**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents for one of thirteen residents (Resident #12) reviewed for accidents and hazards.The facility failed to ensure Resident #12 received the appropriate supervision to prevent elopement from the facility on 6/23/2025 and 07/13/2025.The non-compliance was identified as PNC on 09/11/25 and the IJ template was provided the facility on 09/11/25 at 3:10 PM. The noncompliance began on 07/13/2025 and ended 07/13/2025. The facility corrected the non-compliance before the survey began.These failures could place the residents at risk of serious harm, injury and death from wandering outside the facility in unfamiliar surroundings. . Findings include: Record review of Resident #12's Face Sheet, dated 09/11/2025, reflected the resident was an [AGE] year-old male who admitted to the facility on [DATE]. Resident #12 had diagnoses which included moderate dementia with agitation, diabetes, and unsteadiness on his feet. Resident #12 was ambulatory with a walker. Record review of Resident #12's Quarterly MDS (tool used to assess health status) Assessment, dated 07/02/2025, reflected moderately impaired cognition with a BIMS (screening tool to assess cognitive status) score of 09. Section I (Active Diagnoses) reflected Resident #1's diagnoses included hypertension (high blood pressure), dementia (decline in cognitive function that interferes with daily life), and diabetes (the body does not use insulin effectively). Section N (Medications) indicated Resident #12 received a daily insulin (medication to treat elevated blood glucose) injection. Record review of Resident #'12's Comprehensive Care Plan, dated 05/14/25 and updated 06/23/2025, reflected the resident had impaired cognitive function or impaired thought process related to dementia. One intervention, initiated 06/23/2025, was for visual checks every 15 minutes for a 24-hour period until the resident was no longer at risk for elopement. Additional review of Resident #12's Comprehensive Care Plan, dated 05/14/2025 and updated 06/23/2025, reflected Resident #1 was at risk for elopement as evidenced by attempted elopement. Interventions included Psych services to evaluate and treat. Date initiated 06/23/2025… Determine the reason the resident is attempting to elope… Intervene as appropriate. Date initiated 06/24/2025. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Date initiated: 06/24/2025. Distract resident from elopement attempts by offering pleasant diversions, structured activities, food, conversation, television, books. Date initiated: 06/24/2025. If the resident is exit seeking, stay with the resident, and notify the charge nurse by calling out, sending another staff member, call system. Date initiated: 06/24/2025.” Record review of Resident #12's Progress Notes, dated 06/23/2025, reflected at about 7:00 PM Resident #12 pushed his way past visitors who were exiting the front door. Staff followed Resident #12 to the parking lot where he was agitated and refused to return to the building. Resident #12's family member was called, and after speaking with the resident, Resident #12 agreed to go back inside the facility. Resident #12 told staff members his family was out of town and there was no one to take care of the farm. Record review of Resident #12's Psychiatry Progress Note, dated 07/09/2025, reflected “Medical Necessity: Nursing staff request to address a documented psychiatric issue of concern that requires a timely evaluation and medical intervention. Patient instability or change in condition requiring timely mental status examination to establish appropriate treatment intervention and/or change in treatment intervention…Continue current medication… Monitor patient's behavioral signs and symptoms on each subsequent encounter to determine effectiveness of the medications.” Record review of CNA J's witness statement, dated 07/13/2025, reflected that she answered the facility's phone on 07/13/2025 at about 2:30 PM. A family member reported not seeing Resident #12 on the camera in his room. CNA J checked the resident's room and reported to his nurse a family had called, and the resident was not in his room. An attempt to interview CNA J on 09/11/2025 was unsuccessful. CNA J no longer worked at the facility. Record review of RN I's witness statement, dated 07/13/2025, reflected “This RN visualized resident between 1330 (1:30 PM) and 1400 (2:00 PM) with tray of food on tray table and resident in recliner.” RN I indicated she was called to speak with the family of another resident and then assisted with resident care. “This RN came out of room and weekend manager notified resident was not located. This RN organized staff, building was searched systematically; this RN looked at out on pass log and resident was not signed out. Outside perimeter was checked by this RN and a CNA walking in opposite directions. This RN notified weekend manager unable to locate resident and was going to call 911. This RN called responsible party who stated resident was not out on pass, and was sending family member to facility. This RN called 911. Police dispatched. Provided photo, face sheet description. DON and police assumed search. DON notified this RN resident was found by police, went to hospital, and would discharge to secure unit. This RN notified physician.” An attempt to interview RN I on 09/11/2025 and 09/13/2025 was unsuccessful. Record review of Resident #12's Comprehensive Care Plan, dated 05/14/2025 and updated 07/13/2025, reflected Resident #12 was at risk for wandering. Interventions included “Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television. Date initiated 07/13/2025. If the resident is exit seeking, stay with the resident, and notify the charge nurse by calling out, sending another staff member, call system, etc. Date initiated 07/13/2025. Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Date initiated 07/13/2025. Date initiated 07/13/2025. Referral to secure care unit. Date initiated: 07/13/2025.” Record review of Resident #12's hospital record, dated 07/13/2025, reflected he was admitted to the intensive care unit and treated for severe hyperthermia (critical condition characterized by elevated body temperature) and acute hypoxic respiratory failure (body does not have enough oxygen in the blood) that required intubation (insertion of a tube into the airway to assist with breathing). The environmental temperature on 07/13/2025 was 93 degrees. During an interview on 09/11/2025 at 9:35 AM, the Social Worker stated Resident #12 eloped on 07/13/2025 and police were able to find him not far from the facility by the train railway. She stated the resident was taken to the hospital. She stated Resident #12's family had recently taken a trip and explained to the resident they would not be visiting. She stated Resident #12 was concerned about the farm and who was going to take care of it. She stated the resident had been distraught about it and she believed he had started trying to figure out how to get back to the farm. She stated Resident #12 was discharged from the hospital to a facility with a secure unit. She stated he had not eloped before. During an interview on 09/11/2025 at 9:55 AM, the DON stated Resident #12 rarely left his room except to get coffee. He stated the resident sat in the recliner in his room. The DON stated about two weeks prior to the elopement on 07/13/2025, Resident #12 went out the front door of the facility with visitors. He stated staff immediately followed after him and the resident refused to come back into the facility. He stated he called the resident's family member who reported telling the resident his family was going out of town and would not be coming to the facility to see him. The family member stated the resident asked who was taking care of the farm and he was reminded he had sold it years prior. The DON stated the family member spoke with the resident on the phone and coaxed him to go back inside the building. The DON stated he felt like it was an isolated incident and the family member stated the resident would not be told in the future when family members were going out of town. The DON stated the resident was placed on 1:1 monitoring for 24 hours and evaluated to ensure the resident was not displaying exit seeking behavior. He stated the physician ordered labs and a urinalysis. He stated the facility changed the door code, referred the resident to psych services, and updated his care plan. The DON stated about two weeks later, on 07/13/2025 at about 2:30 PM, a family member called the facility and asked for staff to check the Resident #12's restroom to see if he needed help because they did not see Resident #12 on the camera in his room. The DON stated the resident could not be located inside or outside the building and the police were called. He stated the resident was located a couple of hours from the time the resident was noticed missing. He stated the resident was located not far from the facility by the train tracks. The DON stated he went to the emergency room to check on the resident and was told the resident was intubated and being treated for hyperthermia (elevated body temperature). He stated the resident was extubated the following day. The DON stated he notified family the resident would not be able to return because the facility did not have a locked unit for males. He stated Resident #12 discharged from the hospital to another facility with a memory care unit. The DON stated all residents had a risk assessment for elopement on admission, quarterly, and as needed. He stated after the elopement on 07/13/2025, a risk assessment was completed for all residents in the building and staff received in-service training on monitoring for exit-seeking behaviors and what to do if alerted of an elopement. The DON stated no residents in the facility had a wander guard. He stated no other residents' assessment indicated a high risk for elopement. He stated the only residents who triggered high risk for elopement were located in the memory care unit. The DON stated staff had also participated in weekly elopement drills since the incident. He stated all exit doors were inspected daily to ensure each door functioned properly, the door access codes were changed, and signs were posted at all exits in English and Spanish notifying visitors to ensure residents did not exit and were given the door code. He stated any female resident identified with exit seeking behavior or was at risk for elopement was transferred to the memory care unit and males displaying exit seeking behavior were transferred to a facility with a memory unit for male residents. The DON stated during the day, when the receptionist was at the front desk, the front door was unlocked. He stated when she went to break or left at the end of the day, the front door was locked and to enter or exit required entering a code on the keypad. He stated the facility had also employed a receptionist on weekends to monitor the front door. During an interview on 09/11/2025 at 10:20 AM, the Administrator stated she was not at the facility at the time of the elopement but the facility provided in-service training and had weekly elopement drills with staff members. She provided a binder with documents, dated 07/13/2025, of in-service training on resident rights, abuse, neglect, and exploitation, and elopement prevention and response. She provided documentation of weekly elopement drills and a log of daily inspections of all exit doors completed since the elopement on 07/13/2025. The Administrator also provided documentation showing all residents were assessed for risk elopement on 07/13/2025. She stated prevention was key and the risk was the safety of the residents. She stated it was important for staff to know policies and procedures and to react appropriately. She stated it was important for staff to be alert for any exit seeking communication or behaviors and notify the nurse, DON, or leadership to assess the resident. During an interview on 09/11/2025 at 12:18 PM, Resident #12's family member stated they called the facility at about 2:30 PM on 07/13/2025, after not observing the resident on the camera in his room for 30 – 45 minutes. The family member stated that after the resident was not located in or around the building, the police were called. The family member stated the police used a drone and located Resident #12 near the train tracks, about one-third to one-half of a mile from the facility and was taken to the hospital where he was treated for a heat stroke. The family member stated he remained in the hospital for about a week before discharging to a nursing facility with a memory care unit. During a follow up interview on 09/11/2025 at 12:40 PM, the DON stated the facility had ongoing elopement drills on different shifts. He stated he hid a mannequin in different locations, including various locations outside the facility. He stated residents had participated as well. The DON stated the staff were provided with a scenario and a printed census of the residents. He stated nurses delegated to CNAs during the code orange (code used for an elopement). He stated on weekends, the weekend manager or unit manager shift took charge of delegating. He stated if the resident was not found within 30 minutes, the police were notified. He stated by that time the DON and Administrator would have already been notified. The DON stated that after all efforts to locate the residents inside the facility were exhausted, including rooms, shower rooms, restrooms, offices, and all other assigned areas, assigned staff would begin to search the perimeter. The DON stated the residents' safety was first. He stated if anyone tried to exit, staff knew to move quickly to the alarming door. He stated the front door alarm was the loudest and could be heard throughout the building. He stated the train was near the facility and the highway was less than a mile away. He stated it was important to prevent resident harm at all costs. He stated staff were in-serviced to be alert and observe residents for any exit seeking communication or behaviors. He stated all staff were required to have dementia care training and what to recognize in residents. He stated leadership had also made the decision to secure the front door at all times, even when a receptionist was on duty. He stated it required a code to be entered on the keypad for anyone to enter or exit the front door. Observation of all exit doors on 09/11/2025 at 1:35 PM revealed the doors closed and locked properly and alarms could be heard at the nurses' stations. Observation of all exit doors on 09/11/2025 at 3:05 PM revealed signs posted in English and Spanish notifying visitors to not allow residents to exit the facility and to not share the door code with the residents. Interviews on 09/11/2025 between 3:30 PM and 4:41 PM were conducted with multiple staff members which included the Administrator, DON, Social Worker A, Maintenance Supervisor B, Treatment Nurse C, Occupational Therapist D, Therapy Director E, Physical Therapist F, Dietary Manager G, COTA H, RN K, LVN N, CNA O, PTA P, Therapy Q, CNA R, Dietary Aide S, Floor Technician T, Student Aide U, CNA V, and LVN X. Interviews revealed staff members received elopement in-service training and participated in elopement drills. Staff were reminded to be alert to signs of exit seeking and to notify the charge nurse or DON to assess the resident as needed. Staff members were educated on their role when a code orange (elopement) was called in the facility. Census sheets were provided to cross reference and ensure each resident was present. The elopement drills included the designation of staff members to an assigned search area which included searching every room in the facility to ensure the resident was in the building and safe. If a resident was not located inside or outside the building, police, family, and the physician must be notified. No lack of knowledge or procedure was identified. The facility initiated the following interventions prior to the state surveyor entry on 09/11/2025: The facility door codes was changed and signs were placed at each exit door notifying all to not allow residents to exit the building.Record review of Resident #12's clinical file on 09/11/2025 at 11:15 AM reflected the following:-Resident #12's risk assessments on 06/23/2025 reflected the resident was not a high risk for elopement. The risk assessment completed on 07/13/2025 reflected the resident was at high risk for elopement. -Resident #12's Comprehensive Care Plan was updated with interventions on 06/23/2025 and 07/13/2025 after the resident exited the building.-Elopement risk assessments and care plans were updated on all residents in the building on 07/13/2025. -The medical doctor, psychiatrist, director of nurse, administrator, and Resident #12's family member was notified of the elopement on 06/23/2025 and 07/13/2025.-Documentation of education of staff on resident rights, abuse, neglect, and exploitation on 07/13/2025.-Documentation of education of staff on elopement prevention and response, exit seeking, and door protocols on 07/13/2025.-Documentation of elopement drills beginning 07/13/2025 and conducted weekly following the elopement. -Log of daily inspection of all exit doors beginning on 07/13/2025.- No additional elopements occurred and Resident #12 no longer resided at the facility.

