**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to immediately consult with resident physician and notify the resident representative when there was a significant change in the resident's physical or mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 5 (Resident #1) reviewed for notification of changes of condition. The facility failed to notify the physician and establish vital signs when [AGE] year-old female Resident #1, with a history of dementia, had multiple episodes of emesis. The facility failed to report to the NP or MD 08/10/23 when Resident #1 had a total of six episodes of emesis, beginning at approximately 10 a.m. The day shift CNA stated she informed the day RN after the second episode. The CNAs notified the facility nurses again at the change of shift, 2:20 pm, after 4 episodes. The facility failed to notify the NP or MD until 5:00 pm-5:30 pm after the fifth episode and was not informed of Resident #1 being described as pale and shaking. NP stated if the nurses would have taken vitals for Resident #1 it would have established the baseline for her. The facility failed to assess or document vital signs until 6:40 p.m., when the Resident #1's vitals were BP 90/50, pulse 101, respiration 24 when the resident was looking pale, and cool to touch, and had purplish lips. The NP or MD was not notified of additional episodes of emesis after the medication had been ordered and administered. The facility failed to contact the NP or MD and instead contacted family for the decision to transport Resident #1 to the hospital. Resident #1 expired at the hospital. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 08/31/23. While the IJ was removed on 09/01/23, the facility remained out of compliance at a scope of actual harm and a severity level of isolated because the facility failed to have a system in place to ensure residents are monitored and assessed for changes in condition and are immediately reported to the attending physician. This failure could affect residents by placing them at risk of delay medical treatment, hospitalization, decline in condition, and death. Findings included: Closed record Review revealed Resident #1's face sheet dated 08/12/23 listed initial admission on [DATE] and readmission on [DATE]. Record Review Resident #1's history and physical dated 01/04/22 revealed a [AGE] year-old female. Past medical history multiple sclerosis, neurogenic bladder with chronic urinary tract infections due to intermittent catheterization. Record Review Resident #1's quarterly MDS dated [DATE] revealed resident rarely made self-understood and rarely understands others; short-term, long term memory problems; Active Diagnoses-Renal Insufficiency, Renal Failure, or End-Stage Renal Disease, Neurogenic Bladder, Non-Alzheimer's Dementia, Multiple Sclerosis. Record Review Resident #1's Care Plan revised 04/22/2023 revealed resident had neurogenic bladder and at times required catheterization. Monitor and report to Medical Doctor signs & symptoms of UTI. Record review of the Emergency Medical Services report dated 08/10/23 documented unit was dispatched at 6:36 PM and arrived at 6:47 PM. At resident 6:48 PM. Call Type: Sick Person. Urgency: Immediate. Patient Condition: Hypotension (low blood pressure). Primary Symptom-Hypovolemic (a condition that occurs you're your body loses fluid). Patient Care Narrative: Assessment Exam: Skin: Cyanotic (bluish color due to inadequately oxygenated blood), Mental Status: Unresponsive. Eyes: Non-reactive (A pupil which remains excessively dilated in the presence of light). Patient Care Narrative: According to staff patient was last seen 5 minutes prior to EMS arrival. Upon arrival patient agonal (related to or associated with the act of dying, gasping for air) with cyanotic (bluish or purplish discoloration) presumed patient had aspirated on vomit. EMS assisted ventilations and transferred patient to stretcher where manual Cardiopulmonary Resuscitation was initiated. EMS wheeled patient to rescue. Once in rescue auto pulse pads were placed and patient was showing Asystole (when your heart's electrical system fails, causing your heart to stop pumping). On the monitor, had copious amount of fluid coming from mouth. Patient was being suctioned and given CPR and ventilations throughout transport. Review of hospital emergency room record dated 08/10/23 6:59 PM, revealed [AGE] year-old female brought to emergency department in cardiac arrest. Reportedly was at the nursing facility having aspiration. When EMS arrived around 6:49 PM, she was found to be with agonal respiration (when someone who is not getting enough oxygen is gasping for air) and vomiting. No pulse was noted, and CPR started at this time. Patient was intubated by EMS in field, difficulty with bagging, copious vomitus, abdominal distention. ETT (Endotracheal Tube - tube used to provide oxygen and inhaled gases to the lungs) was suspected to be in the stomach and was replaced in the emergency department. Patient continued to receive CPR in the emergency room. Ultrasound was used to identify cardiac activity, but there were no signs of life until Resident #1 was then pronounced dead at 7:10 PM. Record review of the office of medical examiner investigation dated 08/10/23 at 7:27 PM revealed the decedent was a [AGE] year-old white female who was viewed with episodes of emesis and hypotensive by staff while at the facility on 08/10/23. 911 was phoned and Emergency Medical Services responded and transported the decent to the local hospital with cardiopulmonary resuscitation in progress. The decedent arrived to the Emergency Department on 08/10/23 at approximately 6:59 PM. CPR was continued; however, the decedent was viewed asystolic and was pronounced on 08/10/23 at 7:10 PM by physician. The following information was provided on 08/10/23 approximately 6:30 PM facility staff phoned Representative Party and advised Representative Party, that the decedent had emesis episodes x 6 and had sugar of 340. The facility advised decedent's physician who ordered an abdominal x-ray; however, they wanted to know if Representative Party wanted the decedent to be transported to the hospital. Representative Party advised the facility she did want the decedent to be transported to the hospital. Telephone interview on 08/12/23 at 11:00 AM with Resident #1's family member stated (RN I) called her on 08/10/23 at 6:30 PM to report Resident #1 had been vomiting all day and doctor had ordered an x-ray of the stomach and medication for nausea/vomiting. The family member stated, I told RN I to send Resident #1 to the hospital. When I called the nurse back, RN I reported that EMS had started CPR, when they got to the facility. The family member reported she had not been notified when Resident #1 started to vomit in the morning. The family member stated, If nurses had called to report to me when Resident #1 had the first emesis, I would have gone to check her and asked them to send her to the hospital. Interview on 08/12/23 at 1:04 PM with RN I revealed she worked 08/10/23 and was getting report from RN J at the change of shift at approximately 2:00 PM, when CNA K came to the nurse's station to report Resident #1 had vomited. RN I stated they continued with report and then proceeded to count narcotics. RN I stated she assessed Resident #1 at approximately 3:00 PM-3:30 PM on that day, Resident #1 was sitting in a wheelchair in the dining room, looked pale and complained of nausea. RN I stated that at approximately 5:00 PM MA L reported to her Resident #1 had vomited. RN I stated she checked the resident's physician's orders and there was not a standing order for to treat nausea/vomiting so she called the NP to report resident had vomited x 2 on her shift and was nauseated. NP gave orders for a KUB (KUB is an x-ray performed to assess the abdominal area for causes of