**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident's physician and responsible party of a significant change in condition for one (Resident #1) of three residents reviewed for notification of changes. The facility failed to notify Resident #1's physician and responsible party of a witnessed seizure on 09/15/25. Facility staff did not initiate neurological checks, perform an assessment or obtain labs following the event and the physician was not informed to direct further care. Resident #1 remained without clinical intervention until later that day, when the family requested a hospital transfer due to unaddressed changed in condition. On 09/18/25 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/23/25, the facility remained out of compliance at a severity level of no actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure placed residents at risk for delayed medical evaluation, treatment, lack of timely involvement by the responsible party and the physician in resident care decisions and the potential for worsening of the resident's condition. Findings included:Record review of Resident #1's Face Sheet dated 09/17/25 reflected she was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of anemia (red blood cell or hemoglobin deficiency, leading to reduced oxygen transport in the blood), hyperlipidemia (abnormally high levels of fats in the blood), major depressive disorder (persistent feelings of sadness and loss of interest), insomnia (persistent difficulty falling asleep or staying asleep), hypertensive heart disease (heart problems due to high blood pressure), hemiplegia and hemiparesis-right dominant side (paralysis or weakness affecting one side of the body), acute respiratory failure (sudden inability to maintain adequate gas exchange), gastro-esophageal reflux disease (a chronic condition where stomach acid flows back into the esophagus, causing irritation), osteoarthritis (degenerative joint disease characterized by cartilage breakdown and joint pain), muscle wasting and atrophy (loss of muscle strength and muscle tissue mass). She had no listed diagnosis of a seizure disorder (a condition characterized by recurrent, unprovoked seizures due to abnormal electrical brain activity). Resident #1 had two family members listed as her emergency contacts and resident representative.Record review of Resident #1's admission MDS assessment dated [DATE] reflected she a BIMS score of 04, which indicated severe cognitive impairment. Resident #1 had no signs or symptoms of delirium, no negative mood issues and behavioral symptoms and no rejection of care concerns. Resident #1 required substantial/maximum assistance for activities of daily living and total dependance on eating. Resident #1 had no range of motion issues and did not require any mobility devices. Resident #1 was always incontinent of bowel and bladder. Seizure disorder was not indicated as an active diagnosis on the MDS assessment. Under the section High-Risk Drugs, Resident #1 was noted to take anticonvulsant medication. Record review of Resident #1's care plan dated 07/02/25 and last revised on 08/02/25 reflected, [Resident #1] has Seizure Disorder.Interventions: Give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness-Date Initiated: 07/02/2025, Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated-Date Initiated: 07/02/2025, Post Seizure Treatment: Turn on side with head back, hyper-extended to prevent aspiration, keep airway open, after seizure take vital signs and neuro check, Monitor for aphasia, headache, altered LOC, paralysis, weakness, pupillary changes. Date Initiated: 07/02/2025, Seizure Documentation: location of seizure activity, type of seizure activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after seizure activity-Date Initiated: 07/02/2025, Seizure Precautions: Do not leave resident alone during a seizure, Protect from injury, If resident is out of bed, help to the floor to prevent injury, Remove or loosen tight clothing, Don't attempt to restrain resident during a seizure as this could make the convulsions more severe, Protect from onlookers, draw curtain, etc.- Date Initiated: 07/02/2025.Record review of Resident #1's active physician orders dated 09/17/25 reflected, Keppra Solution 100 MG/ML (Levetiracetam) give 7.5 milliliter via g-tube two times a day for seizures (start date 07/01/25 - present).Record review of Resident #1's September 2025 MAR reflected she was administered Keppra 7.5ml twice a day from 09/01/25 twice a day with the last dose documented the morning of 09/15/25. Record review of Resident #1's nursing progress notes dated 09/15/25 reflected: -11:10 AM-[Written by RN A]-The ADON called this nurse when she noticed resident having seizures when she was doing wound dressing of her roommate. Assessed and positioned the resident and provided all necessary care during and after seizure. Vital signs checked as B.P.-142/76; P/R- 80; R/R-18; SpO2-94; Temp.-97.6 on room air. Resident opening her eyes when calling out her name. Will continue to monitor and provide care. -3:56 PM- [Written by the DON]- [EC] called and states that resident was having a seizure and two nurses in room not doing anything for her. Entered room to check on resident and lying in bed with eyes closed resting peacefully. Informed [EC] after speaking with nurse for resident and make aware of concern. Per nurse resident had seizure earlier this morning. Made [EC] aware that we have informed MD and that [Resident #1] is currently on Keppra BID for seizure. [EC] was also made aware that Keppra levels will be drawn to see what Keppra level. Will continue to monitor.-4:36 PM- [Written by RN A]- Resident awake, oriented and stable but not responding as usual according to the [EC] who came to visit her wants 911 to be called and they want her to be taken to the hospital. Vital signs checked B.P.-136/85; P/R-81; Temp.-98.1; Spo2- 95 on room air. Notified DON and ADON. Called 911 and transferred resident to hospital.-4:41 PM- Transfer Notification- [Resident #1] was transferred to a hospital on [DATE] 5:35 PM related to The family want [sic] her to be sent to hospital as she had seizure in the morning and according to them she is not responding normally.Record review of Resident #1's nursing and social services progress notes revealed no notification of her seizure immediately to the RP or the physician the morning of 09/15/25.Record review of Resident #1's clinical chart to include all assessments and progress notes, reflected no documented neurochecks or monitoring after she had a seizure the morning of 09/15/25. An interview with LVN G on 09/17/25 at 2:56 PM revealed Resident #1 went to the ER on her shift. That morning of the incident, ADON D was rounding with the wound doctor on Resident #1's roommate and noticed Resident #1 was groaning and having seizures. LVN G stated she never saw Resident #1 have the seizure, but ADON D told her when she saw her, the resident was foaming at the mouth and shaking. LVN G stated all she saw was some secretions coming out of Resident #1's mouth when she had been repositioning her. ADON D asked LVN G to come and help and checked her vitals and immediately after the seizure was over, Resident #1 was snoring and sleeping and stable. Then in the afternoon, LVN G went to administer Resident #1's scheduled hydromorphone saw that her vitals were fine and she continued to sleep. In the evening, LVN G stated Resident #1's family member called the facility stating the resident did not look like her normal self on the AEM footage. LVN G said she told the family member yes, Resident #1 did have a seizure but it was earlier that morning and the nurses had been doing one hour vital checks and gave her medicine. LVN G did not believe Resident #1 had another seizure after the initial one due to the nursing staff monitoring her. She said the family member did not want Resident #1 to decline and wanted the facility to call 911 to send her to the ER. LVN G stated, I even checked the vitals prior and she was okay. I told her everything is okay. LVN G stated that when Resident #1 had the initial seizure, she did not notify the MD/NP/PA or the resident's RP. She stated, I had a discharge and an admission coming at that time of day. Typically, I would want to notify the doctor and the party responsible and we will document and check on the resident intermittently and if we see any change in condition after notifying the doctor, we will transfer them out. LVN G stated Resident #1 had remained stable since the seizure. LVN G stated, The error-I did not notify the RP, I should have done that. That is important because, like when they came in the evening, they didn't know, they need to have a choice if there is anything further they want for the resident and to keep ourselves and documentation accurate. LVN G stated the importance of notifying the doctor for a resident's change of condition such as Resident #1 because that was the first seizure she had since she had been at the facility and the doctor needed to be aware in order to be able to make changes to her treatment. LVN G again admitted her fault in not notifying the MD or RP of Resident #1's seizure, which she stated was a change in condition. She said with her being the only nurse on that shift and having to pass meds, do lines and injections, she did not have time for the notification .An interview with the DON on 09/17/25 at 3:48 PM revealed the day Resident #1 had a seizure, her family member called around 2-3pm and said the resident was presently having a seizure and there were two nurses that were just standing there. The DON went to Resident #1's room and there were no nurses in there and nothing was going on and the resident opened her eyes. The DON asked ADON D if Resident #1 had a seizure and ADON D said yes, at 7am that morning. Then she went to LVN G and asked if Resident #1 just had a seizure and she said no, only that morning between 7 am and 9 am and she monitored her and the resident was fine. The DON said she contacted the family member back and said Resident #1 was okay, but the family member wanted her sent out because she had a seizure. The DON stated when a resident had a seizure, the expectation was for the charge nurse to take vitals, call the doctor to notify them, sometimes that doctor will order a lab or ask how long the seizure lasted. If there was no change and the resident continued to have seizures, the DON stated they would need to be sent out. The DON stated it was important to notify the doctor when a resident had a seizure because it could affect the resident's neurological status detrimentally. The DON stated it was important to notify the resident's RP for a change of condition, but with Resident #1, She has a history of it and is already taking meds for it. If she was going to be sent out or it continued, I would notify the family, but I guess she was okay because she responded to me.An interview with ADON D on 09/18/25 at 10:00 AM revealed when Resident #1 had the seizure, she was doing wound care on her roommate. She stated Resident #1 had a mouthful of saliva and was not responding, so she wiped her mouth off. ADON D said she tried to talk to Resident #1 in bed who then rolled over toward the wall. When ADON D started to leave the room, she heard the enteral feeding pump alarm beeping and when she looked at Resident #1, she was having a seizure. At that time, ADON D stated she turned Resident #1 more to her side while she had the seizure which lasted less than a minute. She thought it may have been a grand mal seizure. ADON D stated when Resident #1 stopped having the seizure, she fell asleep immediately and started snoring. ADON D then notified LVN G who checked the resident's vitals which were within normal limits. ADON D said Resident #1 was monitored post-seizure, Like if I was walking down the hall that day, I would look in. ADON D stated she asked LVN G if the doctor was aware of the seizure and LVN G responded yes and that the PA wanted a Keppra lab done for her but did not want to send her out. ADON D stated the Keppra lab was not stat because, She [Resident #1] was calm and not having a seizure. That evening, ADON D stated the business office manager came to her and said the family saw Resident #1 having a seizure on the AEM camera. ADON D went to check on Resident #1 and asked LVN G if she had any additional seizures and she replied no. ADON D stated she did not think Resident #1 had any additional seizures due to her not having any visible indicators of her having a seizure, such as no blankets or sheets looked disturbed and she felt there would have to be more signs. ADON D stated, Like if she was shaking, she did not appear to have struggled with anything because there is going to be movement with her limbs, even though she is paralyzed on one side and can't move.so if she would have had another seizure, there would have been more visible signs. ADON D told the BOM no, that seizure happened earlier in the day. ADON D said later that shift, she saw Resident #1's family member arrive at the facility who felt the resident did not look good and wanted her sent to the ER. The family was saying Resident #1 was not responding like her normal self. ADON D stated Resident #1 was calm, but her family still wanted her sent out because they felt she was having another seizure. ADON D stated she did not feel like Resident #1 had a change in condition and felt she was just being quiet on the day she had a seizure. ADON D said a change of condition could be anything from a resident's norm and if she observed it happen, she had to check vitals, do necessary assessments and notify the doctor. ADON D stated she told the charge nurse (LVN G) that she had talked to the NP and to complete a nursing note that reflected the PA was notified. ADON D stated she notified the NP on her phone via a text message but it did not occur until close to 4:00 PM. ADON D stated she did not notify the physician or extenders timely when the seizure occurred because she thought the charge nurse did. ADON D stated the charge nurse (LVN G) did not contact the physician or extenders. She stated, I didn't know, I told her I would contact [NP] to get an order for Keppra level and she needed to write a note. ADON D stated she did not notify Resident #1's RP when she had the seizure and thought LVN G did. ADON D stated it was important to notify RPs of a seizure because, We need to let them know it