG. Give 1 tablet by mouth every 12 hours as needed for elevated B/P related to essential (primary) hypertension. Give clonidine 0.1 MG if the systolic blood pressure is > 170. Record review of Resident #1's Care Plan, dated 11/09/23, revealed the following, [Resident Name] will remain free from s/sx of hypertension through the next review date. Give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (blood pressure issues when standing up or sitting down) and increased heart rate and effectiveness. Monitor for and document any edema. Notify MD. Monitor/Document/Report to MD PRN any s/sx of malignant hypertension: Headache, visual problems, confusion, disorientation, lethargy, nausea and vomiting, irritability, seizure activity, difficulty breathing. Obtain blood pressure readings per order. Take blood pressure readings under same condition each time. Record review of Resident #1's Medication Administration Record dated, October 2023, revealed a blood pressure reading on 10/17/23 of 200/108 and another blood pressure reading on 10/27/23 of 196/113. There was no documentation of the blood pressure rechecked after these readings. There was no evidence documented that the PRN clonidine was administered to Resident #1 on either of these dates. Record review of Resident #1's Medication Administration Record, dated, November 2023, revealed a blood pressure reading on 11/08/23 of 185/30 and another blood pressure reading on 11/09/23 of 181/111. There was no documentation of the blood pressure rechecked after these readings. There was no evidence documented that the PRN clonidine was administered to Resident #1 on either of these dates. Record review of Resident #1's Progress Notes/Nurses Notes on the electronic record, revealed no documentation on 10/17/23, 10/27/23, 11/08/23, or 11/09/23. There was no documentation on Resident #1' electronic record regarding, rechecked blood pressure, administration of clonidine, or a consultation with the physician. There was no documentation that Resident #1's physician was contacted on either of these days. Record review of the progress note on 11/16/23, revealed the resident's physician was contacted regarding the change in condition. Record review of Resident #1's Progress Notes/Nurse Notes on the electronic record, revealed on 11/16/23, resident was checked on at 6:02 AM by Nurse G, she appeared stable, then 8:30 AM, Nurse G noticed she was not eating her breakfast, did not respond when her name was called, but just looked at the nurse. It was noted Nurse G noticed resident could not swallow, vitals were taken, and Resident #1's blood pressure was 214/117. The PRN Clonidine was noted as given, Nurse G rechecked vital signs at 10:03 AM and Resident #1's blood pressure was 161/89. It was noted that Nurse G noticed resident's jaws shifting to one side. Per the progress/nurse notes, the doctor and family were notified, and Resident #1 was sent to the hospital via ambulance at 10:25 AM. Record review of Resident #1's hospital record dated 12/28/23, revealed an admission date of 11/16/23 with an admission diagnosis of hemorrhagic stroke. Resident #1's blood pressure was documented as 240/158 at admission, after intubation. The hospital record noted, She was hypertensive to the 240s systolic upon arrival and was minimally responsive. The death pronounced at 12:31 PM on 11/18/23. The preliminary cause of death was intraventricular hemorrhage. In an interview on 12/28/23 at 4:59 PM, Corporate Nurse stated typically, the staff, typically the med aide, would give a resident their scheduled blood pressure medication to see if that would help lower the resident's blood pressure. She stated in Resident #1's situation, if the scheduled high blood pressure medication was given, and her blood pressure was checked later, the blood pressure was still elevated, then a nurse should have given the PRN Clonidine medication. Corporate Nurse stated someone should have documented on the resident's electronic record if the blood pressure was elevated, needed to be rechecked, and if the PRN medication was given or not. In an interview on 12/29/23 at 10:12 AM, Med Aide B stated she was the med aide who gave Resident #1 her medication on 10/17/23 and 10/27/23. Med Aide B stated she verbally notified Nurse C of Resident #1's high blood pressure. She stated Nurse C said okay, and she would handle it. Med Aide B stated most med aides don't document in the progress notes in the electronic record. She stated that most nurses would complete the documentation. Med Aide B stated she was told last night by DON, Administrator, and Corporate Nurse that she should have documented the high blood pressure and her verbal notification to Nurse C. She stated she was trained to document the blood pressures when she took them and to notify the