abdominal pain, or to assess the organs and structures of the urinary and/or gastrointestinal system) and Promethazine IM (intramuscular) TID (three times a day) as needed for nausea/vomiting. RN I reported she administered Promethazine IM as ordered to Resident #1 at approximately 5:35 PM. RN I stated CNA K reported to her at approximately 6:40 PM, that Resident #1 had vomited after Promethazine was administered and did not look well. RN I stated she immediately went to the room to assess Resident #1. Resident #1 was lying in bed, blood pressure was low, she looked pale, was sweating and was having difficulty breathing. RN I stated at around 6:40PM-6:45PM she notified Resident #1's family member at which time family member requested resident be sent to ER. RN I stated she had not notified the NP, Resident #1 continued to vomit after the Promethazine was administered, because they had standing order to treat nausea/vomiting. RN I stated she had not notified the NP that Resident #1 was going to be sent out to the hospital emergency room for evaluation per family member's request. RN I stated, they had been trained to immediately notify attending physician and resident's responsible party of changes in condition, notify physician if resident's condition does not improve after PRN (as needed) medications has been administered and get a Physician's Order to send the resident to the hospital for evaluation per family's request. Telephone Interview on 08/12/23 at 2:42 PM RN J stated she worked on 08/10/23 and was assigned to Resident #1 during the morning shift, and resident did not have a change in condition during her shift. RN J denied CNA K had reported to her Resident #1 had vomited x 2 in the morning after breakfast. RN J stated, I was giving report to RN I at the change of shift at 2:00 PM, when CNA K came to the nurse's station to report Resident #1 had vomited. RN J stated she did not assess Resident #1 because her shift was over and continued to give report to RN I who was the on-coming nurse on the evening nurse and assigned to Resident #1. RN J stated that after report they proceeded to counted narcotics. RN J stated nurses have been trained to immediately assess and notify physician and/or nurse practitioner, responsible party when resident has a change in condition. Telephone interview on 08/13/23 at 1:47 PM with RN I stated she did not notify the physician of the 1st emesis Resident #1 had at 2:00 PM. RN I stated that at approximately 3:00 PM-3:30 PM MA L reported to her that Resident #1 had vomited in the dining room, and she went to assess resident and noted had vomited undigested food and did not notify the physician. RN I stated CNA K had reported to her, Resident #1 had another episode of vomiting in the dining room and she did not go assess the resident and did not notify physician. RN I stated nurses had been trained to immediately assess the resident and notify the attending physician and responsible party of the change in condition. RN, I stated Resident #1 vomited for the 4th time in her room and asked resident if she wanted to go to the hospital but resident stated No. RN I stated she had administered Promethazine for nausea and vomiting at approximately 5:35 PM and resident continued to vomit. RN I stated she had not notified the attending physician or NP that resident continued to vomit after the Promethazine was administered because they had a standing order for Promethazine to administered as needed for nausea/vomiting. Interview on 08/14/23 at 3:14 PM with CNA K reveled she had worked a double shift on 08/10/23 in the morning and evening shift and was assigned to Resident #1. CNA K stated, Resident #1 was not her usual self on that day and appeared to be having problems with eating. CNA K stated she went to resident's room after breakfast and noted Resident #1 vomited a large amount of undigested food that appeared to be egg/sausage. Resident #1 had vomitus on her left shoulder down to the leg. CNA K stated she left the room to go to answer the call light for another and forgot to report to RN J that Resident #1 had vomited. CNA K stated that approximately10 minutes later, she was walking by the Resident #1's room and noticed vomitus on the floor next by the side of the bed. CNA K stated she cleaned the emesis and saw RN J passing medications in the hallway and went to report to her that resident had vomited twice that morning. CNAK stated, RN J only looked at me and did not say anything. CNA K stated did not know if RN J had assessed the resident. CNA K reported that at approximately 1:45 PM Resident #1 yelling, so she went to the room to check the resident and noted that she had vomited for the 3rd. CNA K stated she did not immediately report to RN J that Resident #1 had vomited for the 3rd time during the morning shift because she was finishing her rounds. CNA K stated Resident #1 vomited for the 4th time while sitting in her wheelchair in the dining room at dinner time and had notified RN I. CNA K stated she did not know if RN I had assessed Resident #1. CNA K stated she was informed by resident's roommate family member at approximately 5:00 PM-5:30 PM that Resident #1 looked anxious and was shaking. CNA K stated she immediately reported this to RN I and did know if RN I went to go assess resident. CNA K stated MA L had reported to her that resident had vomited 2 times while in the dining and was being taken back to her room. CNA K stated she went to resident's room and Resident #1 did not look good, her breathing was different, fingertips were cold to touch, and lips looked slightly purplish. CNA K stated she informed RN I at around 5:30 PM. CNA K stated her and RN I went back to check on Resident #1 and tried taking Blood Pressure on right arm twice but could not get the reading and changed it to the left arm which was 76/50 and Pulse was 101. CNA K stated RN I gave Resident #1 a medication. CNA K stated at 6:30 PM Resident #1 was transferred to bed and was pale, with dark circles under her eyes. Interview on 08/15/23 at 3:36 PM with MA L revealed she noted Resident #1 had vomited in the dining room at around 5:00 PM and had not immediately reported this to the nurses because she went to get a cup of coffee for Resident #1. MA L stated 1 to 2 minutes later Resident #1 vomited again so she went to report this to the RN I. MA L stated at 6:30 PM she noticed Resident #1's call light room was ringing, went to the resident's room and noted RN I and LVN N were in the room and asked her to assist with changing the resident. MA L stated they had been trained to immediately report to the nurses when a resident had a change in condition. Interview on 08/15/23 at 4:19 PM with LVN N revealed she saw Resident #1 vomiting in the dining room during dinner time at approximately 5:00 PM, RN I was in the dining room and asked the CNAs to take Resident #1 to her room. LVN N stated at 6:00 PM-6:30 PM RN I had asked her to go with her to Resident #1's room to assist with changing the resident. LVN N stated RN I had checked resident's blood pressure and was 95/50, was pale, resident was trying to vomit but could not and was having trouble breathing. LVN N stated the CNAs needed to immediately report changes of condition and nurses immediately assess and notify the physicians of any changes of condition. LVN N stated if the doctor was not notified of a change of condition with a resident that would be a risk of not getting the necessary medical care. Telephone interview on 08/15/23 at 9:04 AM with the NP revealed nurses should immediately report a change in condition to physician and/or NP. NP confirmed RN I, had reported to her in the afternoon that Resident #1 had vomited multiple times and gave orders for a KUB and Promethazine as needed for nausea/vomiting. NP stated Nurses need to assess the resident after each emesis to