happened and we are working on it. Maybe they can give a history or what has worked in the past to intervene. ADON D stated a resident who continued to have seizure activity was at risk of aspiration, even with a g-tube because of saliva. The resident could also bite their tongue or swallow their tongue, and neurologically they could go into shock.An interview with PA E on 09/18/25 at 10:23 AM revealed she remembered being notified by ADON D about Resident #1's seizure and she ordered a lab to get a Keppra level. She stated she was not notified until later in the afternoon closer to 4pm. PA E stated she should be notified on how severe a resident's seizure was, to know if immediate action needed to be taken. PA E felt a seizure longer than a minute in duration would be considered a severe seizure. PA E stated the charge nurse should monitor that resident's vitals at least once an hour after a seizure event and their baseline mental status, like drowsiness and alertness. PA E stated she relied on the nursing staff to tell her if there was a situation going on with a resident. She said she did not know Resident #1 had been sent to the ER. PA E stated the MD/PA or NP were supposed to be notified when a resident was sent to the hospital but she did not see any communication from the facility about it. She stated the only message she received was from ADON D at 4 pm related to Keppra lab and seizure notification. PA E stated the risk of a resident having continued seizure activity was altered mental status, respiratory distress and brain trauma . An interview with the DON on 09/18/25 at 12:10 PM revealed there was no baseline Keppra lab for Resident #1 since her admission to the facility. An interview with Resident #1's RP/family member on 09/17/25 at 5:27 PM and subsequent follow up interview on 09/19/25 at 10:31 AM revealed the RP was not contacted after Resident #1's seizure the morning of 09/15/25. She stated the family was shocked to turn on the AEM camera in Resident #1's room to see her having a seizure that afternoon (time unknown) with nurses present in the room not intervening and then covering her and leaving the room while the resident was foaming at the mouth. The RP stated, They literally just covered her up and walked away! She stated Resident #1 presently was in an ICU unit of the hospital where she had limited brain activity. She stated she showed the camera footage to the medical staff at the hospital where it showed staff doing pericare for Resident #1 while she was foaming at the mouth. The RP said the doctors were shocked at the video. The RP stated while at the hospital, they have increased her Keppra medication for seizures and did and EEG because of her left sided weakness and limited talking ability. When the RP confronted the facility, she talked to the new DON, who told her she had checked on Resident #1 since the seizure that morning and she was okay. The RP was upset family was not contacted and stated the AEM showed that the nurses neglected to check Resident #1's vitals and just covered her up. The RP said when she talked to the DON she told her the situation was inhumane. After that phone call, the RP stated the nurses started pulling the privacy curtain to where the resident could not be viewed through the camera. The RP stated she came to the facility immediately after that to see what was going on. She said she asked the DON to contact Resident #1's doctor but the DON replied no. The RP stated, She [DON] refused everything I asked them to do. I asked what orders were in there by the doctor to help her with seizures and could she contact him if not. The RP said the DON told her that the doctor would see Resident #1 the next day because in her estimation, Resident #1 was still responsive because she responded to her name earlier, so it was not an emergency. The RP then stated, They are misleading and I specifically stated I'm call (911) since you've left [Resident #1] in a non-responsive state as if she's okay, and she wasn't.I will testify in a court of law that there was nothing done or even attempted, to settle my mind that they were truly assisting [Resident #1].Review of AEM surveillance footage for Resident #1's room provided by the RP and time stamped 09/15/25 between 6:52 AM and 10:34 AM revealed the following:-At 6:52 AM, Resident #1 was observed awake in bed, alert and watching television. She used her left arm to adjust bed linens and extend her left leg toward the floor. Her right wrist appeared flexed inward. -At 7:04 AM, Resident #1 paused her movements, reclined her head and exhibited sudden stiffening of her left leg, left foot, left and right arms. Her eyes rolled upwards. -At 7:10 AM, Resident #1 appeared to be asleep.-Between 7:10 AM and 9:46 AM, Resident #1 remained in bed with no visible movement. -At 9:46 AM, foaming at the mouth was observed, with secretions visible along the right cheek. -At 10:10 AM, ADON D entered the room, called Resident #1's name, lowered the bed towards the floor and raised the HOB upright. She wiped Resident #1's mouth of secretions. Resident #1 exhibited minimal movement of the left hand. The ADON exited the room at 10:14 AM.-At 10:19 AM, ADON D and LVN G attempted to move Resident #1's arms; both were flaccid. -The final video segment at 10:34 AM showed LVN G and two additional unidentified staff in the room. Resident #1 remained on her left side, with continued foaming at the mouth along the right cheek.Hospital records were requested on 09/18/25 and 09/29/25 for Resident #1 from two different hospitals, one identified by the facility as the hospital to which Resident #1 was sent, and one identified by the RP as the hospital she reported the resident currently received treatment. As of 10/01/25, the records had not been received .Review of the facility's policy titled, Resident Rights (undated) reflected, The resident has a resident to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility,.3. The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must: a. Facilitate the inclusion the resident and/or resident representative, b. Include an assessment of the resident's strength and needs.14. Notification of changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s), when there is: a) An accident involving the resident which results in injury and has the potential for requiring physician intervention; b) A significant change in the resident's physical, mental, or psychosocial status.; c) A need to alter treatment significantly. An Immediate Jeopardy (IJ) was identified on 09/18/25 at 1:00 PM related to Resident #1's seizure incident. The R-AD and DON were notified and they were provided with the IJ template on 09/18/25 at 1:41 PM. A Plan of Removal was requested.The following Plan of Removal submitted by the facility was accepted on 09/19/25 at 8:12 PM and reflected: Date: 9/18/25- Plan of Removal- F580 Notification of Change in Condition The facility failed to promptly notify the MD of Resident's #1s change in condition when she sustained a seizure on 9/15/25.Interventions: 1. Resident #1 was admitted to the hospital on [DATE]. Resident #1 remains in the hospital as of 9/15/25 [sic]. 2. All residents in the facility that have a seizure diagnosis and are on an anticonvulsant medication were assessed by the DON, ADON, and Charge Nurses for seizure activity or a change in condition that required notification to the MD and post-monitoring of the resident. No additional changes in condition including seizure activity were noted that required notification to the RP and MD or post-monitoring of seizure activity. Completion date 9/18/25. 3. New Process: The DON/ADON/Designee will review the 24hr report and PCC dashboard seven days per week for seizure activity or changes in condition to ensure that assessments, notifications to MD/RP were made to receive orders for post-monitoring, assessment, and documentation. This review will be documented on the morning clinical meeting form. Verification on the review will be completed at minimum of weekly by the Area Director of Operations and/or Regional Compliance Nurse. Completion date 9/18/25. 4. The DON and ADON were in-serviced 1:1 by the Regional Compliance Nurse and Area Director. Completed 9/11/25 . A. Abuse and Neglect Policy: to include the lack of notification of the MD could prolong appropriate treatment for a resident which could be considered neglect. Also, failure to notify the RP immediately could prolong decisions for the resident's care. B. Notification of Change in Condition Policy: charge nurses will notify the MD and RP immediately of all changes in conditions to include seizure activity. Signs and symptoms of seizures include shaking, jerking, twitching, stiffening of the body, loss of muscle control, falling to the ground, nausea and vomiting. The nurses will notify the MD and implement the seizure management protocol. Any additional orders by MD will be implemented by the charge nurse. If the charge nurse cannot notify the MD/RP immediately, the charge nurse will inform the DON or ADON to assist with notifications. Notifications will be documented in PCC in the SBAR or progress notes. C. Documentation: Charge nurses will document changes in condition, notification to the MD/RP, orders, and subsequent assessments and monitoring ordered by the MD. 5. The medical director was notified of the immediate jeopardy citation by the administrator on 9/18/25. 6. An ADHOC QAPI meeting was held with interdisciplinary team including the medical director to discuss the immediate jeopardy and plan of removal. Completed on 9/18/25. In-services: 1. The following in-services were initiated by Administrator, Regional Compliance Nurse, DON, ADON to all staff. All staff not present or in-serviced as of 9/18/25 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will be in serviced prior to assuming their next assignment. Completion date 9/19/25.A. Abuse and Neglect Policy: to include the lack of notification of the MD could prolong appropriate treatment for a resident which could be considered neglect. Also, failure to notify the RP immediately could prolong decisions for the resident's care. B. Notification of Change in Condition Policy: charge nurses will notify the MD and RP immediately of all changes in conditions to include seizure activity. Signs and symptoms of seizures include shaking, jerking, twitching, stiffening of the body, loss of muscle control, falling to the ground, nausea and vomiting. The nurses will notify the MD and implement the seizure management protocol. Any additional orders by MD will be implemented by the charge nurse. If the charge nurse cannot notify the MD/RP immediately, the charge nurse will inform the DON or ADON to assist with notifications. Notifications will be documented in PCC in the SBAR or progress notes. C. Documentation: Charge nurses will document changes in condition, notification to the MD/RP, orders, and subsequent assessments and monitoring ordered by the MD.Monitoring the Plan of Removal implementation occurred on 09/19/25 through 09/23/25 daily onsite visits. Facility monitoring activities included review of 24-hour reports, risk management logs,, change in condition documentation and hospital transfer records to identify any additional incidents that involved seizures, falls, medication refusals or changes in condition. Additional records for three residents were reviewed to verify timely assessments, physician notifications, orders and follow-up actions to verify that timely physician and RP notifications were completed. Additionally, staff in-service records and competency validation tools were reviewed for charge nurses, medication aides and CNAs. In-services covered neurological assessments, changes in conditions protocols, documentation standards, medication refusal and abuse/neglect reporting procedures. Twenty nursing staff were interviewed across all shifts (RN A, LVN B, DON, ADON D, LVN F, CCN K, CNA H, MA J, R-AD , CNA L, CNA M, LVN N, CNA O, CNA P, RN Q, LVN R, CNA S, CNA T, CNA U and LVN V) and demonstrated awareness of the facility's expectations, policies and procedures. An Ad Hoc QAPI Committee meeting dated 09/18/25 and 09/21/25 were reviewed to confirm the facility had analyzed the notification system failure, implemented corrective actions and established enhanced monitoring processes to ensure compliance with physician and RP notification requirements. No additional failures were identified related to notifications during the monitoring period . An interview with the R-AD on 09/23/25 at 11:22 AM revealed his expectation as the interim ADM for a change in condition would be for the charge nurse to call the physician right away, call the DON, call the RP and then the DON would let the R-AD know what happened and keep him up to date. The R-AD stated if a resident had a seizure going forward, the nursing staff were to make sure the resident was safe remove anything from around the head and then call the physician and get an order, get labs if ordered and monitor, but we also want to make sure the resident is not acting different. If interventions were not implemented, the R-AD stated the resident's health could be affected. The R-AD was informed the Immediate Jeopardy was removed on 09/23/25 at 11:55 AM. The Facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility to provide necessary care and services for three (Residents #1, #2 and #3) of three residents reviewed for quality of care. 1. The facility failed to monitor and assess Resident #1 who had a seizure disorder, after she had a seizure on 09/15/25. The facility did not complete any neurochecks, assessment or lab monitoring. The resident was sent out to the ER by family request later that day due to concerns for a change in condition.2. The facility failed to complete and document neurological checks following Resident #2's fall with a head strike and injury when she returned from the ER on [DATE].3. The facility failed to assess, intervene and develop a plan of care for Resident #3 who had dementia and bipolar disorder when she refused to take prescribed psychotropic and dementia medications since her admission in July 2025, resulting in behavioral decompensation requiring psychiatric hospitalization on 09/19/25. On 09/18/25 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 09/23/25, the facility remained out of compliance at a severity level of no actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The