**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 residents' choices for 2 (Residents #11 and #49) of 7 residents reviewed for quality of care. 1. LVN D failed to order xrays for Resident #11 after she fell on [DATE] and complained of right-side pain. The xrays were not completed until the next day 12/17/23 the resident was diagnosed with fractures of the 8th to 10th ribs. 2. The facility failed to assess and document Resident #49's injury to her right ankle on 01/23/24, when therapy heard an audible sound when he attempted to put her shoe back on. On 01/24/24 it was noticed by staff that Resident #49 had swelling and bruising to her right ankle. Resident #49 was diagnosed with a right ankle fracture and underwent surgery. An Immediate Jeopardy was identified on 02/27/24. While the Immediate Jeopardy was removed on 02/28/24, the facility remained out of compliance at a scope of isolated and a severity potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the Plan or Removal. These failure could place residents at risk for diminished quality of care. Findings included: Review of Resident #11's MDS assessment revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease, CVA (stroke), non-Alzheimer's dementia, repeated falls, cognitive communication deficit, difficulty in walking and unsteadiness on feet. Resident #11 has a BIMS score of 12 indicating her cognition was moderately impaired. She usually understood others and was usually understood by others. The MDS further reflected the resident used a wheelchair for mobility and used the assistance of one person for ambulating. Review of Resident #11's care plan revised on 12/18/23 revealed the resident had a fall and was at risk for further falls due to dementia, language barrier, and poor safety awareness. Interventions included frequent reminders to request assistance from staff prior to transfers, toileting. The care plan further reflected the resident self-transferred without calling for assistance. Review of the facility's Provider Investigation Report for Resident #11 dated 12/18/23 revealed the following: .On 12/16/23 at approximately 9:00 p.m. resident was noted by the nursing staff to have fallen trying to go to the bathroom in her room without assistance. Resident was assessed for injury and neuro checks started, pain medication given and MD, Family notified. Nurse stated she called the former Xray company as the resident was complaining of pain to the right side. The nurse left the community at 10:00 p.m. and the xray was not ordered as she stated no one returned her call. The nurse failed to report to the oncoming shift, but did complete the incident report and medicated the resident. The next morning upon rounds the supervisor spoke to this nurse who returned again for her shift and a stat (immediately) xray was ordered Review of Resident #11's progress noted dated 12/16/23 at 6:45 PM documented by LVN D reflected the following: Resident walked without a W/C to the bathroom and fell to her bottom and back. Room mate informed the nurse. When nurse responded to the bathroom, Resident was sitting at the door leaning at the door post. Speaking in Spanish. Unable to understand, this nurse called CNA Spanish speak to translate. Resident denied hitting head, stated she was ok but admitted her back hurt a little bit. Resident said she was hungry and wanted to be left alone to eat her dinner Review of Resident #11's hospital records dated 12/17/24 revealed the following: .Impression 1.There are nondisplaced fractures of the right eighth through 10th ribs posteriorly. These appear acute. There also old healed bilateral rib fractures, old healed right clavicle fracture, and old healed sternal fracture Observation and interview on 02/06/24 at 12:22 PM, revealed Resident #11 was sitting at the dining room table eating lunch. The resident was wearing a back brace that extended up her back around her neck with a collar. The resident was not able to recall her fall and said she was not in any pain at the time. Interview on 02/07/24 at 1:55 PM, CNA A revealed the day of Resident #11's fall, he was making rounds and heard something, so he went to the resident's room and found her on the floor by the bathroom. CNA A said he went to get the nurse, LVN D, and she assessed Resident #11 and took over from there. The CNA said he did not work with the resident often but was told she had to be closely monitored because she would try to get up without calling for assistance. After Resident #11 was assessed by the nurse she was taken to the nurse's station to be monitored more closely. CNA A further stated he did not recall her being in any pain as he pushed her to the nurse's station. Interview on 02/07/24 at 4:16 PM with LVN D revealed CNA A let her know Resident #11 had fallen. When she entered the resident's room she noticed Resident #11 was sitting in the bathroom so she let RN B know, and called the family and the physician to get orders. LVN D said the resident was not complaining of too much pain and stated she was feeling ok so she went ahead and gave her pain medication. LVN D said she was given orders for xrays and she called the xray company but did not recall if she spoke to anyone. LVN D stated she did not recall what xray company she called and did not recall getting a return phone call. LVN D further stated before she left for the night she had let LVN FF know when he came on for the 10PM-6AM shift. When she returned to work the following morning, 12/17/23, she realized the xrays had not been done, so the xray company was called and they said they would send a technician out to the facility. Interview on 02/07/24 at 2:02 PM with RN B revealed she was getting ready to leave for the night of Resident #11's fall. LVN D told her the resident had fallen and was complaining of pain to her lower back, so RN B told LVN D to call the doctor and get xrays. RN B said she went to see Resident #11 and he was not moaning or grimacing or showing any signs of pain. When RN B left, LVN D was calling the doctor and notifying the family. RN B further stated the next day when she arrived to work, she realized Resident #11 did not get xrays so she called the DON to let her know. The xrays were ordered that morning around 10AM and she called to confirm they had been ordered. RN B said Resident #11 was having some pain, so she was medicated by the nurse and it appeared to be effective. The xray company was taking too long so they decided to send the resident to the hospital to be evaluated. Interview on 02/07/24 at 2:36 PM , with the current xray company revealed they received xray orders from LVN D for Resident #11 on 12/17/23 at 10:00 AM. Interview on 02/07/24 at 2:40 PM, RN C revealed she worked the night of 12/16/23 (10pm to 6am) and she was never told by LVN D that Resident #11 had fallen or that she needed xrays. RN C said the resident slept all night and did not appear to be in pain when she made rounds. RN C said the resident would take herself to the bathroom during the night and there was no concern with Resident #11 that night. Interview on 02/08/24 at 9:48 AM, the DON revealed she was notified on 12/16/23 at 9:46 PM by LVN D, that Resident #11 had fallen and said the resident had not sustained any injuries. The following day, 12/17/23, she got a call from RN B telling her about Resident #11's fall and again said there were no injuries noted but the resident had complained of pain to her back. RN B told her LVN D was supposed to have gotten orders for xrays but when she arrived in the morning, she overheard LVN D asking another nurse how to order xrays. The DON said they switched xray companies about three months prior and all the staff had been inserviced about the new company and all the previous stickers had been taken off the nurse's station and replaced with the new company information. The DON called LVN D and initially LVN D said she called the previous company and said they had not answered. The DON also said she thought LVN D had not contacted the previous company either because she (LVN D) said they had not answered but that company was open 24 hours a day and all LVN D kept saying was it was really busy and I was doing the best I could so the DON said she thought LVN D forgot to call the xray company and lied about calling the xray company and said she had called the previous company. The DON also said she asked LVN D if she had passed on the xray order information to the next shift and again LVN D had not given her a straight answer and maintained she had called the incorrect company. The DON said Resident #11 had been medicated when she expressed pain. The resident returned from the hospital diagnosed with rib fractures and a back brace to be worn while she is up in her wheelchair. 2. Review of Resident #49's face sheet, dated 02/09/24, reflected the resident was an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #49's diagnoses included displaced trimalleolar fracture (lower leg sections that form your ankle joint) of right lower leg, subsequent encounter for closed fracture with routine healing encounter for other orthopedic aftercare, unsteady on feet, age-related Osteoporosis without current pathological fracture, pain, muscle wasting and atrophy. Review of Resident #49's MDS Quarterly Assessment, dated 01/31/24, reflected Resident #49 had a BIMs score of 00, indicating severe impairment. The MDS reflected Resident #49 needed some help with self-care and ambulation. Resident #49 was dependent on staff for lower body dressing and taking off and putting on footwear. Resident #49 utilized a walker and wheelchair. Review of Resident #49's Care Plan, reviewed 02/09/24, reflected: Focus: Resident #49 is at risk for falls related to impaired mobility, poor safety awareness. Goal: Prevent a serious fall related injury. Intervention: Anticipate and meet resident's needs, Be sure call light within reach and encourage use, bed lowest position, therapy evaluations as ordered or needed for treatment. Focus: Resident #49 has an Activity of Daily Living self-care performance deficit of fatigue. Goal: Resident will improve current level of function and demonstrate the appropriate use of adaptive devices to increase mobility, transfers, eating, dressing, toilet use and personal hygiene. Intervention: Toilet use and Transferring: requires staff of 1 for assistance, Transfers: The resident is able to weight bear, pivot, use arms to support, take two steps. Review of Resident #49's nurse assessment reflected: there was no documentation on the date of 01/23/24. Review of Resident #49's physical therapy's assessment reflected: there was no documentation on the date of 01/23/24. Record review of Resident #49's x-ray results dated 01/24/24 revealed: Examination of right tibia/fibula, right ankle, Findings: Fracture of the right lower leg. Record review of Resident #49's hospital records dated 01/24/24 revealed resident presents to the emergency department from nursing home due to right ankle swelling/pain. Emergency Medical Services report patient received physical therapy yesterday and upon returning, nurse noticed her right ankle was swollen and painful. Denies head injury or fall. Patient notes pain to right lower extremity. Radiology report indicated: Ankle: fractures and soft tissue about the ankle. Record review of Resident #49's hospital physical therapy evaluation record dated 01/27/24 revealed diagnosis: Patient presents to emergency department from nursing home with ankle swelling - imaging shows right ankle medial and lateral malleoli fractures. Surgery 01/25/24 for open reduction and internal fixation right ankle fracture. Record review of Resident #49's hospital records dated 02/06/24 at 11:30 AM indicated Resident #49 had fractures of the right ankle. Record review of Resident #49's discharge hospital records dated 01/25/24 indicated return to nursing facility, 01/25/24: open reduction and internal fixation right ankle, non weight bearing right lower extremity, use cast guard for shower do not submerge incision keep wound clean and dry, non weightbearing right lower extremity keep cam boot in place at all times. Updated Medications: Acetaminophen (Tylenol Extra Strength) 500 MG every 4 hours as needed. Follow up appointment: orthopedic surgeon, in 1-2 weeks. Record review of Resident #49's medication and treatment administration report for January 2024 indicated she received Tramadol Oral tablet 50 MG. Give 0.5 tablet by mouth two times a day for Pain, revealing she had taken this medication as directed to include dates of January 23, 2024, at 8:00 AM and 5:00 PM, January 24, 2024, 8:00 AM prior to exiting the facility. Review of Resident #49's progress note dated 01/24/24 at 9:03 AM written by LVN H indicated: Note Text: This nurse was notified by CNA this morning to assess resident's right lower leg and ankle. Upon assessment this nurse noticed that the skin was red, and hot to the touch. The foot points to the right when held and resident screams in pain when it is touched. Notified Nurse Practitioner, DON, ADON and Resident Power of Attorney. Received an order for an Xray and Doxycycline. Stat Xray order placed. Resident's right lower leg was wrapped by ADON, and leg elevated on a pillow for comfort. Review of Resident #49's progress note dated 01/24/24 at 9:30 AM, written by LVN H indicated: Note Text: Continued to monitor resident for pain. Resident received scheduled Tramadol for pain. In addition, she was assessed by therapist and iced pack placed on affected area to reduce swelling. Pain administration was effective, resident is calm and resting in bed. Review of Resident #49's progress note dated 01/24/24 at 11:30 AM, written by LVN H indicated: Note Text: Xray done, awaiting results. Review of Resident #49's progress note dated 01/24/24 at 4:15 PM, written by LVN K indicated: Note Text: Transferred to Hospital ER for assessment r/t x-ray results by ambulance service via stretcher. Family Member unavailable by phone but returned call at 4: 20 PM and spoke with ADON on transfer. Review of Resident #49's progress note dated 01/24/24 at 4:33 PM, written by LVN K indicated: Electronic Medication - Administration Note Note Text: Tramadol HCl Oral Tablet 50 MG Give 0.5 tablet by mouth two times a day for PAIN. emergency room Electronic Medication - Administration Note Note Text: Doxycycline Hyclate Oral Tablet 100 MG Give 1 tablet by mouth two times a day for infection for 5 Days. emergency room Observation of Resident #49 on 02/06/24 at 12:00 PM, revealed resident was in the dining room with therapy staff, eating with assistance. Resident was observed with a boot on her right foot. Observation and interview of Resident #49 on 02/06/24 12:00P M - 2:20 PM, revealed resident had been seen about the facility in her wheelchair with staff assist. Resident #49 was able to communicate however she was not able to stay on task when asked about her boot, fall, pain or hospital visit. Last observation revealed resident was in her room in bed sleeping. Resident #49 had a wedge under her knees under the blanket. Interview on 02/07/24 at 1:49 PM, LVN I revealed she did work the morning of 01/24/24. LVN I stated she worked on one side of the hall and LVN H worked on the other side with Resident #49. LVN I said if anything were reported from the night before it would have gone to LVN H. According to LVN I, the aide was about to start bed baths with Resident #49 and she noticed something was wrong and asked LVN H and myself to come assess the resident. LVN I said we were both passing medications at that time. LVN I stated her observation of what she remembered the foot was swollen, red and faced the wrong way. According to LVN I Resident #49 was in pain, she was moaning and had facial expressions of pain. LVN H administered something for pain and called the doctor and DON and sent her to the hospital. Resident #49 did have an x-ray completed, and while they waited for results, they kept her leg still and monitored her for pain. Attempted interview on 02/07/24 at 2:00 PM to CNA P was unsuccessful. Interview on 02/07/24 at 2:16 PM, CNA G revealed she was not present during the incident; however, she did not observe resident in pain at any time prior to or on dates 01/23/24 or 01/24/24 on her shifts. CNA G stated Resident #49 was able to stand and pivot prior to the fracture. CNA G stated that she was able to assist with transfers, however now she was a 2 person assist. Resident #49 was capable to communicate if she was in pain and let you know her needs. Interview on 02/07/24 at 2:35 PM, with LVN H revealed she was not in the building when the incident happened. LVN H stated when she entered the facility the next morning on 01/24/24, she was passing medications when the aide notified me there was something wrong with Resident #49's foot. LVN H said when she entered the room, she saw a bruise on the right lower leg. LVN H said when she tried to turn it, it was not stable. At that time, she called LVN I to take a look at it, it was then confirmed there was a problem. LVN H stated she contacted the nurse practitioner, DON, ADON, and family. X-rays were ordered, and they came out that same morning around 11:00 AM. LVN H stated the findings had not returned by the time she left for the day. LVN H stated she had already alerted LVN K to retrieve the results and alert the doctor. LVN H stated Resident #49 was provided Tramadol for pain. LVN H stated she questioned CNA P about the injury, and she was told that she did care for Resident #49 the previous day on 01/23/24 on the morning shift and Resident #49 did not have any injuries or indication of pain. Interview on 02/08/24 at 5:25 PM, the DON revealed she was notified via text by nursing staff, and on her way to morning meeting