determine if the resident is constipated, amount and color of emesis and they are expected to immediately notify the physician and/or NP each time that the resident had an emesis. NP stated, If the medication ordered for nausea/vomiting, has been administered and the resident continues to have emesis the nurses are expected to immediately notify the physician/NP. Interview on 08/15/23 at 4:43 PM with Roommate revealed that on 08/10/23 in the evening time she heard Resident #1 vomiting in the room but could not remember if it was before or after dinner time. Second interview on 08/16/23 at 9:29 AM with RN J revealed Resident #1 was had an emesis at the change of shift at 2:00 PM, and she had not assessed the resident. RN J stated they had been trained to assess the residents when they had a change in condition, even if it was the change of shift. RN J stated they were trained to check the resident, check the vital signs, and immediately notify the doctor. RN J stated CNAs had been trained to immediately report to the nurses when a resident had a change in condition. RN J stated CNA K came to the nurses' station to report Resident #1 had vomited at the change of shift, when she was giving report to RN I. Interview on 08/16/23 at 9:48 AM with Resident #1's roommates' family member revealed he arrived at the facility 08/10/23 at 5:30 PM and noticed Resident #1 was not in the cafeteria like she always was. Family Member #2 stated that upon return to the room at approximately 6:00 PM, Resident #1was not her usual self and appeared to be anxious and went to report this to CNA K. Family member #2 stated he told can K that Resident #1 was feeling sick and looked bad. Family member#2 stated Resident #1 was pale, eyes looked desperate, and upper body and hands were shaking. Family member #2 stated CNA K walked out of the room, and Family Member #2 followed CNA K and told CNA K Resident #1 needed help. Family member #2 stated he saw CNA K passed by the nurse's station and did not stop to talk to the nurses. Interview on 08/16/23 at 11:34 AM with the DON revealed CNAs had been trained to immediately report to the nurses when residents had a change in condition and the nurses had been trained to immediately report changes in condition to the physician/nurse practitioner and responsible party. The DON stated it was very important for the nurses to report to physician and/or NP when a resident vomited to ensure resident did not have any adverse effects like dehydration or other complications. The DON stated if Resident #1 was administered the prescribed medication for nausea and vomiting and continued to vomit, the nurse should have immediately notified the physician and/or NP to see if the physician and/or NP to see if they wanted to make a change to the treatment plan and/or give orders to send the resident to the hospital for evaluation of change in condition. Interview on 08/16/23 at 1:51 PM with the Administrator revealed CNAs had been trained and were expected to immediately report to the nurses when a resident has a change in condition. The Administrator stated the purpose of immediately reporting changes in condition to the nurses was for them to immediately assess the resident and call the physician and/or NP to ensure that the resident promptly received the needed medical care. The Administrator stated if the prescribed medication was not effective for a resident that had emesis, it was expected for the nurse to immediately notify NP or physician to see if they would make changes to the treatment plan. Second interview on 08/29/23 at 9:56 AM with the DON revealed they had conducted in-service training after the incident with Resident #1 on 08/10/23 for all nurses and CNAs on immediately reporting changes in condition to the nurses; nurses were trained to immediately assessing residents when they had a change in condition, check vital signs, document assessment findings in the resident's electronic clinical record and immediately notifying physician and/or NP of change in condition. Telephone call placed to attending Physician no answer, left a voice message to call surveyor back. Second telephone interview on 08/29/23 at 11:13 AM NP stated the evening nurse had called her on 08/10/23 to report Resident #1 had vomited and had not provide any other information to her on that day regarding the status of the resident. NP stated nurses were expected to assess Resident #1 after each vomiting episode, check vital signs as part of the assessment and immediately report to physician and/or NP. NP stated, If the nurses do not check vital signs when a resident has a change in condition, we do not have a baseline to determine if the residents' condition is getting worse and a need to change the treatment plan and/or send the resident to the hospital for evaluation. NP stated she was not notified that Resident #1 had 6 emesis throughout the day on 08/10/23. Interview on 08/29/23 at 2:01 PM LVN V stated nurses were in-serviced on 08/29/23 on assessing residents when they had a change in condition, checking vital signs, documentation of assessment in residents' electronic clinical record, and immediate notification to physician and/or NP of changes in condition. Interview on 08/29/23 at 3:47 PM RN U stated since working for the facility she had not been in-serviced on anything as far as she recalls. Interview on 08/29/23 at 4:18 PM with LVN S stated she had not been in-serviced on anything since she started working at the facility on the 14th of August 2023. LVN S stated she had not received any in-service training on what to do when a resident had a change in condition. Review of 24-Hour Report Worksheet dated 08/10/23 on the 6-2 shift documented Resident #1 Emesis x1; laying down, now. There was not time indicated on the 24-hour report of when the vomiting occurred. Review of 24-Hour Report Worksheet dated 08/10/23 on the 2-10 shift documented Resident #1 Emesis x4; NP notified. N.O. for KUB and Promethazine 12.5 mg TID PRN. Emesis x2 after New Orders, sent via Emergency Medical Services to hospital per family member's request. Coded on transfer to stretcher. Review of Weights & Vital Signs Summary report for Resident #1 revealed, pulse was last checked on 03/01/23, 81 beats per minute-Regular; Temperature was last checked on 02/18/23 and was 97.2 Fahrenheit; Blood Pressure was last checked on 03/01/23 and was 117/73. Record review RN I had not completed an SBAR assessment for Resident #1 on 08/10/23 when she notified NP on 08/10/23 of Resident #1 having vomited x 3 on the 2-10 shift. Review of Order Recap Report dated 01/01/2023 - 08/31/2023 for Resident #1 documented in part: -Order Date: 08/10/23 for portable KUB due to resident being confined to nursing home. Diagnosis: Pain. -Order Date: 08/10/23 Promethazine HCL (Hydrochloride) inject 12.5 mg intramuscular every 8 hours as needed for nausea/vomiting. The Recap Order Report dated 01/01/2023 - 08/31/2023 for Resident #1 did not document an order to send the resident to the emergency room for evaluation of change in condition. Review of Medication Administration Record (MAR) date 08/01/23 - 08/3123, printed on 08/12/23 for Resident #1 revealed an order for Promethazine HCL injection Solution inject 12.5 mg Intramuscular every 8 hours as needed for nausea/vomiting. Start Date: 08/10/23. MAR did not document Promethazine was administered as ordered on 08/10/23 by RN I. Record review of facility's policy and procedure on Notification of Changes Reviewed/Revised 02/10/21 revealed: Policy: To provide guidance on when to communicate acute changes in status to MD, NP, and responsible party. The facility will immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or appropriate family member(s) of the following: -An emergency response situation that requires EMS involvement-A significant change in the