facility failures placed residents at risk of unmanaged seizure activity, hypoxia, traumatic brain injury, delay in recognition of intracranial bleeding or neurological deterioration, uncontrolled psychiatric symptoms, aggressive behaviors, harm to self or others, unnecessary hospitalization and risk for serious injury, significant decline, life-threatening complications and death.Findings included: RESIDENT #1Record review of Resident #1's Face Sheet dated 09/17/25 reflected she was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of anemia (red blood cell or hemoglobin deficiency, leading to reduced oxygen transport in the blood), hyperlipidemia (abnormally high levels of fats in the blood), major depressive disorder (persistent feelings of sadness and loss of interest), insomnia (persistent difficulty falling asleep or staying asleep), hypertensive heart disease (heart problems due to high blood pressure), hemiplegia and hemiparesis-right dominant side (paralysis or weakness affecting one side of the body), acute respiratory failure (sudden inability to maintain adequate gas exchange), gastro-esophageal reflux disease (a chronic condition where stomach acid flows back into the esophagus, causing irritation), osteoarthritis (degenerative joint disease characterized by cartilage breakdown and joint pain), muscle wasting and atrophy (loss of muscle strength and muscle tissue mass). She had no listed diagnosis of a seizure disorder (A condition characterized by recurrent, unprovoked seizures due to abnormal electrical brain activity). Resident #1 had two family members listed as her emergency contacts and resident representative. Record review of Resident #1's admission MDS assessment dated [DATE] reflected a BIMS score of 04, which indicated severe cognitive impairment. Resident #1 had no signs or symptoms of delirium, no negative mood issues and behavioral symptoms and no rejection of care concerns. Resident #1 required substantial/maximum assistance for activities of daily living and total dependance on eating. Resident #1 had no range of motion issues and did not require any mobility devices. Resident #1 was always incontinent of bowel and bladder. Seizure disorder was not indicated as an active diagnosis on the MDS assessment. Under the section High-Risk Drugs, Resident #1 was noted to take anticonvulsant medication. Record review of Resident #1's care plan dated 07/02/25 and last revised on 08/02/25 reflected, [Resident #1] has Seizure Disorder.Interventions: Give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness-Date Initiated: 07/02/2025, Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated-Date Initiated: 07/02/2025, Post Seizure Treatment: Turn on side with head back, hyper-extended to prevent aspiration, keep airway open, after seizure take vital signs and neuro check, Monitor for aphasia, headache, altered LOC, paralysis, weakness, pupillary changes. Date Initiated: 07/02/2025, Seizure Documentation: location of seizure activity, type of seizure activity (jerks, convulsive movements, trembling), duration, level of consciousness, any incontinence, sleeping or dazed post-ictal state, after seizure activity-Date Initiated: 07/02/2025, Seizure Precautions: Do not leave resident alone during a seizure, Protect from injury, If resident is out of bed, help to the floor to prevent injury, Remove or loosen tight clothing, Don't attempt to restrain resident during a seizure as this could make the convulsions more severe, Protect from onlookers, draw curtain, etc.- Date Initiated: 07/02/2025. Record review of Resident #1's active physician orders dated 09/17/25 reflected, Keppra Solution 100 MG/ML (Levetiracetam) give 7.5 milliliter via g-tube two times a day for seizures (start date 07/01/25 - present). Record review of Resident #1's September 2025 MAR reflected she was administered Keppra 7.5ml twice a day from 09/01/24 twice a day with the last dose documented the morning of 09/15/25. Record review of Resident #1's nursing progress notes dated 09/15/25 reflected: -11:10 AM-[Written by RN A]-The ADON called this nurse when she noticed resident having seizures when she was doing wound dressing of her roommate. Assessed and positioned the resident and provided all necessary care during and after seizure. Vital signs checked as B.P.-142/76; P/R- 80; R/R-18; SpO2-94; Temp.-97.6 on room air. Resident opening her eyes when calling out her name. Will continue to monitor and provide care. -3:56 PM- [Written by the DON]- [EC] called and states that resident was having a seizure and two nurses in room not doing anything for her. Entered room to check on resident and lying in bed with eyes closed resting peacefully. Informed [EC] after speaking with nurse for resident and make aware of concern. Per nurse resident had seizure earlier this morning. Made [EC] aware that we have informed MD and that [Resident #1] is currently on Keppra BID for seizure. [EC] was also made aware that Keppra levels will be drawn to see what Keppra level. Will continue to monitor.-4:36 PM- [Written by RN A]- Resident awake, oriented and stable but not responding as usual according to the [EC] who came to visit her wants 911 to be called and they want her to be taken to the hospital. Vital signs checked B.P.-136/85; P/R-81; Temp.-98.1; Spo2- 95 on room air. Notified DON and ADON. Called 911 and transferred resident to hospital.-4:41 PM- Transfer Notification- [Resident #1] was transferred to a hospital on [DATE] 5:35 PM related to The family want her to be sent to hospital as she had seizure in the morning and according to them she is not responding normally. Record review of Resident #1's nursing and social services progress notes revealed no notification of her seizure immediately to the RP or the physician the morning of 09/15/25. Record review of Resident #1's clinical chart to include all assessments and progress notes, reflected no documented neurochecks or monitoring after she had a seizure the morning of 09/15/25. An interview with LVN G on 09/17/25 at 2:56 PM revealed Resident #1 went to the ER on her shift. That morning of the incident, ADON D was rounding with the wound doctor on Resident #1's roommate and noticed Resident #1 was groaning and having seizures. LVN G stated she never saw Resident #1 have the seizure, but ADON D told her when she saw her, the resident was foaming at the mouth and shaking. LVN G stated all she saw was some secretions coming out of Resident #1's mouth when she had been repositioning her. ADON D asked LVN G to come and help and checked her vitals and immediately after the seizure was over, Resident #1 was snoring and sleeping and stable. Then in the afternoon, LVN G went to administer Resident #1. Her scheduled hydromorphone saw that her vitals were fine and she continued to sleep. In the evening, LVN G stated Resident #1's family member called the facility stating the resident did not look like her normal self on the AEM footage. LVN G said she told the family member yes, Resident #1 did have a seizure but it was earlier that morning and the nurses had been doing one-hour vital checks and gave her medicine. LVN G did not believe Resident #1 had another seizure after the initial one due to the nursing staff monitoring her. She said the family member did not want Resident #1 to decline and wanted the facility to call 911 to send her to the ER. LVN G stated, I even checked the vitals prior and she was okay. I told her everything is okay. LVN G stated that when Resident #1 had the initial seizure, she did not notify the MD/NP/PA or the resident's RP. She stated, I had a discharge and an admission coming at that time of day. Typically, I would want to notify the doctor and the party responsible and we will document and check on the resident intermittently and if we see any change in condition after notifying the doctor, we will transfer them out. LVN G stated Resident #1 had remained stable since the seizure. LVN G stated, The error-I did not notify the RP, I should have done that. That is important because, like when they came in the evening, they didn't know, they need to have a choice if there is anything further they want for the resident and to keep ourselves and documentation accurate. LVN G stated the importance of notifying the doctor for a resident's change of condition such as Resident #1 because that was the first seizure she had since she had been at the facility and the doctor needed to be aware to be able to make changes to her treatment. LVN G again admitted her fault in not notifying the MD or RP of Resident #1's seizure, which she stated was a change in condition. She said with her being the only nurse on that shift and having to pass meds, do lines and injections, she did not have time for the notification. An interview with the DON on 09/17/25 at 3:48 PM revealed the day Resident #1 had a seizure, her family member called around 2-3pm and said the resident was presently having a seizure and there were two nurses that were just standing there. The DON went to Resident #1's room and there were no nurses in there and nothing was going on and the resident opened her eyes. The DON asked ADON D if Resident #1 had a seizure and ADON D said yes, at 7am that morning. Then she went to LVN G and asked if Resident #1 just had a seizure and she said no, only that morning between 7 and 9 am and she monitored her and the resident was fine. The DON said she contacted the family member back and said Resident #1 was okay, but the family member wanted her sent out because she had a seizure. The DON stated when a resident had a seizure, the expectation was for the charge nurse to take vitals, call the doctor to notify them, sometimes that doctor will order a lab or ask how long the seizure lasted. If there was no change and the resident continued to have seizures, the DON stated they would need to be sent out. The DON stated it was important to notify the doctor when a resident had a seizure because it could affect the resident's neurological status detrimentally. The DON stated it was important to notify the resident's RP for a change of condition, but with Resident #1, She has a history of it and is already taken meds for it. If she was going to be sent out or it continued, I would notify the family, but I guess she was okay because she responded to me. An interview with ADON D on 09/18/25 at 10:00 AM revealed when Resident #1 had the seizure, she was doing wound care on her roommate. She stated Resident #1 had a mouthful of saliva and was not responding, so she wiped her mouth off. ADON D said she tried to talk to Resident #1 in bed who then rolled over toward the wall. When ADON D started to leave the room, she heard the enteral feeding pump alarm beeping and when she looked at Resident #1, she was having a seizure. At that time, ADON D stated she turned Resident #1 more to her side while she had the seizure which lasted less than a minute. She thought it may have been a grand mal seizure. ADON D stated when Resident #1 stopped having the seizure, she fell asleep immediately and started snoring. ADON D then notified LVN G who checked the resident's vitals which were within normal limits. ADON D said Resident #1 was monitored post-seizure, Like if I was walking down the hall that day, I would look in. ADON D stated she asked LVN G if the doctor was aware of the seizure and LVN G responded yes and that the PA wanted a Keppra lab done for her but did not want to send her out. ADON D stated the Keppra lab was not stat because, She [Resident #1] was calm and not having a seizure. That evening, ADON D stated the business office manager came to her and said the family saw Resident #1 having a seizure on the AEM camera. ADON D went to check on Resident #1 and asked LVN G if she had any additional seizures and she replied no. ADON D stated she did not think Resident #1 had any additional seizures due to her not having any visible indicators of her having a seizure, such as no blankets or sheets looked disturbed and she felt there would have to be more signs. ADON D stated, Like if she was shaking, she did not appear to have struggled with anything because there is going to be movement with her limbs, even though she is paralyzed on one side and can't move.so if she would have had another seizure, there would have been more visible signs. ADON D told them no, that seizure happened earlier in the day . ADON D said later that shift, she saw Resident #1's family member arrive at the facility who felt the resident did not look good and wanted her sent to the ER. The family was saying Resident #1 was not responding like her normal self. ADON D stated Resident #1 was calm, but her family still wanted her sent out because they felt she was having another seizure. ADON D stated she did not feel like Resident #1 had a change in condition and felt she was just being quiet on the day she had a seizure. ADON D said a change of condition could be anything from a resident's norm and if she observed it happen, she had to check vitals, do necessary assessments and notify the doctor. ADON D stated she told the charge nurse (LVN G) that she had talked to the NP and to complete a nursing note that reflected the PA was notified. ADON D stated she notified the NP on her phone via a text message but it did not occur until close to 4:00 PM. ADON D stated she did not notify the physician or extenders timely when the seizure occurred because she thought the charge nurse did. ADON D stated the charge nurse (LVN G) did not contact the physician or extenders. She stated, I didn't know, I told her I would contact [NP] to get an order for Keppra level and she needed to write a note. ADON D stated she did not notify Resident #1's RP when she had the seizure and thought LVN G did. ADON D stated it was important to notify RPs of a seizure because, We need to let them know it happened and we are working on it. Maybe they can give a history or what has worked in the past to intervene. ADON D stated a resident who continued to have seizure activity was at risk of aspiration, even with a g-tube because of saliva. The resident could also bite their tongue or swallow their tongue, and neurologically they could go into shock. An interview with PA E on 09/18/25 at 10:23 AM revealed she remembered being notified by ADON D about Resident #1's seizure and she ordered a lab to get a Keppra level. She stated she was not notified until later in the afternoon closer to 4pm. PA E stated she