Director of Rehabilitation expressed to her that we need to look at Resident #49's ankle it was really swollen and did not look right. The DON stated she had not received any reports of her having a fall at this time, and reviewed that she had been working with the Physical Therapist so she sat down with him and he reported he did work with her on 01/23/24. She stated he told her that he was having her to stand and ambulate with the gait belt. The DON said the Physical Therapist reported While standing her knees started acting like they would buckle so he sat her down on the chair. He then helped to put her shoe on, he had to work towards putting on the shoe and while doing so heard a click, (he was concerned when he heard the pop, she did not show any pain or emotion at the time) and he went to get LVN J and together they assessed it and had no concerns with range of motion or pain. The DON stated, as time went on it got swollen and red, she also stated when staff sent her a picture of the injury, she did not know what she was looking at, stated she thought it was an issue of Resident #49 with edema. The DON stated x-ray was ordered, there were findings of a fracture and she was sent to the hospital. Interview on 02/08/24 at 6:29 PM, the Physical Therapist revealed he did work with Resident #49 on the evening of 01/23/24 right before dinner. The Physical Therapist stated it was normal routine for Resident #49 to walk the halls with her walker. The Physical Therapist stated on that visit she only took 4-5 tiny steps and it appeared that her knees were buckling so he assisted her to sit down in the recliner. She was not positioned securely in the chair, so he asked her to assist with repositioning and her reaction was like get your hands off me (but this was normal for her). The Physical Therapist said after she was repositioned in the recliner he looked down and noticed her right shoe had slid off her heel laterally. He said he reached down to slide her shoe back on and her whole foot went back as if it was dislocated, and it made an audible click. He said he looked at her and asked her if she was hurt, and she said no. He then took her through range of motion, and she did not have any reaction to eversion (outward turn) of her right foot, but with inversion (inward turn) of her right foot, she grunted and did indicate something. The PT said he went down to get LVN J to assess. The PT said during the assessment she responded that she was not hurt, or in pain, she was not tender to touch and went through range of motion with LVN J, with the same reactions with both eversion and inversion. Resident #49 had no swelling and with range of motion and her ankle moved normally. There was no deformity. The PT stated, I was thinking it was a sprain or dislocation. After the assessment I transferred her from the recliner to her wheelchair on her left side just to be safe, there were still no complaints of pain. The PT said LVN J stated she would wheel her down to dinner. The PT said, There was no x-ray completed that night that I was aware of, I wished I had found the aide to inform her to transfer Resident #49 from the left side. Physical Therapist revealed he did not complete documentation of his assessment. Interview on 02/08/24 at 6:57 PM, the DON and the Administrator revealed they were not told anything about Resident #49 having any pain with inversion (inward turn) during assessment with Physical Therapist or LVN J. According to the DON and the Administrator after their investigation they were told range of motion, and everything was fine during the assessment. The DON stated she did not know what she was looking at when the morning clinical team sent her the picture, and she thought the picture was showing cellulitis(bacterial infection of the skin), until the Director of Rehabilitation came to morning meeting requesting someone to go down to look at her foot. According to the DON not alerting someone about Resident #49 having pain when her foot was turned inward placed Resident #49 at risk for discomfort and delayed services of care. The DON stated it was the responsibility of both the nursing staff and the Physical Therapist to report any negative findings when it relates to residents in the facility. According to the Administrator it was her expectation that all staff are to report any incidents to her immediately, that everyone in the facility was aware she was the abuse coordinator. The Administrator stated it was also the expectation that the charge nurses are notified immediately so that residents have the proper care. The Administrator stated not doing this could place residents at risk of not having the attention and care they need. Interview on 02/08/24 at 7:20 PM, LVN J revealed she did work on hall 300 where Resident #49 resided. According to LVN J she was not aware of any incident or accident regarding Resident #49. LVN J stated LVN K was on one side of the nursing station and she was on the other. LVN J said she was asked by the Physical Therapist to come to the room to assist him to reposition Resident #49 because she was sitting on the edge of her recliner. She stated the Physical Therapist returned to Resident #49's room, then he came back to the nursing station and asked if she could come back to the room. She stated when she returned to the room Resident #49 was laying back, leaning back in the recliner and I asked how did she get like that and he responded, we were working on taking steps and she got weak. LVN J stated she then said, I did not know she could stand and left the room. According to LVN J, the Physical Therapist did not alert her to any situation, and she did not complete an assessment. LVN J stated she only assisted the Physical Therapist to put Resident #49 back in the recliner because Resident #49 likes to lay back with her feet elevated in the recliner. Interview on 02/09/24 at 10:26 AM, the Director of Rehabilitation revealed on the morning of 01/24/24 around 7:00 AM she went to Resident #49's room to complete speech therapy and noticed her right foot was displaced. The Director of Rehabilitation stated she then brought it to the DON's attention via text and verbally. The Director of Rehabilitation stated they were in Resident #49's room to observe her foot, the resident was in bed, and her foot was uncovered. The Director of Rehabilitation stated she interviewed the Physical Therapist because she knew he worked with her the night before and he was surprised to hear there was something going on with her. The Director of Rehabilitation said she was told by the Physical Therapist that Resident #49 stood up, but she was shaky so as he sat her down, he heard a pop. He and nurse LVN J check her vitals, assessed, touched, completed range of motion on both ankles and legs, she had no pain with up and down but with inward turn of her foot she had a slight jump, (stated she usually had pain in general with movement). According to the Director of Rehabilitation, the Physical Therapist stated at the end of their assessment Resident #49's ankle did not have any signs or symptoms of bruises, discoloration or distress. That it looked in place and they did not notice anything out of place. The Director of Rehabilitation stated it was her expectation for him to have reported that he heard a click to the floor nurse, herself, the DON, and the Administrator. The Director of Rehabilitation stated not doing so placed Resident #49 at risk for delayed care and treatment. Interview on 02/09/24 at 10:39 AM, LVN K revealed she was working on the evening of 01/23/24 and was at the nursing station when the Physical Therapist came to the desk. LVN K stated she overheard LVN J and the Physical Therapist talking about someone's foot however she did not know which resident it was. LVN K stated Resident #49 was her resident that night however neither LVN J nor the Physical Therapist alerted her to any issues or concerns. LVN K stated, I never knew it was about my resident. According to LVN K she was not alerted to any complaints of pain, swelling or discoloration for Resident #49's foot. Interview on 02/09/24 at 11:10 AM, CNA M revealed he did not know exactly when Resident #49 was involved in an incident, but he did work the night of 01/23/24. CNA M stated he did not work directly with Resident #49 but did assist CNA N with transferring her to bed at the end of the night. CNA M stated he did not observe Resident #49 with any swelling or pain. CNA M stated Resident #49 was able to communicate if she was having pain, and she was able to stand and pivot. Interview on 02/09/24 at 11:16 AM, CNA N revealed she did work the night of 01/23/24, and she did recall Resident #49 having a swollen foot. According to CNA N she thought it was something that would just go away and stated that she thought to herself, Resident #49 should be in pain. According to CNA N she assisted Resident #49 to bed, and this was when she observed the swollen right foot. CNA N stated she alerted the nurse on the 10:00 PM- 6:00 AM shift about the swelling. According to CNA N she had been trained to notify nursing staff when residents have bruising or swelling, and not doing so will place them at risk of not having proper care. Interview on 02/09/24 at 11:50 AM, LVN L revealed she did not work with Resident #49, and when she entered the facility, Resident #49 was already transported to the hospital. According to LVN L she was not told about Resident #49 having any bruising or swelling to her ankle. LVN L stated if she would have been told about something like that, she would have asked the aide to show her what she was talking about. LVN L stated she was responsible for completing assessments while working the floor and during her shifts she did not observe Resident #49 with any indications of pain or dislocated limbs. LVN L stated not providing proper care placed residents at risk of abuse and neglect. Review of the facility's policy titled Notifying the Physician of Change in Status dated 03/2013 reflected the following: The nurse should not hesitate to contact the physician in any time when an assessment and their professional judgement deem it necessary for immediate medical attention. This facility utilizes the '[change in condition] tool - When to Notify the MD/NP/PA' to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if the resident requires immediate notification of the physician or non-immediate/Report on Next Work day notification of the physician. .1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. Review of the facility's policy titled Preventative Strategies to Reduce Fall Risk revised October 2016 reflected the following: .10. Incident Reporting: Reported falls will be thoroughly investigated to assess fall risk factors and contributing factors in order to provide a safe environment for the resident(s) An Immediate Jeopardy was identified on 02/27/24. The Administrator and DON were notified of the Immediate Jeopardy on 02/27/24 at 12:15 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 Facility's Plan of Removal for Immediate Jeopardy was accepted on 02/27/24 at 4:53 PM and reflected the following: Interventions: An audit was completed by the DON of all x-rays ordered for residents in the last 24hrs to ensure completion, results were obtained in a timely manner, and communicated to the physician. Completed on 2/27/24. No further issues were identified. The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the topic that if x-rays or diagnostics will be delayed or not obtained within 4 hours to notify the physician for a possible transfer to the hospital for x-rays/diagnostics. Completed on 2/27/24. During daily stand-up, ADMIN, DON, and DOR will review all reported changes in condition in Point Click Care to ensure x-rays/diagnostics were followed up within 4 hours. Nurses will report any outstanding x-rays/diagnostics during change of shift report, including the time they were ordered in the [resident's electronic record]. DON/ADON/Compliance Nurse will review orders in [resident's electronic record] during daily stand up to ensure continuation of care for changes in condition, to include x-rays/diagnostics, were completed within 4 hours. Nurses will complete SBAR assessment in [resident's electronic record] for all changes in condition reported. The Medical Director was notified of the immediate jeopardy on 2/27/24 by the Administrator. [QAPI] will be completed on 2/27/24 to include the IDT team and Medical Director to discuss the immediate jeopardy and subsequent plan. In-services: The following in-services below were initiated on 2/27/2024 for all direct care staff (Nurses, CNAs, and CMAs) by the DON, ADON, and/or Regional Compliance Nurse, completed 2/27/24. All staff not present for in-service will not be permitted to work their assignment until in-serviced. All new hires will be in-serviced during facility orientation. All agency staff will be in-serviced prior working their floor assignment. o Abuse a[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide radiology or other diagnostic services to meet the needs of its residents in a timely manner for 2 (Resident #11 and #49) of 7 residents reviewed for radiology services. 1. LVN D failed to order xrays for Resident #11 after she fell on [DATE] and complained of right-side pain. The xrays were not completed until the next day 12/17/23 and the resident was diagnosed with fractures of the 8th to 10th ribs. 2. The facility failed to obtain timely radiology services on 01/23/24, after the Physical Therapist reported to the nurse that Resident #49 had an audible sound to her right ankle and was noted to be in an unusual position. The morning of 01/24/24, the resident was noted to have swelling and after xrays were ordered, she was diagnosed with a right ankle fracture and was sent to the hospital where she underwent surgery. An Immediate Jeopardy was identified on 02/27/24. While the Immediate Jeopardy was removed on 02/28/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the Plan or Removal. These failures resulted in delayed diagnosis, medical treatment, and hospitalization. Findings included: Review of Resident #11's MDS assessment revealed the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included Alzheimer's disease, CVA (stroke), non-Alzheimer's dementia, repeated falls, cognitive communication deficit, difficulty in walking and unsteadiness on feet. Resident #11 has a BIMS score of 12 indicating her cognition was moderately impaired. She usually understood others and was usually understood by others. The MDS further reflected the resident used a wheelchair for mobility and used the assistance of one person for ambulating. Review of Resident #11's care plan revised on 12/18/23 revealed the resident had a fall and was at risk for further falls due to dementia, language barrier, and poor safety awareness. Interventions included frequent reminders to request assistance from staff prior to transfers, toileting. The care plan further reflected the resident self-transferred without calling for assistance. Review of the facility's Provider Investigation Report for Resident #11 dated 12/18/24 revealed the following: .On 12/16/23 at approximately 9:00 p.m. resident was noted by the nursing staff to have fallen trying to go to the bathroom in her room without assistance. Resident was assessed for injury and neuro checks started, pain medication given and MD, Family notified. Nurse stated she called the former Xray company as the resident was complaining of pain to the right side. The nurse left the community at 10:00 p.m. and the xray was not ordered as she stated no one returned her call. The nurse failed to report to the oncoming shift, but did complete the incident report and medicated the resident. The next morning upon rounds the supervisor spoke to this nurse who returned again for her shift and a stat xray was ordered Review of Resident #11's progress noted dated 12/16/23 at 6:45 PM documented by LVN D reflected the following: Resident walked without a W/C to the bathroom and fell to her bottom and back. Room mate informed the nurse. When nurse responded to the bathroom, Resident was sitting at the door leaning at the door post. Speaking in Spanish. Unable to understand, this nurse called CNA Spanish speak to translate. Resident denied hitting head, stated she was ok but admitted her back hurt a little bit. Resident said she was hungry and wanted to be left alone to eat her dinner Review of Resident #11's hospital records dated 12/17/24 revealed the following: .Impression 1.There are nondisplaced fractures of the right eighth through 10th ribs posteriorly. These appear acute. There also old healed bilateral rib fractures, old healed right clavicle fracture, and old healed sternal fracture Observation and interview on 02/06/24 at 12:22 PM, revealed Resident #11 was sitting at the dining room table eating lunch. The resident was wearing a back brace that extended up her back around her neck with a collar. The resident was not able to recall her fall and said she was not in any pain at the time. Interview on 02/07/24 at 1:55 PM, CNA A revealed the day of Resident #11's fall, he was making rounds and heard something, so he went to the resident's room and found her on the floor by the bathroom. CNA A said he went to get the nurse, LVN D, and she assessed Resident #11 and took over from there. The CNA said he did not work with the resident often but was told she had to be closely monitored because she would try to get up without calling for assistance. After Resident #11 