physical, mental, or psychosocial status of the resident. -A decision to transfer or discharge the resident to another facility. Policy Explanation and Compliance Guidelines: -In the case of a resident who is incapable of making decision, the resident should still be notified. Notify the resident's physician. Decisions would be made by the legal representative or appropriate family members. -The facility documents resident assessment(s), interventions, precision and family notifications on SBAR, nurses progress notes or telephone order forms (physician/family notice) as appropriate The administrator, DON, and ADONs were informed on 08/31/23 at 10:44 AM that Immediate Jeopardy (IJ) had been identified and a copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested within the hour. On 09/01/23 at 9:20 AM Administrator was notified 3rd Plan of removal was accepted. The Plan of Removal revealed the facility took following actions: 1. The DON in the morning meeting reviews the 24- hour report to identify any resident with a change in condition. DON/Designee will review documentation/assess if indicated, to verify that any identified change had a physician notification and documentation. 2. The DON/Designee will review the Stop and Watch notebook daily to verify that any communication from nurse assistance to license nurse has been reviewed and with timely interventions as indicated. 3. The DON/Designee will complete: o A license nurse QAPI tool daily x 30 days verifying license nurses training and knowledge in regard to the education they received (Vital Signs Guidelines, Clinical Practice Guidelines Alert Charting, Notification of Change of Condition, and The Stop and Watch program (A program in which CNAs see a resident having a change of condition and fill out a yellow form submitting it and reporting the change of condition to the nurses)) o A Nurse Assistant QAPI tool daily x 30 days verifying nurse assistant training and knowledge in regard to the education they received (Notification of Change of Condition, and the Stop and Watch program) On 8/31/2023 (unknown time) the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to notification of change in condition, and Quality of care and reviewed plan to sustain compliance. Interviews and record review to confirm implementation of the Plan of Removal were conducted as follows: Record review of facility Stop and Watch Early Warning Tool in-service dated 08/31/23-09/01/23 at 4:53 PM was signed and acknowledged competency by the CNAs. Record review of facility changes in condition in-service dated 08/31/23 at 4:53 PM was signed and acknowledged competency by the CNAs. Record review of facility notification changes in-service dated 08/31/23 at 1:00 PM was signed and acknowledged competency by the nurses. Record review of the facility alert charting dated 08/31/23 at 1:00 PM was signed and acknowledged competency by the nurses. Record review of the facility vital signs dated 08/31/23 at 1:00 PM was signed and acknowledged competency by the nurses. Record review of facility SBAR Communication UDS for changes of conditions in-service dated 09/01/23 at 9:00 AM was signed and acknowledged competency by the nurses. Record review of facility's stop and watch binder dated 09/01/23 at 10:03 AM revealed Stop and Watch Early Warning Tool. If you have identified a change while caring for or observing a resident, please circle the change and notify a nurse. Either give the nurse a copy of this tool or review it with her/him as soon as you can. Record review of facility e-mail dated 09/01/23 at 3:23 PM indicating the licensed nurses on all other shifts cannot work until they have had this education (SBAR) and signed the in-service sheet. Make sure nurse manager at the beginning of each shift and throughout the weekend to provide this training before they work. Interview on 08/29/23 at 2:01 PM with LVN V stated they were in-serviced on alert charting, vitals, and notification of changes. LVN V stated on alert charting which was charting everything that was reported by the CNAs regarding residents' changes of condition. LVN V stated vitals are to be taken when residents have changes of conditions. LVN V stated vitals establish a baseline for the resident. LVN V stated if a resident had a change of condition, they need to notify the physician or NP immediately regarding the change in the resident. LVN V stated anytime the CNAs see a change of condition they need to fill out a stop and watch yellow sheet and turn it in to the nurses so they can check on the resident. Interview on 08/29/23 at 4:13 PM with LVN R stated, recently this month (August 2023) she had received in-services on changes of condition and assessing the residents. LVN R stated when preforming a head-to-toe assessment on a resident and something was found to let the physician know. LVN R stated she received an in-service on taking vitals and to communicate anything that was abnormal. LVN R stated it was important to take vitals when a resident had an incident because it could be a change of condition with the resident. LVN R stated she would then document it on the SBAR. Interview on 08/30/23 at 8:53 AM CNA K stated yesterday 08/29/23 was the first time she had got an in-service on stop and watch and changes of condition. CNA K stated if a resident had a change of condition, then they are to report it and write it down on a paper that was at the nurse's station and submit it to the nurses. CNA K stated any changes of condition that are not normal are considered changes to a resident and need to be reported immediately. Interview on 08/30/23 at 9:40 AM CNA W stated she received an in-service on changes of condition and vitals. CNA W stated she would report any changes a resident had that were not normal to the nurses. CNA W stated vitals are taken when a resident has a change in their condition that was different from what they normal act. Interview on 08/30/23 at 9:53 AM CNA X stated she had been in-serviced on changes of condition with a resident, reporting, and stop and watch. CNA X stated if the resident was having a change of condition that was not their normal self, then the CNAs were expected to go to the nurse's station where the Stop and Watch yellow sheet was at and fill one out. CNA X stated once filled it would be turned into the nurses reporting the change in the resident. Interview on 08/30/23 at 10:01 AM CNA Y stated she had received the in-services on changes of condition, reporting, and stop and watch. CNA Y stated anytime a resident shows a change in their condition the CNAs need to report it. CNA Y stated you go to the nurse's station and in the book called Stop and Watch fill out a yellow form. CNA Y stated once filled it was turned into the nurses so they may go assess the resident. Interview on 08/30/23 at 10:10 AM CNA D stated that the Stop and Watch binder was at the nurse's station. CNA D stated it was for when a resident had a change in condition. CNA D stated if they saw a resident different from their norm then they were to report by going to the stop and watch binder and pulling out a yellow sheet and filling it out. CNA D stated it would be turned into the nurses for follow up. Interview on 09/01/23 at 2:20 PM LVN AA stated she was in-serviced on alert charting, changes of condition, SBAR, and calling the physician. LVN AA stated anytime a resident has a change in condition it needed to be reported to the physician or if the CNAs see the change with a resident, they need to notify nursing. LVN AA stated the SBAR was where nurses document vitals, times, and anything vital with changes of condition with a resident. LVN AA stated it was a summary of what was going on with the resident. LVN AA stated everything needed to be charted regarding the residents change of condition and assess[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the