should be notified on how severe a resident's seizure was, to know if immediate action needed to be taken. PA E felt a seizure longer than a minute in duration would be considered a severe seizure. PA E stated the charge nurse should monitor that resident's vitals at least once an hour after a seizure event and their baseline mental status, like drowsiness and alertness. PA E stated she relied on the nursing staff to tell her if there was a situation going on with a resident. She said she did not know Resident #1 had been sent to the ER. PA E stated the MD/PA or NP were supposed to be notified when a resident was sent to the hospital but she did not see any communication from the facility about it. She stated the only message she received was form ADON D at 4 pm related to Keppra lab and seizure notification. PA E stated the risk of a resident having continued seizure activity was altered mental status, respiratory distress and brain trauma. An interview with the DON on 09/18/25 at 12:10 PM revealed there was no baseline Keppra lab for Resident #1 since her admission to the facility. An interview with Resident #1's RP/family member on 09/17/25 at 5:27 PM and subsequent follow up interview on 09/19/25 at 10:31 AM revealed the RP was not contacted after Resident #1's seizure the morning of 09/15/25. The RP stated the family was shocked to turn on the AEM camera in Resident #1's room to see her having a seizure that afternoon (time unknown) with nurses present in the room not intervening and then covering her and leaving the room while the resident was foaming at the mouth. The RP stated, They literally just covered her up and walked away! The RP stated Resident #1 presently was in an ICU unit of the hospital where she had limited brain activity. The RP stated she showed the camera footage to the medical staff at the hospital where it showed staff doing pericare for Resident #1 while she was foaming at the mouth. The RP said the doctors were shocked at the video. The RP stated while at the hospital, they have increased her Keppra medication for seizures and done and EEG because of her left side weakness and limited talking ability. When the RP confronted the facility, the RP talked to the new DON, who told the RP she had checked on Resident #1 since the seizure that morning and she was okay. The RP was upset family was not contacted and stated the AEM showed that the nurses neglected to check Resident #1's vitals and just covered her up. The RP said when he/she talked to the DON he/she told her the situation was inhumane. The RP said after that phone call, the nurses started pulling the privacy curtain to where the resident could not be viewed through the camera. The RP stated they came to the facility immediately after that to see what was going on. The RP said he/she asked the DON to contact Resident #1's doctor but the DON replied no. The RP stated, She [DON] refused everything I asked them to do. I asked what orders were in there by the doctor to help her with seizures and could she contact him if not. The RP said the DON told him/her that the doctor would see Resident #1 the next day because in her estimation, Resident #1 was still responsive because she responded to her name earlier, so it was not an emergency. The RP then stated, They are misleading and I specifically stated I'm call (911) since you've left [Resident #1] in a non-responsive state as if she's okay, and she wasn't.I will testify in a court of law that there was nothing done or even attempted, to settle my mind that they were truly assisting [Resident #1]. Review of AEM surveillance footage for Resident #1's room provided by the RP and time stamped 09/15/25 between 6:52 AM and 10:34 AM revealed the following:-At 6:52 AM, Resident #1 was observed awake in bed, alert and watching television. She used her left arm to adjust bed linens and extend her left leg toward the floor. Her right wrist appeared flexed inward. -At 7:04 AM, Resident #1 paused her movements, reclined her head and exhibited sudden stiffening of her left leg, left foot, left and right arms. Her eyes rolled upwards. -At 7:10 AM, Resident #1 appeared to be asleep.-Between 7:10 AM and 9:46 AM, Resident #1 remained in bed with no visible movement. -At 9:46 AM, foaming at the mouth was observed, with secretions visible along the right cheek. -At 10:10 AM, ADON D entered the room, called Resident #1's name, lowered the bed towards the floor and raised the HOB upright. She wiped Resident #1's mouth of secretions. Resident #1 exhibited minimal movement of the left hand. The ADON exited the room at 10:14 AM.-At 10:19 AM, ADON D and LVN G attempted to move Resident #1's arms; both were flaccid. -The final video segment at 10:34 AM showed LVN G and two additional unidentified staff in the room. Resident #1 remained on her left side, with continued foaming at the mouth along the right cheek. Hospital records were requested on 09/18/25 and 09/29/25 for Resident #1 from two different hospitals, one identified by the facility as the hospital to which Resident #1 was sent, and one identified by the RP as the hospital she reported the resident currently received treatment. As of 10/01/25, the records had not been received. [VT1] RESIDENT #2Record review of Resident #2's Face Sheet dated 09/19/25 reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her active diagnoses were listed as hyperlipidemia (abnormally high levels of fats in the blood) and diabetes (a chronic metabolic disorder characterized by elevated blood glucose levels due to impaired insulin production). Record review of Resident #2's e-chart reflected due to being a new admission, she did not have an MDS completed yet. Record review of Resident #2's initial care plan dated 09/15/25 reflected the following focus areas: 1. Focus: The resident is risk for falls [Date Initiated: 09/15/2025]; Interventions: Anticipate and meet the resident's needs, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, Educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, Encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, Ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in w/c[VT2] , Keep furniture in locked position, Keep needed items, water, etc., in reach, PT evaluate and treat as ordered or PRN, Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter/remove [VT3] any potential causes if possible. Educate resident/family/caregivers/IDT as to causes, Staff to assist with transfers, Fall r/t [VT4] weakness- send to ER, therapy notified, educated -falls-safety [revised 09/19/25], The resident needs a safe environment with: even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach) [Revised 09/19/25]2. The resident has a bruise [Start date 09/15/25]-Interventions: Attempt to determine the cause of the bruising, if known attempt to alleviate that factor, Monitor bruising every shift for 72 hours. Note color and characteristics. If negative changes report to the MD, Monitor for and treat pain as indicated.3) The resident has a skin tear, laceration, or abrasion [Date Initiated: 09/15/2025]-Interventions: The residents skin injury will resolve without complications, Assess reason for skin injury occurrence. Notify staff of cause; determine measures to prevent further skin injuries, Monitor and treat pain as indicated, Monitor the skin injury every shift for 72 hours. Assess for bleeding, signs of infection (increased redness, warmth, drainage, odor) Notify the MD for any negative changes, Perform any wound care as ordered. An interview with LVN G on 09/17/25 at 1:20 PM revealed she was not at the facility when Resident #2 fell and had to be sent to the ER, but came back the next day and there were no new orders or clinical documentation, so she did not know if Resident #2 sustained any injuries. LVN G stated if a resident came back from the hospital with no documentation, then the charge nurse would need to document it and report it to the nursing management who could follow up to obtain them. LVN G stated it was out the charge nurses' control if the resident came back with no hospital documentation and the nurse would not know what happened as a result. An interview and observation with Resident #2 on 09/17/25 at 1:30 PM revealed she was in a wheelchair by the nurses station with non-slip socks on. She was observed with a large fading greenish yellow bruise around her right eyebrow extending down into her right eyelid about three inches in diameter. Resident #2 had approximately a one-inch cut with stitches above her right eyebrow. She was verbal but not oriented to questions. When asked what happened to her right eye, she motioned towards the injury and said her [AGE] year-old sister scratched her but it did not hurt. She said what hurt was the other side of her head where two women had thrown rocks at her. She was unable to give any other details due to her limited cognition. An interview with CNA H on 09/19/25 at 1:45 PM revealed the day of Resident #2's fall, they were short-staffed one CNA that day and she heard Resident #2's family member yell out saying the resident had tripped and fallen. CNA H stated she was the first staff member to enter the her room and found her on the floor with blood coming from her head. CNA H and LVN B then got Resident #2 up and she had a gash above her eye with blood coming out. She said an ambulance was called and Resident #2 said her head was hurting. After she came back from the ER post fall, CNA H stated she had been different, calmer and not as erratic with behaviors as before. An interview with RN A on 09/20/25 at 8:57 AM revealed Resident #2 did not fall on her shift, but she heard about it. She did not feel Resident #2 was acting any different than her baseline since the fall. RN A stated when a resident hit their head, neurochecks were required to be completed. She said neurochecks were important because there could be an internal injury inside the head and it could become a serious problem. An interview with LVN B on 09/21/25 at 11:34 AM revealed she was in the med room when she heard Resident #2's family member calling out for help. LVN B went to see Resident #2 and found her moaning face down on the floor by the bathroom door with a gash on the right side of her forehead. The family member told LVN B that Resident #1 took another resident's walker and when the family member was putting it behind the nurses' station, the resident had the unwitnessed fall in her room. At that point, LVN B stated Resident #2's vitals were checked and the charge nurse assigned to her that shift was LVN F. LVN F came to Resident #2's room and assessed her and there did not appear to be any other injuries, however, due to the head wound and amount of blood, they wanted to send her out. LVN B stated Resident #2 came back from the ER right before her shift was over around 7:00 PM. She stated LVN F checked the resident's vitals and talked with the family and had her hospital paperwork. LVN B stated she helped by putting Resident #2 back into the e-charting system. LVN B stated the charge nurse working when Resident #2 came back from the ER was responsible for charting and doing neuros on her per protocol. LVN B stated the DON and ADON D were texting and calling her to come in during the past week to complete the risk management form (incident report). She told them she was not the nurse, it was LVN F. She said LVN F should have done an incident report that day for Resident #2. LVN B stated she did not know the facility's protocol for doing neurochecks on residents post-fall, including when to start them if they were sent out to the ER. LVN B said when a resident sustained a head strike from a fall, the charge nurse was supposed to do a risk assessment (incident report) and check if the resident took blood thinner medication, get vitals and call the physician and family to see if they want the resident sent out. LVN B stated when a resident hits their head, they could potentially have a brain bleed which could be fatal, so they should be monitored for three days. She said even if the resident was sent out and they returned within 72 hours, neurochecks still had to be completed. An interview with Resident #2's RP on 09/21/25 at 12:07 PM revealed the resident had dementia and when she was visiting her, she could not find her initially and then saw her a few doors down with another resident's walker. The RP stated Resident #2 did not use a walker for ambulation and she was holding the walker backwards, using it like she was driving a car. Resident #2 told the RP that she did not know whose walker it was but some guy was chasing her. The RP removed the walker and guided Resident #2 to her chair and went to place the walker behind the nurses' station. When she went back to Resident #2's room, she was on the floor. The RP started hollering for help and several staff showed up and checked for bleeding. The RP told them she wanted Resident #2 to go out to the ER. At the ER, Resident #2 received some stitches and her CT scan was clear. The RP stated she brought the ER discharge documentation and gave the originals to the evening charge nurse. An interview with the DON on 09/21/25 at 2:10 PM revealed she had located Resident #2's records from the facility's online hospital portal from the ER visit. She stated the hospital records had not been on Resident #2's chart. The DON stated that she had only started employment on 09/15/25 and she had not yet gotten around to seeing if the neurological assessments for Resident #2 were done post-fall. The DON stated neuros should be done for four days and there was a schedule the nursing staff had to follow that started off with 15-minute monitoring, then to one hour, then to once per shift. The DON stated the nurse who did record Resident #2's vitals on the e-transfer form stated the resident was stable when she was sent to the ER. Review of Resident #2's ER hospital records provided by the DON on 09/21/25 reflected the resident seen by the ER on [DATE] due to a head laceration and a head injury from a fall. She had a diagnosis of a closed head injury and a facial laceration. Resident #2 had a CT cervical spine without contrast and a CT head without contrast. Resident #2 had ice applied to the affected area and was given Lidocaine-Epinephrine. The after-visit summary was completed at 2:56 pm on 09/14/25. An interview with LVN F on 09/21/25 at 2:36 PM revealed she was a PRN nurse who worked primarily on the weekends. For a resident