nurse if there were any concerns. In an interview on 12/29/23 at 10:54 AM, Med Aide A stated she was one of the med aides that gave medications to Resident #1. She stated when Resident #1's blood pressure was high she gave Resident #1 her scheduled medications and let Nurse C know about the blood pressure. Med Aide A stated the nurses handled PRN medications and documentation regarding PRN medications given. Med Aide A stated the med aides would tell the nurses about the high blood pressure and the nurses would document in PCC and contact the doctor if needed. On 12/29/23 at 11:15 AM, an attempt was made to contact Nurse G via telephone, but there was no answer or returned call. In an interview on 12/29/23 at 11:28 AM, Nurse C stated she was not told by any med aide that Resident #1 had a systolic reading over 170 on 10/17/23, 10/27/23, or 11/09/23, so she was not aware that the resident might have needed the PRN medication. Nurse C stated Med Aide A told her about Resident #1's systolic blood pressure being over 170 on 11/08/23. She stated they rechecked Resident #1's blood pressure, it was lower, but she failed to document it on Resident #1's electronic record. She stated she did not give the PRN blood pressure medication on that day either. Nurse C stated she failed to document the blood pressure after she rechecked it, and did not remember what the last blood pressure reading was specifically. She stated she remembered the blood pressure went down, so she did not administer the PRN Clonidine. She stated she failed to note the PRN medication was not given due to Resident #1's blood pressure decreasing. Nurse C stated at the time there was no risk of not giving the PRN medication to Resident #1 on 11/08/23, because the resident's blood pressure went down. In an interview on 12/29/23 at 2:47 PM, DON stated the nurse should recheck the blood pressure levels after the med aide voiced any concern. She stated if there were no concerns after rechecking, then the nurses do not have to document anything regarding rechecking and if any PRN medications were given. DON stated Nurse C should have followed the physician's orders for PRN medications, if the systolic blood pressure was over 170. DON stated she considered it a problem if a nurse rechecked a resident's blood pressure and it was still high, and the PRN medication was not given. DON stated the nurses were responsible for giving PRN medication. DON stated since Nurse C did not document on the days in question, she could only take the word of Nurse C when she told her Resident #1's blood pressure was rechecked and went down on the day she was informed by the medication aides of any concerns. DON stated all staff should follow the care plan and all orders. She stated the risk of not following the care plan or orders is possible changes with the resident. Record review of The American Heart Association's article titled, The Facts About High Blood Pressure, dated 05/25/23, revealed the following: Most of the time there are no obvious symptoms. Blood pressure cannot be cured. But it can be managed effectively through life style changed and, when needed, medication. When left untreated, the damage that high blood pressure does to your circulatory system is a significant contributing factor to heart attack, stroke and other health threats. Record review of the facility's undated policy titled, Medication- Administration, Nursing Manual- Nursing Care, revealed the following: Purpose To Provide practice standards for safe administration of medications for residents in the facility. I. Medication will be administered by a licensed nurse per the order of an attending physician or licensed independent practitioner, or as consistent with state law. An Immediate Jeopardy was identified on 12/29/23. Corporate Nurse, Administrator, DON, Regional Director of Operations, and Director of Clinical Education were notified of the Immediate Jeopardy on 12/29/23 at 4:18 PM and were provided with the Immediate Jeopardy Template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Plan of Removal was accepted on 01/02/23 at 10:35 AM and reflected the following: Date: 12/29/23 PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY To Whom it may concern, Summary of Details which lead to outcomes: On 12/29/23, a complaint was initiated at (Facility Name and Address). A surveyor provided an IJ Template notification that the Survey Agency has determined that a condition at the center constitute immediate jeopardy to resident health. The notification of the alleged immediate jeopardy states as follows: F760 Residents Are Free of Significant Med Errors The facility failed to remain free of significant medication errors. Identify residents who could be affected: All residents have the potential to be affected. Identify responsible staff/ what action taken: 7. Director of Nurses was re-educated by the Regional Nurse Consultant on the facility medication administration policy on 12/29/23. Understanding was verified by a written post test. 8. Licensed Nurses received a re-education by the DON on the facility policy medication administration on 12/29/23. Understanding of education was verified by written post test. 9. Training for licensed nurses and medication aides on notification of changes in condition to physician and nurse management with proper documentation was initiated on 12/29/2023 by the Director of Nursing. Understanding of education was verified by written signatures and verbalization of understanding. 