residents' choices for 1 of 5 (Resident #1) reviewed for quality of care. The facility failed to notify the physician and establish vital signs when [AGE] year-old female Resident #1, with a history of dementia, had multiple episodes of emesis. The facility failed to report to the NP or MD 08/10/23 when Resident #1 had a total of six episodes of emesis, beginning at approximately 10 a.m. The day shift CNA stated she informed the day RN after the second episode. The CNAs notified the facility nurses again at the change of shift, 2:20 pm, after 4 episodes. The facility failed to notify the NP until 5:00 pm-5:30 pm after the fifth episode and was not informed of Resident #1 being described as pale and shaking. NP stated if the nurses would have taken vitals for Resident #1 it would have established the baseline for her. The facility failed to assess or document vital signs until 6:40 p.m., when the Resident #1's vitals were BP 90/50, pulse 101, respiration 24 when the resident was looking pale, and cool to touch, and had purplish lips. The NP was not notified of additional episodes of emesis after the medication had been ordered and administered. The facility failed to contact the NP and instead contacted family for the decision to transport Resident #1 to the hospital. Resident #1 expired at the hospital. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 08/31/23. While the IJ was removed on 09/01/23, the facility remained out of compliance at a scope of actual harm and a severity level of isolated because the facility failed to have a system in place to ensure residents are monitored and assessed for changes in condition and are immediately reported to the attending physician. This failure could affect residents by placing them at risk of delay medical treatment, hospitalization, decline in condition, and death. Findings included: Closed record Review revealed Resident #1's face sheet dated 08/12/23 listed initial admission on [DATE] and readmission on [DATE]. Record Review Resident #1's history and physical dated 01/04/22 revealed a [AGE] year-old female. Past medical history multiple sclerosis, neurogenic bladder with chronic urinary tract infections due to intermittent catheterization. Record Review Resident #1's quarterly MDS dated [DATE] revealed resident rarely made self-understood and rarely understands others; short-term, long term memory problems; Active Diagnoses-Renal Insufficiency, Renal Failure, or End-Stage Renal Disease, Neurogenic Bladder, Non-Alzheimer's Dementia, Multiple Sclerosis. Record Review Resident #1's Care Plan revised 04/22/2023 revealed resident had neurogenic bladder and at times required catheterization. Monitor and report to Medical Doctor signs & symptoms of UTI. Record review of the Emergency Medical Services report dated 08/10/23 documented unit was dispatched at 6:36 PM and arrived at 6:47 PM. At resident 6:48 PM. Call Type: Sick Person. Urgency: Immediate. Patient Condition: Hypotension (low blood pressure). Primary Symptom-Hypovolemic (a condition that occurs you're your body loses fluid). Patient Care Narrative: Assessment Exam: Skin: Cyanotic (bluish color due to inadequately oxygenated blood), Mental Status: Unresponsive. Eyes: Non-reactive (A pupil which remains excessively dilated in the presence of light). Patient Care Narrative: According to staff patient was last seen 5 minutes prior to EMS arrival. Upon arrival patient agonal (related to or associated with the act of dying, gasping for air) with cyanotic (bluish or purplish discoloration) presumed patient had aspirated on vomit. EMS assisted ventilations and transferred patient to stretcher where manual Cardiopulmonary Resuscitation was initiated. EMS wheeled patient to rescue. Once in rescue auto pulse pads were placed and patient was showing Asystole (when your heart's electrical system fails, causing your heart to stop pumping). On the monitor, had copious amount of fluid coming from mouth. Patient was being suctioned and given CPR and ventilations throughout transport. Review of hospital emergency room record dated 08/10/23 6:59 PM, revealed [AGE] year-old female brought to emergency department in cardiac arrest. Reportedly was at the nursing facility having aspiration. When EMS arrived around 6:49 PM, she was found to be with agonal respiration (when someone who is not getting enough oxygen is gasping for air) and vomiting. No pulse was noted, and CPR started at this time. Patient was intubated by EMS in field, difficulty with bagging, copious vomitus, abdominal distention. ETT (Endotracheal Tube - tube used to provide oxygen and inhaled gases to the lungs) was suspected to be in the stomach and was replaced in the emergency department. Patient continued to receive CPR in the emergency room. Ultrasound was used to identify cardiac activity, but there were no signs of life until Resident #1 was then pronounced dead at 7:10 PM. Record review of the office of medical examiner investigation dated 08/10/23 at 7:27 PM revealed the decedent was a [AGE] year-old white female who was viewed with episodes of emesis and hypotensive by staff while at the facility on 08/10/23. 911 was phoned and Emergency Medical Services responded and transported the decent to the local hospital with cardiopulmonary resuscitation in progress. The decedent arrived to the Emergency Department on 08/10/23 at approximately 6:59 PM. CPR was continued; however, the decedent was viewed asystolic and was pronounced on 08/10/23 at 7:10 PM by physician. The following information was provided on 08/10/23 approximately 6:30 PM facility staff phoned Representative Party and advised Representative Party, that the decedent had emesis episodes x 6 and had sugar of 340. The facility advised decedent's physician who ordered an abdominal x-ray; however, they wanted to know if Representative Party wanted the decedent to be transported to the hospital. Representative Party advised the facility she did want the decedent to be transported to the hospital. Telephone interview on 08/12/23 at 11:00 AM with Resident #1's family member stated (RN I) called her on 08/10/23 at 6:30 PM to report Resident #1 had been vomiting all day and doctor had ordered an x-ray of the stomach and medication for nausea/vomiting. The family member stated, I told RN I to send Resident #1 to the hospital. When I called the nurse back, RN I reported that EMS had started CPR, when they got to the facility. The family member reported she had not been notified when Resident #1 started to vomit in the morning. The family member stated, If nurses had called to report to me when Resident #1 had the first emesis, I would have gone to check her and asked them to send her to the hospital. Interview on 08/12/23 at 1:04 PM with RN I revealed she worked 08/10/23 and was getting report from RN J at the change of shift at approximately 2:00 PM, when CNA K came to the nurse's station to report Resident #1 had vomited. RN I stated they continued with report and then proceeded to count narcotics. RN I stated she assessed Resident #1 at approximately 3:00 PM-3:30 PM on that day, Resident #1 was sitting in a wheelchair in the dining room, looked pale and complained of nausea. RN I stated that at approximately 5:00 PM MA L reported to her Resident #1 had vomited. RN I stated she checked the resident's physician's orders and there was not a standing order for to treat nausea/vomiting so she called the NP to report resident had vomited x 2 on her shift and was nauseated. NP gave orders for a KUB (KUB is an x-ray performed to assess the abdominal area for causes of abdominal pain, or to assess the organs and structures of the urinary and/or gastrointestinal system) and Promethazine IM (intramuscular) TID (three times a day) as needed for nausea/vomiting. RN I reported she administered Promethazine IM as ordered