who had a fall with a head strike, LVN F stated she would assess the resident for injuries and start neurochecks on them every 15 minutes until they were sent out to the hospital. She stated neurochecks included looking at the eyes to see if they were equal and reactive, checking if a resident could squeeze the nurse's hand and with what force, and if the resident was alert and oriented. LVN F stated she had not seen what neurochecks looked like for the facility's residents. She stated, I actually have not seen one [neuro eval] per say, but I know there are questions pertaining to the neurological in the system itself. I am just learning [online e-charting system]. LVN F stated if neurochecks were not completed after a head strike, a resident could become comatose and the nurse would not be aware when their consciousness slipped if we are not on top of that. LVN F said she was present when Resident #2 fell. She said that day she was working with two CNAs in another resident's room when she could hear the Resident's RP screaming that the resident was on the floor. LVN F entered the room and saw Resident #2 had hit her head on the right side of her forehead on the wooden dresser and her arm was bent in the back position and she was moaning in discomfort. LVN F stated Resident #2 never lost consciousness but was in a chronic state of dementia and due to the heavy bleeding coming from the wound, she called 911 to have her sent to the ER. LVN F stated another nurse named [LVN B] did the incident report for her because she was not as comfortable with the online charting as LVN B was. Also, LVN F stated, I didn't know what to look for in order to generate the report. When Resident #2 came back fro

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident received and was provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care to include but not limited to, the prevention and treatment of mental and substance use disorders for one (Resident #3) of three residents reviewed for behavioral health care. The facility failed to assess, monitor and implement appropriate behavioral health interventions for Resident #3, who lived with bipolar disorder and dementia and repeatedly refused prescribed psychotropic medications.The facility failed to ensure Resident #3's care plan was revised or initiated timely psychological or psychiatric services in response to the refusals. As a result, Resident #3's behaviors escalated, leading to physical aggression towards another resident on 09/19/25 and subsequent transfer to an inpatient hospital for stabilization. An Immediate Jeopardy (IJ) situation was identified on 09/21/25. While the IJ was removed on 09/23/25, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm, due to the facility needing to evaluate the effectiveness of their corrective systems. Findings include: Record review of Resident #3's face sheet, dated 09/21/24, reflected a [AGE] year-old female who admitted to the facility on [DATE]. Her active diagnoses included cognitive communication deficit (Impairment in communication abilities due to deficits in attention, memory or other cognitive processes), dementia with behavior disturbance (progressive cognitive decline accompanied by agitation, aggression or other behavioral symptoms), bipolar disorder (a mental health condition marked by alternating periods of depression and elevated mood/mania or hypomania), major depressive disorder (mood disorder involving persistent sadness, loss of interest and impaired daily functioning) and insomnia (persistent difficulty staying asleep). Resident #1 had two family members listed as her emergency contacts. Record review of Resident #3's admission MDS Assessment, dated 08/06/25, reflected she had a BIMS score of 01, which indicated severe cognitive impairment. Resident #3 sometimes understood others and sometimes made herself understood. She had no signs/symptoms of delirium and no negative mood problems. Resident #3 had no potential indicators of psychosis (a mental health condition characterized by a loss of contact with reality, leading to distorted perceptions, beliefs, and behaviors), which included hallucinations and delusions. Resident #3 had no behavioral symptoms indicated on her MDS assessment and no wandering or rejection of care. Resident #3's activity preferences that were very important and included, having books/newspapers/magazines, being around people and pets, doing favorite activities, going outside to get fresh air when the weather is good and participate in religious services or practices. Record review of Resident #3's care plan, initiated 08/02/25, reflected the following focus areas were added after the resident-to resident behavioral aggression incident on 09/18/25: 1) [Resident #3] has Bipolar Disorder [Date Initiated: 09/18/25]; 2) The resident has a history of trauma that may have a negative impact. The trauma is r/t: Resident to resident encounter [Date initiated 09/18/25];3) [Resident #3] is at risk for wandering- disoriented to place [Date Initiated: 09/19/2025]; 4) [Resident #3] has potential to demonstrate physical behaviors-Poor impulse control [Date Initiated: 09/19/2025]; 5) [Resident #3] has potential to demonstrate physical behavior- Poor impulse control [Date Initiated: 09/19/2025]; 6) [Resident #3] has potential to demonstrate verbally abusive behaviors-Dementia, Mental / Emotional illness [Date Initiated: 09/18/2025]; Resident #3's care plan did not discuss a focus area related to Resident #3's medication refusals. Record review of Resident #3's Physician Order Summary for September 2025 reflected she was prescribed, Buspirone 10mg once a day related to bipolar disorder, current mixed episode (start date 07/26/25, discontinued 09/11/25), Lamictal 25 mg twice a day related to bipolar disorder (start date 07/26/25), Trazadone 100 mg at bedtime related to insomnia (start date 07/26/25), Memantine 10 mg once a day for unspecified dementia with behavioral disturbance (start date 07/26/25 and Aricept 5 mg at bedtime for dementia (start date 07/26/25). Additionally, there was an order dated 07/30/25 to refer Resident #3 for in-house psychiatric and counseling services. On 09/19/25, there was a physician's order which stated, Send to ER for Psyche Evaluation. Record review of Resident #3's August 2025 MAR reflected documented refusals of the following medications: -Buspirone was refused 18 times: (August 2nd ,3rd ,7th ,9th ,10th-13th, 15th-17th, 20th, 21st, 25th, 26th, 29th-31st).-Lamictal was refused 18 times (August 1st, 3rd, 4th, 6th, 8th, 9th, 11th-13th, 15th-23rd) on the AM dose and 16 times (August 2nd, 3rd, 7th, 11th-13th,15th-17th, 20th ,21st, 25th, 26th, 29th-31st) on the PM dose.-Trazadone was refused 16 times (August 2nd, 3rd, 7th, 11th, 12th, 13th, 15th-17th, 20th, 21st, 25th, 26th, 29th-31st).-Memantine was refused 23 times (August 1st, 3rd, 4th, 6th, 8th, 9th, 11th-13th,15th-23rd, 25th-27th, 29th-31st). Record review of Resident #3's September 2025 MAR reflected documented refusals of the following medications:-Buspirone was refused nine times (September 1st, 3rd, 5th-11th). The medication was documented as discontinued on the MAR on 09/11/25 at 12:47 PM. -Lamictal was refused 16 times (September 1st, 3rd, 5th-13th, 15th-19th) on the AM shift and seven times of the PM shift (September 3rd, 4th,7th-9th, 14th and 18th).-Trazadone was refused seven times (September 3rd, 4th, 7th, 8th, 9th, 14th and 18th).-Memantine was refused 15 times (September 1st, 3rd, 5th, 6th, 8th-13th, 15th-19th). Record review of Resident #3's e-administration medication notes starting 08/22/25 through 09/19/25 reflected the main reasons for refusals of medications were because the resident did not think she needed them. Record review of NP K's progress notes (extender for MD J) reflected she saw Resident #3 twice when she first admitted to the facility on [DATE] and 07/30/25. On 07/28/25, NP K documented, Plan:.Monitor for changes in mood or behaviors, refer to psyche for support, monitor for changes in neuro or functional status, does not take routine medications. On 07/30/25, NP K documented the exact same verbiage during the visit. Record review of Resident #3's clinical chart reflected she was seen by MD J on 08/05/25 which reflected, Continue present medication management, we will collaborate with psychiatry services. MD J stated he was unable to complete a full assessment due to Resident #3 having an angry demeanor, cognitive deficits and refusals to engage with him. Record review of Resident #3's e-clinical chart to include all provider progress notes reflected she was not seen by the facility's contracted psych services until 08/25/25. During that visit, the PMHNP reflected Resident #3 was seen for confusion, dementia, depression/sadness, resistance to care or ADLs/meds and insomnia and bipolar disorder. The PMHNP stated, The patient's psychotropic medication is beneficial in this case to control their psychiatric symptoms and to manage the patient's condition, to prevent relapse of hospitalization and to improve restorative potential. The assessment further stated, Patient reports I am doing fine. Staff report there are no issues.Plan: Patient will continue with current medications. The Treatment Plan of Care recommendations included, Ongoing medication management and behavioral management techniques to include reduction in psychotic thinking, stabilization of anxious/irritable mood and stabilization of cognitive problems. The PMHNP reflected Resident #3 had the capacity to participate in treatment and future visits were recommended one to four times a month and treatment was recommended for six months. Record review of nursing progress notes related to Resident #3's behaviors included on 08/28/25, 09/08/25 she refused to take medications. On 09/08/25, Resident #3 slapped a staff who tried to help her find a jacket, then later that day she tried to block a resident from wheeling himself to the dining room. On 09/11/25, Resident #3 was documented as being aggressive and scratched an aide's hand which the aide was trying to stop her from taking other residents' belongings. On 09/14/25, Resident continues with confusion-wandering and taking food off of other residents' tray.Resident came to nurse's station and just started yelling at the staff but was not making any sense - resident was redirected and taken back to her room.Resident is going into other residents' rooms and taking their things - claiming their items as her own - nurse asked her to stop which made the resident angry and she tried to throw a bottle of body wash at this nurse - nurse was able to deescalate the situation and walked away [LVN B]. A CMP and CMP Lab was ordered on 09/18/25 as well as a Lamictal lab. Family notification was documented as attempted with no success. On 09/18/25, Resident #3 also was documented as being aggressive towards another resident in the dining room during breakfast and refused all medications. PA E was notified of the refusals and order to continue to offer resident her medications, responsible party was notified. On 09/18/25, Resident #3 refused her PM medications, became aggressive towards another resident trying to grab the blanket wrapped around the other resident, and then sat on the floor and stated she was mad at ADON D for trying to make her go to her room. The next day on 09/19/25, Resident #3 was noted by the DON to be in the dining room and appeared guarded, uncooperative with cues and not rational, hyperactive and rapidly talking, her mood is anxious with flight of ideas, she continues to be interjecting others and with poor insight to current situations, she is being offered activities, hydration.Resident is very combative to staff and other residents.Resident continues to refuse medication. MD made aware of concerns. Unable to reach family members. ADON D wrote a nursing note on 09/19/25 that reflected Resident #3 was transferred to the hospital for behaviors per PA E for refusing medications, refusing care and being combative. Record review of Resident #3's SW progress note, dated 09/11/25, reflected an attempt was made to contact Resident #3's family member to provide updates on the resident's care and overall well-being. On 09/18/25, a SW progress note reflected a voicemail was left informing the resident's emergency contact that referrals were sent to other facilities with memory care units to better meet the resident's evolving needs. Record review of a Behavior Event Nurses' Notes, dated 09/18/25 at 2:48 PM, written by a Corporate Compliance Nurse reflected a verbal behavioral event occurred in the dining room where Resident #3 was waving a fork in the air, rambling loudly incoherent words at the table with another resident. Neither resident made physical contact with each other. Resident #3's cognition/behavior at the time of the incident was documented as cognitive impairment, refuses to call for assistance, requires cueing, resists redirection, new or increased confusion, combative, agitated, restless. There were no injuries to Resident #3 or the other resident. Resident #3 was noted to be removed from the dining room and redirected back to her room to rest. She was assessed and placed on checks every 15 minutes. Resident #3 was incoherently mumbling, unable to discern words and did not make a statement about the event. The MD and the primary emergency contacts were notified of the incident on 09/18/25 at 2:30 PM. An interview with RN A on 09/20/25 at 8:57 AM revealed if a resident refused to take medications, the med aides and charge nurses should wait a few minutes and try again. If three attempts were unsuccessful, the physician had to be notified, Because we keep these meds for a reason, so if they are not taking them, then that problem isn't being taken care of and maybe the doctor can give an alternative. RN A stated Resident #3 always refused medications and her compliance was unpredictable, like sometimes she would take night meds but not the morning meds. RN A stated Resident #3 was sent out the day before on 09/19/25 and it was reported the resident was being aggressive. An interview with LVN B on 09/21/25 at 11:34 AM revealed when a resident refused medications, the charge nurse should try several attempts and then see if another nurse could convince the resident to take it. If still refusing, the charge nurse should notify the family and physician. LVN B stated since Resident #3 admitted , the resident had never