was assessed by the nurse she was taken to the nurse's station to be monitored more closely. CNA A further stated he did not recall her being in any pain as he pushed her to the nurse's station. Interview on 02/07/24 at 4:16 PM with LVN D revealed CNA A let her know Resident #11 had fallen. When she entered the resident's room she noticed Resident #11 was sitting in the bathroom so she let RN B know, and called the family and the physician to get orders. LVN D said the resident was not complaining of too much pain and stated she was feeling ok so she went ahead and gave her pain medication. LVN D said she was given orders for xrays and she called the xray company but did not recall if she spoke to anyone. LVN D stated she did not recall what xray company she called and did not recall getting a return phone call. LVN D further stated before she left for the night she had let LVN FF know when he came on for the 10PM-6AM shift. When she returned to work the following morning, 12/17/23, she realized the xrays had not been done, so the xray company was called and they said they would send a technician out to the facility. Attempts to interview LVN FF on 02/08/24 were unsuccessful. Interview on 02/07/24 at 2:02 PM with RN B revealed she was getting ready to leave for the night of Resident #11's fall. LVN D told her the resident had fallen and was complaining of pain to her lower back, so RN B told LVN D to call the doctor and get xrays. RN B said she went to see Resident #11 and was not moaning or grimacing or showing any signs of pain . When RN B left, LVN D was calling the doctor and notifying the family. RN B further stated the next day when she arrived to work, she realized Resident #11 did not get xrays so she called the DON to let her know. The xrays were ordered that morning around 10AM and she called to confirm they had been ordered. RN B said Resident #11 was having some pain, so she was medicated by the nurse and it appeared to be effective. The xray company was taking too long so they decided to send the resident to the hospital to be evaluated. Interview on 02/07/24 at 2:36 PM, with the current xray company revealed they received xray orders from LVN D for Resident #11 on 12/17/23 at 10:00 AM. Interview on 02/07/24 at 2:40 PM, RN C revealed she worked the night of 12/16/23 (10pm to 6am) and she was never told by LVN D that Resident #11 had fallen or that she needed xrays. RN C said the resident slept all night and did not appear to be in pain when she made rounds. RN C said the resident would take herself to the bathroom during the night and there was no concern with Resident #11 that night. Interview on 02/08/24 at 9:48 AM, the DON revealed she was notified on 12/16/23 at 9:46 PM by LVN D, that Resident #11 had fallen and said the resident had not sustained any injuries. The following day, 12/17/23, she got a call from RN B telling her about Resident #11's fall and again said there were no injuries noted but the resident had complained of pain to her back. RN B told her LVN D was supposed to have gotten orders for xrays but when she arrived in the morning, she overheard LVN D asking another nurse how to order xrays. The DON said they switched xray companies about three months prior and all the staff had been inserviced about the new company and all the previous stickers had been taken off the nurse's station and replaced with the new company information. The DON called LVN D and initially LVN D said she called the previous company and said they had not answered. The DON also said she thought LVN D had not contacted the previous company either because she (LVN D) said they had not answered but that company was open 24 hours a day and all LVN D kept saying was it was really busy and I was doing the best I could so the DON said she thought LVN D forgot to call the xray company and lied about calling the xray company and said she had called the previous company. The DON also said she asked LVN D if she had passed on the xray order information to the next shift and again LVN D had not given her a straight answer and maintained she had called the incorrect company. The DON said Resident #11 had been medicated when she expressed pain. The resident returned from the hospital diagnosed with rib fractures and a back brace to be worn while she is up in her wheelchair. 2. Review of Resident #49's face sheet, dated 02/09/24, reflected the resident was an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #49's diagnoses included displaced trimalleolar fracture (lower leg sections that form your ankle joint) of right lower leg, subsequent encounter for closed fracture with routine healing encounter for other orthopedic aftercare, unsteady on feet, age-related Osteoporosis without current pathological fracture, pain, muscle wasting and atrophy. Review of Resident #49's MDS Quarterly Assessment, dated 01/31/24, reflected Resident #49 had a BIMs score of 00, indicating severe impairment. The MDS reflected Resident #49 needed some help with self-care and ambulation. Resident #49 was dependent on staff for lower body dressing and taking off and putting on footwear. Resident #49 utilized a walker and wheelchair. Review of Resident #49's Care Plan, reviewed 02/09/24, reflected: Focus: Resident #49 is at risk for falls related to impaired mobility, poor safety awareness. Goal: Prevent a serious fall related injury. Intervention: Anticipate and meet resident's needs, Be sure call light within reach and encourage use, bed lowest position, therapy evaluations as ordered or needed for treatment. Focus: Resident #49 has an Activity of Daily Living self-care performance deficit of fatigue. Goal: Resident will improve current level of function and demonstrate the appropriate use of adaptive devices to increase mobility, transfers, eating, dressing, toilet use and personal hygiene. Intervention: Toilet use and Transferring: requires staff of 1 for assistance, Transfers: The resident is able to weight bear, pivot, use arms to support, take two steps. Review of Resident #49's nurse's assessment reflected: there was no documentation on the date of 01/23/24. Review of Resident #49's physical therapy's assessment reflected: there was no documentation on the date of 01/23/24. Record review of Resident #49's x-ray results dated 01/24/24 revealed: Examination of right tibia/fibula, right ankle, Findings: Fracture of the right lower leg. Record review of Resident #49's hospital records dated 01/24/24 revealed Resident #49 presented to the emergency department from nursing home due to right ankle swelling/pain. Emergency Medical Services report patient received physical therapy yesterday and upon returning, nurse noticed her right ankle was swollen and painful. Denies head injury or fall. Patient notes pain to right lower extremity. Radiology report indicated: Ankle: fractures and soft tissue about the ankle. Record review of Resident #49's hospital physical therapy evaluation record dated 01/27/24 revealed diagnosis: Patient presents to emergency department from nursing home with ankle swelling - imaging shows right ankle medial and lateral malleoli fractures. Surgery 01/25/24 for open reduction and internal fixation right ankle fracture. Record review of Resident #49's hospital records dated 02/06/24 at 11:30 AM indicated Resident #49 had fractures of the right ankle. Record review of Resident #49's discharge hospital records dated 01/25/24 indicated return to nursing facility, 01/25/24: open reduction and internal fixation right ankle, non weight bearing right lower extremity, use cast guard for shower do not submerge incision keep wound clean and dry, non weightbearing right lower extremity keep cam boot in place at all times. Updated Medications: Acetaminophen (Tylenol Extra Strength) 500 MG every 4 hours as needed. Follow up appointment: orthopedic surgeon, in 1-2 weeks. Record review of Resident #49's medication and treatment administration report for January 2024 indicated she received Tramadol Oral tablet 50 MG. Give 0.5 tablet by mouth two times a day for Pain, revealing she had taken this medication as directed to include dates of January 23, 2024, at 8:00 AM and 5:00 PM, January 24, 2024, 8:00 AM prior to exiting the facility. Review of Resident #49's progress note dated 01/24/24 at 9:03 AM written by LVN H indicated: Note Text: This nurse was notified by CNA this morning to assess resident's right lower leg and ankle. Upon assessment this nurse noticed that the skin was red, and hot to the touch. The foot points to the right when held and resident screams in pain when it is touched. Notified Nurse Practitioner, DON, ADON BB and Responsible Party. Received an order for an Xray and Doxycycline. Stat Xray order placed. Resident's right lower leg was wrapped by ADON BB, and leg elevated on a pillow for comfort. Review of Resident #49's progress note dated 01/24/24 at 9:30 AM, written by LVN H indicated: Note Text: Continued to monitor resident for pain. Resident received scheduled Tramadol for pain. In addition, she was assessed by therapist and iced pack placed on affected area to reduce swelling. Pain administration was effective, resident is calm and resting in bed. Review of Resident #49's progress note dated 01/24/24 at 11:30 AM, written by LVN H indicated: Note Text: Xray done, awaiting results. Review of Resident #49's progress note dated 01/24/24 at 4:15 PM, written by LVN K indicated: Note Text: Transferred to Hospital emergency room for assessment related to x-ray results by Ambulance via stretcher. Family Member unavailable by phone but returned call at 4:20 PM and spoke with ADON on transfer. Review of Resident #49's progress note dated 01/24/24 at 4:33 PM, written by LVN K indicated: Electronic Medication - Administration Note Note Text: Tramadol HCl Oral Tablet 50 MG Give 0.5 tablet by mouth two times a day for PAIN. emergency room Electronic Medication - Administration Note Note Text: Doxycycline Hyclate Oral Tablet 100 MG Give 1 tablet by mouth two times a day for infection for 5 Days. emergency room Observation of Resident #49 on 02/06/24 at 12:00 PM, revealed resident was in the dining room with therapy staff, eating with assistance. Resident was observed with a boot on her right foot. Observation and interview of Resident #49 on 02/06/24 12:00P M - 2:20 PM, revealed resident had been seen about the facility in her wheelchair with staff assist. Resident #49 was able to communicate however she was not able to stay on task when asked about her boot, fall, pain or hospital visit. Last observation revealed resident was in her room in bed sleeping. Resident #49 had a wedge under her knees under the blanket. Interview on 02/07/24 at 1:49 PM, LVN I revealed she did work the morning of 01/24/24. LVN I stated she worked on one side of the hall and LVN H worked on the other side with Resident #49. LVN I said if anything were reported from the night before it would have gone to LVN H. According to LVN I, the aide was about to start bed baths with Resident #49 and she noticed something was wrong and asked LVN H and myself to come assess the resident. LVN I said we were both passing medications at that time. LVN I stated her observation of what she remembered the foot was swollen, red and faced the wrong way. According to LVN I Resident #49 was in pain, she was moaning and had facial expressions of pain. LVN H administered something for pain and called the doctor and DON and sent her to the hospital. Resident #49 did have an x-ray completed, and while they waited for results, they kept her leg still and monitored her for pain. Attempted interview on 02/07/24 at 2:00 PM to CNA P was unsuccessful. Interview on 02/27/24 at 2:16 PM, with CNA G revealed she was not present during the incident; however, she did not observe resident in pain at any time prior to or on dates 01/23/24 or 01/24/24 on her shifts. CNA G stated Resident #49 was able to stand and pivot prior to the fracture. CNA G stated that she was able to assist with transfers, however now she was a 2 person assist. Resident #49 was capable to communicate if she was in pain and let you know her needs. Interview on 02/07/24 at 2:35 PM, with LVN H revealed she was not in the building when the incident happened. LVN H stated when she entered the facility the next morning on 01/24/24, she was passing medications when the aide notified me there was something wrong with Resident #49's foot. LVN H said when she entered the room, she saw a bruise on the right lower leg. LVN H said when she tried to turn it, it was not stable. At that time, she called LVN I to take a look at it, it was then confirmed there was a problem. LVN H stated she contacted the nurse practitioner, DON, ADON, and family. X-rays were ordered, and they came out that same morning around 11:00 AM. LVN H stated the findings had not returned by the time she left for the day. LVN H stated she had already alerted LVN K to retrieve the results and alert the doctor. LVN H stated Resident #49 was provided Tramadol for pain. LVN H stated she questioned CNA P about the injury, and she was told that she did care for Resident #49 the previous day on 01/23/24 on the morning shift and Resident #49 did not have any injuries or indication of pain. Interview on 02/08/24 at 5:25 PM, the DON revealed she was notified via text by nursing staff, and on her way to morning meeting Director of Rehabilitation expressed to her that we need to look at Resident #49's ankle it was really swollen and did not look right. The DON stated she had not received any reports of her having a fall at this time, and reviewed that she had been working with the Physical Therapist so she sat down with him and he reported he did work with her on 01/23/24. She stated he told her that he was having her to stand and ambulate with the gait belt. The DON said the Physical Therapist reported While standing her knees started acting like they would buckle so he sat her down on the chair. He then helped to put her shoe on, he had to work towards putting on the shoe and while doing so heard a click, (he was concerned when he heard the pop, she did not show any pain or emotion at the time) and he went to get LVN J and together they assessed it and had no concerns with range of motion or pain. The DON stated, as time went on it got swollen and red, she also stated when staff sent her a picture of the injury, she did not know what she was looking at, stated she thought it was an issue of Resident #49 with edema. The DON stated x-ray was ordered, there were findings of a fracture and she was sent to the hospital. Interview on 02/08/24 at 6:29 PM, the Physical Therapist revealed he did work with Resident #49 on the evening of 01/23/24 right before dinner. The Physical Therapist stated it was normal routine for Resident #49 to walk the halls with her walker. The Physical Therapist stated on that visit she only took 4-5 tiny steps and it appeared that her knees were buckling so he assisted her to sit down in the recliner. She was not positioned securely in the chair, so he asked her to assist with repositioning and her reaction was like get your hands off me (but this was normal for her). The Physical Therapist said after she was repositioned in the recliner he looked down and noticed her right shoe had slid off her heel laterally. He said he reached down to slide her shoe back on and her whole foot went back as if it was dislocated, and it made an audible click. He said he looked at her and asked her if she was hurt, and she said no. He then took her through range of motion, and she did not have any reaction to eversion (outward turn) of her right foot, but with inversion (inward turn) of her right foot, she grunted and did indicate something. The PT said he went down to get LVN J to assess. The PT said during the assessment she responded that she was not hurt, or in pain, she was not tender to touch and went through range of motion with LVN J, with the same reactions with both eversion and inversion. Resident #49 had no swelling and with range of motion and her ankle moved normally. There was no deformity. The PT stated, I was thinking it was a sprain or dislocation. After the assessment I transferred her from the recliner to her wheelchair on her left side just to be safe, there were still no complaints of pain. The PT said LVN J stated she would wheel her down to dinner. The PT said, There was no x-ray completed that night that I was aware of, I wished I had found the aide to inform her to transfer Resident #49 from the left side. Physical Therapist revealed he did not complete documentation of his assessment. Interview on 02/08/24 at 6:57 PM, the DON and the Administrator revealed they were not told anything about Resident #49 having any pain with inversion (inward turn) during assessment with Physical Therapist or LVN J. According to the DON and the Administrator after their investigation they were told range of motion, and everything was fine during the assessment. The DON stated she did not know what she was looking at when the morning clinical team sent her the picture, and she thought the picture was showing cellulitis(bacterial infection of the skin), until the Director of Rehabilitation came to morning meeting requesting someone to go down to look at her foot. According to the DON not alerting someone about Resident #49 having pain when her foot was turned inward placed Resident #49 at risk for discomfort and delayed services of care. The DON stated it was the responsibility of both the nursing staff and the Physical Therapist to report any negative findings when it relates to residents