to Resident #1 at approximately 5:35 PM. RN I stated CNA K reported to her at approximately 6:40 PM, that Resident #1 had vomited after Promethazine was administered and did not look well. RN I stated she immediately went to the room to assess Resident #1. Resident #1 was lying in bed, blood pressure was low, she looked pale, was sweating and was having difficulty breathing. RN I stated at around 6:40PM-6:45PM she notified Resident #1's family member at which time family member requested resident be sent to ER. RN I stated she had not notified the NP, Resident #1 continued to vomit after the Promethazine was administered, because they had standing order to treat nausea/vomiting. RN I stated she had not notified the NP that Resident #1 was going to be sent out to the hospital emergency room for evaluation per family member's request. RN I stated, they had been trained to immediately notify attending physician and resident's responsible party of changes in condition, notify physician if resident's condition does not improve after PRN (as needed) medications has been administered and get a Physician's Order to send the resident to the hospital for evaluation per family's request. Telephone Interview on 08/12/23 at 2:42 PM RN J stated she worked on 08/10/23 and was assigned to Resident #1 during the morning shift, and resident did not have a change in condition during her shift. RN J denied CNA K had reported to her Resident #1 had vomited x 2 in the morning after breakfast. RN J stated, I was giving report to RN I at the change of shift at 2:00 PM, when CNA K came to the nurse's station to report Resident #1 had vomited. RN J stated she did not assess Resident #1 because her shift was over and continued to give report to RN I who was the on-coming nurse on the evening nurse and assigned to Resident #1. RN J stated that after report they proceeded to counted narcotics. RN J stated nurses have been trained to immediately assess and notify physician and/or nurse practitioner, responsible party when resident has a change in condition. Telephone interview on 08/13/23 at 1:47 PM with RN I stated she did not notify the physician of the 1st emesis Resident #1 had at 2:00 PM. RN I stated that at approximately 3:00 PM-3:30 PM MA L reported to her that Resident #1 had vomited in the dining room, and she went to assess resident and noted had vomited undigested food and did not notify the physician. RN I stated CNA K had reported to her, Resident #1 had another episode of vomiting in the dining room and she did not go assess the resident and did not notify physician. RN I stated nurses had been trained to immediately assess the resident and notify the attending physician and responsible party of the change in condition. RN, I stated Resident #1 vomited for the 4th time in her room and asked resident if she wanted to go to the hospital but resident stated No. RN I stated she had administered Promethazine for nausea and vomiting at approximately 5:35 PM and resident continued to vomit. RN I stated she had not notified the attending physician or NP that resident continued to vomit after the Promethazine was administered because they had a standing order for Promethazine to administered as needed for nausea/vomiting. Interview on 08/14/23 at 3:14 PM with CNA K reveled she had worked a double shift on 08/10/23 in the morning and evening shift and was assigned to Resident #1. CNA K stated, Resident #1 was not her usual self on that day and appeared to be having problems with eating. CNA K stated she went to resident's room after breakfast and noted Resident #1 vomited a large amount of undigested food that appeared to be egg/sausage. Resident #1 had vomitus on her left shoulder down to the leg. CNA K stated she left the room to go to answer the call light for another and forgot to report to RN J that Resident #1 had vomited. CNA K stated that approximately10 minutes later, she was walking by the Resident #1's room and noticed vomitus on the floor next by the side of the bed. CNA K stated she cleaned the emesis and saw RN J passing medications in the hallway and went to report to her that resident had vomited twice that morning. CNAK stated, RN J only looked at me and did not say anything. CNA K stated did not know if RN J had assessed the resident. CNA K reported that at approximately 1:45 PM Resident #1 yelling, so she went to the room to check the resident and noted that she had vomited for the 3rd. CNA K stated she did not immediately report to RN J that Resident #1 had vomited for the 3rd time during the morning shift because she was finishing her rounds. CNA K stated Resident #1 vomited for the 4th time while sitting in her wheelchair in the dining room at dinner time and had notified RN I. CNA K stated she did not know if RN I had assessed Resident #1. CNA K stated she was informed by resident's roommate family member at approximately 5:00 PM-5:30 PM that Resident #1 looked anxious and was shaking. CNA K stated she immediately reported this to RN I and did know if RN I went to go assess resident. CNA K stated MA L had reported to her that resident had vomited 2 times while in the dining and was being taken back to her room. CNA K stated she went to resident's room and Resident #1 did not look good, her breathing was different, fingertips were cold to touch, and lips looked slightly purplish. CNA K stated she informed RN I at around 5:30 PM. CNA K stated her and RN I went back to check on Resident #1 and tried taking Blood Pressure on right arm twice but could not get the reading and changed it to the left arm which was 76/50 and Pulse was 101. CNA K stated RN I gave Resident #1 a medication. CNA K stated at 6:30 PM Resident #1 was transferred to bed and was pale, with dark circles under her eyes. Interview on 08/15/23 at 3:36 PM with MA L revealed she noted Resident #1 had vomited in the dining room at around 5:00 PM and had not immediately reported this to the nurses because she went to get a cup of coffee for Resident #1. MA L stated 1 to 2 minutes later Resident #1 vomited again so she went to report this to the RN I. MA L stated at 6:30 PM she noticed Resident #1's call light room was ringing, went to the resident's room and noted RN I and LVN N were in the room and asked her to assist with changing the resident. MA L stated they had been trained to immediately report to the nurses when a resident had a change in condition. Interview on 08/15/23 at 4:19 PM with LVN N revealed she saw Resident #1 vomiting in the dining room during dinner time at approximately 5:00 PM, RN I was in the dining room and asked the CNAs to take Resident #1 to her room. LVN N stated at 6:00 PM-6:30 PM RN I had asked her to go with her to Resident #1's room to assist with changing the resident. LVN N stated RN I had checked resident's blood pressure and was 95/50, was pale, resident was trying to vomit but could not and was having trouble breathing. LVN N stated the CNAs needed to immediately report changes of condition and nurses immediately assess and notify the physicians of any changes of condition. LVN N stated if the doctor was not notified of a change of condition with a resident that would be a risk of not getting the necessary medical care. Telephone interview on 08/15/23 at 9:04 AM with the NP revealed nurses should immediately report a change in condition to physician and/or NP. NP confirmed RN I, had reported to her in the afternoon that Resident #1 had vomited multiple times and gave orders for a KUB and Promethazine as needed for nausea/vomiting. NP stated Nurses need to assess the resident after each emesis to determine if the resident is constipated, amount and color of emesis and they are expected to immediately notify the physician and/or NP each time that the resident had an emesis. NP stated, If the medication ordered for nausea/vomiting, has been