taken any medications from LVN B, she always refused. LVN B stated she last worked with Resident #3 two weeks prior and remembered she was acting weirder than normal, like taking things from people's rooms. She said if staff looked at Resident #3 a certain way or asked her too many questions, she would get upset. LVN B stated she was telling other staff and management about the behaviors but did not know if any follow up was done. LVN B stated if Resident #3 did not take her prescribed medications, it could cause her to become more aggressive and make the dementia worsen. LVN B stated she documented the refusal of medications in Resident #3's progress notes and MD J knew of her behaviors. LVN B said the psychiatrist during a visit mentioned adding more medication to her orders, but LVN B had to explain the resident did not take medications so it would not make sense to change her meds around. LVN B stated she never figured out how to get Resident #3 to take her medications and the resident would often tell her she was healthy and did not need them. LVN B stated if Resident #3's medication refusals were not addressed, her aggressive behaviors could result in self-injury, hurting others, and she would slowly lose her ability to talk. An interview with Resident #3's family member and secondary emergency contact on 09/21/25 at 10:25 AM revealed she did not know the facility sent the resident to a psych hospital for evaluation. She stated on Thursday-09/18/25, the BOM called to see if she knew how to contact Resident #1's primacy emergency contact because he had not called her back. The family member stated there was some negative energy between Resident #1 and that family member as she felt he had stuck her in a nursing home and took away her independence. The family member stated Resident #1 had lived prior to last year in an apartment on her own, with an emotional support service dog and had a caregiver that came in every day to care for her and ensure she was taking her medications. She stated living in a nursing home was the last thing Resident #3 ever wanted and that family member used the threat of putting her in a nursing home as a way to punish her. As a result, the resident was upset about her living situation. The family member stated Resident #3 lived with bipolar disorder from a young age and began treating it with medications when she was in her mid-20's. The family member said, Her temper is terrible since she was a kid, she will get mouthy, hurt your feelings, but would settle down after a few days. She said if Resident #3 did not take her medications for bipolar disorder, she would become agitated and angry. She stated Resident #3 had a history of not taking her medications and a misconception she thought was fine and had been an issue when she lived at home independently. The family member stated with Resident #3's dementia and bipolar disorder, the things that made her happy would be music, specifically country western and gospel. She also said just talking to the resident to get her onto a different topic and taking her outside because she loved plants and flowers. The family member stated, Also being kind.you have to learn to work with her, you get her to do things, but you want to make her think she is doing it because she likes to have control of her decisions and wants to be as independent as possible. The family member stated Resident #3 always was a social person, and sometimes would join games, do activities and reading if she could concentrate, and if there was a pastor or church services she would enjoy that as well for relaxation. The family member stated no one from the facility notified her Resident #3 had been refusing her medications consistently since she was admitted to the facility. The family member stated, I would have been very upset if I would have known they were letting her get by with refusing and I am surprised with those medications.it is not like they are vitamins or over the counter meds, those are for bipolar, thyroid and dementia. She said the resident could not be off them for long before they would, mess her up and she would not make good decisions. An interview with the DON on 09/21/25 at 3:10 PM revealed she was not aware of Resident #3's medication refusals since admission as she had just started employment on 09/15/25. She stated at some point during her first week, she remembered ADON D reported Resident #1 had some behaviors and was not taking her medications. She stated on Tuesday, 09/16/25, she saw Resident #3 calm drinking coffee and talking to herself in third person. She said two days later, on 09/18/25, was when things worsened and she tried to take a blanket from another resident while she was holding a fork in her hand and stemming. The DON stated the facility asked for labs and got them ordered, but it was decided she needed to be sent out on 09/19/25. The DON stated she looked at Resident #3's chart and did not see a psych evaluation, so she called the contracted company who said they saw the resident once on 08/25/25 for what the DON thought was her initial visit. She said going forward, the facility was going to notify the physician and RP of any residents' medication refusals and after three days, the facility would initiate a psych eval for that resident. If that was not possible, then the DON stated they would send the resident out for a psych evaluation. She stated she did not know what the process was prior to her becoming the DON. The DON stated if Resident #3 did not take her prescribed dementia-related and psychotropic medications, It could make her go into many stages and escalate, not just towards the residents, staff.anyone. An interview with CCN K on 09/22/25 at 8:06 PM revealed she did not know about Resident #3's medication refusals and escalating behaviors. She stated her expectation was if there was a resident with continuous medication refusals, the family and MD should be notified to see if there were alternate interventions. CCN K stated if Resident #3 had dementia, then psych should have been seeing her. CCN K stated sometimes a facility could do a Negotiated Risk Assessment (a written contract in long-term care settings that documents a resident's informed decision to accept a specific safety or health risk, such as the risk of falls, despite being aware of the potential consequences) if a resident was non-compliant with medications, It lets them [family] know this can happen. An interview with SW C on 09/23/25 at 10:13 AM revealed she knew Resident #3 had been refusing her medications since she first admitted . She stated Resident #3 had verbal behaviors more than anything and was easily irritated and she did not know what her triggers were. She stated the resident was not aggressive towards self, staff or other residents as far as she knew. If a resident with dementia or psych concerns refused medications, SW C said it would be the nursing staff who would need to address it and notify the resident's emergency contact. SW C stated she did not recommend any interventions when Resident #3 began refusing her medications. She said the nurses were in charge of ensuring residents received psychiatric services and SW C did not communicate any issues with the PMHNP related to Resident #3. SW C stated when Resident #3 began having increased behaviors, she tried to reach out to her EC but was only able to leave a voice mail. SW C stated she was not included in the decision to send Resident #3 to a psych hospital. She said normally the nursing staff would ask her if she saw a change in condition or any incidents, but ultimately that would be up to nursing staff for an evaluation. SW C stated Resident #3 was sent out, based on mood and behaviors. Record review of the facility's, undated, policy titled, Behavioral Health reflected, Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.Individualized Assessment and Person-Centered Planning: In addition to the facility-wide approaches that address residents' emotional and psychosocial well-being, the facility will ensure that residents' individualized behavioral health needs are met.It is also important for the facility to use an interdisciplinary team (IDT) approach that includes the resident, their family, or resident representative. This was determined to be an Immediate Jeopardy (IJ) on 09/21/25 at 3:35 PM. The R-AD and DON were notified. The R-AD and DON were provided with the IJ template on 09/21/25 at 4:38 PM. The following Plan of Removal submitted by the facility was accepted on 09/22/25 at 9:22 PM: Date: 9/21/25-Plan of Removal-F740 Behavioral Health Services Resident#3 refused dementia and psychotropic medication. There were no care planned interventions addressing refusals. The resident experienced escalated behaviors and was transferred to the psychiatric hospital on 9/19/25. Interventions: 1. Resident #3 was admitted to the hospital on [DATE]. Resident #3 remains in the hospital as of 9/21/25. 2. All residents on dementia and psychotropic medications were reviewed by the Regional Compliance Nurse, DON, and ADON for any refusals for 3 or more consecutive days. The attending physician and psychiatrist will be notified for any medication refusals of three or more consecutive days. Orders received for medication refusals will be implemented by DON and Charge Nurse. Completion date 9/22/25. 3. The psychiatric and psychology providers will be notified by the Regional Compliance Nurse and DON to review all residents on services to ensure visits and appropriate treatments are being provided to each resident. Psychiatric/psychological services will be notified of any residents who refuse psychotropic medication. Completion date 9/22/25. 4. All residents on psychiatry and psychological services will have their care plans reviewed by the Regional Compliance Nurse, DON, and MDS Nurse for appropriate interventions are in place to address medication refusals and history of behaviors. Updating care plans going forward will be an interdisciplinary approach by the DON, ADON, and/or MDS Nurse. Completion date 9/22/25. 5. New Process: The DON/ADON/Designee will review the 24hr report and PCC for changes in condition such as escalating behaviors and medication refusals 7 days per week. The medication administration report will also be reviewed during this process 7 days per week to ensure all medications have been administered as ordered. Notifications to MD/RP will be made for 3 consecutive days or more of medication refusals and/or escalating behaviors. MD orders will be implemented by the charge nurse or designee immediately. The care plan will be updated by the DON, ADON, or MDS Nurse. Completion date 9/22/25. 6. The Admin, DON and ADON were in-serviced 1:1 by the Regional Compliance Nurse and Area Director. Completed 9/18/25. A. Notification of Change in Condition Policy: Notifications to the MD/RP will also include medication refusals of 3 or more consecutive days, increased or escalating behaviors. B. Behavior Management Policy- to importance of providing necessary behavioral health care services, pharmacological/non-pharmacological interventions to attain or maintain the highest mental and psychosocial well-being according to plan of care. C. Care Plan Policy- to include that all residents should have in place a person-centered care plan with interventions that address areas that include but are not limited to- resident's physical needs, psychosocial needs, behavioral health care services, non-compliance with care, and behaviors. 7. The medical director was notified of the immediate jeopardy citation by the administrator on 9/18/25 and 9/21/25. 8. An ADHOC QAPI meeting was held with interdisciplinary team including the medical director to discuss the immediate jeopardy and plan of removal. Completed on 9/21/25. In-services: 1. The following in-services were initiated by Administrator, Regional Compliance Nurse, DON, ADON to all charge nurses. All charge nurses not present or in-serviced as of 9/21/25 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency, or nurses on leave will in serviced prior to assuming their next assignment. Completion date 9/21/25.A. Notification of Change in Condition Policy: Notifications to the MD/RP will also include medication refusals of 3 or more consecutive days, increased or escalating behaviors. B. Behavior Management Policy- to importance of providing necessary behavioral health care services, pharmacological/non-pharmacological interventions to attain or maintain the highest mental and psychosocial well-being according to plan of care. C. Care Plan Policy- to include that all residents should have in place a person-centered care plan with interventions that address areas that include but are not limited to- resident's physical needs, psychosocial needs, behavioral health care services, non-compliance with care, and behaviors. Monitoring the Plan of Removal implementation occurred on 09/21/25, 09/22/25 and 09/23/25 through daily onsite visits. Facility monitoring activities included review of 24-hour reports, risk management logs, medication refusal logs, behavior monitoring logs and care plan revisions to ensure interventions were implemented for residents with behavioral health needs. Record reviews for additionally sampled residents with psychotropic medication refusals to verify the assessments, physician notifications, psychiatric referrals and care plan updated were completed. No concerns were noted. Record review of staff in-services conducted on 09/21/25, 09/22/25 and 09/23/25 for nursing staff to reinforce behavioral health policies and notification procedures for physician and psychiatric services reflected that training was completed for all shifts and addressed required documentation, behavioral health concerns and notification procedures. Interview with twenty nursing staff were conducted on 09/21/25, 09/22/25 and 09/23/25 across all shifts (RN A, LVN B, DON, ADON D, LVN F, CCN K, CNA H, MA J, R-AD, CNA L, CNA M, LVN N, CNA O, CNA P, RN Q, LVN R, CNA S, CNA T, CNA U and LVN V. All staff interviewed were able to verbalize the facility's procedures for identifying and documenting medication refusals, to include immediate notification of the charge nurse, documentation in the medication administration record and timely notification to the physician and psychiatric provider. Staff also verbalized the process for escalating behavioral changes, including notifying supervisory staff, initiating behavior monitoring and contacting psychiatric services as needed. Record review of the facility's Ad HOC QAPI meeting on 09/21/25 was conducted to review the facility progress, monitor for additional resident medication refusals or escalations, and verify interventions and physician/psychiatric notifications were completed timely. The R-AD was informed the Immediate Jeopardy was removed on 09/23/25 at 11:55 AM. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and at a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental and psychosocial well-being for one of three residents (Resident #3) reviewed for dementia care. The facility failed to ensure Resident #3 received the appropriate treatment and services for her dementia diagnoses. Resident #3's behavior escalation resulted in a physical aggression incident on 09/19/25 towards another resident and subsequent transfer to an inpatient psychiatric hospital for further evaluation. An Immediate Jeopardy (IJ) situation was identified on 09/21/25. While the IJ was removed on 09/23/25, the facility remained out of compliance at a scope of a pattern with the potential for more than minimal harm, due to the facility's need evaluate the effectiveness of the corrective systems. This failure could place residents at risk for untreated dementia symptoms and behavior escalation, aggression towards residents and staff, physical altercations, injuries, worsening cognitive decline, psychiatric destabilization and the need for emergency interventions such as hospitalization. Findings include: Record review of Resident #3's Face Sheet dated 09/21/24 reflected she was a [AGE] year-old female who admitted to the facility on [DATE]. Her active diagnoses included cognitive communication deficit (Impairment in communication abilities due to deficits in attention, memory or other cognitive processes), dementia with behavior disturbance (progressive cognitive decline accompanied by agitation, aggression or other behavioral symptoms), bipolar disorder (a mental health condition marked by alternating periods of depression and elevated mood/mania or hypomania), major depressive disorder (mood disorder involving persistent sadness, loss of interest and impaired daily functioning) and insomnia (persistent difficulty staying asleep). Resident #1 had two family members listed as her emergency contacts. Record review of Resident #3's admission MDS assessment dated [DATE] reflected she had a BIMS score of 01, which indicated severe cognitive impairment. Resident #3 sometimes understood others and sometimes made herself understood. She had no signs/symptoms of delirium and no negative mood problems. Resident #3 had no potential indicators of psychosis, which included hallucinations and delusions. Resident #3 had no behavioral symptoms indicated on her MDS assessment and no wandering or rejection of care. Resident #3's activity preferences that were very important and included, having books/newspapers/magazines, being around people and pets, doing favorite activities, going outside to get fresh air when the weather is good and participate in religious services or practices. Record review of Resident #3's care plan, initiated 08/02/25, reflected the following focus areas were added after the resident-to resident behavioral aggression incident on 09/18/25: -[Resident #3] is at risk for wandering- disoriented to place [Date Initiated: 09/19/2025]; -[Resident #3] has potential to demonstrate physical behaviors-Poor impulse control [Date Initiated: 09/19/2025]; -[Resident #3] has potential to demonstrate physical behavior- Poor impulse control [Date Initiated: 09/19/2025]; -[Resident #3] has potential to demonstrate verbally abusive behaviors-Dementia, Mental / Emotional illness [Date Initiated: 09/18/2025]; Resident #3's care plan did not discuss Resident #3's medication refusals and did not address her dementia and related behavioral interventions. Record review of Resident #3's Physician Order Summary for September 2025 reflected she was prescribed, Memantine 10 mg once a day for unspecified dementia with behavioral disturbance (start date 07/26/25) and Aricept 5 mg at bedtime for dementia (start date 07/26/25). Additionally, there was an order dated 07/30/25 to refer Resident #3 for in-house psychiatric and counseling services. On 09/19/25, there was a physician's order which stated, Send to ER for Psyche Evaluation. Record review of Resident #3's August 2025 MAR reflected documented refusals of the following medications: -Aricept was refused 18 times (August 2nd, 3rd, 7th, 9th-13th, 15th-17th, 20th, 21st, 25th, 26th, 29th-31st)-Memantine was refused 23 times (August 1st, 3rd, 4th, 6th, 8th, 9th, 11th-13th,15th-23rd, 25th-27th, 29th-31st). Record review of Resident #3's September 2025 MAR reflected documented refusals of the following medications:-Aricept was refused five times (September 3rd, 4th, 7th, 8thand 9th) -Memantine was refused 15 times (September 1st, 3rd, 5th, 6th, 8th-13th, 15th-19th). Record review of Resident #3's e-administration medication notes, starting 08/22/25 through 09/19/25, reflected the main reasons for refusals of medications were because the resident did not think she needed them. Record review of NP K's progress notes (extender for MD J) reflected she saw Resident #3 twice when she first admitted to the facility on [DATE] and 07/30/25. On 07/28/25, NP K documented, Plan:.Monitor for changes in mood or behaviors, refer to psyche for support, monitor for changes in neuro or functional status, does not take routine medications. On 07/30/25, NP K documented the exact same verbiage during the visit. Record review of Resident #3's clinical chart reflected she was seen by MD J on 08/05/25 which reflected, Continue present medication management, we will collaborate with psychiatry services. MD J stated he was unable to complete a full assessment due to Resident #3 having an angry demeanor, cognitive deficits and refusals to engage with him. Record review of Resident #3's e-clinical chart to include all provider progress notes reflected she was not seen by the facility's contracted psyche services until 08/25/25. During that visit, the PMHNP reflected Resident #3 was being seen for confusion, dementia, depression/sadness, resistance to care or ADLs/meds and insomnia and bipolar disorder. The PMHNP stated, The patient's psychotropic medication is beneficial in this case to control their psychiatric symptoms and to manage the patient's condition, to prevent relapse of hospitalization and to improve restorative potential. The assessment further stated, Patient reports I am doing fine. Staff report there are no issues.Plan: Patient will continue with current medications. The Treatment Plan of Care recommendations included, Ongoing medication management and behavioral management techniques to include reduction in psychotic thinking, stabilization of anxious/irritable mood and stabilization of cognitive problems. The PMHNP reflected Resident #3 had the capacity to participate in treatment and future visits are recommended one to four times a month and treatment was recommended for six months. Record review of nursing progress notes related to Resident #3's behaviors included on 08/28/25, 09/08/25 she refused to take medications. On 09/08/25, Resident #3 slapped a staff who tried to help her find a jacket, then later that day she tried to block a resident from wheeling himself to the dining room. On 09/11/25, Resident #3 was documented as being aggressive and scratched an aide's hand which the aide was trying to stop her from taking other residents' belongings. A few days later on 09/14/25, Resident continues with confusion-wandering and taking food off of other residents' tray.Resident came to nurse's station and just started yelling at the staff but was not making any sense - resident was redirected and taken back to her room.Resident is going into other residents' rooms and taking their things - claiming their items as her own - nurse asked her to stop which made the resident angry and she tried to throw a bottle of body wash at this nurse - nurse was able to deescalate the situation and walked away [LVN B]. A CMP and CMP Lab was ordered on 09/18/25 as well as a Lamictal lab. Family notification was documented as attempted with no success. On 09/18/25, Resident #3 also was documented as being aggressive towards another resident in the dining room during breakfast and refusing all medications. PA E was notified of the refusals and order to continue to offer resident her medications, responsible party was notified. Later that day on 09/18/25, Resident #3 refused her PM medications, became aggressive towards another resident trying to grab the blanket wrapped around the other resident, and then sat on the floor and stated she was mad at ADON D for trying to make her go to her room. The next day on 09/19/25, Resident #3 was noted by the DON to be in the dining room and appeared guarded, uncooperative with cues and not rational, hyperactive and rapidly talking, her mood is anxious with flight of ideas, she continues to be interjecting others and with poor insight to current situations, she is being offered activities, hydration.Resident is very combative to staff and other residents.Resident continues to refuse medication. MD made aware of concerns. Unable to reach family members. ADON D wrote a nursing note on 09/19/25 that reflected Resident #3 was transferred to the hospital for behaviors per PA E for refusing medications, refusing care and being combative. Record review of Resident #3's SW progress note dated 09/11/25 reflected an attempt was made to contact Resident #3's son to provide updates on the resident's care and overall well-being. On 09/18/25, a SW progress note reflected a voicemail was left informing the resident's emergency contact that referrals had been sent to other facilities with memory care units to better meet the resident's evolving needs. Record review of a Behavior Event Nurses' Notes dated 09/18/25 at 2:48 PM written by a corporate compliance nurse reflected a verbal behavioral event occurred in the dining room where Resident #3 was waving a fork in the air, rambling loudly incoherent words at the table with another resident. Neither resident made physical contact with each other. Resident #3's cognition/behavior at the time of the incident was documented as cognitive impairment, refuses to call for assistance, requires cueing, resists redirection, new or increased confusion, combative, agitated, restless. There were no injuries to Resident #3 or the other resident. Resident #3 was noted to be removed from the dining room and redirected back to her room to rest. She was assessed and placed on checks every 15 minutes. Resident #3 was incoherently mumbling, unable to discern words and did not make a statement about the event. The MD and the primary emergency contacts were notified of the incident on 09/18/25 at 2:30 PM. An interview with RN A on 09/20/25at 8:57 AM revealed if a resident refused to take medications, the med aides and charge nurses should wait a few minutes and try again. If three attempts are unsuccessful, the physician had to be notified, Because we keep these meds for a reason, so if they are not taking them, then that problem isn't being taken care of and maybe the doctor can give an alternative. RN A stated Resident #3 had always refused medications and her compliance was unpredictable, like sometimes she would take night meds but not the morning meds. RN A stated Resident #3 had been sent out the day before on 09/19/25 and it was reported the resident was being aggressive. An interview with LVN B on 09/21/25 at 11:34 AM revealed when a resident refused medications, the charge nurse should try several attempts and then see if another nurse could convince the resident to take it. If still refusing, the charge nurse should notify the family and physician. LVN B stated since Resident #3 admitted , the resident had never taken any medications from LVN B, she always refused. LVN B stated she last worked with Resident #3 two weeks prior and remembered she was acting weirder than normal, like taking things from people's rooms. She said if staff looked at Resident #3 a certain way or asked her too many questions, she would get upset. LVN B stated she had been telling other staff and management about the behaviors but did not know if any follow up was done. LVN B stated if Resident #3 did not take her prescribed medications, it could cause her to become more aggressive and make the dementia worsen. LVN B stated she documented the refusal of medications in Resident #3's progress notes and MD J knew of her behaviors. LVN B said the psychiatrist during a visit mentioned adding more medication to her orders, but LVN B had to explain that the resident did not take medications so it would not make sense to change her meds around. LVN B stated she had never figured out how to get Resident #3 to take her medications and the resident would often tell her she was healthy and did not need them. LVN B stated if Resident #3's medication refusals were not addressed, her aggressive behaviors could result in self-injury, hurting others, and she would slowly lose her ability to talk. An interview with Resident #3's family member and secondary emergency contact on 09/21/25 at 10:25 AM revealed she did not know the facility sent the resident to a psyche hospital for evaluation. She stated on Thursday-09/18/25, the BOM called to see if she knew how to contact Resident #1's primacy emergency contact because he had not called her back. The family member stated there was some negative energy between Resident #3 and that family member as she felt he had stuck her in a nursing home and taken away her independence. The family member stated Resident #3 had lived prior last year in an apartment on her own, with an emotional support service dog and had a caregiver that came in every day to care for her and ensure she was taking her medications. She stated living in a nursing home was the last thing Resident #3 ever wanted and that family member used the threat of putting her in a nursing home as a way to punish her. As a result, the resident was upset about her living situation. The family member stated Resident #3 lived with bipolar disorder from a young age and began treating it with medications when she was in her mid-20's. The family member said, Her temper is terrible since she was a kid, she will get