10. Medication aides were re-educated on the process of notification to the nurse by medication aides for PRN medications by the Director of Nursing on 12/29/23. Understanding of education was verified by written signatures and verbalization of understanding. 11. An audit of all blood pressure medications with parameters was initiated on 12/29/2023 by the DON and ADON. Resulting in parameters being adjusted by physician and orders updated. 12. Audit of all PRN blood pressure medication with parameters was initiated on 12/29/2023 by the DON and ADON. In-Services conducted: 4. Change in condition. 5. Medication administration 6. Following plan of care The in-services were attended by licensed caregivers which include Registered Nurse, Licensed Vocational Nurse, and Certified Medication Aide. Understanding of in-services will be verified with a written/and or verbal post test. This in-service was initiated on 12/29/23 and all staff must be in-service before they are allowed to work. New staff will be educated about resident change in condition, medication administration before their floor orientation and monitored will be continued ongoing by the DON/Designee. Implementation of changes (Monitoring all or any medication not given and change in condition of residents through 24 hour report). The changes which include monitoring of all or any medications not given and change in condition of residents through 24 hr. reports were started by the Director of Nursing. The changes of monitoring of all or any medications not given and change in condition of residents through 24hr were implemented effective on 12/29/23 and will be ongoing until all staff are re-educated. The Director of Nursing will ensure competency through verbalization of understanding by staff and in servicing. Monitoring The Administrator/Director of Nursing/Assistant Director of Nursing will be responsible for monitoring the implementation and effectiveness of in-service on 12/29/23. The Director of Nursing/Designee will monitor/review vital signs daily and review 24-hour report for change in condition x4 weeks, then weekly x2 weeks, then monthly and report any adverse finding during QAPI. Director of Nursing/Designee will conduct a daily audit of missing medications and change in condition daily x4 weeks, then weekly x 2 weeks, then monthly and report any adverse findings during QAPI. Director of Nursing/Designee will conduct a daily audit of scheduled and PRN blood pressure medications with parameters daily x4 weeks, then weekly x 2 weeks, then monthly and report any adverse findings during QAPI. The Regional Nurse Consultant will audit the implementation process 3x per week x4weeks, then weekly x4weeks, then monthly ongoing and report any adverse findings during QAPI. Involvement of Medical Director The Medical Director met with the Interdisciplinary team on 12/29/23 and conducted an Ad HOC QAPI regarding physician notification and change in condition. The Medical Director, (Doctor's Name) was notified about the immediate Jeopardy on 12/29/23, the Plan of removal was reviewed and accepted by (Doctor's Name). Involvement of QA An Ad Hoc QAPI meeting was held with the Medical Director, facility administrator, director of nursing, and social services director to review plan of removal on 12/29/23. Who is responsible for the implementation of process? The Director of Nursing will be responsible for the implementation of the new process. The New Process/system was started on 12/29/23. The Administrator will ensure DON implements the new process. Regional Nurse Consultant will audit the implementation of the new process. Please accept this letter as our plan of removal for the determination of Immediate Jeopardy verbally issued on 12/29/23. Monitoring: In an interview on 01/02/24 at 12:01 PM, Social Worker stated she had received some in-services since 12/29/23. She stated she received an in-service on change of condition, protocols related to changes in residents, and how those changes should be reported. Social Worker stated she also completed an in-service on taking vital