in the facility. According to the Administrator it was her expectation that all staff are to report any incidents to her immediately, that everyone in the facility was aware she was the abuse coordinator. The Administrator stated it was also the expectation that the charge nurses are notified immediately so that residents have the proper care. The Administrator stated not doing this could place residents at risk of not having the attention and care they need. Interview on 02/08/24 at 7:20 PM, LVN J revealed she did work on hall 300 where Resident #49 resided. According to LVN J she was not aware of any incident or accident regarding Resident #49. LVN J stated LVN K was on one side of the nursing station and she was on the other. LVN J said she was asked by the Physical Therapist to come to the room to assist him to reposition Resident #49 because she was sitting on the edge of her recliner. She stated the Physical Therapist returned to Resident #49's room, then he came back to the nursing station and asked if she could come back to the room. She stated when she returned to the room Resident #49 was laying back, leaning back in the recliner and I asked how did she get like that and he responded, we were working on taking steps and she got weak. LVN J stated she then said, I did not know she could stand and left the room. According to LVN J, the Physical Therapist did not alert her to any situation, and she did not complete an assessment. LVN J stated she only assisted the Physical Therapist to put Resident #49 back in the recliner because Resident #49 likes to lay back with her feet elevated in the recliner. Interview on 02/09/24 at 10:26 AM, the Director of Rehabilitation revealed on the morning of 01/24/24 around 7:00 AM she went to Resident #49's room to complete speech therapy and noticed her right foot was displaced. The Director of Rehabilitation stated she then brought it to the DON's attention via text and verbally. The Director of Rehabilitation stated they were in Resident #49's room to observe her foot, the resident was in bed, and her foot was uncovered. The Director of Rehabilitation stated she interviewed the Physical Therapist because she knew he worked with her the night before and he was surprised to hear there was something going on with her. The Director of Rehabilitation said she was told by the Physical Therapist that Resident #49 stood up, but she was shaky so as he sat her down, he heard a pop. He and nurse LVN J check her vitals, assessed, touched, completed range of motion on both ankles and legs, she had no pain with up and down but with inward turn of her foot she had a slight jump, (stated she usually had pain in general with movement). According to the Director of Rehabilitation, the Physical Therapist stated at the end of their assessment Resident #49's ankle did not have any signs or symptoms of bruises, discoloration or distress. That it looked in place and they did not notice anything out of place. The Director of Rehabilitation stated it was her expectation for him to have reported that he heard a click to the floor nurse, herself, the DON, and the Administrator. The Director of Rehabilitation stated not doing so placed Resident #49 at risk for delayed care and treatment. Interview on 02/09/24 at 10:39 AM, LVN K revealed she was working on the evening of 01/23/24 and was at the nursing station when the Physical Therapist came to the desk. LVN K stated she overheard LVN J and the Physical Therapist talking about someone's foot however she did not know which resident it was. LVN K stated Resident #49 was her resident that night however neither LVN J nor the Physical Therapist alerted her to any issues or concerns. LVN K stated, I never knew it was about my resident. According to LVN K she was not alerted to any complaints of pain, swelling or discoloration for Resident #49's foot. Interview on 02/09/24 at 11:10 AM, CNA M revealed he did not know exactly when Resident #49 was involved in an incident, but he did work the night of 01/23/24. CNA M stated he did not work directly with Resident #49 but did assist CNA N with transferring her to bed at the end of the night. CNA M stated he did not observe Resident #49 with any swelling or pain. CNA M stated Resident #49 was able to communicate if she was having pain, and she was able to stand and pivot. Interview on 02/09/24 at 11:16 AM, CNA N revealed she did work the night of 01/23/24, and she did recall Resident #49 having a swollen foot. According to CNA N she thought it was something that would just go away and stated that she thought to herself, Resident #49 should be in pain. According to CNA N she assisted Resident #49 to bed, and this was when she observed the swollen right foot. CNA N stated she alerted the nurse on the 10:00 PM- 6:00 AM shift about the swelling. According to CNA N she had been trained to notify nursing staff when residents have bruising or swelling, and not doing so will place them at risk of not having proper care. Interview on 02/09/24 at 11:50 AM, LVN L revealed she did not work with Resident #49, and when she entered the facility, Resident #49 was already transported to the hospital. According to LVN L she was not told about Resident #49 having any bruising or swelling to her ankle. LVN L stated if she would have been told about something like that, she would have asked the aide to show her what she was talking about. LVN L stated she was responsible for completing assessments while working the floor and during her shifts she did not observe Resident #49 with any indications of pain or dislocated limbs. LVN L stated not providing proper care placed residents at risk of abuse and neglect. Request for the facility's radiology policy was made to the Regional Nurse on 02/28/24 at 3:00 PM however, it was stated the facility did not have a specific policy covering radiology. The facility provided Notifying the physician of Change in Status. Review of the facility's policy titled Notifying the Physician of Change in Status dated 03/2013 reflected the following: The nurse should not hesitate to contact the physician in any time when an assessment and their professional judgement deem it necessary for immediate medical attention. This facility utilizes the '[change in condition] tool - When to Notify the MD/NP/PA' to review resident conditions and guide the nurse when to notify the physician. This tool informs the nurse if the resident requires immediate notification of the physician or non-immediate/Report on Next Work day notification of the physician. .1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. Review of the facility's policy titled Preventative Strategies to Reduce Fall Risk revised October 2016 reflected the following: .10. Incident Reporting: Reported falls will be thoroughly investigated to assess fall risk factors and contributing factors in order to provide a safe environment for the resident(s) An Immediate Jeopardy was identified on 02/27/24. The Administrator and DON were notified of the Immediate Jeopardy on 02/27/24 at 12:15 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 Facility's Plan of Removal for Immediate Jeopardy was accepted on 02/27/24 at 4:53 PM and reflected the following: Interventions: An audit was completed by the DON of all x-rays ordered for residents in the last 24hrs to ensure completion, results were obtained in a timely manner, and communicated to the physician. Completed on 2/27/24. No further issues were identified. The Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse on the topic that if x-rays or diagnostics will be delayed or not obtained within 4 hours to notify the physician for a possible transfer to the hospital for x-rays/diagnostics. Completed on 2/27/24. During daily stand-up, ADMIN, DON, and DOR will review all reported changes in condition in Point Click Care to ensure x-rays/diagnostics were followed up within 4 hours. Nurses will report any outstanding x-rays/diagnostics during change of shift report, including the time they were ordered in the [resident's electronic record]. DON/ADON/Compliance Nurse will review orders in [resident's electronic record] during daily stand up to ensure continuation of care for changes in condition, to include x-rays/diagnostics, were completed within 4 hours. Nurses will complete SBAR assessment in [resident's electronic record] for all changes in condition reported. The Medical Director was notified of the immediate jeopardy on 2/27/24 by the Administrator. [QAPI] will be completed on 2/27/24 to include the IDT team and Medical Director to discuss the immediate jeopardy and subsequent plan. In-services: The following in-services below were in[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical status and a need to alter treatment significantly for 2 (Resident #32 and #29) of 8 residents reviewed for physician notification. The facility failed to ensure: 1. LVN B immediately notified Resident #32's physician when Resident #32, who did not have a history of shortness of breath complaints, complained of not being able to breathe and requested two breathing treatments the night of 11/28/22. Resident #32 was discovered on 11/29/22 unresponsive and not breathing. CPR was preformed but she was pronounced dead at the facility on 11/29/22. 2. LVN A notified Resident #29's physician when she complained of pain and numbness to both her arms, pain level 9 out of 10 (10 being the worst) and stated that was how she felt the last time she had a stroke. An Immediate Jeopardy (IJ) was identified on 11/30/22 at 5:36 PM and the ADM, DON, and the RNC were notified. While the IJ was removed on 12/02/22 at 7:30 PM, the facility remained out of compliance at a scope of isolated at the severity level of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Findings included: 1. Review of Resident #32's quarterly MDS dated [DATE] reflected she was a [AGE] year-old woman initially admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included: chronic respiratory failure, COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), CHF (long-term condition in which heart cannot pump blood well enough to meet body's needs), dependence on supplemental oxygen, and HTN. Review of her cognition assessment reflected a BIMS of 15 and indicated she was cognitively intact. The prognosis of her health conditions reflected she did not have a condition or chronic disease that may result in a life expectancy of less than 6 months. Review of Resident #32's face sheet dated 12/01/22 reflected RP #1 was a family member and the POA. Her designated code status was full code and indicated if her heart or respirations stopped (cardiac arrest or respiratory arrest), all resuscitation procedures would be provided to keep her alive. Review of Resident #32's Care Plans dated with admission date 06/20/20 reflected Resident #32 had chosen a full code status and interventions included following her advanced directive, initiating CPR in the event of unresponsiveness, no pulse, no respirations, and activating 911. She was at risk for SOB due to CHF and COPD and interventions included giving cardiac medications as ordered, monitoring vital signs, and notifying the MD of significant abnormalities, giving bronchodilators as ordered with monitoring and documenting of effectiveness, monitoring for respiratory difficulty, and monitoring for signs of acute respiratory insufficiency such as: anxiety, confusion, restlessness, and SOB at rest. She was on oxygen due to COPD and interventions included monitoring for signs and symptoms of respiratory distress and reporting to the MD: respirations, pulse, oximetry (test to measure the oxygen level/oxygen saturation of the blood), increased heart rate, restlessness, excessive sweating, headaches, lethargy, confusion, atelectasis (complete or partial collapse of the entire lung or area (lobe) of the lung), coughing up blood, cough, pleuritic pain (pain in chest or shoulder made worse with breathing), accessory muscle usage (contraction of any muscle other than the diaphragm during inspiration or use of any muscle during expiration indicating labored breathing/respiratory distress), and skin color. Other interventions included an O2 setting of 2LPM via N/C and promoting lung expansion by positioning with proper body alignment and a head of bed elevated 30 degrees if tolerated. Review of Resident #32's Physician's Orders dated 12/01/22 reflected the following orders: 1. Full Code. Start date 06/20/20. 2. Oxygen via N/C at 2-4 LPM continuous to keep O2 saturation above 92%. If unable to keep O2 saturation above 92%, notify the MD immediately. Start date 02/28/21. 3. DuoNeb solution (inhalation solution containing a combination of albuterol and ipratropium, bronchodilators that relax muscles in the airways and increase air flow to the lungs) 3mL orally via nebulizer every 6 hours as needed for SOB. Start date 06/20/20. 4. Symbicort (combination of budesonide and formoterol. Budesonide is a corticosteroid that reduces inflammation in the body. Formoterol is a long-acting bronchodilator that relaxes muscles in the airways to improve breathing) 2 puffs inhale orally two times per day for COPD. Start date 03/09/21. Review of Resident #32's e-MARs from 10/01/22 to 10/31/22 reflected there were not any PRN DuoNeb breathing treatments documented as being administered on any dates. Review of Resident #32's e-MARs from 11/01/22 to 11/30/22 reflected she received a PRN DuoNeb breathing treatment on 11/28/22 at 11:02 PM. The following vital signs were documented: BP 134/80, pulse 100, RR 16, O2 saturation 92%. There were not any PRN DuoNeb breathing treatments documented on 11/29/22 or on any other dates. Review of Resident #32's progress notes from 11/01/22 through 11/30/22 reflected the following: 1. On 11/28/22 at 11:02 PM, LVN B administered a DuoNeb breathing treatment for shortness of breath. 2. On 11/29/22 at 7:22 AM, LVN B documented a note from 11/29/22 at 5:10 AM which reflected patient was awake most of the night HOB elevated and breathing treatment given per mar well tolerated.@ 12 midnight she requested to sit upright on wheelchair for comfort call light within reach. respiration even unlabored her vitals [BP 138/80 Pulse 78 02 Saturation 97% Temperature 97.4 ]she was having a conversation with [friend] on the phone and stable continue to monitor. at about 0400am she requested to be put back in bed still texting [friend] on her phone. she was given her early Morning medication per mar well tolerated. patient in a comfortable position HOB elevated call light within reach. The note did not indicate it was a late entry. 3. On 11/29/22, LVN B documented a breathing treatment was given at 11:02 PM and was effective. The note was created on 11/29/22 at 4:19 AM, but the time was changed to 5:19 AM. The note did not indicate the reason the time was changed. 4. On 11/29/22 at 8:46 AM, RN C documented a note from 11/29/22 at 6:05 AM which reflected, This Nurse went to the resident room to check on her, upon arriving the room resident was in bed lying, tried to wake up the resident but she was unresponsive, and no respiration noted, checked the pulse and fainted pulse noted, came to call my colleagues and went back to the room and recheck the pulse and there was no pulse, CPR initiated and about [6:08 AM] 911 was notified of this incident and immediately the paramedics were in the building and took over with the CPR. obtained CPR 30 compressions via machine followed by two ventilation breaths for more than 30 minutes and the machine continues to show asystole [no heartbeat], at [6:55 AM] resident was pronounced dead. [MD P], Administrator notified. [ADON F] notified the family member [RP #1]. The note did not indicate it was a late entry. 