mouthy, hurt your feelings, but would settle down after a few days. She said if Resident #3 did not take her medications for bipolar disorder, she would become agitated and angry. She stated Resident #3 had a history of not taking her medications and a misconception that she thought she was fine and that had been an issue when she lived at home independently. The family member stated with Resident #3's dementia and bipolar disorder, the things that have made her happy would be music, specifically country western and gospel. She also said just talking to the resident to get her onto a different topic and taking her outside because she loved plants and flowers. The family member stated, Also being kind.you have to learn to work with her, you get her to do things but you want to make her think she is doing it because she likes to have control of her decisions and wants to be as independent as possible. The family member stated Resident #3 had always been a social person, sometimes would join games, do activities and reading if she can concentrate, and if there was a pastor or church services she would enjoy that as well for relaxation. The family member stated no one from the facility notified her that Resident #3 had been refusing her medications consistently since she was admitted to the facility. The family member stated, I would have been very upset if I would have known they were letting her get by with refusing and I am surprised with those medications.it is not like they are vitamins or over the counter meds, those are for bipolar, thyroid and dementia. She said the resident could not be off them for long before they would, mess her up and she would not make good decisions. An interview with the DON on 09/21/25 at 3:10 PM revealed she was not aware of Resident #3's medication refusals since admission as she had just started employment on 09/15/25. She stated at some point during her first week, she remembered ADON D reported that Resident #1 was having some behaviors and not taking her medications. She stated on Tuesday 09/16/25, she saw Resident #3 calm drinking coffee taking to herself in third person. She said two days later, on 09/18/25 was when things worsened and she tried to take a blanket from another resident while she was holding a fork in her hand and stemming. The DON stated the facility asked for labs and got them ordered, but it was decided she needed to be sent out on 09/19/25. The DON stated she looked at Resident #3's chart and did not see a psyche evaluation, so she called the contracted company who said they did see the resident once on 08/25/25 for what the DON thought was her initial visit. She said going forward, the facility was going to notify the physician and RP of any residents' medication refusals and after three days, the facility would initiate a psyche eval for that resident. If that was not possible, then the DON stated they would send the resident out for a psyche evaluation. She stated she did not know what the process was prior to her becoming the DON. The DON stated if Resident #3 did not take her prescribed dementia-related and psychotropic medications, It could make her go into many stages and escalate, not just towards the residents, staff.anyone. An interview with CCN K on 09/22/25 at 8:06 PM revealed she did not know about Resident #3's medication refusals and escalating behaviors. She stated her expectation was if there was a resident with continuous medication refusals, the family and MD should be notified to see if there were alternate interventions. CCN K stated if Resident #3 had dementia, then psyche should have been seeing her. CCN K stated sometimes a facility could do a Negotiated Risk Assessment if a resident was non-compliant with medications, It lets them [family] know this can happen. An interview with SW C on 09/23/25 at 10:13 AM revealed she knew Resident #3 had been refusing her medications since she first admitted . She stated that Resident #3 had verbal behaviors more than anything and was easily irritated and she did not know what her triggers were. She stated the resident had no aggressive towards self, staff or other residents as far as she knew. If a resident with dementia or psyche concerns refused medications, SW C said it would be the nursing staff that would need to address it and notify the resident's emergency contact. SW C stated she did not recommend any interventions when Resident #3 began refusing her medications. She said the nurses were in charge of ensuring residents received psychiatric services and SW C did not communicate any issues with the PMHNP related to Resident #3. SW C stated when Resident #3 began having increased behaviors, she tried to reach out to her EC but was only able to leave a voice mail. SW C stated she was not included in the decision to send Resident #3 to a psyche hospital. She said normally the nursing staff would ask her if she had seen a change in condition or any incidents, but ultimately that would be up to nursing staff for an evaluation. SW C stated Resident #3 was sent out, based on mood and behaviors. Record review of the facility's, undated, policy titled, Dementia and Behavioral Health Policy reflected, .Some individuals with dementia may have coexisting symptoms or psychiatric conditions such as depression or bipolar affective disorder, paranoia, delusions or hallucinations. Progressive dementia may exacerbate these and other symptoms.Therapeutic Interventions or Approaches: The use of any approach must be based on a careful, detailed assessment of physical, psychological and behavioral symptoms and underlying causes as well as potential situational or environmental reasons for the behaviors.Identifying the frequency, intensity, duration and impact of behaviors, as well as the location, surroundings or situation in which they occur may help staff and practitioners identify individualized interventions or approaches to prevent or address the behaviors. Individualized, person-centered interventions must be implemented to address behavioral expressions of distress in persons with dementia. The resident and family/representatives should be involved in helping staff to understand the potential underlying causes of behavioral distress and to participate in the development and implementation of the resident's care plan.Facilities should be able to identify how they have involved residents/families/representatives in discussions about potential approaches to address behaviors and about the potential risks and benefits of a psychopharmacological medication, the proposed course of treatment, expected duration of use of the medication, use of individualized approaches, plans to evaluate the effects of the treatment, and pertinent alternatives. The discussion should be documented in the resident's record.Involvement of the Medical Team: Residents who exhibit new or worsening BPSD should have an evaluation by the interdisciplinary team, including the physician and knowledgeable staff, in order to identify and address, to the extent possible, treatable medical, physical, emotional, psychiatric, psychological, functional, social, and environmental factors that may be contributing to behaviors, in order to develop a comprehensive plan of care to address expressions of distress. This was determined to be an Immediate Jeopardy (IJ) on 09/21/25 at 3:35 PM. The R-AD and DON were notified. The R-AD and DON were provided with the IJ template on 09/21/25 at 4:38 PM. The following Plan of Removal submitted by the facility was accepted on 09/22/25 at 2:40 PM: Date: 9/22/25-Plan of Removal-F744 Dementia Care Resident #3 was admitted in July 2025 with a diagnosis of dementia. MARs and nursing notes documented ongoing refusals of medications for dementia (donepezil, memantine) since her admission and escalating dementia related behaviors. The resident's behaviors escalated culminating in psychiatric hospitalization on 09/19/25. Interventions: 1. Resident #3 was admitted to the hospital on [DATE]. Resident #3 remains in the hospital as of 9/22/25. 2. All residents on dementia medications were reviewed by the Regional Compliance Nurse, DON, and ADON for any refusals for 3 or more consecutive days. The attending physician and psychiatrist will be notified for any medication refusals of three or more consecutive days. Orders received for medication refusals will be implemented by DON and Charge Nurse. Completion date 9/22/25. 3. The psychiatric and psychology providers will be notified by the Regional Compliance Nurse and DON to review all residents on services to ensure visits and appropriate treatments are being provided to each resident. Psychiatric/psychological services will be notified of any residents who refuse psychotropic medication. Completion date 9/22/25. 4. All residents with a diagnosis of dementia and/or require psychiatry and psychological services will have their care plans reviewed by the Regional Compliance Nurse, DON, and MDS Nurse for appropriate interventions to address medication refusals and history of behaviors. Interventions will also include pharmacological and non-pharmacological approaches to care. Updating care plans going forward will be an interdisciplinary approach by the DON, ADON, and/or MDS Nurse. Completion date 9/22/25. 5. New Process: The DON/ADON/Designee will review the 24hr report and PCC for changes in condition such as escalating behaviors and medication refusals 7days per week. The medication administration report will also be reviewed during this process 7 days per week to ensure all medications have been administered as ordered. Notifications to MD/RP will be made for 3 consecutive days or more of medication refusals and/or escalating behaviors. MD orders will be implemented by the charge nurse or designee immediately. The orders will include monitoring for any changes in condition after refusals. The care plan will be updated by DON, ADON, MDS or designee. Completion date 9/22/25. 6. The Admin, DON and ADON were in-serviced 1:1 by the Regional Compliance Nurse and Area Director. Completed 9/22/25. A. Notification of Change in Condition Policy: Notifications to the MD/RP will also include medication refusals of 3 or more consecutive days for dementia medications, increased or escalating behaviors. B. Dementia/Behavior Health Policy- to importance of providing necessary behavioral health care services, pharmacological/non-pharmacological interventions to attain or maintain the highest mental and psychosocial well-being according to plan of care. C. Care Plan Policy- to include that all residents should have in place a person-centered care plan with interventions that address areas that include but are not limited to- resident's physical needs, psychosocial needs, dementia/behavioral health care services, pharmacological/non-pharmacological interventions, non-compliance with care, and behaviors. 7. The medical director was notified of the immediate jeopardy citation by the administrator on 9/18/25 and 9/22/25. 8. An ADHOC QAPI meeting was held with interdisciplinary team including the medical director to discuss the immediate jeopardy and plan of removal. Completed on 9/22/25. In-services: 1. The following in-services were initiated by Administrator, Regional Compliance Nurse, DON, ADON to all charge nurses. All charge nurses not present or in-serviced as of 9/22/25 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency, or nurses on leave will in serviced prior to assuming their next assignment. Completion date 9/22/25. A. Notification of Change in Condition Policy: Notifications to the MD/RP will also include dementia medication refusals of 3 or more consecutive days, increased or escalating behaviors. B. Dementia/Behavior Health Policy- - to importance of providing necessary behavioral health care services, pharmacological/non-pharmacological interventions to attain or maintain the highest mental and psychosocial well-being according to plan of care. C. Care Plan Policy- to include that all residents should have in place a person-centered care plan with interventions that address areas that include but are not limited to- resident's physical needs, psychosocial needs, dementia/behavioral health care services, pharmacological/non-pharmacological interventions, non-compliance with care, and behaviors. Monitoring the Plan of Removal implementation occurred on 09/21/25 through 09/23/25 through daily onsite visits. Facility monitoring activities included review of 24-hour reports for 09/21/25, 09/22/25 and 09/23/25, medication administration records, risk management logs and physician notification to verify that interventions for dementia medication refusal and escalating behaviors were implemented. Additionally, staff in-services were reviewed and verified they were conducted on 09/21/25 and 09/23/25 for nursing staff to reinforce behavioral health policies and notification procedures for physician and psychiatric services. Twenty nursing staff were interviewed across all shifts on 09/21/25, 09/22/25 and 09/23/25 (RN A, LVN B, DON, ADON D, LVN F, CCN K, CNA H, MA J, R-AD, CNA L, CNA M, LVN N, CNA O, CNA P, RN Q, LVN R, CNA S, CNA T, CNA U and LVN V. All staff interviewed were able to verbalize dementia care protocols, recognition of escalating behaviors and required notification procedures. Nurses were able to correctly identify procedures for notifying physicians and responsible parties after three or more medication refusals and demonstrated understanding of non-pharmacological intervention expectations. Review of the facility's 24-hour report for other sampled residents with dementia diagnoses from 09/21/25-09/23/25 reflected there were no changes in condition, no behavioral symptoms or care interventions occurred that required documentation during the monitoring period. Review of dementia care plans and behavior monitoring logs from 09/21/25-09/23/25 reflected interventions were the in the process of being updated with individualized, non-pharmacological approaches were identified and documentation was consistent with the residents' assessed needs. Record review of Ad HOC QAPI meeting on 09/21/25 reflected the medical director and interdisciplinary team provided oversight and reviewed the implementation of the corrective actions. The R-AD was informed the Immediate Jeopardy was removed on 09/23/25 at 11:55 AM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and at a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.