signs as well. In an interview on 01/02/24 at 12:22 PM, Med Aide B stated she received in-services since Friday, 12/29/23. She stated she received an in-service on resident blood pressures, what and when to check and when it needs to be reported to a nurse. Med Aide B stated the in-services covered documenting the blood pressure and any changes and documenting that nurse was notified. She stated she also received an in-service on change of condition. In an interview on 01/02/24 at 12:35 PM, Charge Nurse stated she received in-services last Thursday that covered medication administration, change of condition, taking blood pressure, physician's orders, what nurses should do if med aides report any changes of conditions, how to document change of condition in residents, blood pressure medications, care plans, vital signs, what to do when there is irregular vitals, and PRN blood pressure medications, if it's ordered to go ahead and give the medication according to the doctor's orders. In an interview on 01/02/24 at 1:05 PM, Med Aide D stated she was in-serviced yesterday, 01/01/24, that covered medications and residents changes of condition. She stated during the in-service she was told to notify the nurse with any changes of any resident. Med Aide D stated the in-service also covered how to take blood pressures and when to know there were issues with a resident's blood pressure. In an interview on 01/02/24 at 1:14 PM, ADON stated she received in-services last Thursday (12/28/23), and it covered medication administration, elevated blood pressures, change of condition in residents, notifying the resident's physician and family, following the care plan, and proper documentation. She stated she was in-serviced by DON. In an interview on 01/02/24 at 1:20 PM, DON stated she in-serviced all of the staff in the facility that reported to her, and Corporate Nurse in-serviced her. She stated she was in-serviced on change of condition, medication administration, when and how to notify the doctor and family, how to review the 24-hour reports to monitor for a change in condition, and how to ensure nurses are documenting and reporting changes in blood pressure. In a telephone interview on 01/02/24 at 1:30 PM, Med Aide E stated he was in-serviced on change of condition, PRN medications, notifying the nurse when there are concerns, and blood pressures. In an interview on 01/02/24 at 1:36 PM, Nurse C stated she was in-serviced since last Thursday on PRN medications, vitals, change of conditions, and notifying the physician of any changes. In a telephone interview, on 01/02/24 at 1:52 PM, Nurse F stated he received additional training last week, around 12/28/23, that covered notification on changes, how the med aide should notify a nurse of any issues, how a nurse should contact the physician, or the DON/ADON if there are concerns of if the nurses are not able to reach the doctor. He stated the in-service also covered PRN medications, and checking vitals, including blood pressure. In an interview on 01/02/24 at 1:58 PM, Administrator stated he was in-serviced by Corporate Nurse. He stated he was in-serviced on change of condition, medication errors, physician notification, blood pressure, who needs to notify who of a change in condition with a resident, what the nurses should do once they are notified of a change in condition, and what the med aides are required to do in the process. A record review of the following was completed on 01/02/24: Blood Pressure medication audit of all residents, including all revisions since 12/28/23. There were no concerns. An in-service for Medication Administration, Documentation of rechecked Vitals, Documentation when all medications are given, Documentation of notifications to nurse and doctor, Change of Condition, and Following Physician's Orders, dated 12/29/23, instructor noted as DON, and instructor for DON was Corporate Nurse All post tests for all in-services completed Sign-off Verification that all vitals were checked on all residents and audits were completed on calendar for 12/28/23, 12/29/23, 12/30/23, 12/31/23, 01/01/24, and 01/02/24, and signed-off by Administrator, DON, and Corporate Nurse. An untitled, undated, facility document with review of all vitals for residents on 12/28/23, 12/29/23, 12/30/23, 12/31/23, 01/01/24, and 01/02/24, which included weight, respiration, blood pressure, temperature, pulse, blood sugar, height, O2 saturation, and pain levels for each resident. Document of verification of all active orders reviewed and updated if needed. Administrator was notified on 01/02/24, the Immediate Jeopardy was removed. While the immediacy was removed on 01/02/24, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy due to the facility continuing in-servicing and monitoring of the Plan of Removal.