administered and the resident continues to have emesis the nurses are expected to immediately notify the physician/NP. Interview on 08/15/23 at 4:43 PM with Roommate revealed that on 08/10/23 in the evening time she heard Resident #1 vomiting in the room but could not remember if it was before or after dinner time. Second interview on 08/16/23 at 9:29 AM with RN J revealed Resident #1 was had an emesis at the change of shift at 2:00 PM, and she had not assessed the resident. RN J stated they had been trained to assess the residents when they had a change in condition, even if it was the change of shift. RN J stated they were trained to check the resident, check the vital signs, and immediately notify the doctor. RN J stated CNAs had been trained to immediately report to the nurses when a resident had a change in condition. RN J stated CNA K came to the nurses' station to report Resident #1 had vomited at the change of shift, when she was giving report to RN I. Interview on 08/16/23 at 9:48 AM with Resident #1's roommates' family member revealed he arrived at the facility 08/10/23 at 5:30 PM and noticed Resident #1 was not in the cafeteria like she always was. Family Member #2 stated that upon return to the room at approximately 6:00 PM, Resident #1was not her usual self and appeared to be anxious and went to report this to CNA K. Family member #2 stated he told can K that Resident #1 was feeling sick and looked bad. Family member#2 stated Resident #1 was pale, eyes looked desperate, and upper body and hands were shaking. Family member #2 stated CNA K walked out of the room, and Family Member #2 followed CNA K and told CNA K Resident #1 needed help. Family member #2 stated he saw CNA K passed by the nurse's station and did not stop to talk to the nurses. Interview on 08/16/23 at 11:34 AM with the DON revealed CNAs had been trained to immediately report to the nurses when residents had a change in condition and the nurses had been trained to immediately report changes in condition to the physician/nurse practitioner and responsible party. The DON stated it was very important for the nurses to report to physician and/or NP when a resident vomited to ensure resident did not have any adverse effects like dehydration or other complications. The DON stated if Resident #1 was administered the prescribed medication for nausea and vomiting and continued to vomit, the nurse should have immediately notified the physician and/or NP to see if the physician and/or NP to see if they wanted to make a change to the treatment plan and/or give orders to send the resident to the hospital for evaluation of change in condition. Interview on 08/16/23 at 1:51 PM with the Administrator revealed CNAs had been trained and were expected to immediately report to the nurses when a resident has a change in condition. The Administrator stated the purpose of immediately reporting changes in condition to the nurses was for them to immediately assess the resident and call the physician and/or NP to ensure that the resident promptly received the needed medical care. The Administrator stated if the prescribed medication was not effective for a resident that had emesis, it was expected for the nurse to immediately notify NP or physician to see if they would make changes to the treatment plan. Second interview on 08/29/23 at 9:56 AM with the DON revealed they had conducted in-service training after the incident with Resident #1 on 08/10/23 for all nurses and CNAs on immediately reporting changes in condition to the nurses; nurses were trained to immediately assessing residents when they had a change in condition, check vital signs, document assessment findings in the resident's electronic clinical record and immediately notifying physician and/or NP of change in condition. Telephone call placed to attending Physician no answer, left a voice message to call surveyor back. Second telephone interview on 08/29/23 at 11:13 AM NP stated the evening nurse had called her on 08/10/23 to report Resident #1 had vomited and had not provide any other information to her on that day regarding the status of the resident. NP stated nurses were expected to assess Resident #1 after each vomiting episode, check vital signs as part of the assessment and immediately report to physician and/or NP. NP stated, If the nurses do not check vital signs when a resident has a change in condition, we do not have a baseline to determine if the residents' condition is getting worse and a need to change the treatment plan and/or send the resident to the hospital for evaluation. NP stated she was not notified that Resident #1 had 6 emesis throughout the day on 08/10/23. Interview on 08/29/23 at 2:01 PM LVN V stated nurses were in-serviced on 08/29/23 on assessing residents when they had a change in condition, checking vital signs, documentation of assessment in residents' electronic clinical record, and immediate notification to physician and/or NP of changes in condition. Interview on 08/29/23 at 3:47 PM RN U stated since working for the facility she had not been in-serviced on anything as far as she recalls. Interview on 08/29/23 at 4:18 PM with LVN S stated she had not been in-serviced on anything since she started working at the facility on the 14th of August 2023. LVN S stated she had not received any in-service training on what to do when a resident had a change in condition. Review of 24-Hour Report Worksheet dated 08/10/23 on the 6-2 shift documented Resident #1 Emesis x1; laying down, now. There was not time indicated on the 24-hour report of when the vomiting occurred. Review of 24-Hour Report Worksheet dated 08/10/23 on the 2-10 shift documented Resident #1 Emesis x4; NP notified. N.O. for KUB and Promethazine 12.5 mg TID PRN. Emesis x2 after New Orders, sent via Emergency Medical Services to hospital per family member's request. Coded on transfer to stretcher. Review of Weights & Vital Signs Summary report for Resident #1 revealed, pulse was last checked on 03/01/23, 81 beats per minute-Regular; Temperature was last checked on 02/18/23 and was 97.2 Fahrenheit; Blood Pressure was last checked on 03/01/23 and was 117/73. Record review RN I had not completed an SBAR assessment for Resident #1 on 08/10/23 when she notified NP on 08/10/23 of Resident #1 having vomited x 3 on the 2-10 shift. Review of Order Recap Report dated 01/01/2023 - 08/31/2023 for Resident #1 documented in part: -Order Date: 08/10/23 for portable KUB due to resident being confined to nursing home. Diagnosis: Pain. -Order Date: 08/10/23 Promethazine HCL (Hydrochloride) inject 12.5 mg intramuscular every 8 hours as needed for nausea/vomiting. The Recap Order Report dated 01/01/2023 - 08/31/2023 for Resident #1 did not document an order to send the resident to the emergency room for evaluation of change in condition. Review of Medication Administration Record (MAR) date 08/01/23 - 08/3123, printed on 08/12/23 for Resident #1 revealed an order for Promethazine HCL injection Solution inject 12.5 mg Intramuscular every 8 hours as needed for nausea/vomiting. Start Date: 08/10/23. MAR did not document Promethazine was administered as ordered on 08/10/23 by RN I. Record review of facility's policy and procedure on Notification of Changes Reviewed/Revised 02/10/21 revealed: Policy: To provide guidance on when to communicate acute changes in status to MD, NP, and responsible party. The facility will immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or appropriate family member(s) of the following: -An emergency response situation that requires EMS involvement-A significant change in the physical, mental, or psychosocial status of the resident. -A decision to transfer or discharge the resident to another facility. Policy Explanation and Compliance Guidelines: -In the case of a resident who is incapable of making decision, the resident should still be notified. Notify the resident's physician. Decisions would be made by the legal representative or appropriate family members. -The facility documents resident assessment(s), interventions, precision and family notifications on SBAR, nurses progress notes or telephone order forms (physician/family notice) as appropriate The administrator, DON, and ADONs were informed on 08/31/23 at 10:44 AM that Immediate Jeopardy (IJ) had been identified and a copy of the IJ Template identifying the areas of noncompliance, elements of risk, and need for immediate action were provided to the Administrator and a Plan of Removal was requested within the hour. On 09/01/23 at 9:20 AM Administrator was notified 3rd Plan of removal was accepted. The Plan of Removal revealed the facility took following actions: 1. The DON in the morning meeting reviews the 24- hour report to identify any resident with a change in condition. DON/Designee will review documentation/assess if indicated, to verify that any identified change had a physician notification and documentation. 