5. On 11/29/22 at 8:19 AM, ADON F documented a note from 11/29/22 at 7:05 AM which reflected, At 0705am this nurse called resident [RP #1] and notified him that his [Resident #32] had expired. [RP #1] was hurt & crying while on the phone & just hung up. 0734am he arrived to the facility. The note did not indicate it was a late entry. Review of Resident #32's EHR on 11/29/22 reflected the last vital signs documented were on 11/28/22 at 11:02 PM and were BP 134/80, pulse 100 bpm, RR 16, and O2 saturation 92% (did not reflect whether this was on oxygen or on room air). The last documented temperature was on 11/25/22 at 11:59 PM and was 97.4 °F. Review of the assessment forms in the EHR reflected the last assessment documented was a skin assessment on 11/21/22. There were not any change in condition assessments documented from 08/01/22 through 11/29/22. In a telephone interview with RP #1 on 11/30/22 at 10:44 AM, RP #1 said Resident #32 had been at the facility since 2018. RP #1 said he did not have any concerns regarding Resident #32's care. He said he picked up Resident #32's belongings, including her phone, from the facility on 11/29/22 and saw that she had made 2 calls to FM #3 on 11/28/22 at 11 PM. He said he thought Resident #32 made those calls on accident as she was known to pocket dial. He said he had spoken, via telephone, with Resident #32 on 11/28/22 a little after lunch, and she seemed fine. RP #1 said FM #2 could provide more information on Resident #32's medical conditions and placed her on the phone. FM #2 stated Resident #32 had some issues with her breathing recently. FM #2 said Resident #32 was receiving continuous O2 at 6LPM via the oxygen concentrator and she was able to let the nurses know if she was not feeling well or she would send a text message the DON. She said Resident #32 could express herself very well. She said Resident #32 had daily, routine breathing treatments and she never used the PRN breathing treatments. In a telephone interview on 12/01/22 at 1:49 PM, FM #2 stated she and RP #1 initially did not have any concerns regarding Resident #32's care but they had been made aware of a voicemail left for FM #3 by Resident #32 on 11/28/22 and now they had concerns. She said in the voicemail, Resident #32 could be heard asking for help and stating she could not breathe. She said facility staff could be heard in the background. FM #2 said the voicemail could be sent via e-mail for review. In a telephone interview on 12/02/22 at 10:46 AM, FM #3 said she had a missed call from Resident #32 on 11/28/22 at 11:24 PM. FM #3 said she spoke with Resident #32 multiple times daily and Resident #32 had never before stated she could not breathe. She said the last time she spoke with Resident #32 was on 11/28/22 in the evening and they had a normal conversation, which included the resident complaining of how long her call light would be on overnight before anyone came to her room. FM #3 said Resident #32 had COPD and some difficulty breathing was normal for her, but not like she was, on the voicemail. Review of the telephonic voice message sent via email by FM #2 on 12/01/22 at 2:16 PM reflected the message was 3 minutes long. Further review reflected a person was speaking in a distressed tone and paused several times between words. They said, Oh. Oh Lord. Oh Lord please. God. I can't breathe. God help me. Oh Lord. God help me. Oh. Oh. Oh. I can't breathe. Please. Oh Lord. Oh Lord. God. Please. Oh Lord. Oh God. Oh. Oh. God help me. Oh God help me. God. Please! Put me in my chair, so I can breathe. Oh. God help me. God help me. God. Somebody. Oh. Oh. Oh Lord. [Second person heard speaking; portions inaudible. You, ok? You can't breathe? Resident continued .] Yeah. The white ones on the closet floor. Oh God. I don't know her. In an interview with LVN B on 11/30/22 at 1:41 PM, she said on 11/28/22, Resident #32 was awake all night and could not sleep. She said at around 11 PM on 11/28/22, Resident #32 complained of not being able to breathe and requested a breathing treatment. LVN B said she obtained Resident #32's vital signs and gave her a PRN breathing treatment. LVN B could not remember what the vital signs were for Resident #32. LVN B also stated she could not recall the O2 concentrator setting when Resident #32 said she could not breathe. LVN B said after the breathing treatment, Resident #32 still complained of not being able to breathe and requested to be transferred from her bed to her wheelchair. LVN B said she overheard Resident #32 making calls on her phone. LVN B said at around 4:15 AM (11/29/22), she told the agency CNA to place Resident #32 back in her bed so that she could receive incontinent care, but Resident #32 refused to be placed back in bed because she was having trouble breathing. LVN B said Resident #32 agreed to be placed back in bed only if LVN B gave her another breathing treatment because the previous breathing treatment had helped. LVN B said she administered to Resident #32 the second PRN breathing treatment but did not obtain her vital signs. LVN B said she went to give Resident #32 her morning medication on 11/29/22 at around 5 AM and Resident #32 requested water and her cough drops. LVN B said she then went back to the nursing station and when the morning nurses arrived, she gave them report. She said RN C left down the hall to check on Resident #32 and came out of the room yelling for a crash cart and yelling code blue (medical emergency, usually cardiac or respiratory arrest). LVN B said she had known Resident #32 for probably 10 years and said it was not abnormal for Resident #32 to be up at night on her phone but said Resident #32 slept most nights. LVN B said she assessed Resident #32 prior to administering the breathing treatment at around 11 PM including her vital signs, O2 saturation. LVN B said Resident #32's oxygen saturation was at 96-97% and she said her O2 was set to deliver 2LPM to 4LPM. LVN B could not recall the exact setting of the O2 concentrator and said she increased it a little bit. LVN B could not recall exactly what she increased the O2 setting to, but said she increased it to 3 or 4 or so. LVN B said she did not recall if she documented that she assessed Resident #32's lung sounds but said she listened to Resident #32's front left and right upper lung lobes and listened to her back. LVN B said she did not hear any wheezing or crackles (abnormal breath sounds). LVN B said she believed Resident #32's complaints of not being able to breathe were more related to anxiety than respiratory distress. She said there was an agency CNA working with her that night and Resident #32 did not like unknown staff. She said she observed Resident #32 blowing air out through her mouth forcefully and thought Resident #32 was having anxiety. LVN B said Resident #32 also complained of pain but did not get a measure of Resident #32's pain. She said Resident #32 had pain all over, general body pain. LVN B said she could not recall her documented assessment of Resident #32 on 11/28/22 and 11/29/22 and said she wrote some stuff in [her chart]; I documented the breathing treatment. LVN B said she had a very fast and long night on 11/28/22 due to two other residents on the same hall as Resident #32 continually attempting to or getting out of bed and she was afraid they would have a fall. LVN B said she did not recall Resident #32 ever complaining of not being able to breathe or requesting a breathing treatment prior to 11/28/22. LVN B said she did not call the doctor to notify him that Resident #32 had complained of not being able to breathe and was requesting PRN breathing treatments because she did not see it as anything out of the ordinary. In an interview with RN C on 11/29/22 at 1:21 PM, RN C said she normally worked the 6 AM to 2 PM shift on Resident #32's hall and had worked with her at the facility for 2 years. She said Resident #32 had COPD, HTN, and arthritis. She said she normally arrived for her shift prior to 6 AM and on 11/29/22 at 6:05 AM, she had completed receiving report from LVN B. She said she would have normally started her rounds at one end of the hall at that time, but because LVN B told her during report that Resident #32 had issues overnight, she went directly to her room. RN C said when she entered Resident #32's room, she noticed she was not breathing and was unresponsive. She stated she checked Resident #32's radial pulse (inside wrist), and said the pulse was faint. RN C said Resident #32 was wearing a N/C for O2, but she did not observe the settings of the O2 concentrator. RN C said she left Resident #32's room and went to get LVN B, who was at the nurses' station, and LVN A who was in another hall. She said she asked for the crash cart and one of them brought it to Resident #32's room. RN C said when she returned to Resident #32's room, she re-assessed Resident #32's pulse, first at her wrist and then at her neck. She said she did not feel a pulse and she instructed LVN A and LVN B to start CPR. LVN A was doing compressions and LVN B was doing the breaths with the Ambu bag (hand-held device commonly used to provide positive pressure ventilation to people who are not breathing or not breathing adequately). RN C said she left to call 911 and when she returned, she took over compressions and LVN A left to get the AED. She said once LVN A arrived with the AED, the pads were placed onto Resident #32, the AED analyzed and advised a shock to be given. RN C said one shock was given and then CPR was resumed. She said the paramedics arrived and took over CPR by inserting a tube into Resident #32's mouth, and the Ambu bag was connected to the tube. RN C said the paramedics continued CPR for approximately 30 minutes, but it was ineffective, and Resident #32 was pronounced dead on 11/29/22 at 6:55 AM. RN C did not recall at what time she called 911 or at what time the paramedics arrived. RN C said in the two years she worked with Resident #32, she had never heard Resident #32 complaining of not being able to breathe or requesting a breathing treatment. RN C said Resident #32 received a routine breathing treatment during the day and she had never administered to Resident #32 the PRN breathing treatment. RN C said LVN B did not tell her during report that Resident #32 complained of not being able to breathe or that she had administered 2 PRN breathing treatments to Resident #32 overnight. RN C said if a resident complained of not being able to breathe and requested a breathing treatment, she would first assess the resident's vital signs, assess their respiration rate, work of breathing, sit them up or elevate the head of the bed, and assess the lung sounds. She said she would complete the assessment prior to and after the breathing treatment. RN C said she would then assess the resident every 30 minutes, and depending on the findings of her assessment, she would use her nursing judgment in determining to notify the MD. RN C said she would also document her assessment in the resident's EHR. In an interview with LVN A on 11/29/22 at 1:45 PM, LVN A said on 11/29/22, shortly after 6 AM, she was getting report from the overnight nurse when she heard RN C yell for the crash cart. She said LVN B grabbed the crash cart, and they went into Resident #32's room. She observed RN C check for Resident #32's pulse at her wrist and say she did not have a pulse. She said she was doing compressions, LVN B was providing ventilation with the Ambu bag, and RN C left to call 911. She said RN C took over compression when she returned, and she left to get the AED. She said she placed the pads on Resident #32 and one shock was given prior to the paramedics' arrival. LVN A said she could not recall at what time the paramedics arrived. In an interview with the city police department's communications staff on 12/02/22 at 10:08 AM, she stated a call was made to 911 from the facility on 11/29/22 at 6:26 AM. She stated the paramedics arrived at the facility on 11/29/22 at 6:30 AM. In an interview on 12/02/22 at 12:00 PM, ADON F said it would be considered a change in condition if a resident complained of not being able to breathe and requested a PRN breathing treatment. ADON F said she would expect a nurse to assess the resident's vital signs, assess their respirations, seeing if the resident had labored breathing, assess their inhalation and expiration, and listen to the resident's lung sounds. ADON F said she would then expect a nurse to document, notify the doctor, and document the conversation with the doctor. In an interview on 11/30/22 at 11:12 AM, MD P said he was Resident #32's physician. He said he did not receive any phone calls on 11/28/22 or 11/29/22 regarding Resident #32. He said Resident #32's COPD was pretty advanced, and she had orders for routine and PRN breathing treatments. MD P said it was his expectation that a nurse would call him if Resident #32 was having difficulty breathing or receiving a PRN breathing treatment. MD P said he knew nurses would have called if Resident #32 was having difficulty breathing and the nurse would have documented that they called him. In an interview on 11/30/22 at 10:17 AM, MD X said he was the Medical Director. He said it was his expectation a nurse would call the attending physician for a resident's change in condition. Review of the facility's Oxygen Administration dated 2010 reflected, The purpose of this procedure is to provide guidelines for safe oxygen administration . Review the resident's care plan to assess for any special needs of the resident . while the resident is receiving oxygen therapy, assess for the following: signs or symptoms of cyanosis (i.e. blue tone to the skin and mucous membranes); signs or symptoms of hypoxia (i.e. rapid breathing, rapid pulse rate, restlessness, confusion); signs or symptoms of oxygen toxicity (i.e. tracheal irritation, difficulty breathing, or slow, shallow rate of breathing); vital signs; lung sounds . the following should be documented in the resident's medical record: The date and time the procedure was performed . The rate of oxygen flow, route, and rationale . All assessment obtained before, during, and after the procedure Review of the facility's policy Administering Medications through a Small Volume (Handheld) Nebulizer, dated 2010, reflected: The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway . Obtain a physician's order as needed. Review the resident's care plan, current orders, and diagnoses to determine resident needs. Check the treatment record . If the resident suffers from Chronic Obstructive Pulmonary Disease (COPD), refer to the [COPD] Clinical Protocol in addition to this procedure . Remain with the resident for the treatment. Approximately five minutes after the treatment begins (or sooner if clinical judgment indicates) obtain the resident's pulse. Monitor for side effects, including rapid pulse, restlessness, nervousness throughout the treatment. Stop the treatment and notify the physician if the pulse increases 20 percent above baseline . Obtain post-treatment pulse, respiratory rate, and lung sounds . The following information should be documented in the resident's medical record. The date, time, and length of treatment . Pulse, respiratory rate and lung sounds before and after the treatment. Pulse during treatment. Amount and characteristics of sputum production . Any adverse effects of the medication and/or treatment and physician notification, if applicable . Notify the physician is the resident experiences adverse effects from the medication. Notify the physician id the pulse rate during treatment increases 20 percent above baseline. Follow any other orders for physician notification pertinent to the resident. Review of the ACEP COPD recommendations accessed on 12/06/22 at https://www.emergencyphysicians.org/article/know-when-to-go/COPD, reflected: Chronic Obstructive Pulmonary Disease or COPD is a group of long-term inflammatory lung conditions that make it hard to breathe . COPD is one of the most common chronic diseases seen in patients who need emergency care. More than 16 million people in the United States live with COPD, and COPD-related emergencies annually send about 873,000 people to the emergency department, according to the Centers for Disease Control and Prevention (CDC). COPD symptoms can be manageable with regular checkups and care at home that can include healthy behavior changes like quitting smoking, prescription medications or breathing devices. However, flare ups are common. When symptoms appear more suddenly than usual, or become severe or longer lasting, it may be necessary to get medical attention right away. Paying close attention to changes in typical symptoms and knowing when seek help could prevent a medical emergency. People with COPD can have a cough, chest tightness, wheezing or shortness of breath, and heavy amounts of mucus. Call 911 or go to the closest emergency department if you experience: Difficulty breathing or talking. Chest pains. Fever. Racing heartbeat. Fingernails that turn blue or gray (a sign of a low oxygen level in your blood). Recommended treatment is not working, and symptoms are getting worse. Slurred speech, disorientation, confusion, dizziness. Sleepiness and difficulty awakening from sleep. Those with chronic conditions should work with a physician to create a plan to manage their illness that includes an emergency action plan with medication history, important phone numbers, and other information that can be critical to gather before an emergency occurs . 1. Review of Resident #29's face sheet dated 12/01/22 reflected she was a [AGE] year-old woman initially admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included: epilepsy, diabetes, hyperlipidemia (blood has too many lipids (or fats), such as cholesterol and triglycerides), COPD, HTN, right-sided paralysis after a stroke, cerebral infarction (stroke, 08/26/22), and heart failure. Review of Resident #29's quarterly MDS dated [DATE] reflected she had adequate hearing, clear speech, and could make her wants and needs understood. Her BIMS was 13 and indicated she was cognitively intact. She did not have behavioral symptoms such as delusions, hallucinations, physical aggression, or refusals of care. Review of the pain management assessment reflected she did not receive scheduled, or PRN pain medications and she denied pain in the 5 days prior to the assessment. Review of Resident #29's care plans dated 08/27/22 reflected Resident #29 had one sided paralysis due to a stroke. Her goal was to be free from signs or symptoms of complications of a stroke such DVT (blood clot in a deep vein), contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), aspiration pneumonia (infection caused by food or liquid breathed into the airways or lungs), or dehydration. Interventions included giving medications as ordered by the physician. Monitoring and document side effects and effectiveness. Monitoring vital sings and notifying the MD of significant abnormalities. Resident #29 did not have a care plan for risk of stroke. A record review of Resident #29's progress notes in the EHR revealed a note documented on 09/24/22 reflected Resident #29 was sent to the ER via 911 on 09/24/22 due to a low blood pressure, confusion, and slurred speech. The resident was re-admitted to the facility on [DATE] with a diagnosis of stroke. In an interview and observation on 11/30/22 at 8:16 AM, LVN A stated she would need to administer Resident #29's insulin after breakfast. She entered Resident #29's room and Resident #29 was lying in bed with her eyes closed. She had on a N/C which was connected to the O2 concentrator set to deliver 2LPM. She was breathing but was difficult to arouse. LVN A attempted to arouse Resident #29 with loud verbal prompts and physical touch to the resident's left upper arm. The resident did not arouse after approximately 3 minutes and LVN A said she would hold Resident #29's insulin and would instead obtain a set of vital signs. LVN A left the room and promptly returned with a pulse oximeter (device used to measure the O2 saturation of the blood), thermometer, and an automatic wrist BP cuff. LVN A obtained the readings of temperature 97.3 degrees Fahrenheit, pulse 62, O2 saturation 96%, and BP of 35/35 on her left wrist. LVN A said the BP reading did not seem accurate and placed the cuff to Resident #29's right wrist. Resident #29 aroused when LVN A placed the cuff to her right wrist, and LVN A asked her if she was feeling ok. Resident #29 said she was feeling lousy. LVN A obtained a reading of 135/39 from the resident's right wrist. LVN A did not clarify what Resident #29 meant by lousy. The HHSC Surveyor intervened and asked Resident #29 what she meant by lousy. Resident #29 stated she had pain to both her arms and to her back, and both her arms were numb. LVN A said she would administer a pain medication to Resident #29 and began to leave the room without completing a pain assessment. The HHSC Surveyor intervened while LVN A was in the room and asked Resident #29 about her pain. Resident #29 the pain in her back was chronic, but stated her pain was at 9/10, sharp in nature, and said she had only once previously felt this pain when she was having a stroke last month (October 2022). Resident #29 was very lethargic, and her speech was slurred. She had intermittent tremors to both of her hands. LVN A again told Resident #29 she would go get her a pain pill and left the room. LVN A returned promptly to the room and administered a whole pill with water to Resident #29 and said it was tramadol, and then left the room. In an observation and interview on 11/30/22 at 8:44 AM, LVN A returned to Resident #29's room and administered insulin to Resident #29's abdomen. LVN A said she did not know if Resident #29 had a history of a stroke, but to her knowledge she did not. LVN A said she believed Resident #29 was displaying attention seeking behaviors. LVN A then left and sat at the nurses' station down the hall. In an interview and observation on 11/30/22 at 8:50 AM, the HHSC Surveyor intervened and reported to ADON F Resident #29's complaint of pain, statement that that was the way she felt last time she had a stroke, and the BP's obtained by LVN A. ADON F said she would obtain a manual BP and call the MD. ADON F went to the nurses' station and told LVN A to obtain a manual BP on Resident #29. In an observation on 11/30/22 at 9:01 AM, LVN A entered Resident #29's room and applied the BP cuff to Resident #29's left upper arm. She placed the bell of the stethoscope in the inner fold of the elbow and stated the resident's BP was 141/78. ADON F asked LVN A to see if the MD had responded to the electronic text message which had been sent to him earlier. ADON F then attempted to obtain a second manual BP on Resident #29's right upper arm, but the resident began to shake and displayed signs of a seizure. The resident's eyes were open, not blinking, and she was staring but not following objects with her gaze. Both of her arms stiffened and began to shake. This lasted 2 minutes. ADON F said she could not obtain Resident #29's BP because her arms were shaking too much during her seizure; she left the room and said she would go call the MD. The MDS Nurse entered the room during this observation. In an interview on 11/30/22 at 9:22 AM, the MDS Nurse said she had previously worked directly with Resident #29 but recently took the position of MDS Nurse. The MDS Nurse said Resident #29 had a history of seizures, she had one when she was first admitted in 2017, but she had never observed one of Resident #29's seizures or known Resident #29 to have any more seizures. The MDS Nurse said the tremors to Resident #29's hands were new. The MDS Nurse was not aware if Resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and records reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 (Resident #32 and Resident #29) of 8 residents reviewed for quality of care. The facility failed to ensure: 1. Resident #32 was appropriately assessed, monitored, and care plans were followed when Resident #32, who did not have a history of shortness of breath complaints, complained of not being able to breathe and requested two breathing treatments the night of 11/28/22. Resident #32 was discovered on 11/29/22 unresponsive and not breathing. CPR was preformed but she was pronounced dead at the facility on 11/29/22. 2. Resident #29 was appropriately assessed and monitored when she complained of pain to both her arms, pain level 9 out of 10 (10 being the worst) and stated that was how she felt the last time she had a stroke. Resident #29 was difficult to rouse, had slurred speech, tremors in her hands, and then had a seizure, and within 1 day, Resident had a second seizure, was sent to the ER, and was diagnosed with a UTI. Resident #29 had a history of strokes, last on 09/24/22, and several stroke risks such as diabetes, hyperlipidemia (blood has too many lipids (or fats), such as cholesterol and triglycerides), HTN, and heart failure. An Immediate Jeopardy (IJ) was identified on 11/30/22 at 5:36 PM and the ADM, DON, and the RNC were notified. While the IJ was removed on 12/02/22 at 7:30 PM, the facility remained out of compliance at a scope of isolated at the severity level of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Findings included: 1. Review of Resident #32's quarterly MDS dated [DATE] reflected she was a [AGE] year-old woman initially admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included: chronic respiratory failure, COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs), CHF (long-term condition in which heart cannot pump blood well enough to meet body's needs), dependence on supplemental oxygen, and HTN. Review of her cognition assessment reflected a BIMS of 15 and indicated she was cognitively intact. The prognosis of her health conditions reflected she did not have a condition or chronic disease that may result in a life expectancy of less than 6 months. Review of Resident #32's face sheet dated 12/01/22 reflected RP #1 was a family member and the POA. Her designated code status was full code and indicated if her heart or respirations stopped (cardiac arrest or respiratory arrest), all resuscitation procedures would be provided to keep her alive. Review of Resident #32's Care Plans dated with admission date 06/20/20 reflected Resident #32 had chosen a full code status and interventions included following her advanced directive, initiating CPR in the event of unresponsiveness, no pulse, no respirations, and activating 911. She was at risk for SOB due to CHF and COPD and interventions included giving cardiac medications as ordered, monitoring vital signs, and notifying the MD of significant abnormalities, giving bronchodilators as ordered with monitoring and documenting of effectiveness, monitoring for respiratory difficulty, and monitoring for signs of acute respiratory insufficiency such as: anxiety, confusion, restlessness, and SOB at rest. She was on oxygen due to COPD and interventions included monitoring for signs and symptoms of respiratory distress and reporting to the MD: respirations, pulse, oximetry (test to measure the oxygen level/oxygen saturation of the blood), increased heart rate, restlessness, excessive sweating, headaches, lethargy, confusion, atelectasis (complete or partial collapse of the entire lung or area (lobe) of the lung), coughing up blood, cough, pleuritic pain (pain in chest or shoulder made worse with breathing), accessory muscle usage (contraction of any muscle other than the diaphragm during inspiration or use of any muscle during expiration indicating labored breathing/respiratory distress), and skin color. Other interventions included an O2 setting of 2LPM via N/C and promoting lung expansion by positioning with proper body alignment and a head of bed elevated 30 degrees if tolerated. Review of Resident #32's Physician's Orders dated 12/01/22 reflected the following orders: 1. Full Code. Start date 06/20/20. 2. Oxygen via N/C at 2-4 LPM continuous to keep O2 saturation above 92%. If unable to keep O2 saturation above 92%, notify the MD immediately. Start date 02/28/21. 3. DuoNeb solution (inhalation solution containing a combination of albuterol and ipratropium, bronchodilators that relax muscles in the airways and increase air flow to the lungs) 3mL orally via nebulizer every 6 hours as needed for SOB. Start date 06/20/20. 4. Symbicort (combination of budesonide and formoterol. Budesonide is a corticosteroid that reduces inflammation in the body. Formoterol is a long-acting bronchodilator that relaxes muscles in the airways to improve breathing) 2 puffs inhale orally two times per day for COPD. Start date 03/09/21. Review of Resident #32's e-MARs from 10/01/22 to 10/31/22 reflected there were not any PRN DuoNeb breathing treatments documented as being administered on any dates. Review of Resident #32's e-MARs from 11/01/22 to 11/30/22 reflected she received a PRN DuoNeb breathing treatment on 11/28/22 at 11:02 PM. The following vital signs were documented: BP 134/80, pulse 100, RR 16, O2 saturation 92%. There were not any PRN DuoNeb breathing treatments documented on 11/29/22 or on any other dates. Review of Resident #32's progress notes from 11/01/22 through 11/30/22 reflected the following: 1. On 11/28/22 at 11:02 PM, LVN B administered a DuoNeb breathing treatment for shortness of breath. 2. On 11/29/22 at 7:22 AM, LVN B documented a note from 11/29/22 at 5:10 AM which reflected patient was awake most of the night HOB elevated and breathing treatment given per mar well tolerated.@ 12 midnight she requested to sit upright on wheelchair for comfort call light within reach. respiration even unlabored her vitals [BP 138/80 Pulse 78 02 Saturation 97% Temperature 97.4 ]she was having a conversation with [friend] on the phone and stable continue to monitor. at about 0400am she requested to be put back in bed still texting [friend] on her phone. she was given her early Morning medication per mar well tolerated. patient in a comfortable position HOB elevated call light within reach. The note did not indicate it was a late entry. 3. On 11/29/22, LVN B documented a breathing treatment was given at 11:02 PM and was effective. The note was created on 11/29/22 at 4:19 AM, but the time was changed to 5:19 AM. The note did not indicate the reason the time was changed. 4. On 11/29/22 at 8:46 AM, RN C documented a note from 11/29/22 at 6:05 AM which reflected, This Nurse went to the resident room to check on her, upon arriving the room resident was in bed lying, tried to wake up the resident but she was unresponsive, and no respiration noted, checked the pulse and fainted pulse noted, came to call my colleagues and went back to the room and recheck the pulse and there was no pulse, CPR initiated and about [6:08 AM] 911 was notified of this incident and immediately the paramedics were in the building and took over with the CPR. obtained CPR 30 compressions via machine followed by two ventilation breaths for more than 30 minutes and the machine continues to show asystole [no heartbeat], at [6:55 AM] resident was pronounced dead. [MD P], Administrator notified. [ADON F] notified the family member [RP #1]. The note did not indicate it was a late entry. 5. On 11/29/22 at 8:19 AM, ADON F documented a note from 11/29/22 at 7:05 AM which reflected, At 0705am this nurse called resident [RP #1] and notified him that his [Resident #32] had expired. [RP #1] was hurt & crying while on the phone & just hung up. 0734am he arrived to the facility. The note did not indicate it was a late entry. Review of Resident #32's EHR on 11/29/22 reflected the last vital signs documented were on 11/28/22 at 11:02 PM and were BP 134/80, pulse 100 bpm, RR 16, and O2 saturation 92% (did not reflect whether this was on oxygen or on room air). The last documented temperature was on 11/25/22 at 11:59 PM and was 97.4 °F. Review of the assessment forms in the EHR reflected the last assessment documented was a skin assessment on 11/21/22. There were not any change in condition assessments documented from 08/01/22 through 11/29/22. In a telephone interview with RP #1 on 11/30/22 at 10:44 AM, RP #1 said Resident #32 had been at the facility since 2018. RP #1 said he did not have any concerns regarding Resident #32's care. He said he picked up Resident #32's belongings, including her phone, from the facility on 11/29/22 and saw that she had made 2 calls to FM #3 on 11/28/22 at 11 PM. He said he thought Resident #32 made those calls on accident as she was known to pocket dial. He said he had spoken, via telephone, with Resident #32 on 11/28/22 a little after lunch, and she seemed fine. RP #1 said FM #2 could provide more information on Resident #32's medical conditions and placed her on the phone. FM #2 stated Resident #32 had some issues with her breathing recently. FM #2 said Resident #32 was receiving continuous O2 at 6LPM via the oxygen concentrator and she was able to let the nurses know if she was not feeling well or she would send a text message the DON. She said Resident #32 could express herself very well. She said Resident #32 had daily, routine breathing treatments and she never used the PRN breathing treatments. In a telephone interview on 12/01/22 at 1:49 PM, FM #2 stated she and RP #1 initially did not have any concerns regarding Resident #32's care but they had been made aware of a voicemail left for FM #3 by Resident #32 on 11/28/22 and now they had concerns. She said in the voicemail, Resident #32 could be heard asking for help and stating she could not breathe. She said facility staff could be heard in the background. FM #2 said the voicemail could be sent via e-mail for review. In a telephone interview on 12/02/22 at 10:46 AM, FM #3 said she had a missed call from Resident #32 on 11/28/22 at 11:24 PM. FM #3 said she spoke with Resident #32 multiple times daily and Resident #32 had never before stated she could not breathe. She said the last time she spoke with Resident #32 was on 11/28/22 in the evening and they had a normal conversation, which included the resident complaining of how long her call light would be on overnight before anyone came to her room. FM #3 said Resident #32 had COPD and some difficulty breathing was normal for her, but not like she was, on the voicemail. Review of the telephonic voice message sent via email by FM #2 on 12/01/22 at 2:16 PM reflected the message was 3 minutes long. Further review reflected a person was speaking in a distressed tone and paused several times between words. They said, Oh. Oh Lord. Oh Lord please. God. I can't breathe. God help me. Oh Lord. God help me. Oh. Oh. Oh. I can't breathe. Please. Oh Lord. Oh Lord. God. Please. Oh Lord. Oh God. Oh. Oh. God help me. Oh God help me. God. Please! Put me in my chair, so I can breathe. Oh. God help me. God help me. God. Somebody. Oh. Oh. Oh Lord. [Second person heard speaking; portions inaudible. You, ok? You can't breathe? Resident continued .] Yeah. The white ones on the closet floor. Oh God. I don't know her. In an interview with LVN B on 11/30/22 at 1:41 PM, she said on 11/28/22, Resident #32 was awake all night and could not sleep. She said at around 11 PM on 11/28/22, Resident #32 complained of not being able to breathe and requested a breathing treatment. LVN B said she obtained Resident #32's vital signs and gave her a PRN breathing treatment. LVN B could not remember what the vital signs were for Resident #32. LVN B also stated she could not recall the O2 concentrator setting when Resident #32 said she could not breathe. LVN B said after the breathing treatment, Resident #32 still complained of not being able to breathe and requested to be transferred from her bed to her wheelchair. LVN B said she overheard Resident #32 making calls on her phone. LVN B said at around 4:15 AM (11/29/22), she told the agency CNA to place Resident #32 back in her bed so that she could receive incontinent care, but Resident #32 refused to be placed back in bed because she was having trouble breathing. LVN B said Resident #32 agreed to be placed back in bed only if LVN B gave her another breathing treatment because the previous breathing treatment had helped. LVN B said she administered to Resident #32 the second PRN breathing treatment but did not obtain her vital signs. LVN B said she went to give Resident #32 her morning medication on 11/29/22 at around 5 AM and Resident #32 requested water and her cough drops. LVN B said she then went back to the nursing station and when the morning nurses arrived, she gave them report. She said RN C left down the hall to check on Resident #32 and came out of the room yelling for a crash cart and yelling code blue (medical emergency, usually cardiac or respiratory arrest). LVN B said she had known Resident #32 for probably 10 years and said it was not abnormal for Resident #32 to be up at night on her phone but said Resident #32 slept most nights. LVN B said she assessed Resident #32 prior to administering the breathing treatment