2. The DON/Designee will review the Stop and Watch notebook daily to verify that any communication from nurse assistance to license nurse has been reviewed and with timely interventions as indicated. 3. The DON/Designee will complete: o A license nurse QAPI tool daily x 30 days verifying license nurses training and knowledge in regard to the education they received (Vital Signs Guidelines, Clinical Practice Guidelines Alert Charting, Notification of Change of Condition, and The Stop and Watch program (A program in which CNAs see a resident having a change of condition and fill out a yellow form submitting it and reporting the change of condition to the nurses)) o A Nurse Assistant QAPI tool daily x 30 days verifying nurse assistant training and knowledge in regard to the education they received (Notification of Change of Condition, and the Stop and Watch program) On 8/31/2023 (unknown time) the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to notification of change in condition, and Quality of care and reviewed plan to sustain compliance. Interviews and record review to confirm implementation of the Plan of Removal were conducted as follows: Record review of facility Stop and Watch Early Warning Tool in-service dated 08/31/23-09/01/23 at 4:53 PM was signed and acknowledged competency by the CNAs. Record review of facility changes in condition in-service dated 08/31/23 at 4:53 PM was signed and acknowledged competency by the CNAs. Record review of facility notification changes in-service dated 08/31/23 at 1:00 PM was signed and acknowledged competency by the nurses. Record review of the facility alert charting dated 08/31/23 at 1:00 PM was signed and acknowledged competency by the nurses. Record review of the facility vital signs dated 08/31/23 at 1:00 PM was signed and acknowledged competency by the nurses. Record review of facility SBAR Communication UDS for changes of conditions in-service dated 09/01/23 at 9:00 AM was signed and acknowledged competency by the nurses. Record review of facility's stop and watch binder dated 09/01/23 at 10:03 AM revealed Stop and Watch Early Warning Tool. If you have identified a change while caring for or observing a resident, please circle the change and notify a nurse. Either give the nurse a copy of this tool or review it with her/him as soon as you can. Record review of facility e-mail dated 09/01/23 at 3:23 PM indicating the licensed nurses on all other shifts cannot work until they have had this education (SBAR) and signed the in-service sheet. Make sure nurse manager at the beginning of each shift and throughout the weekend to provide this training before they work. Interview on 08/29/23 at 2:01 PM with LVN V stated they were in-serviced on alert charting, vitals, and notification of changes. LVN V stated on alert charting which was charting everything that was reported by the CNAs regarding residents' changes of condition. LVN V stated vitals are to be taken when residents have changes of conditions. LVN V stated vitals establish a baseline for the resident. LVN V stated if a resident had a change of condition, they need to notify the physician or NP immediately regarding the change in the resident. LVN V stated anytime the CNAs see a change of condition they need to fill out a stop and watch yellow sheet and turn it in to the nurses so they can check on the resident. Interview on 08/29/23 at 4:13 PM with LVN R stated, recently this month (August 2023) she had received in-services on changes of condition and assessing the residents. LVN R stated when preforming a head-to-toe assessment on a resident and something was found to let the physician know. LVN R stated she received an in-service on taking vitals and to communicate anything that was abnormal. LVN R stated it was important to take vitals when a resident had an incident because it could be a change of condition with the resident. LVN R stated she would then document it on the SBAR. Interview on 08/30/23 at 8:53 AM CNA K stated yesterday 08/29/23 was the first time she had got an in-service on stop and watch and changes of condition. CNA K stated if a resident had a change of condition, then they are to report it and write it down on a paper that was at the nurse's station and submit it to the nurses. CNA K stated any changes of condition that are not normal are considered changes to a resident and need to be reported immediately. Interview on 08/30/23 at 9:40 AM CNA W stated she received an in-service on changes of condition and vitals. CNA W stated she would report any changes a resident had that were not normal to the nurses. CNA W stated vitals are taken when a resident has a change in their condition that was different from what they normal act. Interview on 08/30/23 at 9:53 AM CNA X stated she had been in-serviced on changes of condition with a resident, reporting, and stop and watch. CNA X stated if the resident was having a change of condition that was not their normal self, then the CNAs were expected to go to the nurse's station where the Stop and Watch yellow sheet was at and fill one out. CNA X stated once filled it would be turned into the nurses reporting the change in the resident. Interview on 08/30/23 at 10:01 AM CNA Y stated she had received the in-services on changes of condition, reporting, and stop and watch. CNA Y stated anytime a resident shows a change in their condition the CNAs need to report it. CNA Y stated you go to the nurse's station and in the book called Stop and Watch fill out a yellow form. CNA Y stated once filled it was turned into the nurses so they may go assess the resident. Interview on 08/30/23 at 10:10 AM CNA D stated that the Stop and Watch binder was at the nurse's station. CNA D stated it was for when a resident had a change in condition. CNA D stated if they saw a resident different from their norm then they were to report by going to the stop and watch binder and pulling out a yellow sheet and filling it out. CNA D stated it would be turned into the nurses for follow up. Interview on 09/01/23 at 2:20 PM LVN AA stated she was in-serviced on alert charting, changes of condition, SBAR, and calling the physician. LVN AA stated anytime a resident has a change in condition it needed to be reported to the physician or if the CNAs see the change with a resident, they need to notify nursing. LVN AA stated the SBAR was where nurses document vitals, times, and anything vital with changes of condition with a resident. LVN AA stated it was a summary of what was going on with the resident. LVN AA stated everything needed to be charted regarding the residents change of condition and assessments. Second interview on 09/01/23 at 3:40 PM with LVN S stated she was in-serviced on 08/31/23 and on 09/01/23 with changes of condition, SBAR, and vital[TRUNCATED]