at around 11 PM including her vital signs, O2 saturation. LVN B said Resident #32's oxygen saturation was at 96-97% and she said her O2 was set to deliver 2LPM to 4LPM. LVN B could not recall the exact setting of the O2 concentrator and said she increased it a little bit. LVN B could not recall exactly what she increased the O2 setting to, but said she increased it to 3 or 4 or so. LVN B said she did not recall if she documented that she assessed Resident #32's lung sounds but said she listened to Resident #32's front left and right upper lung lobes and listened to her back. LVN B said she did not hear any wheezing or crackles (abnormal breath sounds). LVN B said she believed Resident #32's complaints of not being able to breathe were more related to anxiety than respiratory distress. She said there was an agency CNA working with her that night and Resident #32 did not like unknown staff. She said she observed Resident #32 blowing air out through her mouth forcefully and thought Resident #32 was having anxiety. LVN B said Resident #32 also complained of pain but did not get a measure of Resident #32's pain. She said Resident #32 had pain all over, general body pain. LVN B said she could not recall her documented assessment of Resident #32 on 11/28/22 and 11/29/22 and said she wrote some stuff in [her chart]; I documented the breathing treatment. LVN B said she had a very fast and long night on 11/28/22 due to two other residents on the same hall as Resident #32 continually attempting to or getting out of bed and she was afraid they would have a fall. LVN B said she did not recall Resident #32 ever complaining of not being able to breathe or requesting a breathing treatment prior to 11/28/22. LVN B said she did not call the doctor to notify him that Resident #32 had complained of not being able to breathe and was requesting PRN breathing treatments because she did not see it as anything out of the ordinary. In an interview with RN C on 11/29/22 at 1:21 PM, RN C said she normally worked the 6 AM to 2 PM shift on Resident #32's hall and had worked with her at the facility for 2 years. She said Resident #32 had COPD, HTN, and arthritis. She said she normally arrived for her shift prior to 6 AM and on 11/29/22 at 6:05 AM, she had completed receiving report from LVN B. She said she would have normally started her rounds at one end of the hall at that time, but because LVN B told her during report that Resident #32 had issues overnight, she went directly to her room. RN C said when she entered Resident #32's room, she noticed she was not breathing and was unresponsive. She stated she checked Resident #32's radial pulse (inside wrist), and said the pulse was faint. RN C said Resident #32 was wearing a N/C for O2, but she did not observe the settings of the O2 concentrator. RN C said she left Resident #32's room and went to get LVN B, who was at the nurses' station, and LVN A who was in another hall. She said she asked for the crash cart and one of them brought it to Resident #32's room. RN C said when she returned to Resident #32's room, she re-assessed Resident #32's pulse, first at her wrist and then at her neck. She said she did not feel a pulse and she instructed LVN A and LVN B to start CPR. LVN A was doing compressions and LVN B was doing the breaths with the Ambu bag (hand-held device commonly used to provide positive pressure ventilation to people who are not breathing or not breathing adequately). RN C said she left to call 911 and when she returned, she took over compressions and LVN A left to get the AED. She said once LVN A arrived with the AED, the pads were placed onto Resident #32, the AED analyzed and advised a shock to be given. RN C said one shock was given and then CPR was resumed. She said the paramedics arrived and took over CPR by inserting a tube into Resident #32's mouth, and the Ambu bag was connected to the tube. RN C said the paramedics continued CPR for approximately 30 minutes, but it was ineffective, and Resident #32 was pronounced dead on 11/29/22 at 6:55 AM. RN C did not recall at what time she called 911 or at what time the paramedics arrived. RN C said in the two years she worked with Resident #32, she had never heard Resident #32 complaining of not being able to breathe or requesting a breathing treatment. RN C said Resident #32 received a routine breathing treatment during the day and she had never administered to Resident #32 the PRN breathing treatment. RN C said LVN B did not tell her during report that Resident #32 complained of not being able to breathe or that she had administered 2 PRN breathing treatments to Resident #32 overnight. RN C said if a resident complained of not being able to breathe and requested a breathing treatment, she would first assess the resident's vital signs, assess their respiration rate, work of breathing, sit them up or elevate the head of the bed, and assess the lung sounds. She said she would complete the assessment prior to and after the breathing treatment. RN C said she would then assess the resident every 30 minutes, and depending on the findings of her assessment, she would use her nursing judgment in determining to notify the MD. RN C said she would also document her assessment in the resident's EHR. In an interview with LVN A on 11/29/22 at 1:45 PM, LVN A said on 11/29/22, shortly after 6 AM, she was getting report from the overnight nurse when she heard RN C yell for the crash cart. She said LVN B grabbed the crash cart, and they went into Resident #32's room. She observed RN C check for Resident #32's pulse at her wrist and say she did not have a pulse. She said she was doing compressions, LVN B was providing ventilation with the Ambu bag, and RN C left to call 911. She said RN C took over compression when she returned, and she left to get the AED. She said she placed the pads on Resident #32 and one shock was given prior to the paramedics' arrival. LVN A said she could not recall at what time the paramedics arrived. In an interview with the city police department's communications staff on 12/02/22 at 10:08 AM, she stated a call was made to 911 from the facility on 11/29/22 at 6:26 AM. She stated the paramedics arrived at the facility on 11/29/22 at 6:30 AM. In an interview on 12/02/22 at 12:00 PM, ADON F said it would be considered a change in condition if a resident complained of not being able to breathe and requested a PRN breathing treatment. ADON F said she would expect a nurse to assess the resident's vital signs, assess their respirations, seeing if the resident had labored breathing, assess their inhalation and expiration, and listen to the resident's lung sounds. ADON F said she would then expect a nurse to document, notify the doctor, and document the conversation with the doctor. In an interview on 11/30/22 at 11:12 AM, MD P said he was Resident #32's physician. He said he did not receive any phone calls on 11/28/22 or 11/29/22 regarding Resident #32. He said Resident #32's COPD was pretty advanced, and she had orders for routine and PRN breathing treatments. MD P said it was his expectation that a nurse would call him if Resident #32 was having difficulty breathing or receiving a PRN breathing treatment. MD P said he knew nurses would have called if Resident #32 was having difficulty breathing and the nurse would have documented that they called him. In an interview on 11/30/22 at 10:17 AM, MD X said he was the Medical Director. He said it was his expectation a nurse would call the attending physician for a resident's change in condition. Review of the facility's Oxygen Administration dated 2010 reflected, The purpose of this procedure is to provide guidelines for safe oxygen administration . Review the resident's care plan to assess for any special needs of the resident . while the resident is receiving oxygen therapy, assess for the following: signs or symptoms of cyanosis (i.e. blue tone to the skin and mucous membranes); signs or symptoms of hypoxia (i.e. rapid breathing, rapid pulse rate, restlessness, confusion); signs or symptoms of oxygen toxicity (i.e. tracheal irritation, difficulty breathing, or slow, shallow rate of breathing); vital signs; lung sounds . the following should be documented in the resident's medical record: The date and time the procedure was performed . The rate of oxygen flow, route, and rationale . All assessment obtained before, during, and after the procedure Review of the facility's policy Administering Medications through a Small Volume (Handheld) Nebulizer, dated 2010, reflected: The purpose of this procedure is to safely and aseptically administer aerosolized particles of medication into the resident's airway . Obtain a physician's order as needed. Review the resident's care plan, current orders, and diagnoses to determine resident needs. Check the treatment record . If the resident suffers from Chronic Obstructive Pulmonary Disease (COPD), refer to the [COPD] Clinical Protocol in addition to this procedure . Remain with the resident for the treatment. Approximately five minutes after the treatment begins (or sooner if clinical judgment indicates) obtain the resident's pulse. Monitor for side effects, including rapid pulse, restlessness, nervousness throughout the treatment. Stop the treatment and notify the physician if the pulse increases 20 percent above baseline . Obtain post-treatment pulse, respiratory rate, and lung sounds . The following information should be documented in the resident's medical record. The date, time, and length of treatment . Pulse, respiratory rate and lung sounds before and after the treatment. Pulse during treatment. Amount and characteristics of sputum production . Any adverse effects of the medication and/or treatment and physician notification, if applicable . Notify the physician is the resident experiences adverse effects from the medication. Notify the physician id the pulse rate during treatment increases 20 percent above baseline. Follow any other orders for physician notification pertinent to the resident. Review of the ACEP COPD recommendations accessed on 12/06/22 at https://www.emergencyphysicians.org/article/know-when-to-go/COPD, reflected: Chronic Obstructive Pulmonary Disease or COPD is a group of long-term inflammatory lung conditions that make it hard to breathe . COPD is one of the most common chronic diseases seen in patients who need emergency care. More than 16 million people in the United States live with COPD, and COPD-related emergencies annually send about 873,000 people to the emergency department, according to the Centers for Disease Control and Prevention (CDC). COPD symptoms can be manageable with regular checkups and care at home that can include healthy behavior changes like quitting smoking, prescription medications or breathing devices. However, flare ups are common. When symptoms appear more suddenly than usual, or become severe or longer lasting, it may be necessary to get medical attention right away. Paying close attention to changes in typical symptoms and knowing when seek help could prevent a medical emergency. People with COPD can have a cough, chest tightness, wheezing or shortness of breath, and heavy amounts of mucus. Call 911 or go to the closest emergency department if you experience: Difficulty breathing or talking. Chest pains. Fever. Racing heartbeat. Fingernails that turn blue or gray (a sign of a low oxygen level in your blood). Recommended treatment is not working, and symptoms are getting worse. Slurred speech, disorientation, confusion, dizziness. Sleepiness and difficulty awakening from sleep. Those with chronic conditions should work with a physician to create a plan to manage their illness that includes an emergency action plan with medication history, important phone numbers, and other information that can be critical to gather before an emergency occurs . 1. Review of Resident #29's face sheet dated 12/01/22 reflected she was a [AGE] year-old woman initially admitted to the facility on [DATE] and re-admitted on [DATE]. Her diagnoses included: epilepsy, diabetes, hyperlipidemia (blood has too many lipids (or fats), such as cholesterol and triglycerides), COPD, HTN, right-sided paralysis after a stroke, cerebral infarction (stroke, 08/26/22), and heart failure. Review of Resident #29's quarterly MDS dated [DATE] reflected she had adequate hearing, clear speech, and could make her wants and needs understood. Her BIMS was 13 and indicated she was cognitively intact. She did not have behavioral symptoms such as delusions, hallucinations, physical aggression, or refusals of care. Review of the pain management assessment reflected she did not receive scheduled, or PRN pain medications and she denied pain in the 5 days prior to the assessment. Review of Resident #29's care plans dated 08/27/22 reflected Resident #29 had one sided paralysis due to a stroke. Her goal was to be free from signs or symptoms of complications of a stroke such DVT (blood clot in a deep vein), contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), aspiration pneumonia (infection caused by food or liquid breathed into the airways or lungs), or dehydration. Interventions included giving medications as ordered by the physician. Monitoring and document side effects and effectiveness. Monitoring vital sings and notifying the MD of significant abnormalities. Resident #29 did not have a care plan for risk of stroke. A record review of Resident #29's progress notes in the EHR revealed a note documented on 09/24/22 reflected Resident #29 was sent to the ER via 911 on 09/24/22 due to a low blood pressure, confusion, and slurred speech. The resident was re-admitted to the facility on [DATE] with a diagnosis of stroke. In an interview and observation on 11/30/22 at 8:16 AM, LVN A stated she would need to administer Resident #29's insulin after breakfast. She entered Resident #29's room and Resident #29 was lying in bed with her eyes closed. She had on a N/C which was connected to the O2 concentrator set to deliver 2LPM. She was breathing but was difficult to arouse. LVN A attempted to arouse Resident #29 with loud verbal prompts and physical touch to the resident's left upper arm. The resident did not arouse after approximately 3 minutes and LVN A said she would hold Resident #29's insulin and would instead obtain a set of vital signs. LVN A left the room and promptly returned with a pulse oximeter (device used to measure the O2 saturation of the blood), thermometer, and an automatic wrist BP cuff. LVN A obtained the readings of temperature 97.3 degrees Fahrenheit, pulse 62, O2 saturation 96%, and BP of 35/35 on her left wrist. LVN A said the BP reading did not seem accurate and placed the cuff to Resident #29's right wrist. Resident #29 aroused when LVN A placed the cuff to her right wrist, and LVN A asked her if she was feeling ok. Resident #29 said she was feeling lousy. LVN A obtained a reading of 135/39 from the resident's right wrist. LVN A did not clarify what Resident #29 meant by lousy. The HHSC Surveyor intervened and asked Resident #29 what she meant by lousy. Resident #29 stated she had pain to both her arms and to her back, and both her arms were numb. LVN A said she would administer a pain medication to Resident #29 and began to leave the room without completing a pain assessment. The HHSC Surveyor intervened while LVN A was in the room and asked Resident #29 about her pain. Resident #29 the pain in her back was chronic, but stated her pain was at 9/10, sharp in nature, and said she had only once previously felt this pain when she was having a stroke last month (October 2022). Resident #29 was very lethargic, and her speech was slurred. She had intermittent tremors to both of her hands. LVN A again told Resident #29 she would go get her a pain pill and left the room. LVN A returned promptly to the room and administered a whole pill with water to Resident #29 and said it was tramadol, and then left the room. In an observation and interview on 11/30/22 at 8:44 AM, LVN A returned to Resident #29's room and administered insulin to Resident #29's abdomen. LVN A said she did not know if Resident #29 had a history of a stroke, but to her knowledge she did not. LVN A said she believed Resident #29 was displaying attention seeking behaviors. LVN A then left and sat at the nurses' station down the hall. In an interview and observation on 11/30/22 at 8:50 AM, the HHSC Surveyor intervened and reported to ADON F Resident #29's complaint of pain, statement that that was the way she felt last time she had a stroke, and the BP's obtained by LVN A. ADON F said she would obtain a manual BP and call the MD. ADON F went to the nurses' station and told LVN A to obtain a manual BP on Resident #29. In an observation on 11/30/22 at 9:01 AM, LVN A entered Resident #29's room and applied the BP cuff to Resident #29's left upper arm. She placed the bell of the stethoscope in the inner fold of the elbow and stated the resident's BP was 141/78. ADON F asked LVN A to see if the MD had responded to the electronic text message which had been sent to him earlier. ADON F then attempted to obtain a second manual BP on Resident #29's right upper arm, but the resident began to shake and displayed signs of a seizure. The resident's eyes were open, not blinking, and she was staring but not following objects with her gaze. Both of her arms stiffened and began to shake. This lasted 2 minutes. ADON F said she could not obtain Resident #29's BP because her arms were shaking too much during her seizure; she left the room and said she would go call the MD. The MDS Nurse entered the room [TRUNCATED]